|BRIEF RESEARCH ARTICLE
|Year : 2013 | Volume
| Issue : 4 | Page : 268-271
Factors associated with the preference for delivery at the government hospitals in rural areas of Lucknow district in Uttar Pradesh
Manas Pratim Roy1, Uday Mohan2, Shivendra Kumar Singh3, Vijay Kumar Singh4, Anand Kumar Srivastava2
1 Junior Resident, Upgraded Department of Community Medicine and Public Health, CSM Medical University, Lucknow, Uttar Pradesh, India
2 Professor, Upgraded Department of Community Medicine and Public Health, CSM Medical University, Lucknow, Uttar Pradesh, India
3 Associate Professor, Upgraded Department of Community Medicine and Public Health, CSM Medical University, Lucknow, Uttar Pradesh, India
4 Assistant Professor, Upgraded Department of Community Medicine and Public Health, CSM Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||18-Dec-2013|
Manas Pratim Roy
154, H N Road By Lane, Cooch Behar District - 736 101, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
For assuring safe maternal and newborn health, institutional delivery was given paramount importance. In India, in spite of several efforts, lesser than 40% deliveries are conducted at health facilities, mostly at private sector. The present cross-sectional study aimed to find out the determinants of preference for delivery at government hospitals in rural areas of Lucknow, a district in Uttar Pradesh. Multistage random sampling was used for selecting villages. From them, 352 recently delivered women were selected, following systematic random sampling. Overall, 84.9% of deliveries were conducted at health institutions. Out of them, 79.3% were at government hospitals. Applying multivariate logistic regression, Hindu women (odd's ratio [OR] = 3.205), women belonging to lower socio-economic class (OR = 4.630) and late registered women (OR = 2.320) were found to be more likely to deliver at government hospitals. Attention should be given to religion, social status and timing of registration for ensuring higher fraction of deliveries at government set-up.
Keywords: Government hospital, Institutional delivery, Janani Suraksha Yojana, Maternal health, Rural India
|How to cite this article:|
Roy MP, Mohan U, Singh SK, Singh VK, Srivastava AK. Factors associated with the preference for delivery at the government hospitals in rural areas of Lucknow district in Uttar Pradesh. Indian J Public Health 2013;57:268-71
|How to cite this URL:|
Roy MP, Mohan U, Singh SK, Singh VK, Srivastava AK. Factors associated with the preference for delivery at the government hospitals in rural areas of Lucknow district in Uttar Pradesh. Indian J Public Health [serial online] 2013 [cited 2020 Jul 4];57:268-71. Available from: http://www.ijph.in/text.asp?2013/57/4/268/123271
India is the largest contributor in the pool of maternal deaths, accounting for about one-sixth of the deaths.  As we are approaching the deadline for Millennium development goals, the need for improving the standard of maternal care is getting more evident. However, in spite of several efforts, lesser than 40% deliveries are conducted at health facilities in the country, most of which take place at private hospitals.  Although expensive, private sector is still considered to have the best facilities to offer in terms of standard of care. 
To bring pregnant mothers to government hospitals for the purpose of delivery, the primary role has been given to Accredited Social Health Activists (ASHAs) under National Rural Health Mission (NRHM). However, it has not been successful to attract the beneficiaries to the expectation, even after offering cash benefits under Janani Suraksha Yojana for getting ante-natal care (ANC) as well as deliveries done at government hospitals. The reasons for under-utilization of public hospitals are complex, as evident from the literatures. Religion, caste, age, education, parity, economic condition, media exposure and number of ANC visits have earlier been established as factors determining the place of delivery. , In addition, lack of an adequate care, lack of awareness, corruption and other factors were held responsible for the failure of the mission in ensure universal institutional deliveries.  In this perspective, the present study was undertaken to assess the delivery practices and to find out the determinants of preference for delivery at government hospitals in rural areas of Lucknow District, situated in Uttar Pradesh, north India.
