FOCUSED COUNSELING AND ADEQUATE UTILIZATION OF
MATERNAL AND CHILD HEALTH (MCH) SERVICES
- ITS IMPACT ON MATERNAL AND INFANT MORBIDITY
THESIS
Submitted to the Tamil Nadu Dr. M.G.R Medical University in partial
fulfilment of the requirement for the award of the degree of
DOCTOR OF PHILOSOPHY IN MEDICINE
By
Dr. R.Arunmozhi MD
Madras Medical College,
Chennai, Tamil Nadu
FOCUSED COUNSELING AND ADEQUATE UTILIZATION OF
MATERNAL AND CHILD HEALTH (MCH) SERVICES
- ITS IMPACT ON MATERNAL AND INFANT MORBIDITY
THESIS
Submitted to the Tamil Nadu Dr. M.G.R Medical University in partial
fulfilment of the requirement for the award of the degree of
DOCTOR OF PHILOSOPHY IN MEDICINE
By
Dr. R.Arunmozhi MD
Signature of the Co Guide Signature of the Guide
Prof.Dr. Shekhar B Padhyegurjar
Professor & Head
Dept. of Community Medicine SMBT Institute of Medical Sciences Dhamangaon, Near Nasik.
Prof. Dr. Saradha Suresh
CERTIFICATE
This is to certify that this study entitled “FOCUSED COUNSELING AND
ADEQUATE UTILIZATION OF MATERNAL AND CHILD HEALTH
(MCH) SERVICES – ITS IMPACT ON MATERNAL AND INFANT
MORBIDITY” is the original research work done by Dr.R.ARUNMOZHI,
under my guidance and supervision for the degree of Doctor of Philosophy and
represents independent and original work on the part of the candidate.
CERTIFICATE
This is to certify that this study entitled “FOCUSED COUNSELING AND
ADEQUATE UTILIZATION OF MATERNAL AND CHILD HEALTH
(MCH) SERVICES – ITS IMPACT ON MATERNAL AND INFANT
MORBIDITY” is the original research work done by Dr.R.ARUNMOZHI,
under my Co -Guidance for the degree of Doctor of Philosophy and represents
independent and original work on the part of the candidate.
Signature of the Co Guide
Prof.Dr. Shekhar B Padhyegurjar
Professor & Head
DECLARATION
I hereby declare that thesis entitled ‘FOCUSED COUNSELING AND ADEQUATE UTILIZATION OF MATERNAL AND CHILD HEALTH (MCH) SERVICES - ITS
IMPACT ON MATERNAL AND INFANT MORBIDITY’ is a research work done by me, and not used previously either partly or fully for the award of any Degree/ Diploma/ Associateship / Fellowship or any other similar title.
Place: Chennai
CONTENTS
S.NO. CHAPTERS PAGE NO
1 INTRODUCTION 1
2 AIMS & OBJECTIVES 7
3 REVIEW OF LITERATURE 8
4 MATERIALS AND METHODS 26
5 RESULTS AND ANALYSIS 41
6 DISCUSSION 96
7 SUMMARY AND CONCLUSION 117
8 RECOMMENDATIONS 123
9 BIBLIOGRAPHY
APPENDICES
Appendix - I
Copy of the Ethical committee clearance from IRB
Appendix - II
Permission letter from Corporation of Chennai to conduct the study
Appendix – III
Copy of the consent form – For Participants in the Intervention area i. English
ii. Tamil
Copy of the consent form – For Participants in the Control area i. English
ii. Tamil
Appendix – IV
Maternal and Child Health Card – English & Tamil
Focused Counselling Guide
Images of MCP card
Appendix –V
Article 1 - Published by the researcher
Article 2 – Published by the researcher
Appendix – VI
LIST OF TABLES
Table No. Tables Page No.
REVIEW OF LITERATURE
Table: 1 Institute of Medicine Weight Gain Recommendations for Pregnancy
16
MATERIALS & METHODS
Table: 2 Maternal Morbidities 39
Table: 3 Infant Morbidities 40
RESULTS & ANALYSIS
Table: 4 Age Distribution of Antenatal women 43 Table: 5 Education of Antenatal women 44
Table: 6 Education of the Husband 45
Table: 7 Occupation of the Husband 46
Table: 8 Religion 47
Table: 9 Parity 48
Table: 10 Last Child Birth 49
Table: 11 Total Number of Antenatal visits attended 50 Table: 12 Number of Recommended Antenatal visits attended 51 Table: 13 Number of Antenatal women visiting at Recommended time 52 Table: 14 Body Mass Index of Antenatal women 53 Table: 15 Hemoglobin estimation for Antenatal women at Recommended
visits
54
Table: 16 Urine analysis for Antenatal women at Recommended visits 55 Table: 17 Blood Sugar estimation for Antenatal women at Recommended
visits
56
Table: 18 Number of IFA Tablets received 57 Table: 19 Utilization of MCH Services – Mann Whitney U test 58 Table: 20 Service Utilization at Recommended Antenatal Visits -
Consolidated
60
Table: 21 Service Utilization at Recommended Antenatal Visits – By AN women with 5 Recommended Visits
61
Table No. Tables Page No.
Table: 23 Weight Gain during Antenatal Period 63 Table: 24 Comparison of mean maternal weight gain between Intervention
and Control groups
64
Table: 25 Association between BMI and Maternal Weight Gain during pregnancy
64
Table: 26 Hemoglobin values at beginning of Pregnancy 65 Table: 27 Hemoglobin values at the end of pregnancy 66 Table: 28 Comparison of Mean Hemoglobin values at the beginning of
pregnancy
66
Table: 29 Comparison of Mean Hemoglobin values at the end of pregnancy
67
Table: 30 Comparison of Mean Hemoglobin values at the beginning and end of pregnancy
67
Table: 31 Comparison of Hemoglobin status between Study groups 69 Table: 32 Association of Hemoglobin status at the beginning and end of
pregnancy
70
Table: 33 Comparison of AN women who received and consumed 90+ IFA Tab
71
Table: 34 Association of IFA tab consumption and haemoglobin values at the end of pregnancy.
71
Table: 35 Type of Delivery 72
Table: 36 Place of Delivery 73
Table: 37 Gender of the baby 73
Table: 38 Birth Weight of the babies 74
Table: 39 Comparison of Mean Birth Weight of babies between Study groups
75
Table: 40 Linear regression analysis of birth weight 77
Table: 41 Term status of the babies 78
Table: 42 Association between Hb status at end of pregnancy & Term status
78
Table No. Tables Page No.
