Childbirth practices in rural Rajasthan, India: implications for neonatal health and survival.

In a rural community of Rajasthan in north India, we explored family, community and provider practices during labor and childbirth, which are likely to influence newborn health outcomes. A range of qualitative data-gathering methods was applied in two rural clusters of Udaipur district. This paper reports on the key findings from eight direct observations of labor and childbirth at home and in primary health facilities, as well as 10 focus group discussions, 18 case interviews with recently delivered women and 39 key informant interviews carried out within the community. Although most families preferred home delivery, health-facility deliveries were preferred for first births, especially among adolescents. A team of birth attendants led by a traditional birth attendant or an elder female relative took decisions and performed key functions during home childbirth. Modern providers were commonly invited to administer intramuscular oxytocin injections to hasten home delivery, whereas health staff tended to do the same during facility deliveries. The practice of applying forceful fundal pressure, stemming from overriding concern about the woman's inability to deliver spontaneously, was near universal in both situations. In both facilities and homes, monitoring of labor was largely restricted to repeated unhygienic vaginal examinations with little or no monitoring of fetal or maternal well-being. Babies born at home remained lying on the wet floor till the placenta was delivered. The cord was usually tied using available twine or ceremonial thread and cut using a new blade. In facility settings, drying and wrapping of the baby after birth was delayed and preparedness for resuscitation was minimal. Families believed in delaying breast-feeding till 3 days after birth, when they believed breast milk became available. Even hospital staff discharged the mother and newborn without efforts to initiate breast-feeding. A combination of traditional and modern practices, rooted in the concept of inducing heat to facilitate labor, occurred in both home and facility delivery settings. Programs to improve neonatal survival in such rural settings will need to invest both in strengthening primary health services provided during labor and delivery through training and monitoring, and in community promotion of improved newborn care practices.