Mothers’ Beliefs about Infant Care Practices in a South Indian Village:

The Role of Maternal Education in Child Survival

Pamela Rao, PhD Correspondence information: Pamela Rao, PhD

1514 17th St, NW, #212 Washington, DC 20036 Phone: 336-287-1189 E-mail: prao@inbox.com

Mothers’ Beliefs about Infant Care Practices in a South Indian Village:

The Role of Maternal Education in Child Survival

Infant and child mortality rates remain high in many parts of the world despite the existence of

inexpensive, easily implemented interventions. Maternal education has been linked with under-5

mortality rates, but the pathway of influence is unclear. I investigated the relationship between

maternal education and beliefs about survival-promoting reproductive and childcare practices.

Women, regardless of education, reported survival-promoting beliefs concerning practices

targeted by government health education programs, e.g., breastfeeding, immunizations.

However, better-educated women were more likely to report survival-promoting beliefs about

socioculturally or economically constrained practices, e.g., age at marriage, birth setting.

Alternative approaches are needed to influence socioculturally- and economically-moderated

beliefs and behaviors effecting child survival for less-educated mothers.

[child survival, human development, maternal education, childcare practices, India]

Acknowledgement

This project was funded by Grant No. 8584 from the Wenner-Gren Foundation for

Anthropological Research.

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Mothers’ Beliefs about Infant Care Practices in a South Indian Village:

The Role of Maternal Education in Child Survival

INTRODUCTION

Child survival, generally operationalized as the overall infant and child mortality

rates for a region for research and policy purposes, is considered a fundamental indicator

of the overall human development of a population (United Nations Development

Programme [UNDP], 2002). Infant mortality rates (IMR) are sensitive indicators of

socio-economic development, health conditions, and the status of women in a region

(Jain and Visaria, 1988a; Mahadevan, et al., 1985; Misra, et al., 1993; Singh, et al.,

1991). Despite impressive improvements in worldwide health measures, preventable

illnesses and “diseases of poverty” continue to contribute to the deaths of thousands of

children every day throughout the world. Yet many of these deaths could have easily

been prevented using existing interventions that are affordable and accessible even in

relatively resource-poor countries (Jones, et al., 2003; Bryce, et al., 2003; The Bellagio

Study Group, 2003).

Numerous research studies have been conducted worldwide to identify

determinants of infant and child survival at all levels, from the socio-political milieu to

household characteristics to individual behaviors (e.g., Mosley and Chen, 1984; Visaria,

et al., 1997; Scheper-Hughes, 1987). Maternal education has been identified in studies

around the world as the strongest predictor of child survival worldwide, even more so

than access to health care or father’s occupation. Although education may be only a

proxy for a straightforward socio-economic underpinning for child survival, other, more

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subtle, interactions between mother’s education and children’s health outcomes are being

pinpointed (Visaria, et al., 1997). A clearer understanding of the ways in which maternal

education influences child survival is necessary if this important finding is to lead to

reductions in infant and child mortality—a fundamental component of the development

initiatives of many countries.

The case of India deserves special attention because of its large population, which

magnifies the effect of the IMR beyond its rank in the world (Black, et al., 2003), as well

as the low educational and literacy attainment of large segments of the female population

(Government of India, 2004a, 2004b). Despite the implementation of a variety of child

health and women’s development initiatives, rates of infant and child mortality remain

unacceptably high in many parts of the country. The research upon which this paper is

based sought to identify pathways by which mother’s education influences child health in

India (Rao, 1999). This paper describes the results of a component of the study that

assessed the relationship of maternal educational attainment with variations in infant and

young child care practices known to influence child survival (Black, et al., 2003; Jansen,

et al., 1993; UNICEF, 1990).

Child Survival in India

Since gaining independence in 1947, a national goal of the Government of India

has been to improve the health status of its citizens (Jain and Visaria, 1988b). Substantial

research on child health issues has already been conducted, and government health care is

comparatively available and accessible. As a result, infant and child mortality rates

declined substantially during the last half century. The all-India IMR in 2001 was about

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67 per 1000 and the under-5 mortality rate was 93 (UNDP, 2003). IMRs for individual

Indian states ranged from 11 in Kerala to 90 in Orissa (Government of India, 2002).