Table: 45 Postnatal Contraception – Control Group 80 Table: 46 Influence of Type of Delivery on Time of Initiation of Breast
Feeding – Intervention Group
81
Table: 47 Influence of Type of Delivery on Time of Initiation of Breast Feeding – Control Group
82
Table: 48 Distribution of duration of Exclusive Breast feeding 82 Table: 49 Comparison of Mean Duration of Exclusive Breast feeding 83 Table: 50 Influence of utilization of services on duration of Exclusive
Breast feeding – Spearman’s Correlation Test
83
Table: 51 Analysis of Utilization of MCH services by Study Groups – Mann Whitney U test
84
Table: 52 Women with at least one Maternal Morbidity 85 Table: 53 Maternal Morbidity – Antenatal Period 86 Table 54 Maternal Morbidity – Intranatal Period 87 Table 55 Maternal Morbidity – Postnatal Period 88 Table 56 Maternal Morbidity – Beyond Postnatal Period – upto 6 months
following delivery
89
Table 57 Neonatal Morbidity 90
Table 58 Postneonatal Morbidity – Upto 6 Months of Infancy 91 Table 59 Assessment of normality of variables entered in the structural
equation model
93
Table 60 Model fit indices for the path model 94 Table 61 Regression estimates of the path analysis 94
LIST OF FIGURES
Figure
No. Figures
Page No.
Figure: 1 Conceptual framework of social determinants of infant morbidity /
birth outcomes. 24
Figure: 2 Administrative Zones of Chennai 27
Figure: 3 Sampling Method 28
Figure: 4 Enrolment and Follow-up of Study Participants 41
Figure: 5 Comparison of Error plot for Hb values – at the beginning & end of
pregnancy 68
ABBREVIATIONS
Ab Above
ADD Acute Diarrhoeal Disorder AN Antenatal
AOR Adjusted Odds Ratio ARI Acute Respiratory Infection BCG Bacille Calmette Guerin BeyPN Beyond Postnatal BMI Body Mass Index BP Blood pressure CI Confidence Interval cms centimetres
df Degree of freedom dl decilitre
DLHS 3 District Level Household and Facility Survey 3 EMRI Emergency Management and Research Institute EOC Emergency Obstetric Care
Estm Estimation
GDM Gestational Diabetes Mellitus
gm Gram
Govt. Government
Gp Group
Hb Hemoglobin HP Health Post
Hr Hour
HSC Health Sub Centre
ICDS Integrated Child Development Service IFA Iron and Folic Acid
IMR Infant Mortality Rate IN Intranatal
IUD Intra Uterine Device
IUGR Intra uterine growth retardation JSY Janani Suraksha Yojana
Kg Kilogram
LBW Low birth weight
MCH Maternal and Child Health MCP Maternal and Child Protection MDG Millennium Developmental Goals MMR Maternal Mortality Ratio
MRMBS Dr. Muthulakshmi Reddi Maternity Benefit Scheme mths Months
NEC Nutrition Education & Counseling NFHS 3 National Family Health Survey 3 NN Neonatal
NRHM National Rural Health Mission OPV Oral Polio Vaccine
p p value
PHC Primary Health Centre
PICME Pregnancy Infant Cohort Monitoring and Evaluation PN Postnatal
PostNN Post neonatal PTB Preterm Birth
RCH Reproductive and Child Health SD Standard Deviation
tab tablet
UHP Urban Health Post USG Ultrasonogram
UTI Urinary Tract Infection WHO World Health Organisation
wks weeks
Wt. Weight
ACKNOWLEDGEMENT
I thank God, who with His Graciousness and Blessings has helped me to complete the study successfully.
I wish to express my heartfelt gratitude to my guide Dr Saradha Suresh for her encouragement and able supervision without which this study might not have been possible. I appreciate the help and guidance given by my Co Guide, Dr. Shekhar B. Padhyegurjar.
I gratefully acknowledge and sincerely thank Dr. R.Vimala, Dean, Madras Medical College, Chennai, for her kind support.
I owe my profound gratitude to the advisory committee members, Dr. Ramani Rajendran, Rtd. Deputy Superintendent of Inst. of Social Obstetrics & Kasturba Gandhi Hospital for Women and Children and Dr. Parameshwari Srijayanth, HOD, Epidemiology Unit of The Tamil Nadu Dr M.G.R. Medical University, Chennai, for their guidance and suggestions during the entire period of my study.
I wish to extend my sincere thanks to Dr. T.P.Jayanthi, Associate Professor, Department of Community Medicine, Government Stanley Medical College, who has been a great support during the entire period of my research work.
My sincere thanks to Dr. Vijayaprasad Gopichandran, for his technical inputs.
I express my sincere gratitude to all the women and their family members, who participated in the study, for their co operation.
I am greatly indebted to my husband and daughter who have stood by me in all my endeavours. I wish to express my gratitude to my parents for their support and encouragement.
1
INTRODUCTION
Pregnancy and childbirth are considered as normal physiological processes and is looked forward to with a sense of anticipation and joy. As anticipated many women have a very pleasant and fulfilling experience. But some women experience innumerable suffering during pregnancy, in the process of giving birth and in the postpartum period. This is because all women remain at potential risk of developing complications during pregnancy, labor or pregnancy termination, and the postpartum period. The most dangerous period for the mother and infant is the immediate postpartum period especially in the first 6 hours following delivery. Most maternal deaths occur during this period and many of these complications cannot be identified in advance. Complications related to pregnancy and deliveries are the most common causes of mortality among women of reproductive age group
Worldwide more than two lakh women died due to pregnancy and childbirth related causes in 2013. India and Nigeria accounted for one third of maternal deaths across the globe.1 It is known that for every mother who dies, between 30 to 100 women have acute maternal morbidities that are painful, debilitating and often permanently disabling. 2
Millennium Development Goals:
2 India’s effort to achieve MDG Goals:
The Reproductive and Child Health (RCH) program was launched in 1997 – 1998. This initiated a steady decline in the maternal and infant morbidity and mortality. The maternal mortality ratio (MMR) fell from 398 per 100,000 live births in 1997 – 1998 3 to 178 in 2010 – 2012 4 and the infant mortality rate (IMR) declined from 71 infant deaths per 1000 live births in 1997 to 40 in 2013.5 Under this program an array of comprehensive policies containing a range of reproductive health services were formulated and implemented. Emergency Obstetric Care (EOC) centres were established to provide emergency care to women during pregnancy and childbirth. Subsequently the RCH program was integrated with the National Rural Health Mission (NRHM).
Under NRHM, improved program implementation and Health system development were seen as mutually reinforcing forces. A name based tracking of pregnant women and children for antenatal care and immunization was introduced. Janani Suraksha Yojana (JSY) an innovative maternity benefit scheme for pregnant women was introduced to enable women to deliver in institutions. This greatly increased institutional deliveries.
