Utilization of Antenatal Care Services by Urban Squatters of Kathmandu Valley

1. Introduction

[Link]
Maternal health refers to the health of women during pregnancy, childbirth and the postpartum
period. While motherhood is often a positive and fulfilling experience, for too many women it is
associated with suffering, ill-health and even death.(1)

Improving maternal health have become the global concern of international communities after
the conference on Safe Motherhood held in [Link] commitment was reinforced in the ICPD
conference held in Cairo in 1994 where Safe Motherhood (SM) was recognized as one of the key
components of reproductive health.

Safe motherhood has been an issue of growing importance in Nepal over the past decade.
Following the conference in Nairobi, HMG/N formulated the National Health Policy in 1991,
which identified safe motherhood as a priority program and institutionalized SM as a primary
health care. The goal of the National Safe Motherhood Program is to improve the maternal and
neonatal health through preventive and promotive activities as well as by addressing avoidable
factors that causes complications of pregnancy and childbirth.(2)

The National Safe Motherhood Program has made significant progress in terms of development
of policies and protocols as well as expansion of the role of service providers such as staff nurses
and auxiliary nurse midwives. The MDG target for maternal health was to reduce the MMR by
three-quarters between 1990 and 2015. (3)

Maternal mortality is unacceptably high. By the end of 2015, roughly 303 000 women will have
died during and following pregnancy and childbirth. Almost all of these deaths occurred in low-
resource settings, and most could have been prevented.(4)

The condition is similar in our country with maternal mortality rate being 229 per 10000 live
birth, of which most of the death are preventable and treatable.(5)
Preventing problems for mothers and babies depends on an operational continuum of care with
accessible, high-quality care before and during pregnancy, childbirth, and the postnatal period. It
also depends on the support available to help pregnant women reach services, particularly when
complications occur. An important element in this continuum of care is effective ANC. The goal
of the ANC package is to prepare for birth and parenthood as well as prevent, detect, alleviate, or
manage the three types of health problems during pregnancy that affect mothers and babies:
• Complications of pregnancy itself
• pre-existing conditions that worsen during pregnancy
• Effects of unhealthy lifestyles.(6)
In our country Nepal, The National Maternity Care Guidelines recommend a minimum of four
antenatal visits for each pregnancy from a skilled health service provider as soon as the
pregnancy is anticipated.
Antenatal service includes:
  At least four antenatal check‐ups: first at 4th month, second at 6th month, third at
8thmonth and fourth at 9th month of pregnancy;
 Monitoring blood pressure, weight and fetal heart rate;
 Provision of tetanus toxoid (TT) immunization, iron and deworming tablets to all
pregnant women and malaria prophylaxis where necessary
 Providing information, education and communication (IEC) and behavior change
communication (BCC) for danger signs and care during pregnancy and timely referral to
the appropriate health facilities;
 Birth preparedness and complication readiness (BPCR) for both normal and
Obstetric emergencies (delivery by skilled birth attendants, money, transportation
And blood);
 Early detection and management of complications;(3)
Further, Government of Nepal has provision of Rs 400 as an incentive to those mothers who
complete 4 ANC visit on 4th, 6th, 8th and 9th month of pregnancy from the skilled provider
following institutional delivery.

2. Problem statement
Globally, Every day, approximately 830 women die from preventable causes related to
pregnancy and childbirth. Almost all maternal deaths (99%) occur in developing countries. More
than half of these deaths occur in sub-Saharan Africa and almost one third occur in South Asia.
More than half of maternal deaths occur in fragile and humanitarian settings. (4)
A systematic analysis of global cause of maternal mortality in 2009 showed that
Indirect causes and hemorrhage were found to be the largest causes of maternal death
Worldwide with high proportion of deaths due to indirect causes in Southern Asia. Further
breakdown of deaths due to indirect causes suggests that more than of indirect causes are
from pre-existing disorder when exacerbated by pregnancy in Southern Asia(7)

The overall Maternal Mortality Ratio (MMR) in Nepal is229 per 100,000 live births.
Materndherenceal causes accounted for 93% of pregnancy related deaths, giving an overall
pregnancy related mortality ratio of 247 per 100,000 live births.(5)

Low BMI (21%) and short stature (15%)is found to be higher among the women belonging to
lowest quintile Anemia has been the major nutritional problem among the women of
reproductive age in our country, especially among pregnant (48%) and lactating
mothers(39%).(3)

Beside this, neonatal death and still birth is found to be higher in urban slum settlements with
75% early neonatal deaths in Mumbai’s slum settlements. Moreover, Bereaved women tended to
be poorer, had fewer antenatal consultations and were more likely to have suffered previous still
births than non-bereaved mothers.(8)
Nepal has a target to achieve 80 percent of women completing at least four ANC during
pregnancy. But only half of pregnant women make four or more antenatal care visits during their
entire pregnancy. Less than three fifth of the mothers who attended first ANC has completed
4ANCvisit in the FY 2070/71 and still 31% of the mothers do not complete the four ANC
visit.(9)
 According to the study of Care Nepal, The utilization of ANC service is found to be even worse
in urban slums along Bagmati and Bishnumati River i.e. A total of 18.4 percent of the pregnant
women had never attended antenatal check-up (ANC) --majority of them belonged to poor. Only
25% of them had 4 ANC visit.(10)
Moreover, the utilization of component of ANC health care is not satisfactory in our country.
The consumption of Tab Iron (61%), Albendazole (43%) in our country is even lower among the
women belonging to lowest quintile compared to women belonging to highest quintile. Similarly
more than one fourth of the women are not informed about the danger signs of pregnancy.(3)

