Prevalence, care-seeking behaviors and treatment cost for neonatal morbidities in Karnataka (India)

Abstract

Purpose

Around three million infants die within the first four weeks of life each year – nearly all (98%) of these deaths occur in developing countries. Approximately one million newborns die each year in India. Therefore, this study aims to determine the patterns of reported neonatal morbidity and care-seeking behavior and identify factors associated with it.

Design/methodology/approach

A cross-sectional study was conducted during November 2016. A systematic random sampling technique was used to select the sample. Statistical techniques like Binary Logistic regression and chi-square test were used.

Findings

The results of the study showed that around 31% mothers of neonates reported that their neonates suffered from some kind of morbidity. Fever, jaundice, cough and cold, the low birth-weight and difficulty in breathing were the most common dangers signs reported. Birth order and mother’s knowledge of neonatal danger signs were found to be significantly associated with reporting of neonatal morbidity. In all 95% of the mothers sought care for their newborns. Among those who had problems, 59% consulted private hospitals/clinics, 30% visited District Hospital/Taluka Hospital or higher facilities and another 9% to Primary Health Centers/Community Health Centers. Further, findings show that nearly half of the neonates taken to government facilities have got free treatment, whereas an average cost of 7,156 INR were recorded for treatment, 935 INR for outpatient department and 13,774 INR for inpatient department cases.

Originality/value

There is an urgent need to implement intervention modalities that focus on increasing the level of parental education and access to treatment, and advocating the message regarding newborn danger signs during pregnancy is pinpointed.

Citation

Golandaj, J.A., Kampli, M.S. and Hallad, J.S. (2019), "Prevalence, care-seeking behaviors and treatment cost for neonatal morbidities in Karnataka (India)", Journal of Humanities and Applied Social Sciences, Vol. 1 No. 2, pp. 115-131. https://doi.org/10.1108/JHASS-07-2019-0007

Introduction

Neonatal and infant mortality pose a major public health challenge, especially in the developing world, and progress in the reduction in neonatal mortality over the past years has been slow (You et al., 2015). According to the World Health Organization (hereafter WHO) in the year of 2015 around 5.4 million children aged under five years died globally (WHO, 2016; WHO, 2018). Nearly half of all deaths in children under-five occur in the neonatal period, within the first four weeks of life (WHO, 2016; WHO, 2018). Hence, 2.7 million infants die within first four weeks of life each year (You et al., 2015) and nearly all (98 per cent) of these deaths occur in developing countries (Lawn et al., 2005; Dadhich and Paul, 2004). India contributes approximately 25 per cent of all neonatal deaths in the world (Lawn et al., 2005). Although there are no reliable estimates, approximately one million newborns die each year in India. The sluggish decline of infant mortality rates in the past decade in developing countries in general and India in particular could be largely attributed to stagnation in neonatal mortality; deaths in the newborn period now contribute to two-thirds of all deaths under five years (Dadhich and Paul, 2004). It is argued that further decline in infant mortality would require effective implementation of interventions to lower neonatal mortality (Lawn et al., 2005; Dadhich and Paul, 2004).

Infectious diseases such as sepsis, pneumonia, tetanus and diarrhea; preterm birth and complications of birth asphyxia are responsible for most deaths in this period (WHO, 2016; WHO, 2018). Prematurity and intra-uterine growth restrictions are also indirect causes or risk factors for neonatal deaths, especially those because of infection (Lawn et al., 2005). Most of these diseases are readily preventable or treatable with proven, cost-effective and quality-delivered interventions. It is postulated that delayed or inappropriate care seeking behavior contributes significantly to the high neonatal mortality levels in the developing countries including India (Lawn et al., 2005).

