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Patterns of Utilization of Maternal Healthcare Services in Haryana

One of the eight Millennium Development Goals (MDGs) set by United Nations in 2000 is to improve the maternal health targeting at reducing the maternal mortality ratio by three quarters between 1990 and 2015 and to achieve universal access to reproductive health by 2015 . Maternal mortality is unacceptably high about 800 women die per lakh live births from pregnancy or child birth related complications around the world every day. In 2013, 2, 89,000 women died during and after pregnancy and childbirth. Ninety nine percent of these deaths occur in developing countries (WHO, 2014)

Though National Health Policy has set objectives keeping in mind everyone's health needs but maternal health care needs a special attention as women are considered as the most vulnerable group in society.
Health and socio-economic development of any country are interdependent. Levels of maternal mortality tell us about the risk attributable to pregnancy and child birth as well as the performance of health systems in terms of access to health care and quality of care provided. Yet the economic development in India has gained momentum over the last decade, but the public health system is lagging behind. In Haryana, rural population accounts for 71 percent of the state's population. Haryana's per capita income is amongst the highest and fastest growing in the country (Haryana.gov.in).
But the Anthropological Survey of India reports that the position of women in Haryana continues to be bad. Women have lagged behind in all the sectors. Haryana is the second richest state in India in per capita income but sex ratio in Haryana continues to be highly unfavorable to females.

Significance of Study
The study of maternal health care use in Haryana is timely because maternal mortality and morbidity still remain high in this state in spite of all the efforts made to address the healthcare needs of women of reproductive age. The use of National Family Health Survey-III data allows for a comprehensive analysis of maternal healthcare usage. This study is critical in enhancing the quality and effectiveness of national programs for maternal and child health. The main motivation behind this study is to explore the health system in terms of access. Secondly, not many studies have focused on Haryana State per se and not much literature is available despite unfavorable sex ratio. Hence, this topic is worth to be taken in consideration. This study provides an analysis for antenatal care utilization in Haryana and fills a critical gap in understanding this public health issue in this state and will help in future planning and implementation of such maternal health programmes which will aim at improving the health system.

Objective of the study
The main objective of this study is to examine the differentials in utilization of maternal healthcare service i.e. antenatal services in Haryana on the basis of various socioeconomic and Sociodemographic factors.
Anderson's Behavioral Theory (Anderson, 1968, Anderson andNewman, 1973) is used as a conceptual framework for the analysis of maternal health care use based on the socio-economic characteristics as potential correlates. The Anderson behavioral model postulates that the use of maternal healthcare services is influenced by three sets of individual characteristics (a) Predisposing characteristics (i.e. age, parity, woman's education, her husband's education, woman's autonomy); (b) Enabling characteristics (i.e. household wealth , place of residence , woman's employment) ; (c) Need characteristics (i.e. antenatal care, delivery care , postnatal care).
Considering the Anderson's Behavioral theory model predisposing factors are socio demographic that would predispose women to use maternal healthcare services, while the enabling factors are the socioeconomic factors that may make women prove to use healthcare services In this study the Aday and Anderson's model was not tested rather the association between explanatory variables (demographic and social) and utilization of maternal healthcare indicators were explored. Factors affecting maternal healthcare utilization are based on this framework but the variables used in this study are identified after reviewing literature and keeping in mind the background characteristics of population.

Review of Literature
Determinants or correlates of utilization can emanate from demand or supply side.

