Primary health care (PHC) provides basic health services for individuals, families, vulnerable groups, and the public in general. Primary health care (PHC) is the first approach the public seeks for medical care, preventive and curative. It is the responsibility of community-wide networks of health centers and units, and may occasionally outreach the people within their community ⁽¹⁾.

Primary health care is essential health care based on practical scientific and socially acceptable methods, and technology made universally accessible to individuals and families in the community through their full participation, and at a cost that the community and country can afford to maintain at every stage of their development in the community. It is the first level of contact of individuals, the family and the community, with the national health system, bringing health care as close as possible to where people live and work, and constitutes the first element of the continuing health care process ⁽²⁾. The Declaration goes on to define primary health care to include prevention, health promotion, curative, and rehabilitation services.

The work of the women's health movement was important in setting this direction for health policy. It was the women's movement that pioneered the political approaches to health and health care, taking them from the domain of the personal to the domain of the political, understanding that "control over our own bodies" would be impossible without social and economic changes ⁽³⁾.

This, to us, is the most profoundly liberating feminist insight and understanding that our oppression is socially, and not biologically, ordained to act on this understanding is to ask for more than "control over our own bodies ", it is to ask for and struggle for, control over the social options available to us, and control over all the institutions of society that now define these options ⁽⁴⁾.

In contrast to the Alma Ata declaration, Health Canada has defined primary health care as "the first point of contact for Canadians with the health system, often through a family physician" ⁽⁵⁾.

This definition, refreshing in its brevity & simplicity, leaves unanswered important questions, including what constitutes the essential components of primary health care.

Else where, Health Canada has made a strong commitment to understanding the importance of the non-medical determinants of health practices and coping skills; health services; social support networks; gender; and clatter. The commitment dates back to the 1979 report by then federal Minster of Health, Mare Lapland, A New Perspective on the Health of Canadians ⁽⁶⁾. Health Canada also has an expressed commitment to both gender based analysis and women's Health strategy. Its Gender-based Analysis policy and Exploring concepts is in Gender and Health.

Any reformed primary health care system must include the full range of reproductive health care services and their delivery must be organized in ways which recognize women's diversity and which promote women's autonomy, control and health.
Secondly there are conditions more prevalent among women such as breast cancer, eating disorders, depression and self inflicted injuries ⁽⁷⁾.

Mothers and children are vulnerable groups that need special care through maternal care; for married women in the child-bearing period, especially the pregnant and lactating, and through child care; for children below five years (infants and preschool children) ⁽¹⁾.

Mothers are vulnerable groups that need special maternal health programs, due to:

• They are at risk of morbidity (health hazards) and mortality during pregnancy, labour and the puerperium, and which are largely preventable and controllable through maternal care.
  
• Maternal health is a basic requirement of fetal health and favorable outcome of pregnancy.
  
• Mothers are responsible for health promotion and culture of children, and family welfare, and so must be healthy, and aware of requirements of health (1).

In developing countries, more than 500,000 women die every year from complications related to pregnancy and child birth. Many other women suffer pregnancy- and delivery-related complications, that result in long-term health problems. A woman's death during childbirth often means death for the newborn, and both death and disabilities translate into emotional, social, and economic hardships for women's older children, their entire families, and even their communities ⁽⁸⁾.

Maternal and infant death can be prevented by ensuring that high quality maternal and newborn health care is accessible and that maternal health complications are recognized, referred, and treated by skilled health care, or they are deterred from seeking care by cultural barriers such as the status of women within the family and in society. They may postpone their own treatment when sick, in order to pay for care for family members, or they may not seek care at all ⁽⁷⁾.

In Iraq, a study about the frequency distribution of pregnancy education, by PHCC staff on different maternal health aspects, shows that education about breast feeding importance is 48.71%, while, risky factors on pregnancy and labour 40.95%, and guidance by the doctor or pharmacy on the use of medicine, was found in 90.1 % ⁽⁹⁾. (Table (I)).

3.1. Design of the Study :
This study is a cross sectional cohort study, and is conducted during the period from October 2004 to the end of June 2005.

