Sarabjit Kaur, Parvesh Saini, Karuna Sharma

Abstract:

Antenatal Care (ANC) includes education, counseling, screening and treatment to monitor and promote the well-being of the mother and fetus. However, the utilization of ANC services is a complex phenomenon inuenced by many factors, such as maternal education, maternal employment, accessibility, affordability, family support and decision-making power etc. Objectives:1. To determine the extent of utilization of antenatal care (ANC) services among antenatal mothers. 2. To identify the factors affecting utilization of antenatal care (ANC) services among antenatal mothers. Materials and methods: An exploratory study was conducted to assess the factors affecting utilization of antenatal care (ANC) services among antenatal mothers at selected rural communities of Amritsar. Stratied sampling technique was used to select 60 antenatal mothers. Data was collected using the semi structured questionnaire to assess the factors affecting utilization of antenatal care services among antenatal mothers. Results: Most of antenatal mothers (93.3%) were registered and 4(6.7%) were not registered for their pregnancy (investigator came to know at the time of home visit). 50(83.3%) antenatal mothers had adequately utilized antenatal care services. Major factors which affect the utilization of ANC services as reported by antenatal mothers were accessibility (53.3%), family support (33.3%), affordability (26.7%). Conclusion: There is adequate utilization of ANC services though some factors act as barrier in the utilization of ANC services. Health care professionals should determine the factors causing poor or irregular utilization of antenatal care services and nd the ways to improve it.

Key Words: Antenatal care Services; Antenatal mothers; Rural community; Utilizations.

Address for correspondence:

Dr. Parvesh Saini Professor cum Principal SGRD College of Nursing

Mehta Road, Vallah, Amritsar, Punjab Contact: (+91) 99144-34834

Email: pwpsingh@yahoo.com

Introduction

Pre-natal health supervision permit the diagnosis and treatment of pre-existing maternal disorder or disorder that may develop during pregnancy.1   In India most of the mothers have poor knowledge about antenatal care. Illiteracy, poverty, lack of communication and transportation facilities m a k e t h e m v u l n e r a b l e t o s e r i o u s consequences.2  The attention towards health care of the women and child is increasing in all parts of the world including India. Maternal health has emerged as a global priority because of the gap in the status of women in the rich and the poor countries. Millions of women worldwide suffer from various illnesses and disability arising out of pregnancy and child birth. Government of India has launched several programs related to maternal and child health to improve the health status of women and child. World Health Organization (WHO) has summarized three crucial factors underlying maternal deaths. Firstly, lack of access and utilization of essential obstetric care, Secondly, low social status of women in developing countries, Thirdly, too much physical work together with poor diet contributes to poor maternal health outcomes. Out of the three factors, access and utilization of health care is the most crucial factor which is capable of reducing maternal morbidity and mortality. Utilization of health services is complex behavioral phenomenon affected by multitude of factors including availability, distance, cost and quality of care as well.3

WHO denes antenatal care as a dichotomous variable, having had three or more visits to a trained person during pregnancy. It includes routine follow up provided to all pregnant women at primary care level from screening to intensive life support during pregnancy and up  to  delivery4 .  WHO  recommends  a minimum of four antenatal visits, comprising interventions such as Td vaccination, screening and treatment for infections, and identication of warning signs during pregnancy. Globally, during the period 2005–2012, about 55% of pregnant women attended the recommended minimum four times antenatal care. The proportion of pregnant women in developing countries who attended at least four antenatal care visits has been increased from 37% in 1990 to 50% in 2011 but, in low-income countries, only 37% of pregnant women attended four times or m o r e a n t e n a t a l c a r e d u r i n g 2 0 0 5 – 2012.4Antenatal care (ANC) among pregnant women is one of the important factors in reducing maternal morbidity and mortality. Unfortunately, many women in developing c o u n t r i e s d o n o t r e c e i v e s u c h care.5 Approximately  80  percent  of  the maternal deaths globally occur due to hemorrhage, sepsis, unsafe induced abortion, hypertensive disorder of pregnancy and obstructed labor. These deaths are unjust and can be avoided with key health interventions like provision of antenatal care and medically assisted delivery6.

