Received on: January 10, 2018
Accepted on: February 05, 2018
Published on: February 20, 2018
*Corresponding author: Chhabra S, Department of Obstetrics and Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India. E-mail: firstname.lastname@example.org; Tel: +917152284342
It has been reported that 25% maternal deaths occur during pregnancy and disorders during pregnancy, pregnancy care also affect birth outcome. For prevention of maternal, perinatal mortality, morbidity mothers / babies future health, it is essential that women get quality prenatal care.
To know pregnancy care seeking practices of rural women of tribal communities with extremely low resources. Material
Study was done in 52 villages of hilly forestry region with low resources. Women from every 10th house were interviewed with help of predesigned tool in local language. Subjects were married women of 20 - 35yrs, if pregnant then second pregnancy onwards, if nonpregnant then with one or more births, within 5 years to reduce memory bias, willing to give consent for providing desired information about last pregnancy as per protocol. Literacy was similar in all. Of all 520 cases, 86% in 20-25 years, 84% in 26-30 years, 88% in 31-35 years had gone to school.
Their prenatal care started around 5 months. Many had 5; some few had one or two prenatal visits to Aanganwadi (place like Crutch) or Primary Health Centre for prenatal care provided by nurse midwives in villages. However many had gone many times, even dozen times to Accredited Social Health Activists (ASHA), encouraging. However contents of prenatal care needed a lot.
Almost all women did visit prenatal care area, mostly aanganwadi, many 5-6 times but all went first time around 5th month as per local advocacy, did not get quality care, even essentialities, may be because of provider’s lack of knowledge, material. So ones there is awareness about need of prenatal care, opportunity should be used to provide quality prenatal care not only for safe pregnancy, safe birth but also because if complications occurred they will not be able to manage.
Antenatal Care; Rural Women; Low resources
It has been reported that around 25% maternal deaths occurred during pregnancy, 50% within 24 hours of birth, 20% within seven days of delivery and 5% within 2-6 weeks after birth . It is essential that women get quality prenatal care, so that not only mortality during pregnancy is prevented, but there is birth preparedness, complications readiness, which helps in safe birth. Compared to many other provinces, Maharashtra is one of the better doing provinces of India, health indicators are better but women who live in Melghat region of Maharashtra are more than twice at risk of dying during pregnancy, abortion or birth or following abortion or birth. They lack awareness, live with scarce services, resources with access and transport problems. It is essential that they get quality prenatal care and guidance in their villages.
To know the pregnancy care seeking practices of rural women of tribal communities with low resources.
Material and Methods
Community based study was done after ethics committee's approval and informed consent in randomly selected 52 villages (15% of the villages in Melghat region), keeping in mind the distance from the health facility created, togetherness of the villagers for getting the desired information and also keeping in mind the possibility of future services. In these 52 villages, every 10th house was visited with minimum 5 houses in each village, with scope for modifcation, depending on number of houses in a village and available women as per the inclusion criteria. Study subjects were 520, married women of 20 to 35 yrs, willing to give consent for providing the desired information as per the questionnaire, if pregnant then with second pregnancy onwards and if nonpregnant then with at least one previous birth, within 5 years to reduce memory bias about giving information of last pregnancy. So every woman who was interviewed had at least one birth within 5 years. Focus group discussions were also conducted with neither age bar, nor bar of last birth. All those women willing were invited, 10-15 at a time. After taking consent, information was collected from 520 women, about prenatal care in last pregnancy, if pregnant then in the present pregnancy also, through a predesigned and pretested questionnaire which had partly closed ended (yes and no answers) and partly open ended questions. Most women belonged to lower economic class (Modifed Kuppuswami's 2009) (Table-I). Of 520 women, 373 (72% of all) were of 20-25 yrs and of them, 52 (14%) were illiterate, 148 (40%) had primary, 142 (38%) secondary school and 27 (7.2%) had higher secondary education. Only 3 (0.8%) women were graduates and one was postgraduate degree holder (0.2%). Of 138 (26% of all) women between 26-30 yrs, 22 (16%) were illiterate, 28 (20.28%) had primary school education, 71 (51.45%) had secondary and 14 (10.14%) higher secondary education. Two (1.4%) were graduates and one had post graduate degree (0.7%). Of 9 (2% of all) women of 31-35 yrs, there was one illiterate (11%), seven had primary (78.0%) and one secondary school education (11%), no one beyond secondary school. Only 1% graduate and 0.4% postgraduate degree holder, however 14% women were illiterate even in modern era.
Table 1: Antenatal Care
All 520 women had at least one prenatal visit to Aanganwadi (place like Crutch) in the index pregnancy. However many had gone to Accredited Social Health Activists for prenatal advice for some or other issue, maximum 15 times by some. However frst visit was around 5 months as per advocacy of ASHAs. Of the total 373 women of 20-25 years, 337 (90.4%) women had gone to Aanganwadi for antenatal care (ANC) and only 36 (9.6%) to Primary Health Centre (PHC).
