|Year : 2015 | Volume
| Issue : 2 | Page : 92-98
Utilization of ante natal care services and it's determinants by women admitted in a tertiary care hospital of Kolkata
Mausumi Basu1, Sita Chatterjee1, Sima Roy2, Gagori Chowdhury3
1 Department of Community Medicine, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, India
2 Department of Community Medicine, Burdwan Medical College, Burdwan, India
3 Department of Bio-Informatics and Bio-Physics, University of Calcutta, Kolkata, West Bengal, India
|Date of Web Publication||16-Jun-2015|
Department of Community Medicine, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata - 700 020, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Poor access and utilisation of antenatal services contribute to high Maternal Mortality Rate (MMR) along with other socioeconomic factors. Objectives: To evaluates the utiliation of ante natal care (ANC) services and it's determinants among full term pregnant women and recently delivered women. Materials and Methods: A cross sectional study was conducted among 380 full-term ante natal women and recently delivered women (RDW) admitted in obstetric ward of a tertiary care hospital of Kolkata between February 2014 to July. 2014 using a predesigned pretested schedule. Results: About 47.11% of the study population were between the age of 20-30 years; 68.95% were Hindu; 55.53% belonged to nuclear family; 60.53% were from rural area; 53.42% were multipara; 89.47% were literate; 63.95% were homemakers; 28.95% belonged to class III. Cent percent registered for ANC); 91.05% took three ANC visits; 65.26% registered during the first trimester; weight and blood pressure was measured in 99.74% and 98.95% respectively; 99.2% had an abdominal examination; 100% received Tetanus Toxoid (TTTT); 43.96% consumed 100 Iron Folic Acid (IFA) tablets; 97.63% had blood test for Haemoglobin and blood typing; 92.11% had blood test for VDRL; 100% had an urine examination for albumin. All of the subjects was advised about diet and immunisation; 97.89% for rest/sleep; 82.89% for physical activity; 27.89% for personal cleanliness; 27.37% for family planning; 49.21% for breastfeeding and newborn care and 66.05% for warning signs. When comparison between women who went for at least four ANC visits and who did not significant difference was observed in terms of age, educational level, socio-economic status (SES), timing of registration and parity. Conclusion: At this stage of pregnancy, women are usually more receptive to their advices. This opportunity may be utilised today for the sake of a better maternal health tomorrow.
Keywords: Ante natal care, early registration, iron folic acid, recently delivered women, tetanus toxoid
|How to cite this article:|
Basu M, Chatterjee S, Roy S, Chowdhury G. Utilization of ante natal care services and it's determinants by women admitted in a tertiary care hospital of Kolkata. Saudi J Health Sci 2015;4:92-8
|How to cite this URL:|
Basu M, Chatterjee S, Roy S, Chowdhury G. Utilization of ante natal care services and it's determinants by women admitted in a tertiary care hospital of Kolkata. Saudi J Health Sci [serial online] 2015 [cited 2017 Nov 23];4:92-8. Available from: http://www.saudijhealthsci.org/text.asp?2015/4/2/92/157871
| Introduction|| |
A number of initiatives have geared towards achievement of the fifth Millennium Development Goal (MDG5: Improving maternal health), particularly following the launch of the Global Strategy for Women's and Children's Health in 2010 by the United Nations Secretary-General. 
Globally, there were an estimated 289 000 maternal deaths in 2013, a decline of 45% from 1990. The global Maternal Mortality Rate (MMR) in 2013 was 210 per 100 000 live births, down from 380 in 1990. Among the United Nations Millennium Development Goal regions, in 2013, Sub-Saharan Africa had the highest MMR (510, 62% of global maternal deaths). At the country level, two countries that accounted for one third of all global maternal deaths were India and Nigeria. While most countries aspire to achieve MDG5 target 5A (Reduce MMR by three quarters between 1990 and 2015) by 2015, some countries will unlikely to attain this goal if current trends persist. 
Poor access and utilisation of antenatal services contribute to high MMR along with other socio-economic factors. World Health Organization (WHO) recommended a minimum of four antenatal visits, comprising interventions such as tetanus toxoid (TTTT) vaccination, screening and treatment for infections, and identification of warning signs during pregnancy. Globally, during the period 2006-2013, about 56% of pregnant women attended the recommended minimum four times antenatal care. 
