A Study on Utilization of Maternal Health Services and Factors Influencing the Utilization in Urban Slums of Lucknow

Deepak, Jauhari, and Dhungana: A Study on Utilization of Maternal Health Services and Factors Influencing the Utilization in Urban Slums of Lucknow



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.


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.

Figure 1

Showing ANC Registration of the Study Participants.

Table 1

Biosocial Characteristics of Study Participants.

Biosocial characteristics(N-968)
Age of Participant (women)No.Percent
15-24 yrs41442.8
25-34 yrs49350.9
35 and above616.3
Religion of Participant
Literacy Level of Participant
Upto primary15616.1
Upto intermediate10110.4
Graduate or higher202.1
Occupation of Participant
House Wife76378.8
Education of Husband
Upto primary45947.4
Upto intermediate323.3
Graduate or higher30.3
Occupation of Husband
Pvt Job808.3
Parity of Participant
Less than equal to 247449.0
3 to 541442.8
More than 5808.3
Type of Family
Joint family53255.0
Table 2

Distribution of ANC service Availed by Participants.

Registered during ANC(N=968)No.Percent
Any PNC visit undertaken
ANC services availed among those registered (N=744)No.Percent
Place of Registration
Govt. Maternity Centre58578.6
Private Hospital13117.6
No. of ANC Visits undertaken
More than Three11415.3
First ANC Checkup undertaken during
First Trimester26335.3
Second Trimester35948.3
Last Trimester12216.4
IFA Tablets
Less than 10013317.9
More than 10013117.6
not received48064.5
Consumed (n=264)
Less than 10013317.9
More than 1007810.5
not consumed537.1
T.T. Vaccine
One Dose12316.5
Two Dose59680.1
No Dose253.4

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).

Table 3

Association of Religion, Literacy level of Participant and her Husband, Parity and Type of Family with ANC and PNC Visit (N= 968).

ANC visitPNC visit
Religion(N-968)X2- 26.0, d.f.=1, p=0.000X2- 3.87, d.f.=1, p=0.049
Literacy level of Participant (N-968)
Illiterate483208X2- 66.5, d.f.=3, p=0.00027664X2- 24.6, d.f.=3, p=0.000
Up to primary14889147
Up to intermediate9381685
Graduate or higher200218
Husband’s education status (N-968)
Illiterate363111X2- 0.243, d.f.=3, p=0.9728446X2- 2.17, d.f.=3, p=0.538
Upto Primary35410526433
Upto Intermediate257032
Graduate or Higher2103
less than equal to 238490X2- 7.23, d.f.=2, p=0.02727447X2- 0.63, d.f.=2, p=0.969
three to five30610823391
more than five5426476
Type of Family(N-968)
Nuclear336100X2- 0.18, d.f.=1, p=0.8924412X2- 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.

Figure 2

Comparison of Indicators of Current study with Annual Health Survey(2nd update,2012-13).



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.


We are grateful to the faculty and staff of the department for the support in completion of this study.


DC conceptualized, designed, data collection, review of literature, draft and finalization of the study, NJ critical review, finalization of manuscript. HD analysis of data and preparation of manuscript.


None Declared



Ante-natal Care


Post Natal Care


National Rural Health Mission


Iron Folic Acid


Tetanus Toxoid.


Various health programs and policies in the country are being implemented in the country but the certain services (like PNC visits ) under the maternal health care service utilization by eligible women remains dismally low and these low patterns are affected by various socio-demographic factors. The better utilization of the maternal health services can only be achieved by overall socio-economic development.