Integrated Management of Neonatal and Childhood Illnesses (IMNCI) also envisions that family and community health practices, especially health-seeking behavior, are to be improved to reduce morbidity and mortality in the early years of age (WHO and MOHFW, 2003; Ingle and Malhotra, 2007; Black et al., 2003). But documented literature present a picture of poor health-seeking; in the state of Maharashtra (India), for example, less than 5 per cent of newborns suffering from a major illness were taken to a care provider outside the home for medical care (Bang et al., 2001). Even, though improved a lot in the last two decade, recent round of National Family Health Survey (NFHS-4) says that in Karnataka only around 76.9 per cent children suffering from acute respiratory infection and 69.7 per cent children suffering from Diarrhea were taken to a health facility or provider (IIPS, 2016)

Health-seeking behavior is a function not only of the availability of health facilities and other sources of health care but also the motivation and ability of individuals to seek medical treatment (Teerawichitchainan and Phillips, 2007). In this background, the present study is intended to determine the patterns of reported neonatal morbidity and care-seeking behavior and to identify factors associated with it in Karnataka, India.

Methods and materials

Ethical consideration

Communication with the District Medical Officer (DHO) and Taluka Medical Officer (THO) was made through formal letter mentioning Ministry of Health and Family Welfare (MoHFW), Government of India’s approval to take up the study. Having finished informing the purpose and objective of the study, the researchers obtained oral consent from the study participants with an age greater than 18 years. Participants were informed that their participation was purely on a voluntary base, and the information obtained from them will be kept confidential and will be used only for the research purpose.

Study area and sample size

A multi-stage sampling process was adopted to recruit sample from the sub-district. Bidar district[1] of Karnataka[2] state was selected on the bases of maternal and obstetric indicators, and two talukas[3], namely Basavakalyan and Homanabad, were selected purposively among others. Further, five Primary Health Centers (hereafter PHCs) from each block were selected randomly and from each PHC two villages[4] were covered; one headquarters village and one big village in terms of population criteria were adopted, so that a sufficient number of recently delivered women (hereafter RDW) can be obtained. Hence, total 20 villages from 10 PHCs were covered.

Women having a pregnancy outcome during April 2015 to March 2016 were considered as RDW and were identified from the list available with the Auxiliary Nurse Midwife at Sub Health Center (hereafter SHC). A systematic random sampling technique was used to select 460 RDW; 23 RDW were selected randomly from each village. All four hundred and sixty randomly selected mothers were contacted for participation in the study, out of which 376 were successfully interviewed giving a recruitment fraction of 82 per cent. Among them, three mothers had stillbirth; hence, total 373 mothers of neonates who had at least one live birth outcome were included for the neonatal morbidity analysis of the present study. (Figure 1)

Data collection and processing

Pre-tested and face-to-face interview administered questionnaire adopted from different kinds of literature were employed to record mother’s reporting about the experience of danger signs among their newborns. The interview questionnaire included separate sections to collect information. In addition to danger signs among their newborns, socio-demographic, economic and obstetric related information were collected. Seven trained professionals with vast experience in survey research and data collection were conducted the structured interviews, and data was collected during November 14-23, 2016.

Completeness and consistency of the data were checked, cleaned and double entered using The Census and Survey Processing System (CSPro) software version 5.0 and analyzed by Statistical Package for Social Sciences (SPSS) software version 20 (IBM Corp, 2011). Frequencies, proportions and summary statistics were used to describe the study population in relation to relevant variables and presented by using tables and graphs.

Outcome variable

The variables used in this study were broadly categorized into outcome variable and predictor variables. The outcome variable includes any neonatal danger sign prevalence. Danger signs are symptoms that complicate the lives of the neonate and happen during the neonatal period, the first 28 days of life. Prompted responses to the total number of 19 neonatal danger signs were recorded and a minimum score of “0” and maximum of “19” was used to measure the experience of neonatal danger signs. Further, two categories were developed for neonatal morbidity, mothers who reported their neonates had at least one danger sign were categorized as “Yes = 1” otherwise “No = 0”.

Predictor variables

The demographic and socio-economic variables, such as mother’s age, mother’s education, father’s education, religion, caste, sex of the neonate, birth order of the neonate, number of birth the mother had, knowledge of neonatal danger signs have been used as predictor variables. In this analysis, the predictor variables were categorized as follows:

• Mother’s age: <25 years, 25-29 years and 30 and above years.

