Maternal and child healthcare is one of the eight basic components of primary healthcare (PHC) in the Declaration of Alma-Ata . There is an excellent pyramid of infrastructure for the delivery of maternal and child health services through a network of subcentres and PHC centres in rural India. But still, most child deliveries are conducted at home by traditional birth attendants and relatives. The Child Survival and Safe Motherhood, now a component of Reproductive and Child Health Programme, is initiated to achieve a substantial improvement in the health status of women and children in India. It includes early registration of pregnancy, at least three antenatal check-ups, universal coverage with tetanus toxoid and iron and folic acid tablets, early detection and referral of at risk mothers, deliveries by trained health personnel, facilities to manage obstetrical medical emergencies and birth spacing [2,3].
Despite considerable improvements in health service delivery for pregnant women in India, maternal mortality rate is still high (254 per 100 000 live births) . Poor access and utilization of antenatal and other health services continue to contribute to high maternal mortality rate along with other socioeconomic factors. Maternal, infant and child mortality rates are higher among the tribes , and these higher rates are attributed, in larger part, to the lack of/under utilization of healthcare services. In the state of Andhra Pradesh in India, maternal morbidity is reported to be high despite higher levels of utilization of antenatal care (ANC) services . In Andhra Pradesh, the utilization of PHC services varies regionally, particularly between tribal and rural areas. A majority of tribal and rural populations heavily depend on government sector for various health care services. This study reports the utilization of ANC services among women living in tribal and rural areas of Visakhapatnam, a district of Andhra Pradesh.
Participants and methods
The Republic of India is a federal state with 28 states and seven union territories. The state of Andhra Pradesh, the fifth largest state in terms of both area and population, comprises 23 districts. Visakhapatnam district can be broadly divided into rural (plains) and tribal (hilly) areas.
Study design and sampling
This is a cross-sectional study. For this study, four mandals (mandal is an administrative unit of the district), two each from rural and tribal areas, were selected. Each mandal harbours a PHC centre. Thus, the study includes four PHCs (two from the tribal area and two from the rural area). For selecting villages, all health subcentre (HSC) villages and villages having no health institution (neither PHC nor HSC) were listed separately for each PHC area. From each PHC area, the PHC village was selected. Further, two HSC villages and three villages having no health institution from each PHC area were selected randomly. Thus, the study included 24 villages (four PHC villages, eight HSC villages and 12 villages with no health institution). To undertake this survey, five random points were identified in each selected village to cover all areas of the village, after mapping the village. From each random point, three women were selected to obtain at least 15 women from each village. Finally, data were obtained from a total of 380 (185 tribal and 195 rural) women.
Data collection methods and tools
Both qualitative and quantitative methods were used. Quantitative data were collected from women having a child aged less than 1 year on ANC through interview using a structured questionnaire. This questionnaire was designed and pretested to collect the details of utilization of various components of ANC services, in addition to the sociodemographic characteristics of the respondents. The questions enquire about the details pertaining to the recent pregnancy.
The qualitative data were collected through indepth interviews with key informants in the villages (n=12) with regard to utilization of services related to ANC. Key informants were selected according to the recommendations of Spradley  and Hudelson . Indepth interviews were conducted by following Pelto and Pelto  and Lengeler et al. .
The quantitative data were analysed using the SPSS 10.0 (Chicago, Illinois, USA). Chi-square and t-tests were used as tests of significance. A minimum level of P greater than 0.05 is regarded as significant. The qualitative data were computerized through a word processor and analysed through ATLAS.ti .
Data on demographic and socioeconomic characteristics showed that a higher proportion of women (77.3% from rural and 59.4% from tribal areas) fall in the age group of 21–30 years. A total of 34 (12 tribal and 22 rural) mothers were under the age of 19 years. A majority of both tribal (69%) and rural women (54.2%) are illiterate and others possessed primary or secondary education. Approximately 53% of the rural participants were of backward castes, whereas 90% of women sampled from the tribal area were of tribal communities. The majority of respondents (86% tribal and 57% rural) were dependent on daily wage labour and approximately 30% of the rural respondents were housewives. The average annual family income of majority of women (tribal: 66%; rural: 52%) was in the range of 6001–12 000 rupees.
