MODIFICATION OF DELIVERY PRACTICE IN RAJBANSHI MOTHERS OF NEPAL

Introduction: This is a cross-sectional study with the objective of identifying modification in delivery practice in Rajbanshi mothers of Nepal. Methodology: Both qualitative and quantitative tools were used. Semi-structured questionnaires covering 375 samples of its resident districts Morang, Jhapa and Sunsari districts and check lists for in-depth interview were used in the study. Results: People were adopting both traditional and modern care practices concurrently. Among 375 households; 40% adopted local clinic/ hospital/ traditional healer concurrently. Similarly 31.20% adopted local clinic/ traditional healer/ hospital, 10.67% adopted hospital/traditional healer. There were 11.47% (urban 0.54% and rural 10.93%) respondents were having traditional care system as a first choice. During first delivery among 375 mothers 265 (70.67%) had traditional home delivery and 110 (29.33%) had hospital delivery. During last delivery, this was 115 (30.67%) in traditional home delivery and 260 (69.33%) in hospital delivery. Therefore trend of hospital delivery was increasing whereas trend of traditional home delivery was decreasing. It was statistically highly significant (p=<0.0001). There was also remarkable increased in using trained Health Worker/Nurse/Doctor at hospitals is 66.4% during last delivery which was only 6.13% during first delivery. It is statistically highly significant (p= <.0001). Conclusion: Trend of hospital delivery was increasing (from 30.67% to 69.33%) and trend of home delivery was decreasing (from 69.33% to 29.23%) in between first and last child delivery. There was remarkable increased in using trained HW/Nurse/Doctor at hospitals is 66.4% during last delivery which was only 6.13% during first delivery. Traditional care was more practiced in rural than in urban population.


Introduction
The word Rajbanshi means "dynasty of king".Rajbanshi were dwelt and over populated in the Koc-Bod area of upper Tibetan plateau was known as Koch or Koches.These people came down to southern region and also Bramhaputra river valley sometime between 7000 to 5000 B.C. and so physical changes through various doors i.e. hilly paths or passages.When Koches were over populated in the Koc-Bod areas one branch of the common stock achieved prominence around the Kochi (Koshi or Kosi) river banks and in areas between lower Nepal and north Bihar (1).
Rajbanshi themselves considered as Kchhetriya of Hindu caste system.Anthropologists have opined that they are the kiths and kin of the peripheral Koch people of the adjacent states of West Bengal and Asom (Assam) in India.As described in the blogspot of Social Organization of Rajbanshi Aborigines soranepal, they are having Mongoloid features -they consider themselves as a branch of the Kirants.They have a liftedT bone over their throat a little higher than the average height.The structure of their eyes and forehead, etc is like those of a mix of Aryan-Mongloid, Austric, Negrito, Dravidian.They wear clothes conforming to climate and weather.Their physical charecteristics are similar with local indigienous people like Tharu, Meche, Dhimal, Nuniya and Batar.Referering to Ridge(2) has mentioned in article that there are different kinds of Rajbanshis such as Koch Rajbanshi, Poundra Rajbanshi, Mech Rajbanshi, Newar Rajbanshi, and Khataha Rajbanshi in Nepal.There are mainly more than four types of Rajbanshi found in Nepal.Khotaha Rajbanshi-They are Maithil language speaking.They have poor economic or social condition.They even take alcohol and eat pork, chicken, rat and a kind of snail ghongi.They believed that during Ramayan era when Parshu Ram started genocide against Kchhetryas some run away from their place to hide northern part which is now territory of Nepal and they have been settled here since Ramayan era.According to Shrestha(3) their castes are called-Teli, Baniya, Gwar, Kahal, Khatwe, Kipat, Dhanuk, Nuniya, Amat, Kalawar, Kamat, Koiry, Sharma, Pandit, Ganesh, Chuhan, Chanda and Mana Chanda.

Methods and Tools
1. Household Survey: general information taken from head of household and detailed questionnaire filled with mother's interview (n=375).2. Observation: of housing and traditional practices.Tools: 1. Questionnaire (Semi-structured), 2. Check list for Observations.Study Sites: (1) Jhapa and (2) Morang and (3) Sunsari districts.Data entered and analyzed with SPSS-20 software in computer.

