http://doi.org/10.33698/NRF0310-Sushma Kumari Saini, Indarjit Walia
Abstract : Promotion of maternal and child health has been one of the most important objectives of Family Welfare Programme in India. The major concern of national programmes related to maternal and child health has been the low percentage of institutional deliveries. One of the goals of National Population Policy 2000 in India is that 80 % of all deliveries should take place in institutions by 2010 and 100% deliveries should be attended by trained personnel. Further Janani Suraksha Yojna launched under National Rural Health Mission in 2005 was to promote institutional deliveries by giving cash incentive to women living below poverty line who deliver in institutions. Hence present study was conducted to examine the trends in ‘place of delivery’ among women of a low income community in resettled colony at Chandigarh, India. Total 313 women delivered during 2005-2007 were interviewed regarding place of delivery in a low income community of resettled colony at Chandigarh, India. Results were compared with the records of 1992-93 when a similar study was conducted in the same community on 151 women who delivered during that period. In a low income community of a resettled colony at Chandigarh, India, it was found that there is 34.5% increase in the institutional deliveries in last one and half decade. The findings are statistically significant as per chi square test (p<.05). Further analysis of the data shows that women with higher educational status delivered in the institutes in significantly higher percentage than their counter parts as per chi square test (p<.05). During last one and half decade there is a trend of an increase in the percentage of institutional deliveries. This might be as a result
of the various national programmes related to maternal and child health launched by the Indian Government. Hence it was recommended that Impact of existing Midwifery services and nurse public ratio need to be studied to know the requirement of Midwives due to increased Institutional
deliveries. Further it is needed to make improvement in accessibility of maternal health services.
Correspondence at :
Sushma Kumari Saini
National Institute of Nursing Education,
PGIMER, Chandigarh
Key words :
Institutional deliveries, Trends, place of delivery
Introduction
Every year over 500 000 women die from pregnancy and childbir th causes. Among them 95% of deaths are occurring in Africa and Asia. Of all the development indicators, there are differences in risk of maternal death between rich and poor regions. Women in some of the low income settings are facing over 100 times more risk of maternal death as compared to their counter par ts in the west. This situation is not different in India. It accounts for more than one-fifth of all maternal deaths from causes related to pregnancy and childbir th worldwide. One woman dies every minute
around the globe and in India one woman dies every 5 minutes. Over a 100,000 women in India continue to die of pregnancy related causes every year. The Maternal Mor tality Ratio in India is 301 per 100,000 live births.
This is despite of the fact that most maternal deaths are avoidable with well known interventions that have existed for decades. 1 Maternal Mortality is a cause of great concern and its reduction is an impor tant goal of maternal and child health services. The Depar tment of Family Welfare has taken several initiatives. The Maternal Health Programme which is a component of the Reproductive and Child Health Programme
aims at reducing maternal mor tality to less than 100 by the 2010. The major concern of national programmes related to maternal and child health has been the low percentage of institutional deliveries as it is well established that giving bir th in a medical institution under the care and supervision of trained healthcare providers promotes child survival and reduces the risk of maternal mortality. One of the goals of National Population Policy 2000 in India is that 80 % of all deliveries should take place in institutions by 2010 and 100% deliveries should be attended by trained personnel. Fur ther Janani Suraksha Yojna (JSY) launched under National Rural Health Mission in 2005 was to promote institutional
deliveries by giving cash incentive to women living below pover ty line who deliver in institutions.2 India is divided into 28 states and 7 Union Territories and health is a state subject. Hence state governments are also par ticipating with same vigor to reduce the maternal and neonate death rates. Apart from following Central Government policies, the State Governments have also started some parallel scheme. In Delhi, the capital of India its Chief Minister launched a new scheme “Mamta” to bring down maternal and infant mor tality. Stating that the Government was trying to universalize institutional deliveries, the Chief Minister said that there are, however, constraints like lack of adequate government health facilities equipped and functional to provide the comprehensive obstetric services for the mother and the newborn, so private institutes will also be par ticipating in this venture. Rs. 4,000/- would be provided to private hospital providing comprehensive care to pregnant women that included antenatal care, institutional delivery, newborn care and post-natal care under the Mamta scheme. Twenty six nursing homes and private hospitals had already entered into a memorandum of understanding with Integrated District Health Societies. 3 Another effor t is under taken by a southern State Government (Karnatka) that will soon launch a new health scheme, ‘Madilu’, to encourage pregnant women from families living below the poverty line to get them admitted to public healthcare institutions for childbir th. The mother will be given a kit containing all material required for her and the child for three months after delivery.
