International Journal of Medical and Health Sciences

International Journal of Medical and Health Sciences Journal Home Page: http://www.ijmhs.net ISSN:2277-4505 Original article Utilisation Of Maternal Health Care Services In Slums Of East Godavari District Of Andhra Pradesh Swapna Budimelli* 1, Kalyan Chebrolu 2 1&2 Assistant Professors, Department of Community Medicine, NRI Medical College, Chinakakani-522503, Mangalagiri Mandal, Andhra Pradesh, INDIA. ABSTRACT Introduction: The urban poor in spite of their proximity to urban health facilities, their access is severely restricted on account of social exclusion, lack of information and lack of economic resources. The mothers and children who are the vulnerable sections of the society need special attention in this regard. Objectives: 1. To study the socio-demographic profile of the mothers. 2. To study the utilization of maternal health care services by the beneficiaries. Material and Methods:The present observational, descriptive, cross- sectional field based study, conducted in the urban slums of East Godavari district, Andhra Pradesh. From the 15 functional UHCs, 150 mothers, 10 from each UHC area were administered a pre- designed, pretested semi-structured schedule using interview technique. Results:About 70% mothers belong to middle class and 27% to lower socio-economic class, 67% are living in nuclear families. The literacy rate is higher among females (70%) than males (62%). Teenage mothers are a minority (12.3%). 93.3% mothers received complete antenatal care, majority preferring Government Hospitals (46.7%). Tetanus Toxoid immunization was universal. 93.3% mothers received IFA tablets for 100 days but only 76.7% consumed for 100 days. Referral services were needed by a minority (4.7%). Majority (86%) of the deliveries are institutional, 94% were conducted by trained personnel. About 85% of the mothers received postnatal care. Conclusion:UHCs are functioning as the main public sector sources of Primary Health Care for urban slum dwellers. Specific dimensions like home visits during the antenatal period, postnatal care need further improvement. KEYWORDS: Antenatal care, Maternal health, Postnatal care, Slums, Urban Health Centres INTRODUCTION The World is becoming increasingly urban. Although this process varies across regions, the entire world is facing an increase in both the size of the cities and in the proportion of people living in urban areas. Urban growth is influenced by both the pull forces of economic opportunities in cities and the push factors of rural poverty and unemployment. The transfer of rural poverty to urban environment has led to mushrooming of slums in several cities [1]. Historically India has largely been a nation of rural villages, but the situation is rapidly changing [2]. Urban growth in India presents a daunting picture. The growth rate is far higher today for urban population (3.16%) than for total population (2.16%). Within urban areas the growth rate is highest for urban slums [3]. Int J Med Health Sci. April 2013,Vol-2;Issue-2 141

Demographers have described the Indian demographic scenario as the 2-3-4-5-6 phenomenon. All India growth is about 2% a year, Urban India 3%, Mega Cities 4% and slum areas 5-6% per year [4].In urban areas the utilization of health care services by slum population is far from satisfaction. Though health services are available within their reach both in public and private sectors, the population is not effectively using these available services. The present study tries to understand the utilisation of maternal health care services by the urban population. Objectives: 1.To study the socio-demographic profile of the mothers. 