|Year : 2015 | Volume
| Issue : 2 | Page : 89-94
Knowledge regarding antenatal care services, its utilization, and delivery practices in mothers (aged 15-49 years) in a rural area of North India
Rajiv Kumar Gupta, Tajali Nazir Shora, Aruna K Verma, Rayaz Jan
Department of Community Medicine, Government Medical College, Jammu, Jammu and Kashmir, India
|Date of Web Publication||9-Jun-2015|
Dr. Tajali Nazir Shora
Department of Community Medicine, Government Medical College, Jammu - 180 001, Jammu and Kashmir
Background: Antenatal care (ANC) is an effective tool to reduce both infant and maternal mortality rates. In spite of all efforts to reach and register every antenatal mother, the results are not up to desired level. Objectives: To assess the level of knowledge of pregnant women about ANC services and to find out the ANC utilization and factors affecting them. Materials and Methods: This cross-sectional study was carried out in October-November 2013 in Krishna Nagar village of Miran Sahib zone of block R.S. Pura. All the mothers (aged 15-49 years) in this village were interviewed using a predesigned, pretested, and semi-open-ended questionnaire. Results: The respondents had adequate knowledge about ANC services except for the minimum number of visits for ANC. Here, 89.6% (189) of the respondents had registered for ANC, of which 64.5% (136/211) and 9.9% (21/211) had registered in the 2 nd trimester and 1 st trimester, respectively. The results revealed that 79.1% of the deliveries were institutional. The age, literacy status, socioeconomic status (SES), and type of family had statistically significant associations with the utilization of ANC services. Conclusion: The results show that maternal literacy remains a key factor in the better utilization of antenatal services. Moreover, the role of health workers in increasing awareness among mothers about the importance of ANC in general and the danger signs of pregnancy in particular is of paramount concern.
Keywords: Antenatal care service utilization, Knowledge, Attitude and Practice, pregnancy
|How to cite this article:|
Gupta RK, Shora TN, Verma AK, Jan R. Knowledge regarding antenatal care services, its utilization, and delivery practices in mothers (aged 15-49 years) in a rural area of North India. Trop J Med Res 2015;18:89-94
|How to cite this URL:|
Gupta RK, Shora TN, Verma AK, Jan R. Knowledge regarding antenatal care services, its utilization, and delivery practices in mothers (aged 15-49 years) in a rural area of North India. Trop J Med Res [serial online] 2015 [cited 2019 Mar 20];18:89-94. Available from: http://www.tjmrjournal.org/text.asp?2015/18/2/89/158401
| Introduction|| |
Antenatal care (ANC) is the care given to pregnant women so that they have safe pregnancy and healthy babies. ANC is the pivotal factor for safe motherhood but its utilization varies widely across the vast swathes of our country where the population by and large resides in urban slums and rural areas. ANC is potentially one of the most effective health interventions for preventing maternal morbidity and mortality, particularly in places where the general health status of women is poor. The World Health Organization (WHO) recommends a minimum of four antenatal visits, comprising interventions such as tetanus toxoid (TT) vaccination, screening and treatment for infections, and identification of warning signs during pregnancy. 
Annually, 5 lakh women die globally as a result of pregnancy and childbirth.  Goal 5-A of the Millennium Development Goals aims to improve maternal health with the target of reducing maternal mortality ratio (MMR) by 75% between 1990 and 2015.  In India, it is heartening to note that MMR has declined from 212 in 2007-2009 to 178 in 2010-12.  Apart from deaths, 50 million women suffer from maternal morbidity due to acute complications from pregnancy, which could be reduced by encouraging women to deliver with the assistance of skilled birth attendants or in a health-care institution. 
Quality antenatal, intranatal, and postnatal care is the single most important determinant of infants' as well as mothers' morbidity and mortality. The inequality in the health and well-being of women in the developing world is a cause of immense concern. Despite an array of national programs since independence for improving the health of the child as well as the mother, inadequate access and underutilization of modern health services are among the prime reasons for the high maternal mortality rate in India. Other common reasons include high illiteracy among females, early marriages, ignorance, low quality as well as high cost of service, social structure, detrimental health beliefs, personal characteristics, and malnutrition, especially among the rural and tribal populations. So, utilization of these services by the beneficiaries remains unsatisfactory. ,,
It is very important to comprehensively understand the various factors that affect the utilization of maternity care during pregnancy so that the respective programs are implemented more effectively. If we are able to identify these bottlenecks, efforts can be made to increase the utilization rates by removing those bottlenecks. Though studies have been conducted in the past on this subject, it was an attempt to see the status of mothers' knowledge and the utilization of ANC services.