Of 138 women of 26-30 years, 126 (91.3%) women went for ANC to Anganwadis and only 12 (9.5%) to PHC. Of nine women of 31-35 years, 8 women had sought ANC at Anganwadis and one at PHC. Mostly ANC was at Aanganwadi (Table I).
Mostly women had ANC after 5 months at Aanganwadi where there were no beds or tables. Sometimes it was only tetanus toxoid with some questions asked. Abdominal examination if, done by NM was after 7 months on ﬂoor, not even mat. In frst visit around 5 months also pregnancy diagnosis was by pregnancy kits, Height was recorded on 1st visit. Blood pressure, weight were sometimes recorded and Haemoglobin was sometimes done. Iron, Calcium tablets were given. At PHCs doctors, examination tables were available. However ANC was provided by NM as mostly it was male doctor. At PHC there were little better chances of recording Wt, BP and haemoglobin, occasionally urine test too. Blood group Rh type were not done even at PHC. Only difference at PHC was table was available and treatment was possible for minor ailments like, upper respiratory infection, aches.
Of 520 women, 57 (11%) were pregnant at the time of interview, 41 of 57 were of 20-25 yrs., 21 had pregnancy of 14 - 28 weeks, one of them had no prenatal care, 8 (7 women at Anganwadis and 1 at PHC) had 2 visits, 3 had 3 visits all at Anganwadis, 3 (2 Anganwadis & 1 PHC) and had 4 visits, 3 had 5 visits, all at Anganwadis, and 3 had 5 prenatal care visits with one additional to ASHA, all at Anganwadis. Twenty women had pregnancy of 28-37 wks, however one had no prenatal care, [3 had 2 visits, all at Anganwadis, 3 had 3 visits, all at Anganwadis, 4 had 4 visits (all at Anganwadis), 4 women (2 at PHC & 2 at Anganwadi) had 5 visits, 4 women (1 at PHC & 3 at Anganwadi) had 5 visits and one extra and one had 7 prenatal visits at PHC]. Left over 16 of 57 women who were pregnant at the time of study were of 26-30 yrs, one had completed frst trimester and had already gone to ASHA 2 times, 6 were between 14-28 weeks, 3 of them (1 at PHC & 2 at Anganwadi) had 2 visits, one had 3 visits, and 2 had 4 visits, all at Anganwadis. Eight were between 28-37 wks 2 had 3 visits, 2 had 4 visits and 3 had 5 visits, all at Anganwadis. One had 5 prenatal visits with 3 additional visits and one around 37 wks, had 5 prenatal visits at Anganwadi with 4 additional visits (Table II).
Table 2: ANC Care
Nurse midwives of sub centres (usually there was one sub centre for 5 villages) provided ANC at the Anganwadis. They visited the village once in a month where pregnant women were collected by ASHAs. They usually asked little bit pregnancy history, height on frst visit with tape, weight (if had working machine), looked at pallor (by checking conjunctiva or tongue), sometimes did haemoglobin recorded, blood pressure depending on apparatus availability. Women were asked about fetal movements. Abdominal examination was done beyond 7 months on ﬂoor as there were no tables or beds. At PHC abdominal circumference were recorded after 7 months. No other investigations were done. At PHCs minor ailments were treated. At Aanganwadi sometimes it was only tetanus toxoid and some questions. Focus group discussions (10) in bigger villages revealed that women had no expectations from ANC and went because ASHAs advised and they got some tablets. They went to either Aanganwadi or PHC mostly to Aanganwadi. They thought Tetanus toxoid was essential. They expected some tablets which were given. Some also said ANC or no ANC did not matter whatever had to happen will happen. However some did say it helped to know whether all was well. They did not know anything about minimum essential components of ANC.