• Mother’s education: No schooling, 1-9 years and 10 and above years.

• Father’s education: No schooling, 1-9 years and 10 and above years.

• Religion: Hindu, Muslim, and Christian.

• Caste[5]: Scheduled Castes (SCs), Scheduled Tribes (STs), Other Backward Classes (OBCs), and General.

• Sex of the child: Boy, and Girl.

• Birth order of neonate: First, Second, and 3 or more.

• Number of children: 2 or less children, and >2 children.

• Knowledge of danger signs: None, and At least 1.

• Household having BPL card: BPL, and APL.

• Place of treatment: DH/TH and other higher facilities, PHC/CHC, and Private hospital/clinics.

Analytical approach

To assess the determinants of reported neonatal morbidity, first, bivariate analyses were used to examine the nature of association between neonatal morbidity and selected socio economic and demographic characteristics using chi-square test of significance. Second, to examine which factors best explain and predict reporting of any neonatal morbidity among recently born neonates, binary logistic regression model was fitted.

For all the statistical tests, p-values of <0.001, <0.01 and <0.05 were considered for statistical significance and odds ratio (hereafter OR) with 95 per cent confidence interval (hereafter CI) was used to identify significant factors. Model fitness test was conducted with Hosmer and Lemeshow goodness of fit test.

Results

Profile of the study population

Table I depicts the percentage distribution of the neonates (0-28 days) born from April 2015 to March 2016 in the study area. Results, as expected, show that the highest proportion of the neonates (around 53 per cent) included in the study were born to the women who were less than 25 years of age and 37 per cent of the neonates were born to the women in the age group 25-29 years, whereas rest of the neonates (11 per cent) were born to 30 and above year old women. Distribution of neonates, by their mother’s attainment of education, shows that every fourth neonate was born to the mother who has no schooling or completed less than five years of schooling, and one-fourth of the neonates were born to the mothers who have five to eight years of schooling. Whereas, another one-third and one-fifth of neonates were born to mothers who have completed 9-10 years and more than 10 years of schooling respectively.

Around, 79 per cent of neonates included in the study were born to Hindu mothers compared to Muslim[6] (18 per cent) and Christian (2 per cent) mothers. Similarly, majority (42 per cent) of covered neonates were born to mothers belonged to Scheduled Castes (hereafter SCs)/Scheduled Tribes (hereafter STs), whereas, 35 per cent of neonates were born to mothers belonged to Other Backward Castes (hereafter OBCs), and remaining (23 per cent) neonates were born to higher caste mothers. The proportion of male child (55.8 per cent) is more than the female child (44.2 per cent). Further, the proportion of neonates by their birth order reveals that little less than two-thirds of the neonates were of first or second birth order compared to higher birth orders. Seventy-one per cent of the neonates belong to below poverty line (hereafter BPL) families and the remaining 29 per cent born in above poverty line (hereafter APL) families. Approximately, little more than two third of neonates were born to the mothers who mentioned at least one key danger sign during neonatal (0-28 days) compared to their counterpart (Table I).

Prevalence of reported neonatal morbidity

Figures 2 and 3 depicts the distribution of neonates included in the analysis had problem or not. Mothers reported the experience of any danger signs in their recently delivered newborns were considered as had problem. Among the total 373 neonatal included in the analysis, nearly one-third (31 per cent) of the neonates were reported to have a morbid condition (Figure 2).

Further, the result shows that of all mothers who have experienced these signs in their recent delivered newborns, Fever (14.4 per cent) was the most common reported morbidity, followed by Jaundice (7.8 per cent). Six per cent had cough and cold, similarly, low birth weight/Premature (5.6 per cent), breathing difficulty (4.3 per cent) were the most frequent perceived danger signs experienced by mothers (Figure 3).

