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Indian Journal of Community Medicine

Antenatal Care of Pregnant Women in India

Author(s): Padam Singh*, R.J. Yadav**

Vol. 25, No. 3 (2000-07 - 2000-09)

*Additional Director-General, Indian Council of Medical Research, New Delhi. **Asstt. Director, Institute for Research in Medical Statistics, (ICMR) New Delhi.

Abstract:

Research question: What is the status of antenatal care among pregnant women in India?

Objective: To assess the status of antenatal care for pregnant women in India.

Sampling design: WHO 30 cluster survey methodology with certain modifications incorporating information on female literacy and distance of the village has been used.

Setting: Survey covered about nineteen thousand pregnant mothers from 90 districts of the country.

Statistical analysis: Simple proportions.

Results: The characteristics of sample households for pregnant women were broadly in proportion to the characteristics of the all India population. About 89% of the pregnant women availed antenatal visits of which 62% had received three or more ANC visits. Those receiving the second dose of TT or booster dose were about 78%. About 73% of the pregnant women received IFA tablets during their pregnancy. About 53% of the pregnant women had full package of ANC i.e. availed 3 or more ANC visits, both the doses of TT/boster and IFA tablets. The proportion of pregnant women who availed full ANC package was lower in rural as compared to urban areas, lowest for ST followed by SC; higher for literate women as compared to illiterate women. The proportion of Institutional deliveries managed by hospitals and health centres was about 41%, it being higher among literate women and in urban areas.

Conclusion: The literacy of women is the key to improve antenatal care of pregnant women. Hence efforts should be made to have Information, Education and Communication (IEC) activities targeted to educate the mothers especially in rural areas. The tribal, small and inaccessible villages and the states of Bihar, Rajasthan, UP, MP and North Eastern states (combined) should be focused and targeted in the RCH programme.

Keywords: WHO methodology, Antenatal care, Pregnant women

Introduction:

Department of Family Welfare, Ministry of Health and Family Welfare, Govt. of India commissioned ICMR to undertake Coverage Evaluation Survey (CES) for Universal Immunisation Programme (UIP) in all the States and Union Territories. The Coverage Evaluation Surveys undertaken by Indian Council of Medical Research through Institute for Research in Medical Statistics (IRMS), New Delhi covered 90 districts. The number of districts covered from different States were broadly in proportion to their population. Further, while selecting the districts in each major state, due representation was given, to major geographical region in the state1-3. In the past few years, such Coverage Evaluation Surveys were done through UNICEF2. This survey covered the immunisation of children and pregnant women including antenatal care of pregnant women. This study presents the results specific to pregnant women.

Material and Methods:

The WHO 30 cluster survey methodology was followed in the Coverage Evaluation Survey (CES)4. From each district, a sample of 30 villages/wards was selected using PPS systematic sampling. Further, in each selected village/ward, with a random start, samples of seven mothers (of children aged up to 12 months) were selected in the form of clusters of contiguous households. Antenatal care visits, IFA tablets, reasons for no ANC/TT and place of delivery were studied. A village level schedule was used with details on distance from health facility, metalled road etc. in addition to village size and composition. The results on ANC and immunisation of mother only with other aspects of antenatal care were obtained at the State level and all India level. The sampling design was self weighting at district level and hence simple proportions and averages based on the sample are unbiased estimates of corresponding population values. The estimates at all India level were worked out by using appropriate weights based on estimated number of mothers at state level. The results were also obtained by background characteristics of sample households using post stratified methodology. The responsibility of survey work was borne by the Institute Network of Human Reproduction Research Centres (HRRCs), Institutes/Centres of ICMR viz.; TRC Chennai, CJIL Agra, RMRC Dibrugarh, RMRC Jabalpur and RMRC Port Blair, Medical Colleges at Kota (Rajasthan) and Dibrugarh (Assam). The survey work was done mainly during June-Ocotober 1999.

The study aims to assess the antenatal care of pregnant women including immunisation status.

Results and Discussion:

About 19,000 pregnant mothers were surveyed. The characteristics of sample households have been presented below.

Table I: Characteristics of women surveyed.

Characteristics Number Percentage
Overall residence 19030 100.0
Urban 6907 36.3
Rural 12123 63.7
Religion
Hindu 15141 79.6
Muslim 2169 11.4
Sikh 395 2.1
Christian 1037 5.4
Others 288 1.5
Caste
SC 4229 22.2
ST 2149 11.3
Others 12652 66.5
Literacy of women
Illiterate 7062 37.1
Primary 2976 15.6
Middle 3175 16.7
Higher secondary 3649 19.2
Graduate 2168 11.4
Literacy of husband
Illiterate 4009 21.1
Primary 2608 13.7
Middle 3499 18.4
Higher secondary 5192 27.3
Graduate 3722 19.5
Literacy of couple
Both illiterate 3298 17.3
Only woman literate 677 3.6
Only husband literate 3687 19.4
Both literate 11368 59.7

The characteristics of sample households for mothers were similar and broadly in proportion to the characteristics of the All India population. The higher representation of SC and ST in the sample was due to their relatively higher birth rates and because of coverage of minimum of one district from each of the seven NE states.

