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The initial 28 days of life are most vulnerable for a child’s survival. Regardless of the advancement over the past two decades, neonatal mortality and morbidity is still a cause of concern. Throughout the world, about 10 million children die annually before their fifth birthday, most of them in the neonatal period. More than 98% of these deaths occur in developing countries. In emerging nations, the risk of death in the neonatal period is six times greater than in developed nations, and in the least developed countries, it is over eight times higher. In India, neonatal mortality adds to over 64% of infant deaths with maximum deaths happening during the initial seven days of life. Fatality rate in the second month of life is likely higher than in the later years. Any health program that targets at depleting infant mortality rate needs to address in the initial two months of life, particularly in the seven days stretch of life.
In spite of the certitude that overall newborn fatality rate has dropped altogether by 40% between 1990 and 2013, this reduction has not been in pace with the 56% decline of under-5 mortality rate globally over a similar period. The neonatal mortality rate in India has further reduced to 20.34/1000 live births by 2020 with the infant mortality rate of Punjab rural to be 19/1000 live births in 2020. In 2016, newborn illnesses, particularly pneumonia, sepsis, and meningitis, were accountable for 21% of yearly neonatal mortality, nearly all of them occurring in underdeveloped nations.
Neonatal danger signs were recommended by World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF), which includes feeding difficulty, convulsions, fast breathing, severe chest wall in-drawing, pyrexia, hypothermia, activity only when stimulated, or not even when stimulated, yellow soles, redness around umbilicus or pus draining umbilicus and, reddened or pus draining eyes which were also as per Integrated Management of Neonatal and Childhood Illness. Community health workers or potential mothers are expected to easily identify these symptoms. To increase newborn health and survival, timely and appropriate care-seeking is essential. The failure to seek medical attention could be attributed to care givers’ lack of awareness of newborn danger symptoms. A good understanding of these signs is essential for lowering mortality. Different nations and areas have varying degrees of hazard sign awareness. Between 38 and 85% of care givers in Uganda, India, Ethiopia, and Nigeria reported to have a little knowledge of infant danger indicators.
The modified three delays’ model liable for young infant mortality shows that household and healthcare facility-related delays were significant bestower of late presentation, treatment initiation, and upcoming neonatal mortality in many advancing provinces. These delays especially at the household level are especially significant because once there is a delay in the identification of the risk indicators of newborn illnesses, there are automatically delays at all other levels, i.e., initiation of treatment and referral to a better equipped healthcare facility.
Initial detection of neonatal sickness is a significant stage toward enhancing newborn endurance. A mother is the closest individual to a neonate to identify, present, and manage the neonates’ trouble, which ascertains that the newborn can lead a healthy life because mothers’ health-seeking behavior heavily depends on their awareness of neonatal danger indicators, and it is possible to prevent linked neonatal mortality if the mothers are aware of the proper manifestations of the causes of death in neonates (neonatal danger signs).
This was a community-based study using a qualitative method to explore the perceptions of care givers regarding danger signs of illness in young infants using a convenient sampling technique and a qualitative research approach. Ethical approval was obtained from ethical committee of the institute, and written and verbal consent from the participants was taken before conducting interviews and FGDs.
Mothers and other primary care givers who had cared for the sick young infants in the last six months and were willing to participate in the research were recruited as study participants. The care givers caring for mentally retarded and traumatic child and those who were reluctant to participate were excluded from the study.
The data was collected in a selected area of Amritsar, in which the mothers and other primary care givers were identified with the help of Auxiliary Nurse Midwife of the concerned urban health center. Concerning to minimize study bias, participants were dynamically motivated to express their experiences as candidly as possible and reassured on full confidentiality. Five semi-structured interviews and one focus group discussion were conducted for assessing the care giver’s perception regarding danger signs of illness in young infant. Separate set of respondents was recruited for the FGD. The length of interview varied from 30 to 60 minutes. Interview guide and FGD guide were used to conduct the semi-structured interview as well as FGD. Interviews were continued till the acquisition of required data and point of saturation were achieved at five interviews of care givers, and six care givers were involved in the focus group discussion. All the interviews were audio recorded, and transcriptions of the interviews in the form of written verbatim were done manually. Intelligent transcription of the verbatim was done in which light editing of the audio can be done which means that the fillers expressed by the speaker such as “um,” “hmm,” “err” along with the pauses in between the discussions, excessive repetitions, deep thoughts were omitted from the transcribed documents. Additional irrelevant details eliminated were stuttering, stammering, coughing, and clearing throat. Wherever necessary, these transcriptions verbatim were translated to English language.
The study was found to be feasible in terms of availability of subjects. The time required to conduct the semi-structured interview was approximately 30–60 minutes. Problem was faced in retaining the care givers (especially mothers) for longer time due to the household workload. After the pilot trial, two items were added in the focus group discussion guide, considering them important to acquire more acute data in the main study. No changes were made in the semi-structured interview guide.
