Predictors of antenatal care , delivery and infant feeding practices among rural women in Madhya Pradesh , India

Background: Maternal and infant mortality rates and prevalence of under nutrition are high in the State Madhya Pradesh. Regular ante-natal check-ups (ANC), delivery by trained health personnel, delivery practices and optimal infant feeding practices are important to reduce maternal and infant mortality. Objectives: The aim was to assess antenatal care, delivery and infant feeding practices of mothers of <1-year-old children in Madhya Pradesh. Materials and Methods: This was community-based cross-sectional study carried out in the rural areas of Madhya Pradesh by adopting systematic random sampling procedure. Data were collected from 5324 mothers having <1-year-old children. Information on household (HH) socioeconomic and demographic particulars was collected from the mothers. Bivariate and multivariate analysis was performed to study the association between dependent and independent variables. Results and Interpretations: About 36% mothers had undergone at least three ante-natal check-ups and 73% delivered either at government or private hospitals. Only 26% mothers initiated breastfeeding within 1-h of birth and 92% fed colostrum. Step-wise regression analysis showed that ante-natal care for <3 times was signifi cantly (P < 0.01) higher among women with high parity (≥5), illiterate women, and among lower socioeconomic group,s while home delivery was higher among women with high parity (≥5) (odds ratio [OR]: 2.3), among Scheduled Caste and Tribe women (OR: 1.5), illiteracy of head of HH (OR: 2), and among lower socioeconomic groups (OR: 1.3). Discarding colostrum was higher among illiterate women (OR: 1.6), belonging to lower socioeconomic groups (OR: 1.4) and delivery conducted by untrained person (OR: 3.9), while initiation of breastfeeding after 1-h of childbirth was higher among ≥30 years women (OR: 1.9), illiterate women (OR: 1.4), and delivery by untrained person (OR: 2.9). Conclusions: It was observed that antenatal care, delivery and infant and young child feeding practices were associated with type of community, literacy status of mother, wealth index and person conducting delivery. Hence improving the literacy mothers, delivery by trained person and increasing awareness about optimal infant feeding practices will help to reduce infant and maternal mortality.


INTRODUCTION
An appropriate ante-natal care practices and optimal infant and young child feeding (IYCF) practices play an important role in child survival and maternal health.Nutritional status during pregnancy determines the health and nutritional status of the offspring. [1]Healthy mother gives birth to healthy child and maternal under nutrition results in low birth weight of the infant.National population policy 2000 stated that all the pregnant mothers should receive at least three ante-natal check-ups (ANC) during pregnancy, and 100% deliveries should be institutional.Madhya Pradesh is one of the economically backward State in India with highest maternal (269/1 lakh live births) and infant mortality (67/100 live births).The Millennium Development Goals of the United Nations, aimed at achieving 109 maternal deaths/lakh of live births and 28 infant deaths/100 live births by 2015.As per current statistics, Madhya Pradesh is still far to achieve these goals. [4]idence available showed that the optimal use of maternal health services helps in reducing maternal morbidity and mortality.However, the utilization of these services is a complex phenomenon influenced by many factors.Various studies conducted world-wide [5][6][7][8] and in India [9,10] have recognized socioeconomic factors and service delivery environment as important determinants of maternal health.
Poor feeding practices during infancy and early childhood, resulting in under nutrition, impaired cognitive and mental development, poor school performance and reduced productivity in later life.
Studies have showed that use of antenatal care and IYCF practices are strongly correlated with demographic and socioeconomic characteristics. [11,12]vernment of Madhya Pradesh is planning to implement district level special nutrition intervention program to improve the nutritional status of under 5 years children.Therefore, the present study was carried out by National Institute of Nutrition (NIN), Hyderabad during 2010-11 in rural areas of Madhya Pradesh, India.The study identifi es the factors associated with ANC practices, place of delivery, colostrum's feeding and time of initiation of breastfeeding.Data pertaining to <1-year children is presented in this communication.

MATERIALS AND METHODS
The study was carried out during March 2011 to August 2011.The study was approved by the Institutional Ethical Review Board and also Scientifi c Advisory Committee of NIN, Hyderabad.Written informed consent was obtained from the mothers involved in the study.

Sampling design
This was a community-based cross-sectional study carried out in all the districts of Madhya Pradesh State by adopting systematic random sampling procedure.

Selection of villages
For the purpose of the survey, in each district, a total of 20 villages were selected, using systematic random procedure, covering all the taluks/blocks based on "population proportional to size" of the village.