2.To study the utilization of maternal health care services by the beneficiaries. MATERIALS AND METHODS The present observational, descriptive, crosssectional field based study was conducted in the urban slums of East Godavari district, Andhra Pradesh, during the period from January 2012 to June 2012. Fifteen Urban Health Centres (UHC) are currently functional in East Godavari district. Multi- stage sampling was done to select 150 mothers to evaluate the antenatal, intranatal and postnatal care services. In the first stage, by simple random technique, one of the twelve pockets of the slum population being served by each of the 15 Urban Health Centres, are selected by lottery method. In the second stage, by systematic random sampling method 10 mothers from each UHC are selected and administered a pre- designed, pre- tested semi-structured schedule using interview technique. In each UHC area, the first household was selected at random and survey was conducted in the adjacent households until the required numbers of study subjects were covered. The study was restricted only to mothers who had a child less than 1 year. This was stipulated, so as to minimize the recall bias and to avoid the mix up of the responses with the earlier delivery if any. The utilization of services was determined at one point of time. Modified Kuppuswami scale [5, 6] was used to determine the socio-economic status of the mothers. Informed consent of the mothers was taken before the administration of the schedule. Ethical clearance was obtained before commencing the study. Data were entered into the computer with Epi info version 3.4.3 software and were analysed using this software. Results are represented in the form of tables and percentages. RESULTS The present study covered all the 15 UHCs that are functional in East Godavari district of Andhra Pradesh, covering a total slum population of 226,660. Each of the UHCs is catering to a population ranging from 11025 to 18756, with mean population of 15,110 per UHC. The out patient attendance per day ranged from 10 to 70 with a mean of 37. 97.3% of the study subjects were Hindus, 46.7% belonged to backward classes, 36.7%to Scheduled Castes. Majority (42.7%) belonged to class III of Modified Kuppuswamy Socio- economic Scale and 30% to Class IV. Two thirds of the mothers had school level education, 26.7% were illiterates, and 95.3% were remaining at home as housewives. Only 62% of their husbands are literates and majority (89.3%) work as labourers. Two- thirds are living in nuclear families, 47.3% in pucca houses, 23.3% in semi- pucca houses. The age of the mothers ranged from 17 years to 30 years with a mean age of 22.5 years. Teenage mothers account for 12.7% (19) of our study population. Majority of the mothers i.e., 85.3% (128) are in the right age group of 20-29 years. Only 3 mothers were aged 30 years or more. 88% (132) mothers had one or two children. 12% of the mothers had three or more children (Table 1) Int J Med Health Sci. April 2013,Vol-2;Issue-2 142

Table 1: Socio-demographic profile of the study subjects (n=150) Frequency Percentage Religion Hindu 146 97.3 Muslim 3 2.0 Christian 1 0.7 Social Status OC 24 16.0 BC 70 46.7 SC 55 36.7 ST 1 0.7 Socio-Economic Scale (Modified Kuppuswami) Class I 0 0.0 Class II 41 27.3 Class III 64 42.7 Class IV 45 30.0 Class V 0 0.0 Education of the mother Illiterates 40 26.7 School education 100 66.7 College & above 10 6.7 Occupation of the mother Employees 2 1.3 Labourers 5 3.3 House wives 143 95.3 Education of the husband Illiterates 57 38.0 School education 77 51.3 College & above 16 10.7 Occupation of the husband Employees 12 8.0 Labourers 134 89.3 Unemployed 4 2.7 Type of family Joint 51 34.0 Nuclear 99 66.0 Type of housing Pucca 71 47.3 Semi- pucca 35 23.3 Kutcha 44 29.3 Int J Med Health Sci. April 2013,Vol-2;Issue-2 143

More than 93% (140) mothers received a minimum of three antenatal visits and the remaining 10 mothers (6.7%) received only partial care. Tetanus Toxoid immunization was universal in the study population irrespective of the source of service. 93.3% (140) mothers received IFA tablets for 100 days. Only 6.7% mothers did not receive for 100 days. Nearly 59% received the IFA tablets from the Government hospitals and 41.3% from private sources. 