Factors associated with utilization of antenatal care services among tribal women: A study of selected States.

BACKGROUND &
OBJECTIVES: Despite various efforts by the Government of India, utilization of antenatal care (ANC) services continues to be low among women from rural areas particularly those belonging to the Scheduled Tribes. The present study was undertaken to examine the factors associated with the utilization of ANC services among women in four States including Rajasthan, Odisha, Chhattisgarh and Madhya Pradesh which constitute a good share of tribal population of the country.
METHODS: Data from third round of District Level Household and Facility Survey, 2007-08 (DLHS-3) have been used. Bivariate and multivariate analyses (logistic regression model) were used to study the association between the utilization of ANC services and the independent variables at individual, household and village levels along with the motivational factors (motivation by health workers and family members).
RESULTS: The utilization of ANC services among Scheduled Tribes women varied from about 4 per cent in Madhya Pradesh and Rajasthan to 10-14 per cent in Chhattisgarh and Odisha. Utilization was highest among those women with level of education 9th class and above (15-28%) and those women who visited health facility for pregnancy confirmation test (9-27%). Across the States, women who visited health facility for pregnancy testing (adjusted odds ratio, AOR = 1.5-2.5; P<0.001) except in Madhya Pradesh; registration of pregnancy (AOR = 2.1-4.5; P<0.01) and sought treatment of pregnancy related problems (AOR = 1.5-1.8; P<0.06) except in Rajasthan, were more likely to avail complete ANC services than their counterparts. INTERPRETATION &
CONCLUSIONS: The utilization of antenatal care among Scheduled Tribe women across four States was very poor. The reasons behind non-utilisation include both socio-economic and health system factors. For improving ANC utilization among tribes, these factors need to be addressed with special emphasis on woman's educational attainment of high school and above. In addition, the study highlighted the need to create awareness among both pregnant tribal women as well as her family members on the importance of early ANC care.

Maternal mortality ratio (MMR) of India has declined from 437 in 1990-1991 to 178 per 100,000 live births in 2010-2012 period1. This decline was mainly attributed to the Government of India's Reproductive Maternal, Newborn, Child Health+ Adolescent (RMNCH+A) interventions that include many programmes such as promotion of institutional births through Janani Suraksha Yojna; comprehensive obstetric care and tracking of each and every pregnant women; antenatal, intra-natal and postnatal care234. Despite these efforts, little progress has been achieved in eliminating the disparity that exists in reducing maternal mortality and morbidity among the women belonging to Scheduled Tribes and Castes567.

Studies conducted in India8 and globally9 recognise the contribution of the antenatal care (ANC) in not only sustaining better maternal health but also in reducing maternal mortality and morbidity. In an effort to reduce maternal mortality, the Reproductive and Child Health (RCH) Programme under National Health Mission, Government of India is aimed at providing at least three antenatal check-ups which include a weight and blood pressure check, abdominal examination, immunization against tetanus, iron and folic acid prophylaxis, as well as anaemia management10.

Antenatal care utilization is associated with a number of socio-demographic and economic factors such as age of the woman, education, work status, parity, media exposure, household income, awareness and knowledge regarding antenatal care services, cultural beliefs, woman's autonomy, availability and access to health care, prior experience of delivery complications and motivation by either health care provider or family11121314. In India, according to National Family Health Survey (NFHS)-315, more than three-quarters of pregnant women received at least some antenatal care, but only half of the women had received at least three ANC visits as prescribed mandatory by the government norms of ANC in India. Further analysis indicated that the likelihood of receiving any antenatal care and specifically care from a doctor was lowest among Scheduled Tribes women15. Even among the tribal population, there was regional disparity in the health indicators and utilization of health care. The utilization was low among women belonging to tribes of central India as compared to the tribes of eastern and southern India. This is attributed to the diversity of socio-economic, demographic and cultural factors11. In order to increase the utilization of antenatal care facility and thereby reduce the maternal morbidity and mortality, there is a need to understand the factors acting as barriers in the utilization of ANC among women belonging to Scheduled Tribes. The present study was aimed to understand the factors associated with utilization of antenatal care services among tribal women in four Indian States viz. Rajasthan, Odisha, Chhattisgarh and Madhya Pradesh which constitute a good share of tribal population of the country.

