Factors associated with institutional deliveries in Purulia district, West Bengal, India, 2007
By
Dr. Prasun Kumar Das
(MAE- FETP Scholar 2006-2007)
Submitted in partial fulfillment of the requirements for the degree of
Master of Applied Epidemiology (M.A. E) of
Sree Chitra Tirunallnstitute for Medical Sciences and Technology,
Thiruvananthapuram, Kerala-695 011.
This work has been done as part of the two year Field Epidemiology Training
Programme (FETP) conducted at
National Institute of Epidemiology,
(Indian Council of Medical Research),
R-127, 3rd Avenue, Tamil Nadu Housing Board
Ayapakkam, Chennai-600 077.
January 2008
CERTIFICATION
This is to certify that all the field projects submitted in this Bound Volume are -
original work carried out by Dr. Prasun Kumar Das during the two field
postings of six months each under the guidance of faculty of National Institute
of Epidemiology (ICMR), Chennai and the local supervisor specially
nominated for this purpose. This is in partial fulfillment of the requirements for
the degree of Master of Applied Epidemiology and has not been submitted
earlier by him in part or whole for any other (Publication or degree) purpose.
DIRECTOR National Institute of Epidemiology
Chennai
Acknowledgement
Thanks to almighty and my late father for completion of this study peacefully
and uninterruptedly.
I wish to express my respect and gratitude to Dr. M. D. Gupte, Director,
National Institute of Epidemiology (NIE), Chennai for allowing me to undertake
the MAE- FETP course in this esteemed institute. /
I expressed my gratitude and indebtedness to Dr. R. Ramakrishnan, Deputy
. l}iFector, N~E. Ghennai ·for hts expert ~uidance, valuab1e suggestions and
constant encouragement. He remains with me as my mentor throughout the
study, without whom it could not have been completed.
In preparing this study paper, I am greatly indebted to Dr. Yvan Hutin, WHO
resident advisor, Indian FETP; for his meticulous supervision, comments and
valuable suggestions, without which it could not have been possible.
I convey my gratitude to Dr. Manoj Murhekar, Deputy Director, NIE and
course coordinator, MAE- FETP; Dr. Vidya Ramachandran, Deputy Director,
NIE; and always helpful Dr. P. Manickam, Senior Research Officer, NIE for
their keen interest, valuable guidance, encouragement, suggestions and
sympathetic attitude throughout the period of my study work. I must express
my sincere regards and gratitude to all the faculties and teachers in this
course, especially Mr. L. Sundermoorthy and Dr. Vasna Joshua.
I also express my hearty thanks to Ms. Uma Monoharan, secretary to the
FETP, Mr. S. Satish librarian and other office staffs of NIE for their support
and assistance.
I express my sincere thanks to Dr. B. B. Patra formally Chief Medical Officer
of Health, Purulia for his positive attitude and whole hearted cooperation
during the course of my study.
1 grateful to Dr. Asit Kumar Biswas, formally Deputy Chief Medical Officer of
Health- II, Purulia; Dr. Swati Dutta, formally Deputy Chief Medical Officer of
Health - Ill, Purulia; Dr. A. Rahaman, Assistant Chief Medical Officer of
Health, Purulia; Mr. Debasish Ganguly, District Project Manager, Purulia; all
Block Medical Officers of Health, Purulia district for their active cooperation
and whole hearted help.
I convey my heartiest thanks to all the friends and colleagues who have
participated actively in this programme.
I rematn ·indebted to those heatth workers and the respondents, Wno very
graciously spared me their valuable time and information in addition to
extending their cooperation and generous hospitality, which rendered the
entire research, endeavor a very memorable, pleasant and profitable
experience.
My daughter has always been my inspiration to work hard and not to loose
confidence in myself during the course of study.
I wish to express my sincere regards to my mother for her support and
sacrifice.
Lastly I extend my cordial and profound gratitude to my wife for bearing with
me in this endeavor of hard work with patience support without which it could
not have been possible to conduct and to complete the study.
Date: 22nd January 2008 Dr. Prasun Kumar Das
Table of Contents
Page No.
Section 1: Dissertation
1 Introduction 1
2 Methods 5
3 Results 13
4 Discussion 15
5 References 21
6 Tables and figures 23
7 Annexure 29
Section 2: Literature review 51
Table 1
Table 2
Table 3
Table 4
Figure 1
Figure 2
List of tables and figures
Association of socio-demographic factors and
antenatal care with the mothers delivered in institutions
and mothers delivered at home, Purulia district, West
Bengal, India, 2007
Association of past obstetrical history, maternal benefit
scheme and health facility with the mothers delivered
in institutions and mothers delivered at home, Purulia
district, West Bengal, India, 2007
Odds of exposures according to increasing gradient of
exposure variables, Purulia district, West Bengal,
India, 2007
Logistic regression analysis of factors associated with
institutional delivery Purulia district, West Bengal, India,
2007
Frequency distribution of reasons of not attending
institution for delivery according to mothers delivered at
home, Purulia, West Bengal, India, 2007
Frequency distribution of reasons of attending institution
for delivery according to mothers delivered in institutions,
Purulia, West Bengal, India, 2007
Page No.
23
24
25
26
27
28
APNCUI
ASHA
ANC
ANM
BP
CHC
CSSM
FRU
!D
IFA
JSY
NFHS
NRHM
PHC
RCH
RH
RT
sc
WHO
WT
Abbreviations
Adequacy of prenatal care utilization index
Accredited Social Health Activists
Antenatal check-up
Auxiliary nurse midwife
Blood pressure
Community health centre
Child survival and safe motherhood programme
First referral unit
Institutional delivery
Iron and folic acid tablets
Janani Surakshya Yojna
National Family Health Survey
National Rural Health Mission
Primary health centre
Reproductive and child health
Rural hospital
Referral transport
Sub-centre
World Health Organization
Weight
Factors associated with institutional delivery 1n
Purulia district, West Bengal, India, 2007
Abstract
Background
India acc()ljll~s _for rn9r~ the1n_ QQ~:-fifth of ;;:~JI maternal de_aths from cause_s
related to pregnancy and childbirth worldwide. Giving birth in a medical
institution promotes child survival and reduces maternal mortality. In Purulia
district more than half of deliveries still occur at home. We studied the factors
responsible for poor accessibility and utilization of institutional delivery
services.
Method
We conducted a case control study. We sampled 161 cases and 161 controls
from 18 sub-centres. We defined cases as deliveries occurred in institutions
between 1st July 2006 and 301h June 2007 in the district. Controls were
deliveries at home during the same period. We calculated odds ratio of
different exposure variables with 95% confidence interval. We also carried out
a multivariate analysis.
Results
Of 1624 deliveries in 18 sampled sub-centres, 575 (35%) were institutional
deliveries. Institutional delivery mothers were four times more likely to have
three or more antenatal care visits (odds ratio 4.4; 95% Cl 2 6 to 7.5). Among
other factors associated with institutional delivery mothers were adequacy of
prenatal care utilization index 80% or more (odds ratio 3.4; 95% Cl 2 to 5.8),
pre-plan for institutional delivery (odds ratio 16.8; 95% Cl 9.2 to 30.6) and
antenatal check up at private health facilities (odds ratio 2.6; 95% Cl 1.5 to
4.2) ...
Discussion
Antenatal check-ups are a key determinant of institutional delivery. Pre
planning of delivery in an institution and examination in private health sector
facilitate institutional delivery. We recommended ensuring at least three
antenatal check-up, strengthening private-sector health facilities, motivating
mothers and their family members for prior planning of institutional delivery.
Behavioural change communication activities could modify the ideas and
thoughts of parents regarding delivery.
Key words: Institutional delivery, maternal mortality.
Factors associated with institutional delivery in
Purulia district, West Bengal, India, 2007
1. Introduction
According to WHO, a maternal death is defined as the death of a woman
while pregnant or within 42 days of termination (via delivery, miscarriage or
abortion) of pregnancy, irrespective of the duration and the site of the
pregnancy, from any cause related to or aggravated by the pregnancy or its
management, but not from accidental or incidental causes. The maternal
mortality ratio, defined as the number: of maternal deaths per 100,000 live
births. The direct causes of maternal mortality include sepsis, hemorrhage,
complications resulting from unsafe abortion, prolonged or obstructed labour
and hypertensive disorders of pregnancy (eclampsia or pre-eclamsia). Indirect
causes of deaths are due to conditions that in association with pregnancy
hasten the fatal outcome - for instance anaemia, malaria, hepatitis and
increasingly AIDS. An estimated 90% of maternal deaths could be avoided, if
adequate care was provided. 1 Deaths due to abortion could be prevented by
increasing access to safe abortion services. Deaths due to anaemia,
obstructed -labour, hypertensive disorders and sepsis are preventable with
provision of adequate antenatal care, referral and timely treatment of
complications of pregnancy, promoting institutional delivery and postnatal
care. Emergency obstetric services will help saving lives of women with
haemorrhage during pregnancy, complications during deliveries conducted at
homes. Giving birth in a medical institution under the care and supervision of
trained health-care providers promotes child survival and reduces the risk of
1
maternal mortality. 2 The high level of maternal mortality in developing
countries has been attributed partly to the non-availability of services and
partly to the poor utilisation of these services when they are available.