It will contain a mosquito net, soap, lotion, and other items required for hygiene. An initial sum of Rs. 5 crore has been earmarked to launch
the scheme.4 Similarly in a Nor th Indian state (Haryana) Government has constructed 170 deliver y huts to promote institutional deliveries. 5
A Western India state (Gujarat) announced Chiranjeevi Yojna (CY) in April 2005 and operational from December 2005. Chiranjeevi Yojna (CY) was initiated as a scheme to increase institutional deliveries and to encourage private practitioner to provide maternity services in remote areas that record the highest infant mor tality and maternal mor tality rates in the States. On entering the contract each gynecologist is given INR Rs.15000/- as an advance to commence cashless deliveries to women of below pover ty line at their facilities. Though mother receive cash less maternity services, but in the benefit of service providers a package for service charge was developed for a batch of 100 deliveries as capitation payment on fixed rate for each delivery6 Since India is a diverse country, so there are considerable regional diversity in the availability and quality of health services, including maternal health services. Three National Family Health Surveys (NHFS) has been under taken by Indian government gives
a progressive view of maternal and child health in last two decades. These are NHFS -1 in 1992-93, NHFS-2 in 1998-99 and NHFS-3 in 2005-6. According to NHFS -1, the propor tion of mothers receiving antenatal check-ups ranged from 31 percent in one state in nor th east of India (Bihar) to 94 percent in a southern state (Tamil Nadu), the proportion of mothers giving bir th in medical institutions ranged from 11 percent in two states in nor th India (Rajasthan and Uttar Pradesh) to 88 percent in a southern state (Kerala) as stated in survey done by International Institute for Population Sciences (lIPS) in 1995, according to NFHS-2, the propor tion receiving antenatal check-ups ranged from to 34-36 percent in two states in nor th India (Uttar Pradesh and Bihar) to 98 percent in two states of South India (Kerala and Tamil Nadu), the proportion giving birth in medical institutions ranged from 15 percent in Nor th eastern state (Bihar) to 95 percent in a South Indian state (Kerala as per lIPS survey 2000) and this range of institutional deliveries fur ther increased to 100% in South Indian state (Kerala) to 22% in a Nor th Eastern state (Bihar). On an average
the percentage of institutional deliveries increased in all over India from 26% in NFHS-l to 34% in NFHS-2 to 41% in NFHS-3. The explanation of this diversity is complex. Utilization of health services is affected by a multitude of factors including not only availability, distance, cost, and other factor affecting women’s health-seeking behavior. 7,8,9 Looking at the four states situated in south (Andhra Pradesh), West (Gujarat), North
East (Bihar), and Nor th West (Rajasthan), which account for 28 percent of India’s population. As per NFHS-l and NFHS-2 the propor tion giving bir th in medical institutions increased considerably in Andhra Pradesh, Gujarat, and Rajasthan. In Bihar, however, it increased only marginally, from 13 percent to 15 percent. In all four states, the majority of deliveries take place at home (either own home or parents’ home). In NFHS-2, the
propor tion delivering in medical institutions is highest in Andhra Pradesh (50 percent), followed by Gujarat (46 percent), Rajasthan (22 percent), and Bihar (15 percent). In NFHS-3 the propor tion of institutional deliveries fur ther increased to highest in Andhra Pradesh (69%), followed by Gujarat (55%), Rajasthan (32 percent), and Bihar (22 percent).
