|Year : 2016 | Volume
| Issue : 3 | Page : 354-362
A study on knowledge and practices of antenatal care among pregnant women attending antenatal clinic at a Tertiary Care Hospital of Pune, Maharashtra
Barun Bhai Patel1, Pranaya Gurmeet2, Datttreya Ramkrishna Sinalkar1, Kapil H Pandya1, Ajoy Mahen1, Neha Singh1
1 Department of Community Medicine, AFMC, Pune, Maharashtra, India
2 Department of Obstetrics and Gynaecology, AFMC, Pune, Maharashtra, India
|Date of Web Publication||17-May-2016|
Barun Bhai Patel
Department of Community Medicine, AFMC, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The maternal health status of Indian women was noted to be lower as compared to other developed countries. Promotion of maternal and child health has been one of the most important components of the Family Welfare Programme of the Government of India. For sustainable growth and development of country, there is a need to improve MCH Care in the country. Safe motherhood by providing good antenatal care (ANC) is very important to reduce maternal mortality ratio and infant mortality rate and to achieve millennium development goals. Objectives: This study aimed to determine the level of knowledge, attitude, and practice on ANC among pregnant women attending the antenatal clinic at a Tertiary Care Hospital in Pune and their association with various sociodemographic factors. Materials and Methods: A cross-sectional study was carried out among 384 pregnant women in their 3 rd trimester attending the antenatal clinic in a Tertiary Care Hospital of Pune, Maharashtra during October 2011 to September 2012. Pretested questionnaire was used for collecting data by interview after obtaining informed consent. Statistical analysis was performed using SPSS version 20 and Epi Info Software. Results: Study reveals that about 58% women had adequate knowledge regarding ANC. It was 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. 100% women were having a positive attitude toward ANC. Around 70%, women were practicing adequately, and variables such as education and SES had a significant association with practices about ANC. Conclusion: These findings can be used to plan a Health Intervention Program aiming to improve the maternal health practices and eventually improve the health status of the women.
Keywords: Antenatal care, Maharashtra, pregnant women, Tertiary Care Hospital
|How to cite this article:|
Patel BB, Gurmeet P, Sinalkar DR, Pandya KH, Mahen A, Singh N. A study on knowledge and practices of antenatal care among pregnant women attending antenatal clinic at a Tertiary Care Hospital of Pune, Maharashtra. Med J DY Patil Univ 2016;9:354-62
|How to cite this URL:|
Patel BB, Gurmeet P, Sinalkar DR, Pandya KH, Mahen A, Singh N. A study on knowledge and practices of antenatal care among pregnant women attending antenatal clinic at a Tertiary Care Hospital of Pune, Maharashtra. Med J DY Patil Univ [serial online] 2016 [cited 2020 Apr 9];9:354-62. Available from: http://www.mjdrdypu.org/text.asp?2016/9/3/354/182507
| Introduction|| |
Safe Motherhood Initiatives, a worldwide effort was launched by the World Health Organization in 1987 which aimed to reduce the number of deaths associated with pregnancy and childbirth.  Appropriate antenatal care (ANC) is one of the pillars of this initiative. It highlights the care of antenatal mothers as an important element in maternal healthcare as appropriate care will lead to successful pregnancy outcome and healthy babies.
Improving maternal health is one of the eight-millennium development goals (MDGs). Under MDG5, countries committed to reducing maternal mortality by three-quarters between 1990 and 2015. Since 1990, maternal deaths worldwide have dropped by 47%. 
In India data from the most recent National Family Health Survey-3 suggest that the maternal mortality ratio has fallen from approximately 400 deaths per 100,000 live births in 1997 to 301 deaths per 100,000 live births in 2006. 
The maternal mortality ratio (MMR) in India has been maintained at a higher level since long. It was reported that the MMR among Indian women national average of MMR is 212 per 100,000 live births (SRS - 2007-2009) which in itself is very high compared to the international scenario like Sweden (5), USA (24), and Brazil (58) and even in neighboring countries such as Sri Lanka (39) and Thailand (48).  Although the health status of women has improved over the years due to concentrated efforts of Government of India, it is still not at par with the international benchmark and is unacceptably high. Health outcome goals established in the 12 th 5-year plan are to reduce infant mortality rate to 25 per 1000 live births, to reduce maternal mortality ratio to 100 per 100,000 live births by 2017. 
To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at all levels of the health system. Health knowledge is an important element to enable women to be aware of their health status and the importance of appropriate ANC. Very few studied were carried out in India about this aspect of maternal health and hence data in this regard is scarcely available. This study was conducted to determine the level of knowledge, attitude, and practice related to ANC among these pregnant women and to assess the awareness about their own health during pregnancy. This will be used as baseline data and will help in the further planning of Health Intervention Program.
| Materials and Methods|| |
A cross-sectional study was undertaken to assess the knowledge, attitude, and practices regarding ANC among pregnant women attending the antenatal clinic in a Tertiary Care Hospital of Pune from October 2011 to September 2013.
