Maternal and child healthcare services are very important for the health outcomes of the mother and that of the child by ensuring that both maternal and child deaths are prevented.1 Many health programs have been launched in the country in last two-three decades for women and child health care. Health care utilization overall, and for maternal health specifically, has improved in India mainly due to NRHM2 but Maternal mortality and morbidity continue to be high despite the existence of national programs which could be due to sub optimal levels of utilization of services3-4 especially amongst the rural poor and urban slum population.5 Studies have also found the need for such services is greatest, i.e., among disadvantaged populations.6-9 Various studies conducted worldwide and in India have recognized socio-economic, demographic factors and service delivery environment as important determinants for the use of maternal health services.10-16
Uttar Pradesh is one of the eight states which is home to 43% of India’s urban poor with rates of utilization of maternal health services far below the national average. Hence there is a distinctive need of understanding the factors affecting the use of maternal health services. However, scarce research is available in the context of Uttar Pradesh of India.
Hence the present study was conducted with an aim to assess the utilization of maternal health care services (ANC and PNC) and the association of factors on maternal health care utilization in urban slums in Lucknow. This study is expected to provide the policy makers findings which may help in improving the policy efforts in the ongoing program.
MATERIALS AND METHODS
This is a cross sectional study conducted in slums of Lucknow district and the study participants were the mothers who have delivered in last one year. The study was conducted from July 2014 to March 2015. The slums were selected randomly and the study unit who has delivered in the last one year was included in the study. Help of local stake holders, door to door survey etc. were taken to identify the study participants. Every eligible participant who consented was enrolled in the study. The sample size calculated was 968. Sample size was calculated taking utilization of Government health services which is around 20%.40 Design effect of 1.5 was applied to calculate sample size.
The study was piloted on 100 participants to test the questionnaire and the methodology and necessary corrections were made. The interview was recorded on a pre-tested, pre-structured questionnaire. The Data Analysis was done using SPSS-20.0 version. The tests used for analysis of data were Pearsons Chi – Square Test and p<0.05 is taken as significant.Institutional and ethical approval was taken.
The study observed that the majority of participants were illiterate (71.4%) and housewives (78.8%). It was further observed that 96.4% of husband of study participants were either illiterate or literate upto primary level (Table 1). Table 2 depicts that 77% of study participants were registered for ANC (Figure 1), majority of whom being registered at a govt. maternity center (78.6%). ANC registered participants who undertook more than three ANC visits were low (15.3%) and only one third of these participants undertook first ANC visit during the first trimester. Approximately two-third of registered participants did not receive IFA tablets and 96.6% of participants had either one or two doses of TT vaccination. About 95% of all study participants didn’t undertake PNC visit.
Table 3 shows that on statistical analysis the religion was associated with the ANC and PNC visit and the association was statistically significant(X2- 26.0, d.f.=1, p=0.000; X2- 3.87, d.f.=1, p=0.049). Literacy level of participants was also found to statistically significant with ANC and PNC visits(X2- 66.5, d.f.=3, p=0.000; X2- 24.6, d.f.=3, p=0.000). Parity of study participants was found to be statistically significant with ANC service utilization(X2- 7.23, d.f.=2, p=0.027).
|ANC visit||PNC visit|
|Religion(N-968)||X2- 26.0, d.f.=1, p=0.000||X2- 3.87, d.f.=1, p=0.049|
|Literacy level of Participant (N-968)|
|Illiterate||483||208||X2- 66.5, d.f.=3, p=0.000||27||664||X2- 24.6, d.f.=3, p=0.000|
|Up to primary||148||8||9||147|
|Up to intermediate||93||8||16||85|
|Graduate or higher||20||0||2||18|
|Husband’s education status (N-968)|
|Illiterate||363||111||X2- 0.243, d.f.=3, p=0.97||28||446||X2- 2.17, d.f.=3, p=0.538|
|Graduate or Higher||2||1||0||3|
|less than equal to 2||384||90||X2- 7.23, d.f.=2, p=0.027||27||447||X2- 0.63, d.f.=2, p=0.969|
|three to five||306||108||23||391|
|more than five||54||26||4||76|
|Type of Family(N-968)|
|Nuclear||336||100||X2- 0.18, d.f.=1, p=0.89||24||412||X2- 0.82, d.f.=1, p=0.92|
Studies have shown that Utilization of health care services is affected by a multitude of factors and many studies have tried to identify the factors that contribute to differentiation in the utilization of health care services17-18 Literature available across the world suggests that these factors can be identified as cultural beliefs, socio-demographic status, women’s autonomy, economic conditions, physical and financial accessibility and health services issue.19
The strength of our study, conducted to find the utilization of maternal health services, was the primary data collected from the study participants. Our study found the literacy level of mother, parity and her religion to be associated with the utilization of maternal health care services (statistically significant p<0.05). The findings of our study are supported by many studies which have found various socio-demographic factors like maternal education etc. influence the utilization of maternal health services.12-16,20
The findings of our study observed that the majority of participants (87%) were either illiterate or literate upto primary level and the literacy level of mother was found highly statistically significant to be associated with maternal health care utilization. Our findings regarding the influence of maternal education on utilization of maternal health care services are consistent with the studies in India and abroad.1-3,20-26 A study done in Rohilkhand region by Srivastava, A et al in 2014 also identified a number of demographic and socio-economic factors such as education, religion etc. to be the major causes of poor utilization of primary health care services.17 Some studies have also found that women with low level of education are less likely to access antenatal services, even if they are provided.27-29
