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Original Article Factors affecting antenatal services in a rural area of district

Panipat

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MRIMS Journal of Health Sciences 2020;8(1) pISSN: 2321-7006, eISSN: 2321-7294
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Original Article

Factors affecting antenatal services in a rural area of district Panipat

Manveer Singh1, Gauri Shankar Goel2*, S.K. Aggarwal3
1,2
Assistant Professor, 3Professor & HOD, Department of Community Medicine, NC Medical College & Hospital, Israna, Panipat,
Haryana, India

*Corresponding Author:

Email: [email protected]

Abstract:
Background: Being a mother involves many risks which are well known from an era of time. It can range from minor
hyperemesis to life threatening hemorrhages. A very effective measure to counter these risks is Antenatal care involving antenatal
checkups, investigations and specific protection measures like TT immunization and IFA tablets. All these services are provided
to women in India through various schemes, a few like JSY, JSSK and PMSMA.

Objective: This study was planned in an area where limitation of such services due to a density of population is there to estimate
the utilization of Antenatal Care Services and to look for various factors responsible for the pattern of utilization.

Method: A community based cross-sectional survey was done in Madlauda block of district Panipat having a population of 1.43
lakhs on recently delivered women residing in the study area during the period of study. The data were collected with the help of a
semi-structured interview schedule.

Results: Most of the women had antenatal registration and though a good number of women delivered their babies at a healthcare
facility, still most of them did not avail the minimum required antenatal checkups i.e. a minimum of 4 antenatal visits. TT
immunization rate was quite high while consumption of IFA tablets was relatively very low. Analyses of the socio-demographic
factors revealed education status, caste, work and religion to be significantly associated (p<0.05) with antenatal checkups and type
of family, education status, work status and religion to be significantly associated with institutional deliveries. (p<0.05)

Conclusion: Utilization of antenatal services in terms of antenatal checkups was quite low as only one-third of the study
participants had minimum Antenatal checkups.

Key words: Antenatal, Pregnancy, Birth, delivery

Introduction: amounting to one lakh maternal deaths and ten lakh

newborn deaths every year. 2
Birth of an individual epitomizes an era of new beginning
with new hopes but unfortunately this isn’t as easy as it India contributes significantly to the global burden of
seems for a woman who has to give birth in a country with maternal deaths, more than 20% of maternal deaths occur in
low resources and scarcity of healthcare services and India. Pregnant women in India die due to a combination of
primary healthcare just confined to mere management of various factors such as poverty or ineffective and
minor ailments only and that too not distributed universally. unaffordable health services. 3
Antenatal period begins as soon as a woman conceives and
continues till the birth of the baby and lasting for about 9 The common causes for maternal mortality include severe
months this period forces the women to endure certain risks bleeding, infections, eclampsia, unsafe abortion, obstructed
that are quite common and minor and some that are quite labor and social causes are poverty, illiteracy, too close
rare and serious. A pregnancy may affect mental status of a pregnancies, poor environmental sanitation, delivery by
woman, her general confidence; way of living temporarily untrained dais, and mainly due to lack of maternity services.
4
or permanently, may deteriorate physical health or affect Antenatal care means care during such a crucial period of
function of the body. Each year, approximately eight million life that will result in a fruitful outcome in terms of healthy
women suffer pregnancy- related complications and over mother and healthy baby. It is evident that for leading a
half a million die. 99% of all maternal deaths occur in healthy life care should begin as early as possible so why
developing countries. 1 Every five minutes, one woman in not soon after conception? Currently in India the Maternal
India dies due to pregnancy related complications Mortality Ratio is 130 per lakh live births as per 2014-16
reports. 6 A large proportion of these deaths are preventable

MRIMS Journal of Health Sciences, Vol. 8, No. 1, January-March 2020 Page 1

 Singh M et al. Factors affecting antenatal services in a rural area

by safe motherhood interventions via various national health Aim & Objectives:
programs run by Govt. of India. Some of the maternal health
benefits schemes include mainly Janani Suraksha Yojana, 1. To estimate the utilization of Antenatal Care
Janani Shishu Suraksha Karyakaram, Vande Mataram Services in the study area.
Scheme, Indira Gandhi Matriva Yojana, Madilu Yojane and 2. To find out various socio-demographic factors
Prasoothiaraike. The main objectives of the maternal health responsible for the pattern of utilization.
benefits scheme are to promote institutional deliveries and 3. To recommend measures for improvement in the
to reduce maternal mortality rate & infant mortality rate. 4 utilization.