Table 1. Change in Delivery Practices
Table 1 shows that during first delivery among 375 mothers 265 (70.67%) had traditional home delivery and 110 (29.33%) had hospital delivery.During last delivery, this was decreased by 115 (30.67%) in traditional home delivery and increased by 260 (69.33%) in hospital delivery.Therefore trend of hospital delivery was increasing whereas trend of traditional home delivery was decreasing.Statistically highly significant (p=<0.0001).

Table 2. Change in Use of Service Providers
Table 2 indicates practice of using service providers.Among 375 mothers regarding using TBAs, 8% used in first delivery and only 1.87% in last delivery.Similarly, there is also change in using Health workers at community level was 6.67% first and 1.33% at last delivery.Use of TBA/CHW was 67.73% at first delivery and decreased to 27.2% at last delivery.Using HW/Nurse was 11.47 at first delivery and 3.2% at last delivery.But, there was remarkable increased in using HW/Nurse/Doctor at hospitals was 66.4% at last delivery which was only 6.13% at first delivery.Therefore there was increasing in practice of modern health system in Rajbanshi community since it is statistically highly significant (p= <.0001).Ayurveda, Tibetan medicine, indigenous care and faith healing are the major traditional medical systems or folk medicine.Modern or Western allopathic medicine was introduced in the seventeenth century but became dominant from the middle of the 20th century.Multiple and Alternative medical systems are popular in all community in Nepal.This variety is reflected in a tolerant coexistence and co-operation between differing forms of therapeutic practice (3,6,7).A study done before in Katahari and Baijanathpur VDCs of Morang district in same community had noted that Rajbanshi community was adopting modern, self and alternative medications.Modern medication was equally popular in both poor and rich or educated and uneducated.(8) Similarly, a study conducted in Jajarkot also find people were adopting modern, traditional, and natural treatment through the use of herbal medicine and the home/family treatment by food and local herbs.(9) A cross-sectional study was conducted with 482 Hindu women who were pregnant in Maitha, Uttar Pradesh, India.(10) Maternal health care service use among both upper and lower caste women was very low.Upper caste women were almost three times more likely to use antenatal care.Five times more likely to have a trained birth attendant compared to the lower caste women.Caste was a significant determinant of tetanus toxoid use and trained birth attendant even after adjusting for sociodemographic factors.Various trends of practices are seen in US .(11) The study noted two more that are of interest to us.First, there is the multi-disciplinary approach becoming more and more widely recognized.Dualism describes a situation where one sector of society is developed and "Westernized" and the other sector remains "traditional".(12).Even within a particular culture these two sectors have limited interactions and operate parallel to each other.In addition, the existence of cultural diversity within a particular society could produce the different types of explanations and interpretations.(13) This study noted that people were both traditional and modern care practices concurrently.Among 375 households; 40% adopted local clinic/ hospital/ traditional healer concurrently.Similarly 31.20%adopted local clinic/ traditional healer/ hospital, 10.67% adopted hospital/traditional healer, 9.6% adopted traditional healer/ local clinic/ hospital, 3.47% adopted hospital practice, 2.4% adopted local clinic/hospital, and 1.33% adopted traditional healer/hospital concurrently.Local clinics were first choice 65% respondents which is modern care and mainly due to availability at local level.19% respondents reported the first choice for treatment was hospitals.11.47% respondents reported first choice was traditional care system.Study uncovered that 83.50% respondents went to local clinics when mothers or child get sick, 11.50% visited traditional healer and 5% of respondents went to hospitals directly.Therefore, most people were practicing modern care system than traditional when mother and child care.

Changes in traditional practices
Traditional healers are a part of health care system in Rajbanshi community.They know their limitations and so they do refer to health institutions.Since traditional healers have got trainings from health posts they are aware of modern medications.They treat a case and hold normally for 1-2 days and if there is no sign of progress resulted be refered.Usually they are doing refered people to clinics or hospitals due to social construction of their behavior change.Rajbanshi communities are habited geographically on plain areas so that they have easy access of transportation to get health institutions.Due to efforts of government's public health programs focused especially on mother and child and availability of health workers and volunteers were more attracted with modern health system.Regarding the trend of care seeking practices among 375 mothers 69.33% had traditional home delivery at first baby and birth was decreased to 30.67% at last delivery.So, in Rajbanshi the practice of traditional home delivery has been decreased and hospital delivery has been increased remarkably within the decade.

