UTILIZATION OF ANTENATAL CARE SERVICES, CHILD SURVIVAL AND THEIR RELATIONSHIP IN TWENTY FIVE STATES OF INDIA

Anil Kumar G

Dr. ANIL KUMAR. G, Ph. D
Center for Public Health Research,
Administrative Staff College of india ,

Address for Correspondence & reprints

Dr. ANIL KUMAR. G, Ph. D
Consultant Bio-statistician
Center for Public Health Research,
Administrative Staff College of india ,
Bella Vista , Raj Bhavan Road
Hyderabad – 500 082
akgkerala@gmail.com/ akgkerala@yahoo.co.in

Abstract:

It is useful to conduct periodic assessment of the utilization of antenatal care and its impact on child survival. Hence it is imperative to study the relationship between child survival and utilization of antenatal health care services. The second National Family Health Survey conducted in 1998-99 is used to measure utilization of antenatal care services and its relationship with child survival in twenty-five states of India . This survey collected information from a national representative sample of more than 90,000 ever-married women aged 15-49years. In addition, it collected information about 32,393 children born during the three years preceding the survey. An index was constructed for measuring the utilization of antenatal care and child survival by using child mortality rates. The study reveals that there is a wide disparity in utilization of antenatal care services across various states in India . Utilization of antenatal care services is very low in the east, north, central and northeast regions of India as compared to western and southern regions. Also the child survival rate in the twenty-five states was higher in the southern states, although it was low in the other parts. Based on the findings of the study, it is suggested that active interventions be made to improve the utilization of antenatal care by creating proper awareness regarding the health facilities which are available in these regions and give more education on how and when to utilize these services.

Introduction: -

            The plan of action endorsed at the International Conference on Population and Development in September 1994 appropriately recommended that the reproductive health care within the context of primary health care should include education and services for prenatal care, safe delivery and postnatal care (UN, 1994). Reproductive health is multidimensional and associated with various life cycle events of women such as menarche, marriage, pregnancy, child birth and menopause. However, the health risk during these periods is caused by multiple factors related to behaviour, environment, social and policy level effects and efforts.

            Antenatal health care services have a key role in enhancing child health and survival of children. Their utilization is very much concerned with the extent to which personal determinants of health and health behaviour affect the use of these services. Complications of pregnancy and childbirth are believed to be the leading obstacles to child survival in most developing countries. Appropriate and timely antenatal care will help to reduce many of the pregnancy related problems (Jayasree et al, 1997).

            As child mortality is definitely a syndrome of failure and neglect of women and community, many health service related factors like poor coverage and lower quality of antenatal care, lack of trained assistance during delivery, lack of referral and transport systems are some of the major reasons for improper child survival (J Hobcraft, 1993, MOHFW, 2000, Nair, M.K.C, 1998). With the enhancement of antenatal care and child survival concept, India has given ample importance to reproductive and child health programmes especially antenatal care for achieving optimal child survival. Since this programme primarily focuses on efforts to improve child survival, maternal health aspect has to some extent suffered from relative neglect in this programme (Pachauri, 1995).

            In this paper an attempt has been made to examine the relationship between child survival and utilization of antenatal care services with the help of variables such as mothers receiving at least one antenatal check-up, mothers receiving two or more tetanus toxoid injections, mothers receiving iron and folic acid tablets or syrup, deliveries in medical institutions and deliveries assisted by a health professional. This paper also analyses a) the pattern of child survival and utilization of antenatal health care services at state level, and b) the relationship between child survival and utilization of antenatal health care services.

Materials & Methods: -

Database: -

Data from the National Family Health Survey II for the twenty-five states in India has been used for this analysis. The second NFHS conducted in 1998-99 collected information from a national representative sample of more than 90,000 ever-married women aged 15-49years. Information from 91,196 households in the 25 states was collected and 89,199 eligible women in these households were interviewed. In addition, the survey collected information about 32,393 children born during the three years preceding the survey (IIPS, 1999).

Methodology: -

In this paper attempt has been made to measure the relative position of selected Indian states in terms of utilization of antenatal health care services and child survival. An index has been constructed to measure the utilization of antenatal health care services. The index ranges from 0 to 100 with higher values denoting better utilization of antenatal care services  (Gandotra, 1988).