Quality of care received by the mother and baby depend METHODS:

upon the place of delivery. If proper care is not taken during
this child bearing process, it affects the overall health, The present study design consisted of a Cross-sectional
especially the reproductive health of the women as well as Community based survey done from August 2018 to
the health of the new born child. 5 January 2019 on pregnant women residing in the study area
during the period of data collection in Madlauda block of
Janani Suraksha Yojana is a safe motherhood intervention district Panipat. Permission was taken from institutional
under the National Rural Health Mission to promote ethics committee for the study. Verbal consent was taken
institutional deliveries throughout the country. from study participants.

Janani Suraksha Yojana is 100% sponsored by central Inclusion Criteria:

government. The Yojana was launched on 12 th April 2005.
The primary component of Janani Suraksha Yojna are Early 1. Women who delivered live births in the last one
registration, Micro-Birth Planning, Referral transport (home year from date of interview.
to health institution and back), Institutional birth, post- 2. Women who had given consent to participate in the
delivery visit and reporting, family planning advice and study.
Mother and Child Health counselling. 2 The objective is
reducing maternal and neo-natal mortality by promoting Exclusion Criteria:
institutional delivery among the poor pregnant women.
1. Women who didn’t give consent to participate in
Apart from this there are certain roles of ASHA under JSY the study.
i.e. ASHA is to act as a facilitator and is an important 2. Women who could not be contacted even after
component of the JSY strategy10. The mail roles are to three visits.
identify pregnant woman as a beneficiary of the scheme and
Minimum sample size:
report or facilitate registration for ANC, assist the pregnant
woman to obtain necessary certifications wherever 243 (Considering delivery rate of rural Haryana) 80.4% as
necessary, provide and / or help the women in receiving at per NFHS-IV 6; N=3.84pq/l²) 7, 8
least four ANC including TT injections, IFA tablets,
identify a functional Government health center or an This was rounded off to 250 so as to include equal number
accredited private health institution for referral and delivery, of study participants from 10 selected villages.
counsel for institutional delivery, escort the beneficiary
women to the pre-determined health canter and stay with her Sampling Technique:
till the woman is discharged, arrange to immunize the
newborn till the age of 10 weeks, inform ANM/MO about At the first stage Madlauda block was selected out of the 5
the birth or death of the children mother, post-natal visit blocks of District Panipat with the help of simple random
within 7 days of delivery and track mother’s health, counsel sampling (chit method).
for initiation of breastfeeding to the newborn within one-
hour of delivery and its continuance till 3-6 months and At the second stage, a list of all villages of the Madlauda
promote family planning. The compensation package for block was obtained. It consisted of a total of 37 villages with
ASHA is available to her if she escorts/stays with the about 27000 households. 10 villages out of these 37 were
pregnant women in the health centers. selected with the help of currency method after organizing
them in alphabetical order and serializing. Out of each of the
Additionally, in view of the difficulty being faced by the selected villages 25 study participants were interviewed.
pregnant women and parents of sick new born along with
high out-of-pocket expenses incurred by them on delivery Selection of households: After reaching the village, the
and treatment of sick newborn. Government of India has center of the village was identified and by dropping a pencil
launched Janani Shishu Suraksha Karyakaram (JSSK) on 1st a random street was indicated by the tip of the pencil. Then,
June, 2011 to provide completely free and cashless services house to house survey in the selected village was done
to pregnant women including normal deliveries and starting from the selected street. At the end of the street a
caesarean operations and sick new born and sick infants in right turn was taken each time and a fresh adjacent street
Government health institutions in both rural & urban areas. 4 was selected when a dead end was reached or there was no
turn in the street.

MRIMS Journal of Health Sciences, Vol. 8, No. 1, January-March 2020 Page 2

 Singh M et al. Factors affecting antenatal services in a rural area

Selection of Mothers: Every mother who had an infant at the DISCUSSION:

time of survey was interviewed in a household. Verbal
informed consent was obtained before interviewing the This study showed that only one third study participants got
mother. This was repeated till desired sample size of 25 the minimum required antenatal checkups i.e. >=4. Though
from each of the selected village was met. institutional delivery rate was found to be high (83%), still a
lot number of study participants had delivered their babes at
Study Tool: A pre-designed and pre-tested interview home all accompanied by skilled birth attendants like
schedule was used to interview mothers after obtaining ANMs. The antenatal registration findings are similar with
informed consent. It comprised of questions regarding Manish KS et al 10 et al in which 97 % of the recently
socio-demographic characteristics of the study participants, delivered women had ANC registration. The findings are
medical & obstetrics history, awareness & registration of the better as compared to the estimates of DLHS-III 11, where
JSY & JSSK, ante-natal care utilization. almost 75% of women had at least one antenatal care visit.
This could be due to a reason that day by day the health
Statistical analyses: The data were entered in the Excel services in our country are improving and being conducted
spread sheet and statistical analysis was done using IBM prior the later might have got poor results. Almost all of the
SPSS v 20.0.0. Categorical variables were analyzed using study participants included in the present study got
frequency with proportions and percentages. Association immunized by 2 doses of TT while some of them got only
between categorical variables was established by odd ratio single dose and just one was not immunized at all. All
using univariate analysis. Multivariate logistic regression except three study participants in the present study had
model was used to establish adjusted odds. Goodness of fit received 100 IFA tablets. In a study conducted by Kakati R
for the selected models was ensured (Table 1, -2 log et al 12,68.7% of the women had more the three antenatal
likelihood 1.473, X2=21.03, p<0.001) (Table 2, -2 log visits. 71.6% of women consumed full course of IFA or at
likelihood 131.77, X2=935, p<0.001). A p value of <0.05 least 100 tablets and the association between ANC
was considered to be significant. utilization and socioeconomic status, place of delivery and
mode of delivery were found to be significant (P<0.05).12
RESULTS: The full IFA consumption rate was just 42.5%.The findings
of this study are bit lower than the Bui TT Ha et al 13 53.9%
Socio-demographic characteristics of study participants of the women had more than three antenatal visits.In
revealed majority age group of 25-30 years (52.8%) with Awasthi et al 14 60.7% of the mothers utilized the existing
majority belonging to joint families (69.34%) and Hindu ANC care services well whereas the remaining 39.3% of the
religion (75.3%), General caste (51.9%), educational status respondents showed poor utilization of antenatal care
shows majority being illiterate 47.54% while nearly one services. Also the same study reported that 82.0% of the
fourth of mothers had education of high school and above. mothers had consumed Iron/Folates out of which a further
Socio-economic status showed majority towards lower 68.3% of them had consumed the tablets up to 45 days after
middle and middle class. (Modified BG Prasad, AICPI-301 delivery and 70.0% of respondents had received TT
Dec.2018) 9 Vaccines out of which only 65.7% of respondents received
both doses with the remaining mothers either receiving a
A great number 96% had antenatal registration. Only one single or a booster dose of the TT Vaccine during their
third of the participants had ≥4 Antenatal Checkup. (Figure pregnancy. 59.51% of the mothers in the area had three or
1) and a really good number though not all 209 (83.6%) more antenatal visits in a study reported by Danasekaran et
delivered their baby at a healthcare institute. All the ones al. 15 The proportion of women with 4 or more ANC visits is
who delivered at home were accompanied by skilled birth considerably lower than the global average of 61.8% and
attendants. (Figure 2) implementing the recent WHO recommendation of a
minimum of 8 ANC visits will be a major challenge for the
Almost all of the study participants (92.8%) got immunized national program in India. 16 The number of ANC visits may
by 2 doses of TT while the rest got single dose and only 1 of also be critical to the delivery of other components of ANC
the participants was not immunized at all. All except three and to provide adequate follow-up of pregnant women
study participants received 100 IFA tablets while 2 had to closer to delivery. 17 The difference was also noted in
take parenteral iron due to severe anemia and 1 didn’t get findings of NFHS III 18 indicate that 67.5% of mothers had
any. The full IFA consumption rate was just 42.5%. at least three antenatal checkups. Health functionaries
particularly MPHW-F, ASHA, and Anganwadi workers
Multivariate analyses of the socio-demographic factors with need to be sensitized to ensure timely registration and
the findings revealed that education status, caste, work and referral of high-risk pregnancies. TT immunization rate was
religion were significantly associated (p<0.05) with 92.8 % which is more as compared to findings in Sonia P et
antenatal checkups and joint family type, education status, al 19 in which the TT immunization was 70% while Parul S
work status and religion were associated significantly with et al 20 found all the women received complete TT
institutional deliveries.(p<0.05) The variables not found immunization. This study showed that consumption of IFA
significant in univariate analyses were not included in tablets was 42.5% which is almost comparable to the
multivariate analyses.(Table 1 & 2) findings of Tanmay P et al 21 in which consumption of 100
Iron Folic acid tablets was 46.0% and also in Parul S et al 20
which showed consumption to be 48%. The reason for low