76.7% (115) mothers consumed IFA tablets for the stipulated 100 days whereas 23.3% (35) mothers did not. (Table 2) Table 2: Service seeking behaviour of the mothers Source of service Antenatal care services Antenatal checkups T.T. immunization Source of I.F.A. tablets Postnatal services U.H.C. 34 (22.7%) 58(38.7%) 49 (32.7%) 7 (4.7%) Other Government 36 (24.0%) 39 (26.0%) 39(26.0%) 52 (34.6%) Private 50 (33.3%) 53 (35.3%) 62 (41.3%) 69 (46.0%) Multiple 30 (20.0%) NIL NIL NIL Not received NIL NIL NIL 22 (14.7%) The proportion of mothers receiving antenatal care is similar irrespective of their educational status (χ² = 0.29 2df p>0.05) (Table 3). This shows that education of the mother had no significant influence on antenatal care. 97.3% (146) mothers had no complications during antenatal period. Only 4 mothers (2.7%) had complications like swelling of legs & body and burning micturition. Out of the 4 mothers (2.7%) who had complications, two mothers received care from Government sources and two from private sources. Table 3: Education of the mother Vs Antenatal care utilisation Education of the mothers Illiterate School education College & above Antenatal Care utilisation Yes No 37 3 (92.5) (7.5) 94 6 (94.0) (6.0) 9 1 (90.0) (10.0) 140 (93.3) 10 (6.7) χ² = 0.29 2df p>0.05 40 100 10 150 Int J Med Health Sci. April 2013,Vol-2;Issue-2 144

About 95% (143) mothers did not require any referral services during their antenatal period. Only 5% (7) of the mothers needed referral services, of these, 6 mothers received service from a Government health facility, the other from a private source. 86% (129) of the deliveries were institutional in the present study, 14% mothers delivered at home. All the institutional deliveries were conducted by skilled personnel. Only 6.7% of the deliveries were conducted by untrained persons. Overall, 93.3% of the deliveries were safe. Of the 21 mothers (14.0%) delivered at home, 6(28.6%) mothers received care from the UHC staff and 3(14.3%) received care from other health staff. 12 mothers (57.1%) did not receive any care from health staff. When the affect of socio-economic status on the place of delivery was considered the difference found was not statistically significant (χ²=5.4311 4df p>0.05), indicating that socio-economic status had no role on the place of delivery in our study sample.(table 4) Table 4: Socio-economic status Vs Place of delivery Socio-economic status scale Government Hospital Place of delivery Home Private hospital II 15 32.6 7 15.2 24 52.2 46 100.0 III 24 40.7 11 18.6 24 40.7 59 100.0 IV 23 51.1 3 6.7 19 42.2 45 100.0 TOTAL 62 41.3 21 14.0 67 44.7 150 100.0 χ²=5.4311 4df p>0.05 Nearly 15% (22) mothers did not receive any postnatal care. 39.3% (59) mothers received the services from a Government health facility either from UHC or any other government facility and 46% (69) opted for private services. Literacy of the mother showed no significant influence on the postnatal care received by the mother (χ²=11.49 6df p>0.05). (Table 5). 97.3% (146) mothers had no complications during the postnatal period. 4 mothers (2.7%) suffered from complications like postpartum haemorrhage, retention of products of conception and stitch abscess. Out of the 4 mothers (2.7%) who suffered with complications, three (75%) received services from Government hospitals and the other preferred private source. 38% of the slum dwellers in our study utilized the UHC services for treatment of common ailments in the preceding one year. During illness they mainly sought treatment from private practitioners, probably because Urban Health Centers do not provide emergency services round the clock. Int J Med Health Sci. April 2013,Vol-2;Issue-2 145

Table 5: Education of the mother Vs Source of Postnatal care Education of the mother U.H.C. Source of Postnatal Care Other Government Private Not received Illiterate 1 (2.5) 16 (40.0) 13 (32.5) 10 (25.0) 40 School education 6 (6.0) 35 (35.0) 48 (48.0) 11 (11.0) 100 College & above 0 (0.0) 1 (10.0) 8 (80.0) 1 (10.0) 10 7 (4.7) 52 (34.6) 69 (46.0) χ²=11.49 6df p>0.05 22 (14.7) 150 DISCUSSION Almost all the mothers were Hindus, and majority belonged to the backward classes, scheduled castes and tribes communities. Most of the mothers (70%) were in Middle class (both the upper middle and lower middle classes) according to the Modified Kuppuswami socio economic status scale. Nearly 1/3 rd of the mothers belonged to lower class. Education is an important indicator in the context of women s health. Generally women with more education have better health, have improved life opportunities, live in healthier environments and have healthier children than women with little or no education [7]. The literacy rate among the mothers in urban slums in various studies varied from 34.7% to 60% [8, 9, 10]. In the present study 73.4% mothers are literate showing that the mothers