1

Chapter 1

INTRODUCTION

Children are vital to the nation’s present and its future. Parents,

grandparents, aunts, and uncles are usually committed to providing every advantage

possible to the children in their families, and to ensuring that they are healthy and

have the opportunities that they need to fulfill their potential. Yet communities vary

considerably in their commitment to the collective health of children and in the

resources that they make available to meet children’s needs. This is reflected in the

ways in which communities address their collective commitment to children,

specifically to their health. In recent years, there has been an increased focus on

issues that affect children and on improving their health. Children are generally

viewed as healthy when they are assessed by adult standards, and there has been a

great deal of progress in reducing childhood death and diseases. Death is a certainty

of life. Everyone who born alive has to die sooner or later while the first year of

new life is the most important and vulnerable period for child. Infant mortality has

traditionally been viewed as an indicator of the social and economic well-being of a

society. It reflects not only the magnitude of those health problems which are

directly responsible for the death of infants, such as diarrheal and respiratory

infections and malnutrition, but the net effect of a multitude of other factors,

including prenatal and postnatal care of mother and infant, and the environmental
 2

conditions to which the infant is exposed. The high level of infant mortality is an

indication of discouraging socio-economic development and along with the poor

government commitment for improving health status of its nation. Millennium

Development Goal (MDG) 6 focuses on improving maternal health, with target 5

aiming to reduce the child and infant mortality ratio by two-thirds, between 1990

and 2015. Like many developing countries Pakistan too, is facing with problems of

high infant mortality especially, in the rural areas. So this study was focused to

explore the determinants of infant mortality in the, “Warayamal”, a village of

district Chakwal.

Infant mortality refers to deaths of children under the age of one year. It is

measured by the infant mortality rate, which is the total number of deaths to

children under the age of one year for every 1,000 live births. The infant mortality

rate is often broken down into two components relating to timing of death: neonatal

and post neonatal. The neonatal mortality rate refers to the number of deaths to

babies within 28 days after birth (per 1,000 live births). Sometimes a special type

of neonatal mortality is assessed. The prenatal mortality rate measures the number

of late fetal deaths (at or after 28 weeks gestation) and deaths within the first 7 days

after birth per 1,000 live births. The post neonatal mortality rate involves the

number of deaths to babies from 28 days to the end of the first year per 1,000 live

births. The distinction between neonatal (and prenatal) and post neonatal mortality
 3

is important because the risk of death is higher close to the delivery date and the

causes of death near the time of birth/delivery are quite different from those later in

infancy. Therefore, effective interventions to reduce infant mortality need to take

into account the distribution of ages at death of infants (Encyclopedia of Death and

Dying, 2010).

Every day, 1500 women die in pregnancy or due to childbirth related

complications worldwide. Two thirds of all maternal deaths in Asia and the Pacific

occur in India (540 deaths per 100,000 live births) and Pakistan (500). Every year

about 11 million children die, of which 10 million are in the developing world.

South Asia is the continent where world’s poorest population is habituating. It’s

social and economic indicators stand out in terms of the number of persons below

the poverty line, some of the lowest literacy and high infant mortality rates.

Pakistan has the highest maternal and infant mortality rate in the South Asia-male:

70.65 deaths per 1,000 live births and female: 63.91 deaths per 1,000 live births;

total: 67.36 deaths per 1,000 live births; neonatal mortality: 53 (per 1,000 live

births) in which 32 percent with low birth weight, institutional delivery is just 34%

and only 29 percent are feeded with early initiation of breast feeding and 55

percent feeded on breast milk up to 2 years Pakistan is still in a high infant stage of

development as revealed in the census. The infant mortality rate is 106 in rural

areas in Punjab and this figure is much high. Also there is a need to explore infant
 4

mortality in socio economic perspective of rural areas (UNICEF, 2010). Mortality

in female infants was 1.3 times higher than in male infants. Discrimination, which

may lead to increased mortality among female children, has been the subject of

many previous studies. The World Health Organization has reported that the sex

disparities in health and education are higher in South Asia (Khanna et al. 2005).

The human society even having acknowledged this universal truth has been

continuously trying to postponing death since the dawn of civilization. Developed

nations are largely successful in it. But under developed countries have failed in

declining mortality especially infant mortality rates. The infant mortality rate in

Pakistan is quite high and every 11th child who is born alive dies before reaching of

his first birth day (Cleland and Farooqui, 1998). The figure is extremely high when

compared with infant mortality rates with some developed countries like Zealand

and United States where these rates are 6.7 and 7.2. In China and Indonesia

mortality rates are 31 and 46. In developing countries infant mortality rate 64 in

Bangladesh, 111 in Zambia, 98 in Pakistan, 74 in India (Arnold and Cushman,

2005).

All the developing countries including, Pakistan are making utmost effort to

decline the mortality rate among the mothers and children right from the pre-natal
 5

stage to toddler stage. The main factors responsible for the increased death rate

among the women are the high level of still-birth and physically or mentally

handicapped births of the children, lack of health facilities, lacking in utilizing of

these facilities, financial incapacities to afford health facilities, repeated

pregnancies, and the poor level of nutrition and polluted environment. At the same

time, the traditions of our country have hinder our people to be benefited from the

modern health care system because in rural areas still the people don’t want to use

the facilities available at hospital or medical centers. Due to these reasons, the

mother-child health is severely affected and the result is in the form of many

diseases and disabilities Therefore, rural areas of Pakistan have become challenge

to planners, sociologists, administrators and even to politicians to chalk out some

programs to overcome the serious health problems particularly the high level of

child morbidity and mortality (Akhtar et al., 2005). UNICEF pointed out that just

over one in 10 Pakistani children die before their first birth day. Rates are also

highly differentiated according to class, region and the rural urban divide. While in

very poor families it is around 230 per 1000. Rural areas generally suffer more

infant mortality than towns (UNICEF, 1992).

The causes of infant and childhood mortality during the first months and

years of life may be roughly divided between endogenous and exogenous. The term

endogenous refers to deaths caused by factors that are independent of pathological

socioeconomic and cultural conditions into which a child is born. The endogenous
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causes are therefore associated with biological and genetic factors influencing the

survival chances after birth. It has to be noted that the endogenous factors are

strongly influenced by environmental factors such as poor hygienic conditions. It is

quite difficult to imagine an exogenous factor which would not operate through

endogenous causes of a child’s death. In our opinion, such a solely exogenous

cause is preferential infanticide, which is determined culturally, and is not affected

by any biological mechanisms. The above-defined terminologies provide a useful

frame of reference for the study of mortality determinants over the first five years

of human life. It has to be stressed that the biological (endogenous) factors are

closely related and influenced by cultural (exogenous) factors. The biological

factors, such as developmental deficiencies or chromosomal anomalies, are usually

assumed to be the main causes of death in the first days of life. However, the

environmental (cultural) factors, also contribute to the survival chances by

influencing the mother’s health, either directly or through demographic variables.

The mother’s poor health status might translate into a premature or hypothrophic2

birth. Therefore, in both of these coincidental chains, the mother is the most

important factor through which the external environment influences the fetal

development of the child. A child’s health status might also be influenced directly

by demographic variables like sex, survival status of adjacent siblings, season of

birth, survival of parents, or presence of extended family. Especially the sex of the

newborn child greatly influenced its fate. Male infants are much more likely to die

within the first 24 hours after delivery than female infants. It has to be noted that
 7

exogenous factors affect not only the mother’s health, but also the child’s health.

Apart from the bio-genetic factors, exogenous factors—such as epidemics, wars,

and famines—determined child survival to a large extent (Tymicki, 2009).

Ensuring the survival and wellbeing of children is a concern of families,

communities and nations throughout the world. Since the turn of the 20th century

infant and child mortality in more developed countries has steadily declined and,

currently, has been reduced to almost minimal levels. In contrast, although infant

and child mortality has declined in the past three decades in most less developed

countries; the pace of change and the magnitude of improvement vary considerably

from one country to another. In Pakistan infant mortality is still very high and the

neonatal mortality contributes more than half of the Infant Deaths. In 1950s it was

around 50 percent of the Infant mortality; in 1990s it was about 60 percent of the

infant mortality. We can reduce the infant mortality by identifying the factors

(proximate determinants such as, demographic factors, environmental factors,

nutritional factors and health seeking behavior) associated with neonatal and post-

neonatal mortality. The neonatal mortality in the province of Punjab is slightly

increased; however, it is not significant (Mahmood, 2002).

The inverse relationship between socio-economic variables of the parents

and infant and child mortality is well established by several studies and it holds true
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irrespective of the overall level of mortality in the national populations. The

influence of parental education on infant and child health and mortality has proved

to be universally significant. The father’s education, mother’s education and their

work status each have independent effects upon child survival in developing

countries. Economic conditions of the household also help in explaining the

variation in infant and children mortality. The nature of housing, diet, access to and

availability of water and sanitary conditions as well as medical attention all depend

on the economic conditions of the household. For example, poor families may

reside in crowded, unhygienic housing and, thus, suffer from infectious disease

associated with inadequate and contaminated water supplies and with poor

sanitation. Maternal factors, which are biological attributes of birth, such as the age

of mother at the time of childbirth, birth order and birth interval have significant

effects on child survival. Infant and child mortality are also affected by the sex of

the child, and infants born to mothers who have lost a child are at greater risk of

dying during infancy. Breastfeeding has numerous bio-demographic, social, and

economic effects. It affects the health and nutritional status of, both, the mother and

child. The role of breastfeeding is very important in the post-neonatal period.

