European Journal of Cardiovascular Medicine

The reproductive health of women is a crucial aspect of overall health and plays a key role in human development. In India, the rural population accounted for 64.61% of the total population in 2021¹. Despite improvements in maternal and child health, significant challenges remain. In 2020, a maternal death occurred approximately every two minutes, with nearly 95% of these deaths occurring in low and lower-middle-income countries². In India, the maternal mortality ratio (MMR) has decreased from 130 deaths per 100,000 live births in 2014-16 to 97 deaths per 100,000 live births in 2018-20³. Similarly, the infant mortality rate (IMR) has dropped from 44 to 28 deaths per 1,000 live births between 2011 and 2020⁴. These indicators are critical in monitoring progress toward the 2030 Sustainable Development Goals (SDGs), which aim to reduce the global MMR to below 70 per 100,000 live births⁵.

Efforts to improve maternal and child health in India have been ongoing, with significant policy milestones outlined in the table below. For instance, the National Family Health Survey (NFHS-5)⁶ highlights that 56.3% of women in Gorakhpur received at least four antenatal care (ANC) visits, and 67.7% of children aged 12-23 months were fully immunized. However, the utilization of maternal healthcare services remains a challenge, particularly in rural areas and among disadvantaged groups. In Gorakhpur, 29.3% of women took iron-folic acid supplements for a minimum of 100 days, and 63.8% of women were using some form of family planning. Yet, barriers such as limited access to healthcare, inadequate knowledge, and socio-cultural factors continue to impede optimal utilization of maternal health services, contributing to higher maternal and neonatal mortality and morbidity rates.

Several government initiatives, including the National Rural Health Mission (NRHM) and various schemes like Janani Suraksha Yojana (JSY) and Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), have significantly increased the availability of healthcare services. Community health workers, including Auxiliary Nurse Midwives (ANMs), Anganwadi workers, and Accredited Social Health Activists (ASHAs), play a vital role in delivering maternal health services at the community level. Despite these efforts, many women, particularly in rural and marginalized communities, still face significant challenges in accessing maternal care. The lack of transportation, high costs, socio-cultural beliefs, and insufficient quality of services contribute to the underutilization of essential health services⁷.

The three delays model, which explains delays in seeking medical care, reaching healthcare facilities, and receiving appropriate care, is useful in understanding the barriers to healthcare access in rural areas. Additionally, the multidimensional framework focusing on the availability, accessibility, affordability, acceptability, and accommodation of services provides a comprehensive approach to addressing these challenges⁸.

The objective of this research is to determine the utilization of maternal and child health services and their children in the Chargawan block of Gorakhpur district. This research will provide valuable insights that can guide policy interventions and enhance the effectiveness of maternal health programs in rural India.

Study design and study setting

A community-based cross-sectional study was conducted among women in the Chargawan block of Gorakhpur district of Uttar Pradesh, India.  The study participants were recently delivered women and their children up to 24 months who reside in Chargawan block.

Sample size and sampling strategy: The sample size was calculated According to NFHS-5 (2019-2021), the prevalence of at least four antenatal care (ANC) visits in Gorakhpur district is 56.3%⁶. Assuming an alpha error of 5%, a confidence interval (CI) of 95%, and an absolute error of 5%, and to account for non-responses (5%), the final sample size was adjusted to 400. A multistage sampling technique was used for the recruitment of the study participants. In the First Stage (PHC Selection)- two APHCs were randomly selected using the lottery methods from the list of PHC in the study areas. In the Second Stage (Sub-center Selection), from each selected APHC, one sub-center was randomly chosen, in the Third Stage (Village Selection), Two villages were randomly selected from each sub-center, resulting in four villages being selected for the study. A comprehensive list of mothers with children up to 24 months was compiled through ASHA registers from this A total of 400 women were randomly selected from selected villages.

Inclusion Criteria Recently delivered women who are residents of Chargawan block in Gorakhpur district and who gave written informed consent to participate in the study. The ethical clearance was obtained from the Institutional Ethics Committee B.R.D.M.C, Gorakhpur.

Study tool: A pre-tested and pre-designed questionnaire was created at the Department of Community Medicine, BRD Medical College in consultation with the guide and co-guide. The questionnaire collected data on-Bio-social characteristics (age, religion, caste, education, occupation, socioeconomic status, etc.) and utilization of maternal and child health (MCH) services, including ANC, delivery, postnatal care (PNC), family planning, immunization, and childcare and factors influencing access utilization of MCH services among recently delivered women.

Statistical analysis: The continuous variables were presented in mean ± standard deviation (SD), whereas Chi‑square test was used to test the association between two categorical variables. Statistical package for social sciences, version‑26 (SPSS‑26, IBM,Chicago, USA) was used for data analysis. P <0.05 was considered statistically significant.