These rates are high in comparison to the industrialized areas of the world, where IMRs

are below 4 per 1000 in northern Europe and Japan. However, they compare favorably

with IMRs in other less developed regions such as sub-Saharan Africa, where rates are as

high as 180 per 1000 live births. The situation is similar with India’s under-5 mortality

rates in comparison with rates from 3 to over 300 per 1000 worldwide (UNDP, 2003).

As in the rest of the world, mother’s education has emerged as a leading predictor

of child health outcomes influencing survival rates in India (Ashraf, 1990; Beenstock and

Sturdy, 1990; Daga and Daga, 1993; Das Gupta, 1990; Gandotra, et al., 1989; Goodburn,

et al., 1990; Kutty, 1989; Mahadevan, et al., 1985; Mukhopadhyay and Seymour, 1993;

Shariff, 1987; Ware, 1984). The National Family Health Survey of India shows

statistically significant differences in infant mortality based on mother‘s literacy status

(literate versus illiterate) even when adjusted for a variety of socioeconomic factors

(Pandey, 1998). A significant gender gap in educational attainment still exists in India

(Kingdon, 2002). Only 65 girls for every 100 boys were enrolled in secondary school

during 2001 (Government of India, 2004a) and the literacy rate was 75.3% for males as

opposed to 53.7% for females (Government of India, 2004b). These data point to an

important and useful point of convergence for child health and women’s development

interventions.

The Government of India’s Integrated Child Development Service (ICDS) is one

of the most extensive child survival and women’s development initiatives in the world

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(Tandon, 1997; Rattan, 1997a). Services such as preschool education, supplemental

nutrition for children and nursing mothers, and infant care training are offered by lay

health workers in more than 400,000 village service sites known as anganwadi centers

(Rattan, 1997a, 1997b). While the ICDS program’s successes have been somewhat

uneven, it has nonetheless produced many positive outcomes (Tandon, 1997), and it

remains an important component of the Government of India’s long-term development

program.

Refocusing Child Survival Research

Infant or child mortality rates are problematic as measures of unmet need for

infant health and well-being since in effect they represent lost opportunities to influence

outcomes (Jansen, et al., 1993). During the 1990 World Summit on Children, a set of

specific infant care factors were identified as having the greatest impact on child health

outcomes (United Nations Children’s Fund [UNICEF], 1990), including birth spacing,

childbirth practices, breastfeeding, immunizations, infant growth, and diarrheal disease

management. The Child-at-Risk Index (or CAR) was developed by researchers at WHO

in order to shift the focus on child survival research to these indicators that could be

assessed with respect to currently living children (Jansen, et al., 1993). Criteria for

inclusion in the index were:

… their usefulness in program management; a documented relationship to

mortality change; sensitivity to change over time and program

intervention; reliable measurement even with limited resources for

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monitoring and evaluation; and consistency with indicators used by other

donors and in terms of data collection methodology (Jansen, 1993:3).

The specific indicators and related measures are:

1. Birth order and spacing: A healthy reproductive pattern depends on a combination of

factors for both the mother and her children. A younger age at marriage implies a

younger age at first pregnancy, which is a risk factor for infant and child mortality, as

well as poorer health outcomes in surviving children (Mehra and Agrawal, 2004;

Phipps and Sowers, 2002). A belief in the likelihood of one or more children dying in

a family tends to result in larger family sizes, resulting in a decrease in the resources

and attention available per child in the family (Azuh, 1994).

2. Safe delivery care: In the CAR Index, safe delivery is defined by whether or not a

medically-trained person attended the birth. At issue is the proximity of or access to

an individual equipped to handle medical emergencies should they arise. Traditional

birth practices that increase the risk of neonatal tetanus, such as the application of

cow dung to the umbilicus, are still practiced by some non-medically trained birth

attendants. In India, the use of traditional birth attendants is common for economic

reasons (they are much less expensive), and because children are frequently born at

home rather than in a hospital or clinical setting.

3. Exclusive period of breastfeeding: The positive impact of breastfeeding for child

health and survival, particularly in developing countries, is well established.

Research has shown it to be protective against certain childhood illnesses such as ear

and respiratory infections (Bonuck, et al., 2002, Pugh, et al., 2002). In situations

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where the risk of contamination, spoilage or excessive dilution of formula is high, it

can reduce the risk of infection and undernutrition (Wilmoth and Elder, 1995; Rogers,

et al., 1997a, 1997b; Pugh, et al., 2002). Other benefits include suppressed fertility

(natural birth spacing), mother-child bonding, and financial savings to the household

(Wilmoth and Elder, 1995). Although colostrum is generally considered beneficial to

children’s health, in some developing countries it is customarily withheld, which

delays breastfeeding initiation for a day or more after birth (Rogers, et al., 1997a).