According to WHO estimates, about 510,000 maternal deaths (about 0.9
percent of total deaths) occurred globally during the year 2002. Of these
deaths about 231,000 occurred in African countries, 17,000 in Americas,
68,000 in Eastern Mediterranean, 3,000 in European, 171 ,000 in South East
Asia and 21,000 in Western Pacific countries. 3
Women living in South East Asia run a lifetime risk of one in 43 of dying in
pregnancy or childbirth compared to 1 in 60 in developing countries as a
whole and 1 in 74 at the global level. In India, both child mortality (especially
neonatal mortality) and maternal mortality are high. Seven out of every 100
children born in India die before reaching age one, and approximately five out
of every 1,000 mothers who become pregnant die of causes related to
pregnancy and childbirth. India accounts for more than one-fifth of all maternal
deaths from causes related to pregnancy and childbirth worldwide. 1 The
National Health Policy (1982) aimed at reducing the maternal mortality in India
from the over 400 per 100,000 live births to less than 200 per 100,000 live
births by the end of year 2000. 4 Despite the benefits associated with
institutional delivery, India's maternal and child health programmes have not
aggressively promoted institutional deliveries, except for high-risk cases.
Providing facilities for institutional delivery on a mass scale in rural areas is a
long-term goal requiring massive health infrastructure investments. However,
there has been a shift in this policy with the establishment of the Child
Survival and Safe Motherhood (CSSM) in 1992 and the Reproductive and
Child Health (RCH-1) programmes in 1997. The new programmes aim at
2
expanding existing rural health services to include facilities for institutional
delivery. Existing maternal and child health services at primary health centres
(PHCs) are being upgraded, and new first-referral units (FRUs) are being set
up at the sub-district level to provide comprehensive emergency obstetric and
new-born care (Ministry of Health and Family Welfare, New Delhi). Despite
the uniformity in programme design throughout the country, the availability
and quality of health services, including maternal health services varies
throughout the regions. In 1992-93, according to National Family Health - - . ·- ·- - - -
Survey (NHFS-1) the proportions of mothers receiving antenatal check ups
ranged from 31 percent in Bihar to 94 percent in Tamil Nadu and the
proportion giving birth in medical institutions ranged from 11 percent in
Rajasthan and Uttar Pradesh to 88 percent in Kerala.5 In 1998-99, according
to N-FHS-2, the proportion receiving antenatal check-ups ranged from 34-36
percent in Uttar Pradesh and Bihar to 98 percent in Kerala and Tamil Nadu,
and the proportion giving birth in medical institutions ranged. from 22-23
percent in Uttar Pradesh and Bihar to 95 percent in Kerala. 6 In 200_5-2006,
according to NHFS-3, 39 percent of births in the five years preceding the
survey took place in health facilities. Many factors explain this diversity.
Utilization of health services is affected by a multitude of factors including
availability, distance, cost, quality of service, socioeconomic factors and
personal health beliefs. Another factor affecting women's health-seeking
behaviour in the context of pregnancy and childbirth is that traditionally in rural
India pregnancy is considered a natural state of being for a woman rather
than a condition requiring medical attention and care. Such perceptions and
beliefs constitute a lay-health culture that is an intervening factor between the
presence of a morbidity condition and its corresponding treatment. Postnatal
care and infant and child health care are similarly affected by this culture.·
3
I I
1 I
Women often do not avail preventive and curative medical services intended
to safeguard their own and their children's health and well-being. The lay
health culture has effects on utilization of maternal health services in regions
of the country where poverty and illiteracy are widespread. This culture is
difficult to measure directly, but it is possible to include socioeconomic factors
that are correlated with it when analyzing utilization of maternal health
services. To improve the availability of and access to quality health care,
especially for those residing in rural areas, the poor, women, and children, the ~ ,_ - " - - -- - -· - -- - ' - - -
government recently launched the National Rural Health Mission for the 2005-
2012 periods. Governement of India launched RCH II in 2005 under the
National Rural Health Mission (NRHM). The major focus of these programmes
is reduction of maternal mortality and infant mortality. The goal for RCH II is to
reduce maternal mortality ratio to 100 per 100000 live births by 2010. By that
date, 80 percent of all deliveries should take place in institutions and hundred
percent deliveries should be attended by trained personnel. Under this
scheme thrust is being given to institutional delivery, safe motherhood,
operationalization of first referral units (FRUs) making facilities operational for
basic and comprehensive emergency obstetric care, strengthening the referral
system, strengthening of routine immunization and related cold chain system.
Maternity benefit scheme (Janani Surakhya yojona) launched on 1 ih April
2005, is being implemented in all states with the objective of reducing
maternal and neo-natal mortality by promoting institutional delivery among the
poor pregnant women. It is a 100 % centrally sponsored scheme and it
integrates cash assistance with delivery and post-delivery care. One of
the important goals of the National Rural Health Mission is to provide access
to improved health care at the household level through female Accredited
Social Health Activists (ASHA), who act as an interface between the
4
community and the public health system. The ASHA acts as a bridge between
the ANM and the village, and she is accountable to the Panchayat.
In Purulia district maternal mortality ratio still very high (233 per 1, 00,000 live
births in 1998) and is lagging far behind in achieving the goal for RCH II. More
than half (57%) of deliveries in the district still occur at home. Information
about reasons for poor institutional delivery is lacking. Therefore, we
undertook the study in Purulia district with the objective to identify
demographic; socio-economic- and antenatal factors responsible for poor
accessibility and utinzation of institutional delivery services.
2. Methods
Study population
We defined our study population as mothers who delivered between 1st July
2006 and 30th June 2007 residing in the district of Purulia, West Bengal, India.
Study design
We conducted a case control study among mothers who delivered between
1st July 2006 and 30th June 2007 to determine the factors associated with
institutional deliveries.
Inclusion criteria
We included all mothers who are living during the study period
5
Sampling strategy
We adopted a two stage sampling technique. The first stage was the selection
of sub-centres. We selected sub-centres at random from a list of all sub
centres of the district. The second stage was selection of cases and control
mothers at random from the list of mothers who delivered between 1st July
2006 and 30th June 2007 available at the sub-centres.
Sample size
We calculated sample size using Epi6 software. Taking a ratio of one control
per case, an odds ratio worth detecting of three, a percentage of exposure
among controls of 20%, an alpha risk of 5% and a power of 80% we needed
73 cases and 73 controls. Assuming a design effect of two and 1 0% of non
response, the sample size was increased to 161 cases and 161 controls. We
selected 18 sub-centres at random from the list of all sub-centres in the
district. From each sub-centres we selected nine deliveries occurred in
medical institution and nine deliveries at home by random methods from the
list of institution and home deliveries respectively.
Selection and definition of variables
Our outcome variables were deliveries at medical institutions and deliveries at
home. We defined cases as deliveries occurred in medical institutions
(government district /subdivision /rural hospital, block primary /primary health
center /health sub center, private hospital /nursing home) between 1st July
2006 and 30th June 2007 in the district. Controls were deliveries at home
during the same period.
6
Our exposure variables included demographic characteristics, socioeconomic
status, antenatal care, past obstetrical history, maternal benefit scheme and
health facility.
Education variable measured the level of education that a woman had
completed. This variable had been categorized as illiterate, less than primary
and more than primary. The category illiterate included women who had never
attended school, less than primary are those who had not completed primary
level of education and more than primary included all women who had
completed primary level of education.
Literate mother indicates women who had completed primary level of
education.
Family type - Households with three or more related adults were assumed to
have an extended I joint family structure, while households with two related
adults of opposite sex were assumed to have a nuclear family structure.
Total member - The total number of household members was used as an
indicator of household size.
Economic status of the household was measured by a composite score of
several indicators of household possessions. The question was asked
whether the household had such items and facilities as piped water, toilet,
non-dirt floor, telephone, radio, television, cooking gas electricity, bicycle and
motorcycle. Affirmative responses to ten items are counted and a composite
scale ranging from 0 through 10 was created. The variable was graded as low
(score< 3), medium (score 3- 5) and high (score > 5).
7
Family decision by parents - Households where parents were taking family
decision
Husband literate -Husbands who had completed primary level of education.
Husband's occupation - Part time work means work less than four hours
p-er day I seasonal. Full time work means-work more than four hours per day/
throughout the year.
Husband employed - Husbands who engaged in full time work.
Antenatal check up was ascertained by review of the documents (antenatal
card or prescription) available with the study subjects.