Antenatal care of pregnant women:

Table II: Coverage of ANC, TT Immunisation and IFA(%).

ANC/TT/IFA Coverage
Antenatal Care
Three or more ANC visits 62.0
1-2 ANC visits 26.6
No ANC visit 11.4
Tetanus toxoid
TT1 86.4
TT2/booster 77.9
None 13.6
IFA 72.5
Full ANC package
(3 ANC, IFA, TT2/booster) 52.5
Availability of card 63.0

Antenatal visits:

About 89% of the pregnant women had antenatal visits and 62% had made three or more ANC visits. There were about 11% pregnant women who had no ANC visits at all during their pregnancy. About 86% of pregnant women received only one dose of TT while about 77.9% of the pregnant women received two doses of TT or a booster dose. As much as 13.6% of the pregnant women did not get themselves immunised for TT. About 73% of the pregnant women received IFA tablets during their pregnancy. A pregnant women was considered to have received full package of ANC if she availed 3 or more ANC visits for check-up, received two doses of TT or booster and received IFA tablets. Only 52.5% of the pregnant women received full package of ANC.

Full ANC of pregnant women by background characteristics:

The results on pregnant women receiving full ANC package (i.e. those having 3 ANC visits, IFA and TT2/booster) by background characteristics are presented in Table III.

Table III: ANC services in relation to background characteristics(%).

Characteristics 3 ANC visits TT1 TT2/booster IFA 3ANC, IFA, TT2/booster
Overall residence 61.9 86.4 77.9 72.5 52.5
Urban 72.1 90.4 85.2 77.1 60.9
Rural 56.2 84.1 73.9 69.9 47.7
Religion
Hindu 61.4 87.4 79.2 73.2 52.5
Muslim 60.1 87.6 75.4 74.8 52.4
Sikh 70.9 93.4 88.1 82.8 63.3
Christian 68.7 69.1 63.9 54.8 46.5
Others 67.7 73.6 67.3 68.8 57.6
Caste
Caste 56.1 85.8 78.1 72.0 48.7
SC 52.6 69.9 57.0 59.3 40.1
ST 65.5 89.3 81.5 74.9 55.9
Others          
Literacy of women
Illiterate 43.7 76.9 66.6 61.6 37.1
Primary 61.7 88.7 76.7 76.6 53.3
Middle 70.2 90.9 84.1 79.0 59.5
Higher secondary 77.2 93.1 86.9 79.7 65.1
Graduate 84.4 96.4 92.6 81.5 70.7
Literacy of husband
Illiterate 43.2 73.9 63.7 59.6 36.1
Primary 59.1 84.9 73.4 73.1 50.9
Middle 62.6 87.5 78.7 73.3 53.2
Higher secondary 66.5 90.3 83.0 76.5 56.4
Graduate 77.5 94.3 88.6 80.1 65.7
Literacy of couple
Both illiterate 39.1 70.7 60.3 56.8 32.7
Only woman literate 63.1 89.2 80.8 73.4 52.7
Only husband literate 47.7 82.3 72.2 65.8 41.1
Both literate 73.4 92.2 84.9 79.5 62.3

There are large variations in the results on full package of ANC for pregnant women. The proportion of pregnant women availing full ANC package was more in urban areas (61%) as compared to rural areas (48%), the difference being 13 percent. The proportion of pregnant women availing full ANC package was highest for sikhs (63%). The same was 52 percent for hindus and muslims and 47% for christians. The proportion of pregnant women who availed full ANC package was lowest for ST (40.1%) followed by SC (49%) and other castes (56%). The proportion of pregnant women who availed full ANC package was higher for literate women as compared to illiterate women. The difference in the magnitude for graduates women and illiterate was as high as 33 percentage points. The literacy of women alone improved the performance by 20 percentage points and literacy of husband by another 10 percent.

Full package of ANC of pregnant women in different states:

The results on full package of ANC of pregnant women for different States are presented in Table IV.

Table IV: ANC services availed in different States(%).

State 3 ANC visits TTI TT2/booster IFA 3ANC, IFA, TT2/booster
All India 61.9 86.4 77.9 72.5 52.5
Andhra Pradesh 61.2 94.8 92.3 87.9 56.5
Assam 57.3 77.2 65.8 70.3 49.3
Bihar 35.5 72.0 49.8 51.1 29.6
Gujarat 70.7 93.8 87.9 42.9 36.3
Haryana 57.1 93.8 87.9 42.9 36.3
Himachal Pradesh 65.0 82.1 66.2 81.0 58.3
Karnataka 93.4 96.5 92.2 90.1 85.8
Kerala 94.3 99.1 96.0 90.7 88.0
Madhya Pradesh 46.7 85.5 77.5 73.8 41.9
Jammu & Kashmir 66.0 87.6 80.7 83.8 61.4
Delhi 74.7 90.5 85.5 85.4 69.7
Maharashtra 74.3 95.0 86.6 83.4 64.5
Orissa 71.8 92.1 82.5 83.2 63.1
Punjab 64.0 89.8 86.2 77.6 58.1
Rajasthan 39.2 77.8 69.3 54.2 33.7
Tamil Nadu 93.4 99.9 93.1 93.7 88.2
Uttar Pradesh 41.8 82.9 74.8 62.9 35.1
West Bengal 67.5 97.0 91.4 87.3 61.6
N.E. States 63.5 67.5 61.2 44.0 32.8
UTs and others 73.6 90.9 83.7 78.8 54.8