Health seeking behavior includes both, preventive and curative measures.

Preventive measures include immunization against preventive diseases such as

tuberculosis, polio, measles, neonatal tetanus and smallpox, whereas curative

measures include the care and types of treatment undertaken for specific conditions,

both modern and traditional (Mahmood, 2002).

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In developing societies, like Pakistan people still seek health care from the

traditional health care practitioners. This is a significant factor of poor mother-child

health status and high incidence of children mortality and morbidity. Majority of

the selected women (47.5%) delivered their baby under the supervision of

traditional birth attendants. Doctors only supervised 35% births. The dream of high

health status for all Pakistani can only be achieved when people have access to

modern health care system home. Population Report of the world fertility survey in

1985 reported that in 19 out 29 countries infant mortality rates were higher among

children born fourth or later, and in 25 of 29 countries infant mortality rates were

higher among children born seventh or later (Akhtar et al,. 2005).

Infant mortality varies among different groups of population due to

different causes like, endogenous and exogenous factors. A low standard of living

in rural areas of Pakistan is the norm. Housing is poor with inadequate ventilation

and high occupancy, often with cattle or other domestic animals. Transmission of

respiratory diseases is common under such conditions. Low standards of health

affect a society in many ways. Malnutrition, diarrheal illness, acute respiratory

infections, neonatal tetanus and malaria are the common causes of infant mortality.

An estimated 200,000 infants die each year due to diarrhea alone. The varying

characteristics of the Punjab lead to infant mortality to vary due to the regional,

biological, demographic and socio-economic factors in locations. Many

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endogenous factors like sex of child and sex preference child and mother health

maternal age at marriage and birth order, birth interval, birth weight, breast feeding,

contraceptive use and exogenous factors like region, residence, child’s birth place,

mother’s and father’s education, religiosity, land ownership, livestock, assets,

income, occupation, housing traits like water and toilet facilities ( UNICEF, 2002).

Theoretically, Child’s mortality is influenced by its mother’s education,

little explicit attention has been paid to the possibility that also the education of

other women in the community may be of importance. Three main causal channels

are relevant: social learning, social influence, and indirect mechanisms. Social

learning means that knowledge and attitudes are transmitted directly from others by

communication and observation, whereas social influence refers to a more passive

imitation of behavior, driven by a desire to gain other people’s approval or avoid

sanctions. The indirect mechanism is that others’ ideas, resources, or behavior can

influence society and social institutions and thereby individual behavior or events

(kravdal, n.d).

Pakistan is still in a high infant and child mortality state of

development as revealed in the 1998 census. The infant mortality rate is 106

in rural Punjab, Pakistan. This figure is much high in rural areas of northern
 11

Punjab of Pakistan. Population Policy was introduced in 2002 with the goal

to achieve population stabilization by the year 2020 through the

expeditious completion of the demographic transition that entails declines

in fertility and mortality rates and to improve the quality of life. The high

rate of infant and child mortality will necessarily undermine efforts being

under taken to reaching replacement level of fertility by the year 2020. It

has been recognized that improving women's welfare can be an

important measure to reduce child mortality.

Reduction of child mortality rates is mentioned as one of the key

strategy to achieve population stabilization. Thus, there is a need to

explore the determinants of infant mortality in socio-economic perspective

because knowledge of some of the factors affecting infant mortality is a

fundamental requirement for devising appropriate policies and strategies to

accelerate decline in infant mortality and population stabilization. Therefore,

the fundamental objective of this study was to explore the determinants of infant

mortality. This research will be helpful for the policy makers, demographers and

other researcher for further investigation.

Study was focused on following objectives:

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• To explore current patterns of infant mortality in socio-economic and

demographic perspective

• To assess the knowledge and attitudes towards safe motherhood

• To examine the patterns of births preparedness and new-born care those

have a potential threat for infant mortality

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Chapter 2

REVIEW OF LITERATURE

Caldwell (1990) investigated that early supplementation had adverse of

reducing breast milk intake because the child was not hungry, as well as possibly

exposing the child to hygienic practices. To him mothers should use preparing

supplements given to infant when breast milk suddenly inadequate.

Mahmood (1993) explained that mortality and health status cannot be

treated in isolation but it is related very intricately with some of the social

economic conditions. Economic aspects of illness may often over shadow the other

aspects of social component. Poor income may result in lower standard of living

which stands for inadequate food, shelter and recreational that adversely affects

health of family members. Above all, the cost of the medical care may put a family

under a heavy burden of debt, which may further deteriorate their living conditions.
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Thus it may prove a vicious circle specifically for people with poor resources. The

significance of phenomena of infant mortality is hardly irrevocable for its socio-

economic and demographic implications. As infant mortality, in general is

considered to explanative of overall socio-economic development. The factors that

play an important role in the child health are education of mother, household

income, occupation of father, standard of living etc., and other demographic factors

such as age of mother at birth, birth interval and health care factors like medical

facilities and immunization.

Zahid (1996) stated that the highest mortality occurred among children born

to mothers aged less than 20 years. The survival status of the preceding child has a

strong association with neonatal, infant and child mortality in Pakistan. The death

of a preceding child probably indicates the importance of biological factors,

including physiological deficiencies in the mother and environmental problems

which could carry over to later births. Neonatal and infant mortality is higher for

males than for females, as expected; this relationship is then reversed for child

mortality. There are some gender related differences in child rearing practices that

favor boys over girls. The analysis of birth order pattern has found mortality to be

the highest among first order births, and lowest for third order births before

increasing again as the birth order increases. The high mortality of first and high

order births may be related to the age of the mother at the child’s birth which is

termed as high risk births for very young and older mothers. Neonatal, infant and
 15

child mortality are highest for children born less than 18 months after the previous

birth. The mortality risk then declines as the birth interval increases. Mortality is

higher in rural areas than in urban areas as expected. This might be due to factors

including sanitation, water supply, and unequal distribution of health facilities

between rural and urban areas of the country. Differentials in infant and child

mortality are that mother’s education, age at birth and birth interval are strongly

correlated with lower neonatal and infant mortality. Maternal education can

contribute to the reduction in infant and child mortality by promoting preventive

measures. The higher the utilization of health services by mothers during pregnancy

and after delivery of the child, the lower the infant and child mortality. Therefore, it

is suggested that for the improvement of the health conditions of children in

Pakistan, first, it is necessary that the educational status of the population in

general, and of mothers in particular, should be improved, and second, the health

services should be accessible and available for the promotion of health care

practices.

Zerai (1996) examined socio-economic and demographic variables in a

multi-level framework to determine conditions influencing infant survival in

Zimbabwe. He employed Cox regression analysis to the 1988 Zimbabwe DHS data

to study socioeconomic determinants of infant mortality. The unique finding was

that women’s average educational levels in their community exert a greater

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influence on infant survival than the mother’s educational level. This result

supports assertions that child survival is strongly impacted by mass education.

World Bank (1996) investigated that infant mortality rates are much higher

in families with non-educated parents which is particularly pronounced for the

mother’s education. To him education is strongly correlated with the type of work.

Infant mortality is affected by individual, house hold and community

characteristics. Individual characteristics are the characteristics which are related to

parents at marriage, at first birth, education, income, occupation, and

landownership and livestock assets.

Government of Pakistan (1997) recognized infant mortality as one of the

main challenges and a key development goal before the human society when the

world summit for children in 1990 set forth a package of objectives aimed to

reduce infant mortality by one third or 50 and 70 deaths per 1000 births, which is

less to be implemented by the year 2000. This war reaffirmed at ICDP

(International Conference on population and Development) in 1994. The

government of Pakistan through Health Department) recently introduced

population policy to achieve population stabilization by the year 2020 to aid social

and economic development and improve quality of life. The national population
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policy paid full attention towards awareness and promotion of quality family

planning & rural health services to all married couples.

Oscar (1999) documented in his study of co-variants of infant mortality in

the Philippines, Indonesia and Pakistan and found that the risk of dying of children

born to older mothers as well as younger mothers would be greater than babies

born to mother at prime reproductive ages. In each country babies born to women

less than 20 years of age experience much higher mortality than children born to

women of prime reproductive age i.e., 20- 30.

Manda (1999) used data from the 1992 DHS in Malawi to study the

relationship between infant and child mortality and birth interval, maternal age at

birth and, birth order, with and without controlling for other relevant explanatory

variables. He also investigated the direct and indirect (through its relationship with

birth intervals) effects of breastfeeding on childhood mortality. The study

employed proportional hazards models. The results show that birth interval and

maternal age effects are largely limited to the period of infancy.

