Plateaued rate of decline in neonatal mortality rate is one of the major obstacles in achieving Millennium Development Goal-4 especially in developing countries. Even in India, nationwide interventions targeting safe mother and newborn care have not yielded the desired impact, indicating the necessity to combat neonatal mortality rate at population specific level. The objective of this study, in tribal area, is to identify the newborn care practices and beliefs, analyze their harmful or beneficial characteristics, describe the deviations from the essential newborn care practices during institutional and home delivery, explain barriers to care seeking and identify areas of potential resistance for behavior change; and essential newborn care practicesamong the eight different tribal communities. The study uses both qualitative and quantitative data from in-depth interview with mothers who had experienced neonatal and natal death, women who had done home delivery and key-informant interviews with healthcare personnel, traditional healers and the birth attendants. The study was conducted in eight groups of tribal communities and covered 400 households, which was consist 50 households from the each eight different communities, were purposively selected fromsixth number of panchayat in one block of Sundargarh district of Odisha, India. Key finding of this study is the less prevalent of modern health care practices of essential newborn care among all cases irrespective of place of delivery, majority of the mothers are practicing traditional herbal medico-system in child health care. Clustering of deaths in few households added significantly to the existing burden of neonatal deaths, attributed to superstition by tribal. Study has concluded that the introduction and implementation of essential newborn care at institutional and community/ household level are the need of the hour. Quality home based neonatal care through cost effective interventions is deemed necessary where accessing institutional care is not possible in the immediate term. Community health workers can contribute to the eradication of harmful newborn care practices and the sustenance of essential practices through community education and behavior change communication.

Globally, there has been a considerable decline in under- five and infant mortality during last four decades. However, neonatal mortality rates remain unchanged especially in developing countries [Tinker, A. 2005, Arulampalam, W. 2006]. It is estimated that each year around four million neonatal deaths occur almost exclusively in low income countries [Black, R.E., 2003]. In these countries, progress towards achieving Millennium Development Goal 4-“Reducing under-5 mortality from the 1990 baseline by two-thirds” is being hampered by slow progress in reducing the number of neonatal deaths [Bryce, J., Daelmans2015]. The neonatal period is only 1/60th of the first five years of life, but contributes 38 percent of the estimated 10.5 million underfive deaths occurring every year all over the world [Darmstadt, G.L.2005].

India is a home to more than half the world’s tribal population. Over 84 million people belonging to 698 communities are identified as members of Scheduled Tribes (ST) in India [1], constituting 8.2% of the total Indian population [2] which is four times larger than that of the population of Australia.

Scheduled Tribes are mainly the tribal population in India that the Government of India identifies as socially and economically backward and are in need of special protection from social injustice and exploitation. The Government of India identifies communities as scheduled tribes based on a community’s ‘primitive traits, distinctive culture, shyness with the public at large, geographical isolation and social and economic backwardness’, with substantial variations in each of these dimensions with respect to different scheduled tribe communities [3]. Through a constitutional mandate, formulated in 1950, scheduled tribes have been formally recognized as a distinct community in India affirmative action targeted at scheduled tribes [1], and their members are routinely enumerated in national surveys [5-7] and censuses. The proportion of scheduled tribes in the total Indian population has increased from 5.3% in 1951 to 8.2% in 2001 since their formal recognition in 1950. The concentration of scheduled tribes varies substantially across the Indian states.

Orissa, one of the most scenic state in eastern India, occupies a unique place in the tribal map of the country having largestnumber of tribal communities (62 tribes including 13 primitive tribes) with a population of 8.15 million constituting 22.3% of state’s population [2] and 9.7% of the total tribal population of the country. The recently conducted National Family Health Survey (NFHS-3, 2005-06) also shows that 21% of the total women sample populations of Orissa belong to scheduled tribe [8].

The Scheduled tribe population in the State is overwhelmingly rural, with 94.5% residing in villages. Out of 62 Scheduled tribes, Khond is the most populous tribe constituting 17.1% of the total ST population followed by Gond having 9.6% share in the total ST population (Census of India, 2001). Six other tribes namely, Santhal, Kolha, Munda, Saora, Shabar and Bhottada along with Khond and Gond constitute 64.2% of the total ST population of the State [9].

