Grandmothers' influence on child care
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《美国医学杂志》
Department of Foods and Nutrition, Faculty of Home Science, The M.S. University of Baroda, Vadodara, India
Abstract
Objective : This paper compares child care-giving and child's nutritional status among rural families where grandmothers were present and those where grandmothers were absent. Methods: From 27 villages in rural Vadodara, four were randomly selected and all the families (n=31) with children (3-24 months) where grandmothers were present (GMP) were compared with 39 families where grandmothers were absent (GMA). Semi structured questionnaires were used to assess beliefs-practices of mothers and grandmothers regarding breastfeeding and complementary feeding (BF-CF). Nutrient intake of the children and nutritional status were measured using standard procedures. Results : Some deleterious practices were present in a similar proportion of both GMP and GMA groups: giving prelacteals, delaying initiation of BF, exclusive breastfeeding <3 months and delaying initiation of CF. Favorable practices present in significantly more GMP were: active feeding and use of anganwadi services. Grandmother's help enabled mother to practice more care-giving behaviors. However, children in both the groups had low calorie intake (< 40% RDA) and a high prevalence of under nutrition: 56-64% (Weight-for-Age z score < -2). Conclusion : Role of family members in childcare and the benefits of including them in interventions to improve child survival, health and nutrition status need to be further researched.
Keywords: Grandmothers′ support; Complementary feeding; Breastfeeding
Childhood malnutrition is a major public health problem throughout the developing world. India has 20% of the world's children, yet unfortunately 47% children under three years of age are underweight and 46% are stunted. In Gujarat, the prevalence of underweight (45%) and stunting (44%) among children under 3 years is as high as the national average.[1]
Research conducted in a variety of settings demonstrates that post-natal growth faltering begins around six months of age, just as infants begin to receive foods to complement their breast milk intake.[2] This growth faltering peaks at about 2 years of age, after which it is very difficult to reverse stunting.[3] The UNICEF conceptual framework suggests that caregiving and feeding practices are critical for child growth, and development.[4]
Family support to the caregiver/mother in the form of help provided in childcare, household work, emotional support or informational support is an important resource facilitating improved childcare by mothers. In African, Asian, Latin American and the Pacific societies, older women, or grandmothers, traditionally have considerable influence on decisions related to maternal and child- health at the household level.[5] Field-based research data are needed for this region which assess the influence of beliefs-practices of the grandmother on various aspects of childcare by the mother.
This paper, a part of a larger interventional study, compares child breastfeeding and complementary feeding beliefs and behaviours, as well as nutritional status of children 3-24 months in rural families where grandmothers were present (GMP) vs those where grandmothers were absent (GMA).
Materials and Methods
Site of the study and sample selection: The study was carried out with the support of a local Non Government Organization (NGO), which offers health care and other services in 27 villages (population: 42,457) in and around Nandesari area of Vadodara district. From these 27 villages, four villages (population: 5029) were randomly selected for an intervention program to enhance breastfeeding and complementary feeding practices among children 3-24 months of age. For this study all households in the 4 villages having children 3-24 months and presence of grandmother (GMP) (n= 31) were taken. Out of the remaining families where grandmother was absent, 39 families had children in a similar age range of 3-24 months and therefore formed the comparison group. Both groups were similar as regards the key socioeconomic variables i.e. type of house, mean number of children, mean income, and average educational levels of parents. Semi-structured, pre-tested questionnaires were used to assess socioeconomic status and beliefs-practices of mothers and grandmothers related to the key infant and young child feeding (IYCF) practices, health care and grandmother's support to mother for childcare and housework. The 24-hr diet recall method was employed to collect data on nutrient adequacy of complementary foods consumed by the children. The weight and height of the children were measured using standard procedures and equipments,[6] the data were compared with NCHS standards and analyzed using EPI-info 6.04 d computer package (Center for Disease Control, Atlanta). Percentage responses were calculated related to child feeding and health care practices and family support received by the mother. Percentages of recommended allowances consumed for selected nutrients (energy, iron and vitamin A) were calculated.[7]
Results
In both the groups i.e. grandmother present (GMP) and grandmother absent (GMA), one-third women were illiterate (32%), and economic status was poor with mean per capita income of Rs. 502 to Rs. 514. Most of the families did not have pucca houses, and though tap water was available nearby, no individual toilet facility existed.