Improving the utilization of antenatal care services is a global challenge for the health system in low- and middle-income countries. The goal set by the UN (United Nations) MDGs (Millennium Development Goals) to reduce maternal mortality ratio by three quarters between 1990 and 2015. According to latest United Nations report, India is likely to miss the millennium development goal (MDGs) related to maternal health with one maternal death reported every ten minutes. Although there is improvement from maternal death in every six minutes in 2010 to every ten minutes at present. However, India has reduced maternal mortality rate signicantly from 437/ lakh live births in 1999, 212 deaths/1 lakh live births in 2007- 2009 to 178 in 2010-2012 but needs to hasten pace under National Rural Health Mission to achieve the related MDG country’s target109/ lakh live births by 20157.

It is widely accepted that the use of maternal health services helps in reducing maternal morbidity and mortality. However, the utilization of maternal health services is a complex phenomenon inuenced by many factors. Various studies conducted worldwide and in India have recognized socio-economic factors and service delivery environment as important determinants for the use of with an exploratory survey design to conduct study at selected rural communities covered under Rural Health Centre ( RHC) Mallunangal, Amritsar, Punjab. Data was collected in February 2015with interview technique. Before data collection ethical clearance was taken from the research and ethical committee of SGRD hospital, maternal  health  services.8    Maternal  health Amritsar and formal permission was obtained care services utilization is important for early detection of mothers who are at high risk of illness and mortality during pregnancy. The essential maternal health care services during pregnancy included antenatal care, skilled care at delivery and postpartum care and these are necessary to promote good health.9

The World is facing several consequences for not approaching to antenatal care. In developing countries, complications of pregnancy and childbirth are leading causes of death among women of reproductive age and they could be avoided if resources, services and fairness of its distribution were made available (Pokharel et al., 2007)10. On one side there has always been demand and efforts of increasing the infrastructure and manpower to provide necessary services in order to improve the health of the people. D e s p i t e t h e p r e s e n c e o f a d e q u a t e infrastructure and facility people are not utilizing them. Poor utilization reects constraints in the way of utilization either in terms of accessibility or in terms of socio demographic correlates.

Objectives : 1. To determine the extent of utilization of antenatal care (ANC) services among antenatal mothers. 2. To identify the factors affecting utilization of antenatal care (ANC) services among antenatal mothers.

Methodology:

Quantitative research approach was adopted from the Head, Department of Community Medicine. Timings of data collection was 10 am to 2pm. A total of 60 antenatal mothers were selected by using stratied sampling technique from 10 villages covered under RHC Mallunangal, Amritsar. One village is taken as one stratum. The list of antenatal mothers was obtained from ANM Staff. Then from each village (strata) antenatal mothers were selected by using simple random sampling technique. Self-introduction and purpose of collecting information was explained to the mothers. Informed written consent was taken from the antenatal mothers before the interview and were assured of maintaining condentiality of their responses. Average time taken per mother was 20-25 minutes.

Tool was prepared after an extensive review of literature and validated by the subject experts. The tool for data collection was interview schedule comprised of four parts. Part A Socio-demographic prole of antenatal mothers. Part B obstetrical history of antenatal mothers. Part C questionnaire to assess ANC services utilization and Part D Factors affecting utilization of ANC services. The reliability of components of antenatal care services and factors affecting utilization of ANC services is calculated with the test–retest method and is 0.93 and 0.98 respectively. Hence the tool was considered reliable for conducting the main research study. Data was computed and analyze during descriptive and inferential statics

Results :

