Elsevier

Social Science & Medicine

Volume 59, Issue 6, September 2004, Pages 1147-1158
Social Science & Medicine

Antenatal care: provision and inequality in rural north India

https://doi.org/10.1016/j.socscimed.2003.11.045Get rights and content

Abstract

The objectives of this paper are to examine factors associated with use of antenatal care in rural areas of north India, to investigate access to specific critical components of care and to study differences in the pattern of services received via health facilities versus home visits. We used the 1998–1999 Indian National Family Health Survey of ever-married women in the reproductive age group and analysed data from the states of Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh (n=11,369). Overall, about three-fifths of rural women did not receive any antenatal check-up during their last pregnancy. Services actually received were predominantly provision of tetanus toxoid vaccination and supply of iron and folic acid tablets. Only about 13% of pregnant women had their blood pressure checked and a blood test done at least once. Women visited by health workers received fewer services compared to women who visited a health facility. Home visits were biased towards households with a better standard of living. There was significant under-utilisation of nurse/midwives in the provision of antenatal services and doctors were often the lead providers. The average number of antenatal visits reported in this study was 2.4 and most visits were in the second trimester. Higher social and economic status was associated with increased chances of receiving an antenatal check-up, and of receiving specific components including blood pressure measurement, a blood test and urine testing but not the obstetric physical examination, which was however linked to ever-use of family planning and the education of women and their husbands. Thus, pregnant women from poor and uneducated backgrounds with at least one child were the least likely to receive antenatal check-ups and services in the four large north Indian states. Basic antenatal care components are effective means to prevent a range of pregnancy complications and reduce maternal mortality. The findings indicate substantial limitations of the health services in overcoming socio-economic and cultural barriers to access.

Introduction

Reducing maternal mortality and morbidity has been a major focus for the developing world since the launch of the Safe Motherhood Initiative in 1987 (WHO, 1996). Over recent years there has been some debate as to the effectiveness of one aspect of maternity provision, that of antenatal care (Carroli, Rooney, & Villar, 2001; Bergsjø, 2001). The main purposes of antenatal care are to prevent certain complications, such as anaemia, and identify women with established pregnancy complications for treatment or transfer. Tetanus toxoid vaccination of the mother prevents neonatal tetanus as protective antibodies are passed across the placenta. It was hoped that women ‘at risk’ of pregnancy complications could be identified so as to avert problems, and scoring systems were developed for this purpose. However, the use of risk assessment has turned out to be unproductive as women may develop complications in pregnancy or childbirth at any time.

Despite the limitations of antenatal risk assessment the basic functions of detection of pre-eclampsia, anaemia and other incipient complications remain essential. In addition, other less tangible benefits may be realised which are not easily evaluated in isolation. Antenatal consultations provide opportunities for health education, health promotion and social support at both the individual and community level. Especially in the rural setting, accessing antenatal care is an important step in bringing women into contact with the health care system. This contact has facilitated women's access to medical care for future health needs, including postnatal care (Sugathan, Mishra, & Retherford, 2001). Within a context of limited resources there is a need to ensure value for money: overall, antenatal care is considered to represent a cost-effective component of maternity services as part of ‘safe motherhood’ interventions to reduce mortality and morbidity (Jowett, 2000).

Overall, uptake of antenatal care in India has been low. The 1992–1993 Indian National Family Health Survey showed that only 64% mothers received antenatal check-ups and this increased marginally to 65% in 1998–1999 (International Institute for Population Sciences and ORC Macro, 2000). This lack of improvement occurred despite governmental and non-governmental efforts to strengthen service delivery, and is likely to contribute to the continuing high maternal mortality in the country, especially in the northern states. Maternal mortality in the four states Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh ranged between 450 and 700 per 100,000 live births (International Institute for Population Sciences and ORC Macro, 2000). These states have some of the highest fertility (total fertility rate) in the country: ranging between 3–4 children per woman. Similarly, infant and child mortality rate in these states were reported to be among the highest in India with a range 73–87 infant deaths per 1000 live births. In 2001 female literacy in these states was low. According to the 2001 Census, these states account for about 40% of India's total population (Registrar General and Census Commissioner, 2001). Achieving significant improvements in maternal health in these states is vital to improving maternal health in India as a whole.

In India, antenatal care initiatives began in 1951 with the implementation of the First Five Year Plan (1951–1956). However, a lack of rural health infrastructure, and a focus on family planning using a clinic-based approach limited the benefits to rural women. In the Third Five Year Plan (1961–1966) an extension approach to family planning was adopted with recruitment of auxiliary nurse midwives (ANMs) and Health Assistants. This provided rural women access to some elements of antenatal care. However, it may be noted that these programmes were primarily geared to family planning service provision. During the Fifth Five Year Plan (1974–1979) maternal and child health services (MCH) were integrated with family planning services and a new programme entitled ‘Family Welfare’ was introduced. This gave impetus to provision of maternal health services in rural areas. In the Seventh Five Year Plan (1985–1990) a Universal Immunisation Programme (UIP) was implemented, greatly increasing pregnant women's access to tetanus toxoid vaccination. In 1991–1992 a major initiative called ‘Child Survival and Safe Motherhood’ (CSSM) was undertaken by integrating the UIP with expanded MCH activities in states with high mortality rates. Following the recommendations of the International Conference on Population and Development in 1994, in 1997 the Government of India launched the Reproductive and Child Health (RCH) programme for implementation in the Ninth Five Year Plan (1997–2002). This was done by integrating CSSM interventions and adding interventions for reproductive tract infections and sexually transmitted diseases. The idea behind the RCH programme is to provide need based, client centred, demand driven, high quality integrated services to beneficiaries. All districts in the country were covered by the programme as of 1999–2000 (Ministry of Health and Family Welfare, 2001). It is important to note here that Integrated Child Development (ICDS) programmes introduced in 1975 in selected districts also provided women with access to antenatal care.

