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Indian Journal of Community Medicine

Utilization and Coverage of Services by Women of Jawan Block in Aligarh

Author(s): Ranjan Das, Ali Amir, Papri Nath

Vol. 26, No. 2 (2001-04 - 2001-06)

Deptt. of Community Medicine, J.N. Medical College, AMU, Aligarh (UP) - 202002

Abstract:

Research question: What is the status of utilization and coverage of services in married women of 15 to 45 years of age in rural area of Western Uttar Pradesh?

Objectives: To study: 1. Certain selected demographic variables of the women in reproductive age groups. 2. Utilisation of antenatal services. 3. Contraceptive use rate.

Study design: Cross-sectional.

Setting: Rural area of Aligarh district in U.P.

Participants: Married women in age group of 15 to 45 years. Sample size: 382 ever married women, randomly selected from four villages of Jawan Block.

Study variables: Age, marital status, age of effective marriage and at first pregnancy, ANC received during index pregnancy, birth order, place, attendant and outcome of index pregnancy, contraceptive use and reasons for non-usage.

Analysis: Rates and proportions.

Results: Seventy seven percent of women in the reproductive age group were married. The mean age of effective marriage and first pregnancy was 17.9 and 20.7 years respectively. ANC registration was found to be 57.2%. Appropriate IFA consumption was found to be poor. Socio-cultural taboos and obstacles were the main reasons for low ANC coverage. Contraceptive use rate was 28%. Main reasons for not using any method of contraception were, eagerness to have more children (39%) and objection from mother-in-law or husband (23%).

Keywords: Age of marriage, Age of first pregnancy, Antenatal care, Contraceptive use

Introduction

The health of women in the age bracket of 15-45 years is a major area of concern for the governments of many developing countries. This group owing to their vulnerability, deserves special attention. In view of the universality of marriage and social pressure to bear children early, the women are subjected to added risk of morbidity and higher mortality. Now, the National Family Planning Programme has moved on to become the Reproductive and Child Health Programme with a paradigm shift in approach from "Top Down" to "Grass root level micro-planning". While assessing the felt needs of the population for providing the appropriate and optimum range of services, it is, therefore, imperative that an assessment of the ground situation be done, which should include various socio-demographic attributes. The department of Community Medicine, J.N. Medical College, AMU, Aligarh, through its Rural Health Training Centre (RHTC), at Jawan, has been catering to various health needs of women in the reproductive age group since the last 30 years.

In order to give a new direction to the existing services being provided and specially to give a fillip to contraceptive services, we decided to undertake a rapid assessment of certain socio-demographic and health aspects of this group of population.

Material and Methods:

The Present study was conducted in 4 villages registered with the RHTC, Jawan from January 2000 to June 2000. Assuming that Jawan has a Couple Protection Rate (CPR) of 25% and allowing an error of 10%, the sample size worked out to be 300 married women. Thus, a minimum of 75 married women were to be surveyed from each cluster village. Based upon existing demographic data of the RHTC area it was decided to survey 100 households from each village. Interns were sensitized about the issues facing the reproductive and child health programme and trained for the interview. A team of one male and one female intern visited 2 to 3 households in a day. Three such teams under the guidance of a Medical Social Worker went for the interview.

Data collection was done by door-to-door visits and enumeration of population was also done on a household tally sheet. The schedule contained information on a household tally sheet. The schedule contained information on age, sex, marital status, age of effective marriage, age at first pregnancy, antenatal care received during index pregnancy, birth order of index pregnancy, place, attendant and outcome of index pregnancy, place, attendant and outcome of index pregnancy, contraceptive use by married couples and reasons for non-use of contraceptives. Information thus collected was analysed and disseminated to the RHTC field staff and interns for enabling them to conceptualize the problem and come up with innovative solutions for small target groups.

Observations:

Table I: Women in reproductive age group according to marital status.

Age group
(years)
Unmarred Ever married Total
No. (%) No. (%) No. (%)
15-18 52 (70.3) 22 (29.7) 74 (14.9)
18-25 59 (39.3) 91 (60.7) 150 (30.1)
25-35 03 (2.1) 141 (97.9) 144 (29.0)
35-45 01 (0.8) 128 (99.2) 129 (26.0)
Total 115 (23.1) 382 (76.9) 497 (100.0)

A total of 382 ever married women in the age group of 15-45 years were studied. Total population covered was 2679 in 407 households, thereby, giving an average household size of 6.6 persons. The sex-ratio was found to be 852 females per 1000 males. Women in the reproductive age group constituted 18.5% of the population. Of these, 115(23.1%) were unmarried and the remaining 382(76.9%) were either currently married or separated or widowed.

Table II: Women in reproductive age group according to age at effective marriage and first pregnancy.