4. Diarrheal disease management: Diarrheal disease is an important cause of infant

mortality and morbidity, especially in areas with polluted water supplies, as is often

the case in crowded villages with limited sanitation facilities (Waterston, 2003).

However, while diarrheal disease can be difficult to avoid, it is easily managed with

oral rehydration therapy (ORT). Oral rehydration salt mixes are readily available

from anganwadi workers and Primary Health Centres. Because time is of the essence

in treating diarrhea, knowledge, access, and willingness to use ORT are important

factors in reducing mortality.

5. Immunization status: Immunization programs have been successful in reducing the

incidence of childhood illnesses worldwide and are believed to have eradicated some

such as smallpox (Greenough, 1995; Wright, 1995). In India, programs for

promoting the vaccination of children have been an integral part of all health care

delivery systems, including the ICDS program (Streefland, 1995).

6. Nutritional status: Determination of adequate growth is based on the international

reference population established by the National Center for Health Statistics and

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endorsed by the World Health Organization. Adequate weight gain depends upon,

among other variables, when supplemental nutrition is initiated and the types of food

that are introduced (Wilmoth and Elder, 1995; Rogers, et al., 1997b). Adequate

growth is crucial for proper physical and cognitive development, as well as for

reducing vulnerability to risks from a variety of environmental hazards (Engle, et al.,

1996).

THE STUDY: MATERNAL BELIEFS ABOUT INFANT CARE

This paper reports the results of one part of a larger research project to investigate

intracultural differences in beliefs about infant and early childhood care on the basis of

mother's educational level (Rao, 1999). Besides its identification as a crucial predictor of

child health outcomes, maternal educational attainment is a useful independent variable

for research purposes because it is more stable and measurable than most predictive

factors, such as prenatal care or nutritional status during pregnancy, or than

socioeconomic variables, such as income or caste. It is also more easily quantified than

literacy rates, which vary depending on definition. Furthermore, improving educational

levels of women in developing countries is a fundamental component of most human

development programs. The potential synergy from linking child survival and maternal

education initiatives further strengthens the case for including both in development plans.

Study Site

a village in southeastern India in the state of Andhra Pradesh (AP). Gramamu

(Telugu pseudonym, literally “village”), located in a coastal district of AP, was selected

because it is a typical ICDS village with a range of socioeconomic situations and at least

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some relatively well-educated women. It is a fairly large village by Indian standards,

with about 7,000 people living in around 1,400 households. Primary means of livelihood

include agricultural field work (principally rice and peanuts), handloom weaving (for

both export and domestic distribution) and fishing. Handloom weaving for export is the

village’s main source of income; the Padmasali weaver caste makes up the second largest

occupation group after hired farm labor.

In some respects, Gramamu might be considered a "forward" or economically

advantaged village: it has year-round bus connections to a significant town, a large

proportion of homes have electricity and access to clean water, and it has several primary

and high schools. However, it is classified as "backward," or disadvantaged, by the

Government of India because most of its inhabitants are engaged in low-paying

occupations or belong to castes traditionally considered disadvantaged, specifically the

Padmasali weavers, Jalari fishers, and Sri Yanadalu farm laborers. The various

caste/occupational groups live in segregated areas of the village, known locally as

colonies. Despite the presence of numerous educational facilities, rates of female

education are generally low in Gramamu. The lowest rates are found among the Jalari

fishers, who are also the most poor. The few educated women living in the Jalari areas

are married to schoolteachers or to other educated men brought in to work in the newly-

developing aquaculture (prawn) industry.

Sample Selection

A series of interviews were conducted with 130 mothers of children between the

ages of 12 and 72 months. The sampling frame was created by compiling a list of the

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households in the village from the records maintained by the anganwadi teachers, village

level health workers of the ICDS program. Anganwadi teachers are expected to conduct

a quarterly census of the households in their assigned areas of the village, during which

they record any changes (e.g., births, marriages) that have occurred during the previous

three months. Details on all homes were recorded on this list, including number and sex

of residents, caste, occupation of head of household, income, ages of all females who

might have children (of any age), and dates of birth of all children in the target range (up

to 72 months). Registered households that did not list any females who had attained

childbearing age were omitted from the compilation.

