A cross sectional study to determine the reasons for non-utilization of reproductive and child health services in district Etawah

INTRODUCTION

The utilization of any of the social services, including health services, has never been equitably distributed throughout the society. People who have access to the facilities were generally found to make more use of them than the people who have neither knowledge nor access to the facilities.¹ In most developing countries such as India, utilization of basic health services has been remained very poor though there has been an increase in both the public and private expenditure on the provision of advanced health. Maternal health which is important in itself and for the health of the children, deals with the appropriate care of the mother both before and after the delivery. In India more than 50 percent of the newborn were reported to have low birth weight with a low likelihood of survival in the first year. The poor utilization of reproductive and child health (RCH) services also poses a serious threat to maternal and child health care.¹ As there is no reliable way to predict which woman will develop pregnancy-related complications, it is important that all pregnant women should have access to high quality of obstetric care throughout their pregnancies. Maternal complications and poor perinatal outcome were associated with non utilisation of antenatal and delivery care services. Poorer outcomes were seen in unbooked than booked pregnant females.² In lower and middle-income countries, less than 50% of all pregnant women have a minimum of four antenatal care visits.³ In India, the RCH programme aims at providing at least three antenatal checkups that should include weight and blood pressure measurement, abdominal examination, immunization against tetanus, and iron and folic acid prophylaxis, as well as anaemia management.⁴

The public sector, urban health care delivery system, especially for the poor, has so far been infrequent, far from adequate, and very limited in its reach. Although urban areas have more number of doctors per thousand population as compared to rural areas (80 percent of the doctors serve in urban areas), who do not face the transport bottleneck, yet these doctors were functionally inaccessible to a majority of the urban poor population. Cost, distance, viewpoint of health providers, and other factors put the secondary care and private sector facilities inaccessible to most of the poor urban residents. Other factors contributing to the inadequate reach of services were illegality, social exclusion of slums, hidden slum pockets, weak social fabric, lack of coordination among various stakeholders, and neglected political consciousness. The health of the urban poor is considerably worse off than the urban middle and high income groups and is perhaps even worse than the rural population.⁵

Socioeconomic factors have often been used as revelatory factors for low utilization of RCH services. These socioeconomic factors also have a complex relationship with some of the supply factors, and often in the scarcity of good data, it is very difficult to explain the poor utilization of RCH services.⁶

Objectives

• • To determine the reasons for non utilisation of RCH services among recently delivered women of district Etawah.
• • To suggest measures for the enhancement of utilization of RCH services by the community.

METHODS

It was a cross sectional study conducted on 80 recently delivered mothers in villages under 3 selected subcentres of each of the two blocks of district Etawah. The Study was done from July to September 2019 using purposive sampling technique. The data was collected by using pre designed semi-structured questionnaire.

Inclusion criteria

Recently delivered mothers with child upto 6 month at the time of interview, mothers providing consent for being the part of the study, mothers who were permanent resident of villages under selected subcenter of Etawah were included.

Exclusion criteria

Women unwilling to participate in the study, women having severe comorbidities such as cancer, fracture, etc., women whose child were more than 6 months at the time of interview were excluded.

Data analysis

The data collected were encoded into Microsoft Excel sheet and analysed using SPSS version 23. Data was analysed using appropriate statistical tests like frequency, percentage and mean. Charts like bar charts and pie charts were for presentation of data.

Methodology

Two blocks were selected randomly out of 8 blocks of district, Etawah. Three subcentres were selected randomly from each of the two blocks of Etawah district. Study was conducted in the villages covered under the selected subcentre to interview all recently delivered mother to find out the reasons for non-utilization of reproductive and child health services.

Selection of participants were done by asking ASHA of that village about the mothers who were recently delivered at their home and not having institutional delivery with no ANC registration or less than 4 ANC visits and had less than 6 PNC visits by the ASHA. Visit to all the villages under selected subcentre were done on every Thursday of the week. A total of 40 participants from Basrehar block were interviewed. To ensure comparability between the two blocks we also interviewed 40 participants from Jaswantnagar block. So a total of 80 participants were interviewed in the study.

Information was gathered under the following headings:

• • Reason for having non institutional delivery.
• • Reason for not getting money under the JSY scheme.
• • Reason for non-registration of pregnancy at any health facility.
• • Reason for not vaccinating their child.
• • Reason for no/partial intake of IFA tablets and tetanus toxoid during pregnancy.

RESULTS

Table 1 shows that most of the participants belong to age group of 20-24 (55%) and joint family (51.3%). Majority of the participants were educated only up to primary level (50%) and most of them were housewife (90%). Table 1 also shows that most of the participants belong to Hindu religion (95%) and majority belongs to lower middle income group (32.5%).

