Antenatal care coverage of pregnant mothers in Tamil Nadu: evidence from National Family Health Survey 4

INTRODUCTION

Globally, maternal mortality ratio reduced by 44% over the past 25 years, from 385 per 100000 live births in 1990 to 216 per 100000 live births in 2015.¹ Developing countries contribute approximately 99% (302,000) of the global maternal deaths in 2015, with sub-Saharan Africa alone accounting for roughly 66% (201,000), followed by Southern Asia (66,000). India contributes to 15% of the global maternal deaths in 2015, standing second to Nigeria. Although, India have reduced its maternal mortality rate (MMR from 556 per 100000 live births in 1990 to 174 per 100000 live births in 2015, with a reduction of 68.7%.

India is a signatory to millennium declaration at UN general assembly in 2000 and affirmed its commitment to better maternal health care along with other 7 goals. The strategy of availability of trained medical professionals at the field level, infrastructure development for maternal health care and financial schemes like conditional cash benefit schemes and Janani Suraksha yojanas made significance impact in better maternal health care of the community.^1,2 The momentum of millennium development goals (MDG) is continued with sustainable development goals (SGD) with emphasis on reduction of maternal mortality and promotion of universal health coverage.¹

Government of India have implemented several maternal and child health (MCH) innovative programmes from time to time and updated the strategy in order to improve the health status of women and children and fulfil the unmet need of the MCH care in all the states of India. Tamil Nadu is one of the better health care’s providing state in India with better MCH care. Lot of initiations like conditional cast transfer, Birth companion scheme, online mother and child tracking system and widely expanded infrastructure facilities at the rural levels are initiated, pioneering in the country. The state also addresses the gap in MCH services by new approaches like birth waiting rooms and special mobile medical camps. Although Tamil Nadu have achieved the target of MDG earlier, there are differences among the districts in various components of Maternal and child health care. The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted in a representative sample of households throughout India. The first NFHS was conducted in 1992-93. The second and third NFHS Surveys were done in 1998-99 and 2005-06 respectively. NFHS 4 was conducted in 2015-16. Information including population and household profile, maternal health, child health, family planning, nutrition status and information on HIV were collected. The information collected though NFHS 4 are available as tables till the district level. Author intend to understand the MCH care given to the population at the district level of Tamil Nadu state.

METHODS

Author would a secondary data analysis of the NFHS 4 data which was collected for all states under Ministry of Health and Family Welfare.

This survey of conduced in 2015-16 in the month of August 2015. International institute of population sciences, Mumbai conducted this survey in collaboration with other national and international agencies . For Tamil Nadu, a total population of 28,820 were covered in the survey (Table 1). This survey collected information on population demographics, maternal and child health, nutrition and HIV for the states and union territories. Special focus on women of reproductive age group (15-49 years) were given in the survey.

This study was secondary data analysis of the NFHS 4 data collected during the year 2015-16. It was conducted June to November 2019. The data was collected during the period of 2015-16

Data collection methods

Author collected the information of Tamil Nadu from the NFHS 4 fact sheets report and entered in excel sheet. Similarly, information on the districts of Tamil Nadu were also obtained as fact sheets from the NFHS website. Author abstracted the fact sheets data into excel. Author used Microsoft excel and epi-info for analysis.²

Case definitions

Full ante natal care coverage: Full antenatal care is at least four antenatal visits, at least one tetanus toxoid (TT) injection and iron folic acid tablets or syrup taken for 100 or more days.²

The data was calculated for the proportion of ANC coverage by using Epi info 7.2.3.1.

RESULTS

Tamil Nadu showed 45% of Mothers who had full ANC coverage (Table 2). Of the total of 32 districts of Tamil Nadu, Krishnagiri and Coimbatore districts had more than 60% with 65.5% and 64% respectively. Nine districts namely, Vellore, Tiruppur, Dindigul, Karur, Tiruvarur, Salem, Chennai, Sivagangai and Cuddalore showed more than 50% full ANC coverage. Virudhunagar (13.7%), Theni (19.3%), Ariyalur (25.3%), Tirunelveli (26.4%) and Thoothukudi (29%) are the least performing five districts of the state (Figure 1).

Source: Developed using QGIS 2.18

The full ANC coverage of rural population of Tamil Nadu was 43.8% (Table 2), which is lower compared to the overall performance of the state.