In this village of approximately 7,000 people, around 90 women had attended

between one and six years of school, approximately 60 had attended between six and ten

years, but only 20 mothers had been educated beyond the 10th standard. Because the

study was intended to focus on mothers with children in the child survival age group, the

sample was further limited to mothers with children between the ages of 12 and 72

months. After this additional eligibility criterion was applied, the result was a stratified

sample of approximately 30 mothers in each of the lower two educational categories.

Since there were so few mothers with more than ten years of education, all women who

were available were invited to participate regardless of whether they had children in the

target age range. The remaining 46 mothers, who never attended school, included

women from all eight colonies. The number of mothers recruited from each colony was

proportionate with the size of its population in the village as a whole.

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Data Collection

A questionnaire was developed with questions addressing the CAR variables by

asking about beliefs and attitudes towards child rearing issues relevant to each concept.

Each CAR variable was expanded into a set of questions that addressed various aspects in

order to understand how mothers conceptualize those aspects of child rearing most likely

to influence health outcomes. For example, questions were asked about practices

affecting weight-for-age, such as the age at which supplemental feeding should begin and

the types of foods that should be introduced. A list of the questions is provided in the

Appendix.

Date were collected over the course of two interviews and one follow up visit.

All interviews were conducted in the participant’s home in her native language, Telugu,

with the aid of an interpreter. Responses were recorded on paper in English in as direct a

translation from Telugu as was reasonable. Concepts that could not be readily translated

into English were recorded in Telugu, and the meaning was later negotiated with several

native Telugu speakers who are also fluent in English. During the first interview,

background information was gathered on the mother, children, and the household; one or

two children in the target age range (12 to 72 months) were weighed; and the mother and

her children were photographed. During the second interview, which took place

approximately three months later, the CAR questionnaire was administered and the target

children were weighed again. At the end of the field period, a third visit was made to all

informants in order to thank them for participating, give them a copy of the photograph

that was taken during the first interview, and to fill in any gaps in the questionnaire data.

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Results

Responses were analyzed using nonparametric techniques (chi-square). A

summary of the results is provided in Table 1.

[TABLE 1 ABOUT HERE.]

Birth Spacing: a function of the index child's order within the family's children and the

number of months separating that child from older and younger siblings. To obtain an

idea of what mothers in the village consider to be a preferable childbearing strategy,

questions were asked about practices that affect their own reproductive health as well

their children’s survival, such as age at marriage (which influences age at first

pregnancy), the ideal number of children, knowledge of birth spacing methods, and

attitudes towards using them. Ideal age at marriage showed a distinct positive trend

(Table 2), i.e., higher education was associated with later age at marriage. The range of

responses was also narrower for more educated women. The average preferred age at

marriage by less-educated mothers was 16.6 years of age (range 12 to 21 years).

Conversely, mothers with the most education preferred an average age of 19.9 years of

age (range 17 to 21 years). The vast majority of mothers considered two to be the

preferred number of children, and many noted that the ideal family includes one male

and one female child. Less-educated mothers were slightly more likely to suggest that

the ideal number of children is three (Table 2). The majority of mothers indicated that

the ideal number of years between pregnancies (i.e., birth spacing) should be about three

years, but overall, the responses did not demonstrate a strong trend by maternal education

(Table 2). Mothers who had never attended school recommended the highest mean

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number of years between children (3.4 years; range 2 to 6 years), while the lowest mean

response was given by mothers in the second-lowest educational group (2.8 years; range

1 to 5 years).

A surprising number of mothers, including highly literate ones, either responded

that they were not aware of methods for delaying pregnancy for purposes of birth spacing

or refused to discuss the topic (Table 2). Some mothers claimed they simply did not

know about methods of contraception, while others observed that it was not an

appropriate topic of conversation to have with the unmarried researchers. Even well

educated mothers were concerned that admitting knowledge of family planning methods

would be seen by their husbands or in-laws as evidence that they are women of low

morals. Overall, however, less-educated mothers were statistically significantly more

likely to report lack of knowledge of spacing methods.

The last question asked on this topic addressed the mother’s perception of the risk

of children dying. While the risk of infant death was thought to be low in Gramamu, the

responses did reveal a statistically significant trend among less-educated mothers to

believe it was a concern (Table 2). One respondent with no education reported that every

mother in her family had experienced at least one child death.

