Background                                                                                              

Antenatal care around which revolves the whole science of pregnancy care¹,  is the key entry point for pregnant women to receive a range of health services, nutrition advocacy, prevention, detection and treatment of anaemia and other preexisting illnesses, in addition to timely diagnosis and therapy of pregnancy specific disorders, monitoring of the baby’s growth and abnormalities and also get screened for disorders which affect future life. It is also an opportunity to promote birth preparedness, complications readiness (BPCR) and become aware of necessity of skilled attendance at birth and postpartum care for women and newborns. This is also ideal time to counsel about the appropriate breastfeeding as well as contraception. So it is essential that women have positive attitude towards antenatal care, not only when they are pregnant but preconception too. Johnson et al² also reported that pregnancy-related outcomes can be improved preconception by finding out women’s knowledge, perceptions about antenatal care and advocacy accordingly.

Objective

Community based study was carried out to know about rural tribal women’s awareness and attitude towards antenatal care preconception, during pregnancy and antenatal care sought by pregnant women.

Material and Methods

After ethics committee’s approval study was conducted in tribal communities of 100 villages of hilly forestry Melghat region of Amravati, Maharashtra, India. In these 100 villages community based mother and child care activities were initiated after having developed a health facility for 24 hrs 7 days services in one of these villages. After consent information was collected through pretested tools in the language which they understood, with some questions for yes or no answers and others open ended for short answers. It was decided to include minimum 20 preconception women of 15-45 years in each village randomly, making a total of 2400 study subjects. Interviews included information about awareness regarding antenatal care. Amongst 1040 pregnant women information included awareness as well as antenatal care seeking.

Results

Of 2400 preconception women interviewed, 42.8% did not even think that antenatal care was necessary. Though 1372 (57.2%) women did say that antenatal care was necessary, their knowledge was scatchy. Some said it was for maternal wellbeing (14.07%), others said fetal wellbeing (14.9%), preventing complications (15.7%), getting advice about diet (11.09%), hygiene (15.7%) and medication (27.6%), with some overlap. Out of those women who said ANC was needed, 20% said that only one antenatal visit was enough, 19.33% said 2-3 visits, 20.25% said 4-5, and only 18.54% said more than 5 visits were necessary. When asked about contents of the care, their ideas were scatchy, 19.96% women opined that urine should be tested, 14.17% said height should be measured, 15.53% said weight, 19.25% Hemoglobin, 16.17% said Blood pressure and 18.13% said sugar should be tested, with some overlap. Overall only 58.75% women said that additional or special food was required during pregnancy, of which 36.24% said four times meals, 28.44% women said that green vegetables were needed, and only 35.32% said milk was necessary.

A total 1040 pregnant women were interviewed, of which 957 (92%) had antenatal care, one to six visits. Overall 783 (81.8%) women were not told about any abnormalities, however 174 (18.2%) were told that something was wrong without any details, as nothing was told to them about abnormalities. Of 1040 women, overall 323 (31.05%) were of 15-19 years and of them 306 (94.7%) had antenatal care, 148 (48.4%) had 1 to 2 visits, 96 (31.4%) 3-4 visits and 62 (20.3%) 5-6 visits. Of 306 pregnant women 14 (4.6%) were told that everything was not normal but what was abnormal they did not know.

Overall 56 (5.38% of 1040) were illiterate, 34 (60.7%) sought antenatal care, 16 (47.1%) once or twice, 16 (47.1%) three to four times, only 2 (5.9%) five or six times. Sixteen women (47.1%) said that they were told that all was not well but what was the abnormality they did not know. Of 321 (30.86%) high school educated women, 285 (88.8%) had sought antenatal care, 131 (46%) had 1 to 4 visits, 103 (36.1%) had 3 to 4 visits and 51 (17.9%) 5 to 6 visits and 31 (10.9%) were told that there were problems but they did not know what was the abnormality.

Of 1040 pregnant women, 804 (77.30%) were of economically low or low middle class, 790 (98.25%) had sought antenatal care, 355 (44.93%) once or twice, 307 (38.86%) 3-4 visits and 128 (16.20%) had 5-6 visits. And a total of 82 (10.37%) women were told that all was not well but they did not know anything more than that. And of the remaining 193 (18.55%) women of lower middle and middle class 165 (85.49%) women had sought antenatal care, 80 (41.45%) once or twice, 65 (33.67%) 3-4 visits and 20 (0.36%) had 5-6 visits. Total 14 (7.25%) were told of abnormalities with no details.