Mothers who had not received good quality Ante Natal Care (ANC) were found to be more at risk of having low birth weight babies and there is clear association between perinatal mortality rate, infant mortality rate and lack of or poor quality ANC. 
In India, the Reproductive and Child Health Programme II (RCH II) and National Health Mission (NHM) aims at providing quality ANC which includes minimum of at least 4 ANCs including early registration and first ANC in first trimester along with physical and abdominal examinations, Haemoglobin percent estimation and urine investigation, two doses of TTTT immunisation and consumption of iron folic acid (IFA) tablets for 100 days. 
As per National Family Health Survey 3 (NFHS) 2005-06, about 77% women preceding the survey received ANC; 44% received ante natal care during the first trimester of pregnancy; 52% women had at least 3 ante natal check-ups; 76% received two doses of TTTT; 65% received IFA supplement; only 23% consumed IFA for at least 100 days. 
As per Coverage Evaluation Survey (CES) 2009, 91.9% women registered their last pregnancy; 59.2% women received the first ante natal check up in the first trimester; recently delivered women who had received any ANC was 90.4%; women who had three or more ANC was 68.7%; 53.1% women took at least four or more ANC; mothers who had full ANC check up was 26.5%; 85.9%women had two TT; 40.6%women received 100 IFA tablets or syrup for 3 months; and 31%women consumed 100 IFA tablets or syrup for 3 months. 
As deadline for Millennium Development Goals is approaching, the need for improving the standard of maternal care is more than ever.
With this background, the present study was conducted to evaluates the utilisation of ANC services and its determinants among full term pregnant women and recently delivered women admitted in a tertiary care hospital of Kolkata.
| Materials and methods|| |
Study type and design
Hospital based observational descriptive study, cross sectional in design.
Obstetric ward of a tertiary care teaching hospital at Kolkata.
Full-term ante natal women and recently delivered women (RDW) admitted in that setting during the study period between February to July 2014.
A predesigned pretested structured interview schedule and relevant records and reports that is; antenatal card, bed history ticket (BHT), Laboratory investigation reports and prescriptions (if available).
The schedule was prepared in consultation with three experts of community medicine; pretesting of the schedule was conducted at the same site during the first week of the study period among 40 women; the women were not included in the sampling frame; validated by another three experts of community medicine and necessary modification were done before final data collection.
Socio demographic profiles (age, religion, residence, type of family, parity, education, occupation, per capita monthly income converted to socio economic classification as per modified B. G. Prasad scale 2013);  numbers of ante natal check-up, timing of registration, measurement of weight and blood pressure, abdominal examination, TT immunisation, consumption of IFA tablets, laboratory investigations (blood, urine, stool, Ultra-sonogram) done and advices (diet, rest/sleep, immunisation, physical activity, personal cleanliness, smoking and alcohol consumption, family planning, breastfeeding and newborn care, medicine related as well as warning signs) given.
Interview method: Of the patients and Record review method-review of all the prescriptions, ANC Cards with investigation reports, BHT.
- Full term admitted women and RDW of 19 years and above, not seriously ill, willing to give answers, gave informed written consent.
- Other admitted women, full term admitted women and RDW of below 19 years of age, seriously ill, non-motivated, not provided with informed written consent.
Sample size calculation  was done using the formula t² × P (1-p)/m 2
t = confidence level at 95% (standard value of 1.96)
p = estimated prevalence of malnutrition in the project area
m = margin of error at 5% (standard value of 0.05)
The calculated sample size for this study was 361; based on the percentage of women attending antenatal care was 62% in West Bengal, according to the findings of NFHS-3  with a relative precision of ± 5% for the 95% confidence interval (CI). After adding the 5%, non-response error, the final sample size was 380.
Simple random sampling technique was followed using a random number table.
Data collection technique
The informed written consent of the study population was obtained after explaining the purpose and nature of the study and knowing their willingness to share the information. They were assured about their confidentiality and anonymity. They were also told that their participation was voluntary and not compulsory. Then the principal investigator (PI)/Co investigators conducted a face-to-face interview to fill the schedule. Additional informations were noted after consulting the necessary records. The average time of an interview was 40 minutes.