The concept of screening for complications prior to delivery originated more than 100 years ago. Prenatal care evolved to include maternal education and testing for other conditions. Later prenatal care was found to help in screening for fetal growth restriction, fetal heart rate abnormalities, and other diagnosable conditions that increased stillbirth risk . Now we know so much is possible, even for future health of woman and her baby. So many things are possible, but basic essential quality prenatal care is not available to many who need it the most. Over all information from 520 women about 597 pregnancies revealed quite a lot of useful information about prenatal care seeking practices of rural women with very low resources, quite a lot positive sides, on which better services, could be built. Literacy was similar in all age groups of 520 women with information of last pregnancy, 86% in 20-25 years, 84% in 26-30 years and 88% in 31-35 years. Most had gone to school, be primary or middle school education. However those with graduate, postgraduate degree though very few were only young women. Younger women had better education because of thrust on female literacy, since some years. Only few women had one or two prenatal visits. They used to go to Aanganwadis when NM from sub centre or PHC came to their villages monthly with possibility of total 5 or 6 visits as they were advised by ASHAs to visit Aanganwadi or PHC around 5th month. However they did visit ASHAs (maximum 12 times) whatever problem they had and was encouraging. They went on their own to ask ASHAs for their ailments. ASHAs helped them by calling sub center. But this was not always possible due to communication access problem. However women's knowledge of essential components of basic prenatal care needed a lot to be done. Neither providers provided quality prenatal, care nor women knew what all must happen. Those who were pregnant at the time of interviews, while most had already had quite a number of times to Aanganwadi or ASHA's place, there were some with no visit till 7 months of pregnancy. They waited till last days for advice after frst pregnancy and concept of earliest possible quality antenatal care did not exist. Kuuire  reported that timing of frst ANC visit was strongly inﬂuenced by wealth in Nigeria but not in Malawi. The fndings revealed how various contextual factors enabled or inhibited policy performance. Globally, only 58% of women attended at least four ANC visits. It has been reported that many women did not seek prenatal care. Overall coverage in 2013 was 48% in the developing regions compared with 84% in the developed regions. Others reported that in 2013, the estimated coverage of early prenatal care visits was 24.0% in low income countries compared with 82% in high income countries. However in the areas like the study area, advocacy itself was to report around 5 months to the area where basic components of prenatal care were lacking. Caglia  also reported that measurement of height, weight, and blood pressure, urine analysis, blood examination, tetanus vaccine, prescription of folic acid and prescription of vitamins, iron or dietary supplements which were basics in prenatal care, were not available to rural women.
Moller  reported that substantial inequity existed in coverage both within regions and between income groups. In a study in Kenya it was revealed that the quality of maternal care was low, and care available to the impoverished was signifcantly worse than that for the better off. To achieve the national targets of maternal and neonatal mortality reduction, policy initiatives needed to tackle low quality care, starting with high-poverty areas. In the study in Kenya three dimensions, facility infrastructure and clinical process, quality of prenatal and delivery care essential components, particularly for clinical quality of prenatal and delivery care with substantial heterogeneity in quality by population wealth, were looked and it was revealed that all quality indicators were lowest for the poorest population and increased with increasing wealth. There was a quality defcit in health services available to the poor. Few studies have addressed inequities in quality of maternal care . Caglia  also reported socioeconomic disparities across the three outcome categories with women at the higher ends of income and with better housing conditions more likely to receive adequate prenatal care.
Clinicians have also been experimenting with group ANC, gathering several women at similar gestational ages to create a more interactive, supportive environment. Jhpiego has begun implementing a group-based model of prenatal care in response to the problems of low attendance and poor quality that affected traditional prenatal care. The concept of group ANC was introduced in 1988. An article published in the American Journal of Maternal Child Nursing described a program for adolescent mothers . Group ANC was not harmful to women compared to traditional models. Barriers for health systems and facilities implementing group ANC models included inadequate physical space, lack of additional administrative support, limited capacity for facilitator training and fnancial limitations. Given that group ANC was highly dependent on social, economic and other contextual factors, exploring and evaluating locally adapted models was critical . Group ANC, however, vastly increased women's return on their investment. Upon arriving at the clinic for a group ANC session, the pregnant women took each other's blood pressure, weighed each other and asked about the baby's movements. This model reinforced the idea that each woman played a critical role in the success of her own pregnancy and in that of her fellow group members. A midwife or other health provider was part of the model, offering one-on-one private appointments to each woman, but the clients were at the centre of their own care. This new model resulted in increased retention throughout the prenatal care to facility-based deliveries with better pregnancy outcome . In areas with limited manpower, with low resources, access problems this seems to be a good solution. However it needs a lot of input from health providers to have no negative aspects. Interviews with women