Newborn feeding and breastfeeding: Some of the undesirable practices were seen in both GMP and GMA groups in a similar proportion of mothers table1. For example, giving pre-lacteals, delayed initiation of breastfeeding after child birth and not encouraging feeding during illness. A similar proportion in both groups decreased the number of breastfeeds when mother was ill with this view: 'if I breastfeed when I am sick, the child will also fall ill'.
A slightly lower proportion of GMP mothers (45%) had given colostrum as compared to GMA (51%) mothers. Those who discarded colostrum (about half) stated reasons like: ' colostrum was stale milk ' or ' was unhealthy for the child '. The primary reason why two-third of the mothers in both groups gave exclusive breastfeeding (EBF) for less than 3 months was due to initiation of water feeding, with the belief that 'child's mouth would get dry ' without water .
Complementary feeding: [ Table 1] further reveals that initiation of complementary feeding (CF) was delayed beyond 6 months by more GMP mothers (63%) than GMA mothers (48%). Further, in many more GMP families (44%), initiation of CF was delayed beyond 9 months compared to only 19% GMA families. However, significantly more mothers in GMP group practised active feeding (81%) against GMA group (48%) (p<0.01). As regards giving CF during illness, about half the mothers in both groups did not attempt to increase child's food intake during diarrhea because 'child does not feel hungry when ill'; 'child does not have the strength to eat' . When asked about use of anganwadi services, a significantly higher number of GMP mothers (88%) utilized supplementary food for the child from the anganwadi as compared to GMA mothers (32%) (p<0.01).
Similar to the beliefs of mothers, most of the grandmothers believed in giving prelacteals after childbirth, believed in discarding colostrum, in delayed initiation of breastfeeding (beyond 10 hours) as well as in delayed introduction of complementary feeding (beyond 6 months) table2.
The amount and frequency of complementary foods to be given to the child at different ages as mentioned by most of the grandmothers was inappropriate (for 6-9 month child: about 2-3tsp food, twice a day or less; for child 10-24 months: about half a household cup/' katori ' food, twice a day or less). Only 36% grandmothers believed in active feeding behaviors and more of these were in families with boys (47%) than girls (17%). Although 45% grandmothers believed that mother should not breastfeed the child during her own illness, they reported that in practice their grandchild breastfed as usual even during mother's illness because 'child feels hungry so has to be given breast milk' . During child's illness, grandmothers believed that the child should be given breast milk or top foods on demand because 'child does not like anything else during illness', but should not be force-fed .
The amount of nutrients consumed (macronutrients as well as micronutrients), was very inadequate Figure1 in both the groups of children. However, among the 6-11-month-olds, the calorie, iron and retinol intake of the GMP children was higher as compared to GMA children.
Undernutrition (Weight-for-Age: WAZ below -2) and stunting (Height-for-Age: HAZ below -2) was high (>50%) in both the groups. Prevalence of severe undernutrition tended to be higher in GMA children; e.g. low weight-for-height (WHZ below-3) was 8% in GMA and 0% in GMP children. Negligible gender differences were observed for all anthropometric indicators.
Other factors: Besides grandmother's support, this study also looked at other factors influencing child-care practices. Factors like family size significantly influenced initiation of complementary feeding at 6 months (￡6 members: 35%, >6 members: 10%); also, mother's education influenced active feeding (<5 years education: 16%, 35 years education: 39%) (p<0.05). Also, there was a significant inverse relationship between parity and active feeding by the mother (1st parity: 50%, other parity: 23%) (p<0.05). Other factors ( e.g. per-capita income, age of mother, Body Mass Index of mother and sex of child) were not found to have a significant association with the indicators of child feeding and child care, in this study.