Selection of households
In each of the selected villages, a total of 20 households (HHs) were covered.For this purpose, the main village and its hamlets, if any, were divided into fi ve geographical areas, based on natural group of HHs/streets/mohallas/areas, etc. HHs belonging to Scheduled Caste and Scheduled Tribe (SC/ST) communities generally formed one group.From each of these groups, four consecutive HHs having at least one <5-year-old child were surveyed by selecting a random start, starting from the Northeast corner of the area.However, in the selected HH, all the children were included in the study.

Data collection
Information on HH socioeconomic and demographic particulars were collected in the selected HHs, using a precoded and pretested questionnaire.Following information was obtained from all the mothers interviewed.

Maternal particulars and ante-natal care
Maternal particulars such as maternal age, parity, utilization of antenatal care (ANC), tetanus toxoid immunization, receipt of IFA tablets, and particulars of delivery was collected.

Infant and young child feeding practices
Infant and young child feeding practices like time of initiation of breastfeeding, prelacteal and colostrum feeding, exclusive breastfeeding and age at complementary feeding (CF) in terms of age of initiation, type and frequency of CF was assessed by administering precoded, validated questionnaires.In addition, information on sociocultural aspects of IYCF practices by mothers of <3 years children were collected.

Training and standardization
Teams consisting of two postgraduate Research Assistants (Nutritionist/Anthropologist/Social worker) and one graduate fi eld investigator having profi ciency in local language were recruited, trained and standardized in various survey methodologies, by the scientists from the institute.All the survey instruments were developed, translated into local (Hindi) vernacular, validated and pretested before used.
Household wealth was assessed by using principal components analysis.HH socioeconomic and demographic variables such as type of house, occupation of parents, per capita income, type of cooking fuel, electricity, sanitary latrine and separate kitchen were included in the factor analysis.The fi rst component explained about 43% of the variance in the observed set of variables included all the variables.The regression scores from the fi rst component were used to create an index that was divided into tertiles.This was chosen in line with Filmer and Prichett's. [13,14]

Data analysis
The data were scrutinized and entered into the computers at NIN.The data cleaning was done by carrying out range and consistency checks.Descriptive and analytical statistics of the data were carried out using SPSS Windows version 17.0. [15]ivariate and multivariate analysis was carried out using logistic regression model.Those independent variables found to be significant in the bivariate analysis were included in a multivariate regression model for each dependent variable.The results were expressed as odds ratio (OR) with 95% confidence interval (CI).

Dependent variables
Four dependent variables were used for analysis, that is ANC during pregnancy, place of delivery, colostrum feeding and time of initiation of breastfeeding.For ANC, women who had at least three ANC during last pregnancy were coded as "0," and <3 ANC and those not undergone ANC as "1," institutional deliveries were coded as "0," and home deliveries as "1."Colostrum feeding was coded as "0" and discarded colostrum as "1," while initiation of breastfeeding within 1-h of birth was coded as "0" and after 1-h of birth as "1."

Independent variables
Independent variables included in the analysis were age, parity, community, type of family, literacy status, wealth index (as tertiles), while place of delivery and delivery conducted by were added in the analysis of IYCF practices along with above variables.

Coverage particulars
About 2104 mothers are having <6 months children and 3352 mothers of 6-11 months children were interviewed for the present study.Mean age of the mother was 24.9 years (standard deviation 3.79, range: 17-45 years) [Table 1].

Breast feeding practices
Only one-fourth (26%) mothers initiated breastfeeding within 1-h of birth, about 92% fed colostrum to the newborn, about 78% had undergone antenatal check-up during last pregnancy, while 36% had undergone at least three ANCs and 73% mothers delivered in health institutions [Table 2].

Factors affecting ante-natal care and place of delivery
The sociodemographic factors associated with ante-natal checkup and delivery practices are given in Table 3.On bivariate analysis, it was observed that increasing age and parity of women, belonging to SC/ST communities, living in nuclear families, illiteracy of self and husband, and lower wealth index were signifi cantly associated with ANCs for <3 times and home deliveries.

Factors affecting colostrum feeding and time of initiation of breastfeeding
The sociodemographic factors, and delivery practices associated with colostrum feeding and time of initiation of breastfeeding is given in Table 5.On bivariate analysis, discarding colostrum was observed to be signifi cantly (P < 0.01) higher among mothers belonging to SC/ST communities, among illiterate women, illiteracy of head of HHs, lowest wealth index, women delivered at home and delivery conducted by untrained person.
Initiation of breastfeeding after 1-h of childbirth was observed to be signifi cantly (P < 0.01) higher among women of ≥30 years of age, higher parity (≥5), women belonging to SC/ST communities, illiteracy of self and husband, and home delivery and delivery conducted by untrained person.
On multivariate analysis, it was observed that the risk of discarding the colostrum was signifi cantly (P < 0.01) higher among illiterate women, (OR: 1.6, 1.17-2.11)and among women belonging to lowest wealth index (OR: 1.4, 1.02-1.81).The risk of discarding the colostrum was 4 times higher (OR: 3.9, 3.02-4.98)among women whose delivery was conducted by untrained persons as compared to women whose delivery was conducted by medical doctors [Table 6].