The majority RDWs (51.0%) fell within the 25–34 age. In terms of religion, 77.75%      of RDWs identified as Hindu, Caste-wise, 57.75% of RDWs were categorised as Other Backward Class (OBC), The majority of mothers (30.25%) possessed a high school education as their highest qualification. A significant proportion (81.25%) of mothers were classified as non-working, including homemakers. Among the husbands of RDWs, 26.50% had attained a high school education as their highest qualification. About 29.25 per cent of RDWs belonged to nuclear families.  (table 1).

Table 1. Distribution of study participants according to their socio demographic profiles (N=400)

The distribution of MCP card ownership among RDWs reveals that (80.25%) possess MCP cards. the overall registration for ANC services in the study area was 96.50%. Most women who avail ANC services primarily visit the nearest Primary Health Center (36.50%), and 19.00% of RDWs prefer private clinics or hospitals for receiving ANC services. the majority (41.00%) had more than four ANC visits. (Table 2)

Table 2 distribution of study participant according to ANC services availed from different health facility (N=400)

Table 3 Distribution of recently delivered women according to place of           delivery and post-natal services availed (N=400)

The majority (95.75%) of RDWs opted for institutional deliveries. The majority of RDWs (40.75%) delivered at Primary Health Centers (PHC), followed by TCH/MC (26.75%). Home visits by HCW within 6 weeks of delivery was 76.57 percent. About 33.25 percent of RDWs received JSY incentives. (Table 3). Oral Contraceptive Pills use by RDWs was 15.35%, with 56.75% obtaining them from PHCs and Chhaya was used by 5.8% of RDWs (table 4).

Table 4 Distribution of RDW according to family planning services availed (N=400)

*newly CHC

Women aged 25-34 years had the highest utilization rate (54.5%), with younger (<25 years) and older (≥35 years) women using services less. There was no significant difference in service utilization between Hindus (76.7%) and Muslims (73.2%). The utilization rate was lowest among SC/STs (31.2%) compared to OBCs (63.2%) and General categories (5.48%).  Illiterate mothers had lower service utilization (9.67%) compared to those with school education (81.6%).  Women with educated spouses (graduate level) had higher service utilization, while illiterate spouses were linked to lower utilization Women with spouses in professional jobs had the highest utilization (96%), while those with spouses in unskilled or agricultural work had lower rates. Women from lower socio-economic backgrounds had higher utilization (33.2%) compared to those from higher socio-economic groups (8.7%). (Table 5).

Table 5 Factors influencing utilization of Maternal and child health             services in Government health facilities (N=400)

Figure 1 Immunization status of children

In the present study it was found that 77.5 percent registered at government facilities, and 19 percent registered at private hospitals. About 80.25 per cent of mothers had mother-child protection cards. Similar finding in  Pai D V et al. (2018)⁹, and another study by Sangita et al. (2012)¹⁰ Our result were slightly as compared to the finding of NFHS-5⁶, data which showed that in Gorakhpur, 98.6 per cent of mother received Mother and Child Protection (MCP) card. 

Approximate one third (36.25%) of the respondents in our study had less than four ANC visits, while majority 41.00 percent had more than four visits, and 22.75 percent had four ANC visits. While 3.5 percent had not received any kind of ANC services. The findings are lower to Sharma S et al. (2020)¹¹.

First prenatal visits were made by approximately 62.75 percent of recently delivered women (RDW) in the first trimester, 27.75 percent in the second trimester, and 9.50 percent in the third trimester. These results align with the findings of Thakur N, et al. (2015)¹². Additionally, according to NFHS-5⁶ data, mothers who attended prenatal checkups during the first trimester had a 70 percent likelihood, which is higher than the percentage observed in our study

In the present study, the majority (95.75%) of participants opted for institutional delivery, while approximately 4.25% delivered at home. Among those who delivered institutionally, 74.0% chose public health facilities and 21.75% opted for private facilities. Comparison with previous studies reveals that Gulshan Kumar et al. (2014)¹³ reported a lower rate of public health facility In addition, Singh V et al. (2020)¹⁴ found a higher incidence of home deliveries, Srivastava R.K et al. (2009)¹⁵ reported a 30% rate of home deliveries. According to NFHS-5⁶, public health facility deliveries in Gorakhpur were reported at 72.5%, aligning closely with the present study's observations. 