Discussion
The present study revealed that unfortunately a large proportion of rural mothers did not practice desirable child feeding behaviours. Family support (especially from elderly female relatives like the grandmother of the child) is believed to be important for enabling the mother to follow the recommended practices. The presence of grandmothers in this study appeared to favor some desirable practices such as active feeding of complementary foods and utilization of anganwadi services. In fact it was observed that most of the grandmothers helped the mothers more in childcare activities and less in household work (playing with the child, keeping the child clean and feeding him/her). An important trend seen was that more the number of tasks in which the grandmother helped the mother, more were the child caring behaviours practised by the mothers. This could be one reason why calorie intake of the 6-11 month olds (the group being initiated to CF) was higher in GMP group, as seen earlier.
The undesirable IYCF practices which appeared to be encouraged in grandmothers presence were feeding prelacteals and delaying the initiation of complementary foods. A likely reason was that most grandmothers themselves believed in the deleterious practices.
While several studies in literature have shown a high prevalence of deleterious infant and young child feeding practices, very few have looked at the influence of family support. In rural Bolivia, the attitudes of the infant's grandmother towards breastfeeding did not influence the infant feeding pattern.[8] In contrast Asian Indian American mothers relied more on support of the grandmother for feeding during the infant's first 6 months of life.[9] A study in rural Gambia revealed that presence of maternal grandmother had beneficial effects on child's nutritional status and mortality. However, paternal grandmothers and male kin had negligible impact.[10]
Conclusion
Grandmothers appear to play an important role in supporting some desirable child-feeding and childcare practices; and increasing the child's calorie intake from complementary foods. They, however, could also be a negative influence in terms of encouraging some undesirable child feeding behaviours.
There is clearly a need for further research to understand specifically the role of grandmothers in childcare in the Indian context, including the role of maternal and paternal grandmothers. The influence of grandmother's support should also be studied vis-a-vis other household level factors and other socio-demographic variables influencing infant-young child feeding and healthcare. Grandmothers' participation in interventions to improve maternal and child survival, health and nutrition status needs to be encouraged, as including only mothers in behaviour change interventions may have limited impact.
References
1. NFHS-2. National Family Health Survey, India and Gujarat. International Institute for Population Sciences (UPS) and ORC Macro, 1998-1999.
2. Bereng L, Bikes F, Nxumalo TP. Patterns of decision making on complementary feeding practices by caregivers of children aged 0-36 months in Ratchaburi, Thailand. SPH online, http://www.sph.uq.edu.au/acithn/reports/cn/00 , COMPFEEDING.html.2, 2000.
3. Martorell R, Kettel Khan L, Schroeder DG. Reversibility of stunting: epidemiological findings in children from developing countries. Eur J Clin Nutr 1994; S45-S57.
4. UNICEF. Strategy for improved nutrition of children and women in developing countries. New York, 1990.
5. Aubel J, Ibrahima T, Diagne M et al. Strengthening grandmother networks to improve community nutrition: experience from Senegal. Gender and Development OXFAM 2001; 9(2): 62-73(12).
6. Gibson RS. Principles of nutritional assessment . New York, Oxford University Press, 1984.
7. Indian Council of Medical Research. Recommended dietary intakes for Indians. Hyderabad, Avon Printing works, India, 1991.
8. Ludvigsson JF. Breastfeeding in Bolivia - information and attitudes. BMC Pediatr 2003; 3 (4) .
9. Kannan S, Carruth B, Skinner J. Infant Feeding Practices of Anglo American and Asian Indian American Mothers. Journal of the American College of Nutrition 1999; 18(3): 279-286.