            It is computed by transferring each value of the indicators of antenatal care to a ratio. It is obtained by dividing the difference between each value and the minimum value by the entire range of variation in these indicators. If X_ij is the selected indicators of antenatal care services, then

where i = 1,2,3…25, selected states

                                                            j = 1,2,…..5 selected indicators

            Following this transformation to standardize all the values, a weighted average was computed by considering a set of indicators for measuring utilization of antenatal care services, where weights were given to each indicator according to the coefficient of variation. Coefficient of variation (CV) being a pure number could be used for comparing the variation of two or more distributions given in different units. The series having lesser Coefficient of variation is said to be more consistent than the others. Hence the weights are assigned as 1/CV. Such a weighted average is very much needed to make a sound index as each of these indicators has different extent of variation across Indian states. So a composite index is essential to know the overall utilization of antenatal care services in India . Hence the index is

              The   basic measure of infant and child survival is the under five mortality (number of deaths under the age of five years per 1000 live births). A child survival rate per 1000 births can be simply calculated by the formula (Park, 2002).

            To examine the relationship between utilization of antenatal care services and child survival, contingency coefficient analysis and linear correlation analysis were used. The median (middle score) indicates the central tendency of the data (Cohen, 1982). All the twenty five states were then classified into four groups by comparing state wise child survival rate and utilization of antenatal health care services index with their medians. The contingency coefficient (C) has been widely used to indicate the association between two variables in a 2 x 2 contingency table. The contingency coefficient can be calculated by the formula (Cohen, 1982).

            Where C is the contingency coefficient

                         N, Sum of the observed frequency for any cell in Table

                         χ2 Chi-square was calculated as 

                                      where O = Observed frequency for any given cell in table

                                                 E = Expected frequency for any given cell in table

Also, the correlation analysis was employed to examine the linear relationship between utilization of antenatal health services and child survival. For this purpose, Karl Person’s Correlation Coefficient was employed.

Results: -

            The child survival rate and utilization of antenatal health services index in each of the twenty-five states have been shown in Table: 1. The child survival rates in the twenty-five states were rather high ranging from 86.2 (Madhya Pradesh) to 98.1 (Kerala). However, the northern Hindi Belt states the rate was ranging from 89.5 ( Bihar ) to 86.2 (Madhya Pradesh). In the southern region of India rate is high in Kerala and low in Andhra Pradesh (91.5). This variation is because of the inequalities seen in child mortality rate in different regions. These inequalities might be due to improper child rearing practices among women in these areas. Moreover a large proportion of the female population in northern regions was either semi-literate or illiterate. They had limited knowledge of care for children and on how to utilize the health services effectively. This may be the reason for the lower child survival rate in northern regions compared to southern regions. It is expected that the health status of children in these areas would definitely be promoted with intensive and appropriate health education.

             The utilization of antenatal care services in the twenty-five sates ranged from 96.81 (Kerala) to 11.74 ( Bihar ). The median index value of utilization of health services is 56.67. From this it is noticed that twelve states had, as might be expected, relatively high index value. All the northern states are in the low status category except Delhi . Among the “BIMARU” states Madhya Pradesh has the highest index value whereas Bihar has the lowest value. The unexpected point to be noted here is that the receipt of antenatal check-up was significantly lower among north, east and northeastern states as against western and southern states.

            The contingency coefficient has been used to indicate the association between child survival and utilization of antenatal care services. The contingency coefficient shown in Table: 2 suggest that there is significant association exists between the child survival and utilization of antenatal services. As the utilization of antenatal care increased, child survival also increased. Similarly the Pearson correlation coefficient value shows that utilization of antenatal care services has a significant positive effect on child survival. These two variables are highly correlated (0.742). As shown in Table: 3 the twenty-five states were divided into four groups. Among the thirteen states with relatively high utilization of antenatal services, ten also has relatively high child survival rate. Nevertheless, another three states relatively had low child survival rate. Moreover, among the twelve states with relatively low utilization of antenatal care services, three had relatively high child survival rate (see Graph 1). As per the usual assumption, the increase in the utilization of antenatal care was an absolute necessity and a sufficient pre-condition for increasing child survival. However, in the present study some of the states with relatively high utilization of antenatal health care services confirm that increasing the utilization of antenatal care does not necessarily increase the child survival. On the contrary states with relatively low utilization of antenatal health care services have relatively high child survival rate. Thus it is observed that these states do not confirm to the widespread assumption that better antenatal care ensures greater child survival. This implies that there may be other factors which either directly or indirectly affects child survival.