Material & Methods

The data of third round of District Level Household and Facility Survey (DLHS-RCH 3: 2007-08) pertaining to Chhattisgarh, Madhya Pradesh, Odisha and Rajasthan were used. For understanding the factors associated with utilization of ANC services among currently married women, women who delivered at least one child during the five years preceding the survey were considered. The analysis was restricted to the last child birth. In all, there were 2116, 2246, 5294 and 4402 Scheduled Tribes currently married women aged 15-49 yr of rural areas in Rajasthan, Odisha, Chhattisgarh and Madhya Pradesh, respectively.

The outcome indicator was ‘complete ANC’. A woman was counted as having complete ANC, if she had made three ANC visits, received at least one dose of tetanus toxoid (TT) injections and consumed 100 iron folic acid (IFA) tablets/syrup during the last pregnancy. Explanatory factors were: (i) individual (woman) level factors: woman's age at the time of last birth, education, work status in the past 12 months, birth order of the last child, exposure (heard/seen) to ANC messages, whether woman had gone for pregnancy confirmation test at the health facility, whether woman had registered her name for ANC service at the health facility, women's report of time taken by the health provider for antenatal check-up, whether woman sought treatment for any of the pregnancy related problems, whether woman was motivated to visit health facility during pregnancy for health check-up by (a) health workers [Doctor, axillary nurse midwife (ANM), Health Worker, Anganwadi worker, accredited social health activist (ASHA), non-governmental organization (NGO)]; and (b) family members (husband, mother-in-law, mother, other relatives/friends); (ii) Household level factors: wealth index quintiles (wealth index quintiles were computed considering possession of household amenities, assets and durables by using factor analysis at State level. Households were categorized from the poorest to the richest groups corresponding to the lowest to the highest quintiles at the State level); detailed methodology on computation of wealth index can be found in NFHS-3 report15; (iii) Village level factors: village connected by road to a health facility; availability of government health facility in the village.

Statistical analysis: Univarite and multivariate logistic regression analyses were carried out to understand the socio-economic, demographic and the community level factors associated with utilization of ANC services among tribal women in Chhattisgarh, Madhya Pradesh, Odisha and Rajasthan. After the univariate analysis, only the significant variables (significant at 5% level of significance) were taken into the multivariate analysis.

Results

Table I shows the utilization of complete ANC (%) by selected background characteristics among Scheduled Tribes women aged 15-49 yr in four States. Overall, the proportion of Scheduled Tribes women who went for complete ANC was low in both Madhya Pradesh (3.6%) and Rajasthan (4.1%) followed by Chattishgarh (10.4%) and Odisha (14%). Across all the four States, the ANC coverage was high among Scheduled Tribes women belonging to richer households when compared with women belonging to poor households. The ANC utilization was better among educated Scheduled Tribes women. The utilization was low among the Scheduled Tribes women having 3+ birth orders and among women who had not heard/seen message of ANC. ANC utilization was more among the Scheduled Tribes women who went to the health facility for the confirmation or the registration of pregnancy. Time taken for ANC check-up was positively associated with the ANC utilization. Motivation by the family members and the health staff also had a positive effect on the ANC utilization among women belonging to Scheduled tribes. Villages which were connected by road to health facility or where health providers were available, had more proportion of women who reported complete ANC (Table I).

Table I

Utilization of complete antenatal care (ANC) services (%) by selected background characteristics among currently married tribal women in four States, 2005-2006

The logistic regression analysis of complete ANC utilization by various background characteristics of the Scheduled Tribes women was carried out separately in the four States to assess the nature of association between these independent factors and the utilization of complete ANC. Results are presented in Table II.

Table IIA

Unadjusted and adjusted odds ratio (OR) of utilization of complete ANC services by selected background characteristics among currently married tribal women in four States of India, 2005-2006

In the State of Rajasthan, Scheduled Tribes women who went to health facility for pregnancy related urine test were 2.5 times more likely to utilize the complete ANC services compared to the other women. Scheduled Tribes women who went to health facility for ANC and reported of receiving enough time from the health staff for ANC check-up were five times more likely to utilize the complete ANC services compared to the other women. Scheduled Tribes women who were motivated by family members for availing ANC were 1.9 times more likely to avail complete ANC services. In the State of Odisha, Scheduled Tribes women who went to health facility for pregnancy related urine test or who registered their pregnancy with the health facility, were 2.3 times more likely to utilize the complete ANC services compared to the other women. Scheduled Tribes women who sought treatment for pregnancy related problems were 1.5 times more likely to utilize the complete ANC services compared with the other women. Women who were motivated by their family members for availing ANC were 1.9 times more likely to avail the complete ANC services than other Scheduled Tribes women. Education of mother and birth order of the child had effect on the utilization of ANC but it was not found to be significant at 5 per cent level of significant (Table IIA).