10. Sear R, Mace R, McGregor IA. Maternal grandmothers improve the nutritional status and survival of children in rural Gambia. Proceedings of the Royal Society of London, Series B, Biological Sciences 2000; 267: 1641-1647 .(Sharma Minal, Kanani Shub)
Abstract
Objective : This paper compares child care-giving and child's nutritional status among rural families where grandmothers were present and those where grandmothers were absent. Methods: From 27 villages in rural Vadodara, four were randomly selected and all the families (n=31) with children (3-24 months) where grandmothers were present (GMP) were compared with 39 families where grandmothers were absent (GMA). Semi structured questionnaires were used to assess beliefs-practices of mothers and grandmothers regarding breastfeeding and complementary feeding (BF-CF). Nutrient intake of the children and nutritional status were measured using standard procedures. Results : Some deleterious practices were present in a similar proportion of both GMP and GMA groups: giving prelacteals, delaying initiation of BF, exclusive breastfeeding <3 months and delaying initiation of CF. Favorable practices present in significantly more GMP were: active feeding and use of anganwadi services. Grandmother's help enabled mother to practice more care-giving behaviors. However, children in both the groups had low calorie intake (< 40% RDA) and a high prevalence of under nutrition: 56-64% (Weight-for-Age z score < -2). Conclusion : Role of family members in childcare and the benefits of including them in interventions to improve child survival, health and nutrition status need to be further researched.
Keywords: Grandmothers′ support; Complementary feeding; Breastfeeding
Childhood malnutrition is a major public health problem throughout the developing world. India has 20% of the world's children, yet unfortunately 47% children under three years of age are underweight and 46% are stunted. In Gujarat, the prevalence of underweight (45%) and stunting (44%) among children under 3 years is as high as the national average.[1]
Research conducted in a variety of settings demonstrates that post-natal growth faltering begins around six months of age, just as infants begin to receive foods to complement their breast milk intake.[2] This growth faltering peaks at about 2 years of age, after which it is very difficult to reverse stunting.[3] The UNICEF conceptual framework suggests that caregiving and feeding practices are critical for child growth, and development.[4]
Family support to the caregiver/mother in the form of help provided in childcare, household work, emotional support or informational support is an important resource facilitating improved childcare by mothers. In African, Asian, Latin American and the Pacific societies, older women, or grandmothers, traditionally have considerable influence on decisions related to maternal and child- health at the household level.[5] Field-based research data are needed for this region which assess the influence of beliefs-practices of the grandmother on various aspects of childcare by the mother.
This paper, a part of a larger interventional study, compares child breastfeeding and complementary feeding beliefs and behaviours, as well as nutritional status of children 3-24 months in rural families where grandmothers were present (GMP) vs those where grandmothers were absent (GMA).
Materials and Methods
Site of the study and sample selection: The study was carried out with the support of a local Non Government Organization (NGO), which offers health care and other services in 27 villages (population: 42,457) in and around Nandesari area of Vadodara district. From these 27 villages, four villages (population: 5029) were randomly selected for an intervention program to enhance breastfeeding and complementary feeding practices among children 3-24 months of age. For this study all households in the 4 villages having children 3-24 months and presence of grandmother (GMP) (n= 31) were taken. Out of the remaining families where grandmother was absent, 39 families had children in a similar age range of 3-24 months and therefore formed the comparison group. Both groups were similar as regards the key socioeconomic variables i.e. type of house, mean number of children, mean income, and average educational levels of parents. Semi-structured, pre-tested questionnaires were used to assess socioeconomic status and beliefs-practices of mothers and grandmothers related to the key infant and young child feeding (IYCF) practices, health care and grandmother's support to mother for childcare and housework. The 24-hr diet recall method was employed to collect data on nutrient adequacy of complementary foods consumed by the children. The weight and height of the children were measured using standard procedures and equipments,[6] the data were compared with NCHS standards and analyzed using EPI-info 6.04 d computer package (Center for Disease Control, Atlanta). Percentage responses were calculated related to child feeding and health care practices and family support received by the mother. Percentages of recommended allowances consumed for selected nutrients (energy, iron and vitamin A) were calculated.[7]
Results
In both the groups i.e. grandmother present (GMP) and grandmother absent (GMA), one-third women were illiterate (32%), and economic status was poor with mean per capita income of Rs. 502 to Rs. 514. Most of the families did not have pucca houses, and though tap water was available nearby, no individual toilet facility existed.