Table 1 reveals demographic variables of the antenatal mothers that shows majority of the antenatal mothers i.e., 47(78.3%) were in the age group of 21-30 years and 13(21.7%) were in the age group of <20 years. As per the educational status of antenatal mothers, 22(36.7%) were having secondary level education, 18(30.0%) primary education, 9(31.7%) illiterate, 1(1.7%) antenatal mother was post graduate. Educational status of husbands depicts that 25(41.7%) secondary level education, 19(31.7%) were having primary level education and 16(26.7%) were illiterate. Majority of antenatal mothers 56(93.3%) were housewives and 3(5.0%) laborers. Most of husbands i.e., 52(86.7%) were laborers, 6(10.0%) farmer and 2(3.3%) with govt. Job. Family income per month of antenatal mothers depicts that 32(53.3%) mothers income was ranged from Rs. 5001- 10,000, 16(26.7%) < Rs. 5000, 7(11.7%) with

Rs. 10,001-15,000 and 5(8.3%) were with family income > Rs. 15,000. Most of (73.3%) antenatal mothers were from joint family and 16(26.7%) from nuclear family.

Variables f (%)
Gravida  
a.  Primigravida 23 (38.3)
b. Multigravida 37 (61.7)
1.  Trimester of pregnancy  
a.  First trimester 10 (16.7)
b.  Second trimester 22 (36.7)
c.  Third trimester 28 (46.7)
2.  Any medical history  
a. Yes 4 (6.7)
b.  No 56 (93.3)
3.   Any    complication during  
present pregnancy  
a. Yes 5 (7.3)
b.  No 55 (91.7)

 

Table 2 depicts that 37(61.7%) antenatal mothers were multi-gravida and 23(38.3%) were primi-gravida. Nearly half of antenatal mothers i.e., 28(46.7%) were in third trimester, 22(36.7%) and 10(16.7%) in 2nd and

anemia. appropriately and violence occurs when individuals loose control of their anger.

Table 1: Socio-demographic variables of participants       N=60

Socio-demographic variables f (%)
1.  Age  
a.  < 20 years 13(21.7)
b.  21-30 years 47(78.3)
2.  Educational status of antenatal mother  
a.  Illiterate 19 (31.7)
b.  Primary 18 (30.0)
c.  Secondary 22 (36.7)
d.   Post Graduate 1 (1.7)
3.  Educational status of husband  
a.  Illiterate 16 (26.7)
b.  Primary 19 (31.7)
c.  Secondary 25 (41.7)
4.  Occupation of antenatal mother  
a.  Housewife 56 (93.3)
b.  Labourer 3 ( 5.0)
c.  Govt job 1 ( 1.7)
5.  Occupation of husband  
a.  Farmer 6 (10.0)
b.  Labourer 52 (86.7)
c.  Govt job 2 ( 3.3)
6.  Family income per month (in Rs.)  
a.  <5000 16 (26.7)
b.  5001-10000 32 (53.3)
c.  10001-15000 7 (11.7)
d.  >15000 5 (8.3)
7.  Type of Family  
a.  Joint 44 (73.3)
b.  Nuclear 16 (26.7)

Table 2: Obstetrical history of antenatal mothers  N=60

 

1 s t     trimester respectively. 56(93.3%)

antenatal mothers had no medical history and 4(6.7%) had history of hypertension, hypotension and HCV positive. Most of antenatal mothers i.e., 55(91.7%) had no complication during present pregnancy but 5 ( 7 . 3 %) had complications such as hypertension,  gestational  diabetes  and

Table 3 describes ANC services received by antenatal mothers during the antenatal check- ups. It shows that 56(93.3%) mothers were weighed; blood pressure was measured for 55(91.3%) antenatal mothers. Abdominal examination of 43(71.7%) antenatal mothers was done during antenatal check-ups. As per laboratory investigations hemoglobin of 47(78.4%) antenatal mothers is checked, urine test of 47(78.4%), blood group of 38(63.3%), viral markers (HIV, HCV, HBsAg) of 28(46.7%), and other laboratory Investigations such as RBS, BT, CT, VDRL of 8(13.3%) antenatal mothers were done. Another 44(73.3%) antenatal mothers had undergone the abdominal ultrasound. As per antenatal advices 39(65.0%) mothers were advised about antenatal diet, 2(3.3%) about antenatal exercises, 32(53.3%) about personal hygiene, 27(45%) about rest and sleep during antenatal period. One third i.e., 19(31.7%) antenatal mothers were advised about institutional delivery.