Tamil Nadu’s effort:
3
The Tamil Nadu state health society has laid out a road map for the coming years to reduce MMR to 50 per 100,000 live births and IMR to less than 15 per 1000 live births. The main focus was on strengthening emergency and essential obstetric care. In the rural areas of Tamil Nadu, health care is provided by primary health centres (PHC) and health subcentres (HSC). The PHCs have been upgraded to render 24x7 maternal and child health services. In the urban areas the urban health posts (UHP) are the centres for providing primary healthcare and the EOCs are their referral centres. The EOCs provide round the clock services and are equipped with labor ward and operation theatres. A unique Pregnancy and Infant Cohort, Monitoring and Evaluation (PICME) number is generated for the antenatal mother on registration. All information pertaining to the mother and baby are entered periodically in the PICME database by the health worker. In addition to JSY, under Dr. Muthulakshmi Reddy Maternity Benefit Scheme (MRMBS) in Tamil Nadu, a cash incentive of Rs. 12,000/- is given on a conditional basis to pregnant women. It is given in 3 installments of Rs 4,000/- to compensate for the wage loss and also to meet the nutritional requirements of the pregnant women. The MRMBS software links with the PICME software to identify eligible mothers for conditional cash transfer.6 The MRMBS cash incentive has increased the utilization of MCH services in the public sector. The 108 Emergency Management and Research Institute (EMRI) ambulance service provides free quality pre-hospital care and transport of patients to appropriate health facility. It has reduced the financial burden of the people in times of emergencies.
The urban paradox:
4
unlikely to be one of their top priorities. In spite of these constraints, the percentage of antenatal women registering and receiving care in the first 12 weeks of gestation (90%) and getting three or more antenatal checkups (99%) is high in Chennai as per District Level Household Survey 3 (DLHS 3) data.7 But the percentage of mothers receiving full antenatal care (defined as at least three visits for antenatal check-up, at least one Tetanus toxoid injection (Inj TT) received and consumed100+ Iron and Folic acid [IFA] tablets/ syrup) is only 67%. Among women who had complications during antenatal period only 45% of them sought some form of treatment and only half the mothers who developed complications in the postnatal period sought care.7 This data reveals the gap between availability of services and the optimal utilization of these services by the mothers and babies who need it.
Adequate Utilization of services:
Adequate utilization of MCH services has been proven to result in better pregnancy outcomes. It is important to improve the knowledge of the women and their family members on danger signs and health seeking behavior.
5
Women are informed about recommended antenatal visits, the importance of nutrition, self-care family planning, etc. How much of this information is conveyed to the spouse and other decision makers in the family is uncertain. The young antenatal woman who is provided with the knowledge is not empowered to make decisions regarding her health or the health of her baby. It is the spouse, the mother in law or the mother of the pregnant woman who are the decision makers. In the socio cultural milieu of Indian households, major decisions are often made in a consensual manner than by the individuals themselves. Hence, it is important to counsel the mother, the husband and other decision makers in the family. Counseling which involves exchange of information and provision of support, should be extended to the mother and the family members to help them make decisions and take necessary action to improve the health of the mother and baby. Such counseling would improve the confidence of the people on the health facility and increase its utilization.
Rationale for the present study:
6
7
AIMS & OBJECTIVES
Study Objectives:
1. To assess the influence of focused counseling of the mother, spouse and other family members on adequate utilization of recommended maternal and child health services.
2. To study the influence of focused counseling of the mother, spouse and other family members on maternal and infant morbidity.
3. To evaluate the impact of ensuring adequate utilization of recommended maternal and child health services on maternal and infant morbidity.
Study Hypothesis:
8
REVIEW OF LITERATURE
Antenatal Care:
Pregnancy and delivery related complications are the main cause of mortality and morbidity among women in child bearing age.9 It is known that women are at risk of developing complications during pregnancy and childbirth. The antenatal visit is the opportunity to provide women with multiple promotive, preventive and curative services, including health education, counseling and supplementation. Safe delivery is very often an outcome of adequate antenatal care. The time of first visit, number of antenatal visits and the content of care are the determinants of adequacy of care. There are many views on how people adequately utilize antenatal services, what are the factors influencing utilization and how utilization affects pregnancy outcomes.
Number of Antenatal visits:
9
Munjanja et al. tested a newer model with less number of visits with fewer interventions in each of the visits. The women in the newer model had the same outcomes, lesser preterm births and less referrals.10 A randomized controlled trial was conducted to evaluate the new model of antenatal care against the traditional model. The rates of several outcome variables were similar between the two models. But women in the newer model had more referrals, but hospitalization rates and duration of hospital stay were comparable between the groups. Maternal and perinatal outcomes were also similar between the two models. The antenatal women who were allocated to the two groups were satisfied with the concept and care received. The newer model even cost less in some settings. Backed by these outcomes, the new model was recommended as a standard for antenatal care, with necessary adaptations to meet the local needs.10,11 Reduced number of visits, with attention to the content of care, has now been scientifically proven to have the similar or better pregnancy outcomes.12
Reanalysis of the newer model revealed higher perinatal mortality rates after adjusting for confounding factors. The WHO Antenatal Care Trial furnished proof that the traditional model of antenatal visits was more effective in reducing perinatal mortality. Justus Hofmeyr adds that the more number of antenatal visits in the third trimester helps in early identification of preeclampsia, intra uterine growth restriction etc, giving more time for corrective measures.13
The 4+ indicator was considered as a proxy for the delivery of a set of recommended services for many years. Kyei et al.in 2012 defined good antenatal care as getting atleast 4 antenatal visits and receiving eight out of ten of the essential services.14 Using the above indicator would make comparison of performance across countries difficult
10
average of a set of key antenatal services, which can include the number of antenatal visits also, for comparison across populations.15
Quality of Care:
The quality of antenatal care rather than quantity is the latest approach.16,17 Antenatal visits offer a distinctive opportunity for identifying and managing complications in the mother and thereby prevent problems in the baby. Most pregnancies do not have complications. Since most complications cannot be predicted it is advisable to consider all pregnancies as 'at risk’. Therefore it is imperative that all women should receive essential obstetric care.18
Antenatal care helps to save and protect the lives of mothers and babies by ensuring good health status before delivery and the early postnatal period. Antenatal visits act as the entry point for delivery of integrated preventive, promotive and curative services.19 Hulton defines quality of care as the degree to which maternal health services for individuals and populations increase the chances of timely and appropriate treatment for the purpose of achieving desired outcomes that are both consistent with current professional knowledge and uphold basic reproductive rights.20
Hulton goes on to add that the availability of services does not guarantee their use by women. Neither does the use of maternal health services guarantee optimal outcomes for women. Why women do not access services at all, or access them late, or suffer consequences even after timely use of the services, can be attributed to the quality of services, which is intangible and difficult to measure. 20
11
and blood test for syphilis and severe anaemia should be carried out.21 Other services like tetanus immunization. IFA supplementation and counseling women on the danger signs of pregnancy should also be done to improve maternal and newborn health status.22 Greater the frequency of antenatal visits, more the chances of utilizing the maternal and child health services.23 In the cross sectional study done in Lucknow under National Rural Health Mission, 80% of the urban and 50% of the rural women had weight and blood pressure recorded and blood and urine tested.24 Another study on utilization of safe motherhood services by tribal populations reported that 83.3% received TT inj twice, received IFA. 79% had their BP measured, 80% had an abdominal examination, 78% had weight measured, 51% reported having a blood test and 41% had a urine test.25
Women who make antenatal visits are not provided with the full content of antenatal services in many places. In Uganda, where over 90% of women had received antenatal care, blood and urine analysis was not done for most women. Educating women and their family members on the identification of danger signs of pregnancy and delivery and health seeking behavior are important part of antenatal care. In Latin American and the Caribbean, North Africa, West Asia, Europe and certain countries in Sub Saharan region, a high proportion of women receive the essential services. In India also, blood and urine analysis was done for a high percentage of women, but only some women were informed about the warning signs of pregnancy. But in Cambodia it was the reverse.22 This “quality gap”26,27 is an indication that there are several “missed opportunities” at antenatal visits for delivery of effective measures, which can promote maternal and newborn health.28,29
12
The percentage of women using the full range of antenatal services is higher in the urban areas when compared to the rural areas.23 Maternal education levels also impact the utilization of services.30-33
Large surveys which attempted to examine maternal behavior and delivery outcomes, shows that utilization of antenatal care statistically influences birth outcomes in the urban areas. The same cannot be said about the rural areas, which highlights the importance of quality of care provided during the visits.34 Positive birth outcomes are not only a function of adequacy of care but also a consequence of various health promoting behaviors and attitudes.