Newborn feeding and breastfeeding: Some of the undesirable practices were seen in both GMP and GMA groups in a similar proportion of mothers table1. For example, giving pre-lacteals, delayed initiation of breastfeeding after child birth and not encouraging feeding during illness. A similar proportion in both groups decreased the number of breastfeeds when mother was ill with this view: 'if I breastfeed when I am sick, the child will also fall ill'.
A slightly lower proportion of GMP mothers (45%) had given colostrum as compared to GMA (51%) mothers. Those who discarded colostrum (about half) stated reasons like: ' colostrum was stale milk ' or ' was unhealthy for the child '. The primary reason why two-third of the mothers in both groups gave exclusive breastfeeding (EBF) for less than 3 months was due to initiation of water feeding, with the belief that 'child's mouth would get dry ' without water .
Complementary feeding: [ Table 1] further reveals that initiation of complementary feeding (CF) was delayed beyond 6 months by more GMP mothers (63%) than GMA mothers (48%). Further, in many more GMP families (44%), initiation of CF was delayed beyond 9 months compared to only 19% GMA families. However, significantly more mothers in GMP group practised active feeding (81%) against GMA group (48%) (p<0.01). As regards giving CF during illness, about half the mothers in both groups did not attempt to increase child's food intake during diarrhea because 'child does not feel hungry when ill'; 'child does not have the strength to eat' . When asked about use of anganwadi services, a significantly higher number of GMP mothers (88%) utilized supplementary food for the child from the anganwadi as compared to GMA mothers (32%) (p<0.01).
Similar to the beliefs of mothers, most of the grandmothers believed in giving prelacteals after childbirth, believed in discarding colostrum, in delayed initiation of breastfeeding (beyond 10 hours) as well as in delayed introduction of complementary feeding (beyond 6 months) table2.
The amount and frequency of complementary foods to be given to the child at different ages as mentioned by most of the grandmothers was inappropriate (for 6-9 month child: about 2-3tsp food, twice a day or less; for child 10-24 months: about half a household cup/' katori ' food, twice a day or less). Only 36% grandmothers believed in active feeding behaviors and more of these were in families with boys (47%) than girls (17%). Although 45% grandmothers believed that mother should not breastfeed the child during her own illness, they reported that in practice their grandchild breastfed as usual even during mother's illness because 'child feels hungry so has to be given breast milk' . During child's illness, grandmothers believed that the child should be given breast milk or top foods on demand because 'child does not like anything else during illness', but should not be force-fed .
The amount of nutrients consumed (macronutrients as well as micronutrients), was very inadequate Figure1 in both the groups of children. However, among the 6-11-month-olds, the calorie, iron and retinol intake of the GMP children was higher as compared to GMA children.
Undernutrition (Weight-for-Age: WAZ below -2) and stunting (Height-for-Age: HAZ below -2) was high (>50%) in both the groups. Prevalence of severe undernutrition tended to be higher in GMA children; e.g. low weight-for-height (WHZ below-3) was 8% in GMA and 0% in GMP children. Negligible gender differences were observed for all anthropometric indicators.
Other factors: Besides grandmother's support, this study also looked at other factors influencing child-care practices. Factors like family size significantly influenced initiation of complementary feeding at 6 months (￡6 members: 35%, >6 members: 10%); also, mother's education influenced active feeding (<5 years education: 16%, 35 years education: 39%) (p<0.05). Also, there was a significant inverse relationship between parity and active feeding by the mother (1st parity: 50%, other parity: 23%) (p<0.05). Other factors ( e.g. per-capita income, age of mother, Body Mass Index of mother and sex of child) were not found to have a significant association with the indicators of child feeding and child care, in this study.