At the district level, data on rural coverage is not available for Coimbatore, Chennai and Nagercoil. Of the 29 districts for which data is available for rural ANC coverage, Krishnagiri (66.8%) and Tiruvarur (62.5%) had full ANC coverage more than 60%. The least performing five districts in rural population were Virudhunagar (13.4%), Madurai (20.9%), Thoothukudi (21.5%), Ariyalur (23.6%) and Tirunelveli (24.7%).

For urban population, the full ANC coverage for Tamil Nadu is 46.3%, which is higher compared to the rural coverage of 43.8%. At the district level, the data is not available for 9 districts. Of the remaining 23 districts, Karur (61.4%) and Dindigul (61.1%) had full ANC coverage of more than 60%. The least performing five districts in urban population are Theni (13.7%), Virudhunagar (14.1%), Ramanathapuram (25.3%), Tirunelveli (28.7%) and Thanjavur (33.1%).

The three components for calculating full ANC coverage are Mother had at least 4 ANC visits, Mother protected with Tetanus and mother consumed Iron and folic acid for 100 days.

Tamil Nadu showed 81.1% coverage for Mothers with at least 4 ANC check-ups (Figure 2). At the district level, Vellore (92.5%), Thiruvallur (91.6%) and Thanjavur (90.6%) had coverage more than 90% (Table 3). The poor performing district is Thoothukudi (64.8%) followed by Virudhunagar (65.9%), Ramanathapuram (65.9%), Nagapattinam (68.3%) and Madurai (69.5%). The coverage of mothers with at least 4 ANC check-ups are equal in rural and urban areas of Tamil Nadu with 81%.

Although there are minor variations in the difference among the urban and rural population among the districts of Tamil Nadu, the least performing districts for 4 ANC check-up coverages are Thoothukudi, Virudhunagar, Ramanathapuram, Nagapattinam and Madurai among the rural population and Ramanathapuram (66.9%), Tirunelveli (68.2%), Madurai (68.8%), Erode (69.1%) and Virudhunagar (70.2%) are the last 5 performing districts among the urban population.

Regarding the coverage of Mothers whose last birth was protected against neonatal tetanus, Tamil Nadu showed a total coverage of 71% with rural coverage of 69.6% and urban 72.4% (Table 3). The best performing district is Coimbatore (85.4%) followed by Salem (85.1%). The poor performing district is Theni (40.3%) followed by Virudhunagar (46.9%), Tiruchirapalli (51.5%), Ariyalur (51.5%) and Tirunelveli (55.9%). Among the rural population, Krishnagiri was the best performing district with the coverage of 85.8% followed by Tiruvarur (84.2%). The poor performing district was Madurai with 38.1%, followed by Virudhunagar (47.5%), Tiruchirapalli (48.6%), Ariyalur (50.3%) and Theni (50.9%). Among the urban population, Salem district is the top performer with 89.9% followed by Tiruppur (84.6%). The districts that had poor coverage for vaccination of mothers with tetanus toxoid are Theni (33%), Virudhunagar (46.3%), Tiruchirapalli (54.7%), Tirunelveli (56.9%) and Nagercoil (61.2%).

Consumption of 100 Iron and Folic acid (IFA) tablets by pregnant mothers is another factor for full ANC coverage. Tamil Nadu state showed the coverage of 64% with 65.1% in urban population and 62.9% among the rural population (Table 3). Krishnagiri (81.2%) showed top performance followed by Coimbatore (75.3%). Among the rural population, Krishnagiri (81.1%) and Erode (75.1%) showed top performance. The poor performing districts for IFA tablets consumption coverage are Virudhunagar (37.5%), Thoothukudi (39.4%), Tirunelveli (43.3%), Dharmapuri (51.9%) and Madurai (52.3%). Among the urban population, Karur is the top performer with 76.6% followed by Thiruvallur (74.4%). The least five poor performing districts are Virudhunagar (37.5%), Tirunelveli (47.3%), Theni (47.8%), Thanjavur (50.2%) and Ramanathapuram (53.5%).