Health systems should emphasize of quality rather than quantity to attain improvements in maternal and child health. Quality of health care reflects the extent of development of the health system. Quality improvements should pay attention to structure, process and outcome as well as the correct use of quality assurance measures.35
Levels of Utilization:
13
often make use of prenatal services.37 The percentage of women receiving essential services in these antenatal visits was not adequate. India had the highest proportion of women who had blood and urine analysis, but they were poorly informed of the danger signs of pregnancy complications. In Uganda only thirty five percent of women were informed of danger signs and only twelve percent had urine analysis done and about 50% of them had their blood pressure measured.22
Number of antenatal visits does not necessarily reflect the extent of utilization of antenatal services. The reasons why women utilize antenatal services are difficult to measure. Utilization of services is not uniform across countries and even within a country there may be very marked variations. The review also stated that the results of the studies on utilization should be viewed with the cultural and country specific factors in mind. More qualitative studies are needed to understand the factors that influence it. None of the studies examined user satisfaction as a factor influencing antenatal care use.37
14 Counseling and Utilization MCH services:
It is the responsibility of the health care provider to give the women and her family members the right information about pregnancy and childbirth. The National Collaborating Centre for Women’s and Children’s Health 2008 guidelines on antenatal care revealed that women preferred information that was given in a way in which they understood. They wanted difficult concepts to be made simple and explained to them for easy understanding. The women also felt that they would prefer to discuss with the health care provider freely about health care issues.39
All key issues regarding pregnancy, delivery and care of the newborn should be explained explicitly. Counseling should take into consideration the overall context in which the people live, their felt needs and use various methods to suit the situation. The family members should also be included in the counseling sessions. Family members of the delivering women should be guided to develop an emergency preparedness plan.40
One to one counseling is one of the most effective methods of counseling. Job-aids like video clippings etc., help to improve the counseling process. Antenatal women were able to understand the concepts better by following the images and it also helped the health care workers to give counseling in a structured pattern.41
Pre-pregnancy weight:
Alderman et al in his states that women in their early 20s are more likely to be underweight compared to women in the age group of 40. It is in the 20s that most of the Indian women get pregnant.42
15
pre-pregnancy body mass index of Indian women were lesser than that of women in the Sub Saharan Africa. The weight gain during pregnancy was the same among both these women.43 This finding is very similar to the result of a hospital based study conducted in Indonesia by Lubanraja et al. According to this study normal body mass index before pregnancy resulted in adequate birth weight of the baby. This study also added that total weight gain during pregnancy as a significant predictor of birth weight.44 Another meta- analysis study done by Han et al, also added evidence stating that underweight pregnant women in both developed and developing countries, were at increased risk of having an LBW infant with a Relative Risk of 1.48, 95% CI 1.29–1.68, and 1.52, 95% CI 1.25–1.85, respectively. This study also examined the association between underweight women and preterm birth (PTB) wherein it was found that underweight women in developed countries had an increased risk of PTB (RR 1.22, 95% CI 1.15–1.30) but not in developing countries (RR 0.99, 95% CI 0.67–1.45).45
Weight Gain during Pregnancy:
Ludwig et al in his study involving a within family comparison states that there is ample proof that nutritional status during pregnancy influences the birth weight and improves the survival of the newborn.46 A systematic review by Siega Riz et. al. reported that weight gain during pregnancy has an influence on the health of the mother and her baby.47
16
Table 1. Institute of Medicine Weight Gain Recommendations for Pregnancy
Pre-pregnancy Weight Category
Body Mass Index*
Recommended Range of Total Weight (lb)
Recommended Rates of Weight Gain† in the
2nd & 3rd Trimesters (lb)
(Mean Range [lb/wk])
Underweight Less than 18.5 28–40 1 (1–1.3) Normal Weight 18.5–24.9 25–35 1 (0.8–1) Overweight 25–29.9 15–25 0.6 (0.5–0.7) Obese (includes all
classes) 30 and greater 11–20 0.5 (0.4–0.6) *Body mass index is calculated as weight in kilograms divided by height in meters squared or as weight in pounds multiplied by 703 divided by height in inches.
†Calculations assume a 1.1–4.4 lb weight gain in the first trimester.
Source: Modified from Institute of Medicine (US). Weight gain during pregnancy: reexamining the guidelines. Washington, DC. National Academies Press; 2009. ©2009 National Academy of Sciences.