Differentials in neonatal morbidity

Prevalence (per 100) of reported neonatal (0-28) morbidity in the study population according to background characteristics is presented in Table II. Information on danger signs that mothers have real experience in their recently delivered newborns was collected in the study, and mothers who mentioned the experience of at least one danger sign is taken as suffering from morbidity. Expectedly, the neonates born to mothers in the early ages say age group of less than 25 years (38 per cent) and later ages, say 30 and above (30 per cent) were more common than the women in age group 25-29 years (22 per cent), and it is statistically significant. Educational attainment of mothers is showing that as the years of schooling increases the reporting of experienced danger signs were also increasing, more or less similar pattern was reported in case of father’s educational attainment, but these are not significant.

Reported experience of neonatal danger signs by social and religious community reveals that lower percentage of Muslim mothers reported the experience of any morbidity (27 per cent) compared to Christian (44 per cent) and Hindu (32 per cent) mothers. Similarly, mothers belonged to ST and OBC communities reported any morbidity was 28 per cent and 27 per cent respectively, whereas, a higher percentage of mothers reported any morbidity belonged to general (37 per cent) and SC (35 per cent) groups. Prevalence of neonatal danger signs by biological variables shows that newborn danger signs were more common among male child (35 per cent) than among female child (27 per cent). Birth order of the neonate is significantly evident in reporting any danger signs, as birth order increases the proportion of mothers reporting neonate’s morbidity decreases. Neonates of the first order of birth were more common to experience morbidity (45 per cent), followed by second-order birth (29 per cent) and third or higher (23 per cent) birth order. Mother who had knowledge of at least one neonatal danger sign was more common to report neonates experience morbidity than their counterpart and it is statistically significant (Table II).

Determinants of neonatal morbidity

Table III presents the results of the binary logistic regression model estimated to examine the association between selected maternal, socioeconomic and demographic predictors on reporting of any neonatal morbidity condition. Results reiterate that mother’s age is negatively associated with the neonatal morbidity.

Women of age 25-29 years (odds ratio [OR] = 0.930, 95 per cent confidence interval [CI] = [0.351, 1.130]) were less likely to report any neonatal morbidity condition compared with women in the age group of less than 25 years. The odds of mothers reporting any neonatal morbidity are increasing for the neonates whose mother’s years of schooling increases and it is true in case of the father’s educational attainment. Mothers of the female child were less likely to report any morbidity compared with their counterparts (OR = 0.669, 95 per cent CI = [0.415, 1.076]). The odds of neonatal morbidity are decreasing in higher birth order. The knowledge of neonatal danger signs is positively and strongly associated with reporting any neonatal morbidity, mother who had knowledge of at least one danger signs were more likely to report any morbidity (OR = 2.394, 95 per cent CI = [1.362, 4.209]) compared to their counterpart (Table III).

Care-seeking behavior

Figure 4 depicts the distribution of neonates for whom medical care was sought for danger signs. Among the total studied neonates, 117 mothers of the neonates reported had a problem, of them 95 per cent (111) sought care for their neonates (Figure 4).

Types of health facilities used

Among those who had problems, majority mothers of neonates (59 per cent) consulted private hospitals/clinics and two per cent took treatment at home. About 30 per cent went to the higher-level government health facilities, such as District Hospitals (hereafter DHs), Taluka Hospitals (hereafter THs) and other higher-level government hospitals. Only 9 per cent visited the lower level government health facilities, such as PHCs and Community Health Centers (hereafter CHCs) (Figure 5), and only 5 per cent have not sought treatment (Figure 4).

Types of health facilities used by sex of neonates

Further, simple cross-tabulation of the type of health facilities used for treatment by sex of the neonates shows that Care sought from the higher level government health facilities was found to be 9 per cent greater for the male neonates than their female counterparts. Whereas, neonates visited the private hospitals/clinics were found to be 11 per cent greater for female neonates. Such difference was not found among male and female neonates who sought treatment from a lower level of health facilities (Figure 6).

Cost of treatment by providers

As shown in Table IV, many of the neonate cases going to DH/TH and other higher facilities (42 per cent) and PHCs/CHCs (38 per cent) received free treatment, and some other spent very nominal amount. Whereas, even though free treatment is available in government health facilities, some of the neonate cases spent a big amount out of pocket, and this proportion is more in higher-level facilities.