Rashida (2000) pointed out that 70% population of Pakistan lives in rural

areas, so majority of the children are born and brought up there. The overall
 18

condition of our villages gives their life as start with multiple disadvantages. They

suffer from illness caused by malnutrition and unsanitary conditions. Iodine

deficiency is quite prevalent in the Northern areas of Pakistan. Poor maternal

nutrition status result in the high incidence (about 25%) of low birth weight babies,

iron-deficiency anemia and other complications of pregnancy in the women of

child bearing age persist. Protein-energy-malnutrition is prevalent in the vulnerable

population.

Voland and Beise (2002) looked at the question whether the existence or

non-existence of grandmothers had an impact on the reproductive success of a

family. We found that fertility (measured by intervals between births) was not

influenced by grandmothers. However, maternal grandmothers tended to reduce

infant mortality when the children were between six and twelve months of age.

During these six months, the relative risk of dying was approximately 1.8 times

higher if the maternal grandmother was dead at the time of the child’s birth

compared to if she was alive. Interestingly, the existence of paternal grandmothers

approximately doubled the relative risk of infant mortality during the first month of

life. We interpret this as being the result of a tense relationship between mother-

and daughter- in-laws. Grandmothers could be both helpful and a hindrance at the

same time. Geographic proximity tended to increase the effects found. If this

ambivalent impact of grandmothers on familial reproduction could be generalized

beyond the Krummhörn population, the hypothesis that the evolution of the post-

generative life span could be explained by grandmotherly kin-effects would have to

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be stated more precisely: the costs of social stress in the male descendency would

have to be subtracted from the benefits of aid and assistance in the female

descendency.

Freemantle (2003) concluded that Indigenous infants living in a remote

location were at a significantly increased risk of death due to infection compared

with their peers living in a rural or metropolitan location. The risk of death for

Indigenous children was more than three times higher than for non- Indigenous

children. This risk was significantly increased when most of the perinatal maternal

and infant variables were considered. Accident and injury, and infection were the

main causes of mortality amongst Indigenous children. For non-Indigenous

children the main causes were also accident and injury, followed by infection and

cancer. However, the risk of accidental death for Indigenous children was nearly

4½ times higher, and death due to infection nearly seven times higher, than for non-

Indigenous children. The childhood mortality rate in Indigenous children was

highest in those born in remote areas, and in rural areas for non-Indigenous

children.

Ogunjuyigbe (2004) concluded that infant and child mortality remain

disturbingly high in developing countries despite the significant decline in most

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parts of the developed world. The state of the world’s children indicated that about

12.9 million children die every year in developing world Common causes of child

mortality and morbidity include diarrhea, acute respiratory infections, measles, and

malaria. Many children in Nigeria die mainly from malaria, diarrhea, neonatal

tetanus, tuberculosis, whooping cough and bronchopneumonia. Morbidity and

mortality of the child as being influenced by underlying factors of both biological

and socio-economic, operating through proximate determinants. Dirty feeding

bottles and utensils, inadequate disposal of household refuse and poor storage of

drinking water to be significantly related to the high incidence of diarrhea.

Maternal education to be a significant factor influencing child survival. Knowledge

of measles and diarrhea is quite pertinent in an understanding of the role of cultural

beliefs in health seeking among the Yoruba. In the traditional Yoruba setting,

measles attack is usually attributed to a variety of causes which have no link with

the concept of virus. Measles attack is traditionally considered as a punishment for

breaking family taboos or as an evil deed from witches or enemies. The belief that

the measles attack is caused by enemies is common among polygynous family

where co-wives are natural suspects. While measles is perceived as deadly disease

among the Yorubas, diarrhea is perceived merely as a means of getting rid of body

impurities or as a sign of ‘teething’, ‘crawling’, or ‘stretching’. Also some mothers

believe that diarrhea is caused by consumption of sweet things. Mothers with this

view will not likely introduce oral rehydration solution to their children since it

contains sugar and salt.

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Population Council (2005) reported that the infant mortality rate was more

than twice high in class five (workers) as in class one (professionals of) in Pakistan.

There is a large variation in infant mortality rates across the different states. To

them this difference is due to unequal distribution of economic growth over India

and poorer people benefited most in states with low infant mortality rates in their

study the infant mortality in India much faster in rural areas.

Kembo and Ginneken (2005) stated that hat children born to young mothers

(less than 20 years) and those born to older mothers 40-49 years) should have

higher mortality than those born to mothers aged 20-39 years. The lower risks of

child death among children who are first born and those born to mothers aged 40-49

years found in this paper are deviations from the expected mortality pattern and

require further investigation. Birth order and preceding birth intervals, maternal age

and type of birth are dominant determinants of infant mortality, but they are less

pronounced in child mortality. Both maternal and paternal education affects infant

mortality. Provision of piped drinking water and flush toilets to households has a

stronger impact on child mortality than infant mortality. Endogenous factors are

dominant during infancy while during the childhood exogenous factors are dominant

age. Thus family and health planning in Zimbabwe should be directed at educating

men and women with low educational levels and those in rural areas about the

benefits of birth spacing and encouraging them to use birth spacing techniques. This
 22

suggests that improving maternal and child health services, screening for high-risk

pregnancies and making referral services for high-risk pregnancies more accessible,

particularly to the rural women and children, will also contribute to improvement of

child survival rates.

Wichmann (2006) reported that 25% of all preventable diseases are due to a

poor physical environment.' Furthermore, over 40% of the global burden of disease

attributed to environmental factors falls on children below five years of age, who

account for about 10% of the world's population. The burden of disease is defined

as lost healthy life years, which includes those lost to premature death and those

lost to illness as weighted by a disability factor (severity). Air pollution is the

largest single environment-related cause of ill health among children in most

countries. WHO estimated that the number of people exposed to unsafe indoor air

pollution levels exceed those exposed to unacceptable outdoor air pollution levels

in all of the world's cities collectively. In other countries it is the second, after the

scarcity of safe water. Globally, 2.6% of all ill-health is attributable to indoor

smoke from dirty fuels (such as wood, animal dung, crop residues, coal, paraffin),

nearly all in poor regions. Wood, animal dung, coal, crop residues and paraffin

(hereafter ‘polluting fuels’) are at the bottom of the energy ladder regarding

combustion efficiency and cleanliness.

 23

Islam et al. (2006) explained that benefits of breastfeeding on the health of

an infant as an inexpensive and an appropriate source of nutrition are well accepted.

It gives the baby best protection against diarrhoea, infections and food allergies and

thus reduces infant mortality. The people who recognize the beneficial effects of

breast-feeding are quite fretful about the declining trend in the duration of

breastfeeding in many developing countries.

Shamim and Waseem (2006) noted that bottle use is a public health issue in

poor and illiterate mothers of developing countries while, in Pakistan, laws are

enacted against its propagation. The attributes associated with increased bottle use

were mother’s older age, illiteracy and increased parity. It is used not only to give

milk but all other types of fluids e.g. water, tea, juice., etc. its adverse effects are

more profound in the under developed world due to limited economic resources,

lack of clean water, unhygienic surroundings and illiteracy amongst mothers. The

prevalence of unsuitable and/or low-quality bottles and teats further aggravate the

situation. The hazards include over dilution of milk with resultant malnutrition.

There is increased susceptibly to diarrhea and other gastro-intestine infections, ear

infections, allergic tendency and dental caries. In Pakistan, the risk of infant

mortality was estimated to be 4.5 times higher in bottle fed babies as compared to

breast-fed. Many studies on infant feeding practices in Pakistan have found the

declining trend and decreased duration of exclusive breast-feeding. The breast milk

substitute should comprise of a precisely reconstituted formula or properly

 24

sterilized fresh milk. The other important essentials are availability of fuel, clean

water, appropriate equipment and time for preparation, with preferably refrigeration

facilities. The left over milk in the bottle should be discarded; however, it is

observed that, in poor communities of Pakistan, the left over milk is often given for

subsequent feeds due to limited resources, which favors the growth of pathogens.

Mixed breast and bottle-feeding was found to be the most common practice in

infancy. This approximates the bottle-feeding pattern found in urban areas of

Bangladesh. Bottle use appeared to get more common as the age of infant

increased. Employed women have been found to use bottle more than housewives.

Rahman (2007) found that education and media exposure can reduce

inequality. A strong association exists between the level of education of women

and use of reproductive-maternal health services. It improves the status of

women, increases age at marriage, reduces unwanted fertility, and improves

utilization of health services by contributing towards self-confidence of women,

improving their maternal skills, increasing their exposure to information, and

thereby altering the way others respond to them. Conversely, media broadcasts have

tremendous coverage and influence, particularly among women of reproductive age,

instigating significant improvements in health status during pregnancy and also better

utilization of health services. Thus, women exposed to mass media are better

informed about health service facilities compared to non-exposed women.

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Berg and Reiter (2008) analyzed the effects of early-life conditions

(economic, nutritional, meteorological, in terms of disease exposure, and

otherwise) on mortality rates later in life. Recently, there has been a growing

interest in the importance of conditions early in life on health and mortality

outcomes later in life. Knowledge on the magnitude of such long run effects may

have policy implications. If being born under certain adverse conditions increases

the individual mortality rate in the long run (and therefore has a negative effect on

longevity) then the value of life is reduced for those affected, and this would

increase the benefits of supportive policies for such groups of individuals. The

long-run effect of early-life conditions on the mortality rate may be smaller than the

instantaneous effect of current conditions, but the former exert their influence over

a longer time span, and they are more amenable to preventive intervention between

infancy and the manifestation of the effect.