The impact of nutrition education and counseling was more evident when women were provided with food and micronutrient supplements.50,51
Anaemia & IFA supplementation
17
Anaemia has major consequences on the health of the mother and the baby. Globally anaemia contributes to 115,000 maternal deaths and 591,000 perinatal deaths every year.54 Severe anaemia in pregnancy leads to intrauterine growth retardation, still births, low birth weight and neonatal deaths. Twenty percent of maternal deaths in India are directly related to anaemia.55Level of wealth, educational status and caste are indirect indicators of access to services that help to lower the exposure to risk factors of anaemia.56 Anaemia in pregnancy leads to increased perinatal morbidity and long term effects on the development of the child.57The high demand for iron during pregnancy cannot be supplied by diet alone.58
WHO strongly recommends IFA supplementation as it helps to reduce the incidence of low birth weight babies.59 Iron compliance is an important factor in IFA supplementation programmes.60 In developing countries like India, there are various causes that contribute to decreased adherence to iron supplementation including, misunderstanding of instructions, side effects, cultural beliefs, and inconvenient dosing regimens. In addition one may cite access to motivated and trained health professionals.61 Consumption of iron in high doses is associated with nausea, vomiting and constipation. The recommended tolerable limit for iron consumption during pregnancy is 45 mg / day.62 Women may avoid supplements because they believe the pills can cause miscarriages, large babies and difficult deliveries, or they associate iron with more bleeding at delivery.63
18 Nutritional Education and Counseling & Anaemia Prevention:
Oluwafunke Olude states that NEC strategies should focus on increasing the intake of heme and non heme foods, decreasing the intake of iron absorption inhibitors, encouraging iron-folic acid compliance and educating about consequences of being anaemic.67 Socioeconomic factors such as access to adequate health care, food availability, environmental sanitation and personal hygiene which contribute to inadequate diet and substandard disease control and prevention also contribute to anemia.68
Birth Weight:
Low birth weight babies are mostly the outcome of maternal malnutrition.69-71. Intake of essential micronutrients during pregnancy has led to increased birth weight of babies.
70-73
. Complications of pregnancy, nutritional deprivation and stress are other factors which affect the growth of the foetus.74Low birth weight is an important cause for neonatal deaths in developing countries.75and is associated with perinatal morbidity and risk of long term disability.76Preterm birth contributes to increased incidence of low birth weight.77
Abu Saad in his review clearly brings out that maternal nutrition is directly related to foetal growth and birth outcomes.78 A research carried out in Vietnam studied the influence of gestational weight gain on birth weight of the baby for specific BMI category of the mother.79
19
reduced the risk of pre-term birth, There was evidence of high statistical heterogeneity for mean birth weight, but not for pre-term birth.80
Evidence from cohort studies report that total gestational weight gain and exceeding the Institute of Medicine maternal weight gain recommendations were associated with higher z score and elevated risk of overweight or obesity in offpring.81,82
Breast feeding Practices:
Breast feeding is one of the most important interventions to prevent childhood morbidity and mortality.47,83 WHO recommends early initiation of breast feeding and continued exclusive breast feeding for six months of infancy to promote optimal growth and development.47 The mother is advised to continue breast feeding for upto two years and introduction of complementary feeds at the age of six months to meet the growing needs of the baby.84 It has also been shown that measures which promote optimal breast feeding prevents 13% of deaths and optimal complementary feeds prevent 6% of deaths in countries with high mortality rate.85
20
The most common reasons for stopping EBF before six months include perceived lack of milk supply and sore nipples.83 If a woman understands the positive effects of breast feeding on her and her baby’s health, and the harmful effects of formula feeds, she is more likely to exclusively breastfeed her baby for a longer duration.88 A descriptive study from Pondicherry reported that awareness related to breastfeeding among mothers who were given counseling was higher than in women who did not receive counseling. But awareness on correct breast feeding technique was the same between the two groups. Many of the problems of breast feeding can be overcome if the mother is counseled in the antenatal period on the benefits of breastfeeding and adequately supported by the family members and the health care workers.86
Maternal Morbidity:
Maternal morbidity is unique to women. The implications of maternal morbidity extend far beyond the antenatal, intranatal and postnatal period. It may lead to long term morbidities, disability and sometimes to death. It not only affects the mother but it also impacts on the health of her children.89 For every case of maternal mortality there are 20 to 30 women who experience short term or long term ill health that very often disrupts normal life.90,91
Globally maternal deaths account for 2.7% of deaths among women and for 12% of deaths in women of reproductive age group. In South-East Asia maternal deaths contributes to 14% of deaths among women of reproductive age group. An estimated 15-20 million women are affected with maternal morbidities and disabilities worldwide.92,93
21
who have had far too many pregnancies and women without easy access to health services are those who may be most affected.96
Many researchers have tried to study maternal ill health in different health settings. But there is no common terminologies that describe the maternal morbidities and disabilities and the quantitative study methods used are also not uniform.89 There are no standard definition or identification criteria. The Maternal Morbidity Working Group (MMWG) defines maternal morbidity as “any health condition attributed to and/or aggravated by pregnancy and childbirth that has a negative impact on the woman’s wellbeing”.97
The three delays model developed by Thaddeus and Maine in 1994 has been widely cited by many articles even to this day. It explains the principles underlying maternal morbidities. They are:
1. Most maternal morbidities are emergencies 2. They cannot be accurately predicted. 3. Most maternal deaths can be prevented.
The three levels of delay are:
1. The first delay is the time between the onset of the condition and the time taken to identify it as a morbidity that requires shifting of the mother to a health facility.
2. The second delay is the time between leaving the home and reaching the hospital. 3. The third delay is the time between reaching the health facility and getting
appropriate treatment98
22
causing only discomfort, others which become dangerous and yet others which become immediately lethal. They may either be recognized or they may go unrecognized. Certain conditions may appear as single events which resolve by itself or with treatment, or continue to produce long term effects, while other conditions may be recurrent.99
The maternal morbidity conditions that commonly affect women are haemorrhage, obstructed labor, prolonged labor, hypertensive disorders of pregnancy, complications associated with abortion and ruptured uterus.100 Haemorrhage, hypertensive disorders of pregnancy, obstructed labor and obstetric infections were reported as the most common reasons for disabilities and deaths in the first 6 weeks following delivery. Urinary tract conditions and mental health issues are also some of the common maternal morbidities that are reported.101,102
A retrospective cohort study of 412 women of two Aboriginal communities of Australia, showed that despite the high rate of service utilization, maternal morbidities was high comparable to developing nations. Despite the high rate of service utilization, the maternal morbidities which was reported was high and comparable to that of any developing nation's statistics. Aneamia and urinary tract infection was the most common complication during pregnancy. Twenty two percent of women had anaemia which required blood transfusion. Post partum haemorrhage was the most common complication after delivery. This study pointed out that inadequate quality of care and delay in accessing as reasons for this higher rate of maternal morbidities despite accessing heath care services. It also brings out the great disparity in the pregnancy and childbirth between the Aboriginal women and other women of Australia.103
23
was found that only 59.2% of the women with complications sought health care. The factors identified to be associated with seeking health care included antenatal care services by a health care provider (OR – 1.7, 95% C.I.1.1,2.7), belonging to wealthier quintile (OR = 2.5, 95% CI; 1.3, 4.6) and women with a prior plan to possible complications. (OR = 2.5, 1.6, 3.9.104
Intrapartum abnormalities were the main predictive factor triggering maternal morbidity conditions.101 A prospective cohort study to identify the postnatal consequences of pregnancy and childbirth among women done in Matlab between 2007-2008, showed that women with intrantal complications were at a greater risk of postnatal morbidities.105
The health status of women is highly influenced by the social, cultural and economic factors. The place of residence, whether rural or urban, also determines the level of health. An article by Koblinsky et al reported that the likelihood of postpartum morbidity was high among women aged <20 and >35 years, coming from families with poor per capita income, are unmarried, with low level of education, and past obstetric complication.89
24
Infant Morbidity:
According to WHO, every year around twenty five million babies are born with a low birth weigh. These babies need special care as they are more prone to infections, hypothermia and other respiratory conditions. The Indian Council of Medical Research (ICMR) used a risk score which attempted examine neonatal morbidity and mortality. An increased risk score was associated with low birth weight, neonatal morbidity and neonatal mortality. It had a high sensitivity and low specificity in predicting the outcome. Applying this scoring system at the field level needs further evaluation.108
Globally neonatal deaths account for 3.6 million babies.109,110 Among them seventy five percent happen in the first week following birth and these deaths 25-45% occurs in the first 24 hours of life. Most of these deaths are due to low birth weight, prematurity, infections and congenital anomalies. More than sixty percent of these newborn deaths can be prevented by timely and effective health interventions.101
Fig 1: Conceptual framework of social determinants of infant morbidity/ birth outcomes.
