Evaluation of the effect of socio-demographic factors on antenatal care practices in urban slums of Amritsar city, Punjab (India).

Gill KP1, Devgun P2

1. Dr Kanwal Preet Kaur Gill (MBBS,MD), Assistant Professor, Department of Community Medicine, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar 2. Dr Priyanka Devgun (MBBS,MD), Professor and Head, Department of Community Medicine, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar Correspondence e-mail: kpreet224@gmail.com ABSTRACT Objective: The study was conducted to explore the antenatal care practices adopted during pregnancy and the socio demographic factors influencing these practices in various slum areas of Amritsar city in Punjab. Methods: A total of 30 clusters of 7 units each were taken to make a sample of 210 units. The women who had delivered within one year before the interview were taken as study units. They were interviewed with the help of a pretested proforma and regression analysis was applied to evaluate the effect of various socio-demographic factors on antenatal care practices. Results: It was observed that 73% of women contacted a health provider at least once but only 42.4% of them had adequate number of antenatal checkups. While 89.5% of them were immunized against tetanus only 21.4% of women were taking Iron folic acid tablets regularly. Regression analysis showed that literacy of the
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women, literacy of their husbands and socio-economic status of the household were significant factors determining the antenatal care practices. Conclusion: Improving literacy and socio-economic status of households can help us to provide better antenatal care to mothers. Key words: Antenatal care, practices, slums. INTRODUCTION

Pregnancy and its complications continue to claim the lives of over 1000 women in low and middle income countries every day. Many women suffer from long term disabilities developed during pregnancy and childbirth.1 About 15% of all pregnant women develop obstetric complications in the form of haemorrhage, pre-eclampsia and eclampsia, obstructed labour, sepsis, ectopic pregnancy etc. As the obstetric complications cannot be predicted and prevented, all pregnant women need access to good quality antenatal care.2 Antenatal period offers opportunities to reach out to pregnant women requiring intervention that may be vital for their health, their wellbeing and that of their infants. It also provides a route to ensure that pregnant women deliver with the assistance of a skilled health provider.3 The percentage of women having antenatal care during pregnancy is also one of the indicators of Millennium Development Goals. But unfortunately, in urban slums the condition of maternal health with regard to antenatal care during pregnancy is worse in comparison to non-slum population. It is disheartening to know that just 54% of pregnant women in slums have at least three antenatal visits in comparison to 83 % in non-poor urban areas. Only 18% take Iron Folic Acid (IFA) Tablets for more than 90 days whereas the figure for urban non-poor is 40%. Similarly, Tetanus Toxoid is taken by only 76 % women in urban slums which is far less than 91% in urban non2

poor.4 This makes it pertinent to study various determinants affecting these antenatal care practices in slums so that the required measures can be introduced to improve their health. With this aim, the present study was conducted to explore the antenatal care practices and the socio demographic factors influencing these practices in urban slums of Amritsar city in Punjab.

MATERIAL AND METHODS According to the records available in the Office of Municipal Corporation Amritsar, there are 108 pockets of slums in the city of Amritsar. By adopting cluster sampling, 30 clusters of 7 units each were taken up for study making a total of 210 study units. Study units were women who had delivered within one year at the time of interview. Those women were interviewed with the help of a pretested proforma. Modified Udai Pareek (MUP) scale was used to assess the socio-economic status of the study subjects. The data was compiled and analyzed with the help of SPSS 15.0 v for windows . Crude and adjusted odds ratios (ORs) with 95% confidence interval (CI) were generated by univariate and multivariate logistic regression analysis for adequate antenatal care against various socio-demographic factors. The factors found to be significant on univariate analysis were further studied by applying multivariate analysis whereas those found to be insignificant on univariate analysis were discarded.