Approximately 99% of rural women and 90% of tribal women received at least one antenatal check-up (Table 1). Among these, approximately 16% of tribal and 10% of rural women received only one or two antenatal visits, whereas 83.3% of tribal and 87.4% of rural women received three and/or more antenatal check-up visits. With regard to the source of ANC, for a majority (92%) of tribal women the source of ANC was the government health facility, whether it is a doctor at PHC (63%), government hospitals in nearby town (16%) or health workers (13%), whereas approximately 50% of rural women relied on qualified private practitioners. People, particularly the in rural area, sought multiple sources for check-up. Health workers provided antenatal check-ups to a majority (91%) of tribal women during their visits to the houses, whereas this proportion was low among the rural women (56.8%) and the difference was statistically significant (P<0.001). It is observed that 37.7% of tribal women and 26.3% of rural women did not receive any advice on ANC.
Table 2 describes the time of initiation of antenatal check-up. The majority of women received their first antenatal check-up during the second trimester. The details of ANC in terms of health worker's visit, iron and folic acid tablets received and tetanus toxoid injection received during recent pregnancy indicate clear differences between rural and tribal women (Table 3). Higher proportion of tribal women than rural women received iron and folic acid tablets. Health workers visited approximately 91% of women living in the tribal area, whereas approximately 43% of rural women reported that health workers never visited them. Furthermore, a majority of women received only 26–50 iron and folic acid tablets (the programme insists on distribution of 100 iron-folate tablets for each pregnant woman during various visits to the health centre or provided by the health worker during domiciliary visits). Approximately 26% of women living in the tribal area received 50–75 tablets, whereas 23% of women in the rural area received less than 25 tablets, yielding a significant difference between the two groups (P<0.001). A majority of women (97% from tribal and 92% from rural areas) reported that they were vaccinated with tetanus toxoid injection during recent pregnancy. Table 4 shows that 97% of the child deliveries among tribal and 87% among rural women were normal and a majority of normal child deliveries occurred at home.
The qualitative data obtained from key informants mainly focused on the quality of services obtained from health workers and health institutions. The key informants were probed to indicate in what way health workers are helpful to women. In both areas, the respondents unanimously agreed that the health workers look after the pregnant women, mothers and children. Moreover, they alleged that the health workers perform only these activities and they are concerned only about mothers and children. The tribal key informants had a positive opinion on all the activities carried out by health workers in their villages. In the rural area, some of the key informants were not satisfied with the activities of the health workers and emphasized that many of the rural people approach private practitioners for ANC. A clear difference in the services of health workers was observed during qualitative surveys. In a tribal village, a key informant commented, ‘Centre is of no use for us. But nurse (health worker) looks after us well. Our hospital is somewhere (i.e. at far). How it is useful for us. If we go to Paderu (nearest town in tribal area), there is rush of people, (doctor) sees in hurry’. A key informant in a tribal village commented on activities of health worker, ‘Mostly auxiliary nurse midwife comes to village for pregnant women and children. Next for family planning operations…. Giving tetanus toxoid injection to pregnant women, giving iron tablets, putting vaccine to children, polio drops also…, she will do. She says regarding child, what precautions to be taken, when to be taken (to hospital), and so on…’. A typical response from a rural woman was, ‘Now and then nurse comes and sees the pregnant. Gives vaccines to children. That too…once in a month or two’. Meanwhile, all the needy (people) will go to Anakapalle (nearby town) and take vaccines, injections and come back'. A key informant (25-year-old woman) in rural area said, ‘It is satisfactory. That means, services are there when the PHC is opened. Later, what’s the condition? (i.e. after closing the PHC for the day) we do not know where the nurse stays? Then what is the use?'
The study populations of this study has certain disadvantages such as illiteracy and low socioeconomic status. A considerable proportion of women from these backward tribal and rural areas are conceiving at younger ages, resulting from early age at marriage, and this is a serious issue to be addressed. With regard to the utilization of ANC services, the study results are in consonance with the National Family Health Survey . However, in this study, approximately 10% of tribal mothers had not received even a minimum component of ANC, which is a serious issue. Most of the mothers who had not received ANC elicited reasons such as ‘not aware of ANC’, ‘felt unnecessary’ and ‘financial problem’. This emphasizes the need for educating the community on the need of ANC and its benefits to mother and child. Health workers' role is crucial in this respect. This disparity between higher rates of utilization and lower rates of advice from the governmental sources on ANC indicates the target-oriented approach rather than motivational approach in government services. This study indicates that, although ANC and the knowledge of mothers regarding the available services have to be improved, the situation appears some what better when compared with the situation reported by another major study (1996) undertaken among scheduled tribes and scheduled caste women in nine northern and eastern states of India .