Mluleki Tsawe, Amos Moto, Thendo Netshivhera, Lesego Ralesego, Cassandra Nyathi, ASathiya Susuman , authors. Factors influencing the use of maternal healthcare services and childhood immunization in Swaziland. International Journal for Equity in Health. 2015; 14 (1): 32 –3


Vidler M, Ramadurg U, Charantimath U, Katageri G, Karadiguddi C, Sawchuck , authors. et al. Utilization of maternal health care services and their determinants in Karnataka State, India. Reproductive Health. 2016; 13 (1): 37 10.1186/s12978-016-0138-8


Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C , authors. et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014; 384 (9947): 980 –1004. 10.1016/S0140-6736(14)60696-6


Omrana P, McClure EM, Wright LL, Saleem S, Goudar SS, Chomba E , authors. et al. A combined community- and facility based approach to improve pregnancy outcomes in low-resource settings: A Global Network cluster randomized trial. BMC Medicine. 2013; 11 (1): 215


Agarwal P, Singh MM, Garg S , authors. Maternal health-care utilization among women in an urban slum in Delhi. Indian J Community Med. 2007; 32 (3): 203 –5


Bhandari B, Mandowara SL, Kumar A, Agarwal D , authors. Underutilization of MCH services-the major factor for very high IMR in rural Rajasthan. Indian Pediatr. 1989; 26 (3): 228 –33


Kloos H , author. Utilization of selected hospitals, health centres and health stations in central, southern and western Ethiopia. Soc Sci Med. 1990; 31 (2): 101 –14


Sarin AR , author. Underutilization of maternal health services. World Health Forum. 1997. 18: p. 67 –8


Wilder-Smith A , author. Current status of ‘essential obstetric care’ activities internationally: a literature review. Trop Doct. 2003; 33 (3): 135 –38


Magadi MA, Madise NJ, Rodrigues RN , authors. Frequency and timing of antenatal care in Kenya: Explaining the variations between women of different communities. Social Science and Medicine. 2000; 51 (4): 551 –61


Kesterton AJ, Cleland J, Sloggett A, Ronsmans C , authors. Institutional delivery in rural India: The relative importance of accessibility and economic status. BMC Pregnancy and Childbirth. 2010; 10 (1): 30 10.1186/1471-2393-10-30


Gage A , author. Barriers to the utilization of maternal healthcare in rural Mali. SocSci Med. 2007; 65 (8): 1666 –82


Say L, Raine R , authors. A systematic review of inequalities in the use of maternal health care in developing countries: Examining the scale of the problem and the importance of context. Bulletin of the World Health Organization. 2007; 85 (10): 812 –9. 10.2471/BLT.06.035659


Kulkarni M, Nimbalkar M , authors. Influence of socio-demographic factors on the use of antenatal care. Ind J Preventive Soc Med. 2008; 39 (3): 98 –102


Babalola S, Fatusi A , authors. Determinants of use of maternal health services in Nigeria - looking beyond individual and household factors. BMC Pregnancy and Childbirth. 2009; 9 (1): 43 10.1186/1471-2393-9-43


Raj Baral Y, Lyons K, Skinner J, Van Teijlingen ER , authors. Maternal health services utilization in Nepal: Progress in the new millennium? Health Sci J. 2012; 6 (4): 618 –33


Srivastava A, Mahmood S, Mishra P, Shrotriya V , authors. Correlates of Maternal Health Care Utilization in Rohilkhand Region, India. Annals of Medical and Health Sciences Research. 2014; 4 (3): 417 –25. 10.4103/2141-9248.133471


Sugathan K, Mishra V, Retherford R , authors. Mumbai, India: International Institute for Population Sciences, and Honolulu: East-West Center, Population and Health Studies, USA; 2001. Promoting Institutional Deliveries in Rural India: The Role of Antenatal-Care Services.


Shaikh BT, Hatcher J , authors. Health seeking behaviour and health service utilization in Pakistan: Challenging the policy makers. J Public Health (Oxf). 2005; 27 (1): 49 –54


ZelalemAyele D, Belayihun B, Teji K, Admassu Ayana D , authors. Factors Affecting Utilization of Maternal Health Care Services in Kombolcha District, Eastern Hararghe Zone, Oromia Regional State, Eastern Ethiopia. International Scholarly Research Notices. 2014. 27: p. 49 –54


Goudar SS, Goco N, Somannavar MS, Vernekar SS, Mallapur AA, Moore JL , authors. et al. Institutional deliveries and perinatal and neonatal mortality in Southern and Central India. Reproductive Health. 2015; 12 (2): 13 10.1186/1742-4755-12-S2-S13