DISCUSSION
Madhya Pradesh is one of the backward States in India with high infant and child mortality.According to sample registration survey 2011 report, [16] infant mortality was highest in the State of Madhya Pradesh (67/1000 live births, National average 48/1000 live births), while maternal mortality was 269/100,000 live births against the national average of 212/100,000 live births.
This was the fi rst of kind large survey that the sample was drawn from all the 50 districts of the State.The study revealed high rates of illiteracy among mothers in Madhya Pradesh (49% as against the national average of 35%).The study showed that the utilization of ante-natal services for at least 3 times during pregnancy was 36%, which was similar to that observed in District Level Household and Facility survey (34%) in Madhya Pradesh [17] and slightly lower   (41%) as per NFHS-3 survey. [2]The utilization of ANC services for at least 3 times was higher in the Southern States of India (80% in Karnataka and 96% in Tamil Nadu). [3]Multivariate analyses revealed that utilization of ANC practices for <3 times was higher among women with high parity, living in nuclear families, among illiterate women and lower SES.NFHS-3 also reported similar fi nding for Madhya Pradesh. [3,18,19]The probable reasons cited for not utilizing or partial utilization of ANC services were unaware of the need (14%), no faith and loss of wages (3% each) and no ANCs held in village/place not accessible (4% each).Unaware of need was more common (68%) among illiterate women when compared to literate women (32%).
Present study revealed that about 74% of mothers had institutional delivery, mostly at the government hospitals (67.8%), but initiation of breastfeeding within 1-h of child birth among those delivered at hospital was very low (29.5%).This fi nding revealed that even medical persons needs to be educated for encouraging these practices in case of hospital delivery.Multivariate analysis revealed that home delivery was signifi cantly higher among women with high parity, among schedules caste and scheduled tribe women and lower SES.Mumbare and Rege and Pradhan et al. also reported lower rates of institutional deliveries among women belonging to low SES, among illiterate parents and among three-generation families. [18,19]ble 4: Multivariate regression analysis for antenatal check-up and place of delivery with sociodemographic particulars Infant and young child feeding practices are the important determinants of nutritional status of below 5 years children.
In the present study, it was observed that only 26% newborn received breastfeeding within 1-h of birth, while about 9% received breast feeding after 24 h of birth.Early initiation of breastfeeding is important for establishing successful lactation as well as for providing the colostrum (mother's fi rst milk) to the baby. [20]Colostrums contain antiinfective substances which protect the baby from infectious diseases such as diarrhea and ARI to which the child might be exposed during the 1 st few weeks after birth which are the important reasons for infant mortality and morbidity. [21,22]Multivariate analysis revealed that discarding colostrum and late initiation (after 1-h of birth) was signifi cantly higher among illiterate women and among women whose delivery was conducted by untrained personnel.These fi ndings are similar to that reported in other studies. [23,24] was also observed that the utilization of health services was higher among literate mothers compared to illiterate as observed in other studies. [25]This is because better-educated women are, more aware about their health, know more about availability of maternal health care services and use this awareness and information in accessing the health care services.

CONCLUSION
As it was observed that antenatal care, delivery and IYCF practices were associated with literacy status of women, community and wealth index and person conducting delivery.Thus improving the literacy of women along with SES, deliveries by trained health personnel and improved information, education and communication services can improve these practices and thus nutritional status of under 5 years children.
[2] International Journal of Medicine and Public Health | Oct-Dec 2014 | Vol 4 | Issue 4 ANC = Antenatal care, ANM = Auxiliary nurse midwife, LHV = Lady health visitor, TBA = Traditional birth attendant International Journal of Medicine and Public Health | Oct-Dec 2014 | Vol 4 | Issue 4

Table 1 : Sociodemographic particulars of the study subjects
SC = Scheduled caste, ST = Scheduled tribe, OBC = Other backward community, HH = Household

Table 3 : Bivariate analysis for antenatal check-up (ANC) and delivery practices with sociodemographic particulars
OR = Odds ratio, ANC = Antenatal care, SC = Scheduled caste, ST = Scheduled tribe, OBC = Other backward community, CI = Confi dence interval, HH = Household