Age group
(years)
Marriage First pregnancy
  No. (%) No. (%)
12-15 11 (2.8) 0 (0)
15-18 186 (47.3) 82 (22.8)
18-21 192 (48.9) 265 (73.6)
21-24 4 (1.0) 13 (3.6)
Total 393 360
Mean 17.94 years 20.67 years

Besides the 382 married women in the age group of 15-45 years, 11 adolescent girls (12-15 years) were also found to be married. In 49% of the married women, the effective age at marriage was 18 to 21 years, while in 47% it was in between 15 to 18 years. More than half of the women were married at an age below the legally prescribed age of 18 years. The mean age at effective marriage was found to be 17.94 years. Table II also shows the age of women at first pregnancy. In majority (73.6%) of the women, the age at first pregnancy was between 18 and 21 years while in nearly 23% it was less than 18 years. The mean age at first pregnancy was 20.67 years.

Table III: Type of antenatal care received by women.

Care received* RHTC
No.
CHC/PHC
No.
Others
No.
Total
No.
(%)
ANC visits
1 visit 6 5 3 14 (23.7)
2 visits 4 3 1 8 (13.6)
3 visits 14 1 0 15 (25.4)
>4 visits 22 0 0 22 (37.3)
Tetanus toxoid-I 46 9 4 59 (100.0)
TT-II/booster 45 8 2 55 (93.2)
Iron and folic acid
1-50 tablets 35 9 4 48 (81.3)
51-100 tablets 10 0 0 10 (16.9)
>100 tablets 1 0 0 1 (1.7)
Weight recording 44 2 0 46 (78.0)
Pallor/Hb estimation 44 7 4 55 (93.2)
Pulse 42 2 3 47 (79.7)
Blood pressure 46 3 4 53 (89.8)
Urine examination 43 0 4 47 (79.7)
Health & nutrition education 31 0 0 31 (52.5)
Other blood examination 43 0 4 47 (79.7)
Nothing (except TT and IFA0 0 2 0 2 (3.4)
Total 46(78.0) 9(15.2) 4(6.8) 59 (100.0)

Out of the 382 ever married women in the reproductive age group, 51 were found to be currently pregnant, while 103 were found to have delivered within that last 12 months. Such women who delivered within the last one year, irrespective of the outcome of the pregnancy (herein called "Index Pregnancy"), were surveyed for the type of antenatal care received by them, as shown in Table III.

Of 103 women included in the study, 44 were not registered at all. Thus, only 59(57.2%) of the antenatal cases were registered, 78% at the RHTC, 15% at the CHC and the remaining 6.8% by private practitioners. Of all the ANC registrations, 39 cases (66.1%) got themselves registered in second trimester, while 11(18.6%) and 9(15.2%) women were registered in third and first trimester respectively. All the registrations in first trimester were done at the RHTC.

Sixty two percent of the registered cases had 3 or more ANC visits, while over 37% had 1 or 2 visits. Seventy eight percent of cases registered with the RHTC had 3 or more ANC visits, while only one case registered at a source other than RHTC, completed the mandatory 3 ANC visits.

All the registered ANC cases (59) were protected with atleast one dose of tetanus toxoid (TT), while only 55 were given a second dose or booster. The drop-out rate was nearly 7%, 16.9% and 81.3% for more than 100 tablets 51 to 100 tablets and 1 to 50 tablets respectively.

Table III also shows other specific types of care rendered during the antenatal check-ups. Pallor/haemoglobin estimation was most frequently done (93%). On the other hand, health and nutrition education was least frequently attempted (52.5%). Pulse examination, urine examination and other blood investigations were done with equal frequency in about 80% of the registered cases. Blood pressure and weight recording was done in 90% and 78% of the registered cases, respectively.

The reasons for non-availing of ANC services were lack of knowledge/ignorance (11.4%), obstacles (36.4%) and socio-cultural taboos (52.3%). It was also noted that higher birth order and illiteracy were associated with poorer antenatal care.

As far as receiving of supplementary nutrition was concerned, only 9(8.7%) of the pregnant women were enrolled at the anganwadi centre, while only 5 (4.8%) actually received the supplementary nutrition.

Table IV: Place and outcome of delivery according to birth order of present pregnancy.

Birth order Place and outcome Total
Institutional Domiciliary
Live births Still births Live births Still births
No. (%) No. (%) No. (%) No. (%)
Ist 6 (21.4) 0 (0) 21 (75.0) 1 (3.6) 28 (27.2)
2nd and 3rd 2 (5.4) 0 (0) 33 (89.2) 2 (5.4) 37 (36.0)
>4th 3 (7.9) 0 (0) 35 (92.1) 0 (0) 38 (36.8)
Total 11 (10.7) 0 (0) 89 (86.4) 3 (2.9) 103 (100.0)

Nearly 90% of the deliveries were domiciliary and outcome was in the form of still-births in about 3% cases. All the still-births were in the domiciliary group (Table IV).