In the present study found that home visits by Health Care Worker within 6 weeks of delivery was observed in 76.57 percent. First- time home visit by HCW was within seven days in 64.84 percent. Only 39.25 percent of  RDW had post-natal visits at the health facility and 60.75 percent of RDW had no postnatal care visits. About 33.25 per cent of RDW received Janani Suraksha Yojana incentives. Our finding are in similar to Sharma S, et al. (2020)¹¹ Devasenapathy N,et al, (2015) ¹⁶ As per NFHS-5⁶, In our study, 60.25% of women in the RDW reported using family planning services. Among them, 42.32% utilized condoms, with 20.58% obtaining them from Sub Centres, 27.45% from PHCs, and the majority purchasing them from private facilities. Additionally, 15.35% used oral contraceptive pills (OCP), all of which were provided at government health facilities. About 5.80% of users opted for Chhaya, and 11.61% used Antra, with 75% of Antra users receiving it from PHCs. Furthermore, 13.27% used the intrauterine contraceptive device (IUCD), with 59.37% obtaining it from PHCs and 40.6% from Medical Colleges.

These findings are consistent with the study by Pai D.V. et al. (2018)⁹, Similarly, Logaraj M. et al. (2017)¹⁷ contradictory results were observed in a study by Sangita et al. (2012)¹⁰, Other studies, such as those by Devasenapathy N. et al. (2015)¹⁶ and Singhal A. et al. (2015)¹⁸, reported condoms as the most commonly used contraceptive. According to NFHS-5⁶, 63.8% of women in Gorakhpur used some form of contraception, with 48.9% using modern methods. Of those, 20.1% used condoms, 0.8% used IUD/PPIUD, and 6.9% used pills.

In our study, it was found that 92.0 percent of RDW had immunization  cards.. About 76.2 percent of children were completely immunized for age, 15.7 percent children were partially immunized and 8.0 percent do not have Mother and Child Protection (MCP) cards. In comparison to the findings of Logaraj M, et al(2017)¹⁷, this is higher, while it is similar to study by Pai D V, et al. (2018)⁹  Sangita, et al.(2012)¹⁰ and NFHS-5⁶ data shows 69.6 percent and in Gorakhpur 67.7 percent children were fully immunized from either MCP card or by mothers recall, which is lower than present study.

About 69.00 percent of the children of RDWs had a history of diarrhoea. For the treatment of the same, 33.3 percent utilized to PHC, while the 36.9 percent went to private healthcare centres.While a study done by Beyene SG, et al. (2018)¹⁹ and Borah H, et al. (2014)²⁰ As per NFHS- 5⁶, it was observed that  diarrhoea  in the last 2 weeks preceding the survey was 7 percent. Children with diarrhoea in the last 2 weeks were taken to a healthcare facility was 76 percent but in our study history of diarrhoea  is taken from since birth by recall of mothers.

In our study, about 10.50 percent of children of RDWs had a history of ARI since birth of the child. For the treatment, only 21.42 percent of these women went to the nearest PHC, most of the RDWs (50.0%) went to other private health facilities. This is in accordance with that of Nirmolia N et al. (2018)²¹ NFHS-5⁶, it was observed that frequency of symptoms of acute respiratory infection (ARI) in the last 2 weeks preceding the survey was 2.8 percent. Children with fever or symptoms of ARI in the last 2 weeks preceding the survey taken to a healthcare facility were 56.1 percent.

Women aged 25-34 years had the highest utilization rate (54.5%), with younger (<25 years) and older (≥35 years) women using services less. There was no significant difference in service utilization between Hindus (76.7%) and Muslims (73.2%). The utilization rate was lowest among SC/STs (31.2%) compared to OBCs (63.2%) and General categories (5.48%). Devasenapathy N, et al, (2015)¹⁶. There was statistically significant relation between cast and utilization of MCH services at government health facilities (p-value <0.05). Illiterate mothers had lower service utilization (9.67%) compared to those with school education (81.6%).  Women with educated spouses (graduate level) had higher service utilization, while illiterate spouses were linked to lower utilization Women with spouses in professional jobs had the highest utilization (96%), while those with spouses in unskilled or agricultural work had lower rates. Women from lower socio-economic backgrounds had higher utilization (33.2%) compared to those from higher socio-economic groups (8.7%). This finding is acordance with the findings reported by Bose S et, al. (2021)²², Neyaz A, et al. (2015)²³, Devasenapathy N, et al. (2015)¹⁶ and Singhal A, et al. (2015)¹⁸.

Strength and Limitations

The study's limitations include small sample size and limited generalizability due to a specific geographic or demographic focus. Additionally, the study might not account for healthcare

Our findings suggest that maternal health service utilization is influenced by a complex interplay of socio-economic, educational, and demographic factors. To improve access and utilization, there is a need for focused efforts to enhance education, particularly for women in marginalized communities, and to address socio-economic barriers. Additionally, improving the involvement of spouses, especially in professional and educational aspects, could further increase maternal health service utilization. Policy and programmatic interventions must be tailored to address these determinants, ensuring equitable access to maternal health services for all women.

Conflict of Interest: None

Funding: Nil

Acknowledgement: None

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