RESULTS Table - 1. Distribution of households according to their profiling features Parameters Nativity Native Migrant Identity proof Yes No Caste Scheduled caste Others Type of family Nuclear Joint Socio-economic status Upper Upper middle Lower middle Lower No. (n=210) 95 115 148 62 167 43 110 100 12 40 90 68 Percentage 45.2 54.8 70.5 29.5 79.5 20.5 52.4 47.6 5.7 19.0 42.9 32.4

Table-1 describes the profiling features of households. As is evident from table, 45.2% of study subjects claimed themselves to be natives while 54.8% were migrants. In all, 29.5% of the respondents did not have any identity proof like voter card or ration card. Respondents belonging to the scheduled castes were to the tune of 79.5%. 52.4% of the women were living in nuclear families. 75.3% of the households were put in lower and lower middle socio-economic class whereas only 24.7% of them qualified to be categorized as upper middle and upper class.

Table 2: Distribution of respondents according to socio-demographic characteristics Parameter Current Age <20 20-30 >30 Age at marriage <15 15 -18 >18 Education No schooling Below matriculation Matriculation Graduate Postgraduate Occupation Working Housewife Husbands education No schooling Below matriculation Matriculation Graduate Postgraduate Parity 1 2 No. (n=210) 19 179 12 19 65 126 131 52 20 07 0 61 149 118 50 34 8 0 77 133 Percentage 9.0 85.3 5.7 9.0 31.0 60.0 62.4 24.8 9.5 3.3 0 29.0 71.0 56.2 23.8 16.2 3.8 0 36.7 63.3

Table -2 elucidates socio-demographic characteristics of respondents included in the study. 85.3% were belonging to 20-29year of age. Also, 40% of study subjects got
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married before the age of 18 years and 9% got married before attaining 15 years of age. More than 60% (62.4%) of them did not go to school for formal education. Only 3.3% studied up to graduation level and no one could continue her education to postgraduation level. Among all respondents, 29% were involved in income generating activities. Education status of husbands of study subjects was a little better than women. Though more than half of them did not enter school, 16.2% of them studied up to matriculation and 3.8% of them were graduates. Parity of nearly two third of women was two or more. Table 3: Distribution of women according to antenatal care practices Practice Planned pregnancy Yes No Minimum one antenatal checkup Adequate No. of antenatal checkups* Iron folic acid tablets Yes No Yes No Yes No If yes, Regularity Regular Irregular TT immunization Yes No No. (n= 210) 136 74 154 56 89 121 110 100 45 65 188 22 Percentage 64.8 35.2 73.3 26.7 42.4 57.6 52.4 47.6 21.4 31.0 89.5 10.5

* Minimum four ANC were taken as adequate.

Table - 3 shows antenatal care practices of women. Among 210 women, about one third (35.2%) pregnancies were unplanned. Though about three quarter (73.3%) of respondents contacted a health provider at least once, less than half (42.4%) of them had adequate number of antenatal checkups. Iron folic acid (IFA) tablets were taken by 52.4% of women and only 21.4% took the tablets regularly. Nearly ninety percent (89.5%) of study subjects were immunized against tetanus. Table 4: Distribution of women according to reasons for not having adequate number of antenatal checkups, IFA and TT immunization Reasons Antenatal checkups (121) No perceived need Nobody to accompany Economic constraints Others (younger child at home, mother-in-law/ husband not willing) IFA (100) No perceived need Bad taste, caused nausea Economic constraints Hot, lead to abortions No. 46 42 27 06 Percentage 38.0 34.7 22.3 5.0

45 29

45.0 29.0

11 06

11.0 06.0 09.0

Others (leads to big baby, 09 decrease appetite etc) TT immunization (22) No perceived need Migration Others (No body to accompany) 11 08 03

50.0 36.3 13.7

Table - 4 illustrates that no perceived need is the commonest reason for not having antenatal care (38.0%), Iron Folic Acid tablets (45.0%) and Tetanus Toxoid vaccination (50.0%). For not having adequate antenatal care, other common reasons described by study subjects were nobody to accompany (34.7%), and economic constraints (22.3%). Similarly, bad taste (29.0%), economic constraints (11.0%) and considered hot hence causing abortions (6.0%) were common reasons for not taking IFA Tablets. For not getting Tetanus vaccination, their migration was the second common reason (36.3%).