- To assess the level of knowledge of pregnant women about ANC services
- To find out about ANC utilization and the factors affecting them.
| Materials and Methods|| |
This cross-sectional study was carried out in October-November 2013 in Krishna Nagar village of Miran Sahib zone of block R.S. Pura. This block is attached to the postgraduate section of the Department of Community Medicine, Government Medical College, Jammu as a field practice area. This village was chosen out of 24 villages by simple random sampling. All the mothers (aged 15-49 years) in this village were interviewed using a predesigned, pretested, and semi-open-ended questionnaire. After taking informed consent, relevant information about the utilization and place of delivery of ANC services were recorded, along with sociodemographic data using the modified Udai Pareek socio-economic status scale.  The institutional Ethics Committee clearance was duly sought before the conduct of study.
The mothers who could not be contacted in the first visit were tried to be enrolled in the second visit. Those who were still left after the second visit were excluded from the study. A total of 211 mothers were the study subjects for the current study. The data thus collected were tabulated, and to find the association between the sociodemographic variable and utilization of ANC services, Chi-square test was applied.
| Results|| |
The sociodemographic profiles of all of the 211 study subjects are given in [Table 1]. The majority of the mothers were ≥26 years of age. Only 15/211 (7.1%) were illiterate and 113/211 (53.6%) were residing in joint families. An overwhelming majority, i.e. 199/211 (94.3%) were housewives.
|Table 1: Frequency distribution of sociodemographic data of respondents |
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Regarding the knowledge about ANC services, 182/211 (86.2%) respondents knew about early registration (preferably before 16 weeks) and a similar number of subjects had knowledge about iron-folic acid (IFA) tablet supplementation. It was observed that 199/211 (94.3%) and 130/211 (61.6%) had adequate knowledge about the increase in food intake and the importance of TT injection during pregnancy. But knowledge about adequate antenatal visits was poor, as only 23/211 (10.9%) knew that >3 ANC visits were essential [Table 2].
|Table 2: Frequency distribution of respondents according to their knowledge regarding ANC services |
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It was seen that a majority (79.1%) of the deliveries conducted were institutional and only 20.9% were domiciliary [Table 3]. Of the study subjects, 84.9% had outcome as full-term delivery [Table 4]; 89.6% (189/211) of the mothers had registered for ANC, out of whom 64.5% (136/211) and 9.9% (21/211) had registered in the 2 nd trimester and the 1 st trimester, respectively [Figure 1] and [Figure 2].
|Figure 1: Distribution of study subjects according to their ANC registration status|
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|Figure 2: Distribution of mothers according to their time of ANC registration|
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ANC service utilization was found to be significantly associated with age (P < 0.001), literacy (P < 0.001), socioeconomic status (SES) (P < 0.001), and type of family (P < 0.001), but was not significantly associated with the occupation of the mother [Table 5].
|Table 5: Association of SES, literacy status, and occupation with ANC service utilization |
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On enquiring about the reasons for inadequate utilization of ANC services, the three major responses were nonawareness, financial constraints, and nonavailability of transport facilities.
| Discussion|| |
The respondents in the present study had adequate knowledge about ANC registration, IFA tablet supplementation, TT injection, and increase in food intake, but knowledge regarding the number of ANC visits was dismal. The most plausible reason for the respondents' good knowledge about ANC services was their higher levels of literacy as only 7.1% of them were illiterate. According to Becker et al.,  mothers' education was the most consistent and important determinant of the use of child and maternal health services. Several other studies also found a strong positive impact of mothers' education on the utilization of health services. ,
Kishk  in his rural-urban study in Alexandria found that urban women had a higher mean total score for their knowledge on ANC than their rural counterparts.
Our results were also in agreement with those reported by Onasoga et al.  in his study in Osun State, Nigeria where 83.3% of the respondents knew of the services rendered at antenatal clinics and 79.4% replied that ANC helps to reduce maternal and neonatal morbidity and mortality.