A total of 11 care givers were interviewed to explore the perception of care givers regarding danger signs of illness and practices followed in young infants out of whom five were interviewed during semi-structured interviews and six care givers during focus group discussion. The sociodemographic characteristics of the care givers and their young infants are given in Tables 1.1 and 1.2.
The data analysis of the participants leads to the emergence of nine distinct but interconnected themes with considerable subthemes and codes. The themes were generated from the interview and FGD guide, and out of them, the emergent subthemes and codes were formulated from the discussions and experiences of the care givers. A total of six themes, 12 subthemes, and 55 codes were emerged from semi-structured interviews, and three themes, seven subthemes, and 20 codes were generated from the focus group discussion, which was finalized by the final revision of the supervisor and cosupervisor.
The themes generated from the semi-structured interviews were conducted by the care givers [Table 2]:
_1.1 Recognition of general signs of illness_
_1.2 Recognition of danger signs of illness_
The initial step in child’s journey of illness includes the recognition of the signs of illness. Clarity was seen among the care givers regarding the identification on the general symptoms which may worsen if not taken care of. According to the live experiences of the care givers, the general signs explored were inactivity, warm body, reduced feed, yellowish skin, crying, and irritability, whereas the danger signs recognized include increased frequency of loose stool, jelly-like stool, excessive crying, decreased intake of feed, yellow palms, skin eyes, increased body temperature, chest and nasal congestion, chest sound, cough which were generated as codes. It was concluded that almost all the mothers reported excessive crying as danger sign. As many infants had suffered from diarrhea, important signs like bulging fontanelles, nasal flaring, etc., (as per IMNCI) were not recognized by any mother. Rests of the signs were as per IMNCI, but signs like decreased feeding, inactivity, sneezing, and nasal congestion were not as per IMNCI.
_2.1 Personnel from whom care givers seek medical care_.
_2.2 Delay in medical care-seeking_.
From the discussion with most of the care givers, it was concluded that all the mothers rely on the specialist care, i.e., pediatrician, but despite having fine knowledge regarding danger signs, still for the delay in medical care, majority of care givers waited for 2–3 days for recovery with home remedies or seek medical care when the symptoms worsen, which shows a negative outcome for medical care-seeking on behalf of the care givers.
_3.1 Home remedies adapted by care givers_.
Various home remedies like applying asafetida water and ginger extract around umbilicus, giving carom seed water, etc., showed that the practice of giving additional foods along with breastfeeding is still prevalent, failing the concept of exclusive breastfeeding. These remedies are just giving temporary relief to the young infant. It was also seen that practices like preparing extract of ajwain (carom seeds) by chewing it in a cotton cloth and mixing the extract in 2–4 drops of mothers’ feed are some of the extremely unhygienic practices that can worsen the infection and are a call to the additional infections. Some of mothers are also exercising useful practices like administration of homemade ORS to infants suffering from diarrhea.
_3.2 Treatment or advices given by health worker_.
As majority of young infants were suffering from diarrhea, doctors’ advise includes the cessation of bottle feed and continuing exclusive breastfeeding along with the laboratory investigations and medications.
_3.3 Traditional/other methods adopted by care givers_.
The other methods adopted by care givers were coded as **superstitious methods** in which it was discovered that all the mothers believe the illness as a result of some evil eye, and mothers use to cast-off the evil eye by rotating the salt over the body 5–7 times and then throwing it under running water or by rotating red chilies over the bodies and burning it; other methods adopted by care givers include dipping the tip of a burning hot iron knife in the extracted milk before giving catori feed especially during hospital stay to cast-off evil eye, and the **spiritual methods involve** using massa (holy chants or incantations) oil for massaging the body, giving Holy water to drink application of ghee from holy flame on the site of effected organ, reading holy book near the child, and reciting special prayer for child’s health by Godmans at holy places. Mothers believe that adapting all these methods helps their child in speedy recovery and also keeps their child away from evil eye. It was concluded that all these methods adopted were of no medical significance but provides them with emotional and spiritual satisfaction.
_4.1 Part of advice followed_
_4.2 Part of advice not followed at all_
It was explored that most of the mother follows the instruction of administration of prescribed medicine as pharmacological advise, but the non-pharmacological advises include cessation of bottle feed and resuming complete motherfeed which were followed by all the non-working mothers, but working mothers were not able to exclusively breastfeed their babies as they have to go to their work (one of the mothers was a daily wager and others were doing private job and were not getting maternity leave), even the homemakers were also giving the artificial feed along with the breastfeed, the reason being the child’s hunger satiety not relieved by only breast feed.
_5.1 Initiation of recovery_
_5.2 Full recovery_
After interviewing the mothers regarding their young infant’s recovery, it was revealed that according to the experience of most of the mothers, the recovery of their child after following the advises had started after 3–4 days, but the time taken for full recovery to take place varies from one week to 15 days.