Data entry and analysis
Data entry and analysis were done by the computer using PASW Statistics version 19.0 (SPSS Inc., Chicago, IL, US). Frequency and percentage for categorical variables were calculated. The Chi-square test were used to compare between the study participants, who took at least four antenatal care visits and who did not. Results were expressed in terms of odd's ratio (OR) and 95% CI, P < 0.05 was considered as significance.
This study was approved by the Institutional Ethical Committee (IEC).
- Full term pregnancy: The World Health Organisation (WHO) defines normal term for delivery as from 37 completed weeks to less than 42 completed weeks (259-293 days) of gestation 
- RDW: A post natal woman who had delivered a baby within 7 days of the data collection period
- Utilisation of antenatal care: Having made at least one antenatal visit before delivery
- Early registration of antenatal care: Within the first trimester of pregnancy (during the optimal first 12 weeks of pregnancy) 
- Number of ante natal visits: Every pregnant woman must receive at least four checkups during pregnancy including registration 
- Full ante natal care: Full ANC includes minimum of at least four ANCs including early registration and 1 st ANC in first trimester along with physical and abdominal examinations, Hb estimation and urine investigation, two doses of TT immunisation and consumption of IFA tablets for 100 days 
- Parity: The number of times that the woman has given birth to a foetus with a gestational age of 20 weeks or more, regardless of whether the child was born alive or was stillborn.
| Results|| |
A total of 380 full term pregnant women and RDW with an age range of 19-35 years were interviewed. The response rate was cent percent. About 179 (47.11%) of the study population were between the age of 20-30 years; 262 (68.95%) were Hindu; 211 (55.53%) belonged to nuclear family; 230 (60.53%) were from rural area and 203 (53.42%) were multipara women. Regarding educational level, majority 340 (89.47%) were literate. So far the occupation was concerned, 243 (63.95%) were homemakers Regarding Socio Economic Status, 110 (28.95%) belonged to class III, as per Modified B. G. Prasad's classification 2013 [Table 1].
|Table 1: Socio demographic characteristics of the study population (N=380)|
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All the study population got themselves registered for ANC. Majority 346 (91.05%) of them took at least three ANC services during their last pregnancy; and 248 (65.26%) of them got registered during the first trimester. Overall weight was measured in 99.74% of cases, 99.2% women had an abdominal examination, 98.95% women had their blood pressure measured and cent percent received at least one TT injection. However only 43.96% consumed 100 or more IFA large tablets. Regarding laboratory investigations, 97.63% reported of having a blood test for haemoglobin estimation and Blood grouping; 92.11% had a blood test for VDRL; 42.37% had examined their blood for FBS/PPBS and 79.21% reported of having a blood test for HBsAg/HIV/TSH etc., About 100% had an urine examination for R/E including albumin; and 25.79% had their urine tested for C/S. About 25.79% reported of having stool test for Oligomeric Procyanthocyanides (OPC) and 67.53% had ultrasonography (USG) of pregnancy profile . So far the advice was concerned, again 100% of the study population was advised about diet and immunisation followed by rest/sleep (97.89%) and physical activity (82.89%). However advice regarding personal cleanliness (27.89%), smoking and alcohol consumption (23.42%), family planning (27.37%), breastfeeding and newborn care (49.21%), drugs related (64.47%) and warning signs (66.05%) was not adequate [Table 2].
[Table 3] depicted the comparison between women who went for at least four ANC visits and who did not; significant difference was observed in terms of age, educational level, socio economic status (SES), timing of registration and parity. About 66.96% of the study population who took at least four ANC visits were of age group 25 years or more while 54.25% were below 25 years and the difference was statistically significant (P < 0.05). Similarly 68.3% of the study population who had education above primary level had more number of ANC visits than 54.49% who were either illiterate or read up to primary standard and it was statistically significant (P < 0.01). Again 67.34% of the pregnant women who got them registered early, went for more number of antenatal check-ups than 51.52% women who registered late which was also statistically significant (P < 0.01). Moreover significant difference (P < 0.05) was observed between multipara women (67.49%) who were the maximum utilizers of ANC services than primipara women (55.37%). Significantly more women with a higher SES (Class I, II and III) (68.20%) utilised ANC services as compared to those of lower SES (Class IV and V) (53.37%, P < 0.01). The influence of religion, type of family and residence was not statistically significant (P > 0.05) [Table 3].