25
According to Solar and Irwin’s conceptual framework, access and utilization of health care including prenatal care is a determinant of infant morbidity, but a lesser important one when compared to the other social determinants.111 A community based birth cohort study conducted in Vellore district of Tamil Nadu, has shown that anaemia in pregnancy and preterm births are independent prenatal risk factors for LBW.112 According to a narrative review conducted by Dolotian in Iran studies showed significant relationships between absence, lack, or irregularity of prenatal care and preterm delivery in four out of six investigations.113 A population based study on women conducted in Manitoba, Canada reveals that there is a strong association between utilization of prenatal care services and pregnancy outcomes. Adequacy of prenatal care may be assessed using two indices namely R-GINDEX and the APNCU.114
A prospective study done in South India showed 3.28 episodes of illness during the period of infancy. The morbidity was higher in male babies. The high incidence of infant morbidity indicated low health status of the people and exposure of the babies to poor living conditions and defective feeding practices.115
26
MATERIALS AND METHODS
Study design:
A non randomized controlled trial was carried out with one intervention group and one control group. The women assigned to the intervention group were given focused counseling in addition to routine care. Women assigned to the control group received routine care alone. The participants were followed up during antenatal period, postnatal period and up to 6 months following delivery. Their babies were followed up from birth to six months of age. The objective of the research was to study the influence of focused counseling on adequate utilization of recommended MCH services and maternal and infant morbidity.
Research setting:
27 Selection of study area:
A multistage sampling method was used to select the study area. In the first stage of sampling two corporation zones of Chennai were chosen by simple random sampling. In the second stage of sampling one health post was chosen from each of the selected zones by simple random sampling (Fig 3). Vadapalani health post area from Vadapalani Zone was chosen as the intervention area and Wadia Nagar health post area from Pulianthope Zone was chosen as the control area.
28
Fig 3 - Sampling Method
Sample size calculation: For sample size calculation, anaemia which is the most
common cause of morbidity among pregnant women, is taken as the parameter. As per National Family Health Survey III, 58.7% of pregnant women are found to be
anaemic.116 Expecting a 40% reduction in the prevalence of anaemia among pregnant women in the intervention group, the sample size was calculated as follows:
2 2 1 2 /2 ) (p ) Z )( 1 )( ( 2 p Z p p n − + −
= β α
n = sample size in each group
= Proportion in control group = 59% = Proportion in intervention group = 35.4%
p =
= .
= 47.2
/= Z value for α at 0.05 = 1.96 = Z value for β at 0.20 = 0.84
Calculated sample size in each group: 2
2 ) 354 . 0 (0.58 ) 96 . 1 84 . 0 )( 472 . 0 1 )( 472 . 0 ( 2 − + − =
n = 70
Expecting a 10% dropout rate the sample size was estimated to be 77. Applying a design effect of 2 the calculated sample size in each group was 154 antenatal women. This study utilized a non randomized controlled design. Only the intervention and the control areas
Simple Random Sampling Simple Random Sampling
Pulianthope Vadapalani
Vadapalani West
(Intervention Area) (Control Area) Wadia Nagar Zone
HP
29
were randomly selected. The antenatal women in the individual groups could not be randomly selected under field conditions. This may lead to a loss of variability as women residing in a particular area and availing the health care services from a particular health centre may be homogenous and show correlation within the group. To make up for the loss of variability, design effect was used which increases the sample size and improves the validity of the study.
Study subjects: In both the intervention and control areas pregnant women who
registered in the first 12 weeks of gestation and residing in the catchment area of the selected health facilities and willing to participate in the study formed the study population.
Exclusion criteria: Women with documented pre-existing conditions like heart disease, renal disease, diabetes, hypertension, thyroid disorders, etc were excluded.
Study period: Enrollment of the study participants was started from the month of April
2013. The women were followed up through antenatal, postnatal and until six months following delivery. Their babies were followed up from birth to 6 months of infancy. The counseling and follow-up were completed in October 2014.
Study Outcome: In this study, focused counseling, which is the intervention tool, is
30
PROCEDURE:
(i) Procedure in the Intervention Area:
The name, address and contact number of eligible pregnant women were obtained from the health post records of the intervention area. The women were contacted over phone and according to their convenience an appointment was fixed to meet them at their house. In that visit, the purpose and procedure of the study was explained, and those women who were willing to participate were enrolled in the study after obtaining a written consent. Consecutive eligible women were enrolled in the intervention group till the required sample size of one hundred and fifty four was reached. On enrolment the women were assigned unique study identification number, which is entered in the data collection tool developed for the study.
The antenatal woman, the spouse and her family members were given focused counseling during antenatal, postnatal and up to 6mths following delivery in addition to routine care given by the health centre. During the antenatal period, focused counseling sessions were given on four occasions, once in first 12 weeks, 20–24 weeks, 28–32 weeks and 36–40 weeks of gestation respectively. Focused counseling sessions were also given on four occasions following childbirth, once in the 1st week, 5th week, 7th week, and 4th month. A visit was made in the beginning of 7th month to collect data up to 6 months following child birth as per study protocol.
31
Counseling following delivery: The first two sessions that were in the postnatal period, was generally given at home. The subsequent counseling sessions were either at home or at the health centre when the mother came to the health centre for health care either for herself or for the child eg. immunization of the child.
Data collection: At the first counseling session, which lasted for 35 – 40 minutes, details
pertaining to socio demographic profile, obstetric profile, services availed by the antenatal woman and any high risk condition identified during the first antenatal visit were obtained. On subsequent sessions, information on MCH services availed, morbidity conditions experienced and health seeking behavior, and other particulars were collected. The subsequent sessions lasted for 15 – 20 minutes. The information was collected at the time of counseling by interviewing the mother and also from the records available with the mother. This was entered in the tool developed for the study. The general schedule and broad components of the focused counseling sessions is given in the instruments used section.