_6.1 Time of follow-up visit done by the care givers_
After exploring the care givers’ personal experience, it was depicted that the mothers whose child had recovered early did not take their child for follow-up rather than the child who left with a few symptoms taken for follow-up after 7, 15 days, which shows the negligence on the part of care givers regarding inappropriate follow-up visits. Therefore, the importance of follow-up visit should be notified and emphasized by the health workers during the initial visit itself.
The themes generated from the focus group discussion were conducted by the care givers:
_7.1 Signs requiring emergency consultations_.
_7.2 Signs requiring routine consultations_.
The overhead theme portrayed the signs recognized by the care givers requiring emergency and routine consultations, and various signs were explored for the emergency consultations like bluish discoloration, loose and frequent passage of stool, unconsciousness and decreased body movements, etc., but for routine consultation, all the mothers in the group mentioned that none of the mothers were going for routine consultation or either they are taking their young infant to the health centers routinely just for the purpose of vaccinating their young infant.
_8.1 For discussion about illness_
_8.1 For treatment of illness_
It was expressed by the mothers that the first person with whom they were discussing about their child’s illness was primarily their mother-in-laws (in case of providing home remedies) and secondarily their husbands, or they inform husband only when they need to take the child out for visiting some health centers. And for treatment, almost all the mothers preferred doctor; only a single mother trusted in the traditional healer (Baba) for the treatment.
9.1 Availability
9.2 Sufficiency
9.3 Frequency of use
It was explored that people were having facilities like government and private hospitals, with services of free delivery and vaccination, and along with that private hospitals were also available. Difficulties were reported regarding 24-hour availability of doctors in both government and private hospitals for the provision of emergency services which was lacking; care givers said that doctors were available only during day time but not at night. When talked about the frequency of use, people were often utilizing all these services whenever they require.
Neonatal illness, specifically in the first week of life, is a major cause of death globally. Enhancing the ability to identify young infants who need to be referred for serious disease is crucial for public health importance.
The discoveries of the current research construed that significant signs like dry lips, bulging fontanelles, nasal flaring, and so forth (according to IMNCI) were not perceived by any mother. Similar studies conducted by Alfonso Rosales _et al_. concluded that most of the care givers found it difficult to identify the danger indications in newborns. Due to care giver limitations in recognizing danger signs, delays in obtaining medical assistance were attributed to all newborn deaths. Jemberia MM and Solomon Shitu also reported very low level of maternal as well as paternal knowledge about neonatal danger signs. Mose A further documented less knowledge of newborn warning signs among postnatal mothers.
Mothers perceiving excessive crying as danger sign was another finding of the current study; similarly, Awasthi S _et al_. suggested the possible inclusion of persistent crying as an additional warning sign.
One of the significant findings of the ongoing review showed that larger part of parental figures waited for 2–3 days for recovery with home remedies or seek medical care when the symptoms worsen, which shows a negative outcome for medical care-seeking on behalf of the care givers. Similarly, the findings of Bulto GA depicted that only 60.5% of mothers whose neonates developed warning signs procured medical care immediately. Lassi _et al_. identified social, cultural, and health service factors and barriers which include: early recognition of warning signs, availability of funds to arrange for transport and affordability of healthcare cost, and accessibility to a proper health care facility, which contributes to delay in health care-seeking and influence the decision to seek care. Tsering P. Lama _et al_. explored the illness recognition, decision making, and care-seeking for maternal and newborn complications. Improved recognition of danger signs and increased demand for skilled care, motivated through community-level interventions and health worker mobilization, needs to be encouraged.
It was also seen in the existing research that some of the extremely unhygienic practices can worsen the infection and is a call to the additional infections. An alike detection by Tariku Nigatu Bogale _et al_. concerning their beliefs about the treatment practices and preferences for WHO defined neonatal danger signs. When compared to biomedical therapy resources, some respondents indicated that non-biomedical forms of treatment produced superior results. It has been noted that major impediments in receiving treatment for neonatal danger indicators include cultural and religious beliefs.
The present study concluded that almost all the mothers reported excessive crying as danger sign, and important signs like bulging fontanelles, nasal flaring (as per IMNCI) were not recognized by any mother. Moreover, mothers are adapting few unhygienic practices as home remedies leading to worsening the symptoms and making a call for additional infections which are needed to be addressed by the health authorities at community level. One among the major issues which needs to be dealt with was the inability of mothers to exclusively breastfed their babies due to unavailability of maternity leave. Despite of the fact that impressive improvements have been accomplished throughout the last few years because of the extended publicity of maternal and their offspring’s care administration, still there are a critical number of mothers who have restricted information about neonatal warning signs; in this manner, interventional procedures that will fortify maternal knowledge and antenatal as well as postnatal care follow-up ought to be expanded.
Nil.
There are no conflicts of interest.
If any, I would like to extend my sincere thanks all the mothers and other care givers who cooperated for the purpose of collecting interview data by sparing time from the busy household schedule which made me to complete the project to the ultimate conclusion.
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