[TABLE 2 ABOUT HERE]

Safe Delivery: the presence of a trained medical attendant at the index child's birth.

Mothers were asked where children should be born and who should be present during

labor and delivery. There was overwhelming agreement that the delivery attendant

should be female, regardless of whether she is a physician (“daktar-amma,” literally “lady

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doctor”), a traditional birth attendant, or a female relative. The stated preference for

delivery location tracked closely with the preference for type of birth attendant. Mothers

who preferred hospital deliveries also preferred medical attendants, while traditional birth

attendants were fine for home deliveries. Both variables were statistically significant

with respect to mother’s education, with less-educated mothers more likely to prefer a

traditional birth attendant and home delivery (Table 3).

[TABLE 3 ABOUT HERE]

Exclusive Breastfeeding: the number of months the child was exclusively breastfed before

any kind of supplemental nutrition was introduced. Mothers in the study were asked

about when breastfeeding should be initiated, when solid or other foods should be

introduced (ending the period of exclusive breastfeeding) and when the child should be

weaned completely. Most mothers indicated that breastfeeding should be initiated on the

day the child is born and that all the milk, including the colostrum, should be given. A

few mothers indicated that the first day’s milk is bad and should not be given to children,

but others noted that although they used to hold that belief, they were now better

educated on the matter and knew the importance of giving all the milk.

Most mothers said that supplemental feeding, usually rice, should be introduced

around 6 months. In India, the introduction of solid food, specifically rice, is culturally

mandated to take place in the child’s sixth month in a “first rice” ceremony

(“annaprasanam,” literally “offering rice”). This important ceremony is observed by

Indians of all socio-economic groups and tends to correspond with the generally

recommended age for the introduction of other foods. A preference for a longer duration

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of breastfeeding by less-educated mothers is evident in the responses to question

regarding the age at which children should be weaned. The mean age at weaning

recommended by uneducated mothers (34.3 months) was over twice as long as that

recommended by the most educated mothers (14.3 months). This is the only variable that

showed a negative trend with respect to mother’s education (Table 4).

[TABLE 4 ABOUT HERE]

Diarrheal Disease Management: the use of oral rehydration therapy for the index child's

most recent episode of diarrheal disease. Mothers were asked what they believed to be

the cause of diarrhea and what treatments were available and preferred. Diarrhea was

attributed to a wide range of causes, including teething, playing in mud, digestion

problems, contaminated food or water, changes in food or water, and lack of

environmental cleanliness. It was also observed that foods that have the humoral

property of producing “heat,” such as buffalo milk, chilies, pickles and wheat flour, can

cause diarrhea, whether ingested directly by the child or indirectly through the mother’s

milk. Change in the weather (particularly the onset of summer) was another oft-

mentioned cause, as was poor health in general.

Twenty-five percent of mothers across all educational levels included oral

rehydration therapy on the list of possible treatments for diarrhea (data not presented).

Alternative therapies included giving the child syrups, drops or tonics obtained from the

village’s Registered Medical Practitioner (RMP), or taking him/her to the hospital or

doctor for injections or prescription medicines. A few mothers recommended traditional

treatments, including coconut water, buttermilk, pomegranate juice, dry ginger, and a

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homemade medicine comprised of leaves of a locally common tree (wapu), ginger and

honey. Diarrhea could also be treated by feeding the child foods with the proper humoral

properties, such as leafy vegetables (which are “cold” foods) to balance and treat diarrhea

(a “hot” condition).

Immunization: the percentage of recommended immunizations received. Mothers in this

study were asked about their knowledge of recommended vaccinations for children and

about their purpose. All mothers in the study indicated that they knew the value of

immunizations for children, although one relatively well-educated mother chose not to

allow her younger children to receive the polio vaccination after her oldest daughter

developed polio after receiving it. Those mothers who were familiar with the purpose of

immunizations were most likely to mention polio, measles, tetanus, tuberculosis, and

whooping cough. Other diseases mentioned included cholera, malaria, chicken pox, and

goiter. A surprising number of mothers believed that brain tumors (“meda wapu”) could

be prevented by immunization. They had heard claims that ayurvedic medicine could

prevent brain tumors and assumed by extension that allopathic medicine could do

likewise. Responses to these questions did not vary by mother’s education (data not

presented).