3.2. Socio-Demographic Characteristics:
The study was conducted in PHC centers of Tikrit City, which serves a large proportion of the community of different socio economic levels. Cluster sampling was used dividing Tikrit City into 5 sectors {Al-Alam, Ibn-Sinaa, Alrazee, Ibn-Rushed, and Al-Rbidaa PHCC}.
Salahaldeen Governorate has an estimated population of {1162490}. Tikrit city represents {159721} of the population. Out of Tikrit city population, 20% are in the reproductive age group {15-45} years, and another 20% of the population is under 5 years of age ⁽⁷¹⁾.

3.3. The Study Groups :
Random sampling from each PHCC was taken from October 2004 to the end of June 2005, by interviewing women attending PHCC for Maternal and Child health services who have children less than 2 years of age. Sample size was 5% of the women in the reproductive age group, equal to about 760. Five PHCCs were selected.
Daily visits were carried out by the investigator herself. In each day, one of the PHCCs were visited over a period of 6 months. Interviews with each woman visiting the centers were conducted separately and with complete privacy, so that the answers (especially about their opinions) were less likely to be affected by hearing the answers of others. Each question was asked in simple language. A total number of 760 women were interviewed from all the centers.

3.4. Sources of health care:
As in PHCCs in Iraq, the centers in Tikrit City provide a comprehensive package of primary health care services. There are 5 PHCCs in Tikrit city, and all of them provide antenatal and maternal child health care, and one ⁽¹⁾ main general hospital and ⁽²⁾ small hospitals, and there are some health insurance clinics and many private clinics.
The main emphasis of care is on maternal and child health, school health, curative care and communicable diseases.
Among the programs that have high priorities are the expanded program of immunization (EPI), oral rehydration therapy (ORT) for control of diarrhoeal diseases, and case management of acute respiratory diseases.

3.5. Pilot Study and Pretest :
A small- scale pilot study was carried out on a sample of 30 cases including babies with their parents, to identify any areas of ambiguity in the questionnaire and to have an idea about time required and other practical points before the final study was launched.

3.6. Development of Questionnaire and Data Collection:
The questionnaire was developed to collect the following information and variables from all involved women (study population, see appendix):
The questionnaire related to:
1. Mother's Education/ Occupation.
2. Breast feeding/ Nutrition.
3. Growth monitoring.
4. Diarrhoeal diseases.
5. Acute respiratory tract infection- ARI (Respiratory illness).
6. Immunization.
7. Child care.

3.7. Statistical Analysis:
The data collected on (760) mothers and their babies was studied, and conventional statistical techniques were applied to the data in study of distribution by frequency percentage, bar charts, pie charts and table representations.

From data collected randomly from 5 health centers in Tikrit city, the data collected according to pre-set questionnaire sheets, 760 mothers attending to the PHC where subjected to the survey.

The results of the study revealed that most children were weighed 85.79% at the registration visit, while 14.21% were not recorded (Table 1).
Disappointment of mothers was high (82.89%) while those who attend one time only 17.11% (Table 2)

The results of the study shows the highest percent of housewife mothers (86.89%) were within age group 25-34 years, while the highest percent of employed mothers (33.87%) were within the age group (35-44) years (Table 3). The mothers who were attending higher education was at 31% only, while highest percent had secondary education 50% (Table 4).

The results of children according to type of feeding shows that most babies were breast feed 44.74%; 35.53% were bottle feed and 19.74% were mixed fed (Table5).
The mothers who breastfed their children during the first hour after delivery were 30.26% only and the mothers who starting breastfeeding from 1-8 hours after delivery were 31.84% (Table 6). The most prevalent extra food presented to the babies from 1-2 years was honey or sugar 92% (Table 7).

The mothers who knew that avoiding bottle-feeding would keep their babies breastfed were 35.26% while those who believed that exclusive breast feeding was the correct behavior to keep them breast-feeding, constituted about 28.95% (Table 8).
The results showed that 43.95% give food rich in iron for their babies while 35.26% have no idea at all about what should added according to the child's age (Table 9).

The results show that only 2.1% of mothers know the role of vitamin .A and what food contains that vitamin (Table 10).