Demand side Determinants
Demand side determinants are individual and household level factors that affect the utilization of services.
The household socio-economic status and mother's education were the most important factors associated with the use of Antenatal Care and skilled attendance at delivery in Madhya Pradesh. (Jat, Ng, & Sebastian, 2011) Women's age at child birth appears to be a related factor to the use of maternal healthcare services. In a study based on India (Bhatia and Cleland, 1995) found that mothers younger than 18 were less likely to use antenatal services compared to women above 18 years of age. While some studies such as (Chakraborty et al., 2002) suggests that women's age can also indicate women's knowledge of healthcare services and can have a positive effect on utilization of maternal healthcare services A study based on north-eastern states of India suggests that for better maternal health care utilization, policies should be directed towards the vulnerable group i.e. women representing the SC/ST background because high percentage of population belongs to scheduled tribes in the north-eastern states. The result showed that education of both the woman and her husband plays a vital role in utilization of maternal health care services. Other variables that can have significant impact on availing of the maternal health care services are media, autonomy enjoyed by women and their occupational status (Chakrabarti and Chaudhuri, 2007).
A study based on Uttar Pradesh suggests that women's autonomy plays an equally important role in maternal health care utilization as women's educational status. The analyses show that women with greater freedom of movement are more likely to use safe delivery care and obtain higher levels of antenatal care. (Bloom, Wypij, & Dasgupta, 2001).
The utilization of maternal healthcare services also depends on geographical and topographical characteristics of a state. The number of women utilizing antenatal services is less in Uttaranchal which is a hilly area in comparison to Jharkhand and Chhattisgarh (Pandey, Roy, Sahu and Acharya, 2004). According to the study (Bhattacharya and Tandon, 1991), mother's educational level has a positive impact on utilization of maternal healthcare services. Visit of a health worker has a significant positive impact on the utilization of full antenatal and post natal care services among women (Sunil et al., 2006) Bhatia and Cleland (1995) suggested that for improving maternal health services women should have adequate knowledge of health-care seeking behavior during the reproductive process and its determinants.
Not only women's education, a study shows that husband's education has a significant influence on the adequacy of maternal healthcare utilization in India.
Maternal care usage was measured by a composite index based on responses of both antenatal and delivery care and categorized from poor to excellent and husband's education was found to be linked with excellent maternal healthcare use (Sunil et al, 2006).
A study conducted in rural North India suggests that there is a caste divide as majority of traditional birth attendants called Dias belong to the lower caste and trained birth attendants such as nurses or doctors belong to upper caste. For providing maternal healthcare services both the caste groups have to be in contact with each other, upper caste health providers prefer to cater to upper caste women and lower caste women choose to utilize services offered by traditional birth attendants for the sake of avoiding embarrassment of caste discrimination (Saroha, Altarac & Sibley, 2008). Pallikadavath et al. (2004) found that Muslim women utilized these services more than others whereas, there was low utilization of services among scheduled castes and scheduled tribes. A study observed that Muslim women give birth outside medical facilities more often than Hindu women. But nothing has clearly emerged in India on utilization of healthcare services based on religion.
Another study found that women who have a job that paid them in cash were more likely to utilize healthcare services during their pregnancy (Chakraborty et al., 2002).
Other factors such as economic status of women of the household also affect the utilization of antenatal care services and delivery care (Pandey et al., 2002). A study was conducted on Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh using National Family Health Survey  found that higher social and economic status is associated with increased utilization of antenatal care including blood pressure measurement, blood test and urine test, but the obstetric physical examination depends on education of women and their husbands. Women from poor and uneducated backgrounds with at least one child are less likely to receive antenatal care services (Pallikadavath et al., 2004)

Supply Side Determinants
Utilization of healthcare services is possible only if healthcare services are available for access. Healthcare facilities in terms of proximity and providers of healthcare play an important role in utilization of services.
A study based on Andhra Pradesh, Karnataka, Kerala and Tamil Nadu found that variations in use of services were primarily related to availability and access (Navaneetham & Dharmalingam, 2002).
Utilization of healthcare services also depends on access to health facility. However, (Bhattacharya and Tandon, 1991) found out that even if rural women are staying near health centre still they do not utilize healthcare services.
Women who lived near a village health worker/nurse were more likely to receive adequate and early antenatal care visits than women without a village health worker (Nielsen et al., 2001).
Another study based on Nepal has shown that services are utilized twice as high if health facility is in the community and also if there are regular visits by health workers (Acharya and Cleland, 2000).
This literature review has highlighted the importance of individual, household and community level factors that affect the use of antenatal services.