7 Going by the trend, another state in West of India (Gujarat) is focusing on 100 percent institutional delivery and two of its districts, Mehsana and Gandhinagar, will soon be declared “safe delivery districts.” Between 2001-02 and 2007-08, the percentage of institutional deliveries in the State has gone up to 76 from a little above 50. Comparison of institutional deliveries in a North eastern state (Bihar) between April and July in 2006 and 2007 shows that thenumbers have increased from 3,745 to 17,293 in April; 3,716 to 22,848 in May; 3,805 to 30,510 in June and 7,233 to 46,928
in July. Similarly in a Nor th Indian state (Haryana) institutional deliveries increased from 28% in 2004-05 to 43.60% in 2005-06 due to construct of over 170 of the proposed 300 delivery huts to promote institutional deliveries.
10 A Study conducted in the Villages of Veerapandi Panchayat Union of Salem District, Tamil Nadu, a South Indian state reported the percentage of institutional deliveries 87.8%, which is much higher than the national figure of 35%, although this rural area was situated 20-30 kms from Salem city. 11 Reports from a state of Central India (Madhya Pradesh) indicate significant increase in institutional deliveries because of demand side financing under Janani Suraksha Yojana. From 6 lakh JSY cases last year, the number has already reached more than 21 lakhs so far. In 1152 PHCs in 50 Blocks of the state (Madhya Pradesh) under the Dhanwantari Yojana (families living below pover ty line are given special cards and the holder of Dhanwantari Card gets free health care services), institutional deliveries recorded more than 100% increase (From 26% to 53%). In an Eastern Indian state (Orissa), figures from 3 CHCs in Malkangiri and Koraput districts of the KBK region, shows increase in institutional delivery from 88 to 149 and 59 to 120 and 97 to 169 respectively over a corresponding time period. In Haryana a North Indian state with the innovative delivery hut scheme, the institutional deliveries went up from 28% in 2004-05 to 43.60% in 2005-06.12 Janani Suraksha Yojana (JSY) was
introduced towards the beginning of the year 2006 in the orrisa, an Eastern Indian state.
However full fledged operation took place in August 2006. As per NFHS -3 Institutional delivery in the state is 38.7% and amongst the JSY beneficiaries institutional delivery is 48.5% .The analysis of three month data on JSY shows an increasing trend in institutional delivery numbers. To be more specific for the months of October, November, December 2006 institutional delivery among JSY beneficiaries is 46.7%, 47.8% and 48 .5% respectively. In Mathili CHC of Malkangiri district of this state the institutional delivery has increased from 88 (April 2005 to December 2005) to 149 during April 2006 to December 2006. Similarly, institutional delivery of Koraput district in Ravanaguda PHC of this state has gone up from 59 to 120; and in another district Boriguma CHC from 97 to 169 in the period from April 2005 – December 2005 to April 2006 – December
200613 From the above discussion it is evident that there is trend towards increase in number of institutional deliveries in many regions of the country. But the increase is slow in low socio income communities Hence in order to examine the trends in ‘place of delivery’ among women of a low income community in resettled colony at Chandigarh, India the present study was conducted. The objectives of the study was:
• To study the trends in ‘place of deliver y’ among low income community, Chandigarh, India.
Material and Methods
Present study was conducted in a low income community of Dadu Majra colony at Chandigarh, India. Chandigarh also called as city beautiful, dream conceived by Pandit Jawaharlal Nehru, the first Prime Minister of India and planned by Le Corbusier, the French architect. Chandigarh has witnessed two phases of planning, and third is still on the drawing board. Since 1975, the Chandigarh Housing Board has taken up schemes, which have resettled 14,619 families, earlier living in squatter settlement. Low cost housing has been created for such thousands of people and
hence small colonies for slum dwellers around left over villages. Dadu Majra Colony is such a resettlement Colony is situated on the Nor thwest
corner of Chandigarh and is at a distance of 5 km from PGIMER, Chandigarh, a ter tiary level hospital and 10 km from the Interstate Bus
Terminus of Sector- 43, Chandigarh. The colony has a population of 18,000 approximately.