Nutritional Status: numerical score reflecting relative weight-for-age. Mothers were

asked when supplemental feeding should begin, and what types of foods are

recommended. There was very little variation in the recommended age at first feeding,

with responses tending towards the timing of the annaprasanam ceremony (6 months).

The least educated mothers recommended waiting the longest, an average of around 5.1

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months. Mothers educated between one and five years averaged 5.3 months, between six

and ten years averaged 5.0 months, and over eleven years averaged 4.3 months.

Although not a strong trend, there was the appearance of a relationship in which mothers

with less than eleven years of education generally recommended later introduction of

supplemental feeding. Suitable foods included bananas and other soft fruits, biscuits

(similar to bland cookies or crackers), boiled carrots or potatoes, various types of

porridge (rava, ragi, paisam), rice diluted with water or curds, and an extensive selection

of commercial infant formulas (e.g., Nestam, Cerelac, Farex, Complan), as well as

powdered mixes normally intended for adults (e.g., Horlicks, Bornvita).

DISCUSSION

Inspection of the trends listed in Table 1 reveals that responses to about half of the

Child-At-Risk Index questions have the hypothesized relationship with mother’s

education, that is, higher education is associated with infant and child care beliefs and

practices that generally predict better health outcomes. Of those, responses to four

questions were statistically significant. Only one variable showed a negative trend, and

the remainder showed no discernible trend with respect to mother’s education. Because

the questions in this portion of the study were intended to elicit beliefs about particular

child rearing practices, rather than actual behaviors, responses tended to cluster around

certain locally observed or culturally directed patterns, weakening any statistically

significant variation with respect to mother’s education. Definite trends are nonetheless

evident in the results, and several variables did show statistically strong correlations with

mother’s education.

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Direct association: knowledge of birth spacing methods, preferred birth location and

attendant, and belief about the risk of child mortality

Family planning has been a major preoccupation of the Indian Government’s

population control and women’s health programs since the 1960s. Numerous programs

to promote the use of spacing methods and to encourage permanent methods after the

second child is born have been implemented with varying results. Given the ubiquity of

the family planning messages, which can be seen on seemingly every building beam and

sign post in rural and urban India and heard on television and radio announcements, it is

hard to imagine that anyone could be unaware of the suggested methods or the goal of the

programs regardless of literacy status. However, women must be very careful to

maintain their own and their families good names by not giving the impression of

impropriety that a public admission of knowledge might indicate. It is to be expected that

women from the groups that restrict women’s education would be even more reluctant to

admit knowing about birth spacing methods. Delaying and spacing child bearing can be

difficult in a situation where “lack” of knowledge of birth control is culturally sanctioned.

Ideally, it should be more acceptable for educated girls to know about birth

control methods, however, women were reluctant to demonstrate in public, e.g., under the

watchful eye of friends and relatives during an interview, that they were familiar with

birth control methods. This last finding may indicate a need for attention to the attitudes

of men as much as those of women on the subject of birth control and spacing. Perhaps if

men were more familiar with the available alternatives, their minimal risk to health and

fertility, and the benefits to parents and children of properly spaced births, they would be

18

more inclined to participate in those decisions, and women would feel more free to learn

about, obtain, and use them.

A related question, ideal age at marriage, also showed a positive trend with

mother’s education, although not a statistically significant one. Since later age at

marriage, and thus at first pregnancy, is associated with better birth outcomes and lower

rates of maternal mortality, the educational process itself indirectly effects birth and

health outcomes by delaying marriage, and consequently, age at first delivery. Less-

educated mothers are often expected by their extended families to arrange daughters’

marriages at a relatively young age (between 12 and 16). These mothers usually belong

to castes that do not traditionally educate daughters because it is expected that they will

leave home immediately after marriage and never contribute economically to their natal

family. Moreover, they represent a financial burden while they are living there unless

they are working, which precludes attending school. Conversely, mothers who belong to

castes that believe in educating their daughters will delay arranging their marriages until

after they reach their expected level of education. These are more likely to be the case

with mothers who are themselves more educated.