Evidence of diarrhoea during the last two weeks among children, was 47.37%
(Table 11). The results show that a high percent of mothers (37.63%) stopped breast-feeding completely during diarrhoea (Table 12). About 38.89% of mothers give fluid more than usual during diarrhoea, while 11.11% of them stopped completely
(Table 13).

The results also show that about half of mothers give antibiotic or ante-diarrhoeal medicine during diarrhoea (52.78%) while 16.67% give Oral Rehydration Therapy (ORT) only (Table14). A high percent (95%) of mothers sought medical advice for their children (Table 15) and the highest percent of mothers in the study go to the general hospital - 44.44% (Table 16).

Most of the mothers seek advice or treatment for the child when ill with difficult breathing, and most of the mothers take their children to the general hospital 24.5% and 30% to the health center (Table 17).

The results showed that only about 18.4% of mothers knew the exact amount of tetanus toxoid vaccine needed during pregnancy (Table 18).
Most children are immunized, about 82%, while 4% don't know if their children have been immunized at all (Table 19).

The results revealed that only 49.2% of mothers have a maternal card (Table20), and that only 43.8% of mothers who have a maternal card were vaccinated twice, against tetanus during pregnancy (Table 21).

About 95% of mothers have space to record antenatal care visit in the maternal card (Table 22), and only 38% of mothers have one antenatal visit recorded in their card (Table 23). Only 17.9% were pregnant (Table 24).

About 54% of mothers wished to become pregnant in the next 2 years (Table25). The use of contraceptives was 86.84% (Table 26). About 33% of mothers under study go to PHCC at the last trimester of pregnancy (Table 27).

The results show that 24.2% of mothers don't know what food is good for women to prevent anaemia (Table 28).

The mothers who know the correct answer about weight gain during her pregnancy was 22.89% (Table 29).

Since the 1960s, family life programs in developed countries have yielded positive results in terms of increasing both knowledge of child development and parent-child interaction skills among families, as well as changing parental attitudes. Such programs have also been found to increase the likelihood that teen parents will return to school and obtain significantly more education. In comparison, teen mothers who have not attended parenting classes have been found to demonstrate more dependency, greater isolation, less interest in activities, more stress raising their children, and more unrealistic expectations of their children ⁽⁷²⁾.
In view of these facts, it is essential to assess the knowledge and attitudes of the female population concerning different issues related to maternal and child health. This will then enable us to implement appropriate programs to improve the health of both women and children, and fight the spread of some communicable diseases.

5.1. Distribution of Study Sample:

The data collected had shown that the majority of mothers were housewives 82.3%, with most of them at age group 25-34 years (i.e. 86.9%). Only about 31% of them had higher education. These data were expected in our country, especially in our province, and a predominancy of rural habits are seen here- especially those concerned with women being employed and leaving school early in the academic life period.

About 82.8% of the mothers under study were delayed beyond the appointment given by PHC workers for their routine visits, which might reflects= their poor interest and the indifference of those mothers to PHC services. Aalso the political situation may play a role.

5.2. Knowledge and Attitude of Breastfeeding

Data from 86 countries revealed that there are very large differences in breast-feeding practices between countries, between population groups within counties, and within different groups over a period of time ⁽⁷³⁾. A downward trend in breast-feeding has been noted widely in different countries of the Middle East, especially in urban areas where mothers with raised socioeconomic status resort to bottle-feeding quite early ⁽⁷⁴⁾.

In the current study, most sampled mothers believed that breast milk was the best food for their infants and knew that breast milk had many advantages for infants, mothers and families, but only about 45% of the mothers had a positive attitude towards breast feeding, and only 30% of the mothers were breast feeding their children during the first hour of life. Grover et al ⁽⁷⁵⁾ in India also found that although the majority of the respondents had good knowledge towards breastfeeding, the percentage of breastfeeding in his study was also lower than it should be, and only about 9.1% of them breast fed their children during the first hour of life. The promotion of breast-feeding is one of the essential interventions for reduction of infant mortality and improving infant development worldwide (⁷⁶⁾, thus it is important to encourage mothers to start breastfeeding as early as possible. It is noticed in our current study that about 62% of mothers started breastfeeding during the first 8 hours after delivery, which agreed with what Schemes ⁽⁷⁷⁾ at Libya noticed in his study (i.e. 65%).