MRIMS Journal of Health Sciences, Vol. 8, No. 1, January-March 2020 Page 3

 Singh M et al. Factors affecting antenatal services in a rural area

IFA tablets consumption could be attributed to low literacy 4. Park K. Park’s text book of preventive and social
level among mothers of rural areas and minor effects of the medicine. 23rd ed. Jabalpur: Banarasidas Bhanot;
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rate was found to be almost similar to the state estimates. births); Available from:
The result was better in comparison to Vikram K et al 22 http://niti.gov.in/content/maternal-mortality-ratio-mmr-
institutional delivery rates was found to be 71% and also 100000-live-births Accessed on 21 Dec 2018
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deliveries. Further continuation of this study in the form of 7. National Family Health Survey – 4[Internet]: MOHFW
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checkups was quite low as only one-third of the study Gorkha, Nepal: A Cross-Sectional Study. J Pregnancy
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deliveries were seen among most of the participants while https://doi.org/10.1155/2018/3467308. Accessed on 21
all were attended by skilled birth attendant at home. Dec 2018
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MRIMS Journal of Health Sciences, Vol. 8, No. 1, January-March 2020 Page 4

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scheme) in rural areas and urban slums. Indian J Socio-demographic characteristics of study participants revealed majority
Community Med 2011;22(2):11-14. age group of 25-30 years (52.8%) with majority belonging to joint families
21. Panja TK, Mukhopadhyay DK, Sinha N et al. Are (69.2%) and Hindu religion (75.6%), General caste (52%), educational
status shows majority being illiterate 47.2% while nearly one fourth of
Institutional Deliveries Promoted by Janani Suraksha
mothers had education of high school and above. Socio-economic status
Yojana in a District of West Bengal, India? Indian J showed majority towards lower middle and middle class.
Public Health 2012;56(1):69-72.
22. Kumar V, Sharma AK, Kannan AT. Beneficiary level Table 1: Multivariate analyses showing relationship between various
factors influencing Janani Suraksha Yojana utilization in socio-demographic factors and antenatal checkups (N=227)
urban slum population of trans-Yamuna area of Delhi.
Indian J Med Res 2013; 138:340-346. Factor N (%) Odds 95% P value Β
23. Khatib N, Syed Q, Gaidhane AM et al. Predictor of CI
antenatal services and pregnancy outcome in rural areas. Education Literate 129 7.2 1.73- 0.0001 0.976
Indian J Med Sci 2009;63(10):436- 444. (57) 4.7
24. Lim SS, Dandona L, Hoisington JA et al. India’s Janani Illiterate 98 1 ---
(43)
Suraksha Yojana, a conditional cash transfer program to
Caste General 123 1 --- 0.421 1.06
increase births in health facilities: an impact evaluation. (54.1)
Lancet 2010; 375: 2009-20. Others 104 0.82 0.21-
(45.9) 3.72
Figure 1: Depicting number of antenatal checkups in the study Work Working 20 0.72 0.17- 0.342 -1.32
participants (N=250) status (8.8) 3.07
Not 207 1 ---
59.2 working (91.2)
Religion Hindu 172 1 --- 0.0001 -14.89
60 (75.7)
Muslim 30 0.69 1.65-
50 (13.2) 9.34
Percentage of study participants

40
31.6 Table 2: Multivariate analyses showing relationship between various
socio-demographic factors and institutional deliveries. (N=209)
30
Factor N (%) Odds 95% P value Β
CI
20
Family Joint 163 0.63 1.48- 0.006 -5.724
9.2 type (78) 10.3
10 Nuclear 46 1 ---
(22)
Education Literate 119 3.9 0.94- 0.562 -12.547
0 (57) 6.65
No Checkup <4 Checkups ≥4 Checkups Illiterate 90 1 ---
(43)
Work Working 16 2.1 1.46- 0.007 -19.831
Figure 2: Pie chart showing percentage of institutional deliveries
status (7.6) 4.86
among the study participants
Not 193 1 ---
working (92.4)
Religion Hindu 177 1 --- 0.0001 0.188
(84.6)
Muslim 15 0.59 0.23-
(7.17) 1.5
16.4 Others 17 0.76 0.34- 0.07
(8.14) 1.82
Home
deliveries
Institutional
83.6 Deliveries

Cite this article as: Singh M, Goel GS, Aggarwal SK.

Factors affecting antenatal services in a rural area of
district Panipat. MRIMS J Health Sci 2020;8(1):1-5

Source of Support: Nil. Conflict of Interest: None

MRIMS Journal of Health Sciences, Vol. 8, No. 1, January-March 2020 Page 5

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