(ii) Procedure in the Control Area:
32 Data collection: Information on socio-demographic profile, obstetric profile, services
availed and any underlying problems identified in the first antenatal visit were obtained in the first contact when the antenatal woman was enrolled for the study. The next contact was at the health centre at 32 weeks of gestation. Subsequent contacts in the 2nd month and 4th month following delivery were either at the health centre or / in the area when the mothers brought their babies for immunization. The last contact was at the beginning of seventh month to collect information on the mother and child up to 6 months following delivery. The information on antenatal, intra-natal, postnatal and beyond postnatal period were obtained either from the health centre records or the MCP card available with the health worker or from the MCP card retained by the mother. Certain information like, feeding practices was collected directly from the mother when she came to health centre. The information was then entered in the tool developed for the study and this information was used for analysis.
Instruments used:
(1) Maternal and Child Health card (Developed for the Study)
A new MCH card was designed for the study. This card had provisions for additional information to be entered on counseling sessions and other study variables. Details of health status of mother and infant upto 6 months following delivery, infant feeding practices including breastfeeding and morbidity pattern and care seeking behavior of the mother and baby were included. The MCH card was pretested in the field and necessary changes were made to it. Information collected from the mother was entered in the MCH card and this data was used for analysis.
(2) Focused Counseling Guide
33
knowledge and attitude of men towards care of their spouses during antenatal, childbirth and in the period following delivery, and how they actually take care of their spouses and babies. In-depth interviews were conducted with 5 recently delivered women and 5 men whose wives had delivered in the last six months. One focus group discussion was also conducted with a group of 8 men whose wives had recently delivered. A focused counseling guide was prepared based on World Health Organization (WHO) manual on Integrated Management of Pregnancy and Childbirth.117 The information that emerged from the in-depth interviews and focus group discussion was then incorporated to suit local conditions.
(3) Schedule & Components of Counseling Sessions
34
Schedule and Broad Components of Focused Counseling Sessions during Antenatal Period:-
1. First counseling session (In first 12 weeks of gestation)
1.1. Adequate utilization of recommended maternal health services
1.2. Supportive Environment
1.3. Self-care: Personal hygiene, rest, safe sex, avoid all forms of tobacco / alcohol, avoid lifting heavy weights, avoid hard physical labor, avoid unnecessary medication.
1.4. Nutrition
1.5. Identification of danger signs & health seeking behavior
1.6. Maternity Benefit Schemes
2. Second counseling session (20 – 24 weeks)
All issues counseled in the first session were reinforced in the second session. In addition, counseling was also given on:
2.1. Iron & Folic acid supplementation 2.2. Birth & Emergency Preparedness
2.3. Early and Exclusive Breastfeeding
3. Third counseling session (28 - 32 weeks)
All issues counseled in the second session were reinforced in the third session. In addition, counseling was also given on:
35 4. Fourth counseling session (36 - 40 weeks)
All issues counseled in the third session were reinforced in the fourth session. In addition, counseling was also given on care of the Newborn
B. Schedule and Components of Focused Counseling Sessions during Postnatal and Beyond Postnatal Period
1. First session (Immediate Postnatal period – Within 1 week)
1.1. Postnatal care and Hygiene 1.2. Supportive Environment 1.3. Nutrition
1.4. Iron & Folic acid supplementation 1.5. Postnatal visits
1.6. Family Planning& Contraception
1.7. Care of the newborn including how to keep the baby warm 1.8. Exclusive Breastfeeding
1.9. Correct positioning & Attachment for breastfeeding
1.10. Identification of danger signs in the mother (including heavy vaginal bleeding) and infant & appropriate care seeking.
1.11. Immunization of the Infant
2. Second Counselling session (5th week following delivery)
36 3. Third Counselling session (7th week following delivery)
All issues counselled in the second session (except postnatal visit) were reinforced in the third session of focused counselling following delivery.
4. Fourth Counselling session (4th month following delivery)
All issues counselled in the third session were reinforced in the fourth session of focused counselling following delivery. Mothers were also counselled on introduction of
complementary feeds.
Ethical Approval: Institutional Ethics Committee clearance was obtained from Government Kilpauk Medical College, Chennai, and permission to carry out the study was obtained from Corporation of Chennai. An informed written consent was obtained from all the participants.
Operational Definitions:
Adequate utilization: Utilization of all recommended maternal and child health services
provided by the public health care delivery system.
37 (i) Mother:
a. Antenatal visits: Recommended minimum number of check-ups during AN period:
First visit : In the first 12 weeks Second visit : 20 – 24 weeks Third visit : 28 – 32 weeks Fourth visit : 32 – 36 weeks Fifth visit : 36 – 40 weeks
b. Weight and blood pressure recording - on every visit.
c. Hemoglobin and urine analysis for albumin and glucose - on every visit. d. Blood glucose estimation - 3 times (once in each trimester).
e. Ultrasonogram (USG) – once before 28 weeks of gestation. If indicated, it may be repeated.
f. Injection Tetanus toxoid– 2 doses, the 1st dose on confirmation of pregnancy and 2nd dose, four weeks after the first dose. In women who had their last child birth within 3yrs, one Booster dose is given.
g. Antenatal Iron supplementation – 100 tabs of Iron and folic acid during antenatal period. The antenatal woman is advised to take one tablet a day for 100 days starting from second trimester.
h. Tab. Albendazole – A single dose of tab Albendazole given for deworming in the second trimester.
i. Maternity Benefit Schemes: Janani Suraksha Yojana and Dr.Muthulakshmi Reddy Maternity Benefit Scheme.
j. Institutional delivery
38 (ii)Infant:
Immunization -
At birth - BCG, '0' dose Oral Polio Vaccine (OPV) and Hepatitis B 6 wks – I dose of Pentavalent vaccine & OPV
10 wks – II dose of Pentavalent vaccine & OPV 14 wks – III dose of Pentavalent vaccine & OPV
Focused counseling: Focused counseling is defined as counseling guided by each
woman’s individual situation. It is holistic individualized counseling of the mother, inclusive of the husband and other family members, to help maintain the normal progress of her pregnancy.
Family members: Husband, mother in law, mother of the antenatal woman and other
decision makers in the family.
Maternal Morbidity: Any health condition attributed to and / or aggravated by
pregnancy and child birth that has a negative impact on the woman’s wellbeing.119 As the mother and the foetus are usually considered as a single unit, maternal morbidities in this study includes both maternal and materno-foetal conditions that directly or indirectly affect the physical, mental or social well being of the mother as included in Table 1.