For the purpose of sample size estimation, prevalence was taken as 50%, confidence level as 95% and absolute error of margin (d) was set at 05% (i.e., α = 0.05). The minimum sample size was estimated to be 384. The study population comprised of all pregnant women in their 3 rd trimester attending the antenatal clinic. Ethical approval for conducting the study was obtained from Institutional Ethics Committee of the Hospital. Written informed consent was obtained from each subject.
The data were collected by interviewing all the eligible subjects willing to participate in the study. Predesigned, pretested questionnaire was used [Annexure 1]. Study subjects were selected by systematic random sampling technique. Approximately, 2500 pregnant women come every year to this health center for ANC checkup. "K" was determined by using formula "N/n," and "K" 7. The first subject was randomly selected between 1 and 7 women and thereafter every 7 th pregnant women was included in the study and this procedure was carried out until the completion of required sample size.
Knowledge was assessed about ANC visits, tetanus immunization, investigations, and nutritional factors, danger signs of pregnancy, contraception, and personal habits. Each parameter was awarded 1 mark for the correct answer and 0 mark if the answer was wrong. Thus total marks for questions related to knowledge were 44. Those who scored 70% and above were considered as having adequate knowledge, and those who scored below 70% were considered inadequate knowledge.
Variables to assess attitude were an opinion on the place of delivery, the effect of smoking on mother and fetus and effects of alcohol on the health of mother and fetus, ANC registration, visits, motivation, investigations, dietary changes, and iron and folic acid (IFA) intake and its regularity in the intake. Also smoking, alcohol and drug intake, medical problems, and use of contraception. Each attitude questionnaire was scaled using 5-point Likert scale. Total score for questions related to attitude were carrying 75 marks. Those who scored 70% and above were considered as having a good attitude toward ANC.
Questions were asked to assess the practices with regards to ANC visit, dietary changes made during pregnancy, IFA tablets taken. Questions related to smoking, alcohol, self-medication were noted. Tetanus immunization during pregnancy and practice with regard to use of contraception was also noted. Each parameter was awarded 1 mark for good practice and 0 marks if the practice was not found appropriate. Thus, total marks for questions related to practices were 21. Practice on attending number of visits carried 2 marks (<3 visits = 0, 3-5 visits = 1 and >5 visits = 2). Practice of IFA tablet consumption carried 5 marks (0-49 = 1, 51-99 = 2, 100-149 = 3, 150-200 = 4, >200 = 5). Those who scored 70% and above were considered as practicing adequately and those who scored below 70% were considered inadequate practices with regard to ANC.
Demographic characteristics namely age, parity, type of family, education and occupation, and socioeconomic status (SES) were selected for studying association with knowledge and practices regarding ANC. For the ease of study, age is categorized into two categories namely age <20 years and ≥20 years. Family was divided into two categories namely joint family and other. Education was categorized divided into those below 10 th standard and more than 10 th standard. Occupation was divided as unemployed and employed. Study participants were divided into two categories; 1 st up to upper lower class and 2 nd category included more than the lower middle of Kuppuswamy Scale.  SPSS version 20.0, (IBM Corp, Armonk, New York, USA) and Epi info 7 (developed by Centers for Disease Control and Prevention (CDC) Atlanta, USA) were used for analysis of collected data and appropriate statistical test used after consulting with a statistician.
| Results|| |
In our study, the age range of study subjects ranges from 18 to 37 years with mean age of 24.02 years. 193 (50.3%) women were primigravida and 49.7% were multigravid. 29.2% women were educated up to high school, followed by 20. Three percent graduate, 18.5% intermediate, 16.1% until middle school, 10.7% until primary school, and 1.3% were professional. Only 3.9% women have not attended any formal schooling. About 91% women were unemployed and were working as housewives, and only 8.9% were working.49.2% study subjects belonged to lower middle class, 44.5% in upper lower, 5.7% in the upper middle, and 0.3% each in lower and upper class. 61.7% respondent belonged to joint family followed by 37% nuclear and only 1.3% three generation.
Out of 384 study participants 223 (58%) study subjects had adequate knowledge about overall ANC care. Hundred percent women scored more than 70% marks with mean of 88.6% and standard deviation 7.14 meaning they have an adequate attitude toward ANC care. 69.3% study subjects followed adequate ANC practices [Table 1]. [Table 2] and [Table 3] summarize the association of knowledge and practices regarding ANC with sociodemographic factors.