Economic realities influence preferred behaviors in many of the decisions made

by mothers and families. The traditional preference that a mother’s first delivery take

place in her natal home (i.e., with her own mother and perhaps sisters in attendance), with

later births taking place in her marital home means that many births do not occur in

hospitals. It would therefore be unrealistic to expect them to be attended by a

biomedically-trained physician. The stated preference of less-educated mothers for a

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non-medical delivery setting was explained by several mothers as stemming from

concern about the expense of a hospital delivery, as well as a desire to avoid the

possibility of a surgical delivery. However, many mothers also specified that home

deliveries were only appropriate in the case of a normal delivery. Giving birth in a

hospital is still relatively uncommon, although if there was any possibility of a difficult or

complicated delivery, it was preferable. The generally later age at the introduction of

supplemental feeding recommended by mothers with less education may also have

economic significance since they may not have the access to resources to initiate

supplemental feeding at a younger age. Finally, beliefs about the risk of child mortality

may also stem from economic realities. Educated mothers who are generally from

wealthier families are less likely to experience child death and may therefore perceive

themselves as having more control over the possibility. Conversely, a mother who is

restricted by both lack of literacy and of resources is more at the mercy of her

environment and circumstances and may feel she has little or no control over her own

(and her children’s) fate.

Inverse association: breastfeeding practices

The issues surrounding breastfeeding practices are somewhat more complex to

interpret, since their association with mother’s education differed among questions. On

the one hand, breast milk is a nutritious, convenient, and inexpensive food source for

children, especially in low income households and/or those with a larger number of

children. On the other hand, bottle feeding frees a mother for other activities, and may

appeal to educated mothers because of its apparent air of sophistication. The notion that

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colostrum is “bad” and should be discarded, as well as the shorter duration of

breastfeeding among educated women in developing countries has been observed in other

studies (Rogers, et al., 1997a). The longer periods of breastfeeding given by the less

educated women probably reflects information received on this topic from the anganwadi

workers, as this is a major focus of ICDS educational activities.

It has been suggested that growth faltering provides a more broad-based indicator

of health status than morbidity or mortality counts (Mosley and Chen, 1984). While it is

widely agreed that breastfeeding is the ideal source of nutrition for infants, it is equally

important that supplemental nutrition be initiated by an appropriate age. This is

especially important for low-income mothers who might be tempted to delay introducing

supplemental foods for economic reasons. Because breast milk is an ideal source of

nutrition and a longer period of exclusive breastfeeding extends the time during which

the child is protected from potentially contaminated food and water, a later age at first

supplemental feeding should be a positive factor. However, there is a point at which the

child’s need for nutrition exceeds that which can be produced by the mother, after which

continued exclusive breastfeeding could put the child at risk for stunted growth. But the

use of contaminated water in infant formulas can cause diarrhea, which also inhibits

growth, a fact noted by several mothers. This issue is highly complex, especially when

considered in the context of the widespread observance of the annaprasanam ceremony,

which skewed the responses of all the educational categories towards introducing

supplemental feeding at six months.

No association: immunization, ORT, number of children, birth spacing, colostrum

21

Immunization, use of oral rehydration therapy, preferred number of children, birth

spacing, and giving the colostrum by initiating breastfeeding on the day of birth, have

been central components of the Government’s family planning and population control for

years. Immunization rates are very high in this village, as is the case throughout much of

India. However, while many mothers could not state the specific purpose of

immunizations other than to keep the children healthy or to prevent disease, their children

were nonetheless fully immunized. The stated preference for medical treatment of

diarrhea rather than the oral rehydration therapy promoted by the public health experts

reflects a general preference for biomedicine (when affordable and available) observed in

other areas of health maintenance, such as immunization coverage. In reality, nearly half

the mothers (48 percent) in another part of this study (Rao, 1999) actually reported using

ORT to treat one or more of their children. Most of those mothers who used ORT were

from the less-educated groups, but there was no statistical significance to the responses

with regards to preferred treatment. The slogan of the family planning program in India

promoting small family size, “We two, our one,” is another ubiquitous campaign of the

central government, and, as noted by one mother, the importance of colostrum has been

emphasized in the ICDS activities. That these variables show no effect by mother’s

education may reflect the success of those programs in this part of India, and throughout

the country as demonstrated by the steadily improving child survival rates.

CONCLUSION

The results of this study generally support the relationship between maternal

education and child survival found in the international literature. More importantly, they

22

also demonstrate that health education programs targeting specific infant care-related

behaviors do indeed benefit mothers with minimal education. Programs such as India’s

ICDS that emphasize low literacy, popular education approaches hold considerable

promise for improving the future of children in developing countries. The women in this

study were clearly not entirely restrained by lack of education or by socially acquired

beliefs about proper infant care practices such as breastfeeding. When the educational

message was received and the necessary resources were available to the mothers, they

were open to new ideas to encourage their children’s health growth and development.