There may be a number of reasons for association of women literacy level with maternal health care utilization like education increases the communication within the family especially with the husband on health related issues and helps the women to develop confidence to take decisions regarding her health.23 Educated women seek out better service quality, has a greater ability to improve their health by using health related inputs. Studies have proven the more the women is educated, the more they are aware about their health, know more about availability of maternal health care services and use this awareness and information in accessing and availing the health care services.25,26 Our study also observed that literacy level of husband was not associated significantly statistically with maternal health utilization and the findings of our study are in contrast with other studies.5,20,31
Our study also found that the association of religion is statistically significant with respect to use of Ante-Natal and Post Natal care by mothers. The similar findings were reported from other studies as well.2-3,21-22 Studies from other sub-continent countries like Pakistan32,33 and Bangladesh34 observed religion to be an important predictor of health outcomes, independent of socio-economic factors. But a study conducted by Jat et al in 2011 found that religion had considerable influence on the use of ANC and safe delivery services whereas no noteworthy influence of these factors was found on post natal care and also observed that women from schedule tribes population and Hindu religion were least likely to be users of the three dimensions of maternal health services.31 Similarly, a study conducted by Singh, PK et al in 2012 found that the postnatal care was utilized more by women from other religious groups (42%), followed by Hindu (35%) and Muslim (30%) women.30
Studies have attributed differences (lifestyle and theological) between different religions to the greater level of maternal health service utilization among different religions.35 Some norms and characteristics of religious groups may encourage negative attitudes healthcare service utilization.36 Evidence from African country suggests that collaboration between religious leaders and health officials are vital for changes in health.37 Hence considering the influence the religion exerts, its inclusion and involvement of religious bodies in the maternal health services programs may have a positive impact on overall utilization of health services.
The Current study also found that the utilization of maternal health care services (ANC and PNC) decreased as the birth order (parity) of the study participant increases. The finding was supported by other studies and the association of parity with the ANC utilization of maternal health care services was found to be statistically significant.2-3,21,17 The reason could be mothers with lesser number of child (esp. with the first child) are more cautious and concerned about pregnancy and thus likely to undertook healthcare visits.38 Further, one more explanation could be that as the parity increases, women have an experience and knowledge of earlier pregnancies and related conditions and they may have a belief that healthcare may not be as necessary.24 Other reason may be the cultural practice of women going to her maternal place for delivery (esp. the first pregnancy). May be for these reasons, the maternal health care utilization could be decreasing with higher parity.
We also observed that the study participant residing in nuclear families were availing ANC services almost similar to the participants residing in joint families. The association between them was also not statistically significant and the findings were in contrast to the study done by Srivastava et al in 2014 at Rohilkhand.17 This requires further research into the matter.
Utilization of maternal health care services like ANC registration, Registration at Govt. facility, Consumption of IFA (more than 100 tablets), at least one dose of tetanus Toxoid is found to be better in our study in comparison to Annual Health Survey (2nd update 2012-13) while the First ANC visit in First trimester was lower in comparison to AHS39 (Figure 2). The reason may be that our study confined to small area may not represent the state level scenario. Our study observed that 78% of ANC care was received from Govt. maternity center while the same was also found by Delhi slum study5 and a study in Rohilkhand region of UP also found that Majority of the women received ANC from a government functionary.17 The low level of PNC in our study was in accordance with other studies1,5 The low utilization of Postnatal Care services could be explained by that the mother may believe that it is not necessary to go back for check-ups after delivery without complications.
Even though there is a high utilization rate of antenatal maternal health services in urban slums of Lucknow, still there is scope of improvement. The use of postnatal services is dismal. The low PNC services puts the mother at undue risk of maternal mortality, therefore postnatal care should not be overlooked. The better utilization of the maternal health services can be achieved by overall socio-economic development including focus on women empowerment and education, incorporation of religious norms and faiths in the health policies. Interventions should focus on factors like overall literacy levels of couple, parity and religion. It is also suggested that further research should be carried out to study issues with low use of PNC and the qualitative aspect of maternal health care services. The potential beneficiaries of our study would be the community and the mother in particular. We also suggest that future studies could use the qualitative approach to study issues associated with the low use of postnatal services. Further organizations working on maternal health care services may find the results of this study as an input in their planning for improving utilization of maternal health care services.
Based on the findings of our study, we recommend that focusing and improving education of community in general and women and girls in particular and incorporation of opinions and norms of religious bodies could be an appropriate strategy to improve the utilization of maternal health care services.
Limitations of the study
Since the study being the cross sectional, only associations can be examined, causal relationship cannot be. The quantitative assessment of service utilization doesn’t comment on the quality of services available and satisfaction/feedback of client. Few other variables which could have potentially influence the pattern of maternal health care utilization were not taken into account like distance of health facility from residence of participants etc.