Table 3 : Services received during antenatal check-ups by antenatal mothers

N=60

Services f (%)
Investigations  
1. Weighed 56(93.3)
2. Blood pressure measured 55 (91.7)
3. Abdomen examination 43 (71.7)
4. Hemoglobin checked 47 (78.4)
5. Urine test checked 47 (78.4)
6. Blood group checked 38 (63.3)
7. Viral markers(HIV, HCV,HBsAg) 28 (46.7)
8. Any other lab. investigation(RBS, BT, CT,VDRL) 8 (13.3)
9. Ultrasound 44 73.3)
Advises  
1. Antenatal diet 39 (65.0)
2. Antenatal exercises 2 (3.3)
3. Personal hygiene 32 (53.3)
4. Rest and sleep 27 (45.0)
5. Institutional delivery 19 (31.7)

Table 4 shows that iron folic acid consumption was done by 51(85%) antenatal mothers. Half of antenatal mothers i.e, 26(51.0%) had started iron folic acid in 3rd month of pregnancy, 13(25.5%) in 2nd month of their pregnancy, 6 (11.8%) started iron folic acid in 4th month, 3(5.9) in 1st month, 2(3.9%) in 6th month and 1(2.0%) antenatal mother started iron folic acid in 7th month of p r e g n a n c y. A s p e r t e t a n u s t o x o i d immunization, 56(93.3%) antenatal mothers were immunized and out of these 14(25.0%) were immunized with one dose and 42 (75.0%) were immunized with two doses of Td.

Table 4: Iron folic acid consumption and Td immunization among antenatal mothers.          N=60

 

S.No Variable f (%)
1

a.

b.

c.

d.

e.

f.

Iron/Folic acid consumption (n=51) 1 month

2 month

3 month

4 month

6 month

7 month

3 (5.9)

13 (25.5)

26 (51.0)

6 (11.8)

2 (3.8)

1 (2.0)

2

a.

b.

Td immunization (No of doses) (n=56)

One Two

 

14 (25.0)

42 (75.0)

 

Table 5 describes distribution of antenatal visits related to trimester of pregnancy. It shows in 1st trimester of pregnancy 6 mothers had at-least 1 antenatal visits. Where as in 2nd and 3rd trimester of pregnancy 50 mothers had 2 and >2 antenatal visit. Thereby when a cumulative score of adequate ANC was calculated using criteria of at least 1 antenatal visit for mothers in 1st trimester and 2 or >2 antenatal visits for mothers in 2nd and 3rd trimester of pregnancy, it showed that 50(83.3%) antenatal mothers had adequately utilized antenatal care services.

Table 6 shows major factor which affects the utilization of ANC services as reported by antenatal mothers are accessibility i.e., 32(53.3%), media exposure to ANC services is reported by 31(51.7%) of antenatal mothers, 20(33.3%) mothers reported no one to accompany during antenatal visits that why they were not able to attend antenatal clinic regularly. So, it is family support which affects the utilization of ANC services and 16(26.7%) mothers reported affordability as a factor which affects utilization of ANC services.

Table 5:Antenatal visits related to trimester among antenatal mothers

N=60

 

Trimester

of pregnancy

0 visit

(f)

1 visit

(f)

2 visit

(f)

3 visit

(f)

>3 visit

(f)

st trimester

1

4 4 2
nd trimester

2

0 4 9 2 7
rd trimester

3

0 2 2 6 18

 

Table 6: factors affecting utilization of antenatal care ( ANC) services by Antenatal mothers

N=60

 

Factors                       affecting utilization f (%)
Accessibility 32 (53.3)
Media exposure 31 (51.7)
Family support 20 (33.3)
Affordability 16 (26.7)

Discussion

Antenatal care is health care provided to pregnant women from conception until delivery, with the goal of diagnosing any existing problems that may arise during pregnancy and affect the pregnant woman and her unborn child. Pregnancy is that wonderful period in a woman’s life when she spends each and every day in pleasant anticipation, waiting to hold her bundle of joy in her arms at the end of the ninth month. Every woman hopes for a normal pregnancy and normal delivery so that she can cradle and nurse a healthy baby11.