As far as ANC registration status was concerned, the authors found that 89.6% had registered themselves but 10.4% had not registered. The results are in contrast to the Karnataka study by Javali  and the rural Lucknow study by Roy,  both of whom revealed 100% ANC registration. The most probable reason for suboptimal ANC registration in the current study could be that many study subjects had delivered a decade or two earlier when no accredited social health activist (ASHA) workers under the National Rural Health Mission (NRHM) were available. Out of those registered for ANC, 64.5% (136/211) had registered in the 2 nd trimester followed by 15.2% (32/211) and 9.9% (21/211) in the 3 rd trimester and the 1 st trimester, respectively. Our results are in contrast to Javali,  who reported 56.5% and 42.9% women under ANC registration in the 1 st trimester and the 2 nd trimester, respectively, and Berhe  who reported that 48%, 42.4%, and 1.8% women made their first visit in the 1 st trimester, 2 nd trimester, and 3 rd trimester, respectively. Also, higher rates to the tune of 63.9% were reported by Mumbare. 
In the current study, 63% (133/211) respondents had ≥3 ANC visits followed by 26.6% (56/211) who had <3 ANC visits. The rest of the study subjects, i.e. 10.4% (22/211) unfortunately did not have even a single ANC visit. Our results are in agreement with the Coverage Evaluation Survey (2009) where 68.7% women reported at least three ANC visits, though the Third National Family Health Survey (NFHS-3) and the Third District Level Household and Facility Survey (DLHS-3) rates were on the lower side, i.e. 52% and 49.7%, respectively.
This study has revealed that 79.1% (167/211) of mothers had opted for institutional delivery, out of whom 45.5% (96/211) had delivered in community health centers (CHCs) and 22.3% (47/211) in tertiary care hospitals. NFHS-2 and NFHS-3 reported rate of deliveries of 28.3% and 48.8%, respectively, in health facilities in the rural areas of Jammu and Kashmir. The results of the present study thus reflect a healthy trend of institutional deliveries in the study subjects. Mumbare et al.  in their study in north Maharashtra also reported similar results with 65.7% of deliveries being carried out in various health centers. Roy  in his Lucknow study also reported 84.9% of deliveries being carried out in health institutions.
The present study found that 84.8% (179/211) of the study subjects had full-term babies as the outcome of delivery. These findings can be very well correlated to early registration of pregnancy. Several authors have suggested that ANC is more beneficial in preventing adverse pregnancy outcomes when received early in pregnancy and continued until delivery. ,
In the current study, sociodemographic factors like age, maternal literacy, SES, and type of family showed a significant association with the utilization of ANC services. Similarly, significant association with factors like maternal education and SES was also reported by other authors. ,,,,, Literacy enhances women's autonomy, confidence, and decision-making about the health of the self as well as children. Educated females are more likely to seek higher quality services and have greater ability to use health-care inputs that offer better care. 
The reasons regarding inadequate utilization of ANC services in this study like financial constraints, nonawareness, and nonavailability of transport facilities are in agreement with the results of a similar study by Mumbare.  Other factors like affordability and the husband's acceptance of the services also have a bearing on the utilization of these services, as reported by Onasoga et al. 
| Conclusion|| |
The results revealed that the respondents had adequate knowledge regarding ANC services except for the number of ANC visits. A large number of deliveries took place in governmental institutions. Approximately 90% had registered for ANC and most of them did so in the 1 st and the 2 nd trimesters. It needs to be emphasized here that early registration should be utilized for continuum of care and institutional delivery. The age, literacy of the mother, SES, and type of family significantly influence ANC service utilization. To improve effective utilization of ANC services, we need to bring behavior change communication, improve the quality of service delivery, along with effective monitoring and evaluation.
Since the selection of subjects was based on simple random sampling, the size of the study may therefore not be large enough to generalize the results. Another weakness of this study is the recall bias of the study subjects. A more advanced epidemiological design like cohort study can better bring out the relationships (noncausal) between the predictor and the outcome variables. It must also be mentioned here that although a minimum of four ANC visits are required for ANC to be optimal, the authors have taken three ANC visits to be essential.
- Increasing awareness among mothers about the danger signals in pregnancy and further emphasizing the importance of ANC
- Improving educational opportunities for women, which will help them to learn and in turn empower them to make independent decisions
- Improving the quality of health-care services
- To make mothers aware about the provision of financial help and transport facilities under the National Health Mission (NHM) through information, education, and communication activities by involving ASHA, Anganwari workers (AWW), and multipurpose health workers (MPHW).
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]