Changes in Modern Care Practice
There was change noted within modern care practice.Practice of hospital delivery was increasing.During first delivery 70.67% had home delivery and 29.33% had hospital delivery during first delivery (n=375).It was transformed to when their last delivery as 30.67% home delivery and 69.33% hospital delivery.Therefore trend of hospital delivery was increasing whereas trend of home delivery was decreasing.That was statistically highly significant (p=<0.0001).It was because of the government's policy and program being conducted in the name of safe motherhood.In the program government of Nepal has managed incentives for both mothers and health workers.Woman gets Rs 500 from government for transportation.Health workers and hospitals also received incentives for delivery.These are claimed by government on their annual reports.(14)Mothers' behavior has been socially constructed to have hospital delivery for safer child births.
There was also change in use of service providers in between first and last delivery.Use of doctors or skill birth attendants was increasing and demand of hospital environment with skilled health workers has been socially constructed.Among 375 mothers, use of TBAs was 8% at first delivery and only 1.87% used at last delivery.Similarly, use of Health workers at community was 6.67% at first delivery and 1.33% at last delivery.Use of TBA/CHW was 67.73% at first delivery that decreased to 27.2% at last delivery.Using HW/Nurse was 11.47 at first delivery also decreased to 3.2% at last delivery.But, there was remarkable increase in using Doctors/Nurse/HW at hospitals which was 6.13% at first delivery and was increased to 66.4% at last delivery.Therefore there was changes in use of skilled service providers that was statistically highly significant (p= <.0001).
Traditional healers are a part of health care system in Rajbanshi community.They know their limitations and so they do refer to health institutions.Since traditional healers have got trainings from health posts they are aware of modern medications.They treat a case and hold normally for 1-2 days and if there is no sign of progress resulted be refered.Usually they are doing refered people to clinics or hospitals due to social construction of their behavior change.Rajbanshi communities are habited geographically on plain areas so that they have easy access of transportation to get health institutions.Due to efforts of government's public health programs focused especially on mother and child and availability of health workers and volunteers were more attracted with modern health system.

Conclusion
People were adopting both traditional and modern care practices concurrently.Among 375 households; 40% adopted local clinic/ hospital/ traditional healer concurrently.Similarly 31.20%adopted local clinic/ traditional healer/ hospital, 10.67% adopted hospital/traditional healer, 9.6% adopted traditional healer/ local clinic/ hospital, 3.47% adopted hospital practice, 2.4% adopted local clinic/hospital, and 1.33% adopted traditional healer/hospital concurrently.There were 11.47% (urban 0.54% and rural 10.93%) respondents were having traditional care system as a first choice.During first delivery 70.67% had home delivery and 29.33% had hospital delivery was transformed to 30.67% home delivery and 69.33% hospital delivery during last delivery.Therefore trend of hospital delivery was increasing whereas trend of home delivery was decreasing.That was statistically highly significant (p=<0.0001).There was also remarkable increased in using trained HW/Nurse/Doctor at hospitals is 66.4% at last delivery which was only 6.13% at first delivery.It is statistically highly significant (p= <.0001).
They are habited in Biratnagar city covering from east of Sindhiya river and have marital linkage with Rajbanshi of Purniya in Bihar.

Table 3
indicates that 11.47% Rajbanshi had practiced traditional care as first choice.In urban area it is 0.54% and in rural area it is 10.93%.A Traditional Birth Attendant (TBA) said: "There is huge difference between today and before.During past days there were traditional healer who used to jharphuk and chanting mantras in water pot with holy basil tulasi leaf and gave pregnant woman to drink and some water sprinkled on the body.After that they used to call TBA and started to massage over stomach.It was risky practice.They didn't have suggested for even antenatal check up.So, maternal death was reported.But today, every woman goes for ANC, take TT, and Iron tabs.They also go to health institutions to take suggestion from health workers.Most of them go to hospital for delivery.Some people still call TBAs for home delivery but when it gets prolonged then I referred to the hospital."(TBA1)