Total ANC 2= 3- Total ante natal check up three times or more
ANC started before 16 weeks - First ante natal check up started within 16
weeks of last menstrual period (LMP).
Third ANC after 28 weeks - Third or last ante natal check up done after 28
weeks of last menstrual period (LMP).
Adequacy of prenatal care utilization index (APNCU) - This index, also
known as the Kotelchuck Index of Prenatal Care. It attempts to characterize
prenatal care (PNC) utilization on two independent and distinctive dimensions
- namely adequacy of initiation of PNC and adequacy of received services
(once PNC has begun). It has four values: [1] Adequate Plus - prenatal care
8
began by the end of the 4th month and 110% or more recommended visits
received, [2] Adequate- prenatal care began by the end of the 4th month and
80-109% or more recommended visits received, [3] Intermediate - prenatal
I care began by the end of the 4th month and 50-79% or more recommended
visits received and [4] Inadequate - prenatal care began after the 4th month or
less than 50% or more recommended visits received. This index does not
assess quality of the prenatal care that is delivered, only its utilization.
Antenatal check up done by doctor~ ..., Women whose ante natal check up
was conducted by a doctor.
Blood pressure check up ~ 3 - Women whose blood pressure check up
done three times or more during whole ante natal period.
Weight taken ~ 3 - This variable indicates women whose weight measured
three times or more during whole ante natal period.
Abdominal examination done - It indicates those women whose abdominal
examination done at least once during antenatal period.
lnjecti.on tetanus toxoid ~ 2 - Women who had taken two or more injection
tetanus toxoid during ante natal period.
Urine examination during ANC - Women whose urine was examined for
protein at least once during ante natal period.
Home visit by health workers during ante natal period - It indicates those
women who have been visited by the health workers at least once during ante
natal period.
9
Ante natal check up in private health facilities - Women who have done
their ante natal check up in any private health facilities (other than
Government facilities).
Previous plan for institutional delivery - Women who planned for
. institutional delivery during ante natal period.
Complications during ante natal period - Women who had suffered from
any one of the following during ante natal period - oedema, anaemia,
bleeding, convulsion, visual impairments, high blood pressure and no foetal
movement.
Birth order~ 2- Mothers who had second or higher-order birth.
Place of delivery determined by parents - Households where parents were
taking decision for place of delivery.
Previous delivery at home - Women ·who delivered at home before last
delivery
Knowledge of Janani Surakshya Yojna (JSY) - Mothers who knew the
benefits of Janani Surakshya Yojna
Received financial benefit of JSY before delivery - Mothers who received
the financial benefit of Janani Surakshya Yojna during ante natal period
Knowledge of financial benefit for institutional delivery - Mothers who
were aware about the financial benefits of institutional delivery
10
Knowledge of financial benefit for referral transport - Mothers who were
aware about the financial benefits of referral transport
Nearest health facility < Skm -Availability of a health facility within five km
of women's residence.
Availability of night transport in the village - Villages where transport
facilities were available during night.
Data collection
We collected information through interviews using structured questionnaires
regarding demographic characteristics, socio-economic status, antenatal
check up, obstetrical history, place of delivery, mode of transport, and
knowledge of maternal benefit scheme (Janani surakshya yojona).We
selected interviewers among district female health workers who were trained
centrally at the district head quarter.
Data entry and analysis
We entered the data in excel and created a variable directory. We calculated
odds ratio of different exposure variables with 95% confidence interval. We
examined variables that we expected as confounder or effect modifier in
stratified analysis. We used Epi-lnfo and Epi6 for data analysis. We carried
out a multivariate analysis to determine which factors were independently
significant when controlled for other factors found to be important in the study.
We calculated adjusted odds ratio after multivariate analysis. The analyses
with respect to antenatal check up (ANC) by doctors, measurement of blood
pressure and weight three times or more, abdominal examination during ANC,
11
injection tetanus toxoid two or more, urine examination during ANC, antenatal
care done in private health facilities variables were to be done only among the
mothers who had antenatal check up. Mothers with no antenatal check up
were not to be included here. However, as I have selected my study subjects
from the sub-centre register, so all of them visited sub-centre at least once
and hence had at least one ANC. Therefore, I performed those analyses
among all my study subjects.
Quality assurance
We did peer review of the protocol and verified field procedures. We prepared
the questionnaires in English translated to local vernacular and back
translated to English. We pilot tested the questionnaires in a small group
which was not a part of study population. The principal investigator validated a
tenth of interviews through observations of field procedures of data collection
for quality assurance and consistency.
Human subject protection
There was no physical risk to the participants in the study. The study subjects
had to spend 15 minutes with the field investigators to participate. We
informed the participants that their participation was voluntary and that they
were free to withdraw at any time. Study participants had an opportunity to
communicate to the health system the constraints they have faced with. We
did not write any identifiers on the data collection instrument and used a code
instead. All elements of the conversation made with the study subjects were
kept confidential. We informed the participants about the objectives of the
present study and sought their informed written consent to participate in the
12
present study. We obtained approval for the project from the ethical
committee of the National Institute of Epidemiology, Chennai. We took
permission from the district health administration, Purulia to conduct the
study.
3. Results
h1 the 18 selected sub-centres total 1624 deliveries occurred during the study
period. Of which 575 (35%) were institutional deliveries. We included 161
mothers delivered at institution as cases in the case control analysis. We also
recruited 161 mothers delivered at home as controls.
Socio-demographic profile of the respondents (table 1)
Mothers who delivered in institution were three times more likely to be under
20 years of age. Compared to home delivery mothers, institutional delivery
mothers were more likely to be follower of Hinduism and less likely to belong
to scheduled caste and scheduled tribe. Institutional delivery mothers were
more likely to be literate and belonged to a household with medium or high
standard of living than home delivery mothers. It was observed that, the
likelihood of institutional delivery increased with increasing level of education
and economic status of the women (table 3).
Antenatal care and past obstetric performance (table 1and 2)
Institutional delivery mothers were four times more likely to have three or
more antenatal care visits. The likelihood of third antenatal check up after 28
13
weeks was higher in mothers who delivered in institutions. Similarly,
compared with others, 80% or more adequacy of prenatal care utilization
index (APNCUI) was more likely in women who delivered in institution.
Institutional delivery increased with increasing gradient of antenatal check up
and APNCUI (table 3). Institutional delivery mothers also had more chances
of receiving antenatal check ups by doctors and antenatal care at private
health facilities. Institutional delivery was more likely in mothers who planned
for it beforehand. Pre-plan of delivery in medical institution was 16 times more /
associated with women who delivered in institution than who delivered at
home.
Compared with others, institutional delivery mothers were less likely to have
birth order more than one (multipara). Previous history of institutional delivery
was more in mothers delivered in institution than at home. Women who
delivered in institutions were more likely to be involved in decision making
about their own place of delivery.
Maternal benefit scheme and health facility (table 2)
Mothers who delivered in institutions were not more aware of the various
financial support schemes including Janani Surakshya Yojna (JSY), the
incentives to institutional deliveries or the support for transport to institution
than mothers who delivered at home.
Institutional delivery mothers were also less likely to stay within five km of the
health facility compared to mothers who delivered at home. The likelihood of
availability of night transport facilities in the villages were more in institutional
delivery mothers.
14
Multivariate analysis indicated that institutional delivery were associated with
ante natal check up three times or more, adequacy of prenatal care utilization
index 80% or more, pre-plan for institutional delivery, antenatal check up at
private health facilities and literacy of the women. The strongest factor was
pre-plan for delivery in institution (adjusted odds ratio 17, p value 0.0000)
(table 4).
Reasons for not going health institutions for delivery- In our study out of
161 home delivery mothers, 101 (63%) stated that it was not necessary to
deliver in health institutions (Figure 1). 21 (13%) women felt that it was not
customary to have delivery in health institutions. Other factors reported as
reasons for home delivery included the lack of time (18%), the absence of
transportation (5%) and others (1 %).
The main reported reasons for institutional delivery were related to safe
delivery (41 %), health personnel advice (35%) and failed attempts at home
(20%) (figure 2).
4. Discussion
The probability of giving birth in a medical institution was related to many
factors. We identified three groups of factors for institutional delivery in Purulia
district. The first were related to demographic and socioeconomic
characteristics, the second to antenatal care and past obstetric performances
and the third to maternal benefit scheme and health facility. The information
available gives input on prioritization of activities to improve institutional
delivery towards safe motherhood initiatives. A review of these factors
15
provides some understanding of the practices that expose the community to
institutional delivery and provide useful direction to suggest behaviour change
interventions to increase institutional delivery.
Proportion of institutional delivery in the district was far behind the National
Rural Health Mission target. Factors influencing the institutional delivery were
educational status of the mother, ante natal check up three times or more,
adequacy of prenatal care utilization index 80% or more, ante natal check ups
in private health facilities and pre,..planning of delivery at medical institution.