Hypothesis
Based on literature review and previous empirical research, the following associations are expected. Younger mothers(less than 18 years of age) have lower odds of using antenatal care than mothers above 18 years of age. Higher level of education for both the woman and her husband will be positively associated with antenatal care usage.
Women who have high autonomy (decision making power and mobility) are more likely to utilize these maternal healthcare services compared to women with low autonomy. Women with any mass media exposure (read magazine, watch Television and listen to radio) will utilize these maternal healthcare services more than women with no mass media exposure. Women with lower levels of household wealth will be less likely to use antenatal care services. Rural residence will be negatively associated with antenatal care usage. Women who have a job are more likely to have adequate antenatal care. Women who have met with an auxiliary nurse midwife (ANM) or community health worker are more likely to utilize maternal healthcare services.
Women belonging to other castes will utilize these services more. Hindu women are more likely to use these services.

Data Source
The present study uses the third round of the National Family Health Survey (

Sampling Plan
The sampling plan and design explained in this study is done by International Institute of Population Sciences (IIPS), Mumbai who conducted NFHS -III survey.
NFHS-III adopted a two stage sample design in most rural areas and three stage sample design in most urban areas in all the 29 states. In each state, the rural sample was typically selected in two stages: the first stage involved selected of primary sampling units (PSU's), which are villages with probability proportional to population size (PPS), the second stage involved the systematic selection of households within each PSU.
Stratified sampling was adopted. In rural areas, list of villages was taken from 2001 census and it served as the sampling frame. Stratification was done to ensure the inclusion of villages with different socio economic characteristics in the sample. The first level of stratification was geographic, with districts being subdivided into contiguous regions. The selection of required number of households from the list of households was done using systematic sample. The overall response rate for women was 92.4 percent whereas for men it was 84.9 percent.

Study Population and Sample Size
The present study examines the pattern of utilization of maternal health services among currently married women age (15-49) years in Haryana.
In Haryana, NFHS-III is based on a sample of 2,302 households that is representative at the state level and within state at the urban and rural levels. The study interviewed 2,790 women age 15-49 years from all sample households and 1,083 men age 15-54 from a sub sample of households for obtaining information related to population, health and nutrition in the state. The household response rate in the state as a whole was 99 percent and the individual response rates were 96 percent for eligible women and 85 percent for eligible men.
In this study data related to currently married women (15-49) years of age is examined and a total of 2134 currently married women from both rural and urban areas is included.

Dependent Variables
The study measures the outcome variables namely Antenatal care to explore For this study, Antenatal care includes those women who had a minimum of three antenatal care visits. The MOHFW recommends that a woman should have at least three antenatal care visits during pregnancy and this standard was used to construct this dependent variable. In this study, Antenatal care was coded as a binary dependent variable, with a value of 1 if the woman had at least three antenatal visits and a value 0 if the woman had less than three antenatal care visits.

Independent Variables
The independent variables used in this study are socio-economic and sociodemographic.

Predisposing Factors
Women's age at child birth is defined as women's age in years. A variable was created (womanage). Womanage was coded as 0 if women's age was less than 18 years and was coded as 1 if women's age is greater than 18 years.
Women's and their Husband's education level are defined using highest education level. Variables Womeneduc and Husbandeduc were created and were categorized into 0,1,2,3. It was coded as 0 if they had no education, coded as 1 if the woman had studied till primary, coded as 2 if till secondary and coded as 3 if till higher level of education.
Religion of the woman was categorized as Hindu, Muslim, and Sikh. Religion was coded as 0 if Hindu, coded as 1 if Muslim and coded as 2 if Sikh.
Caste is defined according to the social group that woman belongs to as per the categorization and identification done in NFHS-3 data. Variable caste is coded as 0 if women belong to none of them, coded as 1 if women belong to scheduled castes (SCs), coded as 2 if women belong to scheduled tribes (STs) and coded as 3 if women belong to other backward classes (OBCs).

Women's Autonomy was computed by taking into account decision making and
women's mobility. Decision making was computed on the basis of decision about healthcare for yourself, decision about making major household purchases, decision about making purchases for daily household and decision about visits to your family or relatives. These four factors were combined and were coded as 0 if respondent and respondent plus husband take decisions and were coded 1 if someone else is taking decision on respondent's behalf. Women's mobility was computed by taking into account following factors whether women is allowed to go to market, allowed to go to health facility, allowed to visit places outside the village/community. These three factors were combined and were coded as 0 if women were allowed to go alone or with someone else and were coded as 1 if they were allowed to go anywhere. Both decision making and women mobility were combined to construct a variable wautonomy using information from NFHS-3 data. Wautonomy was coded as 0 if women were allowed to go out and were involved in decision making and was coded as 1 otherwise.
Mass media exposure was computed by taking into account how often respondents read magazine, listen to radio and watch television. They were coded as 0 if they don't read magazine, listen to radio and watch television and coded as 1 otherwise.
All three factors were combined to create variable media and then from media we created media exposure and coded it as 0 if they had no exposure and coded as 1 if they had some exposure.