Kumar C, Singh PK, Rai RK , authors. Coverage gap in maternal and child health services in India: assessing trends and regional deprivation during 1992-2006. J Public Health (Oxf). 2013; 35 (4): 598 –606


Navaneetham K, Dharmalingam A , authors. Utilization of maternal health care services in southern India. Social Science and Medicine. 2002; 55 (10): 1849 –69


Singh L, Rai RK, Singh PK , authors. Assessing The Utilization Of Maternal And Child Health Care Among Married Adolescent Women: Evidence From India. Journal Of Biosocial Science. 2012; 44 (1): 1 –26. 10.1017/S0021932011000472


Pallikadavath S, Foss M, Stones RW , authors. Antenatal care in rural Madhya Pradesh: provision and inequality in Obstetric Care in Central India. Southampton: University of Southampton; 2004. p. 111 –28


Navneetham K, Dharmalingam A , authors. Utilisation of maternal health care services in Southern India. Social Science and Medicine. 2002; 55 (10): 1849 –69


World Health Organization, United Nations Children’s Fund , author. Antenatal care in developing countries-promises, achievements and missed opportunities. Geneva: World Health Organization; 2003


Houweling TA, Ronsmans C, Campbell OM, Kunst AE , authors. Huge poor-rich inequalities in maternity care: An international comparative study of maternity and child care in developing countries. Bull World Health Organ. 2007; 85 (10): 745 –54


Simkhada B, Teijlingen ER, Porter M, Simkhada P , authors. Factors affecting the utilization of antenatal care in developing countries: Systematic review of the literature. Journal of Advanced Nursing. 2008; 61 (3): 244 –60. 10.1111/j.1365-2648.2007.04532


Singh PK, Rai RK, Alagarajan M, Singh L , authors. Determinants of Maternity Care Services Utilization among Married Adolescents in Rural India. PLoS ONE. 2012; 7 (2): 316 –66. 10.1371/journal.pone.0031666


Jat TR, Ng N, San Sebastian M , authors. Factors affecting the use of maternal health services in Madhya Pradesh state of India: A multilevel analysis. International Journal for Equity in Health. 2011; 10 (1): 59


Nasir JA, Hinde A , authors. Factors associated with contraceptive approval among religious leaders in Pakistan. Journal of Biosocial Sciences. 2011; 43 (5): 587 –96


Mahmood N, Ringheim K , authors. Factors affecting contraceptive use in Pakistan. Pakistan Development Review. 1996; 35 (1): 1 –22


Miah MM , author. The cultural-structural contexts of high fertility in Bangladesh: A sociological analysis. International Review of Modern Sociology. 1992; 22 (1): 99 –110


Addai I , author. Determinants of use of maternal-child health services in rural Ghana. Journal of Biosocial Science. 2000; 32 (1): 1 –15


Gyimah SO, Takyi BK, Addai I , authors. Challenges to the reproductive-health needs of African women: On religion and maternal health utilization in Ghana. Social Science and Medicine. 2006; 62 (12): 2930 –44


UNAIDS. , author. AIDS Education through Imams: A spiritually motivated effort in Uganda. 1998. UNAIDS Case Study, UNAIDS/98.33. http://data.unaids.org/Publications/IRC-pub01/jc126-imams_en.pdf


Raj A, Saggurti N, Balaiah D, Silverman JG , authors. Prevalence of Child Marriage and its Impact on the Fertility and Fertility Control Behaviors of Young Women in India. Lancet. 2009; 373 (9678): 1883 –9. 10.1016/S0140-6736(09)60246-4


Annual Health Survey second Updation Bulletin. 2012-13 , author. http://www.censusindia.gov.in/vital_statistics/AHSBulletins/AHS_Bulletin_2012-13_Presentation.pdf


National Family Health Survey-3, Uttar Pradesh, (2005-2006) Fact Sheet UP , author. IIPS- Mumbai.