who received maternal health care across 13 districts in Nepal revealed that long wait times; overcrowding and not being given the opportunity to ask questions were associated with dissatisfaction in prenatal clinics. It was known if women were more satisfed they were more likely to use the facility again/recommended to a friend . For many women around the world, particularly in low- and middle-income countries, prenatal care was their frst adult contact with the formal health system. This increased utilization of services. Content and quality of ANC are very important factors but seem to be lacking in care of rural women as was in the study area. Universal prenatal iron supplementation was safe and effective for combating maternal iron defciency and anaemia which was present in most of the women. A number of trials have found an association between multi-micronutrient supplementation and reduced risk of low birth weight . Fortunately this was being done in the region where anaemia is very common. User's perception of quality of ANC services crucially impacted continuity of use of services which affected outcome. Edie et al  did a study about user's perception of quality of prenatal services and reported it crucially impacted continuity of use of services and pregnancy outcome. Researchers reported that geographical accessibility and perceived quality of care were the predominant reasons for choosing or changing a site for ANC. There were elements of dissatisfaction with health centre services, poor sitting facilities, amenities, few health education talks and poor nursing skills. Yeoh  reported that the purpose of prenatal care was to monitor and improve the wellbeing of the mother and foetus for appropriateness. It helped in detection of complications, response to women's complaints, and their preparedness for birth and promotes healthy behaviour. Chukwuma  reported that higher quality of ANC predicted retention for skilled birth in Africa. Quality of skilled care received prenatally increased client retention during delivery there by reducing maternal perinatal mortality. Quality prenatal care was an essential component of the reproductive, maternal, newborn and child health continuum of care. During the critical prenatal period, health care providers could educate women about healthy pregnancy behaviour, danger signs of complications, breastfeeding and family planning; identify and treat pregnancy-related conditions such as pre-eclampsia/eclampsia; refer mothers to specialized care when necessary; encourage the use of a skilled birth attendant; and minimize the risk of motherto-child transmission of HIV. But for rural women with lack of resources, access never gets opportunity for all this. For many women around the world, an ANC visit is their frst adult contact with the health care system for not only diagnosing and managing pregnancyrelated complications, but an opportunity to screen and treat other chronic conditions and non-communicable diseases. Integrating ANC with other health services has the potential to improve utilization, quality and outcomes and additional research is needed . Linard et al  reported that inadequate prenatal care utilisation was associated with severe maternal morbidity and severe perinatal morbidity, prenatal care, to degrees that varied with the component of care and the outcome. The timing of the frst prenatal care visit was paramount for ensuring optimal health outcomes for women and children but is knowingly delayed for women who need the most. It was recommended that all pregnant women initiated prenatal care in the frst trimester of pregnancy. However for women of study region advocacy was visit around 5th month. So a lot is needed, better training of health providers of the region with access problem poverty, lacking awareness and material too.
We are grateful to everyone at British Columbia University, especially Dr. Shafk, Professor & Associate Dean, Social Accountability, School of Osteopathic Medicine, University of the incarnate Word. Broadway, Canada, Indo Canadian Shastri Institute, Canada for the support for this study. Our gratefulness is also due to the women and communities of villages of Melghat region where the study has been done.
1. WHO (2012) World Health Statistics. Website available at: [http://www.who.int/gho/publications/world_health_ statistics/2012/en/]
2. Goldenberg RL, McClure EM (2017) Importance of Prenatal Care in Reducing Stillbirth. BJOG.
3. Kuuire VZ, Kangmennaang J, Atuoye KN, et al. (2017) Timing and Utilization of Antenatal Care Service in Nigeria and Malawi. Glob Public Health 12: 711-727.
4. Caglia J (2016) A Fresh Look at The Adequacy of Antenatal Health Care.
5. Moller AB, Petzold M, Chou D, et al. (2017) Early Antenatal Care Visit: A Systematic Analysis of Regional and Global Levels and Trends of Coverage from 1990 To 2013 5: 977-983.
6. Sharma J, Leslie H, Kundu F, et al. (2017) Poor Quality for Poor Women? Inequities in the Quality of Antenatal and Delivery Care in Kenya.
7. Hodin S (2017) Strength in Numbers: Is Group Antenatal Care the Way Forward? 2017. 8. Smith J (2017) Reﬂections on women centered health care then and now.
9. Mehata S, Paudel Y, Dariang M, et al. (2017) Factors determining satisfaction among facility-based maternity clients in Nepal 17: 319.
10. Hodin S (2017) Effective Antenatal Interventions to Prevent Maternal and Newborn Mortality.
11. Edie G H, Obinchemti TE, Tamufor EN, et al. (2015) Perceptions of Antenatal Care Services by Pregnant Women Attending Government Health Centres in The Buea Health District, Cameroon: A Cross Sectional Study. Pan Afr Med J 21: 45.
12. Yeoh PL (2016) Antenatal Care Utilisation and Content between Low-Risk and High-Risk Pregnant Women. PLoS One 11: 0152167.
13. Chukwuma A, Wosu A, Mbachu C, et al. (2017) Quality of Antenatal Care Predicts Retention in Skilled Birth Attendance: A Multilevel Analysis of 28 African Countries. BMC pregnancy and childbirth 17:152.
14. Antenatal care. MHTF. Website available at: https://www. mhtf.org/topics/antenatal-care/
15. Linard M, Blondel B, Estellat C, et al. (2017) Association between Inadequate Antenatal Care Utilisation and Severe Perinatal and Maternal Morbidity: An Analysis in the Precare Cohort. BJOG.