|Table 3: Relationship between number of ante natal visits and socio demographic characteristics (N=380)|
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| Discussion|| |
Under the RCH programme, early registration, that is, within 12 weeks of pregnancy, has been given much stress as it is important for early identification of problems and prevention of morbidity and mortality This study showed 100% registration of pregnancy, of which 65.26% registered within 12 weeks. The extent of registration and early registration was in accordance with the findings of previous studies in India and abroad; such as studies conducted by Banerjee at Kolkata  (100% and 58%), Roy et al., at Lucknow  (100% and 53.7%), Sharma et al., at Lucknow  (98.6% and 58.5%), Ashwini et al., at Belgaum  (100% and 42.6%), Javali et al., at Karnataka  (100% and 56.5%), Koppad et al., at Kakati (96.6% registration),  Singh et al., at Uttar Pradesh (89% registration),  Deb at East Khasi Hills (82% and 52.4%),  Birmeta et al., at Ethiopia (87% and 42%),  Zhao et al., at Shanghai (90.1% registration but only 19.7% early registration)  and Eijk et al., at Kenya (90% registration but only 14% early registration.  However, this was not in accordance with the findings of the study conducted by Kumar et al., at Etawah  where only 46.61% had registration and 29.06% had early registration. According to NFHS III- India,  76% women preceding the survey received ANC, and only 44% started antenatal care during the first trimester of pregnancy. As per Coverage Evaluation Survey (CES) 2009,  91.9% of mothers registered their pregnancy, but 59.2% women received the first antenatal check-up in the first trimester.
In our study, 91.05% of the study population took at least three ante natal services during their last pregnancy period which was corroborative with the findings by Banerjee (93%),  Roy et al., (85.5%),  Sharma et al., (78.4%),  Javali et al., (83.1%)  and Eijk et al., (80%).  However findings of some other previous studies conducted by Ashwini et al.,  Singh et al.,  Deb,  Birmeta et al.,  and Zhao et al.,  demonstrated lower results where 29.8%, 62%, 21.7%, 66.3% and 49.7% respectively had at least three ante natal checkups. As per NFHS-III  India, 52% had at least three ANC visits. CES 2009  revealed that women who had three or more ANC was 68.7%; and 53.1% women took at least four or more ANC.
In the present study, the study population were asked about the components of ANC offered at least once; recording of weight and blood pressure was done for 99.74% and 98.95% of the study population respectively, 99.21% had an abdominal examination, 97.63% had their blood test for haemoglobin and blood grouping; cent percent had routine urine test; and ultrasonography was the least utilised component (67.53%); which was almost similar to some other previous studies conducted at Kolkata,  Lucknow,  Belgaum,  Karnataka,  Uttar Pradesh.,  East Khasi Hills.;  Kenya  and Etawah.  In contrast to NFHS-III, India  and CES2009  the results of our study was a better one.
In this study, it was seen that only 43.96% of pregnant women in their second trimester had received and consumed at least 100 tablets of IFA; similar to study at Karnataka,  Kakati  and Kenya;  where 65.6%, 48.4% and 48% mothers consumed at least 100 IFA tablets respectively. Moreover NFHS-III  and CES 2009  revealed that only 65% and 40.6% women received 100 tablets or syrup and 23% and 31% consumed tablets or syrup for 100 or more days respectively. On the contrary, 92% of the study population took at least 100 IFA tablets at Kolkata,  93.5% at Lucknow,  72.5% at U. P.,  79.3% at East Khasi Hills  and 89.32% at Etawah. 
In our study, 100% of the study population received at least one TT; comparable to NFHS-III (78%),  CES-2009 (85.9%),  Kolkata (100%),  Lucknow (95.5%),  Belgaun (98.4%),  U. P. (86.4%)  and East Khasi Hills (100%).  In contrast, lower results were observed at Kakati (50%)  and at Etawah (46%). 
Full pregnancy care had been received by 85% of our study population, which was in accordance with the study by Banerjee (86%),  Javali (62.6%).  and Singh et al., (52.5%).  However as per CES 2009  mothers who had full ANC check up was 26.5% and as per Deb  it was only 21.7%.