Whereas, all most all the neonates who visited private hospitals/clinics have spent money out of pocket, moreover, around two-thirds (71 per cent) of them have spent ranging from 1,000 to 70,000 Indian rupees (hereafter INRs), remaining 29 per cent cases have paid up to 1,000 INRs. As the result shows among those who had problems, majority mothers of neonates (59 per cent) consulted private hospitals/clinics, indicating still, with the strong network of government health facilities at various level, many rural mothers are visiting private practitioners and spending out of pocket.

Mean out-of-pocket expenditure

Figure 7 and Table V present the average expenditure incurred by the households for neonatal health care services by background characteristics and type of patient care. The analysis of expenditure on these services shows the considerable burden on households, on an average, each household, had spent 7,156 INRs. Further, the results revealed that there are considerable differences among the population groups as well as the type of facility and type of patient care in the spending on household expenditure on neonatal health care services.

Results show that each household spent, on an average 935 INRs on outpatient care (hereafter OPD) and 13,774 INRs on inpatient care (hereafter IPD) cases. Though as expected, the out of pocket expenditure is more in private health-care facilities, but still a considerably high amount had been spent out pocket in public health-care facilities also. In total, each household had spent on an average 5,749 INRs in public facilities compared to 8,185 INRs in private health facilities respectively. Similarly, each household had spent 636 and 1,151 INRs for OPD and 11,118 and 15,741 INRs for IPD in public and private health-care facilities respectively (Figure 7).

Results show that place of treatment, sex of the child, household having BPL card and caste were significant predictors of expenditure on neonatal health care. The differences are still clearer in the case of OPD services instead of IPD services. Each household on an average had spent 1,082 and 14,095 INRs for boy child compared to 731 and 13,300 INRs for girl child on OPD and IPD respectively. Similarly, household having APL card had spent more (1,049 and 14,263 INRs) compared to BPL household (886 and 13,606 INRs) for both OPD and IPD, respectively (Table V).

Discussion

The present study was intended to determine the patterns of reported neonatal morbidity and care-seeking behavior, and to identify factors associated with the prevalence of reported neonatal morbidities.

Consistent with one of recent study in Bangladesh (Chowdhury et al., 2018), the present study found a high prevalence – nearly one-third (31 per cent) of all participated neonates have reported one or the other morbidity – though it was lower compared with findings from previous studies (Awasthi et al., 2006; Ahmed et al., 2001). Fever was found to be the most common symptom which is also truly consistent with earlier studies (Awasthi et al., 2006; Ahmed et al., 2001) followed by jaundice.

Further, the results shows that the majority (nine out of ten) of the mothers in this study reported of receiving care for their sick neonates from health-care providers, which is again consistent with other recent studies (Chowdhury et al., 2018), and much better than the earlier studies in the Indian context which is obviously expected (Awasthi et al., 2006).

Strengths and limitations of the study

Present study, though the sample is relatively small, was conducted in rural and hard-to-reach areas. However, data in this study were from interviews with an 18-20 months recall period and therefore, were susceptible to recall errors when reporting symptoms and care-seeking practice. To address this issue, experienced research staffs were collected the data collection task after receiving rigorously training on appropriate questioning methods and other potential issues related to neonatal danger signs and health-care utilization among others.

Further, information on the timing and duration of the symptoms after delivery, and care-seeking were not collected during the survey which restricted us from analyzing and explaining the number of incidence and duration of the morbidities and care-seeking; similarly, the different socio-economic and demographic factors affecting the care-seeking practice was also not analyzed in the present study due to less number of samples. We propose that studies are needed with a relatively large number of samples to address these issues in details.