In India, government, bilateral and multilateral agencies have made several efforts in the area of maternal and child health welfare. The introduction of government schemes like Janani Suraksha Yojana, Chiranjeevi Scheme, Propagation of Emergency Obstetric Care (EmOC), Implementation of Integrated Management of Childhood and Neonatal Illness, POSHAN etc. has resulted in an increase in institutional delivery and decrease in infant and child mortality rates. But there is no significant difference in neonatal mortality rates, as evidenced by analysis of infant and child mortality rates over the past decadeprovides a comparison of neonatal, post-neonatal, infant, child and under five mortality rates from past three National Family Health Surveys (NFHS3, 2005-06). Even though the primary causes of neonatal deaths are estimated to be preterm birth (28 percent), severe infections (26 percent), birth asphyxia and injuries (23 percent), tetanus (seven percent), congenital anomalies (seven percent) and diarrhea (three percent), with Low Birth Weight contributing to large proportion of neonatal deaths; studies show evidence about contribution of care practices immediately following delivery to newborn’s risk of morbidity and mortality. Studies report that most newborns in low income countries like India die at home while they are cared by mothers, relatives, and traditional birth attendants.

In India, the practices of essential newborn care in tribal area are not studied comprehensively and hence relatively less knowledge exists about the influence of practiced traditional newborn care practices on newborn survival. Studies on newborn care in tribal communities shows that the knowledge and practice of basic newborn care for instance prevention of hypothermia, feeding of colostrums and exclusive breast-feeding are lacking; even awareness regarding care seeking on the identification of life-threatening signs has been found to be very low. Despite implementation of proven cost-effective solutions such as promoting antenatal tetanus toxoid immunization, skilled attendance during delivery, immediate and exclusive breast-feeding, and clean cord care; there has been relatively little change in neonatal mortality rate (NMR).

The World Health Organization recommends improving essential newborn care practices at birth in order to reduce neonatal morbidity and mortality. Effective promotion of essential newborn care at scale could significantly contribute to reducing the leading causes of newborn deaths in low incomecountries, especially those due to sepsis/pneumonia, preterm births and tetanus. The essential practices include clean cord care, thermal care, initiating breast-feeding immediately or within an hour after birth, skilled assistance at birth for resuscitation, care-seeking and extra care for sick and underweight babies. Two Lancet series, on newborn health and maternal health propose key evidence-based interventions and packages which, if implemented to scale, could greatly contribute to saving maternal and newborn lives in tribal communities. These interventions emphasize strengthening the continuum of maternal,newborn and child care during the antenatal, natal and postnatal phase.

Literature suggests that the challenge for reducing neonatal deaths in any developing country requires solutions through research to inform program innovation and action oriented policies designed to improve newborn health and increase their probability of survival. Implementation of an effective program for the promotion of childbirth and newborn care practices requires understanding of the community and household traditional newborn care practices. Such information will enable the development of programs which promote culturally sensitive and acceptable change in practices. Information about reasons for delivering at home, preference of traditional birth attendant for delivery and newborn care practices is still alive tribal and rural areas of India, which is necessary for healthcare planners to design health services.

The objective of this study is to describe the deviations from the essential newborn practices followed during institutional(hospital) and home delivery. Study also explores the tribal specific home based newborn care practices during the antenatal, intra-natal and postnatal care period and assesses its impact on the morbidities of neonate and hence the neonatal health outcomes. It also identifies the socio-demographic, antenatal and delivery care factors associated with these practices; along with understanding of care seeking behavior of mother and family members. This study by analyzing the newborn care practices in the tribal communities , study area of “Odisha” has made an attempt to recommend the desired interventions necessary for improving the newborn survival which are cost effective and which can be practiced by healthcare personnel irrespective of place of delivery.