Factors preventing institutional delivery were birth order of two or more,
previous delivery at home (in case of multigravida) and place of delivery
determined by the parents.
Mothers who have received more than primary level education had a
tendency towards institutional delivery. The higher the level of education was,
the more were the chances of institutional deliveries. It was seen that most of
the institutional delivery mothers themselves had chosen their place of
delivery. Several reasons were there why education of women had
significantly positive relationship with maternal health care utilization. In a
study of Nepal, educated women were more likely to realize the benefits of
using maternal health services; so most of them tend to use this service. In
addition, education may enhance female autonomy; hence increasing
women's ability to make decisions regarding their own health. 8 Studies also
reveal that, education increases the knowledge of modern health care, thus
increasing the demand for modern health services. 9·10 In a Kenian study,
having more than 8 years of education and being of higher socio-economic
status were the most important factors associated with ANC attendance .11
16
rn our study, three or more ante natal care visits influenced mothers for
delivery in a medical institution. It was also observed that, antenatal care
services like third antenatal check up after 28 weeks, adequacy of prenatal
care utilization index 80% or more, measuring blood pressure and weight
thrice or more facilitated institutional delivery. Studies showed that antenatal
check-ups has got an association with institutional delivery.1 So it is possible
to promote institutional delivery by encouraging antenatal check-ups and
associated counselling. The principal mechanism which affects institutional
aeliver{ seems to be. that of the counselling provided by the health workers to
the mothers during ante natal check ups. Another study show, mothers who
did not seek ante natal care during pregnancy were 4.5 times more likely to
choose delivery at home. 12
Women those who had received antenatal care in private health facilities and
those attended by doctors tend to institutional delivery. Ante natal care given
by doctors inspires institutional delivery in mothers by building up their
confidence and to take decision in favour of it. 1 A study in Cuba reported that,
Cuban women had a strong preference of frequently visiting the doctor for
they felt that the period of pregnancy was something very worth and special in
their life.13
Our study reveals that most of the pregnant women are not going for
institutional delivery as they feel it is it is neither necessary nor customary.
One of the reasons behind it is probably for their ignorance and lack of
importance regarding their basic health situations not only from their part but
also from the part of their family, society and surroundings. It being a very
common and natural phenomenon to them, they do not feel any urge of going
to the institution or realize the hidden danger of it if any.
17
h other studies show that the distance of the hospital plays a key role in
· ing institutional delivery but this picture is not the same here. Rather
is seen that distance had nothing to do with the institutional deliveries here.
Again availability of transport during night also favours institutional deliveries.
In this concern instead of increasing the number of hospitals it is more likely
necessary to focus on increasing easy availability of transport during night
and of quality antenatal services along with proper guidance not only to the
women but also to their family members.
The trend of home delivery was found to be higher among multigravida
women. Similar findings had also been reported in other studies too. 6·7
Uncomplicated first delivery and quicker child birth tends multiparous mothers
to deliver at home.12 So to increase institutional delivery counselling and
encouragement to multigravida mothers should be one of the priority.
The influence of the family especially of the parents and in laws in deciding ',<
Jj·····
the place of delivery is another major aspect for home deliveries. In this
respect parents and in-laws are first needed to be motivated about
institutional deliveries by making them aware of the risk factors of home
deliveries as well as also the privileges and benefits of institutional deliveries.
It is seen that most mothers who delivered in institution had more or less
planned their place of delivery beforehand. Thus it is necessary to make the
mothers and their parents including in-laws to understand the benefits of pre
planning of institutional deliveries during antenatal period.
18
limitations
Our study had three limitations. First, the study was conducted in rural areas
and so the findings may not be generalized in urban areas. Second, we
collected the list of mothers from the sub centre, both who have delivered at
institution and at home. So those who had not attended the sub centre might
have been excluded. They more likely belong to two extremes of the society
-the well-off and the most under privileged. Each of this group was likely to
have a stronger association between place of delivery and exposure variables
compared to the remaining population. So, their exclusion from the study
might have led to under estimation of strength of association. Third, a
statistical power calculation suggested that our sample size for stratified
analysis would not have had a power of 80% to detect an odds ratio of three.
Hence, we did not have a reasonable capacity to document stratified analysis
to eliminate confounders and identify effect modifiers. In the stratified analysis
of different variables we obtained overlapping confidence interval for strata
odds ratio. It was not enough to say that there was no confounding or effect
modification because such overlapping could have happened due to low
power of the study. We managed and overcame this limitation by multivariate
analysis.
Conclusions
Antenatal check-ups are a key determinant of institutional delivery. Overall,
the analysis indicates that receiving three or more antenatal check-ups, the
last one which after 28 weeks significantly facilitates institutional delivery. Our
study suggests that it is possible to promote institutional delivery by
expanding antenatal-care coverage and associated counselling. As it is seen
19
that a higher proportion of institutional deliveries are taking place among
mothers who are examined in private health sector facilities, so by facilitating
private sector health facilities in rural areas will in turn increase institutional
deliveries. The low utilization of maternal health services is partly due to the
poor planning by the women and their family members. To increase
institutional delivery there is a need to plan regarding the place of delivery
during antenatal period. Parents I in laws decision regarding place of delivery
mostly favours home delivery. Behavioural change communication (BCC)
activities could modify their ideas and thoughts regarding delivery. The
number of institutional delivery is more in the villages where there is transport
facilities at night. So provision of such facilities may improve institutional
delivery.
Recommendations
To promote institutional delivery first, ensure at least three antenatal check
up, of which the third or last check-up should be after 28 weeks. Second,
strengthen private-sector health facilities to make them more accessible to
rural mothers, in terms of availability and quality of services and cost. Third,
motivate mothers and help their family members for prior planning of
institutional delivery. Fourth, behavioural change communication activities
with specific target group in the community like parents I in-laws along with
multigravida women to make them understand that though giving birth is a
normal physiological phenomenon, each and every delivery should take place
in a medical institution under supervision of trained professionals and fifth,
build up intersectoral co-ordination with other departments particularly with
panchayet and rural development to find out the possibility of arranging local
transport at night in each gram panchayet.
20
Faundes A, Rosenfield A, Pinotti JA: Maternity care m developing
countries: relevance of new technological advances. lnt J Gynecol
Obstet 1988, 24:103-109.
Promoting Institutional Deliveries In Rural India: The Role of Antenatal
Care Services, K. S. Sugathan, Vinod Mishra, and Robert D.
Retherford National Family Health Survey Subject Reports Number 20,
December 2001, International Institute for Population Sciences
Mumbai, India and East-West Center, Population and Health Studies
Honolulu, Hawaii, U.S.A.
3. WHO, UNICEF, UNFPA. Maternal mortality in 2000: Estimates
developed by WHO, UNICEF, UNFPA. Geneva: WHO. 2003.
4. National Health Policy, Ministry of Health and Family Welfare,
Government of India, New Delhi, 1982
5. International Institute for Population Sciences (liPS). 1995. National
Family Health Survey (MCH and Family Planning), India 1992-93.
Bombay: liPS.
6. International Institute for Population Sciences (liPS) and ORC Macro.
2000a. National Family Health Survey (NFHS-2), 1998-99: India.
Mumbai: liPS.
7. NFHS Survey 1998-99. India: National Family Health Survey (NFHS-2),
International Institute for Population Sciences, Mumbai.
21
B. Women's status, household structure and the utilization of maternal
health services in Nepal by Masaki Matsumura and Bina Gubhaju,
Asia-Pacific Population Journal, March 2001.
9. Jejeebhoy, S.J. (1995). Women's Education, Autonomy and
Reproductive Behavior: Experience from developing counties (New
York, Clarendon Press).
10.Celik, Y. and D.R. Hotchkiss (2000). "The socio-economic determinants
of maternal health care utilization in Turkey", Social Science and
Medicine 50(12): 1797-1806.
11. Use of antenatal services and delivery care among women in rural
western Kenya: a community based survey. Anna M van Eijk, Hanneke
M Bles, Frank Odhiambo, John G Ayisi, lise E Blokland, Daniel H
Rosen, Kubaje Adazu, Laurence Slutsker and Kim A Lindblade.
Reproductive health 2006, 3:2; Published: 06th April, 2006.
12. Socioeconomic and physical distance to the maternity hospital as
predictors for place of delivery: an observation study from Nepal.
Rajendra Raj Wagle, Svend Sabroe and Birgitte Bruun Nielsen. BMC
pregnancy and childbirth 2004, 4:8; Published: 22 May, 2004.