Infant Morbidity: A disease condition or state from birth to six months of age. All
39 Table 2: Maternal Morbidities
PREGNANCY LABOR PUERPERIUM
Hemorrhage Severe Headache & Blurred vision Obstructed Labor Hemorrhage
Seizure Hemorrhage Prolonged labor High fever
Severe Headache & Blurred
vision
High fever Cervical dystocia Fever with:
Bad smelling mucus
Or discharge
Low abdominal pain
Burning micturition
Mastitis
High Fever Seizure Placental retention
Fever with Burning micturition Intrauterine death Failed Induction
Jaundice Still birth Preterm labor
Hypertensive Disorders of
Pregnancy
Induced abortion Premature rupture of
membranes
Paleness Spontaneous abortion Foetal distress
Dizziness & Fatigue Rupture of uterus / cervix / vagina Diminished liquor High BP
Severe Vomiting Perineal laceration Polyhydramnios Seizure
Violence during pregnancy Hypertensive Disorders of Pregnancy Malposition of foetus Infected Caesarean Wound
Ectopic pregnancy Placenta previa
Gestational Diabetes Mellitus Cord around the neck
Cephalopelvic disproportion
Multiple pregnancy
Mobile head
40 Table 3: Infant Morbidities
CONDITIONS REQUIRING ADMISSION UNPROMPTED REPORTING BY MOTHER
Respiratory Distress Syndrome (RDS) Not feeding well
Birth Asphyxia Breathing difficulty
Sepsis Fever
Meconium Aspiration Syndrome Convulsion
Neonatal jaundice Diarrhoea (ADD)
Congenital anomaly Boils
Pneumonia Jaundice
Seizures Redness/discharge from the umbilicus
Shock Loss of weight
Very Low Birth Weight Ulcer in the mouth
Cough and cold (ARI)
Rash
Burning Micturition
Fits
Others (mention)
41
RESULTS AND ANALYSIS
In the intervention and control areas, 154 and 156 antenatal women were enrolled respectively after obtaining informed consent. The number of antenatal women enrolled and followed up is shown in Figure 4.
[image:61.595.103.536.210.487.2]
Fig 4: Enrolment and Follow-up of Study Participants
In the intervention area five women had abortions and four other women were lost to follow up because they had moved out of the study area. One hundred and forty five women had live births. There were no still births. There was one neonatal death, but there was no maternal death. 150 women were followed up for 6 months following the end of pregnancy.
42
births. There were no still births. There was one neonatal death but there was no maternal death. 150 women were followed up for 6 months following the end of pregnancy.
Plan of Analysis
I. Characteristics of Study Participants - Socio- demographic and Obstetric profile II. Utilization of Antenatal services
1. Antenatal visits
2. Antenatal services availed during the visits 3. Identification of risk factors
4. Outcomes of Utilization of services
III. Outcome of Pregnancy
1. Type of delivery 2. Birth weight
3. Complications during delivery
IV. Postnatal services:
1. Contraception – Tubectomy and Intra Uterine Device (IUD)
2. Feeding practices – Time of Initiation of breast feeding, duration of Exclusive Breastfeeding
3. Immunization of the baby
V. Morbidity in the mother and baby
1. Maternal Morbidity - Antenatal, Intra-natal & Postnatal Morbidity 2. Infant Morbidity: Neonatal & Post neonatal Morbidity
43
I. Characteristics of the Study Participants
1. Socio-demographic profile
1.1. Age of the Antenatal Women: The age distribution of the study participants is given in
[image:63.595.98.536.459.712.2]Table 4. There are an equal proportion of women in the 20 – 25 yrs and 25 – 30 yrs age category in the intervention group. In the control group greater number of women belonged to the 20-25 years age group. There was no pregnant woman aged less than 19 yrs. The mean ages of the women were 25.4 yrs (SD 3.6yrs) and 25.2 yrs (SD 3.9yrs) in the intervention and control group. Pearson’s Chi square test at 0.05 percent alpha level, carried out to examine the relationship between the two groups and category of age, did not show any significant relationship. [Chi square value = 2.208, degree of freedom (df) = 3, p value = 0.503]. There was no statistically significant difference in the age groups of the women between the intervention and control groups.
Table 4: Age distribution of Antenatal women
Intervention Group Control Group
Age Category No. of AN women
n = 150 %
No. of AN women
n = 150 %
< 20 yrs 3 2.0 4 2.7
20 - 25 yrs 63 42.0 68 45.3
25 - 30 yrs 63 42.0 55 36.7
30 yrs & above 21 14.0 23 15.3
Total 150 100.0 150 100.0
44 1.2. Education of the Antenatal women: Almost 98% of the women had some form of
formal education in both the groups. There were more graduates in the intervention group. The distribution of the educational status of the antenatal women is shown in Table 5. Fisher’s exact test, at an alpha level of 0.05 percent, carried out to study the relationship between the two groups and educational status of antenatal women, did not show relationship between the two variables [Fisher’s Exact value = 5.847, p value = 0.322]. There was no statistically significant difference between the two groups.
Table 5: Education of Antenatal women
Intervention Group Control Group
Education Status
No. of AN women n = 150
%
No. of AN women n = 150
%
No formal education 3 2.0 2 1.3
Primary School 8 5.3 8 5.3
Middle School 23 15.3 38 26.3
High School 56 37.3 56 37.3
Higher Secondary School 25 16.7 20 13.3
Graduate & Above 35 23.3 26 17.3
Total 150 100.0 150 100.0
45 1.3 Education of the Husbands: All the husbands of the antenatal women belonging to the intervention and control groups had some form of education, except 2 men in the intervention group who had no formal school education. The distribution of the educational status of the husbands is given in Table 6. Fisher’s exact test, at an alpha level of 0.05 percent, was done to examine the relationship between the two groups and educational status of the husband. There was no statistically significant difference in the educational status of the husbands between the two groups [Fisher’s Exact value = 6.595, p value = 0.232].
Table 6: Education of the Husband
Intervention Group Control Group
Educational Status No. of Husbands
n = 150 %
No. of Husbands
n = 150 %
No formal education 2 1.3 0 0.0
Primary School 5 3.3 8 5.3
Middle School 25 16.7 30 20.0
High School 58 38.7 52 34.7
Higher Secondary School 18 12.0 28 18.7
Graduate & Above 42 28.0 32 21.3
Total 150 100.0 150 100.0
Fisher’s Exact Value = 6.595 p value = 0.232
1.4 Occupation of Antenatal women: Most of the antenatal women in the intervention and
46 1.5 Occupation of the Husbands: Pearson’s Chi square test was conducted to study whether there was a relationship between occupational status of the husbands and the intervention groups. The results revealed that there was a statistically significant relationship between the two variables [Pearson’s Chi square value = 16.270, df = 2, p value = <0.001]. There were significantly more casual labourers among the control group (28%) compared to the intervention group (12.7%). And significantly more husbands who were self-employed (23.3%) in the intervention group compared with contro