Tribal healthcare status The health status of tribal populations is very poor and worst among the primitive tribes because of the isolation, remoteness and being largely unaffected by the developmental process going on in India. The Tribal communities are in general and primitive tribal groups in particular are highly disease prone. Because, they do not have access to basic healthcare facility. They are most exploited, neglected, and highly vulnerable to diseases with high degree of malnutrition, morbidity and mortality (Balgir, 2004). As a reason some of the special health problems are attributed to the Tribal communities, like:-

a) Due to extreme poverty, illiteracy, ignorance of causes of diseases, hostile environment, poor sanitation, lack of safe drinking water and blind beliefs etc.

b) The chief causes of high maternal mortality rate are found to be poor nutritional status, low hemoglobin (anaemic),unhygienic and primitive practices for parturition. Average calories as well as protein consumption is found a below the recommended level for the pregnant as well as lactating women.

c) Some of the preventable diseases such as tuberculosis, malaria, gastroenteritis, filariasis, measles, tetanus, whooping cough, skin diseases (scabies) etc. are also high among the tribal.

d) Due to some genetic origin reported to be occurring in the Indian tribal population are sickle-cell anaemia, thalassemia, glucose-6-phosphate dehydrogenize (G6PD) deficiency, etc.

e) There is no infrastructure for water, which is being fetched from far of streams which force them to curtail consumptions ultimately affecting the sanitation and hygiene.

f) Social barriers and taboos (cultural ethics and values) preventing on utilization of available healthcare services.

The present study was conducted in a six block of Sundargarh district of Odisha wherein the population constituted 85 percent of “Scheduled tribe” population. They have their own typical mode of thinking, feeling and common beliefs and attitudes, sentiments and ideals. As members of the scheduled tribes, they have distinctive social identities and face different forms of social and economic discrimination. Hence within this population and tribal entity, differences in dialect, health practices, unique customs, values and traditions are apparent.

Distribution of causes of neonatal deaths (samplingframe and sample).Workers and four birth attendants (out of which two weretrained birth attendants and other twowere untrainedbirth attendants).The data collection tool or questionnaire for in-depthinterview consists of two parts. First part has informationrelated to socio-economic, maternal, birth and deliveryrelated factors. The second section has information ofessential newborn practices followed during delivery,neonatal death history and traditional newborn care practices.

The questionnaire was framed for investigating neonatal deaths with added questions on socio-economic profile, maternal,pregnancy and child-birth factors. The instrument wasfurther adapted to local context and culture. The questionnairestarted with close ended questions followed byopen ended questions to elicit a narrative about neonate’sdeath. The researcher obtained an informed consent fromall the participants before conducting the interview. Thedata collection was done by researcher herself. During data collection, interviewswere conducted in Odisha using local tribal languadges.

Analysis of the in-depth interviews and Key Informant interviews was done using latent thematic content analysis. Transcripts were first read several times to get anoverall picture and then meaningful units were coded,condensed and categorized into broad themes [13]. Analysisis presented in different table and graphs which include analysisof current practice of various components of essentialnewborn care and traditional newborn care practicesduring the antenatal, natal and postnatal phase.

Neonatal deaths account for almost two-thirds of infant mortality worldwide; most deaths are preventable. Here the data signifies that two-thirds of neonatal deaths occurred during the first week of life, usually at home. The study reflects previously in tribal area have identified provider (dai) practices contributing to maternal mortality, none has focused on neonatal care. But the same practices still remaining in the tribal area, because lack of awareness and poor health consciousness still they are lagging behind the society. This study identified antenatal advice of birth attendants to mother about neonatal care and routineintra-partum and post-partum practices. While mothers usually received antennal care from physicians, but those who do not able to avail, they prefers to traditional birth attendants (Dai) conducted most deliveries.

The study observed, routine practices included handwashing by attendants, sterile cord-cutting, prompt wrapping of newborns, and postnatal home visits are very rare among the Dai. Suboptimal practices included lack of disinfection of delivery instruments, unhygienic cord care, lack of weighing of newborns,and lack of administration of eye prophylaxis or vitamin K. Onethird of complicated deliveries occurred at home, commonly attended by relatives, husbands, mother-in-laws etc., and the umbilical cord was frequently pulled to hasten delivery of the placenta. In facilities mothers reported (explain) frequent use of forceps, and asphyxiated neonates were often hung upside-down during resuscitation. Consequently, high rates of birth injuries were reported by the tribal households (Table 3).