It hosts the stay of migrants from different states of India like Punjab, Haryana, Himachal Pradesh, Rajasthan, Uttar Pradesh, West Bengal and Bihar etc and neighboring country Nepal. The socioeconomic status of residents ranges from lower to middle class. Some of the residents are sweepers, peons, petty businessmen, masons, rickshaw pullers, while a few are Government employees, teachers and clerks. The Colony is well
equipped with all modern sanitary facilities like an underground drainage system, tap water supply, electricity and other amenities like market, anganwadi, Senior Secondary School, adult education centers, a Government allopathic dispensar y and many private practitioners. There is a regular bus service to the area. All the women of Dadu Majra Colony, Chandigarh who delivered in 2005 to 2007 comprised the sample. From the records a list of women delivered in 2005 to 2007 was prepared along with their addresses. An interview schedule was prepared to find out
the socio demographic profile of the women i.e. educational status and earning status; obstetric history i.e. Gravida, parity and number of living children; history of delivery during 2005-2007 i.e. date of delivery and place of delivery.
The women were interviewed at their own homes as per interview schedule. The purpose of study was explained to the women and verbal consent was taken from them to be the part of study. They were explained that they are free to participate or refuse to be the par t of study. Data was analyzed by using a statistical package SPSS-16. Results were compared with the records of 1993-94 when a similar study was conducted in the same community. 14
Results
Total 313 women who delivered during 2005-2007 were interviewed. About three four th of women were house wives (75.9%) and most of the women were literate (79.9%). Among them 144(45.9%) of them were 1st gravida, 126(40.1%) were 2nd gravida and 44 (14.1 %) were third or higher gravida the highest being the sixth gravida. Fur ther at the time of delivery 146(46.5%) had no living child, 124(39.5%) had one living child,
30(9.6%) had two living children and 14(4.5%) had three or more living children maximum being five living children. Regarding place of bir th the data revealed that 278(88.8%) deliveries were\ conducted in the institutions i.e. either in Government institutions (78.3%) or in private clinics (10.5%) run by doctor/nurse/auxiliary worker/dai and only 35 (11.2%) deliveries were conducted at home i.e. either at their own home 29 (8.3%) or at their parents home 6(1.9%). The data was compared with the literature of 1993-94 when a similar study was conducted in the same community.
Regarding place of birth data depicted that 82(54.3%) deliveries were conducted at institution and 69(45.7%) deliveries were conducted at home one and half decade back. (Table-1) This difference was statistically significant (p<.05 as per chi square test)
Table-I : Trends in place of birth Period Institutional deliveries Home deliveries X2 test value n(%) n%) P value 1993-94 82(54.3) 69(45.7) 70 at 1df
2005-07 278(88.8) 35(11.2) p<.05 Further analysis of the data shows that women with higher education level delivered in the institutes in significantly higher percentage than their counter par ts as per Chi square test (p<.05). Self financing status of women was not related to the place of delivery in 1993-94 data though in 2005 -2007 all the earning women delivered in the institutions as compared to 60% of earning women delivered at home during 1993-94.