There was significant association found between age and overall knowledge about ANC. (P = 0.002 and odds ratio [OR] =2.39 and 95% confidence interval [CI] includes 1). There was no significant relation found between type of family and overall Knowledge about ANC. (P = 0.35 and OR 1.22 and 95% CI includes 1). It is clearly evident that knowledge is not significantly associated with increasing parity (Chi-square, P = 0.667 and OR 1.09 and 95% CI includes 1).
|Table 1: Score based on knowledge attitude and practices regarding ANC among study subjects|
Click here to view
|Table 2: Association of overall knowledge regarding ANC with sociodemographic factors|
Click here to view
|Table 3: Association between selected demographic factors with overall ANC practices|
Click here to view
Although both groups were having knowledge about ANC care but it was associated more closely with those women who were more educated (more than 10 th class). (Chi-square test, P = 0.000 and OR 5.80). Although the adequate knowledge women were distributed among both employed and unemployed women, but it was more associated with employed women. It means that working women were more knowledgeable than unemployed women (Chi-square, P = 0.003 and OR 3.71).
There was significant relation found between SES and overall knowledge about ANC (Chi-square, P = 0.003 and OR 3.60). Similar trends were noted between SES and practices regarding ANC.
[Table 4] shows association between level of knowledge and practice. There was a significant association between knowledge of ANC and practice. Those who had adequate knowledge about ANC care they had adopted good practice (Chi-square value 56.48; OR 5.72).
| Discussion|| |
In our study, mean age for respondents was 24 years with age range from 18 to 37 years. Our study showed that statistically significant association between age and knowledge about ANC but not with overall ANC practices. A study done by Sanjel et al., 2011 in Tamang also shows a significant association between age and knowledge. 
A study done by Sanjel et al. shows a significant association between numbers of pregnancy and ANC visits during most recent pregnancy at 95% level of confidence (P < 0.05) whereas no such association was found in our study.
Agarwal et al. in their study in 2007 found that ANC received was significantly lower among illiterate women. This finding is similar with our finding in which women who were more educated were better aware about almost all the factors of ANC. However, women with lower education (<10 th ) were performing better in term of visits and women with higher education (>10 th ) were doing better practice with regards to nutrition and other factors. Overall educated women were practicing in a better way than noneducated women (OR 2.28). 
Our study findings were comparable with a study done by Al-Shammari et al. in 1994 which found that educated mothers and mothers aged <20 years had more prenatal visits which was similar to our study findings.  Similarly, working women were better aware about almost all the factors of ANC. But it was not uniform with regard to practice. Nonworking women were doing better practice with regards to antenatal visits, rest, etc., whereas working women were practicing in a better way than nonworking women with regards to nutritional aspects. However, overall there was no significant association found between education and practice (P = 0.341, OR 1.49 (0.65-3.4).
We also found a significant association between Socioeconomical status and awareness about almost all the factors of ANC. With regard to practice; women from high socioeconomic class were doing better practice with regards to nutrition but women from low socioeconomic class were doing better practice with regard to visits and other care. Overall, women with the higher socioeconomic class were practicing better (P < 0.001, OR 2.47).
There are few limitations of this study. Findings of the study can only be extrapolated on urban women who are attending antenatal services, and there is a possibility of recall bias among study participant. Different findings might be seen if the study is conducted among the other places due to different cultural practices, norms and belief. However, this study may act as a preliminary survey due to the scarcity of published data regarding the ANC care.
| Conclusion|| |
The still higher proportion of (41.9%) of pregnant women has inadequate knowledge, and about one-third of study participant have poorly practice ANC care. Their knowledge on certain aspects of ANC were still poor especially regarding the importance of early antenatal check-up, health screening and complications related to diabetes and hypertension in pregnancy. Specific intervention program need to be planned and conducted to improve their maternal health practices and eventually improve the health status.
We would like to thank and acknowledge the faculty of Department of Community Medicine and Gynecology Department of hospital for their support throughout the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Bank. Safe Motherhood - A Review. The Safe Motherhood Initiatives, 1987-2005 World Bank Report. New York: Family Care International; 2007.
United Nations. The Millennium Development Goals Report 2011. New York: United Nations; 2011.
WHO, UNICEF UNFPA, The World Bank. Trends in Maternal Mortality 1990 to 2008. Geneva: WHO Press; 2010.
Planning Commission, Government of India. Twelfth Five Year Plan (2012-2017). New Delhi. SAGE Publications, India Pvt Ltd. 2013.
Kumar N, Gupta N, Kishore J. Kuppuswamy′s socioeconomic scale: Updating income ranges for the year 2012. Indian J Public Health 2012;56:103-4.
Sanjel S, Ghimire RH, Pun K. Antenatal care practices in Tamang community of hilly area in central Nepal. Kathmandu Univ Med J (KUMJ) 2011;9:57-61.
Agarwal P, Singh MM, Garg S. Maternal health-care utilization among women in an urban slum in Delhi. Indian J Community Med 2007;32:203-5.
Al-Shammari SA, Khoja T, Jarallah JS. The pattern of antenatal visits with emphasis on gestational age at booking in Riyadh Health Centres. J R Soc Health 1994;114:62-6.
[Table 1], [Table 2], [Table 3], [Table 4]