Of 943 housewives (90.6%) out of 1040 pregnant women, 882 (93.5%) had sought antenatal care, 303 (34.4%) had ANC once or twice, 461 (52.3%) 3-4 visits and 118 (13.4%) 5 to 6 visits and 3 (0.3%) were told that there were abnormalities without women knowing any details.

Of 1040 women, 117 (11.25%) were primigravida and 60 (51.3%) of them had sought antenatal care, 34 (56.7%) once or twice, 11 (18.3%) 3 to 4 visits and 15 (25%) had 5 to 6 visits and 3 (5%) were told that all was not well but they did not what was wrong. Of 820 (78.84%) women with 3 or more births, 813 (99.14%) had antenatal care, 578 (71.9%) had ANC once or twice, 178 (21.89%) 3-4 visits and 57 (7.1%) had 5-6 visits. Total 160 (19.68%) were told that there were problems with no details. Overall of 1040 pregnant women, 957 women (92%) had antenatal care either by nurse midwives or by medical officers at primary health centres. But only 234 (22.5%) of 1040 had done registration for place of delivery and 81 (34.6%) of those who registered did registration only at Aaganwadi, 100 (42.7%) at Subcentres and 53 (22.6%) at PHCs. Of 1040 pregnant women, 83 (8.0%) women did not seek ANC. When asked reasons for not seeking antenatal care 34 (41.0%) said they had no money, 23 (27.7%) had fear of going to medical facility, 12 (14.5%) said there was no medical facility around, 8 (9.6%) had family restrictions and 6 (7.2%) did not give any reason for not seeking antenatal care. When asked about knowledge about tetanus toxoid during pregnancy 992 of 1040 (95.4%) knew but 48 of 1040 (4.6%) were not aware. A total of 919 of 1040 (88.4%) had some knowledge of hygiene during pregnancy. 

Discussion

Hill et al³ reported that health professionals and policy makers should actively pursue opportunities to improve knowledge of reproductive age women through ANC clinics. Actually researchers found that 57% women knew about importance and the benefits of antenatal care. Getachew et al⁴ and Kawungezi et al⁵ reported that around 30% women considered antenatal care a waste of time and delays in antenatal clinics were worrisome. However researchers also reported that mother’s experience of abortions and stillbirths increased the probability of using antenatal care.

Onasoga et al⁶ reported only 58% women received regular antenatal care and 56% got registered in the first trimester, around 40% women did know about possible complications. In the present study overall of 2400 preconception women, 1028 (42.83%) did not even think that antenatal care was needed. Among those women who said yes, also knowledge was low, and scatchy. Overall 27.6% said ANC was for medicines, 15.7% for learning about hygiene and prevention of complications, 14.9% for fetal wellbeing, 14.07% for maternal wellbeing and 11.9% said for getting advice about diet. About minimum visits required for ANC, 21.88% women said it was not required at all, 20% said only once, 19.33% said 2-3 times, 20.25% said 4-5 times, 18.54% said more than 5 times. On asking about investigations also the information was scatchy, 19.25% said hemoglobin estimation, 18.13% said sugar, 16.96% urine test, 16.17% blood pressure and 15.33% weight and 14.17% said height should be measured during ANC visits.  Overall only 58.75% women said additional food was required during pregnancy, 35.32% said milk and 28.44% said vegetables were needed. Total 41.25% women said no additional food was needed.

The attitude was positive in 69.6% women in the study by Dulla et al⁷. Faye et al⁸ reported that women receiving antenatal care knew the importance of acceptable intake of protein, vegetables, fruits and milk during pregnancy and that green leafy vegetables and meat prevented anaemia. Takelab et al⁹ reported that utilization of at least one antenatal care visit by a skilled provider reduced the risk of neonatal mortality by 39% in Sub-saharan African countries. Grenier et al¹⁰ reported that ANC was associated with higher facility delivery rates in Nigeria.

Grenier et al¹⁰ also reported that low quality and low frequency of antenatal care were associated with lower uptake of facility based deliveries, believed to be a key intervention to reduce maternal and neonatal mortality. In the present study of rural tribal preconception women of reproductive age, 52% women were aware about anaemia, 43.3% women were aware that prevention and treatment of anaemia before pregnancy could prevent pregnancy complications like giddiness (34.6%), swelling (29.4%) and excess blood loss during delivery (36%). Overall 42% women were not even aware of that additional micronutrients were required during pregnancy and lactation, 41.65% said that calcium and iron supplements were needed and 58.51% said that high protein and high fibre supplements were sufficient. Patel et al¹¹ did a study to determine the level of knowledge, attitude, and practice of ANC among pregnant women attending the antenatal clinic at a Tertiary Care Hospital and reported that 58% women had adequate knowledge of ANC. Researchers found that almost all the variables such as age, education, occupation, parity, type of family, and socioeconomic status (SES) had a significant association with awareness about ANC.

