Pregnancy and childbirth are special events in women’s lives and indeed, in the lives of their families. So, promotion of maternal health has been one of the most important objectives of Family Welfare Program in India. Reproductive and child health (RCH) program recommends that under antenatal care, women should receive at least three antenatal check-ups that include blood pressure monitor and other procedures to detect pregnancy complications, 100 IFA tablets to prevent and treat anaemia, 2 doses of TT (MoHFW, 1997; 1998b). Antenatal Care (ANC) is the care of women during pregnancy by systemic supervision to access the progress of foetal growth, foetal health and maternal health at regular intervals.

The primary aim of ANC is to achieve, at the end of programme, a healthy mother and healthy baby. Quality care is more important than quantity. The pregnancy related health-care services are provided by Qualified Doctor, or a Health Worker.

The Millennium Development Goal 5 focuses on Indian health care services to improve maternal health (MDG 5 WHO), with targets to reduce maternal mortality by three quarters between 1990 and 2015 and to achieve universal access to reproductive health by 2015. To achieve this goal, urban populations need more attention as the urban slum population constitutes nearly a third of India’s urban population. Health status among urban slum dwellers is poor and far from adequate, due to factors like inadequate reach of services (Agarwal, 2005). Though on average health indicators, the situation in cities is better than in rural areas, the enormous social and economic stratification with in urban areas results in significant health inequalities (World Health Report 2008).

There is strong positive relationship between utilisation of Antenatal services and socio-economic background of mother’s in terms of literacy, place of resident and standard of living. Poor utilisation of services reflects cultural and socio-economic constraints as well as perceptions regarding accessibility of facilities and quality of care revealing low utilisation of ANC by different segments of society for varying reasons.

This study was formulated against this background with an objective of studying the factors influencing utilisation of health services in the spectrum of antenatal period of a mother.

A community based cross-sectional study was conducted from September 2016 to February 2017 among RDW (Recently Delivered Women) at an urban field practice area of Veer Surender Sai Institute of Medical Sciences and Research (VIMSAR),Burla(UHTC,Goudpali), Sambalpur,Odisha.

Inclusion criteria: All RDW residing in the slums willing to participate in the study were included .

Exclusion criteria: Those RDW who were not willing to participate in the study were excluded

The urban field practice area caters a total population of about 18,132 spread over 14 slums like Tripathy pada, Mahatabnagar, Tiarpada, Santoshi pada, Sadeipali-1, Sadeipalli-2, Sweeper colony-A, Sweeper colony-B, Goudapali, 1RC, 3RC, Old Burla, Board colony and Pathanbandh.

Sample size

A total of 202 recently delivered women (RDW)[RDW is defined as all the women of reproductive age who delivered their baby in last one year prior to data collection]  from all the 14 slums willing to participate in the study were identified with the help of local anganwadi workers (AWWs) and included in the study.

Study tool: A predesigned pretested semi-structured questionnaire was prepared for interviewing the study participants. The schedule contains information regarding socio demographic variables (age, religion, caste, education, occupation, monthly household income) and utilization of ANC (ANC registration, number of ANC checkups, number of TT injection taken and IFA tablets /syp consumption in days) .It also includes utilization of ANC and full ANC which was collected by reviewing their maternal and child protection (MCP) card. Full ANC is defined as ≥ 4 ANC visits, at least one TT injection and reported consumption of IFA tablets or syrup for a minimum of 100 days.5

Data collection method: Data collection was done by door to door visit with the help of local anganwadi worker (AWW).The data regarding socio demographic variables (age, religion, caste, education, occupation, monthly household income) and utilization of ANC (ANC registration, number of ANC checkups, number of TT injection taken and IFA tablets /syp consumption in days) were collected from each study participant in a predesigned pretested semi-structured questionnaire. Apart from mother’s interview data regarding utilization of ANC and full ANC was collected by reviewing their maternal and child protection (MCP) card. Full ANC is defined as ≥ 4 ANC visits, at least one TT injection and reported consumption of IFA tablets or syrup for a minimum of 100 days.⁵

Statistical analysis: The data obtained was compiled, tabulated and presented by using descriptive statistics like number and percentages.

Ethical clearance: Ethical permission was obtained from Institutional Ethical comittee(VIREC),VIMSAR,Burla.Informed verbal consent was obtained from each study participant prior to data collection.              

Table 1: Socio demographic profile of study participants (N=202)

Table 1 summarises out of 202 mothers, 160(79.21%) belonged to age group 20-29 yrs and majority173 (85.64%) were Hindu by religion. There was a well-mixed of caste with 71(35.15%) SC, 55(27.23%) OBC, 45(22.27%) General and 31(15.35%) ST. Most of mothers were educated with middle school and above165 (81.68%) and only 11(5.44%) were illiterate. Majority of mothers were housewife 162(80.20%). So far household income was concerned, most 98(48.51%) belonged to Rs 5000-10000 income group followed by 46(22.77%) with less than Rs 5000 per month.