Conclusion

Over the recent years, with a formulated policy, a lot of money is being pumped by central as well as the state government to empower the health-care facilities/providers to improve neonatal and infant health services at the grass root level, especially in rural areas. By the results of the study, by socio-demographic variables, it is evident that the reporting of neonatal morbidity was more prevalent among young, educated, higher caste mothers. It may be due to the level of awareness of danger signs was more linked to belonging of well off and higher educational attainment of women (Nigatu et al., 2015). On the other hand, the older women less educated and belonging to socially marginalized class respondents were poorly reported the morbidities. Whereas, by obstetric variables, it is mothers of the boy child, first order birth and mother of two or less number of children have reported more neonatal morbidity compared to their counterparts.

Further, interestingly the study found that the majority of mothers were seeking care from private practitioners for their sick neonates, though the strong network of government health facilities is available at various levels, and consequently spending more money out of pocket.

The results of the study suggest that efforts should be made to raise awareness regarding neonatal morbidity, its prevention and the importance of seeking care from trained personnel among expectant mothers, especially mothers belonging to marginalized communities. Therefore, intervention modalities that focus on increasing the level of parental education, access to treatment, and advocating the message regarding newborn danger signs during pregnancy were pinpointed. There is a well-established network of government health-care facilities and medical practitioners along with front line workers at gross root level, they are the major contributors in this regard, hence proper utilization of this government setup is emphasizes. Furthermore, different non-government organizations, private health-care providers and international organization need to play crucial role. Further, this task can be done using strong Information, Education and Communication materials through using mass media broadcasts including radio, television and even social network forums. While doing so focus should be given for improving the utilization of services in government health facilities, especially PHCs and CHCs, to minimize out of pocket spending.

Figures

Figure 1.

Selection of sample for analysis

Figure 2.

Percentage distribution of neonates with reported morbidity (n = 373)

Figure 3.

Patterns of reported neonatal morbidity in the study population (n = 373)

Figure 4.

Percentage of ill neonates to whom medical care was sought (n = 117)

Figure 5.

Types of health facilities used for the treatment of neonatal (0-28 days) morbidities (n = 111)

Figure 6.

Types of health facilities used for the treatment of neonatal (0-28 days) morbidities by sex of neonates (n = 67 Boys and n = 44 Girls)

Figure 7.

Mean out-of-pocket expenditure on health care seeking for neonates (0-28 days) having morbidity by type of health-care facility and type of patient care (n = 97)

Table I.

Percentage distribution of study population according to the sex of the neonatal (0-28 days) by background characteristics

	Per cent of the study population
Background characteristics	Boys	Girls	Total	N
Mother’s Age
<25 Years	52.4	52.7	52.5	196
25-29 Years	37.5	35.8	36.7	137
30 and above	10.1	11.5	10.7	40
Mother’s Education
No Schooling	20.2	19.4	19.8	74
1-9 Years	32.2	44.2	37.5	140
10 and above Years	47.6	36.4	42.6	159
Father’s Education
No Schooling	21.6	22.4	22.0	82
1-9 Years	32.2	30.3	31.4	117
10 and above Years	44.7	43.6	44.2	165
Religion
Hindu	79.8	78.8	79.4	296
Muslim	18.3	18.2	18.2	68
Christian	1.9	3.0	2.4	9
Caste
SCs	17.8	24.2	20.6	77
STs	21.2	21.2	21.2	79
OBCs	36.5	33.3	35.1	131
General	24.5	21.2	23.1	86
Sex of the child
Boy	NA	NA	55.8	208
Girl	NA	NA	44.2	165
Birth order
First	27.9	29.7	28.7	107
Second	36.5	37.6	37.0	138
3 or more	35.6	32.7	34.3	128
Number of children
2 or less	63.9	66.7	65.1	243
More than 2	36.1	33.3	34.9	130
Household having BPL card
BPL	71.2	71.5	71.3	266
APL	28.8	28.5	28.7	107
Knowledge of danger signs
None	28.8	36.4	32.2	120
At least 1	71.2	63.6	67.8	253
Total	100.0	100.0	100.0	373

Notes:

N = Number of cases; SCs = scheduled castes; STs = scheduled tribes; OBCs = other backward classes; NA = not applicable; BPL = below poverty line; APL = above poverty line

Table II.