 Discussion: -

            Antenatal care services utilization index in the twenty-five Indian states was ranged between 96.81 (Kerala) and 11.4 ( Bihar ). It is seen that there were significant regional differences in utilization of antenatal care services among these states. Also the child survival rate in twenty-five states was still rather high in southern and western regions, although it was low in the other regions. Among the thirteen states with relatively high utilization of antenatal services, ten also has relatively high child survival rate. Nevertheless, another three states relatively had low child survival rate.

            It is to be seen whether there may be certain cultural factors besides socio-economic factors, which may affect the utilization of antenatal services. It appears that these features also evaluated by states quarterly. Village level meetings can be conducted by state administrators and educate community about the importance of effective utilization of MCH services. In the light of these results, it may be suggested that awareness regarding utilization of health care in general and antenatal health care in particular needs to be created in the north, east, central and north-east regions. Adults as well as couples in the reproductive ages need to be effectively catered to in order to achieve a spectrum of benefits in the field of child health and survival. Finally, because of state differences in child survival with respect to the utilization of antenatal services levels and performance in India, stratified reproductive and child health policies are needed that take in to account state specific and demographic patterns and key determinants of child survival and utilization of antenatal care services. In this context priority should be accorded to states like Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh, Orissa, Hariyana, Arunachal Pradesh, Meghalaya, and Assam , which are more or less stagnating with, lows utilization of antenatal care service with low child survival.

Acknowledgement

            The author would like to express his thanks to Dr. K. Krishna Kumari, Reader In-charge, Department of Demography, University of Kerala, Kariavattom, Trivandrum, and Dr. M. Danabalan, Professor & Head, Department of Community medicine, Mahatma Gandhi Medical College & Research Institute, Pondicherry for their valuable suggestions for making this article.

References

1.       United Nations, (UN), 1994, International Conference on Population and Development (ICPD), Programme of Action, New York : United Nations.

2.       Jayasree, R and Jayalakshmi, 1997, Reproductive Health Status of Rural Women an Empirical Analysis: Paper presented in IASP Conference , India .

3.       Hobcraft John, 1993, Women’s education, Child Welfare and Child Survival: A Review of the evidence, Health Transition Review 3: 159-175.

4.       Ministry of Health & Family Welfare, 2000, Department of Family Planning, Child Health Division Newborn Health Key to Child Survival.

5.       Nair, M.K.C, 1998, Monograph on Early Detection and Development Delay 0-5 years, CDC, Thiruvanthapuram.

6.       Pachauri Saroj, 1995, Defining a Reproductive Health package for India : A Proposed Frame Work South and East Asia Regional Working Papers $; New Delhi , The Population Council.

7.       International Institute of Population Science (IIPS), 1999, National Family Health Survey (NFHS- 2), India , 1998-99, International Institute of Population Science, Mumbai. MEASURE DHS+, ORC MACRO, Calverton , Maryland , USA . December.

8.       Gandotra, M.M, Padhiyar, A.C et.al, 1988, Interrelationship between Development and Fertility, Demography India, 17 (1):19-20.

9.       Park, K, 2002, Text Book of Preventive and Community Medicine, 17^th edition.

10.   Cohen, L and Holliday, M, 1982, Statistics for Social Scientists, London , Harper and Row.

 

Table: 1

State Wise and Rank Wise Utilization of Antenatal Care Index and Child Survival Rate – India

 

 

 

 

Table 2. Association between Utilization of Antenatal Care and Child Survival in India

 

*Contingency Coefficient is significant at the 5% level

† Correlation is significant at the 1% level.

 

Table 3. Classification of the Twenty Five States in India according to Utilization of Antenatal Care and Child Survival

CSR   Utilization index	Less than Median	Grater than or Equal to median
Less than Median	Orissa Hariyana Arunachal Pradesh Madhya Pradesh Rajasthan Uttar Pradesh Meghalaya Bihar Assam	Mizoram Manipur Nagaland Sikkim
Grater than or Equal to median	Jammu & Kashmir Gujarat Andhra Pradesh	Kerala Tamil Nadu Karnataka Himachal Pradesh Maharashtra Goa Delhi West Bangal Punjab