Unfortunately, cultural norms still restrict women’s ability to fully exploit existing

resources with respect to certain messages, such as birth spacing and contraception.

Further research is needed to better understand the situation so that programs can be

tailored to meet the needs of mothers.

The findings of this study are limited by the possible confounding effect of using

education as a proxy for literacy and/or socioeconomic status. Number of years of school

attendance in and of itself does not determine a given person’s literacy level, nor does it

necessarily co-vary with access to other resources that influence child health outcomes.

It is not possible to know with certainty where the mothers in this study learned their

infant care beliefs and practices. It is therefore not possible to know the extent to which

access to education influences their access and receptivity to new information and

knowledge about such practices. Nevertheless, the strength of the trends found in this

relatively small sample suggests that the relationship between maternal education and

23

children’s health outcomes is worth pursuing as a development pathway in many parts of

the world.

A country’s investment in maternal education and children’s health reflects the

importance it places upon human development, and ultimately, its dedication to

improving the future of its people. While current technology and knowledge exist to

make a significant improvements in much of the world, the resources and political will

are not always equally sufficient or available. Encouraging such an emphasis in priorities

of both the public health and international development communities will both benefit the

current population and lay the foundation for healthier populations in the future.

24

APPENDIX:

Infant care Knowledge and Practices Questionnaire

Birth Order and Spacing:

• At what age should women get married?

• At what age should she have her first child?

• How many children is the ideal number?

• How far apart should they be born?

• What can you do to achieve that the time period between births?

• How great is the risk of children dying?

Safe Delivery:

• In what setting should babies be born?

• Who should be with the mother when a child is born?

Breastfeeding:

• What day should it start?

• Should you give all the milk (including colostrum)?

• How long should it be continued?

Nutrition:

• When should you start giving food in addition to milk?

• What foods should you give?

Treatment for Diarrheal disease:

• What causes diarrhea?

• What should be done when a child has diarrhea?

Immunizations:

• What is the purpose of immunizations?

• Should children receive immunizations?

25

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Table 1: Summary of Child At Risk Variables

Statistical Trend with

Mother’s Education

Child At Risk Variable

Positive Trend Preferred Delivery Attendant *

Preferred Delivery Location *

Knowledge of Birth Spacing Methods **

Belief about Risk of Child Mortality **

Ideal age at marriage ***

Mean Age in Months at Introduction of Supplemental Nutrition ***

Negative Trend Mean Age at Weaning

No Significant Trend Preferred number of children

Ideal Birth Interval

Day of Initiation of Breast Feeding

Giving of Colostrum

Preferred Treatment for Diarrhea

Immunization Acceptance

* p < 0.01

** p < 0.05

*** positive trend, not statistically significant

Table 2: Birth Order and Spacing Beliefs by Mother’s Educational Attainment Category

Mother’s Educational Attainment (Years)

Birth Order and Spacing Beliefs none 1-5 6-10 11+

Average ideal age at marriage (years) 16.6 18.4 19.3 19.9

Average ideal number of children per couple 2.1 2.0 2.0 2.0

Average ideal birth interval (years) 3.4 2.8 3.2 2.9

Percent reporting knowledge of birth spacing

methods *

45.2 41.4 76.7 81.3

* p < 0.05

Table 3: Delivery Preferences by Mother’s Educational Attainment Category

Mother’s Educational Attainment (Years)

Delivery Preferences none 1-5 6-10 11+

Percent preferring medical attendant at birth * 53.8 73.3 83.3 100.0 Percent preferring medical setting for delivery * 48.7 51.6 80.0 93.8 * p < 0.01

Table 4: Beliefs about Breastfeeding and Nutritional Status by Mother’s Educational Attainment

Category

Mother’s Educational Attainment (Years)

Breast Feeding Beliefs none 1-5 6-10 11+

Average day on which breastfeeding should begin

(day of birth = 1.0)

1.0 1.0 1.1 1.0

Percent believing that colostrum should be fed to

infant

93.2 86.7 90.0 100.0

Number of months at introduction of supplemental

feeding

5.1 5.3 5.0 4.3

Average age in months when child should be

weaned

34.3 31.1 26.8 14.3