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Ante natal care utilization and delivery services in a tertiary care hospital

Maternal health care is important for better maternal, perinatal and infant health outcomes. High maternal and neonatal mortality rates are associated with inadequate and poor quality maternal health care, including antenatal care, skilled attendant at birth and postnatal care. Hence achieving MDG goal on maternal health requires providing high quality pregnancy and delivery care, improving sexual and reproductive health care and universal access to all its aspects. 1-3 Antenatal care is recognized as a key maternal service in improving a wide range of health outcomes for women and children. It provides an opportunity to provide interventions for improving maternal nutrition, to encourage skilled attendant at birth and use of facilities for emergency obstetric care. 1,4


INTRODUCTION
Maternal health care is important for better maternal, perinatal and infant health outcomes. High maternal and neonatal mortality rates are associated with inadequate and poor quality maternal health care, including antenatal care, skilled attendant at birth and postnatal care. Hence achieving MDG goal on maternal health requires providing high quality pregnancy and delivery care, improving sexual and reproductive health care and universal access to all its aspects. [1][2][3] Antenatal care is recognized as a key maternal service in improving a wide range of health outcomes for women and children. It provides an opportunity to provide interventions for improving maternal nutrition, to encourage skilled attendant at birth and use of facilities for emergency obstetric care. 1,4 In any community, mothers and children constitute a priority group. In India, woman of the child-bearing age (15-44 years) constitute 22.2% and children <15 years of age about 35.3% of the total population. Together they constitute nearly 57.5% of the population. 5 Pregnancy and child birth constitute significant events in the life of a woman. In this aspect, care of mother and child occupies a paramount place in our health service delivery system. 'MCH' refers to the promotive, preventive, curative and rehabilitative health care for mothers and children's.

Magnitude of problem
Pregnancy and child birth are the natural physiological phenomenon but unfortunately its consequences are still the leading cause of death, disease and disability among women of reproductive age in developing countries more than any other single health problem. WHO estimates show that out of 529,000 maternal deaths globally each year 136,000 (25.7%) are contributed by India, which is highest burden for any single country in the world. Currently, India's Maternal Mortality Ratio is 212, infant mortality rate 47, child mortality rate 18.4. Only 50.7% of women getting minimum 3 ANC checkups during pregnancy and only 40.8% deliver in the health facility. Of these, only 42.8% of women getting minimum 3 ANC checkup in rural area and 73.8% in urban area (NFHSIII).
The purpose of present study was to identify the determinants of antenatal care services utilization and delivery services, in order to increase the level of use of antenatal care.

METHODS
A prospective, descriptive study was conducted on 3rd trimester pregnant women attending tertiary care hospital by convenience sampling method during October 2012 to October 2014. As per the previous year's statistics, every month about 200 pregnant women were registered in 3rd trimester. The data collection period of the study was 8 month, so by using formula estimated sample size was n= 4pqN/ (N-1) e2 +4pq n= 320 (where e= error which is 10% of p) Presuming that the dropout rate is approx. 33%, sample size was 425. But 18 women were lost to fall up during subsequent visit. So, the finally 407 pregnant women were included for analysis.

Data collection
Ethical clearance was obtained from the Institutional Ethics Committee of the Institution. A semi-structured questionnaire was prepared in accordance with the study objective and it was pilot tested for clarity of questions and its response. Consent from Subjects was taken before administering the questionnaire. Information regarding the socio demographic profile, antenatal health checkup was recorded in the first interview. Later, follow up for mode of delivery.