Jamal and Hussain (2008) explained that neonatal and post-neonatal

mortality were found moderately high in Bangladesh, varying significantly by a

number of characteristics related to socio-economic, bio-demographic and health

care facilities. The results suggest that education of parents had been identified the

most important socio-economic characteristics - for which infant mortality were

varied significantly. Fathers' education played dominant role in reducing the risk of

post-neonatal mortality and mothers' education played significant role in reducing

 26

the risk of neonatal mortality. Mothers' occupation was found to have significant

influence on post-neonatal mortality only; however, fathers' occupation has played

significant role in reducing the risk of post-neonatal mortality. The neonatal and

post-neonatal mortality was found significantly low for the children who born in

medium (5-7 members) and large (8 members) sizes family. There were no

significant variation in mortality for the socio-economic variables - religion,

mother's exposure to mass media, place of residence and working status of mother.

Among bio-demographic variables, breast-feeding status was found to have

significant influence on neonatal and post-neonatal mortality. Further, mother's age

at the birth of child and type of birth had significant influence on neonatal and post-

neonatal mortality. Birth spacing was found significant for neonatal mortality only

and the risk of neonatal mortality was very low if the birth spacing was more than 30

months. There was no significant variation in infant mortality according to sex of the

child.

Kapoor (2010) concluded that education of the mother has often been treated

as a proxy for socio-economic status. Mothers who are more educated tend to get

married upon adulthood, this in turn delays child bearing. She is likely to be more

knowledgeable about nutrition, health care and hygiene of the infant (washing and

feeding practice, care of the sick child and immunization). It is still quite common in

villages to cut the umbilical cord with unsterilized sickles, keep the cooked food

uncovered and exposed, leave the child un-immunized or follow orthodox methods
 27

to cure common childhood diseases like tetanus and diarrhea. Educated mother is

can take advantage of public health services and can earn more. She can change the

range of feeding and child care practices without imposing significant extra cost on

the household. Work status of the mother can have a two way effect on mortality.

The need to work outside the house, may affect child survival rates simply by

preventing the mother from caring for the infant. The dual burden of employment

and household work can reduce the time available for childcare activities. This could

lead to substantial effect through a lack of feeding, especially breast feeding early in

life. On the other hand, working outside the home leads to higher family income and

gives the mother a modern outlook, both of which could increase the probability of

survival. Role of women as agricultural laborers also seem to have a significant and

negative influence of infant mortality. Due to diversity of cultural norms might

influence and govern the attitudes towards female children, female work

participation rates and other factors important to infant mortality.

Chowdhury et al. (2010) concluded that Infant and child mortality reflect a

country’s level of socioeconomic development and quality of life. Socio-economic

variables (e.g., place of residence, religion, marital status, education, occupation,

family income, household income etc.) reflect the socio-economic status of a

community that have a high influence on morbidity and mortality level. Parent’s

occupation determines the economic status, nutrition and housing condition, access
 28

to health care and clothing of a family. It has been noted that mother’s education

and occupation, type of latrine and electricity are the influential factors of neonatal,

post neonatal, infant and child mortality. Both male and female education

participation needs to increase because it consequently brings an improvement in

infant and child mortality situation.

Quamrul et al. (2010) stated that the infant and child mortality influenced

by a number of socio economic and demographic factors such as sex of the child,

mother’s age at birth, birth order, preceding birth interval, length and survival of

preceding sibling(s).. Sex and birth order of the child, maternal age at birth, birth

interval, and survival of earlier sibling(s) has significant effect on infant and child

mortality. However, the relative importance of these factors in relation to infant and

child mortality risks varies with the level of social and economic well-being of a

society. A number of studies conducted in different parts of the world by have

revealed the influence of maternal age at delivery on the health and survivorship of

children. Since a very young mother usually less than 20 years of aged mother is

biologically not fully mature and the chances of pregnancy related complications

are high and she might not be able to provide good care for the infants effectively.

Woman with short birth intervals have insufficient time to restore their nutritional

reserves, a situation, which is thought to be adversely, affected fetal growth. This

situation may have a deficit on the nutrition of the young's child. Levels of infant

and child mortality in many developing countries remain unacceptably high, and
 29

they are disproportionably higher among high-risk groups such as newborn and

infant of multiple births. A mother's poor health and poor nutritional status may

also have postnatal consequences such as impaired lactation and render her unable

to give adequate care to her children. Infant mortality is higher for boys than for

girls but child mortality is lower for boys.

United Nations (2010) reported that There is increasing evidence that The

Millennium Development Goal (MDG 4) of reducing children mortality can be

achieved, but only if countries in Sub-Saharan Africa, Southern Asia and Oceania

target the biggest killers of children. In sub-Saharan Africa, diarrhea, malaria and

pneumonia cause more than half of under-five deaths. A common feature of

countries that have made the most substantial progress, especially in sub-Saharan

Africa, has been rapid expansion of basic public health and nutrition interventions,

such as immunization, breastfeeding, vitamin A supplementation, and safe drinking

water. However, on the whole, coverage of low-cost curative interventions against

pneumonia, diarrhea, and malaria, remains low. In Southern Asia, more than half of

all childhood deaths occur in the 28 days after birth. To substantially reduce these

deaths, innovative solutions are required, including to provide compensation for

women to deliver in designated centers or to increase the use of public–private

partnerships to improve provision of skilled delivery services. Undernutrition is an

underlying cause of at least a third of all under-five death. Increased nutrition

 30

interventions, such as early and exclusive breastfeeding, will reduce not only

undernutrition but also the prevalence of pneumonia and diarrhea.

Chapter 3

MATERIALS AND METHODS

3.1 STUDY AREA

District Chakwal is bordered by the districts of Rawalpindi and Attock in the north,

district Jhelum in the east, district Khushab in the south and district Mianwali in the west.

The total area of district Chakwal is 6609 square kilometers and the total population is

1059451, 87.7 percent of which lives in rural areas and 12.3 percent in the urban areas,

making it a predominantly rural district pivoted on an agrarian economy with a very small

industrial sector (Govt. of Pakistan, 1998).

 31

Study was conducted in Waryamal village--rural area of district Chakwal, situated in

the north of city at the distance of 10 KM with a number of 143 households having an

estimated population of 1270.

3.2 SAMPLING

A sample of 40 respondents was selected from 143 households by using

purposive sampling as it was focused on only those households in which there were

cases of infant mortality in last 8-10 years. One respondent was selected from each

household and this respondent was selected purposively as every respondent in the

household was not eligible for interview so main focus was the parents of infants.

3.3 DATA COLLECTION

Data was be collected by using interview schedule having both open and

close ended questionnaires. Researcher conducted face to face structured interviews

based on interview schedule rather than dropping questionnaire.

3.4 PRE-TESTING

Interview schedule was constructed on the basis of information provided by key

informants and literature review. Pre-testing was done in order to ensure the validity and
 32

accuracy of interviewing schedule and quality of data. During pre-testing some

ambiguities were identified so, a few modification and addition were.

3.5 DATA ANALYSIS

Collected data was analyzed statistically through Statistical Package for Social

Sciences (SPSS.13) and was presented in the tabulated form by statistical techniques of

percentage and frequency by using the following formula:

P = (F/N) X 100

Chapter 4

RESULTS AND DISCUSSIONS

Table 1 shows that a handsome number of girls (27 %) were early marriages

and 33% were married within the range of 18-25 years. While 28% were married

within the age group of 25-35. There were also few cases (12%) of delayed

marriages also within age group of more than 35. It is evident from the literature

that early marriage practice is a threat to mother-child health.

UNICIEF reported that very few girls in early marriages in developing

countries have access to contraception; nor would delayed pregnancy necessarily be

acceptable to many husbands and in-laws. Indeed, in many societies, childbearing

soon after marriage is integral to a woman’s social status. The risks of early
 33

pregnancy and childbirth are well documented: increased risk of dying, increased

risk of premature labor, complications during delivery, low birth-weight, and a

higher chance that the newborn will not survive. Pregnancy-related deaths are the

leading cause of mortality for 15-19 year-old girls worldwide (UNICIEF, 2001).

Table 2 reflects that majority of mothers were illiterate (43%), 32% has passed

primary class, 10% were middle passed while just 5% were matriculate. And only

10% were more than matric up to MSc level. It shows that community awareness

about mother child health can not be improved easily.