Discussion
The present study revealed that unfortunately a large proportion of rural mothers did not practice desirable child feeding behaviours. Family support (especially from elderly female relatives like the grandmother of the child) is believed to be important for enabling the mother to follow the recommended practices. The presence of grandmothers in this study appeared to favor some desirable practices such as active feeding of complementary foods and utilization of anganwadi services. In fact it was observed that most of the grandmothers helped the mothers more in childcare activities and less in household work (playing with the child, keeping the child clean and feeding him/her). An important trend seen was that more the number of tasks in which the grandmother helped the mother, more were the child caring behaviours practised by the mothers. This could be one reason why calorie intake of the 6-11 month olds (the group being initiated to CF) was higher in GMP group, as seen earlier.
The undesirable IYCF practices which appeared to be encouraged in grandmothers presence were feeding prelacteals and delaying the initiation of complementary foods. A likely reason was that most grandmothers themselves believed in the deleterious practices.
While several studies in literature have shown a high prevalence of deleterious infant and young child feeding practices, very few have looked at the influence of family support. In rural Bolivia, the attitudes of the infant's grandmother towards breastfeeding did not influence the infant feeding pattern.[8] In contrast Asian Indian American mothers relied more on support of the grandmother for feeding during the infant's first 6 months of life.[9] A study in rural Gambia revealed that presence of maternal grandmother had beneficial effects on child's nutritional status and mortality. However, paternal grandmothers and male kin had negligible impact.[10]
Conclusion
Grandmothers appear to play an important role in supporting some desirable child-feeding and childcare practices; and increasing the child's calorie intake from complementary foods. They, however, could also be a negative influence in terms of encouraging some undesirable child feeding behaviours.
There is clearly a need for further research to understand specifically the role of grandmothers in childcare in the Indian context, including the role of maternal and paternal grandmothers. The influence of grandmother's support should also be studied vis-a-vis other household level factors and other socio-demographic variables influencing infant-young child feeding and healthcare. Grandmothers' participation in interventions to improve maternal and child survival, health and nutrition status needs to be encouraged, as including only mothers in behaviour change interventions may have limited impact.
References
1. NFHS-2. National Family Health Survey, India and Gujarat. International Institute for Population Sciences (UPS) and ORC Macro, 1998-1999.
2. Bereng L, Bikes F, Nxumalo TP. Patterns of decision making on complementary feeding practices by caregivers of children aged 0-36 months in Ratchaburi, Thailand. SPH online, http://www.sph.uq.edu.au/acithn/reports/cn/00 , COMPFEEDING.html.2, 2000.
3. Martorell R, Kettel Khan L, Schroeder DG. Reversibility of stunting: epidemiological findings in children from developing countries. Eur J Clin Nutr 1994; S45-S57.
4. UNICEF. Strategy for improved nutrition of children and women in developing countries. New York, 1990.
5. Aubel J, Ibrahima T, Diagne M et al. Strengthening grandmother networks to improve community nutrition: experience from Senegal. Gender and Development OXFAM 2001; 9(2): 62-73(12).
6. Gibson RS. Principles of nutritional assessment . New York, Oxford University Press, 1984.
7. Indian Council of Medical Research. Recommended dietary intakes for Indians. Hyderabad, Avon Printing works, India, 1991.
8. Ludvigsson JF. Breastfeeding in Bolivia - information and attitudes. BMC Pediatr 2003; 3 (4) .
9. Kannan S, Carruth B, Skinner J. Infant Feeding Practices of Anglo American and Asian Indian American Mothers. Journal of the American College of Nutrition 1999; 18(3): 279-286.
10. Sear R, Mace R, McGregor IA. Maternal grandmothers improve the nutritional status and survival of children in rural Gambia. Proceedings of the Royal Society of London, Series B, Biological Sciences 2000; 267: 1641-1647 .(Sharma Minal, Kanani Shub)