In the current study, the exclusive breastfeeding rate was low among breastfeeding mothers (i.e. 28.9%). Li et al ⁽⁷⁶⁾ in a study at Thailand also noticed a relatively low rate of exclusive breastfeeding among mothers under the study compared with the total number of breastfeeding mothers. Antenatal plans for exclusive breast-feeding and newborn feeding in hospital after birth may play key roles in the duration of exclusive breastfeeding. These findings suggest the importance of strengthening implementation of prenatal health education regarding breast-feeding ⁽⁷⁶⁾.

Exclusive breastfeeding for about six months is increasingly being shown to be central to infant health and even maternal health due to its impact on birth spacing. Previous research has too often been based on an inadequate definition of exclusive breastfeeding, and thus has underestimated its importance. Even the giving of glucose water soon after delivery or the feeding of complementary water, are unnecessary and harmful practices ⁽⁷⁸⁾.

The use of bottles makes breastfeeding failure more likely for a number of reasons, including nipple confusion for the infant. In the current study, about 35% of the mothers know that avoiding bottle-feeding promotes their maintenance of breastfeeding practice. Supplements provided by cup do not fulfill the sucking needs of the infant, and this may explain why traditionally complementary feeding from early ages was easier to maintain alongside continued breastfeeding than bottle- feeding seems to be ⁽⁷⁹⁾.

Complementary food included all meals given to the child besides milk. The timing of complementary foods is of critical importance for the health and wellbeing of the child. On the one hand, before 6 months, breast-feeding offers general protection to children from diarrhoeal disease and other infections. In addition, delay in introduction of other foods offers some protection ⁽⁷⁷⁾

On the other hand, after 4-6 months, growth cannot be sustained on breast milk alone. According to WHO, the International Pediatric Association and other bodies, introduction of complementary foods should commence at 4-6 months of age ⁽⁷⁷⁾.
More than 35.7% of mothers in the current study were adding complementary food earlier than 4 months of the child's life, in comparison with 17.9% noted by Schemes ⁽⁷⁷⁾ at Libya and 87.9% seen by Saowakontha ⁽⁸⁰⁾ in Thai villages. About 58.6% of mothers in the current study were introducing supplementation before 6 months of age, while Al-Sekait (81) has mentioned that a study in Sudan showed about 76%-91% of mothers there were introducing supplementation before 6 months of age. This high difference suggests the big gap between knowledge and attitude of mothers in different areas of the developing countries- regarding complementary food- and the big effort that should be undertaken to overcome this poor background of these mothers in these areas, including our country.

The purpose of complementary food is to transfer the child from breast milk to family diet. The complementary food practices have been surveyed in most of the Arab countries ^(82,83). The general pattern in the present study is largely the same as in corresponding socioeconomic strata.

Water, juice, semisolid food, eggs, and adding sugars and honey were the most common supplementation given for the children by mothers in the current study, which agreed with what Shembesh noticed in Libya ⁽⁷⁷⁾, Serenius in Saudi Arabia ⁽⁸²⁾, and what Patwardan in the Middle East have conducted ⁽⁸⁴⁾.

Cultural influence plays a major role in the decision about which foods are to be introduced and at what age ⁽⁸²⁾. About 35.2% of the mothers in current study have no idea about what should be added exactly to the child at his age, but they follow the advice of older females in their families or friends. A simple question about the role of Vitamin A and what food contains that vitamin show that only 2.1% of mothers know the right answer, which gives us a clue about their poor background.

5.3. Growth Monitoring

Recent studies evaluating the efficacy of growth monitoring programs have scrutinized their educational and preventive capabilities. Advocates claim that growth monitoring can be effective if communities and mothers are more actively involved in the process of weighing and measuring, and if the technology is understood by all as an aid for disease prevention and health promotion rather than as a "curative" procedure. Others have argued that this theory is rarely possible to implement. The ways in which preventive growth monitoring can be made possible are still under exploration, given that the reasons for such deeply imbedded "curative" expectations of growth monitoring are not fully understood. Any such understanding requires an analysis of growth monitoring within the context of the GOBI (growth monitoring, oral rehydration therapy, breastfeeding and immunization) child survival framework ⁽⁸⁵⁾.