Twenty seven percent of births were of first order, whereas 36% were of second/third order and nearly 37% were of birth order four and above.

Among the 92 home deliveries, only 37(40.2%) were attended by trained personnel or doctors. Overall, 46.6% of the deliveries wee attended by trained persons.

Table V: Contraceptive use by married women according to their age.

Age group (years) Type of contraceptive Total
None Condom OCPs IUCDs Vasectomy Tubectomy No. (%)
No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)
15-18 21 (95.4) 1 (4.5) 0 (0) 0 (0) 0 (0) 0 (0) 22 (5.8)
18-25 60 (66.0) 23 (25.3) 5 (5.5) 2 (2.2) 0 (0) 1 (1.1) 91 (23.8)
25-35 93 (66.0) 11 (7.8) 24 (17.0) 4 (2.8) 2 (1.4) 7 (5.0) 141 (36.9)
35-45 101 (78.9) 6 (4.7) 6 (4.7) 3 (2.3) 0 (0) 12 (9.4) 128 (33.5)
Total 275 (72.0) 41 (10.7) 35 (9.2) 9 (2.3) 2 (0.5) 20 (5.2) 382 (100.0)

Table V shoes that among the ever married women, 72% did not use any method of contraception. Of the remaining 28% who were using any of the modern methods, nearly 30% were in the 15-25 years age group, while 45% and 25% were in the 25 to 35 to 45 years age group respectively. Of all the 107 contraceptive users, 38.3% used condoms, 32.7% used OCPs and 8.4% had IUCDs showing thereby that over 79% depended on spacing methods. The remaining 20.6% relied on terminal methods, tubectomy being the predominant method over vasectomy (10:1).

Table VI: Reasons for not using contraceptive.

Reasons Age group (years)
15-18 18-25 25-35 35-45 Total
No. (%) No. (%) No. (%) No. (%) No. (%)
Fear of side effects 1 (4.5) 4 (18.2) 9 (40.9) 8 (36.4) 22 (8.0)
Want son/more children 12 (11.2) 36 (33.6) 33 (30.9) 26 (24.3) 107 (38.9)
Religious taboo 2 (6.2) 4 (12.5) 11 (34.4) 15 (46.9) 32 (11.6)
Husband/mother-in-law objects 4 (6.2) 11 (17.2) 25 (39.1) 24 (37.5) 64 (23.3)
Not aware of F.P. methods 2 (4.0) 5 (10.0) 15 930.0) 28 (56.0) 50 (18.2)
Total 21 (7.6) 60 (21.8) 93 (33.8) 101 (36.7) 275 (100.0)

The main reasons for not using any contraceptive was desire of a son or more children followed by objection from husband or mother-in-law and being not aware of family planning methods etc.

Discussion:

The average household size of 6.6 persons, found in the present study, matches quite well with 6.22 of census data for U.P. (1991)1. The sex-ratio reported in the 1991 census for Aligarh was 8672. Our finding of 852 females per 1000 males speaks of the distressingly low socio-cultural esteem and high morbidity and mortality to which women are subjected in this part of the country. Urgent steps are needed to find out the reasons for this great mismatch as also appropriate remedial action.

In our study, about 30% of the women in 15-18 years age group were married, which is lower than the figure of 34% as per sample registration system (1992)3. Other than this, our findings match with those of the SRS statistics, with minor variations in different age groups.

It is quite distressing to note that half of all marriages are still taking place before the legal age of marriage, with 3% even earlier than 15 years of age. Our finding of mean age at effective marriage of 17.9 years was lower than 19.1 years of U.P. and national average of 19.3 years (SRS-1992)3.

Further, early marriage resulted in early child births and this resulted in about one fourth of the first pregnancies occurring in women less than 18 years of age. However, some relief can be drawn from the fact that the mean age. However, some relief can be drawn from the fact that the mean age of being pregnant for the first time was 20.7 years.

Even though the population under study had two important sources of antenatal care, the CHC and the RHTC, yet the ANC coverage was very low. The RHTC had the services of one Public Health Nurse, who also assists the Lady Medical Officer to run the Gynae. and Obst. OPD along with ANC clinic on five days of the week. On the other hand, the ANMs of CHC have many grey areas in work. It was found that 57% of the women had been registered and had received at least one dose of tetanus toxoid and IFA tablets; the NFHS study4 had reported lower figures (39% TT and 25% IFA) for rural areas of U.P. and almost similar figures (55.3 and 45.1%) for India. Mothers receiving at least three ANC check-ups, ranged between 30 and 90%, in different parts of the country5, while our finding was 36%. The source of these ANC check-ups was the RHTC in 97% of the cases. Aggarwal et al6 reported that 25% of the mother paid 1 or 2 ANC visits while 23% paid 3 or 4 visits.

