European Journal of Cardiovascular Medicine

The World Health Organization recommends comprehensive postnatal care, including early postnatal check-ups, counselling on breastfeeding, nutrition, family planning, and timely identification of complications (1). In India, national programs such as Janani Suraksha Yojana (JSY) (2), Janani Shishu Suraksha Karyakram (JSSK) (3), Pradhan Mantri Matru Vandana Yojana (PMMVY) (4) and Kasturba Poshan Sahay Yojana (KPSY) (5) have been implemented to enhance maternal health service utilization and reduce financial barriers.

Despite high institutional delivery rates, utilization of postnatal care services remains inadequate. National Family Health Survey-5 (NFHS-5) reports that although institutional deliveries exceed 85%, postnatal contraceptive use and awareness of maternity benefit schemes remain suboptimal (6). Maternal education, socioeconomic status, and awareness of health schemes have been identified as important determinants influencing postnatal care utilization and reproductive health practices (7,8).

Although urban areas have better health infrastructure, disparities in service utilization persist due to socioeconomic inequalities and gaps in awareness (9). Evidence on postnatal care utilization and its determinants in urban areas of the Saurashtra region of Gujarat is limited. Therefore, this study was undertaken to assess postnatal maternal health care utilization and its determinants among urban women aged 18–45 years.

Aims: To assess various determinants related to maternal health care services utilization and assess the utilization status of healthcare services during the postnatal care period

The sample size for this study was determined to be 508. The calculation was based on the maternal health care service utilization rate of 76.9% as reported in the National Family Health Survey (NFHS-5) for Gujarat (10). A relative error of 3.845% (5% of the prevalence) was considered, along with a non-response rate of 10%. The sample size was estimated using the formula: N = (1.96)2 (*p*q)/l^2 where N represents the required sample size, p is the prevalence rate (76.9%), q is the complement of prevalence (1 - p = 23.1%), and l is the relative error (3.845). Using this formula, the calculated sample size was 462. Considering a 10% non-response rate, which accounts for 46 participants, the final sample size was adjusted to 508 to ensure adequate representation and reliability of the study findings. Sampling method: Probability proportional to size Study area is divided in to 12 - sector according to ICDS data. According to ICDS data, total number of mothers who had a child age between 42 days to 6 months is 1405 and calculated sample size is 508 so, I took 36.1565 % mothers from each sector by systematic random sampling. Verbal informed consent was obtained from all participants prior to data collection. Study duration: 12 months Inclusion criteria: The study included women aged 18 to 45 years who had given birth, with children aged between 42 days and 6 months, and who had been residing in the study area for at least six months prior to the survey. Exclusion criteria: Women with severe physical or mental illness that impaired their ability to respond to the questionnaire were excluded Women who don’t want to participate in this study. Women who had a child >6 months old are excluded in this study. Data collection: Semi-structured, Pilot-tested Questionnaire was administered in local language by interview technique. A pretested semi structured questionnaire was made using google form that include questions regarding their sociodemographic profile, information about postnatal care services. Data analysis: The questionnaires was administered with a face-to-face interview and further entered in MS excel for its compilation and all the data and analysis done using Software R. Ethical Issues Considered: This study approved by Institutional Ethics Committee. The patient's right to take part in the study was protected. They were allowed to leave the study at any moment, for any reason, and without losing access to medical treatment because participation was entirely voluntary.

Table 1. Socio-Demographic Characteristics of Study Participants (n = 508)

The majority of mothers were aged 23–27 years (46.3%), followed by 28–32 years (41.3%). Nearly one-fourth of the participants were illiterate (24.2%), while most had primary education (61.0%). A large proportion of mothers were unemployed/housewives (80.3%). Most participants belonged to the Hindu religion (82.1%). Nuclear families were the most common (54.9%), followed by three-generation families (36.2%). Regarding socio-economic status, the majority belonged to the middle (44.5%) and lower-middle classes (35.4%), with very few participants from the upper class (0.6%).

Table 2. Reproductive Characteristics of Study Participants (n = 508)

Nearly two-thirds of the participants reported that their last pregnancy was planned (65.2%). Slightly more than half of the mothers had ever or were currently using contraception (53.5%). The majority of participants had two or fewer children (72.1%), while about one-fourth had three or more children (28.0%).

Table 3. Delivery-Related Characteristics and Pregnancy Complications (n = 508)

Most deliveries occurred in government health facilities (96.9%), and the majority of women delivering in these facilities did not incur any out-of-pocket expenditure (87.2%). Pregnancy-related complications were reported by a small proportion of participants (6.9%), with postpartum haemorrhage being the most common complication (77.1%). Government ambulance services were the most frequently used mode of transport during delivery (52.4%). Vaginal delivery was the predominant mode of childbirth (76.8%), while nearly one-fourth of deliveries were by caesarean section (23.2%).

Table 4. Utilization of Postnatal Care Services (n = 508)

Footnote:
ASHA – Accredited Social Health Activist; HBNC – Home-Based Newborn Care; IUCD – Intrauterine Contraceptive Device.

Postnatal contraception use was low, with only 11.6% of women adopting a contraceptive method after delivery, of which IUCD was the most commonly used method (78.0%). The vast majority of participants utilized government facilities for postnatal care (96.5%). Almost all mothers received home visits by ASHA workers under the Home-Based Newborn Care programme (99.2%), indicating excellent outreach and coverage of postnatal services.

Table 5. Postnatal Micronutrient Supplementation Among Study Participants

Most participants consumed iron–folic acid and calcium supplements for 4–5 months during postnatal period. Iron–folic acid intake for four and five months was reported by 32.4% and 33.2% of women, respectively, while similar durations were observed for calcium supplementation (32.1% for four months and 30.1% for five months). A smaller proportion of participants reported no intake of iron–folic acid (7.0%) or calcium (11.1%), indicating overall good postnatal micronutrient supplementation coverage.