Upon this importance of growth monitoring of the children, the percentage of children (24.3%) with no growth monitoring card, and the percentage of children (14.2%) who were not weighed at all during the last 4 months of their age were considered high percentages.

5.4. Mother's Knowledge and Attitude Concerning Diarrhoea

Diarrhoea continues to plague the developing world, resulting in more than 3 million deaths ⁽⁸⁶⁾. In the current study, about half of the mothers said that their children have had diarrhoea during the last two weeks, which shows us how big the problem is in our society, especially in summer.

According to WHO guidelines for the management of diarrhoea, anti-diarrhoeal, anti-amoebic and anti-bacterials have little role to play ⁽⁸⁷⁾. Despite this fact, overuse of antimicrobial agents has been reported for the management of the diarrhoea conditions ⁽⁸⁸⁾. In the current study, although about 96% of mothers sought medical advice for their children with diarrhoea from medical personnel, about 53% of their children were taking antimicrobials for treatment. This suggests the wide abuse of these antimicrobials by the medical personnel, which leads in turn to gradual tapering in use of oral rehydration therapy (ORT) over time. In the current study, the fluid replacement for children with diarrhoea was practiced only by 38.9% of mothers correctly, which is in accordance with what Datta et al ⁽⁸⁹⁾ found at India (i.e. only about 40% of mothers were correctly giving ORT to their children).

Community health education is of utmost importance for effective case management, since it has the potential to establish productive contact between the health services and the community, to increase capability of families to recognize the danger signs of diarrhoea in children and to encourage appropriate and early care seeking behaviors ⁽⁹⁰⁾. About 13% of mothers did not know what signs of diarrhoea need medical attention; others were seeking medical advice as soon as their children had fever or vomiting.

Effective health education can only be provided on the basis of an accurate understanding of prevailing knowledge, attitude and practices of the community ⁽⁹⁰⁾. This study showed that the knowledge and attitude of mothers is not satisfactory, since about 44% of mothers were taking their children to the general hospital as soon as they notice diarrhoea episodes, and only about 16% of these mothers were giving more fluids to their children, while less than 6% were giving small frequent meals to their children. Surprisingly, about 17% of mothers did not even know what to do after their children recovered from diarrhoea.

5.5. Knowledge and Attitude of Mothers About ARI:

Control of acute respiratory infections (ARI) is a major public health problem in developing countries. The child respiratory illness is one of the big problem affecting the children in Iraq in the study group. It also consumes a greater share of the government budget of the primary health sector. Implementation of case management protocols requires participation of the community to reduce morbidity and mortality from ARI. Health education programs can only be effective when designed to take into account the prevailing knowledge, attitudes and practices (KAP) of the community towards ARI in their children ⁽⁹¹⁾.

In the current study, mothers said that more than 52% of their children suffered from cough and/or difficult breathing in the last two weeks. This high percentage suggests the magnitude of this problem in Tikrit city. All the mothers were aware of these two symptoms, but when those with positive "cough" answers were asked about development of subsequent difficult breathing during illness, eighteen women (i.e. 4.5%) did not know , and 12% of women did not even seek medical advice for their children's difficult breathing, which is in accordance with what Simiyu ⁽⁹¹⁾ in Kenya found, in that the mothers had good knowledge of mild forms of ARI but not the severe forms.

It was also noticed that about 7% of mothers sought advice for their ill children from non-medical personnel, and about 14.7% did not know the main symptoms that should make them take their children to the hospital, which indicates their poor knowledge and/or attitude about the serious condition of their children. It is important to understand that low utilization of health services for moderate ARI may result in continued high mortality because of delayed identification of seriously ill children.

A KAP ARI survey in Iraq at 1995 ⁽⁹²⁾ revealed that 46% of the 900 mother sample covered, could detect the risk signs of ARI related infections, with the current study showing a higher amount (about 65%), which is, perhaps, due to better diagnosis and better management, that may lead to increase the mother's knowledge about ARI.