Our finding of only 10.7% institutional deliveries was in agreement of 11.3% for U.P. as reported in NFHS data4. Trained birth attendants (TBAs) delivered 40% of the ANC cases, while the national figures and those for U.P. were 35.1 and 33.3% respectively. It can also be seen that other ANC services were made available to high proportion of ANC mothers, specially by the RHTC. However, the same cannot be said about the state government health machinery.

While in this study ratio of 1st, 2nd and 3rd birth orders to total births, matched with those reported for the state of U.P. in SRS - 1992 report, the difference was significant for higher birth orders. This difference was even more prominent when national figures were tallied. Thus we are experiencing higher fertility and an increased growth rate.

A contraceptive use rate of 28% is certainly much lower than the national average of 37% reported in the NFHS study. The low CPR is helping the population to increase and is derailing all the developmental activities of the state, but the silver lining was that temporary spacing methods were found to be more popular in this study than those found in the NFHS. Condom, IUDs and OCP usage were 10.7, 2.3 and 9.2% in our study as compared to 2,2 and 1% in the NFHS study respectively. While tubectomy and vasectomy accounted for 27% and 3% of all contraceptive use in the NFHS study. It was much lower at 5.2 and 0.5% respectively in the present study. This is a welcome change in attitude of the population in reproductive age, as postponing pregnancy by temporary methods also means reducing births. Gupta et al7 in his study in Rajasthan, reported a CPR of 47%, with Condoms at 13, IUDs at 8, OCPs at 5 and sterilization at 2%. Chandra has also reported higher contraceptive use rate of 48.2%8. However, the last two studies were for urban areas.

In our study, the foremost reason for not using any method of contraception were eagerness to have more children (39%), followed by objection from husband or mother-in-law (23%), lack of knowledge (18%) and fear of side effects (8%) etc. Religious taboos were also responsible in 11% of non-users. On the other hand, in a study in Calcutta, lack of knowledge and health concern/side effects were the predominant barriers, accounting for 26 and 25% of non-usage. Objection from family quarters accounted for only 12% of non-usage9. We can, therefore, assume that women in the reproductive age group in our study, though well informed are unwilling to use contraceptives and limit their families due to social reasons. To promote the use of contraceptives, the mother-in-law and husband need to be motivated first of all.

Conclusion and Recommendations:

The study population has demographic features of a late expanding type, with a sex-ration weighted adversely against the females. The reasons for this needs to be found out by further studies covering a greater population and remedial social action is highly warranted. The age of marriage must be raised through education of the family level decision makers viz. father, grand-mother, mother etc. The same persons also need to be educated on the desirability to delay child bearing in young to be mothers at least by one to two years. The ANC coverage by no means was satisfactory and the state health sector service delivery has a long way to go to meet the set targets. This can only be done by ensuring accountability at all levels and random cross-checking by independent institutions. The information collected at various levels, must also be utilized at the same level for giving inputs to improve the services.

For bringing about a quantitative and qualitative change in the coverage of reproductive health programme, support should be obtained from local NGOs. An effective increase in the CPR can only be achieved by motivation and tactful communication with the prospective users and their family level decision makers. It is also recommended that people should preferably have the option of availing services from sources other than government sector alone.

References:

  1. Census of India 1991. Final population totals, brief analysis of primary census abstract, series-1 paper No.-2 of 1992.
  2. Census of India 1991, Provisional population totals; Rural - Urban distribution series-1, paper no.-2 of 1991.
  3. Office of the Registrar General, India, Ministry of Home Affairs, New Delhi; sample registration system, fertility and mortality indicators, 1992.
  4. International Institute of Population Sciences, Bombay, India, Introductory Report - National Family Health Survey - 1992-93.
  5. Proceedings of session on Maternal Morbidity and Mortality, Ind Journal of Community Medicine, 1997; 22:9.
  6. Aggarwal OP, Kumar Rakesh, Gupta Anita et al. Utilization of antenatal care services in Peri-urban area of East Delhi, Ind Journal of Community Medicine, 1997; 22: 29-32.
  7. Gupta S, Gupta R, Sachdeva L. Socio-demographic factors affecting termination of pregnancy, Ind Journal of Community Medicine, 1993; 18: 86-88.
  8. Chandra S. Neoliterates and Family Planning acceptance in Rajasthan, Ind Journal of Community Medicine, 1998; 23: 69-71.
  9. Ram R, Ghosh MN, Bhattahrya S et al. Study of unmet need for family planning among married women of reproductive age attendings immunization clinic in a Medical College of Calcutta. Ind Journal of Community Medicine, 2000; 25: 22-5.
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