Prevalence (per 100) of reported neonatal (0-28 days) morbidity in the study population by background characteristics (n = 373)

	Experience at least 1 neonatal morbidity
Background characteristics	Yes, n (%)	p-values^	N
Mother’s Age
<25 Years	75 (38.3)	0.006	196
25-29 Years	30 (21.9)		137
30 and above	12 (30.0)		40
Mother’s Education
No Schooling	19 (25.7)	0.447	74
1-9 Years	44 (31.4)		140
10 and above Years	54 (34.0)		159
Father’s Education
No Schooling	21 (25.6)	0.179	82
1-9 Years	34 (29.1)		117
10 and above Years	60 (36.4)		165
Religion
Hindu	95 (32.1)	0.462	296
Muslim	18 (26.5)		68
Christian	4 (44.4)		9
Caste
SCs	27 (35.1)	0.358	77
STs	22 (27.8)		79
OBCs	36 (27.5)		131
General	32 (37.2)		86
Sex of the child
Boy	72 (34.6)	0.129	208
Girl	45 (27.3)		165
Birth order
First	48 (44.9)	0.002	107
Second	40 (29.0)		226
3 or more	29 (22.7)		40
Number of children
2 or less	87 (35.8)	0.012	243
More than 2	30 (23.1)		130
Household having BPL card
BPL	84 (31.6)	0.890	266
APL	33 (30.8)		107
Knowledge of danger signs
None	24 (20.0)	0.001	120
At least 1	93 (36.8)		253

Notes:

Prompted responses to the total number of 19 neonatal danger signs were recorded and mothers who reported their neonates had at least one danger sign were categorized as ‘Yes’ otherwise ‘No’; N = Number of cases; SCs = scheduled castes; STs = scheduled tribes; OBCs = other backward classes; BPL = below poverty line; APL = above poverty line; ^{^} = p-value represents the significance level estimated from χ² test

Table III.

Factors associated with reported neonatal morbidity in the study population by background characteristics (n = 364)

			95% CI for Exp(B)
Background characteristics	OR	p-values	Lower	Upper
Mother's Age
<25 Years	1
25-29 Years	0.631	0.120	0.353	1.128
30 and above	0.951	0.911	0.395	2.289
Mother's Education
No Schooling	1
1-9 Years	1.247	0.555	0.599	2.595
10 and above Years	0.996	0.993	0.446	2.227
Father's Education
No Schooling	1
1-9 Years	0.870	0.713	0.414	1.827
10 and above Years	1.231	0.591	0.577	2.627
Religion
Hindu	1
Muslim	0.984	0.964	0.487	1.988
Christian	2.516	0.230	0.558	11.347
Caste
SC	1
ST	0.647	0.251	0.307	1.361
OBC	0.644	0.226	0.316	1.314
General	1.084	0.827	0.525	2.237
Sex of the child
Boy	1
Girl	0.682	0.120	0.422	1.105
Birth order
First	1
Second	0.548	0.047	0.302	0.993
3 or more	0.519	0.279	0.158	1.700
Number of children
2 or less	1
More than 2	0.699	0.283	0.364	1.344
Knowledge of danger signs
None	1
At least 1	2.336	0.003	1.362	4.209
Constant	0.641
Hosmer and Lemeshow Test x2	11.111
−2 log likelihood	416.078

Notes:

OR = Odds ratio; CI = confidence interval; SCs = scheduled astes; STs = scheduled tribes; OBCs = other backward classes

Table IV.

Percentage distribution of cost by place of treatment sought (n = 97)

Cost in INRs	DH/TH and higher facility (n = 31)	PHC/CHC (n = 8)	Private hospitals/clinics (n = 56)	Home (n = 2)
Free	42	38	−	100
1-999	10	38	29	−
1,000-9,999	29	13	46	−
> =10,000	19	13	25	−
Total	100	100	100	100

Note:

Dollar-rupees average exchange rate 1 USD = 67.18 INR as in the year 2016; INRs = Indian rupees; n = number of cases; DH = district hospital; TH = taluka hospital; PHC = primary health centers; CHC = community health centers

Table V.