The Table 3 highlights the various reason are inter-relatedand these factors responsible for child mortality. The 11.9 percent children are either premature or low in weight at birth. The 9.52percent of cases were found in birth injuries. While 1.19percent children suffer from acute respiratory infection (ARI), the 4.76percent suffered from cord-infection, the 9.52percent had congenital malformation and neonatal infection, the 8.33percentsuffered from birth asphyxia trauma complex, the 2.58 percent suffered from diarrhea , the 3.57 percent from jaundice, the 2.38 percent are affected by typhoid , the 11.90 percent from pneumonia, 3.57 percent were not able to suck mother’s milk and 30.95 percent had other unclassified neonatal deaths. These reasons are obvious, some are classified by the parents of children and most of the diseases are unclassified. The study reflects that, if there is a facilities of medical institutions then these problems are reduced in tribal area.

One area where traditional practices seems healthy is breast feeding. Almost all mothers breast fed their infants and use of formula was minimal. Moreover, in tribal families 57.00percent of babies had been fed in the first hour, considerably more than the43percent described in another study. This positive finding has implications for nutrition, prevention of infection, and thermal control and should be supported wholeheartedly. Prelacteals were given to less than 46percent of infants. (Table 4)

The Table4 showsthe practices of breast feeding of the tribal households considered for the research. It reflects that around 57.0percent of respondents started feeding within hours after birth, 21.0percent gave the squeezed first milk of the mother, whereas 10.5percent of them fed the baby with mother’s milk after more than two hours of birth. On the other-hand, 4.5percent started giving mother’s milk one day after the birth of the newborn due to some traditional customs. The reason for not giving the first milk to the babies is simply, because they perceived that the first milk of mother is unhygienic and impure. For this, they squeeze out the colostrums milk and only after that women areallowed to feed a child. While 3.5percent of the respondents failed to feed the babies due to some problems related to mother’s health. The 3.5percent started breast feeding, but the babies were not taking breast milk. Overall, the data shows how the family practiced the traditional faiths and customs. However, the data signals the level of awareness among the women, the communities and the localities. (Table 4)

Table 4 illustrates the birth practices of the eight tribal communities. It shows the types of instruments used by the communities for cutting the umbilical cord during deliveries. While 7.3 percent of the households used sickle for cutting the cord of child, the 10.8 percent used knifes. Use of other instruments are as follows: 5.0 percent respondents used bamboo-sticks, whereas 17.5percent of the households used arrow-head, the 9.3percent of the households used old-blade, and only 1.0 percent of the respondents used new-blade. At homes, however, birth attendees used unsafe materials for cutting the umbilical cord as well they are not skilled person. (Table 5)

Different types of materials are used after birth of child, for tying the cord after cutting umbilical cord in home deliveries. The data states, practically the untrained dai or other family members those who conducted delivery at home have the less knowledge regarding to safe-birth practices. As reason, 10.0 percent of the respondents had used threads after cutting the umbilical cords of the babies, while 31.3 percent of the respondents explained that they used piece of cotton-cloth to tie-up the cord and the 9.5 percent of the respondents used shred to tie the cord after cutting the umbilical cord. The data reveals on 40.3 percent households were referred to for institutional deliveries. During home deliveries however, it has been noticed that traditional methods continue to be practiced. It had been observed here that after cutting the umbilical cord, the dai ties the cord with different materials.

The Table 6 has identified important information aboutnewborn care practices in tribal area that will assist in planning health interventions to change behavior. In terms of public health and population attributable risk, the findings suggest that some changes would be particularly beneficial. These include increasing skilled attendance at births, improving hygiene at delivery, reducing delays in wrapping the baby, and delaying bathing (Table 6).

The research observed that after the birth of baby, the dai used various types of traditional materials after cutting the umbilical cords of the newly born babies, which sometime leads to high child morbidity among the tribals. The findings observed that 6.5 percent of the respondents used ghee and turmeric on the umbilical cords. 3.0 percent of the respondents used cowdung, whereas 7.5 percent of the households are used green leaves (bhuneems) prescribed by traditional healers or untrained dais, and the 18.8 percent of the households are used mustered oil. From the data, it is found that around 51.00percent of the households are used unsafe materials after cutting the umbilical cords of the newly born babies. The research thus observed that the use of unsafe mechanisms, these tribal areas suffer from high morbidity and mortality rates. At the same time, it is worth noting that 49.0 percent of the respondents had access to medical institutions.