Figure 1 shows that most of the participants who delivered at home have not availed most of the RCH services adequately as most of the services have utilization proportion less than 10 percent with the exception of IFA tablet i.e, this service was availed by 40% mothers.

Table 2 explains that main reason for not having institutional delivery is long waiting time in hospital/lack of proper facilities (50%) followed by non-cooperative hospital staff (36.2%).Around 32% mothers thinks that better environment at home was the main reason for having home delivery.

Figure 2 shows that most common reason for not getting money under JSY was non issuance of JSY card (33%) and non-cooperative hospital staff (33%). Figure 3 shows that most common cause for no vaccination of child was that they don’t feel necessary to vaccinate their child (42%). Around 26% participant told that lack of information was the main reason for not vaccinating their child.

Figure 4 illustrate that most important reason for no consumption was that they feel there is no use of taking IFA tablets (53.1%). The other major reason was found to be fear of side effects like nausea, vomiting and gastritis. (17%).

Figure 5 shows that main reason for non-registration was no felt need (31.3%) and lack of money (31.3%). Around 30% don’t have any knowledge of ANC registration.

Figure 6 explains that non utilisation of contraceptive services was mainly due to objection by husband (45.5%) followed by poor accessibility of contraception (23.4%) and fear of side effects (19.4%). Figure 7 shows that not feeling necessary to take tetanus toxoid was major reason for not receiving tetanus toxoid (50%). Second most common reason was founded to be lack of information about tetanus toxoid information.

DISCUSSION

This current study revealed that the main reason for not having institutional delivery is long waiting time in hospital/lack of proper facility (50%) followed by better environment at home (31.8%). This was not found consistent with other studies where tradition was found main reason for not having institutional delivery in studies of Kushwaha et al (23.9%), Srivastav et al (36%) and Verma et al (39.5%). Other studies like Shukla et al, revealed the main reason for non-institutional delivery as no felt need (62.2%, 53% and 67.2% respectively).This difference may be due to different population setting.^7-12

Present study shows the most common cause for no vaccination of child was that they don’t feel necessary to vaccinate their child (42%). This was consistent with the study done by Mahajan H et al that also found no felt need as the main reason for low utilization of vaccination services (35.8%). In contrast to this study by Banerji B et al found the main reason for low vaccination utilization rate as lack of knowledge (66%).^13,14

The study revealed that contraception services usage was found only 3.8%. Main reason for such a low contraceptive usage was found to be objection by husband (45.5%), followed by fear of side effects (19.4%). This was in contrast to the study conducted by Malathi et al that revealed main reason for non-usage of contraception was wish of one more child (51%).¹⁵

This study shows that most of the participants who delivered at home have not availed most of the RCH services adequately as most of the services have utilisation proportion less than 10%. JSY services were utilised by only 5% participants. Main reason for this was non issuance of JSY card by ANM (33.3%) and non cooperative hospital staff (33.3%). While study conducted by Pahwa et al revealed 11% utilization of JSY services, but the reason was found consistent with our study i.e., non-filling of JSY card.41The study found that pregnancy registration proportion was only 6.5%. The major reason for no registration of pregnancy was found to be lack of knowledge (31.5%) and no felt need (31.5%). Studies conducted by Huirem et al revealed pregnancy registration proportion as 21.5% and 20.5%. Shukla et al revealed in their study no felt need as the main reason (63.8%) for non-registration of pregnancy.^10,11,16

The study found that 40% participants had nil/incomplete consumption of IFA tablets. Major reason for this was found to be no felt use (53.1%). Proportion of no or incomplete consumption of IFA tablet was found 33.7%, 41%, 34.6%, 54.3%, 14.3%, and 60.5% in studies of Srivastav AK et al respectively. The study conducted by Shukla M et al were consistent with our study that also revealed no felt need (63.8%) for nil/incomplete consumption of IFA tablets, while Kotresh et al revealed poor acceptability as the major reason for no consumption of IFA tablet.^8,9,15-17

This current study revealed very less utilization of different RCH services compared to other studies, the reason for this was that the study was done only on females who were delivered at home and other studies that have been done for this objective may have included both home and institutional deliveries.

CONCLUSION

The main reason for having non institutional delivery was found to be long waiting time at hospital in the study done for determining reason of non-utilization of RCH services. This study revealed lack of knowledge, no felt need and financial constraints as the most common reason for not utilizing the different RCH services.

Recommendation

For increasing proportion of institutional deliveries in villages the 24×7 subcentres should be increased, and more number of CHC and PHC should be constructed and made functional as long waiting time was found main reason for home delivery.

Counselling for contraception should be done for husband also along with wife as main problem was found to be objection by husband in the study.

IEC activities must be strengthened to create awareness among the community about various health schemes as the main reason for not using RCH services was found to be lack of knowledge.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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