In rural areas, ANMs posted at the sub-Primary Health Centres (sub-PHCs) are responsible for providing antenatal care either in homes or clinics. Sub-PHCs are the grass-roots level government health service points covering a population of 5000 in non-hilly areas. Sub-PHCs refer to Primary Health Centres (PHCs) manned by medical and other paramedical staff. Antenatal care services to pregnant women are also provided by the ‘Anganwadi’ centres working under the ICDS Programmes.

In developing countries uptake of antenatal care is determined by socio-economic factors, demographic factors, and availability and access to health facilities. In many parts of the developing world women's education was found to be an important predictor of antenatal care utilisation. In Jordan (Obermeyer & Potter, 1991), Nepal (Matsumura & Gubhaju, 2001), and Surabaya in Indonesia (Taguchi, Kawabata, Maruo, & dewata, 2003) higher levels of education of women were associated with greater use of antenatal care. However, in Kenya maternal education was not significantly related to utilisation of antenatal care once other variables were considered (Magadi, Madise, & Rodrigues, 2000). However, the potential impact of husbands’ or partners’ educational status has not been explored.

In India, a relationship between maternal education and utilisation of antenatal care is evident in many studies. In Karnataka state in India, Bhatia and Cleland (1995) reported that higher levels of maternal education increased the uptake of antenatal care. Similar finding was reported in a study of four Southern Indian states: Kerala, Tamil Nadu, Karnataka, and Andhra Pradesh (Navaneetham & Dharmalingam, 2002). Indeed a national study conduced by the Indian Medical Council Research (ICMR) in 90 districts of the country in 1999 concluded that literacy of women is the key factor to achieving improvements in antenatal care in India (Singh & Yadav, no date).

Demographic factors such as order of pregnancy (or number of children), marital status, maternal age, and marital duration are reported having influence on the utilisation of antenatal care. Less use of antenatal care was found among women having larger numbers of children in Jordan (Obermeyer & Potter, 1991) and Kenya (Magadi et al., 2000). In India utilisation of antenatal care was low among women with higher order pregnancies: Chandrashekar et al. (1998) working in rural Karnataka noted that multiparous and unskilled mothers aged over 30 were less likely to have used antenatal services. Similar findings were reported in Tamil Nadu (Neilsen, Liljestrand, Thilsted, Joseph, & Hedegaard, 2001). Low antenatal care utilisation was reported among teenagers in Jamiaca (McCAW-Binns, Grenade, & Ashley, 1995) and Kenya (Magadi et al., 2000). Other relevant variables were unmarried status, unions of very short duration, desire for large families, never-use of family planning, unwanted pregnancies. In India, Bhatia and Cleland (1995) noted reduced antenatal care use among women aged under 18. In Karnataka, consulting for pregnancy confirmation and a prior history of neonatal or fetal loss were important determinants of subsequent antenatal care utilisation.

The interplay of socio-economic factors and accessibility of health care facilities was highlighted in Kenya (Magadi et al., 2000): even if health care services are easily accessible socio-cultural factors at community level determine whether to use the facility. In India, using the 1992–1993 National Family and Health Survey, Misra, Roy, and Rajan Irudaya (1998) revealed that lack of knowledge about antenatal services was an important reason for non-utilisation in the northern states of India. A study in four southern Indian states found that variations in service use were primarily related to availability and access (Navaneetham & Dharmalingam, 2002).

In India, religion and caste are two important social factors that influence social practices, including belief systems surrounding pregnancy. However, these do not follow a stereotypical pattern. For example, while Muslims were more likely to go for medical check-ups in Karnataka they were less likely to do so in Kerala (Bhatia & Cleland, 1995, Navaneetham & Dharmalingam, 2002).

Recognising that socio-cultural factors are likely to be critical determinants of care seeking and service utilisation in the context of pregnancy, the objective of this paper is to examine factors associated with use of antenatal care facilities in the rural areas of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh (the latter including the newly created state of Uttaranchal). The paper also examines factors associated with access to specific critical components of care. A final objective is to study the differences, if any, in the pattern of antenatal check-ups and services received through health facilities versus home visits.

Section snippets

Data and methods

Data from the 1998–1999 National Family Health Survey (NFHS-2) were utilized in the present study. This survey was undertaken by the International Institute for Population Sciences, Mumbai on behalf of the Government of India, Ministry of Health and Family Welfare. This was a nationally representative population based sample survey of 90,303 ever-married women aged 15–49 from 26 states comprising 99% of India's population. The survey methods are described in detail together with univariate

Antenatal check-ups

Table 1 provides information about antenatal check-ups in the four northern states in India. In Bihar and Uttar Pradesh nearly 70% of women in their last pregnancy did not receive any antenatal check-up. In Rajasthan, antenatal check-ups were slightly more common, and in Madhya Pradesh more than half of women received antenatal care during their last pregnancy. The proportion of women who received any antenatal check-up through visits to a health facility was greatest in MP (38%) and lowest in

Discussion

The present study shows continuing inequity in access to antenatal care in northern India. As the two successive NFHS used similar methods to sample a population of ever-married women it is likely that the present findings truly reflect a lack of substantial progress towards increasing uptake in antenatal care. The impact of nationally driven service initiatives implemented since the survey, especially the RCH programme, cannot of course be assessed in the present study. The present findings

Acknowledgements

This study was funded by the UK Government Department for International Development.

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