4.1: Current Pattern of Infant Mortality in Socio-economic and Demographic

Perspective

Table 1. Age Distribution of mother when she married

Age Frequency Percentage

Less than 18 11 27
18-25 13 33
25-35 11 28
More than 35 5 12
TOTAL 40 100

Table 2. Distribution of the Educational Background of mothers

Education Frequency Percentage

Illiterate 17 43
 34

Primary 13 32
Middle 4 10
Matric 2 5
Up to MSc 4 10
Total 40 100
Table 3. Distribution of the educational background of fathers

Education Frequency Percentage

Illiterate 14 36
Primary 9 23
Middle 9 23
Matric 5 10
Up to MSc 3 8
Total 22 100

Table 4. Distribution of family pattern of respondents

Origin Frequency Percentage

Joint 22 55
Extended 11 27
Nuclear 7 18
Total 40 100

Table 5. Distribution of numbers of children living with you

 35

No. of children Frequency Percentage

1 5 10
2 11 21
3-5 19 59
5+ 5 10
Total 40 100

Table 6. Distribution of parent’s jobs according to their sex

Parents job Frequency Percentage

Only father 28 70
Only mother 3 7
Both 9 23
total 40 100

Table 3 reflects that educational background of the fathers is also not

satisfactory that is always a major potential threat for the reproductive health. Data

from the field shows that majority (36%) of respondents was illiterate, 23% were

primary passed and same (23%) were middle class passed. A few (10%) were

matriculate while higher level education was too low (8%). In such situation where
 36

parental educational is so low obviously it increases the chances of infant mortality

due to lack of proper knowledge about reproductive health.

Table 4 shows that majority (55%) of respondants were living in joint families

and 27% were in extended families while a few (18%) were in nuclear family

pattern.

Table 5 shows that majority (59%) of the families had children in the range

of 3-5 and there were families (10%) who had more than 5 children. Only 21%

families had 2 children and 10% were with single child but as it was noted from the

field they were newly married and still they were interested in few more children.

Now it can be evaluated that in poor rural areas where literacy is low, larger size of

family can be major threat for infant mortality as you can not afford the proper

health facilities for all children.

Table 7. Distribution of mother’s occupation

 37

Mother’s occupation Frequency Percentage

Professional 4 10

House wife 28 70
Labor and others 8 20
Total 40 100

Table 8. Distribution of monthly income of household

Monthly Income (Rs) Frequency Percentage

Up to 5000 5 12
5000-10000 20 50
10000-15000 8 20
More than 15000 7 18
Total 40 100

Table 6 reflects that main earner (70%) of the households are father wile

mothers are normally not allowed for jobs as it is cultural norms of the society.as

change is coming in rural areas too due to modernization and increasing poverty

level. It can be noted that 25% of the families both spouses were earning for their

families. There were also female headed households (7%) where mother was sole

earner.
 38

Table 7 shows that majority (70%) of the mothers was house wife, 20% were

involved in labor and just 4% were in professional occupation. This table clearly

indicates the females have less exposure and authority in society than men that can

trigger the infant mortality.

It is clear from table 8 that majority (50%) of respondent belong to lower

economic class (5000-10000 Rs), 20% were earning 10000-15000 Rs /month and

12% living in hand to mouth as their monthly income was up to 5000 only. While

18% of the respondents were living in relatively good position as their monthly

income was more than 15,000 Rs. It can be concluded that overall scenario of their

economic conditions is not good at all. Due to poverty they can not afford utilization

of costly health services so infant mortality rate is high in the area.

Table 9. Distribution of the No. of dead infant in last 10 years according to

their sex

Dead infants Frequency Percentage

Males 21 44
Females 26 56
Total 47 100

Table 10. Distribution of the ages of infant at death

 39

Ages Frequency Percentage

Prenatal (1 week) 17 44
1 Month (Neonatal) 11 28
3 Months (Post n a t a l ) 7 18
Infant (1year) 5 10
Total 40 100

Table 9 shows that majority (56%) of dead infant were females while male

infants were also in great in numbers 27%. As it has been discussed in chapter 2 that

infant mortality rate is always higher in female infants due to son preference and

gender discrimination.

Table 10 describes that death rate is very high (44%) among prenatal l (1st

week) while it is lower (28%) in natals ( 1st month). Mortality rate among postnatals(

up to 3 months) is 18% and 10% in the infants (3-12 months).It is clear from above

data that the more lethal time period for an infant is first three months. There is need

to adopt serious precautionary measures in this time period.

 40

Table 11 shows that 90% mothers were exposed to TV, 15 % have

also arability of radio and 7% were exposed to newspaper and 11% has also touched

with other sources too. In spite of the media exposure, awareness about mother-child

health was not satisfactory. Reason for that was that they were not utilizing it for the

purpose of information but they were using it for the purpose of entertainment.as it

was noted in the field that whenever commercials of family planning ran they

change the channels or engaged in other households works. So there was need to

adopt other measures to educate them about the reproductive health.

4.2. Assessment of the Knowledge and attitude towards safe motherhood

Table 11. Distribution of media habits in mothers

Media Habits Percentage

TV 90%
Radio 15%
Newspaper 7%
Any other sources 11%

Table 12. Distribution of perception of mothers about diarrhea for infant

 41

Diarrhea is Dangerous Frequency Percentage

Yes 12 30
No 16 40
To some extent 12 30
Total 40 100

Table 13. Distribution of number of visits to health service

No. of Visits Frequency Percentage

Once a week 1 3
After 2 weeks 4 10
Once in month 8 20
Only in serious problem 27 67
Total 40 100

Table 14. Distribution of Use of boiled water

Boiled Water Frequency Percentage

Yes 4 10
No 10 25
Not always 26 65
total 22 100
 42

Table 12 provides the perception of the mothers about seriousness of

diarrhea. As it has been discussed in chapter 2 that diarrhea is most killer for

children in the world but majority (40%) of the mothers were not perceiving it

dangerous at all and 30% replied the it is not so much dangerous. Only 309% were

awarded of deadly consequences of this disease. In such situation, there is need to

address social cultural determinants that are deeply rooted in the perception so that

we can combat the infant mortality issue.

Table 13 evaluates the health seeking behaviors of the mothers. It can be

noted the majority (67%) of the mothers were going to health providers only in

serious complications while only 20% were going monthly and just 10% were

going after 15 days. Only 1 respondent was going to basic health unit weakly due

to a relative, working there. It is obvious that such situation can worsen the infant

health where people like to visit the facility in critical situations.

Table 14 reflects that majority (65%) of the respondents were not always

using boiled water for their infant, only 10% mother were using boiled water while

25% were totally using unboiled water. This is pure lack of awareness which was

causing gastro-intestinal diseases that’s why diarrhea was common in the area.
 43

Table 15. Distribution of complications during pregnancy

Pregnancy Complications Percentage

Spotting (slight vaginal bleeding) 79%
Blurring of vision 76%
Unconsciousness 74%
High blood pressure 55%
Severe abdominal pain 54%
Swelling in face 38%
Severe vomiting 32%
High fever with 26%
Fits or Convulsions 6%
Jaundice 8%

Table 16. Distribution of vaccination course completed during life of infants

Vaccination Frequency Percentage

Full 8 20
Few time 26 65
No 6 15
Total 40 100

Table 17. Distribution of local perception about prevalence of disease in last 10

years

Common Diseases Frequency

Diarrhea 73%
Malaria 56%
Allergy 39%
Typhoid 34%
Measles 23%
Jaundice 17%
Total 40
 44

Table 18. Distribution of visit to health providers

Facilities/Service providers Frequency Percentage

Community Midwife 3 7
BHU/RHC 15 38
DHQ 11 27
Private hospital 2 5
LHW/LHV 9 22
Total 40 100

Table 15 provides the Pregnancy Complications most common among the

mothers that shows that conditions of motherhood. Majority of mothers reported

(79%, 76% and 74%) the complications like, spotting (slight vaginal bleeding),

blurring of vision and unconsciousness respectively. Complications like, abdominal

pain (54%), swelling of face (38%), severe vomiting (32%) and high fever (26%)

were so common and were major threat for mother-child health care. While fits

(6%) and jaundice (8%) were also reported. This is the overall scenario of

miserable conditions of a pregnant female that’s why maternal mortality rate is

highest in the chakwal district from whole country.

Table 16 describes that community people are not interested in long term

vaccination programs that is the reason majority (65%) of the families did not

complete the vaccine course for infants while 15% has not been vaccinated at all

among them few were died in first month. Just 20% of infants were fully

vaccinated in last 10 years but still they died.

 45

Table 17 reflects that epidemiological scenario of the study areas. Most

common diseases were diarrhea (73%), malaria (56%), allergy (39%), typhoid

(34%), measles (23%) and jaundice (17%). Although there were ecological

determinants of diseases were noted in the areas but there were a lot of

sociocultural factors that were responsible of diseases that will be discussed at the

end of this chapter.

Table 19. Distribution of animals in the courtyard

Animals in the Courtyard Frequency Percentage

Yes 27 68
No 13 32
Total 40 100

4.2: Patterns of Births Preparedness and New-born Care those have a Potential

Threat for Infant Mortality

Table 20. Distribution of place of delivery

 46
Place of Delivery Frequency Percentage
Midwife 25 64
BHU/RHC 5 12
DHQ 3 7
Private doctor 2 5
LHW/LHV 5 12
Total 40 100

Table 18 describes the health seeking behaviors of the community. Most of

the mothers (38%) go to BHU, 27% go to DHQ, and 22% go to LHV/LHW, 7% go

to midwife for home medicines and 5 % access the private hospitals. But as it has

been discussed in the table 13 that majority of the respondents consult the health

providers only in critical situations that’s why infant mortality was high in the area.

