Socio economic differentials in utilization of maternal health care services : A study in urban slums of District Dehradun

Background: Health inequity is becoming an emerging issue all over the world. Improving maternal health is one of the UN Millennium Development goals. Pregnant women inhabiting urban slums are a “high risk” group with limited access to health facility. Objective: To study the socio economic profile of the mothers and to study the differentials in utilization of maternal health care by the beneficiaries. Study Design: Descriptive, observational crosssectional field based study in two purposively selected urban slums of district Dehradun. Results: About 70.9% of mothers belonged to social class II and III and 66% of them belonged to nuclear families. Teenage pregnancy was seen in 8.5%. 93.8% of women received complete antenatal care, majority preferring government hospitals. 93.2% of the women received 100 IFA tablets or more but only 63.7% consumed them for 100 days. Majority of the deliveries were institutional and 79.9% were conducted by trained personnel. About 68.5 % received postnatal care. Conclusion: Although usage of ANC service was high, opportunity to deliver important health services was not fully utilized. Policy and programme to improve the quality and care of antenatal mothers, especially for the poor and under privileged are essential to improve maternal health care. Special interventions should be undertaken on priority basis so as to achieve millennium developmental goals in all population groups.


Introduction
Urbanization is a growing phenomenon worldwide, but response to this situation has been inadequate in low income countries1.Indian cities have experienced population growth particularly among the disadvantaged population groups living in the slums2-3.In the last decade, India grew at an average annual growth rate of 2% but urban population grew at 3% , megacities at 4% and slum population rose by 5-6%4.Slums have often been conceptualized as social clusters that engender a distinct set of health problems5.The poor environmental condition coupled with high population density makes them a major reservoir for a wide spectrum of adverse health conditions such as under nutrition, deliveryrelated complications, postpartum morbidity, etc.In India, there have been limited efforts to study the health of individuals especially women living in slums.There is very sparse evidence on socio• economic differentials in the quality of antenatal care in developing countries6.Most of the studies in India7-10 and in other developing countries11- 13 have attributed socio-economic differentials in antenatal care utilization to a combination of poor access to health services, low education levels and poor demand.Few studies examined the socio economic differentials in the quality of antenatal care and its association with utilization.Some studies, however, have suggested poor quality, unfriendly treatment and less information sharing by health providers to the poor and disadvantaged women14-16.These studies also suggested that the perception of poor quality of care m a y lead to underutilization of health services by the poor women.Inequity in health poses a major challenge to achieve the millennium d e v e l o p m e n t goals, particularly those related to maternal health as existing programs are often not able to reach the most needy17.Therefore, assessment of the coverage of disadvantaged populations under reproductive and child health programs should receive priority.This study was planned with the objective of studying socio demographic status of the mothers and estimating utilization of maternal health service by the beneficiaries living in slum areas.

Material and methods
The present observational, descriptive crosssectional study was conducted in two purposively selected urban slums of Dehradun district from May 2010 to March 2011.The selected slums formed the field practice area of the department and also were located near to HIHT Satellite Clinic, Rishikesh.The slums were divided into 12 areas and each community health volunteers (CHV) were given approximately 200 -250 families from the area.Before administering the pre designed, pre tested semi structured questionnaire to the participants, the purpose of the study were explained to them.The data were collected after taking informed consent of the mothers by the CHV's trained for the study.The study was restricted only to mothers who had a child less than one year.This was done to minimise the recall bias and to avoid the mix up of the responses with the earlier delivery, if any.The utilization of service was done at one point of time.Modified Kuppuswamy scale18 i.e. education of the head of the family, occupation of the head of the family and total monthly income of the family was used to determine the socio economic status of the family.
To ensure the quality of the data, 10% of the questionnaire was randomly cross-checked by the principal investigator.After checking the questionnaire for errors, the data were entered into computer database and analyzed using SPSS version 18.0 Software.Chi-square test was used for categorical variables.Differences were considered to be statistically significant at 5% level.

Results
Table I shows the socio demographic profile of the study subjects.Seventy one (70.9%)percent of the mothers belonged to social class II and III.Most of the mothers were young (91.5% being less than 30 years of age) and two thirds (66%) lived in nuclear family.Teenage pregnancy accounted for 8.5% in our present study.Approximately three-fifth (58.7%) of the mothers had completed school education while approximately one third (34.7%) were illiterates. of Bangalore 20 while it was 100% in Kolkata 21 slums which is almost similar to our finding.tablets consumption for 90 days or more when they were pregnant with their last child varied from 10% to 81% 19-23 in various studies done in urban slums across the country.In the present study IFA tablet for 100 days was consumed by only 67.3%.Importance of taking regular IFA tablets needs to be emphasized to the mothers to prevent nutritional an aemia which is a well recognized public health problem.Safe delivery practices by trained care providers along with essential new born care and appropriate referral are the main stay of new born survival and wellness of mother and child.In the present study 61.5% deliveries were institutional.Home delivery has been the norm in urban slums and the same is also seen in the present study but in our study most of the home deliveries were conducted by trained Red Cross birth attendant.The main reason cited out by the mothers for home delivery was "Tradition" which reflects lack of knowledge about the importance of safe delivery practices.The other possibility could be due to the a ttitude of health workers and their "rude behaviour" at times which also turns the mothers away from institutional delivery to "traditional" home delivery practices.Although the emphasis of the National Reproductive and Child Health Programme is to promote institutional deliveries, the poor infrastructure, and limited government health facilities also makes women opt for home deliveries.In the private sector poverty and out of pocket expensed is a major hindrance towards institutional delivery.Awareness of the mothers about various government incentives like JSY and JSSK and also their accreditation with the private institution can go a long way in promoting institutional delivery.
Postnatal care provides an excellent opportunity to find out how a mother is getting along with her child and also to see the woman recuperating both physically and emotionally from her experience of child birth24.The urban health centres being located in the heart of the service area are often utilized by the slum dwellers.Inequity does exist in utilization of these services and poor maternal and child indicators reflect this inequality .Health staff, local and political leaders with their effort and commitment should try to bridge these gaps.More a wareness regard ing array of services being provided by these centres should be disseminated so that the maternal and child health indicators shows improvement.

Ack now led gem en t
The authors wish to thank and acknowledge SCOVA for providing financial support.Thanks are als o due to HIHT University for their support and all the CHVs along with community members for their participation.

Table II
Delivery by unskilled birth attendants was seen in one fifth of the cases.97.3 % mothers had no complication during delivery.

natal check up within 2 days of delivery:
About one third of the mother did not receive any post natal care by any health personnel within 2 days of delivery.The traditional birth attendant in other cases visited the mothers for massage and oil bath but they did not examine the mother.

Table III : Education of mother and antenatal care utilization
X2 =1.63, d.f=2 (p>0.05)d.f = degree of freedom Prime Minister of India has recently announced an initiative in lines of NRHM 26 to improve the health services of urban poor in view of glaring inequalities in urban health settings.Jawaharlal Nehru National Urban Renewal Mission has also been l aunched to augment basic services for the urban poor 27 in terms of availability, accessibility, affordability, adequacy and acceptability .