However, on method of treatment 71% still believe in antibiotic use and 64% revert to cough medicine. In the North of Iraq, a survey was undertaken in the three northern governorates in December 1994 with the 30-cluster immunization survey. The survey revealed that mothers are not fully aware of earlier signs and symptoms of respiratory infections in their children and when to seek medical advice, as evident in their limited knowledge about rapid breathing as an indication of ARI. However, their knowledge about difficult breathing as an indicator of acute respiratory infection and correlating that with the prognosis of their children's health, was good ⁽⁹²⁾.

5.6. Knowledge and Attitude of Mothers about Immunization:

Immunization is a timely step for prevention of mortality and morbidity due to communicable diseases in the 0-5 year age group. The delivery system of immunization has many inherent problems to which an addition may be made by the people themselves, with their prejudices, carelessness and apathy ⁽⁹³⁾. In the current study, a small percentage of mothers (i.e. 4%) were not vaccinating their children -or do not know if their children have received immunization at all, in spite of all the programs held for vaccinating young children, which emphasizes what we have mentioned above.

Surprisingly, about one-quarter of the mothers did not know why immunization was given to the mothers during pregnancy; others gave different answers. Also, only about 18.4 % of mothers knew the right answer about stages of immunization against tetanus. El-sherbini ⁽⁹⁴⁾ in Egypt also found that about 25.5% of mothers lacked basic and essential knowledge about antenatal care. Enhancing mothers' knowledge on tetanus is important to increase the coverage of tetanus toxoid. Moreover, antenatal care would cause contact with sources of tetanus toxoid and hence increase the chance of having the immunization ⁽⁹⁵⁾.

Another two questions were asked regarding the availability of space in their maternal card, for recording of such events, and the number of tetanus vaccination times reported in that card. Even though there was room to record this information, (about 96% of cards), only in 43.8% of those mother's was the vaccination reported twice, which also shows the poor knowledge and attitude concerning tetanus toxoid immunization.

5.7. Knowledge and Attitude of Mothers About Pregnancy and Family Planning:

In the current study, about 17.9% of mothers were pregnant, and 54.5% of the remaining wish to be pregnant in the next two years. Also, about 13% of females who don't want to be pregnant or who have not decided yet to be pregnant in the next two years, are not currently using contraceptive methods to avoid pregnancy. These percentages show us the poor family planning of these females.

In the current study, a low level of knowledge and attitude regarding family planning was found, in contrast to what Aja et al ⁽⁹⁶⁾ in Nigeria found, The findings in their study showed a high awareness level with a moderately positive attitude, and generally a low level of practice.

Concerning antenatal care visits, about 38% of mothers only had one antenatal care visit during her last pregnancy, and 2 (i.e. 0.5%) women did not have any visit at all. This explains the poor knowledge and attitude of mothers towards the benefits of maternal care, especially if we know that about one-third (33%) of the mothers under study attend PHC centers at the last trimester of pregnancy and not before.
As an example of mothers' poor knowledge, about 22.9% of mothers know that (10 -12 kg) will be gained during pregnancy, the remaining either don't know or gave a wrong response. Also, about 24% of mothers don't know what food is good for women to prevent anaemia during pregnancy; even the answers about the question regarding the amount of food taken and whether it changed during pregnancy, was disappointing.

Conclusions:

1. Only about 31% of these mothers attended high education academies.
   
2. About 82.8% were delayed beyond their appointment given by PHC workers for their routine visits, which reflected their indifference and poor interest towards PHC services.
   
3. The knowledge and attitude of mothers is, generally, not satisfactory regarding diarroheal disease for their children.
   
4. About 65% of mothers in our study have good knowledge about these signs compared with 46% in 1995.
   
5. Poor knowledge and attitude of mothers concerning immunization against tetanus, and also regarding antenatal care.

Recommendations:

1. To Ministry of Health- Directory of Health Education:

• Promotion of breast-feeding among mothers through educating them about beneficial effects by periodic conferences.
  
• Educating the mothers about the best KAP regarding ARI, diarrhoeal disease, and perinatal care through multiple periodic conferences and mass media.

2. To our Colleagues in Medical Colleges: Further studies should be held to evaluate the practices of mothers regarding childhood survival.

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Significant (P value < 0.05)

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