Women were further asked about the type of advice received during antenatal check-ups which revealed that dietary and immunisation advice was given to cent percent of mothers, followed by rest/sleep (97.89%), physical activity (82.89%), medicine related (64.47%); information regarding danger signs (66.05%) and breastfeeding and newborn care (49.21%); similar to findings of CES 2009,  and study by Javali et al.,  but dissimilar to study by Sharma et al.,  and Kumar et al.,  where these important services were least consulted.
At the comparison between the profiles of the women who went for four ANC visits and who did not, significant difference was found in terms of age, educational status, SES, timing of registration and parity.
Among different factors, less age has earlier been established as the determinant for more ANC visits. ,, In contrary to these studies, the present study suggested that increased age is associated with more number of antenatal visits. Some other studies also supported this view. ,,,
As per our study; more women of higher SES utilized ANC services more as compared to those with lower SES; previous studies also pointed towards economic factor as a determinant of ANC. ,,,,,,, Reason may be that the women of higher SES are in a better position as compared to those of lower SES to pay for the transport to the health facilities where the ANC services are being provided. Moreover they have not the problem of loss of daily wages on days of ANC check-ups. However SES had no relation with the utilization of ANC services in Kakati study. 
Maternal education is a very strong and consistent predictor of utilization of ante natal services; seen in the present study and some other previous studies. ,,,,,,, Education by imparting awareness and autonomy to the women, encourages utilisation of maternal services and leads to demand for maternal health care services. However the findings were different from the observation of some previous studies which revealed that level of education of women was not found influencing their utilization of ANC services. ,,
The effect of early registration was also evident on utilisation of antenatal care in this study. Encouraging early registration will ensure better maternal health in a long run. A study from Lucknow also found the same. 
In our study, there was an increase in the proportion of women obtaining ANC services with increasing parity. This may be due to the fact that women of high parity are usually more aware and anxious about their pregnancy as they had children before; they faced various problems related to pregnancy and child birth and they thus they knew the importance of ANC. On the contrary, some previous studies showed that the number of women with less number of ANC increased with increasing parity. ,,,,
It was noted in the present study and some other studies , that there was no statistically significant difference in the two groups on variables like religion, type of family and residence. However religion was found to have significant effect on utilisation of ANC services (more Hindu as compared to Muslim women utilised ANC services) in a study at NFHS III India;  CES 2009  and at Lucknow  and at U. P. 
Moreover, NFHS III,  CES 2009  and Singh  reported that larger proportion of women with no ANC were from rural area as compared to urban area.
This study was an attempt towards achievement of the fifth Millennium Development Goal (MDG5: Improving maternal health) and MDG5 target 5A (Reduce MMR by three quarters between 1990 and 2015) by 2015, as deadline for Millennium Development Goals is approaching, the need for improving the standard of maternal care is more than ever.
- Cross sectional study design
- Institution based study
- We did not ask from where they have taken ante natal care services
- Moreover we did not ask for the reasons for getting less number of antenatal care visits. Elicitation of such causes would have revealed the views of the study population in this regard. Further research focusing on this aspect is warranted in future.
| Conclusion|| |
All the study population got themselves registered for ANC; almost two third of them took at least four ANC checkups and got registered during the first trimester of pregnancy. More than 95% had their weight and blood pressure measured, had an abdominal examination, received their TT injection, had a blood test and had an urine test, advised on diet, rest/sleep and immunization. However advice regarding some important issues like personal cleanliness, smoking and alcohol consumption, family planning, breastfeeding and newborn care, drugs related and danger signs were neglected. There was a statistically significant relationship between number of ANC visits and age, education, SES, timing of registration and parity.
- More focus on young mothers should be the thrust areas in maternal health programme as younger mothers are easily convincible; personal interaction with them could bring in successful changes in behaviour
- At this stage of pregnancy, women are usually more receptive to their advices. This opportunity may be utilised today for the sake of a better maternal health tomorrow
- Counseling for early registration should also get priorities, as it would be the first step for sufficient ANC visits to the health facility
- Promotion of female literacy and empowerment are required to improve utilisation of maternal health services
- On job training can be given to health care providers on various antenatal components and advices.
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[Table 1], [Table 2], [Table 3]