Table 5: Odds ratios obtained from logistic regression analysis of adequate number of antenatal checkups in relation to socio-demographic factors Parameter Adequate no. of ANC Yes (n=89) No. (%)
Nativity Native (95) Migrant (115) ID Proof Yes (148) No (62) Caste Upper (43) Lower (167) Socioeconomic status Type of family Age in years Education of mother Husbands Education Parity Upper (52) Lower (158) Joint (110) Nuclear(100) <20 (19) 20 (191) literate (79) Illiterate (131) Literate (92) Illiterate (118) < 2 (77) 2 (133) Planning of pregnancy Planned (136) Unplanned (74) 53(55.8) 36(31.3) 75(50.7) 14(29.5) 21(48.8) 68(40.7) 39(75.0) 50(31.6) 54(49.1) 35(35.0) 04(21.1) 85(44.5) 57(72.2) 32(24.4) 61(66.3) 28(23.7) 44(57.1) 45(33.8) 70 (51.5) 19 (25.7)

No (n=121) No. (%)

42(44.2) 79(68.7) 73 (49.3) 48 (70.5) 22 (51.2) 99(59.3) 13(25.0) 108(68.4) 56(50.9) 65 (65.0) 15(78.9) 106(55.5) 22(27.8) 99(75.6) 31(33.7) 90(76.3) 33(42.9) 88(66.2) 66 (48.5) 55 (74.3)

Crude OR (CI)*

p Adj. value OR (CI)

p value

2.7 (1.64.9) 3.5 (1.86.9) 1.4 (1.23.4) 6.5 (3.213.2) 1.8 (1.023.1) 0.33 (0.100.8) 8.0 (4.3 15.0) 6.3 (3.511.6) 2.6 (1.54.6) 3.07 (1.75.7)

<0.01

1.10 (0.542.2) 2.4 (0.65.9) 1.2 (0.85.6) 2.25 (1.55.5) 0.6 (0.281.28) 0.35 (0.091.3) 3.2 (1.367.57) 2.52 (1.135.6) 1.57 (0.733.3) 1.74 (0.793.86)

0.77

<0.01

0.6

<0.05

0.06

<0.01

<0.05

<0.05

0.18

<0.05

0.12

<0.01

<0.01

<0.01

<0.05

<0.01

0.24

<0.01

0.16

* OR (CI) Odds Ratio (Confidence Interval)

A perusal of Table 5 shows that on univariate analysis, nativity, Identity proof, caste, socio-economic status of women, type of family, age of women, literacy status of women and their husbands, parity and pre-planning of pregnancy had

determining effect on antenatal care practices of the mothers. Native women are 2.7 times more likely to have adequate antenatal care [OR- 2.7, CI-1.6- 4.9, p -< 0.01] and the same is true for women having identity proof (OR=3.5, CI=1.8-6.9, p=<0.01) and women belonging to upper castes (OR=1.4, CI=1.2-3.4, p=<0.05). Similarly socioeconomic status of women had a significant effect on antenatal care of mothers (OR=6.5, CI=3.2-13.2, p=<0.001). Women residing in joint families(OR=1.8,