are well educated in East Godavari district when compared with the rest of the country. But majority (95%) of the mothers preferred to remain as house makers and their men were the main breadwinners working as contract labourers (89.3%) woman has the right to health care, especially during pregnancy and child birth [11]. The utilization of antenatal care services varied from 50% to 90% in various studies done in urban slums of the country [8, 9, 12, 13, 14, 15, 16, 17]. In the present study, even though the UHCs are situated in close proximity to the slum population, only about 23% mothers exclusively preferred antenatal checkups from them, where as 1/3 rd mothers preferred private practitioners. The mothers preferred other government tertiary care centres in the city rather than UHCs. TT immunization was found to be 86.2% in Bangalore slums [16], 89.8% in Mumbai slums [18] and 100% in the slums of Kolkata [17]. In the present study, TT immunization was universal (100%) in the study population irrespective of the source of service, which is a very good sign. IFA tablets consumption varied from 10% to 81% in various studies done in urban slums across the country [8, 12, 13, 16, 17, 18]. In the present study, two- thirds of the mothers could complete the full course of 100 IFA tablets received by them, which is similar to the previous studies. Joint families (34%) are a passé and more and more people prefer to live in Nuclear families which are becoming more popular these days (66%).Every pregnancy deserves attention as Safe delivery practices by trained care providers, there is always a risk of something going wrong. essential newborn care and appropriate referral Many dangers can be avoided if the woman goes services are major determinants of the survival to a health care centre or to a skilled attendant and well being of mothers and newborns. when she first suspects that she is pregnant. Every Institutional deliveries varied from a low of 40.5% Int J Med Health Sci. April 2013,Vol-2;Issue-2 146

in slums of Bangalore City [16] to a high of 93% in slums of Kolkata [17] in studies done by Joseph Bobby et al and Banerjee B respectively. In the present study 86% mothers preferred institutional deliveries, this is very good. Better literacy rates and government incentives like Janani Suraksha Yojana are playing a part in mothers preferring institutional deliveries. But the remaining 14% home deliveries would have been prevented if the staff had provided better antenatal care services and educated the mothers.postnatal care offers an excellent opportunity to find out how the mother is getting along with her baby and to see that the woman recuperate both physically and emotionally from her experience of delivery[19]. In a study done by Reddy M. B. et al in Andhra Pradesh, 64% of the mothers did not receive a single postnatal checkup from the health personnel within 2 days of delivery [20]. In the present study, 85% mothers had at least a postnatal checkup done, which is good. Srinivas DK et al reported 24.6% postpartum morbidity including 2.2% life threatening complications in South Indian populations [21]. In the present study only 2.7% of the mothers reported postnatal complications, as most of the deliveries (94%) were conducted by trained health personnel. CONCLUSION Even though the majority of the mothers belonged to either middle or low socio-economic classes, the mothers are seeking health care services be it either private or government, this is mainly due to better literacy rates among the mothers. The intranatal care in the urban slums in the present study is better, once again due to the literacy rate among the mothers. The Urban Health Centres are functioning as the main public sector sources of Primary Health Care and Reproductive Child Health Care services for urban slum dwellers. Since these centres are located in the heart of the service area, they are often utilized by the slum dwellers. their close proximity and the array of services they are offering. REFERENCES 1. Sherin Varkey, Challenges and options for the delivery of primary health care in disadvantaged urban areas Indian Journal of Community Medicine (2003); 28(2): 91-95. 