Mean out-of-pocket expenditure on health care seeking for neonates (0-28 days) having morbidity by background characteristics (N = 97)

	OPD			IPD
Background variables	Mean ± SD (INRs)	Median (INRs)	N	Mean ± SD (INRs)	Median (INRs)	N
Place of treatment
DH/TH and other higher facility	858 ± 1767	0	13	9,131 ± 14,008	1,100	18
PHC/CHC	200 ± 245	100	6	29,000 ± 29,698	29,000	2
Private hospitals/clinics	1151 ± 1162	600	29	15,741 ± 17,927	10,000	27
Sex of the child
Boy	1082 ± 1572	400	29	14,095 ± 16,809	7,500	28
Girl	731 ± 722	500	21	13,300 ± 18,095	10,000	19
Birth order
First	807 ± 928	500	15	11,250 ± 13,533	7,500	26
Second	981 ± 1,506	400	17	17,526 ± 19,298	12,000	14
3 or more	997 ± 1,380	500	18	15,643 ± 24,908	8,000	7
Number of children
2 or less	880 ± 1,268	400	31	13,447 ± 15,834	8,500	40
More than 2	1024 ± 1,346	500	19	15,643 ± 24,908	8,000	7
Mother's Education
No Schooling	830 ± 1,281	100	5	19,650 ± 20,306	14,000	8
1-9 Years	1,139 ± 1,662	500	20	14,770 ± 17,212	10,000	21
10 and above Years	792 ± 928	400	25	10,000 ± 15,652	5,250	18
Household having BPL card
BPL	886 ± 1,209	500	35	13,606 ± 16,970	7,000	35
APL	1049 ± 1,492	380	15	14,263 ± 18,425	10,000	12
Caste
SCs	646 ± 853	500	13	12,447 ± 14,027	9,000	12
STs	1535 ± 2,468	290	8	12,333 ± 15,930	8,000	9
OBCs	796 ± 991	400	12	19,316 ± 20,828	14,000	19
General	971 ± 960	750	17	2,857 ± 3,388	1,000	7
Total	935 ± 1,287	500	50	13,774 ± 17,150	8,000	47

Note:

Dollar-rupees average exchange rate 1 USD = 67.18 INRs as in the year 2016; INRs = Indian rupees; OPD = outpatient department; IPD = inpatient department; SD = standard deviation; N = number of cases; DH = district Hospital; TH = taluka hospital; PHC = primary health centers; CHC = community health centers; BPL = below poverty line; APL=above poverty line; SCs = scheduled castes; STs = scheduled tribes; OBCs = other backward classes

Notes

1 Districts are local administrative units; they generally for the tier of local government immediately below that of India’s sub-national states and territories.

2 Karnataka is a state in the southwestern region of India. It was formed on November 1, 1956, with the passage of the States Reorganization Act. Originally, known as the State of Mysore, it was renamed as Karnataka in 1973.

3 Taluka, which is also called as Tehsil or Block, is an administrative sub-district division, typically comprising a number of villages.

4 Village is a group of houses and associated buildings, larger than a hamlet and smaller than a town, situated in a rural area.

5 The Scheduled Caste (SCs) and Scheduled Tribe (STs) are the official designations given to various groups of historically marginalized people, recognized in the Constitution of India. During the period of British rule, they were known as the Depressed Classes. In modern literature, the SCs are sometimes referred as “Dalits”, whereas STs are mentioned as “Adivasis” (i.e. traditional forest dwellers). The SCs and STs comprise about 16.6 per cent and 8.6 per cent of India’s population respectively (RGI, 2013). OBCs represent other backward classes.

6 It is very important to know here that the proportion of Muslim population is high in the Bidar district compared to most of the other districts of Karnataka and more so in the selected taluka. Hence, the coverage of higher proportion of women goes with the higher representation of Muslim community in the district.