The proportion of pregnant women availing full ANC was lower in the states of UP, MP, Bihar, Rajasthan and North East (combined). It was mainly due to lower proportion of pregnant women getting three ANC visits in UP, MP, Bihar and Rajasthan, whereas in N.E. states it was lesser proportion of pregnant women who got IFA tablets. Thus there is greater need to increase the number of contacts in the former states and the improve the quality of care in the later states.

Delivery management:

The results of place of delivery by background characteristics are presented in Table V.

Table V: Place of delivery by background characteristics(%).

Characteristics Place of delivery
Home Hospital Health centre Others
Overall residence 51.7 34.2 7.1 7.1
Urban 31.4 48.7 8.5 11.5
Rural 63.3 25.8 6.3 4.6
Religion
Hindu 53.1 32.9 7.2 6.8
Muslim 49.9 37.6 5.3 7.2
Sikh 50.4 35.9 10.1 3.5
Christian 37.8 42.2 7.2 12.7
Others 45.5 41.0 8.3 5.2
Caste
SC 60.9 30.0 5.0 4.1
ST 57.3 31.0 5.4 6.3
Others 47.7 36.0 8.1 8.2
Literacy of women
Illiterate 75.1 18.0 3.4 3.4
Primary 53.5 35.4 5.8 5.3
Middle 44.7 40.0 8.0 7.2
Higher secondary 31.4 48.8 10.8 9.1
Graduate 17.6 51.4 13.2 17.8
Literacy of husband
Illiterate 74.8 18.0 3.4 3.9
Primary 58.0 33.2 4.8 4.1
Middle 54.3 34.0 6.0 5.7
Higher secondary 44.9 39.5 8.7 6.8
Graduate 29.5 44.7 11.4 14.4
Literacy of couple
Both illiterate 78.7 15.4 2.5 3.4
Only woman literate 55.7 30.4 7.7 6.2
Only husband literate 71.9 20.4 4.3 3.4
Both literate 36.8 44.4 9.4 9.5

The proportion of institutional deliveries managed by hospitals and health centres was 41%, (57% in urban areas and 32% in rural areas). Significant difference was observed among the couples who were illiterate and literate in case of institutional deliveries.

Conclusion:

The literacy of women is the key to improve antenatal care of pregnant women. Hence efforts should be made to have Information, Education and Communication (IEC) activities targeted to educate the mothers especially in rural areas. The tribal, small and inaccessible villages and the states of Bihar, Rajasthan, UP, MP and NE States (combined) should be focussed and targeted in the national RCH programme.

Acknowledgement:

The authors are grateful to Shri A.R. Nanda, Secretary, Department of Family Welfare, Ministry of Health and Family Welfare, Government of India for sponsoring the study. Authors are also indebted to Shri Gautam Basu and Dr.(Ms.) Meenakshi Dutta Ghosh, Joint Secretaries, Dr. V.K. Manchanda, Dy. Director General (CH), Dr. S. Sarkar, AC (Imm) for their keen interest and encouragement throughout the course of investigation.

The authors are grateful to Prof. N.K. Ganguly, Director General, Indian Council of Medical Research for granting permission to the Institute to undertake the study. The authors are thankful to the Chief (RHN) ICMR, Officers-in-Charge, HRRCs, Directors of ICMR Institutes/Centers viz; TRC, Chennai, CJIL, Agra, RMRCs Dibrugarh, Jabalpur and Port Blair as well as Principals of Medical Colleges of Kota and Dibrugarh for sharing the responsibility of survey work.

The authors are thankful to the Chief Secretaries and Secretaries of the Department of Health as well as District authorities of the State for providing logistic support and extending assistance in the conduct of the study.

The officers and staff of the Division of Training and Field Survey and other Divisions of the institute shared the responsibilities of data collection and timely completion of work relating to the project. The entire responsibility of data processing of the project was shouldered by Sri Anil Kumar, Sr. Research Officer. The help received from all is acknowledged.

References:

  1. "Coverage Evaluation Survey 1999" Institute for Research in Medical Statistics, New Delhi.
  2. Evaluation of routine immunisation 1997-98. Ministry of Health and Family Welfare, Govt. of India, organised by UNICEF, funded by USAID.
  3. Rapid Household Survey, RCH Project 1999, Ministry of Health and Family Welfare, Govt. of India.
  4. WHO 30 cluster Methodology.
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