Table 19 depicts a sketch of rural agricultural community who keep animals

in their courtyards.it can be noted that majority (68%) of local were keeping their

animals in the courtyards where all family is involved in the household activities

and children were playing there too. One can easily imagine the hygiene of the

household in such environment. Only 32% of the respondents have not animals in

their courtyards but as noted in fieldwork their hygienic conditions were not

satisfactory. That’s why diseases like; malaria and diarrhea were common in the

area (table 17).

 47

Table 20 reflects that majority (64%) of women were accessing the midwife

for delivery in the own or her home, depends upon the situation and domestic

norms. A small number (12%, 12%) were going to BHU/RHC and LHV/LHW for

the delivery respectively. While 7% were going to DHQ as it was 10km from

village and transport is not available always and 5% of the respondents were going

to private hospitals.

Table 21. Distribution of No. of outcome of pregnancy

Pregnancy Outcome Frequency Percentage

Live birth 22 55
Still birth 8 20

Abortion 10 25
Total 40 100

Table 22. Distribution of mode of delivery

 48
Mode of Delivery Frequency Percentage
Normal vaginal delivery 25 62
13 32
Assisted vaginal delivery

Caesarean section 2 6

Total 40 100

Table 23. Distribution of surface for delivery

Surface for Delivery Frequency Percentage

cloth 15 38
Floor 13 33
Chatai 10 25
Others 2 5
Total 40 100
 49

Table 24. Distribution danger signs in postpartum period

Postpartum Period Frequency Percentage

High fever 13 33
Excessive vaginal bleeding 11 27
Unconsciousness 8 20
Fits or Convulsions 2 5
Prolapsed uterus 2 5
Total 40 100

Table 21 shows that majority (55%) of the respondents reported the out

outcome of pregnancy was live birth while 20% reported still birth. Abortions

(25%) as outcome of pregnancy were also in considerable numbers.

Table 22 shows that majority of delivery was normal, 32% of the vaginal

deliveries were assisted and 6% were caesarean deliveries. Even in normal

 50

deliveries many postpartum complication were noted from field that will be

discussed later.

Table 23 shows that surface of the delivery was different in different

cases and situations. Cloth (38%), floor (33) and chatai (25%) were used in most of

the cases while 2% of the deliveries used other means for delivery. Unhygienic

surface was reported for delivery that spread the infections.

Table 24 explains the common danger signs reported in postpartum period

in the mothers after delivery. The most common signs were high fever (33%),

excessive vaginal bleeding (27), unconsciousness (20%), fits (5%) and prolapsed

uterus (5%). It can be concluded that if a mother is in such a critical conditions in

poor and rural community where awareness is also low and gender discriminations

Table 25. Distribution of danger signs in newborns

 51

Danger Signs In Newborns Percentage

Baby is very cold/shivering 42%

Blue skin color 37%

Difficult breathing 22%

Fever/High fever 21%

Skin lesion 20%

Yellow skin color (Jaundice) 17%

Red swollen eyes 10%

Fits/Abnormal/Jerky movement 8%

Unable to suck/poor sucking 8%

Baby won’t cry/weak cry 7%

Table 26. Distribution of main reason that you choose this care provider for

conducting delivery
 52

Main Reasons Frequency Percentage

Family choice 18 45

Low cost 12 30

Nearby 8 20

More knowledgeable 2 5

Total 40 100

Table 27. Distribution of decision to seek health care

Decision-making Frequency Percentage

Midwife/ Dai 18 45

Husband 13 33
In-laws 5 12
Myself 4 10
Total 40 100

is high what will be consequences for infant? Obviously such situation triggers the

infant mortality rate.

 53

Table 25 shows that most dangers signs reported newborns who became the

victim of death in last 10 years. These danger signs include; shivering (42%), blue

skin (37%), respiratory problem (22%), high fever (21%), skin leision (20%),

yellow skin/jaundice (17%), red eyes (10%), poor suck (8%) fits and abnormality

(8%), no or poor cry (7%).

Table 26 indicates the reasons to choose health provider. It can

noted that majority (45%) of the women relied on their family and 30% of the

respondents preferred low cast, 20 % preferred short distance of facility and just 5 %

considered knowledge of care provider for the conducting delivery.

Table 27 the autonomy of women to seek health facility. It can be

noted only 10 % decided at their own, Majority (45%) of the mothers are guided by

midwife, 33% followed their husbands in such situations while other (12%) relied

on their in-laws.

Table 28. Distribution of time period of breastfeeding for infants

 54
Breastfeeding Frequency Percentage
No 5 12
Up to 3 months 2 5
3-6 months 4 10
Up to 1 year 12 30
1-2 year 17 43
Total 40 100

Table 29. Distribution of first time start of breast-feeding

Started Breast-feeding Frequency Percentage

Within 1 hour 1 3
1-3 1 3
3-6 5 14
6-12 12 34
More than 12 16 46
Total 35 100

Table 30. Distribution of time period of infant when he was kept naked after

birth

Frequency Percentage
Naked after birth ( minutes)

Up to 10 7 18
10-20 12 30
20-45 21 42
Total 40 100
 55

Table 31. Distribution of type of cloth was used to wrap infant after birth

Type of Cloth Frequency Percentage

6 15
Towel/blanket
24 60
Old cloth
10 25
New cloth
Total 40 100

Table 28 reflects the decreasing trends of breast feeding even in

rural community. It can be noted that only 43% of infants were feeded from 1-2

years, 30% were brest feeded from6-12 months and 10% of the mothers breast

feeded their infants from 3-6 months. While 5% of these just breast feeded their

infant up to 3 months and 12% of these did not involve in breast feeding due to

insufficiency of milk or poor sucking.

Table 29 shows the first time initiation of breast-feeding. It shows majority

(46%, 34%, 14%) of the mothers started breast-feeding very late. i.e., more than 12

hours, 6-12 hours and 3-6 hours respectively. Only 3% started breast-feeding

within 1 hour while 3% also started 1-3 hours later. Such delays become very lethal
 56

for infants where they are not vaccinated completely and living in poor and

unhygienic conditions as it has been discussed in chapter 2.

Table 30 provides the information about the time period in that baby has

been kept naked. Majority (42%) of the infants were kept naked 20-45 minutes and

30% were kept naked 10-20 minutes while 18% were covered within 10 minutes. It

can be also noted from table 24 this long duration for the baby leads to shivering

(42%) of the infants.

Table 32. Distribution of the weight of infant at birth

Weight Frequency Percentage

Normal 15 38
Less 19 47
More 6 15
Total 40 100

Table 33. Distribution of the size of infant at birth

 57

Size Frequency Percentage

Normal 17 43
Shorter 17 42
Taller 6 15
Total 40 100

Table 31 indicates the distribution of types of the cloth that was used to

wrap the infant after birth. Majority (60%) of infants was wrapped in old cloths and

25% were covered by new cloths. While blanket and towel were used for 15% of

the infant. All the health personals question the hygiene of the old cloths that is

always polluted with germs and can spread infections and it is also discussed in

table 24, there were a lot of cases of skin problems in infants.

Table 32 shows that majority (47%) of infants were perceived week due to

under-weight, 38% were considered as normal while 15% were over-weighted. It

was noted from field observation that malnutrion was common in the mothers and

children. Black spot under eyes were clearly visible in mothers.

 58

Table 33 shows that majority (42%) of infants were perceived shorter, 43%

were considered as normal while 15% were taller.

Table 34 depicts that majority of the families used ghutti as first food for

infants, only 5% of the mothers provided colostrum. While animal milk (23%) and

formula milk (5%) were also used as first food for infant.

Table 34. Distribution of first food of newborn

First Food of Newborn Frequency Percentage

31 77
Ghutti

2 5
Colostrum

9 23
Animal milk

Formula milk 2 5
Total 40 100

Table 35. Distribution for rejection of the of colostrum

Rejection of Colostrum Frequency Percentage

Elders didn’t allow 23 57
It is dirty 9 23
6 15
Harmful to child
4 10
Child didn’t suck
Total 40 100
 59

Table 36. Distribution for first medical examination after birth

1st Medical Examined Frequency Percentage

Same day 3 8
1 weak 6 15
1 month 11 27
Only in seriousness 20 50
Total 40 100

Table 37. Distribution of advices for new-born after examination

Advices Frequency Percentage

Keep the baby warm 13 32
Breastfeeding 11 27
Immunization 9 23
Colostrum 5 13
2 5
Danger signs
Total 40 100

Table 35 reflects the reason to reject colostrum. Majority (57%) of

respondents did not use it because elders were not in favor of it, 23 % of the mothers

thought it dirty and 15% rejected due to its harmful impacts for infant. While 10%

of the mothers complained that at time their infant could not able to suck it.
 60

Table 36 reflects that only 8% of infants were provided by medical care on

first day, 15% were provided with medical care in first week and 27 % were taken

for medical examination within first month. Majority of infants were taken to

health providers in only critical situations.

Table 37 describes the responses of health service providers advices for the

infant after medical examination. Majority of the infants were advised to keep them

warm, 27% were asked for breast-feeding and 23 % were referred for

immunization. While 13% of the infants were advised for colostrum. Danger signs

(5%) were also present in the few infants also.