Table-2 : Socio demographic profile of women in relation to place of delivery 1993-94 X2 test 2005-07 X2 test Socio-demographic Variable Institutional Home value Institutional Home value deliveries deliveries P value deliveries deliveries P value n(% ) n(%) n(%) n(%) Education status of women
– Illiterate 26 (31.7) 43 (62.3) 16.3 at 50 (18.0) 14 (40.0) 19.9at
– Can read & write 06 ( 7.4) 02 ( 2.9) 3df 48 (17.3) 12 (34.3) 3df
– Up to middle 27 (32.9) 23 (33.3) p<.05 150 (54.0) 08 (22.9) p<.Ol
– 10+2 and above 23 (28.0) 01 ( 1.5) 30 (10.7) 01 0(2.8)
Self financing status of women
– House wife 76 (92.6) 60 (44.1) 0.8 at 265 (95.3) 35 (100.0)
– Earning 06 ( 7.6) 09 (60.0) Idf 13 (4.7) –
p>.05
Gravida
– 1 21 (25.6) 10 (14.5) 133 (47.8) 11 (31.4) 14.8
– 2 19 (23.1) 13 (18.8) 4.8 at 111 (39.9) 14 (40.0) 4df
– 3 13 (15.9) 18 (26.1) 4df 025 0(9.0) 05 (14.3) P <.01
– 4 13 (15.9) 12 (17.4) p>.05 006 0(2.2) 04 (11.5)
– 5th and above 16 (19.5) 16 (23.2) 003 0(1.1) 01 0(2.8)
Similarly gravid status of women in relation to place of delivery it was observed that a higher percentage of women having first and second pregnancy delivered in institution as compared to third and higher order of pregnancies in 1993-94 but when data of 2005-07 were analyzed it was observed that order of bir th was significantly associated with place of delivery. (Table-2)
Discussion
Every year in India, more than 26 million women give bir th (estimated population for 2006, 110 crore; bir th rate, 24 per 1,000 population). Among these, more than 1 lakh women die of pregnancy-related issues every year, without any concern/advocacy expressed by professional organizations in the medical and paramedical fields and women’s national-Ievel / state-Ievel organizations. Fur ther, more than 1 million babies
die in the neonatal period ever y year (pregnancy wastage). It is unfor tunate that even after 60 years of Independence, such a scenario continues. The suffering women are cer tainly the most impor tant stakeholders in rapidly reducing MMR and neonatal mor tality rate by achieving 80% institutional deliveries, which is recognized in the National Population Policy 2000. Indian Government and State Governments are putting in their effor ts to improve institutional deliveries by launching various schemes to promote institutional deliveries. 1,2 How much these effor ts of government are affecting the place of delivery was the aim of the present study. In the low income community near Chandigarh, India which has
an easy access to health facilities within 5 kilometer distance and well connected with the public transport the trend of institutional deliveries was observed over one and half decade and an increase of 34.5% in institutional deliveries was observed i.e. increased from 54.3% to 88.8% against the Indian average increase during this period is 15% ( 26% to 41% during NHFS-l to NFHS- 3). The trend towards increase in institutional deliveries has been observed in all the states as per National Family health Surveys though there was no increase in two states (Arunachal Pradesh and Nagaland) between NFHS-2 to NFHS-3 and increase was below 7% in another seven states while the ten states had shown 7-14% increase and same number has shown more than 15% increase.
Even in Delhi, the capital of India only 2% increase was repor ted. 7,8,9 It is evident from the above discussion that though the trend is towards the increase in institutional deliveries but the rate of increase is very slow. Only 10 states have achieved more than 50% percent institutional deliveries
and only 3 states have achieved more than 80% institutional deliveries which is one of the goals of National population policy 2000 to be achieved by 2010. Time is too shor t and it is long way to go. In the present study the results are very encouraging. We have already achieved the goal of 80% institutional deliveries. This may be due to various programmes relates to maternal and child health, good transpor t network and easy availability of health services. Fur ther improvement in women’s education may be a contributing factor. Still there is need to progress more in this direction in achieving 100% institutional deliveries so that we can achieve all millennium development goals related to maternal and child health. Hence it was recommended that Impact of existing Midwifery services and nurse public ratio need to be studied to know the requirement of Midwives due to increased Institutional deliveries. Fur ther it is needed to make improvement in accessibility of maternal health services.
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