Data analysis
All results were tabulated using Microsoft Excel 2010. Data was analyzed by simple proportions and chi square test. Table 1 shows that 320 (78.62%) respondents were in the age group 20-30 years contributing highest number to the study and 18 (4.42%) women were < 20 years at the time of present pregnancy. It was observed that 20 (4.91%) study subjects were illiterate. Nearly half i.e. 212 (52.09%) respondents were studied up to higher secondary school. And only 34 (8.35%) study subjects were studied up to graduation. Maximum respondents 187 (45.95%) were belonged to lower middle socioeconomic class. 56 (13.76%) respondents were married before the legally permissible age of 18 years and more than 4/5th of these i.e. 47 (83.93%) got pregnant before the age of 20 years. proportional to antenatal care. Women educated more than secondary school had more no. of visits. While primipara visited to seek health care more often than women with more no. of children. This could be due to more anxiety and insecurity for the first time.  Figure 1 illustrates that 339 women consumes iron folic acid (IFA) tablets regularly whereas 68 women consumes it irregularly. The most common reason for irregular intake was forgotten to take followed by concept of no need to take daily. 100% women took two doses of TT injection. Figure 2 shows that 78% women delivered by normal vaginal delivery while 22% required assistance in delivery (LSCS).   Early marriage increases the chance for early pregnancy which is a risk for both mother and baby and also marriage at late age is a risk factor for congenital anomalies in baby. Thus ideal age at marriage is a prerequisite for fruitful pregnancy outcome. Dasgupta Urmila et al 105 (17.5%) had married before 18 years of age. 9 Education is a strong predictor of use of maternal health care services. A study on utilization of maternal health services in Southern India has shown that women with High School education and above were eleven times more likely to use antenatal care in Karnataka. Women's education was also an important predictor of whether women received adequate number of antenatal visits. 10 In the study conducted by H. Tuladhar, N. Dhakal observed that most of the women i.e. 228 (75.8%) started to attend ANC only in 2 nd trimester and only 66 (21.9%) had started from 1 st trimester. 11 In the study conducted by Dasgupta Urmila et al on ante natal care utilization from a metropolitan city revealed that 36.5% of mothers had done ante natal registration in first trimester which is similar to our study. 9 Registration of pregnancy is essential to provide the effective care & follow up care of the mother. The best care can be possible if it is started early during pregnancy preferably within 1 st 12 weeks i.e. 1 st trimester.

DISCUSSION
The study reveals that the antenatal visits occur late in the pregnancy; the reason could be that they believed that pregnancy being a natural phenomenon did not need any special care.
A study conducted by Kulkarni MS, Nimbalkar MR. 12 in North Goa found that 78.8% of women registered for Antenatal care and received 5 or more visits.
A cross sectional descriptive study conducted by Gupta Anita et al 6 on determinants of utilization pattern on Antenatal and delivery services. In the study majority 92% of the women received ANC during pregnancy and 76.5% of the respondent had 3 or more visits. Women with lower education and those belonging to lower income groups had less than three ANC visits as compared to those with higher education and belonging to high income groups. This difference was statistically significant. Numbers of visits were more in women who got married at age more than 18 years than those married at less than 18 years. 339 (83.29%) respondents consumed regular IFA tablets while 68 (16.71%) consumed irregularly. In the study conducted by S Revathi, Paul Niranjan, Hiremath S G, Mane Abhay, Patil RS found that a high proportion of the women who had been prescribed iron supplements (87.7 per cent) reported taking them adequately which is similar to our finding. 13 15 Defensive obstetrics is another common reason for high rates of CS. It has been observed that 82% of physicians performed CS to avoid negligence claims. Kulkarni MV et al in their study on utilization of maternal health care services in an urban slum of Nagpur found that out of total 151 hospital deliveries, 25.17% delivered by caesarean section which is similar to our finding. 16

CONCLUSION
Efforts to encourage women to attend ANC could be targeted at less educated women and could include formal or informal education sessions for younger women who include information on ANC and childbirth.
Further studies on quality of ANC and its impact on obstetric outcome are needed. Within the limited resources, safe motherhood strategies need to be targeted in order to increase access to ANC and delivery care. Such interventions may include preparing community health workers to promote ANC, improving the quality of ANC offered and strengthening health systems to ensure the availability of medical supplies.