In this study, a majority of mothers were provided ANC during the second trimester and it needs concern as the number (minimum three ANC visits) and the initiation of the first check-up (i.e. in first trimester) are important for the health of the mother and the outcome of the pregnancy. The situation in the tribal area, where most of the ANC services are provided by the government sources, is better than in the rural area. The results have to be understood in concordance with the source of advice and also with the health worker's visits. Generally, the family/elderly women consider third or even later months, rather than the early period of pregnancy, as appropriate for consultation. Second trimester, when the pregnancy becomes visible, is determined to be high time for antenatal check-up and indicates that home visits were not made regularly and sincerely by health workers. Regularity and intensity of the health workers visit will have a bearing on the early check-up and further gives more scope for advice and motivation. The pattern of utilization of ANC services in these areas suggests that social, economic and structural elements also influence the decision-making process. Results suggest that efforts to intensify health workers' visits in rural area may enable more rural women to receive appropriate ANC services.
A great proportion of child deliveries occurred at home and most of them were conducted by elderly women, despite a good proportion of women who received some components of ANC. It appears that visits mainly aim at distribution of the tablets and giving tetanus toxoid injection, that is, a target-oriented approach, rather than involvement and motivation for institutional child deliveries. However, the knowledge and awareness of the recipients and attitude of the health care providers also play a role in the service extension and utilization. Some studies showed that relatively high utilization of health services, despite low levels of perception about the seriousness of the morbidities, is a common feature particularly related to obstetric health [13,14]. Barua et al.  described inefficient work schedules, nonavailability of functioning equipment, poor contraceptive and drug supplies, poor skills and knowledge of health workers and poor access to services in villages without health centres as the weaknesses of the system that provides maternal and childcare service.
It is usually observed, particularly in rural villages, that the private sources are open to sell their services at any time of the day, whereas the PHC and HSC will be kept open and will work for a specified time. The utilization of government sources was high in tribal areas because of two reasons: lack of private health institutions and poor economic condition of the people. In rural areas also, the PHC service users are mostly from lower socioeconomic strata. It was brought out by the informants that those who can afford or have money will go/prefer to go to a private facility and if the facility is available for a longer time in the day, it could have helped needy people to utilize the services. At the same time, the role of local practitioners and unqualified practitioners cannot be ruled out. Making round-the-clock health centres more effective in functioning by providing a lady doctor, improving the condition of roads and covering more villages with the programme can help in declining the morbidity levels in rural areas .
Some of the indicators of healthcare outreach are poor among scheduled tribe population and the situation is not fair in rural areas also. It is well-documented that the conventional, bureaucratic approach of looking at health-related issues for tribals in a sectoral, compartmentalized manner can have a little impact on achieving health goals. The constitution of India mandates states to provide healthcare to all citizens. In reality, the positive aspects of the impressive spread of infrastructure have become negated by the highly dispersed nature of the population. The average number of villages/habitations that have to be covered by a PHC and an HSC are also more in tribal areas than in rural areas. The PHCs and HSCs have been located at farther distances and the distance to be covered is more (and many times people cover it by means by foot). Similarly, although manpower availability in terms of ratios does not seem to be adverse, the setting of the facilities and poor communication have resulted in making distance and physical access a major barrier for utilization of healthcare services. However, this study tribal area is not a typical hilly rough terrain that poses problem in reaching the households by foot, and transportation facilities are also available. These positive factors might have contributed to the higher levels of health-care provision, thereby higher utilization.
Conclusion and recommendations
Health services were largely under utilized at the PHC system in rural areas, although the large urban government hospitals are frequently overcrowded. Hence, these paradoxes such as lower utilization of public health services and lack of confidence in the system have to be rectified with greater involvement of all partners including community, service providers, planners and administrations. There is a need to reorient health staff, particularly health workers, who work with the community for a community-centred attitude. Reorientation has to be attempted to build-up confidence in the community.
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