As like the better health, child immunization is most essential but those who had done hospital delivery they are only almost took first birth TT; and rest of the TT or Oral vaccine they cannot.

The reasons are obvious; in tribal area. Instead of that they had some blind faith on vaccination both mother and child;- they thought for women (the female fertile has reduce through injecting (TT injection) during the pregnancy), and for child health Vaccination not good because of injection child fall-in-sickimmediate etc. because of these reason they are not prefer child immunization. (Table 7).

The Table 7 evidently shows that the child immunization system of tribal communities. The data reveals that, those who had done institutional delivery, child[ren] (new-born baby) received 32.33percent of first birth- BCG, Hepatities-B1st and oral Polio vaccine. But gradually, it reduced on child immunization, like:-

On six weeks only 15.05 percent of children were received: - DPT-1st, Hepatities-B1st and oral polio vaccine

In ten weeks the 15.06 percent of children were received: - DPT-2nd dose, Oral polio vaccine and Hepatites-B1 dose.

In fourteen (14 weeks) weeks 13.65 percent of children were received: -DPT-3rd dose , Hepitites-B3rd dose and Oral polio vaccine.

In 9 months only 10.44percent of children were received Measles vaccine.

In 15-18 months only 8.43percent of children were received MMR and Oral polio vaccine.

And in 2-5years of age only 5.02percent of children received Typhoid vaccine.

Here the evidence speaks, though the institutional deliveries done in rural tribal area but still in this backward-zone the families are unaware about child- immunization. The data in Table 7 states, out of 32.33percent of child immunization was done during her first birth- life but gradually it reduces very fast till 5years of age only 5.02percent of children are fully immunized. These circumstances address that, because of poor income, poor health awareness, poor education etc. found more infant mortality and maternal mortality

The poor literacy coupled with non-exposure to mass media was apparent on early age of childbearing among the tribal women of Orissa. Our findings show that a higher proportion of tribal women of Orissa are in the higher birth order (4+) and desire more children after having four living children. The possible reason for this high desire for children could be high infant and child mortality among the tribal population in India [22], which is largely due to lack of health care and poor condition of water andsanitation. Maternal health care is an important aspect of health seeking behavior, which is largely neglected among the tribal women of Orissa [24]. At the same time contraceptive use among this group is quite low. Use of modern methods of contraception is significantly less among the tribal women in India [30] and thus unintended pregnancies are quite high among the tribal women [31].

Malnutrition as expected is the most common health problems among tribal women of Orissa as in other tribal population of India [19, 23, 32-33]. Generally, tribal diets are seen to be deficient in protein, iron, iodine and vitamins [34]. A comparative analysis of nutritional status of within different tribal communities of women shows poor pattern of consumption of some important and specific food items except green leafy vegetables. The effect of nutritional deficiency is visible on the women’s health also as we found a substantially higher proportion of tribal women of Orissa are underweight as well as anemic.

Delay in deciding to seek care Food consumption pattern of Households: Markedly, the food consumption pattern of the households as shown in graph the majority of 40 percent households are able to afford normally one squire meal per-day but less than one squire meal occasionally. The 31percent of the households consumed less than one squire meal per-day for major part of the year. The 14.00 percent of the households consumed one squire meal perday throughout the year. Only 8.00 percent of the households affording enough food throughout the year. The 7.00 percent of the households affording two squire meal per-day with occasionally shortage.

In addition, the research found enormous differences among the eight tribal communities with respect to the mean expenditure on food and nutrition. The mean expenditure on food & nutrition value shows that the Oraom communities with 82.63 have high-value of mean, while the Lohara communities with 20.65 have a less - value of mean, and thereby, Lohara community can be considered as the most vulnerable within the group. Evidently, the overall study presents a very grim picture of the tribal households— how people fail to fulfill their basic needs for their sustainability;—they do not have enough food to eat, poor education status, with little or no access to drinking water and sanitation, poor income, poor health, etc. However, these indicators are basic requirements for every life. The research also observed that the inadequacy of food and nutrition leads to high malnutrition among women and children, high morbidity, high mortality, high drop-out, indebtness, etc. All these in turn reflect that acquiring nutritious foods, good education, more income, etc. remains a dream. Of course, overcoming acute forms of poverty remains a major challenge of all these indicators. (Graph 1)