13. Women's' opinions on antenatal care in developing countries: results
of a study in Cuba, Thailand, Saudi Arabia and Argentina. Gustavo
Nigenda, Ana Langer, Chusri Kuchaisit, Mariana Romero, Georgina
Rojas, Muneera AI-Osimy, Jose Villar, Jo Garcia, Yagob AI-Mazrou,
Hassan Ba'aqeel, Guillermo Carroli, Ubaldo Farnot, Pisake
Lumbiganon, Jose Belizan, Per Bergsjo, Leiv Bakketeig and Gunilla
Lindmark. BMC Public health 2003, 3:17; Published: 20 May 2003.
22
Table 1: Association of socio-demogra.phic mothers delivered ath6me, Puruli'a'itfis,tri:Ct;·
Frequency of exposure amo
Delivering Delivering Exposures in institutions at home
(N=161) (N=161) Estimate confidence # (%) # (%) interval
Demography and Follower of Hinduism 159 99 151 94 5.3 1.1-244
socioeconomic Belong to scheduled caste and scheduled tribe 36 22 50 31 0.6 0.4-1.0
Age below 20 years 26 16 10 06 2.9 14-6.3
Literate mother 59 37 32 20 2.3 14-3 9
Engaged in outside work 10 06 31 19 0.3 0.1 -0.6
Living in joint family 137 85 122 76 1.8 1.0- 3.2
Adult member in the family < 3 24 15 46 29 04 0.3- 0.8 Family decision by parents 98 61 105 65 0.8 0.5-1.3 Husband literate 101 63 59 37 2.9 1.9-4.6 Husband employed 33 21 12 09 3.2 1.6-6.5 Medium to high economic status 47 29 14 09 4.3 2.3- 8.3
Antenatal care ANC started before 16 weeks 101 63 68 42 2.3 1.5- 3.6 Third ANC after 28 weeks 73 45 40 25 2.5 1.6-4.0 Total ANC;:: 3 136 85 89 55 4.4 2.6- 7.5 ANC done by doctor 61 38 33 21 2.4 1.4-3.9 Blood pressure check up ;:: 3 95 59 59 37 2.5 1.6-3.9 Weight taken;:: 3 94 58 63 39 2.2 1.4- 3.4 Abdominal examination done 123 76 121 75 1.0 0.6-1.8 Injection Tetanus toxoid;:: 2 153 95 145 90 2 1 0.9- 5.0 Urine examination done during ANC 65 40 46 29 1.7 1.0- 2 7 Home visit by health worker during antenatal period 13 08 10 06 1.3 0.6-3.1 Adequacy of prenatal care utilization index ;:: 80% 58 36 23 14 3.4 20-58 Complication during antenatal period 34 21 31 19 11 0.7-1.9 ANC in private clinic 61 38 31 19 2.6 1 5-4.2 Previous plan for institutional delivery 107 67 17 11 16.8 9.2- 30 6
·~-
23
Table 2:. ~~sociation of past obstetrical hi$tory, m•..-n4\ ..• Ji~ •~trnf'•c:l health fa~i~Jl¥,~'!1(~~-1)9& .. 11 delivered in institutions and mothers delivered at home, Purulia distritt~ West Bengal, India, 200T
Frequency of expo:sure among mothers Odds ratio
Exposures Delivering Delivering 95% in institution at home confidence
(N=161) (N=161) Estimate Interval
# (%) # (%)
Obstetrical Birth order 2: 2 90 56 137 85 0.2 0.1-0.4 history Place of delivery determined by parents 60 37 80 50 0.6 0.4-0.9
Previous delivery at home 18 20 97 71 0.1 0.05-0.2
Maternal benefit Knowledge of Janani Surakshya Yojna (JSY) 140 87 125 78 1.9 1.0-3.5
scheme Received financial benefit of JSY before delivery 11 30 11 31 1.0 0.4-2.6 Knowledge of financial benefit for institutional delivery 114 71 101. 63 1.4 0.9- 2.3 Knowledge of financial benefit for referral transport 117 73 101 63 1.6 1.0-2.5
Health facility Nearest health facility < 5 km 47 29 36 22 1.4 0.9-2.4
Availability of night transport in the village 150 93 137 85 2.4 1.1-5.0
24
Table 3: Odds of exposures a.ccording to increasing gradient of e~Uf~ :V.tlli,"'b,~,, Pu.-"'lll.C\~~t~
India, 2007
Exposure
Education
Level
Illiterate Less than primary
More than primary
Socio-economic status Low (score <3) Medium (score 3- 5) High (score >5)
Number of ANC One
APNCUI*
Two Three Four or more
Inadequate (<50%)
Intermediate (50- 79%)
Adequate (80- 109%)
Adequate plus (;?:11 0%) t
*Adequacy in prenatal care utilization index
tNone of the study subjects belonged to Adequate plus group
" Chi-square for trend: 11.6; P-value: 0.0031 b Chi-square for trend: 23.6; P-value: 0.0000 c Chi-square for trend: 51.9: P-value: 0.0000 d Chi-square for trend: 20.4; P-value: 0.0000
I
Frequency of exposure among mothers
Delivering in Delivering at h0me
institution (n = 161) (n = 161)
# % # %
72 45 96 60
30 19 33 21
59 37 32 20
114 71 147 91
23 14 10 6 24 15 4 3
4 2 14 9 21 13 58 36
100 62 86 53 36 22 3 2
48 30 68 42
55 34 70 43
58 36 23 14
Odds ratio
Estimate 95%
Confidence interval
1
1.2 0.7-2.2
2.5 1.5-4.28
1
3.0 1.4-6.5 7.7 2.6- 23b
1 1.3 0.4-4.3
4.0 1.3-12.8
42 8.3- 212c
1
1.1 0.7-1.9
3.6 1.9-6.6d
25
~----~~ - 1111111111.....,11111111111111111111
Table 4: Logistic regression analysis of factors associated with institutional delivery Purulia district,
West Bengal, India, 2007
Exposure variables Crude Adjusted 95% confidence P value
odds ratio odds ratio interval
Antenatal check up :::: 3 4.4 3.1 1.5-6.5 0.0022
Adequacy of prenatal care utilization index (APNCUI):::: 80% 3.4 2.8 1.3-6.0 0.0073
Plan for institutional delivery 17 19 9.6-38 0.0000
Antenatal check up at private health facilities 2.6 4.2 2.1-8.6 0.0001
Literacy of the women 2.3 2.5 1.3-4.9 0.0087
26
Figure 1: Frequency distribution of reasons of not attending institution for delivery according to
mothers delivered at home, Purulia, West Bengal, India, 2007
Not customary 13%
LKk of time 18%
Others 6%
Not necessary
63%
27
~
Figure 2: Frequency distribution of reasons of attending institution fo:r delivery according to - ..... ~n
delivered in institutions, Purulia, West Bengal, India, 2007
Faded attempts at home
20%
Health personnel
<1clvice 35%
Others 40/
IV
S<.1fc.clelivcry 41%
rs
28
Annexure
Annexure 1: Map showing sampled sub-centres ~in Purulia district, West Bengal, India, 2007
I ~EENscr:~ District Purulia
*Sampled sub-centres
/ r_...--,__...,..._
~...,_.-.,. _(·-- l . NETURII\ }--w ( .-/'C....'"1RAGHUNAT·:s.J'•\ . " f/ \
aypJr\ / ......__ wr1 .. ~-j_.... J
r ...... ~- -~ ... -.. . I '·· --""'' >< ' J I F * .· L 1- PARA ~ ~SANTUFIII "\.1011 .. r--,. ,. . . =· .. ~- ' ' r .,JHALIY\'i ~+ 't,.,,C. -..J~'"" .• _j~ 71..-~. ..·, l ·, r""l- < f. + ~---\. * ' .I
) JHAlDA.I) / -.,.,(_ \ ~ I i'fl ~-~ r + ---"-'.) "·, ,~'~"'"k *" ~~,,~ ,, \ J-V ~ . ARSHA ~ '-, ,J ! . *·. r·· L.~ "":._ .~---......... , v r · r .. "'-> . HURA Jo..~ \ BAGMLNDII )'--.!.1. . UR.ULIJ>X_r* ~
,,_.-...." ( ~ .::k( * 'v/~ \ \ ~ ' ·~'- PANQM * \ . ) ~' ~
"--.., .. ' cBALARAMP f '\. -~r'"Vv:y'" "-· (r 7.. r BARABA ') \_ ~:J,. * ~~~AZAR 1 )
. --·v-~~ ~ . f /V~ 3( '\: ~MANBAZARII
/ vA ) '
( BUNDWAN r '\.. / ............