Table 38 describes the major causes of infant death in last 10 years as told

by victim families. Among these killers, diarrhea (35%) and pneumonia (30%)

were most common. While respiratory infections (10%), typhoid (2%) and other

(5%) also reported. There are also families who believe on superstitious believes

like, evil eyes (18%) for cause of death for their infants.

Table 38. Distribution of perceived cause of death

 61

Cause of Death Frequency Percentage

Diarrhea 14 35
Pneumonia 12 30
Evil eyes 7 18
Respiratory infection 4 10
Typhoid 1 2
2 5
Others
Total 40 100

Table 39. Distribution of perception about less breast-feeding during her

disease

Less Breast-feeding during Disease Frequency Percentage

Yes 26 65
No 6 15
Don’t Know 8 20
Total 40 100

Table 40. Distribution of type of feeding

Type of Feeding Frequency Percentage

Bottle feeding 5 12
Breast feeding 11 27
Both 24 61
Total 40 100

Table 41. Distribution of Sources of drinking water

 62

Sources of Water Frequency Percentage

Open Wells 27 68
Hand pump 4 10
Electric motor 9 22
Total 40 100

Table 39 shows that majority (65) of the mothers were in the favor of less

breast-feeding during her disease as it could further weakened him only 15%

denied this assumption. While 20% of the mothers replied that they don’t know.

This lack of medical knowledge about health and crude cultural practices fuel up

infant mortality rate.

Table 40 provides the information about type feeding given to the

infants. Infants were feeded by breast (27%) and bottle (12%) too. Majority (61%)

of the mother were feeding their infants by both means.as we have discussed in

chapter 2 imbalance mixture of formula milk can also leads to infant mortality

through diarrhea.
 63

Table 41 discusses the sources of water for households. It is noted from

field that that most of the village water is saline and women go to fetch the water

from open wells (68%) with sweat water, at far off place that is in unhygienic

condition and potential threat for gastro-intestinal diseases. Use of domestic electric

motors (22%) and hand pump (10%) also present there. But as it has been noted by

researcher personal and domestic hygiene was not satisfactory at all.

Table 42. Distribution of preceding birth interval

Preceding Birth Interval Frequency Percentage

24+ months 11 27
1st birth 11 27
Less than 24 months 18 46
Total 40 100

Table 43. Distribution of types of latrine

Types of latrine Frequency Percentage

Unhygienic toilet 22 77
Hygienic toilet 9 23
Open areas 9 23
Total 40 100
 64

Table 42 shows that majority (46%) of the parents do not care for 2 years

break in pregnancy while 70% of the families has 3-5 children as it has been

discussed in table 5. 0nly 27% 0f parents has birth interval more than 2 years while

27% of mothers have experienced first time of birth we can not predict their

fertility behavior to reduce the family size. Short birth interval and large family size

both can be a threat to mother-child health.

Table 43 describes the sketch of unhygienic environment. It was noted in

field too that children were playing courtyard with animals and hiding in

unhygienic latrine (23%) and only 23% toilets were hygienic. While 23% of the

families were using open areas for this purpose.

Table 44 explains the local perception about causes of diarrhea.

Cause of diarrhea was perceived by evil eye (27%), indigestible food by mother

(27%), unsuitable mother milk (18%), measles and hot food (13). It was shocking

that neither a single mother pointed out polluted water/ stuff or unhygienic

conditions can be responsible for diarrhea.

 65

Table 45 presents the incidence and prevalence of diarrhea in the study area.

Majority of the mothers reported this incidence from last 4-12 months, while 32%

Table 44. Distribution of Cause of diarrhea

Cause of diarrhea Frequency Percentage

Measles 6 15
Mother milk unsuitable 7 18
Hot food 5 13
Indigestible food by mother 11 27
Evil eye 11 27
Total 40 100

Table 45. Distribution of mothers about incidence of diarrhea

Incidence of Diarrhea Frequency Percentage

Past 2 weeks 6 16
Past 3 months 13 32
4-12 months 21 52
Total 40 100

of mothers reported this in last 3 months. While 16% of the mothers experienced

this disease in last 2 weeks. So it can be conclude that diarrhea is so common in the

area and there is totally lack of awareness as it has been discussed in the table 43.
 66

4.1. CONCLUSIONS

On the basis of findings, conclusions are depicted as follows:-

 67

It can be stated that different demographic and socio-economic factors are

primarily responsible for health and rearing of children. The determinants of infant

mortality are family size, family structure, gender discriminations, income of

household, education and knowledge of parents, mother health, availability and

quality of health services, access to these facilities, environmental factors such as

hygiene etc.

Most of the families of this poor agricultural community are living in joint

and extended families and family size is also larger. So due to poverty it is very

difficult to provide better health facilities to the infants because consultancy fee of

good doctors, medical tests and costly medicine are unaffordable a poor family so

they prefer home remedies and cheap and near facilities that can not improve health

standard of infants. In large families it is also impossible for an individual level

care of infants that overall becomes a major threat for infant life. Literacy rate of

parents, especially of mother is very low that is a big hazard for mother –child

health. We can not reduce infant mortality without educating the mothers who has

a key role in child rearing.

UNICEF pointed out that just over one in 10 Pakistani children die before

their first birth day. Rates are also highly differentiated according to class, region

and the rural urban divide. While in very poor families it is around 230 per 1000.
 68

Rural areas generally suffer more infant mortality than towns (UNICEF, 1992).

World Bank reported that infant mortality rates are much higher in families with

non-educated parents which is particularly pronounced for the mother’s education.

To him education is strongly correlated with the type of work. Infant mortality is

affected by individual, house hold and community characteristics. Individual

characteristics are the characteristics which are related to parents at marriage, at

first birth, education, income, occupation, and landownership and livestock assets

(World Bank, 1996).

In developing societies, like Pakistan, people still seek health care from the

traditional health care practitioners. This is a significant factor of poor mother-child

health status and high incidence of children mortality and morbidity. Majority of

the selected women (47.5%) delivered their baby under the supervision of

traditional birth attendants. Doctors only supervised 35% births. The dream of high

health status for all Pakistani can only be achieved when people have access to

modern health care system home. Population Report of the world fertility survey in

1985 reported that in 19 out 29 countries infant mortality rates were higher among

children born fourth or later, and in 25 of 29 countries infant mortality rates were

higher among children born seventh or later (Akhtar et al,. 2005).

Other factors such as birth intervals are very short in community while girls

are facing the problems of early marriages too due to increasing crimes and poverty

too. Females are not autonomous so their authorities don’t prefer the family
 69

planning techniques although few mothers were engaged in job but yet there is

another issue of social acceptance and she faced the discriminations by family too

that in turns threatens the infant health because she feels difficulty to manage time

for children with job..

Mahmood (1993) explained that mortality and health status cannot be

treated in isolation but it is related very intricately with some of the social

economic conditions. Economic aspects of illness may often over shadow the other

aspects of social component. Poor income may result in lower standard of living

which stands for inadequate food, shelter and recreational that adversely affects

health of family members. Above all, the cost of the medical care may put a family

under a heavy burden of debt, which may further deteriorate their living conditions.

Thus it may prove a vicious circle specifically for people with poor resources. The

significance of phenomena of infant mortality is hardly irrevocable for its socio-

economic and demographic implications. As infant mortality, in general is

considered to explanative of overall socio-economic development. The factors that

play an important role in the child health are education of mother, household

income, occupation of father, standard of living etc., and other demographic factors

such as age of mother at birth, birth interval and health care factors like medical

facilities and immunization.

 70

Breast feeding has so vital role in infant health but as it has been seen in

community this trend is declining and was replaced by bottle feeding which has

own hazard in poor and illiterate community. There was also norm that of ghutti as

first food for infant that delays the breast feeding up to many hours. It was also

noted that there were cultural barriers of rejecting colostrum and less breast feeding

during diseases like diarrhea. So it downs the immunity level of children with an

additional threat of malnutrition. Moreover most of the infant were not completely

vaccinated too. Gender discriminations (son preference, ignorance of females

especially in case of multiple birth and unwanted babies) are needed to be

addressed as it was noted that due to this factor infant mortality rate was higher in

girls.

Shamim and Waseem (2006) noted that bottle use is a public health issue in

poor and illiterate mothers of developing countries while, in Pakistan, laws are

enacted against its propagation. The attributes associated with increased bottle use

were mother’s older age, illiteracy and increased parity. It is used not only to give

milk but all other types of fluids e.g. water, tea, juice., etc. its adverse effects are

more profound in the under developed world due to limited economic resources,

lack of clean water, unhygienic surroundings and illiteracy amongst mothers. The

prevalence of unsuitable and/or low-quality bottles and teats further aggravate the

situation. The hazards include over dilution of milk with resultant malnutrition.
 71

There is increased susceptibly to diarrhea and other gastro-intestine infections, ear

infections, allergic tendency and dental caries. In Pakistan, the risk of infant

mortality was estimated to be 4.5 times higher in bottle fed babies as compared to

breast-fed. Many studies on infant feeding practices in Pakistan have found the

declining trend and decreased duration of exclusive breast-feeding. The breast milk

substitute should comprise of a precisely reconstituted formula or properly

sterilized fresh milk. The other important essentials are availability of fuel, clean

water, appropriate equipment and time for preparation, with preferably refrigeration

facilities. The left over milk in the bottle should be discarded; however, it is

observed that, in poor communities of Pakistan, the left over milk is often given for

subsequent feeds due to limited resources, which favors the growth of pathogens.