The Food Consumption Index value (FCIV);- markedly, indicates the differences (values in parentheses) among the eight tribal groups: Bhuiya(20.0), Gond(21.14), Kissan(32.28), Kumbhar(14.28), Lohara(23.71), Munda(30.85), Kharia(26.85) and Oraom(51.14). (Table 2)

Of the 400 households, hospital births accounted for 58.5 percent, and home delivery were 40.3 percent and transit to facility is 1.3 percent. There is obvious, reasons are inter-relatedwith health and income, expenditure, education etc. The incidence of home delivered neonatal deaths was high among tribals families because of prevalent belief that hospital for deliveries should be accessed only in the absence of traditional birth attendant alias “Dai” or in instances of postpartum complications. Even among women who had accessed health facility for delivery, the reasons for preference of Institutional delivery were: quite touched with the main urban sector those who easily access to healthcare institutions. It was quite surprising to find that the mothers usually did prefer institutional delivery, but the decision was subdued by family members and Community health worker like ASHA and ANM. But this is the one way to reduce the infant mortality rate through the institutional delivery in tribal backward region. The grabh-2 depicts the infant mortality rate. (Graph 2)

The above graph presents the total number of infant death rate (Infant mortality rate-IMR) is 342.24 in the tribal area. There are different factors involved like environmental and nonenvironmental, which leads to high infant mortality rate in the tribal rural village area. The unhygienic birth practices by birth attendees and mother’s poor nutrition, various health hazards and unsafe drinking water, unavailability of medical institutions, etc., further add to the menace. The data shows that gender-wise, the neonatal deaths are affected more among the males, that is, the 8.3 percent and 6.3 percent of female children. While comparing to inter-community difference of infant mortality rate (IMR) the highest number found in Oraom community 800, and lowest in Gond community 133.33. The Infant Mortality Rate (IMR) in total 342.24, of the eight tribal communities significantly differs among the communities (values are shown in parentheses): Bhuiya community (161.29), Gond community (133.33), Kumbhar community (192.30), Kharia community (347.82), Kissan community (592.41), Lohara community (166.66), Munda community (437.5), and Oraom community (8000). While comparing with socio-economic status of eight tribal communities, the Oraom community possesses a good economic status rather than other seven communities. The data reveals that though the tribal households are slowly developing their economic status, on one hand; the other hand, they still remaining poor health strata. Because till today they believes on traditional herbal medicine for their good health rather than the scientific medical treatments. There is also another reason for high IMR in tribal area, that is poor health infrastructure, poor medical professionals as-well the low level of health consciousness among the people in remote area.

Ensuring universal access to skilled care is the accepted strategy to make childbirth and the early postnatal period safe for mother and newborn. Community based health workers have a major role to play in the eradication of harmful newborn care practices and the sustenance of good practices and also prove to be a link between families and health system. Emphasis for provision of essential newborn care at both health facility level as well as community/household level is required. Essential newborn care should start during pregnancy with Tetanus toxoid immunization, proper nutrition including iron/foliate supplements. The traditional child health care practices have to be curtailed in order to check infant death. The percentage of institutional delivery is very low as well as delivery being conducted by the trained health personnel. The home delivery and delivery being conducted by the traditional birth attendants and relatives be reduced immediately.

Our study demonstrated that, tribal women and children of Orissa were deprived of important aspects of health. The finding calls for urgent implementation of special health care strategies for reducing health and nutritional disparities among the tribal population of Orissa. The health of the tribal women will play an important role in shaping the future population scenario of the state because every fourth person in the state is a scheduled tribe.

The tribal people are largely staying in the far-flung and unreached areas. Moreover, the health care personnel are also not quite interested to serve in these difficult areas. The mobile and satellite health care services needed to be offered to these far lug tribal communities in order to check infant mortality rate. In conclusion we can say that while there are critical issues related to political and social marginalization that are central to improving the health and wealth of tribal populations in absolute terms. Our findings suggest that a focused approach to addressing inequalities in social and economic well-being within and between the tribal and non-tribal populations in Orissa would contribute to reducing health inequalities to a large extent.

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