CI=1.02-3.1, p= <0.05) , equal to or more than 20 years of age (OR=0.33, CI=0.100.8, p=<0.05), literate women (OR=8.0, CI=4.3 15.0, p=<0.05), women having literate husband (OR=6.3, CI=3.5-11.6, p=<0.01), parity less than two (OR=2.6, CI=1.5-4.6, p=<0.01) and pre-planning of pregnancy (OR=3.07, CI=1.7-5.7, p=<0.01) had also a significant positive effect on antenatal care of women. But, on multivariate analysis, literacy of women and of their husbands and socio-economic status remained significant factors whereas others transpired to be insignificant. Literate women were 3.2 times more likely to have adequate number of antenatal checkups. Similarly women whose husbands were literate were 2.5 times more likely to have adequate number of antenatal checkups and the same was true for those who were belonging to upper socio-economic status (OR-2.25, CI-1.5-5.5, p< 0.05). DISCUSSION: Generally, slum dwellers are migrants to the city from the far off places. In the present study too [Table -1], more than half (54.8%) of the respondents were migrants from other states. Similar findings were observed in another study of slum
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of Karampura, near Rattan Singh Chowk in Amritsar where 48.4% of respondents were found to be migrants.5 More than one quarter (29.5%) of study subjects did not have any identity proof in the form of ration card or voter cards, depriving them of the basic facilities thus. There is a higher concentration of households belonging to the scheduled castes in slum areas in all cities.6 In the present study too, more than three quarter (79.5%) of the respondents belonged to scheduled castes. Findings are also in conformity with another study in the slums of Amritsar where 72% of slum dwellers were found to be belonging to scheduled castes.7 The trend of nuclear families, which is so prevalent in the modern urban population, has shadowed the slum population too. In the present study, the nuclear families (52.4%) had a little edge over the joint families (47.6%). National Family Health Survey III
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results have also shown that in the slums of Mumbai and Indore,

59% respondents were living in the nuclear families and the figure was even higher in the slums of Chennai i.e.70%. As expected, socio-economic status of households does not reflect any encouraging picture. Three quarter of study subjects (75.3%) belonged to the lower socio-economic class (MUP Scale). Table 2 elucidates socio-demographic characteristics of respondents included in the study. A majority of women (85.3%) belonged to 20-29year of age indicating high fertility rates in this age group. Also, 40% of study subjects got married before the legal age of marriage i.e.18 years. So much so that 9% of total study subjects got married before reaching 15 years of age. NFHS III Results has also shown that 51%

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women among urban poor got married before 18 yrs of age whereas the figure for urban non-poor is 21%.4 The education level of study subjects was alarmingly low. More than 60% (62.4%) of them did not go to school for formal education. Only 3.3% studied up to graduation level and no one could continue her education beyond that. NFHS III results also reported the similar findings. More than three quarter of poor women in Delhi (82%), Meerut (81%) and Kolkata (77%) had a little or no education.6 In Ahmadabad city, in a study of slums, it was reported that nearly half (i.e. 49.2%) of the women were illiterate. It was also revealed that among literate women, only 29% got education up to higher secondary level and merely 2% were graduate.8 Among all respondents, 29% were involved in income generating activities. Similar findings were reported in a study of slums in Pune where it was observed that 28% women in the age group of 15 65yr were engaged in income generating activities.9 Education status of husbands of study subjects was a little better than women. Though more than half of them (56.2%) never went to school, 16.2% of them studied up to matriculation and 3.8% of them were graduates. Parity of nearly two third of women was two or more. Improving antenatal care is the important indicator to achieve universal access to reproductive health (MDG-5). Immediate and effective professional care during pregnancy can make the difference between life and death for both women and their newborns. But antenatal care among women in slums is very poor (Table 3). It shows that among 210 women, about one third (35.2%) pregnancies were unplanned.