(Nq:>l'bttoScde)
29
Annexure 2: Schematic presentation of sampling
From each sub-centre
cases are selected
at random from the
list of mothers
delivered in
institution (n = 9)
District Purulia
Total number of sub-centres: 485
1 Random selection of 18 sub-centres
From each sub-centre
controls are selected
at random from the
list of mothers
delivered at
home (n = 9)
30
Annexure 3: List of selected sub-centres for the study of factors associated with institutional deliveries, Purulia district, West Bengal, India, 2007
Blocks
Barabazar
Chakaltore
Hura
Jhalda I
Jhalda II
Joypur
Kolloli
Kustaur
Para
Puncha
Raghunathpur
Sub-centres
Bansbera
Kalidasdih
Manara
Kalibari
Bispuria
Khamar
Kanki
Adardih
Joypur
Chapaitarh
Gamarkuri
Simla
Jahajpur
Udaypur
Panipathar
Napara
Nutandih
Sanka
Annexure 4: Identifiers collection form
Study on Factors associated with institutional delivery in rural areas of Purulia district, West Bengal, India, 2007
Community Block
Sub center
Village
Name ofthe head of household
House Number
Respondent's name
Serial number of questionnaires
Date of interview
Identification
Result status of questionnaires
Complete
Incomplete
Field checked by
Date of field check
Refused
Withdrawal
Absent
Dwelling locked
Quality control
Signature of investigator
32
Annexure 5: Informed consent statement
Greetings,
You know that maternal death and infant death are the main concern in our country. Though it is well establish that institutional delivery can reduce both maternal and infant mortality it is well away for general practices to utilize the facility for institutional delivery. I am (name of interviewer) and working with the department of health and family welfare of this district. We are look in to reasons that why people are not availing institutional delivery. Your response will help us to identify the problem and thus we will able to suggest improving the institutional delivery.
To find out the reasons behind the place of confinement, we need to ask you questions on your household, pregnancy, place of confinement, local health facilities and knowledge, attitude and practices regarding place of delivery. Thus, between and , we will be asking these questions to mothers who delivered a live I stillbirth baby during the period from August 2006 to July 2007 in selected households in selected villages. We would like to confidentially ask these questions. Answering these questions should take 20 minut-e. Taking part in this survey is voluntary. You can choose not to take part. You can choose not to answer a specific question. You can also stop answering these questions at any time without having to provide a reason. This will not affect your right to health care. However, taking part in the survey may benefit the community, as it will help us to understand the problem.
The information we will collect in this survey will be completely confidential. We will not write your name on the questionnaires form. We will only use a code instead. This key to this code will only be with principal investigator. It will be kept under lock and key. It will be destroyed after completion of the analysis.
If you wish to find out more about this survey before taking part, you can ask me all the questions you want. You can also contact Dr. Prasun Kumar Das, MAE scholar, NIE, ICMR at the telephone number +91 9434130398.
I have received sufficient information about the project, I have had opportunities to ask questions and these questions have been answered to my satisfaction. I consent voluntarily to this assessment and I understand I have the right to withdraw ~t any time without any consequence on the type of medical care I receive.
Date _______ _ Signature-----------
33
I
Annexure 6: Data collection instrument
Serial number of questionnaires
Status: 1- Case 2- Control
Part A I would like to ask a few questions about your household and socio economic status
Q No Question Answer with code
1 Age in yrs· Yrs
2 What is your religion? 1- Hindu
I
2- Musiim
3 - Christian
4- Others I -~-·--
3 What is your caste? 1 -Scheduled Caste
2 -Scheduled Tribe
3- Others
4 Do you have BPL card? 1- Yes
2- No
5 Are you doing any work? 1- Yes (aside from household) 2- No
6 Do you have any cash 1- Yes earning from work? 2- No
7 What is your husband's 1- No work occupation? 2 - Part time work
3- Full time work
8 What is your education? 1 -No education (illiterate)
2 - Studied up to class IV
3- Class V-class X
4 - Class X pass and above I
34
9 What is your husband's 1 -No education (illiterate) education? 2 - Studied up to class IV
3- Class V-class X
4- Class X pass and above
10 Which type of family you 1 -Joint belong to? 2- Nuclear
11 Number of total family members
12 Number of adults (above 18 yrs)
13 Do you have the following items and facilities in your household?
Pipe line water 1- Yes /
2- No
Toilet 1- Yes 2-No
Nori dirt floor 1- Yes 2- No
Electricity 1- Yes 2-No
Radio 1- Yes 2-No
Television 1- Yes 2-No
Telephone I mobile 1- Yes 2-No
Bicycle 1- Yes 2-No
Motorcycle 1- Yes 2-No
Gas for cooking 1- Yes
2-No
35
Part B: I would like to ask a few question about your past obstetric history
Q No Question Answer with code
14 What is your parity? 1- 1st
2- 2nd
3- 3rd
4-4th and above
15 What was the birth order of last child 1 -1st child
2- 2nd
3- 3rd
4-4th
5-5th and above
16 Number of living issue excluding the 1-0 last one 2-1
3-2
4 - 3 and above
17 What was the place of your previous 1 - Institution confinement prior to this one? 2- Home
3- Does not arise (1st child)
Part C: I would like to ask you a few questions regarding antenatal check up during last pregnancy
18 Did you have any antenatal check 1- Yes up? 2-No
19 Where you had gone for check up? 1 - Sub-centre I outreach camp
2 - Govt. Hospitals including RH /CHC /PHC
3- Private health facilities
4 - Other place -
36
20 Who did your check up?
21
22
23
24
25
26
27
28
During the entire pregnancy period how many times did you visit the health facility for antenatal check up?
In which time of pregnancy you had gone for ANC check up first?
In which time of pregnancy you had gone for 2nd ANC check up?
In which time of pregnancy you had gone for 3rd ANC check up?
In which time of pregnancy your last ANC done
When you were pregnant, did any health worker visit you at home for an antenatal check up?
How many months pregnant you were when ANM first visited you for an antenatal check up?
How many times did she visit you for an antenatal check ups during this pregnancy?
1 -Doctor
2 - ANM /GNM /PHN
3 - Quack and others
times ------
1 -Within 12 weeks
2- 13 to 16 weeks
3- 17 to 28 weeks
4 - After 28 weeks
1 -Within 12 weeks
2 -13 to 16 weeks
3- 17 to 28 weeks
4 - After 28 weeks -·---.. -~·---~--·-------
1 -Within 12 weeks
2- 13 to 16 weeks
3- 17 to 28 weeks
4 - After 28 weeks
1 -Within 12 weeks
2- 13 to 16 weeks
3- 17 to 28 weeks
4 - After 28 weeks
1- Yes
2- No
month
times
---
37
29 How many dose of tetanus toxoid 1 - 1dose given during pregnancy? 2 - 2 dose or more
3- No TT
30 How many iron tablets supplied for 1 - Less than 1 00 consumption during pregnancy? 2- 100 tabs
3 - More than 1 00
4-Nil
31 Did you have following performed at least once during ANC?
Weight 1- Yes
2-No
Height 1- Yes
2-No
Blood Pressure 1- Yes
2-No
Blood test 1- Yes
2-No
Urine test 1- Yes
2-No
Abdominal exam 1- Yes
2-No
32 Did you receive advice on any of the following at least once during ANC?
Diet 1- Yes
2-No
Danger sign 1- Yes
2- No
Institutional delivery 1 -Yes
2- No
38
Breast feeding
New born care
l Family planning
Institutional delivery
33 Had you suffered with any one of the following during antenatal period
Swelling of hands and feet
I Paleness
Bleeding
Visual disturbances
Convulsion
Hypertension
No foetal movement
34 Whether you were referred to any hospital I doctor for any of these complications during ANC?
1- Yes
2- No
1- Yes
2- No
1- Yes
2- No
1- Yes
2- No
1- Yes
1- Yes
1 2 No -
1- Yes
2- No
1- Yes
2- No
1- Yes
2- No
1- Yes
2- No
1- Yes
2- No
1- Yes
2- No
39
l
Part D: Place of delivery
35 ~· Which place you have planned for confinement?
I I !
1 - Medical institution
2- Home i
j3- No plan
36 Who took the decision in the family 1- Self about the place of confinement? 2- Husband
3- Both
4- Father-Mother /in laws
Part E: Knowledge, attitude and practice
QNo Question Answer with code
37 Which place of delivery is safe? 1 - Institution
2- Home
9 - Don't know
38 Did you know about Janani 1- Yes
Suraksha Yojana (JSY) fund? 2- No
39 Did you received financial 1- Yes
benefitofJananiSuraksha 2-No Yojana (JSY)?
40 If yes, 1 - Before delivery
When you receive the fund? 2 - After delivery
41 Did you know about referral 1- Yes
transport money? 2-No
42 Did you know about money for 1- Yes
institutional delivery? 2-No
40
43 From whom you come to know 1 -Doctor /Health worker /AWW about JSY and referral 2 - Panchayet member I Mukhia transport facility under RCH II
3 -Television
4 - Newspaper
5- Others (specify)
6- Does not arise
Part F: Now, I would like to ask you a few question regarding health facilities available in or near the village.
Question Answer with code
44 Availability of health facility in 1- Yes the village 2-No
45 Whether delivery conducted in \1- Yes that health facility 2- No
46 Availability of transport in the 1- Yes village 2- No
Thank you very much for your co-operation.