Table 2: Utilisation of antenatal care by study participants (N=202)

Table 2 showed that 100% mothers registered their pregnancy with an early registration of 170(84.15%). Out of all, 138(68.32%) had done ≥4 ANC check-ups with at least 1dose of TT 191(94.55%) and ≥100 IFA tablet consumed 91(45.05%).

Fig. 1 Utilisation (%) of full antenatal care and its different components

From Fig 1 it was observed that only 37.63% of pregnant women utilised full antenatal care during their last pregnancy. The proportion of women who had a minimum of 4ANC visits was 68.32%.At least one dose of tetanus toxoid was received by 94.55% of women. IFA was consumed for a minimum of 100 days by only 45.05% of women.

Table 3: Socioeconomic backgrounds of mothers and Utilization of antenatal care

From table 3 it was revealed that, out of 202 registered mothers from different caste groups, early registration was only slightly high in OBC (89.09%) and General (88.88%) caste as compared to ST (80.64%) and SC (78.87%) but ANC check-ups of ≥4 was very high in General (77.78%) and OBC (74.55%) caste than SC (64.79%) and ST (51.61%) . The study also shows the differences in continuation of ANC checkups in different caste groups. The mothers from General (46.66%) and OBC (40.0%) caste were more likely to continue full ANC care compared to SC (35.21%) and ST (25.8%).

When education of mothers was taken into account, early registration was more in mothers    with secondary and above (89.83%) than middle (83.0), illiterate (81.82%) and primary standard education (76.92%). The percentage of ≥4 ANC checkups more with higher education standard i.e. Secondary and above (84.75%) and middle (67.92%) as compared to primary(53.85% ) and illiterate( 18.18%) mothers. Utilization of full ANC care decreased with decreased in education standard i.e. mothers with secondary and above standard (49.15%) were more regular in full ANC care than middle (37.73%), primary (26.92%) and illiterate (0.0%).

Occupational status of the registered mother showed significant impact on utilisation and continuity of ANC services. Service mothers (90.47%) and housewife (84.56%) had done early registration more as compared to others i.e. manual labour (60%) and petty business and/shop (56%). It is interesting fact that those women who are engaged in petty business/shop have demonstrated slightly higher (85.71%) ≥4ANC check-ups compared to housewives (68.52%), mothers doing services (66.67%) and manual labours (20%). The continuation of full ANC care was more in service mothers (57.14%) compared to labourers (40%), housewives (37.65%) and it was very low in mothers with petty business/shop (7.14%).

Majority of mothers had done early registration of pregnancy irrespective of their monthly household income though the trend was slightly more among Rs 10000-15000 income group (89.19%) and Rs >15000(85.71%) as compared to Rs <5000(84.78%) and  Rs 5000-10000(81.63%).When ≥4ANC check-ups was compared the trend was more in Rs 10000-15000 income group (83.78%) and Rs >15000(76.19%) than Rs 5000-10000(64.29%) and Rs <5000(60.87%). But the adherence to full ANC care was more in mothers with higher income group >15000 (57.14) and Rs 10000-150000(45.94%) compared to those with low income group Rs 5000-10000(32.65%) and Rs <5000(32.60%).

In the present study all the 202(100%) mothers got themselves registered for antenatal care services at different Anganwadi Centres (AWCs). This finding is in consistent with Uppadhaya SK et al. and Roy MP etal.^1,2 Contradicting to this study different researchers found different from  a minimum of 80% to maximum up to 95.1% registration of pregnancy. ^3-8

 Time of registration plays a very crucial role in evaluation of ANC services. In the current study the early registration of pregnancy was quite impressive as 84.15% mothers registered during 1^st trimester of pregnancy when compared to NFHS-4 data of Sambalpur district (71.9%) and Odisha(64%).⁹ But study conducted in different parts of India observed very low percentage of early registration i.e. 37.88%,53.7% ,44% and 58.4% respectively.^1,2,5,8 This is not in accordance with the finding of previous studies . This finding is important, since it implies that encouraging early registration will ensure better maternal health in a long run.The improved registration of pregnancy by mothers might be due to increased IEC activities of mostly ASHAs, AWWs and HWF as well as introduction of “MAMATA scheme” in the state a conditional case transfer scheme since 2011.

In this study early registration of pregnancy was170 (84.15%) quite impressive compared to NFHS-4 data of Sambalpur district (71.9%), Odisha (64%) and India (58.6%). Early registration was only 37.88% ,53.7% and 44% respectively in study conducted at other parts of India.^1,2,5

¹ The proportion of early registration was not quite impressive as only 37.88% of the mothers registered during the first trimester. This is similar to the findings of DLHS-3 (2007-08), Rajasthan and Jodhpur district in which 1st trimester registration was 32.7% and 31.7% respectively.¹²

In the current study 68.32% mothers had done ≥4 ANC check-ups in their last pregnancy. Though this finding is higher than the global average (61.8%) and NFHS-4 data of India (51.2%) and Odisha (61.9%) and other studies conducted both within and outside India.^{1,8,9,10,11,12}  But  this finding is discouraging, as it is considerably lower when compared with NFHS-4 data of Sambalpur district (83%).⁹The lower percentage of ≥4 ANC check-ups might be attributed to  the fact that mothers resides in the underprivileged living conditions in  these slums often belonging to low socioeconomic strata, which usually lag behind the basic sources of information and knowledge as compared to other residential communities .