Enabling Factors
Place of residence is defined as the place of stay. It is coded as zero if the woman stays in urban area and is coded as 1 if woman stays in rural area.
Wealth index is defined as woman falls into which category (poorest, poorer, middle, richer and richest) and this categorization is taken from NFHS-3 data. Poorest is coded as 0, poorer as 1, middle as 2, richer as 3 and richest as 4.

Met with ANM/Community health worker is defined as whether in last 3 months woman has met any ANM/Community health worker. It is coded as 0 if not met and coded as 1 if otherwise.
Work status is defined whether the woman is working or not. If the woman is not working it is coded as 0 and 1 otherwise.

Statistical Methods
Univariate analytic techniques were used to provide a description of all variables used in the analysis. The NFHS -3 dataset was used to extract information and STATA 10 was used to correctly estimate population means, proportions and standard deviations.
To identify factors associated with maternal healthcare utilization, bivariate and multivariate analyses were performed. Bi-variate analyses were performed to examine the nature of association between utilization of maternal healthcare services by selected socioeconomic and demographic background characteristics.
Multivariate analyses were performed to examine the nature of predictor variables and their relative contribution in explaining the dependent variables. Since both outcomes in this analysis are dichotomous in nature, logistic regression was used to predict the association between the dependent variables and the independent variables. Ordinary least square regression would be inappropriate as it assumes error variances (residuals) to be normally distributed. The binary response(y) for each individual was related to a set of categorical predictors (X), logit of the probability of each outcome can be modeled as: Logit (π i ) = log( π i / 1-π i ) = β 0 + β(X) +ε The probability of an individual who had received antenatal care or had safe delivery or received assistance in postnatal care is π i . β 0 estimates the log odds of antenatal care or had safe delivery or received assistance in postnatal care for the reference group, and the parameter β estimates with maximum likelihood, the differential log odds of full antenatal care or had safe delivery or received assistance in postnatal care are associated with the predictor X, in comparison to reference group. Ε represents the error term. Odds ratio and confidence intervals for each independent variable were presented for the interpretation of the coefficients. This analysis was performed using STATA10.
Before running the analysis, the models were checked for multicollinearity using the variance inflation factor (VIF). The VIF measures how much of the variance of the coefficient estimate is being by multicollinearity. VIF values greater than 10 indicate multicollinearity. The models used in this study satisfy this condition and this indicates that covariates are not collinear. Therefore, no explanatory variable was dropped from the analysis. Table 1 represents the percentage of women (15-49) years of age who had at least one live birth during the last five years preceding the survey by selected background characteristics. Majority of women were above 18 years of years. With regard to education, 46% of women had no education but 57% of Husband's were educated till secondary level. Most of the women 88% were Hindu. As per the social group most women were from other backward classes (OBCs).around 63% women enjoy high autonomy and 74% have exposure to any of the mass media. Most of the women are not working and residing in rural areas. 24% and 29% of women fall in middle and richer wealth index respectively. 92% of women had not met any health worker in the past three months. Note: all N are unweighted.

Differentials in Utilization Pattern of Antenatal care Services
This section identifies the factors associated with the utilization of antenatal care, services; we examined the bi-variate differential of the selected socio economic and demographic characteristics. This was done by finding the association between predisposing and enabling factors and the use of antenatal services. Chi-square statistics are used for differences in distribution of predisposing and enabling factors among women (15-49) years of age who had at least one live birth in last five years utilizing antenatal care services Table 2 shows the percentage of women who utilized antenatal care services by selected background characteristics. The pattern of utilization of antenatal care is high for women who are above 18 years of age. Women who are not working and enjoy more autonomy and have any mass media exposure utilize antenatal care services more. On the other hand, women with no education utilize these services more. Rural women who have not met any health worker in past 3 months take more antenatal care. Women belonging to other social groups and richest wealth quintile utilize these services more than women belonging to other castes and lower wealth quintiles.