The present study was conducted to assess the factors affecting utilization of Antenatal care services among antenatal mothers at selected rural communities, Amritsar, Punjab. As per WHO guidelines every antenatal mother must have at least minimum four antenatal visits. The rst visit or registration of a pregnant woman for ANC should take place as soon as the pregnancy is suspected. Ideally, the rst visit should take place within 12 weeks, Second visit between 14 and 26 weeks, third visit – Between 28 and 34 weeks and fourth visit  –  Between  36  weeks  and  term.12         In present study in 1st   trimester of pregnancy 6 mothers had at-least 1 antenatal visit. Where as  in  2nd    and  3rd    trimester  of  pregnancy  50 mothers had 2 and >2 antenatal visit. Thereby when a cumulative score of adequate ANC was calculated using criteria of at least 1 antenatal visit for mothers in 1sttrimester and 2 or >2 antenatal visits for mothers in 2nd  and 3rd trimester of pregnancy, it showed   that 50( 83. 3%) of antenatal mothers had adequately utilized antenatal care services.

As reported by pregnant the major factor which affects the utilization of ANC services is accessibility, family support and affordability. Similar results are reported in the study of Simkhanda et al. that most commonly identied the factors affecting antenatal care uptake: maternal education, husband’ s education, marital status, availability, cost, household income, women’s employment, media exposure and having a history of obstetric complications. Cultural beliefs and ideas about pregnancy also had an inuence on antenatal care use. Parity had a statistically signicant negative effect on adequate attendance.13

As per the ndings of the study 50(83.3%) of antenatal mothers had adequately utilized antenatal care services. The study ndings are consistent with Namrah Sadiq. et. al. (2011)14 the frequency of utilization of antenatal care was (84.4%). Another study conducted by Anna M van Eijk, et. al (2006)15  revealed that 90% mothers visited the antenatal clinic (ANC) at least once during their last Pregnancy. Similar study conducted by M.D 0.012 and there is no association of affordability with the of age of antenatal mothers, occupation of antenatal mothers and occupation of husband and type of family .The ndings of the study shows educational status of husband (χ2 = 9.09. p =0.011) and family income (χ2 = 7.22, p = 0.027) is signicantly associated with family support and there is no association of family support with age of antenatal mothers, educational status of antenatal mothers, occupation of antenatal mothers, occupation of husbands ad Dairo  (2010)9     showed  that  307(76.8%) type of family. Family income (χ2 = 9.32, p = attended ANC clinic at least once during their last pregnancy.

The ndings of the present study revealed out 20(33.3%) mothers reported no one to accompany during antenatal 79 visits that why they are not able to attend antenatal clinic regularly. So it is family support which affects the utilization of ANC services. The study ndings are consistent with Sharma A, et. al. 0.009) is signicantly associated with media exposure and there is no association of media exposure with other socio-demographic variables.14

Conclusion: Utilization of antenatal care services is a complex behavioral phenomenon affected by multitude of factors. The present study assesses the factors affecting utilization of antenatal care services. The study result (2013)16     revealed  that  the  major  factors revealed that antenatal mothers had responsible for inuencing the utilization of ANC services by the pregnant women included accessibility and affordability of ANC services. Similar study conducted by Virk A.  et.al  (2011)17   shows  that  no  one  to accompany is the factor affecting utilization of ANC services. Another study conducted by Uddin (2009) shows that mothers who were exposed to TV and Radio are more likely to use ANC than mothers who were not exposed to TV and radio (mass media).18

According to the result of the study, there is no Association of accessibility of antenatal care services utilization with selected socio- demographic variables. Where as study by Namrah S et al 2011 reported a signicant association between antenatal care services utilization with Educational status of mother (χ2 = 6.68, p = 0.035) and husband (χ2 = 7.85, p = 0.020) and family income (χ2 = 8.86, p = adequately utilized antenatal care services. Major factors which affect the utilization of ANC services are accessibility, affordability, family support and media exposure.

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