In the present study it was observed that in spite of 100% antenatal registration 94.55% of mothers had taken either two doses of TT or booster as required or at least 1 dose of TT injection in their last pregnancy. Similar findings were reported by NFHS-4 data of sambalpur district (96.4%) and Odisha (94.3%) and studies conducted in other states of India.^{1, 8, 9, 13}   Contradictory to that,  NFHS-4 data of India (89%) and  study conducted  by Gupta SK and Nandeswar S in urban slums of Bhopal (87.2%) observed less proportion TT immunisation among RDW.^10,14

The high proportion of mothers with at least one tetanus toxoid immunisation can be achieved even in a single visit during any trimester.

In the current study only 45.05% RDWs consumed ≥100 IFA tablet during antenatal period. Similar finding was reported in NFHS-4 data of sambalpur district (43.5%).⁹   Contradictory to this NFHS-4 data of India (30.8%),Odisha(36.5%) and study conducted by Uppadhaya SK etal(37.37%) and Diipti S and Shukla M (13.4%) reported lower percentage of  ≥100 IFA consumptions.^{1,8 ,9,15} But  Gupta SK and Nandeswar S observed a higher percentage ( 61.3%) of ≥100 IFA consumptions by the mothers during antenatal period in urban slums of Bhopal. ¹⁴ Consumption of ≥100 IFA tablets is possible only if multiple visits are made as currently the supplies are given for 1 month at each visit and lower number of visits along with side effects of  IFA tablets may be the reason for its low utilization .

The low compliance of ≥100 IFA tablets consumptions might be due to lesser number of ANC visits and side effects IFA tablets.

Full ANC care

In the present study it was observed that, in spite of 100% antenatal registration and 94.55% TT coverage, the proportion of mothers who had utilized full ANC services (minimum 4 ANC visits, minimum one TT and minimum 100 IFA tablets taken during pregnancy) remained low (37.63%). This finding is higher than NFHS-4 data of Sambalpur district (35.1%), Odisha (23.1%) and India (21.3%). Out of 30, only 2 district of Odisha i.e. Puri (40%) and Subarnapur(45.1%) had higher full ANC than the present study. ^9,10   Likewise 17 out of 36 states/UTs of India reported less than 30% full ANC among pregnant women .¹⁵ Uppadhaya SK et al reported low (26.26%) full ANC among women in rural area of Rajasthan.¹ A study among tribal women in selected states the full ANC was also found very low in Madhya Pradesh (3.6%) and Rajasthan (4.1%) followed by Chattishgarh (10.4%) and Odisha (14%).¹⁶

Contradictory to the present study, full ANC care was found high (71.2%) in a slum-based study in South Delhi. The difference in the percentage could be because the observation of the latter is for ≥3 ANC visits. ⁴

The main reason for sluggish full ANC utilization was the low performance in IFA consumption (only 45.05% of mothers taken ≥100 IFA tablets/syp) and limited number (68.32%) of ≥4 ANC visits.

The study also shows the differences in continuation of ANC checkups in different caste groups. The mothers from General (46.66%) and OBC (40.0%) caste were more likely to continue full ANC care compared to SC (35.21%) and ST (25.8%). It means that utilization of reproductive health services varies with social status of the household in urban slums of Burla. It represents that mothers of general caste are having more aware for their health compared to those who are from lower social status. Kumar et al also observed inequity in full ANC utilization among those belongs to socially disadvantaged groups (SC/ST/OBC).  Similar type of findings was found in urban slums of Delhi. ¹⁷

In this study utilization of full ANC care decreased with decreased in education standard i.e. mothers with secondary and above standard (49.15%) were more regular in full ANC care. Educated women are more concerned about full ANC care in other sudy.^{15, 17}

This study also observed that, continuation of full ANC care was more in service mothers (57.14%) compared to labourers (40%), housewives (37.65%) and it was very low in mothers with petty business/shop (7.14%). Service mothers are educated and knows the importance of full ANC care than other occupation.¹⁷

In our study, the adherence to full ANC care was more in mothers with higher income group compared to those with low-income group. A gradient in full ANC utilization observed across the wealth quintiles i.e. the highest utilization was among the richest and vice versa.¹⁵ Similar findings were observed in Delhi slums.¹⁷

Though the ANC care was more than the state and national level it was inadequate and inequitable. Full ANC was very low among mothers of lower caste groups, low standard of education, petty business and low household income.Strategies to address the socio-economic factors associated with low and inequitable utilisation of full ANC are vital for strengthening maternal health program. Educating mothers, creating awareness by IEC and BCC activities to improve effective utilization of antenatal care services. Future surveys should capture details of antenatal care with higher granularity to understand the quality of care received at each visit. Coordinated effort is needed from the different sections of the government involved in delivering maternal care during pregnancy.

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