Additionally, maternal health was found to be poor among the slum residents of India compared
to the non-slum residents. Fifty-four percent of pregnant poor women had three antenatal care
visits compared to 83% pregnant women in the urban areas (Table 16)[Link] women were
found to be suffering from anaemia in slums than in non-slum areas. Analysis of the NFHS-III of
India showed that women living in urban slums were less likely to receive the full complement
of government recommended antenatal care (11)

2.1. Rationale
Most maternal deaths are avoidable, as the health-care solutions to prevent or manage
complications are well-known.(4)
Similarly, Many antepartum stillbirths are potentially preventable in low and middle-income
countries, through improving the quality of antenatal care – particularly including diagnosis and
management of high-risk pregnancies – that pregnant women receive.(12)
Government of Nepal has given high priority to National Safe Motherhood and Neonatal Health
Programme. Nepal had a target to achieve 80% of women completing at least four ANC visit
from a skilled providers during their last pregnancy by 2015.
Antenatal care (ANC) from a skilled provider provides an essential role in preventing the
maternal and neonatal mortality through various interventions like regular health checkup,
monitoring blood pressure, deworming, and consumption of iron tablets, tetanus toxoid injection
and identification of any complication etc. (3)
High nutritional problems, low BMI, lower compliance with Tab Iron, Albendazole and low
awareness among pregnant women on danger sign of pregnancy is found higher among the
women belonging lowest quintile, posing them further into the risk of pregnancy and child birth
Nevertheless, Antenatal services, skilled attendance during delivery are found to be major unmet
health needs in squatter settlements of Bagamati and Bishnumati River. Further, the lack of
awareness regarding the Government of Nepal’s free health service scheme is found to be
widespread.(13).
Further, no any study has been carried out to assess the factors associated with the adherence to 4
ANC visits in urban squatter of Kathmandu valley.
 On this backdrop, study on status of ANC health care utilization and factors affecting adherence
to recommended 4 or more ANC visit in urban squatter of Kathamandu valley would be helpful
in determining the current status of ANC health care utilization, identifying the real causes
behind poor ANC health care utilization and developing the plans and policies accordingly
further contributing in improved maternal and neonatal health in urban squatter of Kathmandu
Valley.
Objective
2.1.1. General Objective
 To assess the ANC health care utilization among mothers of <1 year children in
urban squatter of Kathmandu Valley
2.1.2. Specific Objective
 To estimate the prevalence of ANC visits.
 To determine the factors associated with the utilization of ANC service.
 To determine the barriers associated with the utilization of 4 ANC visit as per protocol.

1.4. Research Questions

 What is the prevalence of recommended four or more ANC visits in urban squatter of
Kathmandu Valley?
 What are the factors associated with adherence to 4 ANC visits?
1.5. Variables
1.6. Conceptual Framework
1.7. Operational definitions of variables

2. Literature Review
3. Methodology
3.4. Study Design: Descriptive cross sectional
3.5. Study Method: Quantitative followed by qualitative
3.6. Study Site: Urban squatter of Kathmandu Valley
3.7. Study Population: Mothers of <1 year children
3.8. Sample size:
According to Annual Report 2070/71
 Prevalence of 4 ANC visit among first ANC visit in Nepal (P): 59%
 Desired allowable errors (d) = 10% at 5 % level of significance
Thus,
Using the formula:
N= Z2PQ/L2
Or, N= (1.96)2 * (0.59*0.41)/ (0.1)2
Or, N = 92.92
Designed effect was taken 2
Therefore N = 2* 93=186
5% non - response rate= 10
 The required sample size in 196
3.9. Sampling technique: Cluster Sampling
3.10. Data collection process
Before the process, a permission from Kathmandu DPHO will be taken. Primary data
collection will be done by researcher herself. First, quantitative data will be taken through
interview and later qualitative data will be taken to support the quantitative data.

3.10.2. Data collection tools and technique

Following tools and technique will be used:
Technique Tools
Interview Semi structured questionnaire
In-depth interview Semi structured questionnaire

3.11. Data Management, Processing and Analysis

After the collectionprocess, raw data will be edited and classified into different categories and will
be coded according to the variables set. Epi data will be used for data entry and SPSS will be used
for data analysis.
Descriptive method of analysis will be done that includes preparation of tables, graphs and charts.
Rate, ratios, proportions, percentage and central tendency will be calculated to get the
interpretation. Chi square and p values will be calculated for assessing the association using cross
tab.
3.12. Exclusion Criteria
 Mothers of <1 year children
 Mothers with still birth and pregnant women will be excluded.
3.13. Validity and reliability
3.14. Ethical Consideration:
3.15. Limitation of study

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