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It is highly desirable that women should have minimum four antenatal checkups during pregnancy. But in the present study, though about three quarter (73.3%) of respondents contacted a health provider at least once, less than half (42.4%) of them had adequate number of antenatal checkups (ANC) putting the recommendations on the back burner. District level health survey reported that in Punjab, majority of women (82.9%) received at least one ANC during their pregnancy and nearly two third of them (64.1%) had three or more ANC.10 Therefore the figures in the present study are on lower side. Findings similar to the present study were reported in slums of Indore where 76.6% mothers had at least one ANC but only 40.1% had it thrice or more.11 The most common reason for not availing antenatal checkups (Table-4) was no perceived need (38.4%), followed by lack of support of husband or other family members to take her to health facility (34.7%) and economic constraints (22.3%). Iron folic acid (IFA) tablets were taken by 52.4% of women and only 21.4% took those tablets regularly (Table-3). These findings are in conformity with the results of NFHS III which showed that 18.5% women among urban poor consumed IFA for 90 days or more. In slums of Meerut12 and Indore13 7.5% and 23.7% women consumed IFA tablets for more than three months respectively. These findings are on lower side when compared with the figure for urban non-poor which is 41.8%.6 The common reasons reported by women for not taking IFA tablets [Table -4] were no perceived need (45.0%), bad taste (29.0%) of tablets and economic constraints (11.0%). Certain myths attached to tablets that they are hot and can lead to abortions cause big babies and hence lead to caesarean sections etc. were also common.

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Nearly ninety percent (89.5%) of study subjects were immunized against tetanus which is close to the percentage for urban non-poor.6 Common reasons for not getting immunized [Table-4] were no perceived need (50.0%), migration to native place (36.3%) and lack of companion who could accompany her (13.7%). Factors associated with adequate antenatal care were assessed using logistic regression analysis (Table-5). Univariate analysis identified nativity, availability of identity proof, caste, socio-economic status of women, type of family, age of women, literacy of study subjects and their husbands, parity and planning of pregnancy as significant factors affecting the antenatal care of women. But, on multivariate analysis, only literacy of the study subjects (OR= 3.2, CI=1.36 7.57, p<0.01), literacy of husbands of study subjects (OR= 2.5, CI=1.13-5.56, p<0.05) and socioeconomic status (OR= 2.25, CI=1.5 5.5, p<0.05) emerged as significant determining factors of antenatal care practices. A systematic review of literature of factors affecting the utilization of antenatal care in developing countries has also shown education of women and income of family as significant factors influencing the antenatal care use in developing countries.14 Similar findings were also observed in slums of Mumbai.15 It indicates that the overall educational and socioeconomic status of women needs to be improved to boost the antenatal care during pregnancy.

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9. Kapadia, N. Slum demography. Institute of health management Pachod, Chandan Nagar, Pune, Maharashtra, India; 2003 [cited 2013 May 23]. Available from: http://www.ihmp.org/ihmp_pune.html 10. International Institute for Population Sciences. District Level Household and Facility Survey 2007-08, Punjab. Ministry of Health and Family Welfare; 2010. 11. UHRC. Maternal and newborn care practices among the urban poor in Indore. India: Gaps, reasons and potential program options. Urban Health Resource Centre (New Delhi); 2007. 12. Timsi J, Singh JV, Bhatnagar M, Garg S, Chopra H, Mohan Y. Status of antenatal care in slums of Meerut city. Indian Journal of Maternal & Child Health. 2010 [cited 2013 Jan 09]; 12(4). Available from:

http://www.ijmch.org/home/previous-online-journals/volume-12-octoberdecember-2010 13. Aggarwal S, Sethi V, Shrivastva K, Jha PK, Baqui AH. Birth preparedness and complication readiness among slum women in Indore city, India. Journal of Health, Population & Nutrition. 2010 Aug [cited 2013 Jan 12]. Available from: http://findarticles.com/p/ articles/mi_6829/is_4_28/ai_n55386326/ 14. Simkhada B, Teijlingen ER, Porter M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: Systematic review of the literature. Journal of advanced nursing. 2008 Feb; 61 (3): 244-60. 15. Sarode VM. Does illiteracy influence pregnancy complications among women in the slums of greater Mumbai. International Journal of Sociology & Anthropology. 2010 [cited 2013 Jan 18]; 2 (5): 84-94. Available from http://www.academicjournals.org/ijsa

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