I
Annexue 7: Variable directory
Study on factors associated with institutional delivery in Purulia district, West Bengal (India), 2007
Variable dictionary
ld No
Identification number -··-
Status
Status of the respondent 1 =Case
2 =Control
Age
Age of the respondent years
Relig
Religion of the respondent ·1 =Hindu
2 =Muslim
3= Christian
4= Others
Caste
Caste of the respondent 1 = Scheduled caste
2= Scheduled tribe
3= Others
Edu
Education status of the respondent 1 = Illiterate
2= Up to class IV
3= Class V to X
4= X pass or more
Outwrk
whether the woman is employed in any type of work 1= Yes aside from her own housework 2= No
42
Outinc
Whether the woman is engaged in any incomegenerating activities
FamTyp
Type of family
TotMem
Total members in the family
AdltMem
Adult members In the family
FmlyDecs
Decision maker in the respondents family ..
HusEdu
Education of the respondent's husband
HusOcu
Ocupation of the respondent's husband
1 =Yes
2 =No
1= Joint
2= Nuclear
numbers ---
numbers ---
1- Respondent or her -husband
2= Father or mother in laws
3= Father or mother
4= Others
1 = Illiterate
2= Up to class IV
3= Class V to X
4= X pass or more
1 =Unemployed
2 = Seasonal/Part time
3= Throughout the year I full time
I
SocEco
Socioeconomic status of the respondent 1 =Low (score < 3)
, 2 = Medium (score 3-5)
I 3= High (score > 5)
BrthOrd
Birth order of the last child 1 =1 51 child
2 = 2nd or more
ANC
Antenatal check up done 1 =Yes
2 =No
ANCSC
I
Antenatal check up done at sub-centre 1 =Yes
2 =No
ANCGH
Antenatal check-up done at Government hospital 1 =Yes including RH/CHC/PHC 2 =No
ANCPC
Antenatal check up done at private health facilities 1 =Yes
2 =No
ANCOPL
Antenatal check up done at other places 1 =Yes
2 =No
ANCANM
Antenatal check up done by ANM 1 =Yes
2 =No
AN CDR
Antenatal check up done by doctor 1 =Yes
2 =No
44.
ANCQK
Antenatal check up done by quack
AN COP
Antenatal check up done by other persons
ANC1
First antenatal check-up
ANC2
Second antenatal check-up I
ANC3
Third antenatal check-up
LastANC
Last antenatal check-up
TotaiANC Total number of antenatal check-up
1 =Yes
2 =No
1 =Yes
2 =No
1 -Within 12 weeks
2 - 1 3 to 16 weeks
3- 17 to 28 weeks
4 -After 28 weeks
1 -Within 12 weeks
2 - 1 3 to 16 weeks
3- 17 to 28 weeks
4 - After 28 weeks
1 -Within 12 weeks
2 - 1 3 to 16 weeks
3- 17 to 28 weeks
4 - After 28 weeks
1 -Within 12 weeks
2- 13 to 16 weeks
3- 17 to 28 weeks
4 - After 28 weeks
1 = 1 2=2 3=3 4 = 4 and more
\ i
--'
APNCUI
Adequacy of prenatal care utilization index 1 = Adequate plus
2 =Adequate
3 = Intermediate
4 = Inadequate
TT
Number of tetanus toxoid injection during antenatal 1 = 1 period 2 = 2 or more
3 = No injection
IFA
Number of iron and folic acid tablets received 1 = <100 tablets
2 = 1 00 tablets
3 = >1 00 tablets
4 = No tablets
BP
Blood pressure measured during antenatal period 1 =Once
2 =Twice
3 = Thrice and more
4 = Not measured
WT
Weight measured during antenatal period 1 =Once
2 =Twice
3 = Thrice and more
4 = Not measured
AbdEx
Abdominal examination done during antenatal 1 =Yes check-up 2 =No
Blood Ex
Blood examination for haemoglobin estimation during 1 =Yes antenatal period 2 =No
46
Urine Ex I T 1 =~Yes .. ·~
Urine examination for protein estimation during antenatal period 2 =No
Anhv I
Home visits by ANM during antenatal period 1 =Yes
2 =No
FreqVisit
Number of home visits by ANM during antenatal times period
Diet
Received advice regarding diet during antenatal 1 =Yes period 2 =No
Dangersign +-
Received advice regarding danger sign of pregnancy 1 =Yes during antenatal period 2 =No
lnstDel
Received advice regarding institutional delivery 1 =Yes during antenatal period 2 =No
NBC
Received advice regarding care of the newborn 1 =Yes during antenatal period 2 =No
Beastfeed
Received advice regarding breastfeeding during 1 =Yes antenatal period 2 =No
FmlyPing --1 Received advice regarding family planning during 1 =Yes antenatal period 2 =No
Edema
Suffered from edema during antenatal period 1 =Yes
2 =No
Anaemia
Suffered from anaemia during antenatal period 1 =Yes
2 =No
Bleeding
Vaginal bleeding during antenatal period 1 =Yes
2 =No
Convulsion
Suffered from convulsion during antenatal peiiod 1 =Yes
2 =No
Vlisualimp
Suffered from visual impairment during antenatal 1 =Yes period 2 =No
HighBP
Suffered from high blood pressure during antenatal 1 =Yes period 2 =No
NoFoetalmov
Absent of foetal movement 1 =Yes
2 =No
Refer
Referred to any hospital or doctor for any 1 =Yes complications during antenatal period 2 =No
Plan Place
Place planned for confinement 1 = Medical institution
2 =Home
3 =No plan
I PlaceDes
II Decision maker in the family about the place of confinement?
SafePiace
According to respondent safe place for delivery
KgeJSY
Respondent's knowledge about JSY
I RecdJSY j
Received financial benefit of JSY
TimeJSY
Time of getting JSY benefit
KgeRT
Respondent's knowledge about financial assistance
of referral transport
KgeiD
Respondent's knowledge about financial benefit of
institutional delivery
11- Self I 12- Husband I l 3- Both
\4- Father-Mother /in 11aws I l
1 = Medical institution I
I 2 =Home I !
1 =Yes
r --·-·~~
I 11 =Yes
2 =No
1 - Before delivery
2 - After delivery
1 =Yes
2 =No
1 =Yes
2 =No
49
I I
I I
I I
--
I KgeSource
From whom information regarding financial benefit of 1 1 = Doctor /Health JSY, referral transport and institutional delivery worker /AWW
I received 2 = Panchayet member I Mukhia
3 =Television
4 = Newspaper
5 =Others
Distance
Distance of health facility from residence km
NightTrans
Whether transportation available during night at I
1 =Yes I respondent's village 12 =No
50
Section 2: Literature review
Review of literature
Severa! studies have attempted to identify and measure the effects of the
factors that contribute to differential use of maternal health services. Based on
data from NFHS-1, a multivariate analysis of utilization of maternal and child
health services in India and four major northern states concluded that
utilization of maternal and child health services in rural areas is driven
primarily by socioeconomic factors, such as education, media exposure, and
standard of living, that create a demand for services and much less so by
physical access to and availability of health and family welfare services [1 ].
It has also been pointed out that difference in household characteristics
influence the utilization of maternal health services [2]. This is partly because,
in developing countries, the decision to use any kind of health care for women
is made at the household level. Women's status is measured using three
indicators which include education, employment status and intra-household
decision-making power. Education of women is an important status indicator.
In general, women with higher education tend to have a better position in
society [3]. In some cases, however, education alone may not be sufficient to
increase women's empowerment.
Another study, also based on data from NFHS-1, found that woman's
education is a major factor affecting utilization of maternal health services in
both north and south India [4].
51
...
A number of other studies have stressed the role of socioeconomic and
demographic factors in influencing demand for and utilization of maternal and
child health services [5-14]. Many of these studies have also shown that
utilization of maternal and child health services are strongly affected by
woman's education. Other socioeconomic factors usually found to be
important are urban-rural residence, woman's work status, woman's status
relative to men, religion, caste/tribe membership, household standard of living
(or economic status of the household), and community development.
Women's employment is also considered an important factor in enhancing the
status of women [15]. Thus, we also include the employment status indicator
to measure women's status. In addition, women's involvement in intra
household decision making is used as another indicator of women's status.
Their ability to communicate with their spouses or other members of the family
indicates their decision-making autonomy. Women with greater decision
making power are presumed to have greater autonomy and a high status in
the household.