DISCUSSION

Antenatal care is one of the main strategies for positive pregnancy outcome.^2,3 Many studies have proved the effectiveness of antenatal care in pregnancy outcome.^2-4 For instance, non-communicable diseases, one of the increasing trends of illness is better monitored among pregnant mothers by ANC care.²

Full ANC care is a package of antenatal care recommended by WHO and adopted by Health and Family Welfare department of India, which includes 4 ANC check-ups, one dose of tetanus toxoid vaccination and consumption of 100 IFA tables. National Family Health Survey collected information on Full ANC coverage among the states and districts of India. The data was available specific to urban and rural also.

India shows full ANC coverage of 21%. Among the southern states, Kerala has better coverage with 61.2% followed by Tamil Nadu (45%), Andhra Pradesh (43.9%) and Karnataka (32.8%).⁶ Other states of India including Delhi (39%), Himachal Pradesh (36.8%), Gujarat (30.7%), and West Bengal (21.8%) had coverages below Tamil Nadu.⁶

Tamil Nadu showed full ANC coverage of 45% in 2015 - 16. Comparing 27.5% coverage in 2005-06, there is a 63% increase over a period of 10 years. Although there is a marked improvement in the full ANC coverage, there is a need for improvement. The Government of Tamil Nadu had implemented lot of activities for better maternal health care. Availability of Village health Nurse for every health sub-centre, focusing and give special importance for MCH activities at the primary health centres, exclusive availability of district level MCH officer for monitoring the MCH care are available in the state. Initiatives like online tracking of pregnancy cohort for better MCH care, conditional cash benefit scheme for first two pregnancies and availability of lab facilities and ultrasound scan facilities at the block level are also implemented. Awareness among the community for enrolment and continuum of care of pregnant mothers are also widely disseminated in the state. Lower coverage in spite of the efforts taken by health department of Govt of Tamil Nadu need to be evaluated to find gaps and design appropriate strategies to improve.

Author can see a wide variation in the coverage of Full AN care within the districts of Tamil Nadu, ranging from 65.5% in Krishnagiri to 13.7% in Virudhunagar. Of the 32 districts of Tamil Nadu, less than quarter districts had coverage more than 50% ANC coverage. Five districts had coverage less than 30% which impacted the overall reduction of full AN care of the state. Virudhunagar and Theni are having less than 20% full AN coverage. These districts need special attention to elevate to districts like Krishnagiri and Coimbatore. The facilities available in the districts are the same throughout the state. Variation in performance in spite of the common facilities available for all the districts, need to be evaluated.

In the neighbouring state of Kerala, Kannur (71.5%) and Kozhikode (71.4%) districts could achieve more than 70% coverage on full AN care with 13 of 14 districts having coverage more than 50%. This indicates the possibility level of achievement and efforts health department of Tamil Nadu have to take.

When authors compare the coverage on components of full AN care of Tamil Nadu, authors can see that, the state had better coverage on at-least 4 ANC visits by pregnant mothers (81.1%) followed by 71% for TT coverage. But for consumption of IFA, the coverage is 64%, which indicates that more attention is to be given for better coverage for IFA consumption among the pregnant mothers. Also, there are scopes for improvement for improved coverage for TT vaccination among the pregnant mothers and increasing the frequency of ANC care among the pregnant mothers.

Krishnagiri, the best performing district with 65.5% in full AN coverage could achieve more than 80% in all the three components. Although Vellore topped in coverage of 4 ANC visits with 93.5%, reduced coverage of IFA consumption of 69.4% pushed the district to 4^th place. For Virudhunagar, the lower performance of at least 4 ANC visits coverages (65.9%), administration of TT vaccination (46.9%) and consumption of 100 IFAs (36.6%) have pushed the districts to last in the state. The contributing factor for making Theni stand second last in the full AN coverage is coverage of TT vaccination (40.3%), in spite of better performance in at-least 4 AN checks-up (75.9%) and consumption of 100 IFA tables (55.5%). Hence, it is necessary for the health officials of the districts to focus on the key areas of poor performance to improve the coverage.

CONCLUSION

Focusing on the coverage of IFA tablet consumption is the key are of focus. Special interest among the rural population is needed to increase the coverage in this population. A detailed assessment for understanding the factors for poor performance among the districts of Tamil Nadu is needed for better evidence-based practices.

ACKNOWLEDGEMENTS

Author would like to thank the NFHS 4 team for generating the data for usage.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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