Discussion & Conclusion
This study examined differentials in the use of maternal health care services namely antenatal care in Haryana on the basis of various socioeconomic factors such as woman's age at child birth, woman's education level, her husband's education level, mass media exposure, autonomy, wealth, place of residence, meeting with a health worker, work status, religion and caste. The relationship between outcome variable and predisposing and enabling factors is based on Anderson's model. The data was analyzed to find the relationship between predisposing and enabling factors and the outcome.
Bivariate analysis of antenatal care utilization with predisposing and enabling factors show several patterns.
Women who are not adolescents i.e. above 18 years of age tend to utilize antenatal care services two times more than adolescent women i.e. below 18 years of age. A study based in rural north India (Pallikadavath et al., 2004) also explain that age at marriage was positively associated with access or attendance for ANC. Antenatal check-ups were more likely among women whose age at the time of marriage was 19 years or above as compared to those women who married at younger age.
The odds of receiving antenatal care were high for women whose husband's had secondary or higher level of education in comparison to women whose husband had no formal education. This also conforms to another study that shows Husband's education was a statistically significant predictor in Andhra Pradesh but not in Karnataka (Navaneetham and Dharmalingam, 2002). The odds of receiving antenatal care were highest for women belonging to other backward classes in comparison to women belonging to scheduled castes or scheduled tribes. The low utilization of maternal health care among certain groups shows the lack of access to health care services among socially backward communities. This was demonstrated by another study based on rural Hindu women in Maitha, Uttar Pradesh which suggests that majority of Dais, untrained TBA's belong to the lower caste and trained TBA's belong to upper caste. Because of class discrimination and to avoid physical contact at the time of service with lower caste women Trained TBA's only cater to upper caste women (Saroha, Altarac, Sibley, 2008) Women from richer and richest index are nearly two and four times more likely to utilize these services respectively compared to women belonging to poorer and middle wealth quintile. Household economic status has a positive impact on use of ANC. This is proved by a study that women with high economic status were more likely to receive adequate and early ANC than those with low economic status (Magadi et al. 2000, Matsumura & Gubhaju 2001.

Limitations of the study
The study had some limitations, which need to be considered while interpreting the results.
1. The study used the data from a cross sectional survey and the association between explanatory variables and the indicator of the use of maternal health services was examined, could not draw conclusions about causality.
2. Some correlates of maternal health care utilization are missing from our analysis such as distance of health facilities from the locality of residence, and this could have influenced the patterns of utilization of maternal health services. Since data on this variable was not available in the survey.

Recommendations
Efforts need to be made at community as well as household level to improve maternal health care services.
At community level, there should be call for action to reduce financial barriers while increasing awareness about the maternal healthcare services, particularly among women belonging to low wealth quintile. Efforts should be put to educate the men about the importance of maternal health care services. There should be more schemes for scheduled castes, scheduled tribes and other backward classes. Not just the literacy, there should be overall development of women. They should be exposed to newspapers, radio, television etc. the most important indicator of maternal health care is antenatal care as delivery care and post natal care are linked to this indicator. So, more emphasis should be laid on improvement of antenatal care services. At Household level, Husband and mother in law should be used as targets for messages.
There should be pregnant women groups and some incentive based competition among mothers to be model mother who can set an example for other mothers.
Health is a social phenomenon whose determinants cannot be separated from other social and economic determinants. Haryana has progressed at some fronts but still large gaps persist between the need and provision of services. It will require monitoring and evaluation of ongoing programs and effective implementation.
Health services no matter how efficient cannot change the condition of the marginalized people unless they are helped to become self-reliant and the root problems are addressed. People who are poor and illiterate are like uncut gems hidden under the dirt and stone. Given the opportunity, they can reach their full potential and live as responsible, sensitive human beings, possessing selfreliance and the liberty to shed those old customs and traditions that impede health and development (Arole and Arole, 1994)

Future Scope of Study
Further on, the other components of maternal healthcare services such as delivery care and postnatal care can be examined based on the various socioeconomic and Sociodemographic variables.