Factors Affecting Antenatal Care Utilization Among the Disadvantaged Dalit Population of Nepal: A Cross- sectional Study

1. INTRODUCTION

Developing countries account for 99 percent of the global maternal deaths, with the sub-Saharan Africa region alone accounting for 62% followed by Southern Asia 24% [1]. Antenatal care (ANC) can be defined as “the care provided by skilled health-care professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both mother and baby during pregnancy” [2]. Utilization of Antenatal care service promotes institutional delivery and decreases maternal morbidity and mortality both directly and indirectly [2-4]. ANC provides a mother the opportunity to familiarize and interact with the health system and with the health facility, thereby increasing the chance that she chooses to deliver in a health institution [5]. As recommended by World Health Organization (WHO), Nepal has required at least four ANC services scheduled in the following way: first visit at the 4th month, second at the 6th month, third at the 8th month and fourth at the 9th month of pregnancy [6]. In Nepal, ANC services are based on monitoring of mother's blood pressure, weight and fetal heart rate; providing information education and communication and behavior change communication for danger signs, care during pregnancy, timely referral to the appropriate health facilities; birth preparedness and complication readiness; early detection and management of complications; and provision of tetanus-toxoid immunization, iron and de-worming tablets to all pregnant women and malaria prophylaxis as needed [6]. Further, the government of Nepal provides financial incentives to women and health facilities to promote ANC and institutional delivery [6-8]. Despite these efforts, Nepal is still one of the countries in South and Southeast Asia where women are less likely to receive ANC from health professionals (doctors, nurse/midwife) and low proportion of births are delivered in a health facility [9].

Nepal has made impressive improvements in maternal health during the years between 1990 and 2015. Several statistics point to this progress, for example: the decrease in Maternal Mortality Ratio (MMR) from 850 per 100,000 Live Births (LB) in 1990 to 229 per 100,000 LB in 2010 [10, 11]; the increase in institutional delivery from 8% in 1996 to 57% in 2016; the increase in percentage of women receiving four or more ANC visits from 9% in 1996 to 69% in 2016 [7, 9, 12]. However, these gains are unevenly distributed, with the most disadvantaged group of caste (Dalit) benefitting the least. For example, the national MMR is 229/100,000 LB, versus 273/100,000 LB among Dalits and the percentage of women with four or more ANC visits is 64% among upper caste (Brahmin/Chhetri) and 40% among Dalits [11]. Dalit communities continue to suffer from caste-based discrimination and are considered “untouchable.” As a result, Dalits are considered some of the most “backward” in social, economic, educational, political and religious dimensions and unsurprisingly have lower developmental indicator than other castes [13].

This study was conducted to understand the rate and factors associated with the antenatal care service utilization among the most disadvantaged ethnic group (Dalit women) and recommend interventions to improve ANC utilisaiton, in the Mahottari district of Nepal.

2. MATERIALS AND METHODS

3. RESULTS

4. DISCUSSION

From the methodological point of view, this study was based on the literatures review of cross-sectional studies with a large sample size in Nepal and other countries; and the respondents were the mothers who had delivered their child within past one year [14, 19, 20] and within last two year [21]. In this study, mothers with formal education were found to be three times more likely to have four or more ANC visits than mothers who did not have formal education. This is in keeping with other literature, the NDHS 2016 showed that non-educated mother constituted a higher proportion (12%) of those who had no ANC at all, while School Leaving Certificate (SLC) or the above-educated mothers constituted only 1% of women with no ANC [12]. Similarly, a number of studies showed that by increasing education levels of women, the probability of receiving four or more ANC visits also increased [16, 19, 20, 22-27]. The increased education may have also brought increased knowledge and awareness of health services, higher receptivity to new health-related information, better communication with the husband, more decision making power, increased self-worth, negotiating skills, and ability to demand adequate services. Higher education of husband level has shown similar effect, wife receiving twice ANC utilization than their counterparts. This is similar to the result of systematic review carried out in low-income countries [28]. Studies conducted in Nepal [16], Ethiopia and Shanghai [25, 29] support the similar findings. This could be explained on the basis that educated husbands may be aware of ANC's benefits, put fewer constraints on their wives' mobility and decision-making and able to communicate with health workers to demand appropriate service. Another finding from our study was that non-daily waged mothers had utilized three times ANC services than their counterparts. This is consistent with another study conducted in the mid and far western region of Nepal found that women having occupation-service, business, wage labor and housewife had more ANC visit than women having occupation- agriculture [19] while another study of Sindhupalchok district of Nepal showed that the mother's occupation whether agriculture/labor or business/service was not significantly associated with ANC utilization [14]. This dissimilarity may be due to the different basis of categorizing the occupation. Our study showed that Perceived “good quality” of ANC was significantly associated with the ANC utilization. Other studies have shown that women reported better quality of care in private facilities but the cost prevented them from the utilization of those services [5]. Consequently, the mother who perceived getting all the components of ANC services was more likely to repeat the ANC visit. In this study, a mother exposed to maternal health messaging was found to be, on average, three times more likely to use ANC services. These findings were echoed in studies conducted in Pakistan and Nigeria [20, 27]. Mothers who had not perceived health workers behavior as discriminatory had three times ANC utilization than mothers who had perceived health workers behavior as discriminatory, indicating that the discriminatory behavior of health workers lower the ANC utilization which was similar to Nepal Maternal Mortality and Morbidity Study [11]. This is likely because positive past experiences encourage future utilization, and negative experiences discourage them. The mothers exposed to FCHV were about twice more likely to utilize ANC service than their counterparts. This is because exposure to FCHV increases the possibility of sharing information about health services.

CONCLUSION

This is the first study conducted among the most disadvantaged caste (Dalit) that identified ANC utilization rate and critically analysed factors affecting them in the Mahottari district of Nepal.

Despite the provision of ANC service to community level by the government, its full utilization was lower (42%) in Dalit caste, which was lower than the national figure (69.4%). The major reasons reported by women interviewed for the low utilization of ANC were-lack of information regarding ANC service and the prohibitively far distance of health facility. ANC utilization was significantly associated with the education of women and husband, the non-waged occupation of mother, perceived “good quality” of ANC, exposure to SDIP and maternal health message and FCHV, and the perceived unbiased behaviors of health workers

Maternal health intervention targeted to Dalit women recommended to increase ANC utilization among Dalits. The program should focus on improving the quality of ANC service, promoting unbiased behavior of health workers, increasing the mobilization of FCHV and community health workers of government health facilities in Dalit community; and implementing awareness activities and dissemination of health messages to support demand generation and the uptake of ANC service by Dalits. Simultaneously, improving the education of a couple could be a strategy to improve the ANC utilization in the long term. Further, coordination with other sectors would be vital for Dalit women to have daily income.

REFERENCES