In the State of Chhattisgarh, Scheduled Tribes women from households with rich wealth index were about 4.6 times more likely to utilize the complete ANC services than the poorest women. Women who went to health facility for pregnancy related urine test were almost 1.5 times more likely to utilize the complete ANC services compared with the other women. Women who went to health facility for registering their pregnancy were 4.5 times more likely to utilize the complete ANC services compared with other women. Women, who were given enough time for the ANC check-up, completed their ANC check-up schedule in double the proportion than the women who were not given enough time. Scheduled Tribes women who sought treatment for their pregnancy related problems completed ANC in almost double the proportion than those who did not seek treatment. Motivation by health staff of ANC check-up had an positive effect on the utilization of ANC but it was not found to be significant at 5 per cent level of significance. In the State of Madhya Pradesh, education of mother, registration of pregnancy and treatment sought for pregnancy related problems, were the factors independently associated with complete ANC of Scheduled Tribes women. Women with education level 6-8th class were more than twice likely to avail complete ANC than the illiterate women. Women who registered their pregnancy were 3.3 times more likely to avail complete ANC than the women who had not registered their pregnancy. Women who sought treatment for their pregnancy related problems, had 1.6 times greater chance of availing complete ANC after controlling for other factors (Table IIB).

Table IIB

Unadjusted and adjusted odds ratio (OR) of utilization of complete ANC services by selected background characteristics among currently married tribal women in four States of India, 2005-2006

Looking at the results in all the four States it was observed that pregnancy related urine test, registration of the pregnancy with the ANC clinic, treatment sought for pregnancy related problems, quality of care at these clinic in terms of time devoted for the check-up, motivation by family members for ANC check-up and education of mother, were the main facilitating factors for the utilization of ANC services. Economic status of the women in terms of wealth quintile was positively associated with the utilization of ANC in the State of Chhattisgarh.

Discussion

Findings from the study indicated the low proportion of Scheduled Tribes women availing complete ANC in the four States, increasing the vulnerability of these women to maternal morbidity and mortality89. These findings reinforce studies documenting the need to promote the utilization of ANC among women belonging to tribal population1213. Consistent with prior research, findings demonstrate a strong causal relationship between the timing of contact of a pregnant woman with the health system and her compliance to availing complete ANC services offered by the health facility1617. Early contact with the health system not only provides better opportunity to pregnant women to receive information at the right time regarding importance of complete ANC services and pregnancy care13 but also motivates her to utilize these services. One of the significant findings evident from the States of Rajasthan and Odisha was the role of family members in motivating women to attend the ANC clinic and thereby improving the chances of availing complete ANC. Unlike previous studies on the subject which have more often focused on the motivation provided by husband in utilization of ANC care181920, this study considered the motivation for complete utilization of the ANC services by other family members also. Motivation by the family members has come up as another significant causal factor for the utilization of ANC among the tribal women.

Education of women as observed in Madhya Pradesh and Odisha was positively associated with utilization of complete ANC. Educated mothers were more likely to be aware of the need for ANC and registering with the health facilities. Similar findings have been observed in other studies11121314.

As noted in the States of Rajasthan and Chhattisgarh, quality of care in terms of time devoted by the health staff for ANC check-up was a causal factor for complete utilization of ANC services among the Scheduled Tribes women. The variation in factors responsible for the utilization of complete ANC among Scheduled Tribes women across Chhattisgarh, Madhya Pradesh, Odisha and Rajasthan, highlights the need for State specific policies and programmes. These regional disparities in utilization of maternal health care among Scheduled Tribes women have been reported earlier study21.

This study may be considered in the light of certain limitations including reliance on self-reports on complete ANC and absence of data relating to cultural practices or earlier birth events which are known to have an association with service utilization. Also, operational definition of ‘complete ANC’ may have in part attributed to the low proportion of Scheduled Tribes women availing complete ANC in all the States. The data used for analysis were about a decade old and may not be representative of the current conditions.

In conclusion, our study findings emphasize the need of the RCH programmes to mobilize tribal women to register early with the health care facility and also create awareness among family members towards the need for utilization of complete ANC at the health facility.