Mixed breast and bottle-feeding was found to be the most common practice in

infancy. This approximates the bottle-feeding pattern found in urban areas of

Bangladesh. Bottle use appeared to get more common as the age of infant

increased. Employed women have been found to use bottle more than housewives.

Mahmood (2002) concluded that infant and child mortality are also affected

by the sex of the child, and infants born to mothers who have lost a child are at

greater risk of dying during infancy. Breastfeeding has numerous bio-

demographic, social, and economic effects. It affects the health and nutritional

status of, both, the mother and child. The role of breastfeeding is very important in

the post-neonatal period. Health seeking behavior includes both, preventive and
 72

curative measures. Preventive measures include immunization against preventive

diseases such as tuberculosis, polio, measles, neonatal tetanus and smallpox,

whereas curative measures include the care and types of treatment undertaken for

specific conditions, both modern and traditional.

Common diseases in the areas were diarrhea, tetanus, respiratory

infections, measles, pneumonia, malaria and malnutrition but the most severe

threats were diarrhea and pneumonia. Illiteracy, poverty and unhygienic domestic

environment were major causes of diarrhea. Toilets were uncleaned, hands and

dress were dirty, animals were kept in courtyards, pots were kept uncovered,

inaccessibility of clean water and uses of unboiled water, these all were so

common. While crude cultural etiologies of diarrhea like hot food, evil eye, mother

milk as impropriate and perceiving it as not threating were also shocking and

needed to address. The other killer was pneumonia. Babies after birth were kept

naked for a long time for cultural norms and lacks of awareness while infant was

already was not vaccinated and breast feeded too so it leads to pneumonia.

WHO (2009) stated that, the most common causes of child mortality are

pneumonia, diarrhoea, malnutrition, malaria, and measles. All of these diseases are

linked to the socio-economic conditions of the children. “If you want to control
 73

these five killing elements, you have to alleviate poverty, reduce overcrowding,

decrease malnutrition, increase health education, and control environmental

pollution,” he said, and added that the management of these diseases required

multiple strategies including breastfeeding, clean water, sanitation, and

vaccinations. Diarrhea is a common cause of death in developing countries and the

second only to pneumonia as the cause of these deaths. In 2009, diarrhea was

estimated to have caused 1.1 million deaths in people aged 5 and over and 1.5

million deaths in children under the age of 5. In Pakistan, 4-5 million babies are

born every year. It is more prevalent in the developing world due, in large part, to

the lack of safe drinking water, sanitation and hygiene, as well as poorer overall

health and nutritional status. According to the latest available figures, an estimated

2.5 billion people lack improved sanitation facilities, and nearly one billion people

do not have access to safe drinking water. These unsanitary environments allow

diarrhea-causing pathogens to spread more easily. Improving unsanitary

environments alone, however, will not be enough as long as children continue to

remain susceptible to the disease and are not effectively treated once it begins.

Evidence has shown that children with poor health and nutritional status are more

vulnerable to serious infections like acute diarrhea and suffer multiple episodes

every year. At the same time, acute and prolonged diarrhea seriously exacerbates

poor health and malnutrition in children, creating a deadly cycle. Improvements in

access to safe water and adequate sanitation, along with the promotion of good

hygiene practices (particularly hand washing with soap), can help prevent
 74

childhood diarrhea. In fact, an estimated 88 per cent of diarrheal deaths worldwide

are attributable to unsafe water, inadequate sanitation and poor hygiene.

SUMMARY
 75

Children are the future builders of every nation. Children’s health can be

best examined in the light of the level of infant and child mortality prevailing in the

society and also it is the most important index of socioeconomic development. The

high level of infant mortality is an indication of discouraging socio-economic

development and along with the poor government commitment for improving

health status of its nation. Infant mortality is a worldwide phenomenon that has

attracted the attention of policy makers and program implementers. Pakistan has

also high infant mortality rate as more than one child die before their first birthday.

All the developing countries including Pakistan are making utmost effort to decline

the mortality rate among the mothers and children right from the pre-natal stage to

toddler stage.

This study was focused to explore the social and cultural determinants of

infant mortality in factors associated with infant survival in Pakistan in the domain

of medical sociology. The primary objectives were to explore current patterns of

infant mortality in socio-economic and demographic perspective, assess the

knowledge and attitude towards safe motherhood and to examine the patterns of

births preparedness and new-born care those have a potential threat for infant

mortality. Study was conducted in Waryamal village--rural area of district

Chakwal, situated in the north of city at the distance of 10 KM with a number of

143 households having an estimated population of 1270. A sample of 40

 76

respondents was selected from 143 households by using purposive sampling as it

was focused on only those households in which there were cases of infant mortality

in last 8-10 years. Data was collected by using interview schedule. Collected data

was analyzed statistically through Statistical Package for Social Sciences

(SPSS.13) and was presented in the tabulated form.

Different cause and factors play an important role in the infant mortality.

The basic reasons are illiteracy especially among mothers, early marriages, poverty

and non-availability of doctors band medicine at affordable rate. Mother-child care

was ignored. Both of they receive late medical treatment; this practice is very

dangerous because they lose body resistance. Malnutrition is already prevailing.

Avoidance of full vaccination and rejection of colostrum and delayed or less breast

feeding are very serious issues while bottle feeding has its own constraints.

Guidelines during pregnancy and delivery and after delivery are not followed.

Precautionary measures are not adopted for new born due to cultural norms that

further increase the risk of mortality

The most common causes of child mortality are pneumonia, diarrhoea,

malnutrition, malaria, and measles. All of these diseases are linked to the socio-

economic conditions of the children. These unsanitary environments allow

diarrhea-causing pathogens to spread more easily. Improving unsanitary

 77

environments alone, however, will not be enough as long as children continue to.

These killing elements can be control by alleviating poverty, reduction of

overcrowding, decreasing malnutrition, increasing health education, and controlling

environmental pollution.

In the end the researcher concludes that all determinates of infant mortality

are correlated with one another which are needed to address by applying multiple

strategies.

After observing the causes for the deterioration of the women

health and high infant deaths, it would be important to give some suggestions on

tentative solutions which can help to improve women status and lower infant

mortality.

1- Population consisted of only 143 households to represent 7,228,857

households in rural Punjab, Pakistan. This sample size may be inadequate

to provide consistent estimates of the effects of socio-economic and

demographic factors and may deprive the results from a wide range of

validity. It would have been preferable if the sample size could be larger.
 78

2- Purposive sampling technique was used to identify the required households as

there was no sampling frame for infant mortality and also there were not a great

number of cases so time period of last ten year infant mortality were uses to make a

sample of 40 households by purposive sampling while for generalization random

sampling is preferred.

3- Obviously there will be difference in determinants of infant mortality in present

time and 10 years ago. So study should be designed in up to last 3 year maximum

rather than last 10 years with an increase in sample size and expansion of study

areas.

4- Infant mortality should be understood in theoretical frame work that can add

bulk of conceptual knowledge in medical sociology and can serve the coming

generations of the whole world.

5- The education of women can improve the health of the entire family; therefore it

has also some role in controlling infant mortality. Many women might be able to

get more education if the parents are encouraged to educate not only their sons but

also their daughters. This is because in the long run these educated girls will

become mothers and so they will help to defeat infant mortality by bringing up their

children in good health.

 79

6- There is low nutrition in the rural areas due to unavailability of protein

and fruits and that the knowledge among the people is low. People especially in

the rural areas should be encouraged to start gardening around the

swamps. A campaign is much required in the rural areas at least for each

family to grow one tree of any fruit. This will be well implemented if water

supplies will also be close to home. Also nutrition education programs, even at

the clinics, however, have tended to focus on infants, children and pregnant mothers

rather than on women generally. The lessons should be changed to enable

women know that nutritious food is essential to them throughout their life.

5- It appears that some of the problems associated with infant mortality are
caused by after delivery complications. This is due to lack of after delivery
checkups. It is high time for the Ministry of Health to introduce postpartum
services for all women who give births not only for those with complications as
is the case now.

6- Low breast feeding among the more educated women is attributed to the short

maternity leave. Also working women are not allowed to go home to breast feed their

children during the working days. The maternity leave then should be increased from

the present three months to six months so as to allow mothers to fully breast feed

their children for at least four months. A policy should be formulated so that

working mothers should be allowed one hour everyday during working days to go
 80

home and breast feed until the child is one year old.

7- Provision of water is a pre-requisite to health. Improved water supply affects

child survival indirectly through decreasing the time for collecting water for the

households. More readily available water may also improve food production, child

care and allow more time for rest thus improving the nutritional status especially of

pregnant women. Water supply also leads to improvement in environmental

sanitation and personal hygiene. Garbage collection and the drainage system in the

village need attention as the sewage system is extremely poor. Besides that, a

campaign for environmental Sanitation and personal hygiene is required in the

villages. People should be encouraged to dig pits for domestic waste water and

garbage disposals and use them. The health officers should also visit the rural areas

to enforce sanitation and hygiene regulations.

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