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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