In the present study of 1040 pregnant study subjects, 957 (92.0%) had sought antenatal care but 653 (68.2%) women had only once or twice, 201 (21.0%) three to four times and only 103 (10.8%) five to six visits. Out of those who received ANC, of them 174 (18.2%) said they were told that all was not well but, they did not know about the problems. Rest did not know anything. So quality care is essential. Lack of communication affects their care, may discourage for revisit and others to seek services. Overall 83 (8%) women had no ANC. Of 1040 women 957 (92%) who received ANC, many did not even have basic investigations like urine, albumin, sugar and hemoglobin. Of 1040 pregnant women, when asked about registration for birth only 234 (22.5%) had done, 53 (22.6%) at PHC, 100 (42.7%) at Sub Centre and 81 (34.6%) just at Aaganwadi Accredited Social Health Activists (ASHA) were to decide other things. A big number 806 (77.5%) had not planned place of delivery. Of 83 (8%) study subjects, when asked about not having antenatal care, 34 (41.0%) said they had no money, 23 (27.7%) had fear of going to medical facility, 12 (14.5%) said no medical facility was nearby and 6 (7.2%) said they were not aware. Of 1040 pregnant women, 48 (4.6%) had no knowledge about pregnancy care, 121 (11.6%) had no knowledge of cleanliness during pregnancy. Hijazi et al¹² reported that taking women’s experience of ANC as a key reporting for quality care is more likely to lead to increased utilization of ANC services by women in highly disadvantaged communities. Afulani et al¹³ reported that quality of ANC was suboptimal in both service provision and experience domains, with disparities in demographic and socioeconomic factors and facility type. More efforts are needed to improve quality of ANC and to eliminate the disparities. Awasthi et al¹⁴ reported that low education and lack of awareness among mothers, low socioeconomic condition, early marriage and pregnancy, inappropriate antenatal check-up, and cultural taboos were significant factors affecting the satisfactory utilization. Akowuah et al¹⁵ reported that to ensure adequate utilization of services, the government and other stakeholders should offer support to the less-privileged mothers. Gupta et al¹⁶ reported that the age, literacy status, socioeconomic status (SES), and type of family had significant association with the utilization of ANC services. Their study revealed that maternal literacy remained a key factor in the better utilization of antenatal services. Yadav¹⁷ reported that 50% women had good knowledge. 40% had average knowledge. In the present study knowledge regarding antenatal care in pregnant mothers and utility was much less in primi gravida and low socio-economic status and low educational level too affected antenatal care seeking. Ali et al¹⁸ reported that various factors associated with utilization of antenatal care have not been synthesized collectively. So group antenatal care was being advocated in which women attended a health facility at regular intervals with about 10 pregnant peers. The antenatal care provider, usually a nurse or midwife, performed brief but thorough exam in privacy while the women socialized and helped one another checked their vital signs. The provider facilitated discussion of important pregnancy education topics. Research suggested that model, which offered education and support as well as recommended clinical care, had the potential to improve perinatal outcomes in some populations. Byerley et al¹⁹  reported that African-American women who participated in group antenatal care in the United States demonstrated a significantly reduced risk of preterm births. Studies of the effects of group antenatal care revealed improvements in blood sugar control among pregnant women with diabetes, smoking cessation and decreases in rapid repeat pregnancy²⁰.  Strengthening counseling during antenatal care services that involved men together with partners is being recommended. Their involvement in antenatal care is identified as important in maternal health²¹.

Conclusion

Even in the present era quite a few preconception tribal rural women of low resource region did not think ANC was needed. Those who said it was needed also had scatchy knowledge. Of those pregnant women quite a few had ANC but some had only once and they had scatchy knowledge. Also information revealed that there was lack of proper communication between health providers and pregnant women which is essential to have impact and quality care.

Conflict of Interest- No conflict of Interest.

Table I: Preconception Awareness about Antenatal Care

Table II: Preconception Women’s Opinion of Number of Prenatal Visits