2. USAID, (India Urban Health Program), An evaluation of activities to date and recommendations for the future ; Oct 2005. The Bureau for Global Health. [Last cited 2013 Jan 03] Available from http://pdf.usaid.gov/pdf_docs/pdacf849. pdf 3. Project Implementation Plan for vulnerable groups under RCH-II (Dec 2004) Government of India, Department of Family Welfare, Ministry of Health & Family Welfare. [Last cited 2013 Jan 03] Available from http://www.mohfw.nic.in/nrhm/rch/gui delines/volunerable_communities _MODIFIED.pdf 4. Chatterjee.G (2002) Consensus versus Confrontation, Urban Secretariat, United Nations Settlement Program, UN- HABITAT. [Last cited 2013 Jan 03] Available from http://www.unhabitat.org/downloads/docs /4075_58516_report.pdf 5. Kuppuswamy B. Manual of socioeconomic status scale (urban). Delhi: Manasayan; 1981. 6. Kumar N, Gupta N, Kishore J. Kuppuswamy s socioeconomic scale: Updating Income Ranges for the year 2012. Indian Journal of Public Health (2012); 56 (1):103-4. There is a need on part of the UHC staff to 7. DHS Comparative reports, The context of improve the maternal health care services, women s health results from the especially the postnatal care, which is found Demographic and Health Surveys 1994- wanting in the present situation. The health staff 2001; No.11: Maryland, USA.. [Last cited and the local leaders should bring about awareness 2013 Jan 03] Available from about the availability of Urban Health Centres in http://www.measuredhs.com/pubs/pdf/cr1 1/CR11.pdf Int J Med Health Sci. April 2013,Vol-2;Issue-2 147

8. Agrawal Shraddha, Bharti BM, Reproductive health in urban slums The Journal of Obstetrics and Gynaecology of India, (2006); 56 (3): 255-257. 9. Venkatesh R.R, Umakantha.A.G, Yuvaraj.J, Safe Motherhood Status in the urban slums of Davangere city Indian Journal of Community Medicine (2006); 30(1): 6-7. 10. Dharani Kumari.Y, Women s position and their behaviour towards Family Planning in two districts of Andhra Pradesh Health and Population Perspectives and Issues (2005); 28(2): 58-70. 11. UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and the World Bank, Facts for life 3 rd edition, 2002.. [Last cited 2013 Jan 03] Available from http://www.unicef.org/uzbekistan/ffl- Eng.pdf 12. National Family Health Survey-3, Andhra Pradesh, International Institute of Population Sciences, (2005-06). [Last cited 2013 Jan 03] Available from http://www.measuredhs.com/pubs/pdf/fri ND3/FRIND3-Vol1[Oct-17-2008].pdf 13. District Level Household & Facility Survey on Reproductive and Child Health - round 2, published by RCH project, IIPS, Mumbai (2002-04). [Last cited 2013 Jan 03] Available from http://www.rchiips.org/pdf/rch2/national_ Report_RCH-II.pdf 14. Banerjee.B, Maternal care rendered at an UHC of a metropolitan city Indian Journal of Community Medicine (2006); 31(3):183-184. 15. Bajaj.J, Knowledge and utilization of Maternal and Child Health Services in Delhi slums Journal of Family Welfare, (1999); 45(1): 44-52. 16. Bobby Joseph, Sri Krishna.SR, Jisha Philip, Belinda George, Preferences for home deliveries in a sub urban community of Bangalore city. Health and Population Perspectives and Issues (2002); 25(2): 96-103. 17. Bratati Banerjee, A qualitative analysis of Maternal and Child Health Services of an Urban Health Centre, by assessing client perception in terms of awareness, satisfaction and service utilization Indian Journal of Community Medicine (2003); 28(4): 153-156. 18. Siddharth Agarwal, Urban Maternal Newborn Health Scenario in Maharashtra Presentation made at stake holders consultation for sure start PATH S Initiative, (Aug 4 th, 2006). [Last cited 2013 Jan 03] Available from http://www.uhrc.in/name- CmodsDownload-index-req-getit-lid- 38.html 19. Park. K, Park s textbook of Preventive and Social Medicine, 21st Edition, M/s Banarsidas Bhanot, J, Feb 2011. 20. Reddy MB, Chaturvedi.SK, Thomas.V, Evaluation of the maternal Services coverage in the state of Andhra Pradesh 1998-99, Indian Journal of Community Medicine; 4(2), 5(1): 1-17. 21. Srinivas.DK, Narayan.KA, Oumachigui.A. Prevalence of Maternal Morbidity in a South Indian Community Report of the project by Ford Foundation, Department of Community Medicine, JIPMER, Pondicherry (1997); 1-20. *Corresponding author: Dr. Swapna Budimelli E-mail: swapna_budimelli@yahoo.co.in Int J Med Health Sci. April 2013,Vol-2;Issue-2 148