Although the decision to use health services is an individual choice and
related to individual characteristics such as . women's status, various
household characteristics may also act as determining factors in influencing
the individual decision. Particularly in the case of developing countries, the
decision to use any kind of health services is often made at the household
level. A woman cannot visit a clinic or hospital without the permission of her
husband, mother-in-law or the head of the household [3]. Thus, the effect will
depend on the type of households whether nuclear or extended type and
52
household size. On the one hand, in a nuclear family unit, there is less
pressure on the value of an obedient daughter-in-law than is often observed in
most joint families. Since value is placed on the individual's own abilities and
attributes, women in nuclear families may be more likely to take the initiative
in seeking care for themselves [16]. On the other hand, in nuclear
households, women's freedom is limited since they have to take responsibility \
for the full burden of housework, while there is much more sharing of tasks
between women in extended households, thereby enabling pregnant women
to seek care outside the home [17].
-Similarly, the effect of the sex of the household head has been debated. On
the one hand, female-headed households are more likely than male-headed
households to have a positive influence on health-seeking behaviour owing to
the greater autonomy and decision-making power of the female [2]. As a
result of their position, women who are household heads have more control
over the household's resources, part of which could be devoted to seeking
health services outside the home [17, 18]. However, female-headed
households are often poorer than male-headed households. They are usually
the sole providers for the household [18]. Thus, their lower economic status
might pose a burden to female-headed households in terms of seeking health
care services. Finally, we examine the economic status of the household as a
determinant of use of health services, because several studies have shown
the relationship between the use of modern health care and the financial
stability of the household [19, 20]
It has been argued that changes in women's status have been the key to
differentiate the behaviour of those seeking modern health care from those
following traditional practices [21]. In genera!, \Nomen with low status are less
likely to use modern facilities, whereas women with higher status take the
initiative in seeking care for themselves and their children [16].
Previous studies about home deliveries in urban and periurban areas of
Kathmandu have reported poor maternal education, multiparity and low
socioeconomic status as the predictors of home deliveries [22, 23].
It is well recognized that maternal health services have a critical role to play in
the improvement of women's reproductive health in developing countries [24-
26, 3]. It is also well known that the utilization of maternal health services is
undoubtedly influenced by the characteristics of the health delivery system
such as the availability, quality and cost of the services. However, this does
not necessarily mean that where there is a good supply of services, demand
is created in and of itself, which will then lead to increased utilization. Thus,
there has been considerable debate in the literature recently as to whether the
mere provision of health services will lead to increased utilization [24, 27, and
28]. It may be true that, even under the same condition of availability, some
women are more likely to use maternal health services than others. If so,
characteristics of the health delivery .system may not be the only explanatory
factors for the utilization of maternal health services. Other factors such as the
social structure and characteristics of individuals should also be considered in
promoting the utilization of maternal health services.
Studies on health-seeking behaviour have identified the importance of the
characteristics of health services such as the availability and accessibility of
services to the general population in determining increased utilization [24, 26,
and 29]. The focus of such studies is mainly on the supply side of services;
increasing the availability and accessibility of the health services is sufficient
to increase utilization [7, 30, and 31 ]. However, other studies argue that the
mere existence of health services is not enough to lead to better utilization
[28]. Since health care is a consistent choice of individuals, the factors that
change women's perception of the available alternatives and their motivation
to seek care need to be understood properly. In the case of preventive health
care such as maternal health services, women must realize the potential
benefits of utilizing the services.
Elo in 1992 found quantitatively important and statistically reliable estimates of
the positive effect of maternal schooling on the use of prenatal care and
delivery assistance. In addition, large discrepancies were found in the
utilisation of maternal health~care services by place of residence [7].
In rural Nigeria, maternal education and occupation, religion, and occupation
of the husband are found to be most consistently associated with the use of
health institutions for delivery - at the same time maternal age, parity, and
marital status and place of the residence are not significantly associated [32].
In a Ugandan study, it was shown that access to maternity services is one of
the influencing factors in choice of delivery site [33]. In most of these studies,
low socio-economic status of the women measured by different variables
individually or by combining information from several variables is implicated
as being a predictor for home delivery.
A review of the literature reminds us that there is no consensus on the
definition of socio-economic status and there are longstanding debates on its
measurement [34-36]. Composite measure of education, income and
occupation is classically used in Great Britain as a constructed variable of
social class for studying general health issues. A household social class
measure is proposed to serve as a better predictor of reproductive outcomes
and economic level, than does individual social class standing [37]. The
distance to the maternity hospital has been reported to be more important in
maternity care than other general curative health services [38].
In a study conducted by the Ministry of Health, Nepal (Department of Health
Services, 1998) showed that among districts, there is also a wide variation in
the number of prenatal visits made by women and the use of prenatal
services was high (30 to 80 per cent) in 25 districts of Nepal and low (less
than 10 per cent) in nine districts. Districts with low utilization are scattered
throughout the country. Furthermore, the higher utilization of maternal health
services was not confined to the regions where maternal health services are
more accessible.
Some studies have stressed the importance of access to health services as a
factor affecting the utilization of services [31, 39- 41]. Historically, improving
access to services has been a primary strategy for increasing health-service
utilization in developing countries. In recent years, field experience and data
from both qualitative and quantitative studies have indicated that
56
improvements in the quality of services can further increase service utilization.
Programmes that maximize quality as well as access to services enhance
client satisfaction, leading to greater utilization [42 and 43]. !t is argued that
access helps determine whether an individual makes contact with the
provider, while quality of care influences a client's decision whether to accept
and use the service or to continue using the service [44]. Many of the above
studies have stressed outreach programmes, including home visits, mobile
clinics, and community-based delivery systems, as mechanisms to increase
both the quantity and quality of services. Although quality of services is often
mentioned as an important factor in the utilization of health services [45 - 48],
much of the research on this subject refers to family planning services rather
than institutional delivery (43, 49 ~ 58]. Some studies have presented
evidence that the effects of inadequate access to services on utilization of
services are greater than the effects of socioeconomic factors [7 and 59] and
that as access to public health facilities improves, the effects of
socioeconomic factors on utilization of services become less important [4,30].
Other studies argue that lack of motivation is the major factor in nonutilization
of services, and that provision of services alone cannot overcome lack of
motivation or demand for services [5].
A study done by K. S. Sugathan, and others based on data from India's first
and second National Family Health Surveys (NFHS-1 and NFHS-2) indicated
that, even after statistically controlling for other factors, mothers who received
antenatal check-ups are two to five times more likely to give birth in a medical
institution than mothers who did not receive any antenatal check-up [60].
57
Among the other factors considered, mother's age and education and child's
birth order also have strong effects on the likelihood of institutional delivery.
Older mothers are somewhat less likely to give birth in a medica! institution
than younger mothers. It also shows that first-order births to rural mothers are
much more likely to take place in a medical institution than second or higher
order births. Contrary to expectation, access to health services, as measured
by availability of a hospital within 5 km of the village and by availability of an
all-weather road connecting the village to the outside, does not have .a
statistically significant effect on institutional delivery in most cases.
A study carried out in Kathmandu reported 'cost' and 'convenience' as the
reasons for delivering at home [22]. Thus low socio-economic status and the
long physical distance of more than one hour to the maternity hospital acted
as barriers to hospital delivery[23].
In a study of Nepal [61], 58% of all home deliveries were planned and in 65%
of these planned home deliveries the reasons cited by the mothers were 'I
prefer home delivery', 'home delivery is easy and convenient' and 'all my
previous deliveries were at home'.
Although the debate on the safety and women's right of choice to a home
delivery vs. hospital delivery continues in the developed countries, an
undesirable outcome of home delivery, such as high maternal and perinatal
mortality, is documented in developing countries [62, 63]. A study in Tanzania
showed that in home births conducted without a trained attendant; the
perinatal mortality was three times higher than that for hospital or dispensary
births with trained attendants (64]. In Papua New Guinea, a high rate of
58
obstetric complications was found amongst seemingly normal pregnancies
delivering at home [65]. The Dutch system is an exception to the rule in the
developed countries, as it is still based on the idea that women with low-risk
pregnancies are free to choose where to give birth to their children. And in
1991, 35% of all Dutch babies were born at home [66]. Dutch perinatal
mortality statistics are comparable with that in the Scandinavian countries,
and are uninfluenced by the relatively high proportion of home deliveries [67].
In a Norwegian study, it was reported that the safety of low-risk women while
delivering in small maternity clinics run by midwives with a general practitioner
as the forma! leader, was unquestionable and that a decentralised birth
organisation should be offered to a low-risk population is more a question of
politics, than a medical problem [68]. At the same time, in the U.S., where
automobiles and highways are plentiful, it has been shown that geographical
inaccessibility to obstetric care is associated with more frequent negative
pregnancy outcomes. Women who live in communities with poor access to
antenatal and obstetric services are likely to bear infants who are premature
and have prolonged hospitalisations with higher costs or both [69].
As this brief review of literature illustrates, previous research provides
conflicting evidence on the relative importance of programmatic (supply) and
nonprogrammatic (demand) factors affecting health-seeking behaviour. Also,
there is little research on how utilization of one type of health service might
affect utilization of other types of health service.
59
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