Table 6. Counselling and Advisory Services Received During Postnatal Period (n = 508)

The majority of participants received counselling and advisory services during the postnatal period. Breastfeeding advice was received by almost all mothers (99.6%), followed by nutritional advice (98.4%) and child vaccination advice (98.2%). Information on pregnancy spacing (96.7%) and family planning (94.7%) was also widely provided. Advice regarding postnatal exercises was received by a slightly lower proportion of participants (91.1%), though coverage remained high overall.

Table 7. Association Between Maternal Educational Status and Reproductive Health Indicators

Footnote:
JSY – Janani Suraksha Yojana; JSSK – Janani Shishu Suraksha Karyakram; BPL – Below Poverty Line; IFA – Iron–Folic Acid.

Maternal educational status showed a statistically significant association with all assessed reproductive health indicators. Higher education was significantly associated with contraceptive use, planned pregnancies, and having fewer children (p < 0.001). Educational status also demonstrated significant associations with the duration of iron–folic acid and calcium tablet consumption. Additionally, knowledge regarding maternal health schemes such as JSY (BPL) and JSSK was significantly higher among educated mothers, highlighting the important role of maternal education in improving reproductive health awareness and practices.

In the present study, out of 492 participants, 63 (12.8%) incurred out-of-pocket expenditure at government health facilities. This finding is in line with observations by Rakesh Chandra et al., who reported a marginal decline in out-of-pocket expenditure for maternal health services in the government sector, in contrast to a substantial increase in private facilities, indicating a relative reduction in financial burden for households utilizing public maternal health services (11).

In the present study, among 508 participants, 1.57% reached the health facility on foot, 52.36% used government vehicles or ambulances, and 46.06% relied on private motor vehicles or rickshaws. In contrast, a study by Sandeep Sharma et al. reported that 20.81% of participants reached the health facility on foot and 79.19% used private vehicles, with none utilizing government transport during delivery, highlighting better utilization of government transport services in the present study (12).

In the present study, out of 508 participants, 76.77% had vaginal deliveries and 23.23% underwent caesarean sections. These findings are comparable to those of Sandeep Sharma et al., who reported that 78.33% of participants had vaginal deliveries and 21.67% underwent caesarean sections, indicating a similar pattern of mode of delivery across studies (12).

In the present study, among 59 participants adopting postnatal contraception, 77.97% opted for postnatal IUCD insertion, while 22.03% underwent tubal ligation. In contrast, NFHS-5 data report much lower IUCD use (2.1%) and a higher preference for tubal ligation (37.9%) among women, indicating a markedly higher uptake of postnatal IUCD in the present study population (13).

In the present study, among 500 participants, 7% did not consume iron–folic acid (IFA) tablets during the postnatal period, while 9.8%, 6.2%, 5.6%, 32.4%, 33.2%, and 5.8% consumed IFA tablets for 1, 2, 3, 4, 5, and 6 months, respectively. As per national recommendations, pregnant women should receive a prophylactic dose of 60 mg elemental iron and 500 µg folic acid for 180 days (6 months), indicating that only a small proportion of women in the present study completed the recommended duration of IFA supplementation (14).

In the present study, among 505 participants, 11.09% did not consume calcium tablets during the postnatal period, while 11.49%, 4.75%, 6.93%, 32.08%, 30.10%, and 3.56% consumed calcium tablets for 1, 2, 3, 4, 5, and 6 months, respectively. According to national guidelines, all pregnant women should receive 1000 mg of calcium supplementation daily from the 14th week of pregnancy until 6 months postpartum, indicating that only a small proportion of women in the present study completed the recommended duration of calcium supplementation (14).

In the present study, among 508 participants, 99.61% reported receiving breastfeeding advice during the postnatal period. This contrasts with findings by Dadhich JP et al., who reported that only 24.5% of mothers in India initiate breastfeeding within the first hour of birth and that exclusive breastfeeding up to six months is practiced by only 46.4% of mothers, underscoring the importance of effective breastfeeding counselling during the postnatal period to improve early initiation and exclusive breastfeeding practices (15).

In the present study, out of 508 participants, 96.65% received information regarding pregnancy spacing during the postnatal period, while 3.35% did not. This high level of counselling is crucial, as evidence suggests that short birth intervals are associated with adverse outcomes. Studies by Periyasami Kuppusamy et al. have shown that under-five mortality is nearly twice as high among infants born after short birth intervals compared to intervals of three years or more (16), while Priyanka Sahu et al. reported that birth intervals of less than 24 months are linked to increased risks of adverse maternal and perinatal outcomes, including preterm birth, low birth weight, and small-for-gestational-age infants (17).

The present study highlights that utilization of maternal health care services during the postnatal period in urban areas of Saurashtra, Gujarat, remains inadequate despite high institutional delivery rates. While most mothers received essential postnatal services such as IFA and calcium supplementation, breastfeeding guidance, and home visits by ASHAs, the use of postnatal contraception and awareness of key maternity benefit schemes was low. Maternal educational status emerged as a significant determinant, influencing knowledge of government schemes, adherence to micronutrient supplementation, family planning practices, and reproductive behaviour. These findings underscore the critical role of maternal education and targeted health awareness programs in improving postnatal care utilization. Strengthening community-based interventions, enhancing awareness of government schemes, and promoting education among women can potentially reduce maternal morbidity and improve health outcomes for both mothers and children in the region. Limitation: This study has certain limitations. As a cross-sectional study, causal relationships cannot be established. Data were self-reported and may be subject to recall and social desirability bias. The study was conducted in an urban setting, limiting generalizability to rural populations.

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