The study, cross-sectional descriptive in nature, was conducted among rural recently delivered women (RDW) in Lucknow district from August 2009 to July 2010. A RDW was defined as a post natal woman who had delivered a baby during the period from January 2009 to June 2010 (operational definition). As a part of a larger study which addresses the whole spectrum of pregnancy and its outcome, the article focused on institutional deliveries. Sample size calculation was done using the formula the formula 4PQ/d.  The percentage of women attending ANC was 64.2% in rural UP, based on the findings of National Family Health Survey-3.  After multistage random sampling, a total of 352 women were interviewed from 32 villages. Sample size was calculated with relative precision of 10% and a design effect of 1.5. Considering non-response, an additional list of RDW (10% of the sample size for every village) was kept ready and utilized in case of absence or unwillingness of the RDW. The list of RDWs was collected from ASHA, auxiliary nurse midwives and Anganwadi workers (AWWs) and used as the sampling frame. Systematic random sampling was followed to pick up the required number of beneficiaries.
The beneficiaries who had delivered a baby during the period from January 2009 to June 2010 and were present in the village on the day of the survey were included. The study was conducted after getting clearance from the Institutional Ethical Committee from the university and permission from the superintendents of the concerned community health centers. Verbal consent was obtained from beneficiaries before interviewing.
A pre-tested structured interview schedule was developed to collect required information. Necessary modification was done in the schedule after pilot study. For calculating socio-economic status (SES), modified Pareek's classification for rural area was used.  The main outcome variable was delivery at government hospitals. Among different independent variables, age, religion, caste, education, SES, family type, parity, timing of ante-natal registration, number of ANC visit to the health facility and number of iron tablet consumption were included.
Data entry and analysis were performed using the SPSS for Windows software (Version 19.0; SPSS Inc., Chicago). Binary logistic regression was applied to find out the predictors. Results were expressed in terms of odd's ratio (OR) and confidence interval (CI). Independent variables that were significant at univariate level were included in the multivariate model for avoiding confounding. Backward logistic model, based on likelihood ratio, was used to find predictors for institutional deliveries at government hospitals. The fit of the final model was assessed using Hosmer-Lemeshow goodness-of-fit test.
Almost 54.5% of the RDWs were above the age of 25 years. Most of them (91.2%) were Hindu and illiterate/educated until primary standard (63.6%). Regarding SES, 89.8% belonged to Class IV or V (two lower most classes, as evident from total score 13 to 23 and <13, respectively, out of the maximum possible score of 49), as per Pareek's classification. Approximate half of the RDWs (53.7%) were registered in the first trimester of their pregnancy and 85.5% took at least three ANC visits. Overall, 299 deliveries (84.9%) were institutional ones. Out of which, 79.3% were at government hospitals.
On logistic regression at univariate level, no significant relation was found between delivery at government facilities and the age, parity, family type, number of ANC visits or number of iron tablet consumption by the RDWs. However, significant relation was found between delivery at government hospitals and religion (OR = 3.665, 95% CI = 1.656-8.112), caste (OR = 2.669, 95% CI = 1.446-4.929), education (OR = 1.962, 95% CI = 1.114-3.456), SES (OR = 5.074, 95% CI = 1.953-13.185) and timing of ante-natal registration (OR = 2.538, 95% CI = 1.374-4.686). Hindu, Scheduled castes/tribes, educated, lower socio-economic class and late registered RDWs were found to be more likely to get their deliveries at government hospitals [Table 1].
|Table 1: Factors associated with institutional deliveries at government hospitals of the recently delivered women on binary logistic regressions|
Click here to view
At multivariate level, religion (OR = 3.205, 95% CI = 1.382-7.433), SES (OR = 4.630, 95% CI = 1.763-12.155) and timing of registration (OR = 2.320, 95% CI = 1.232-4.369) stood significant, indicating that Hindus, lower socio-economic class and late registered RDWs are more likely to deliver at government hospitals [Table 1]. Possible two-way interaction between factors was not significant. The result of Hosmer-Lemeshow goodness-of-fit test was not significant (P = 0.829, df = 4). Overall correct classification result indicated that 79.3% of the RDWs are predicted rightly about their place of institutional deliveries.
The findings suggest that the majority of the RDWs went for institutional deliveries. It contrasts with most of the previous studies conducted in rural UP. ,, Out of the RDWs who delivered at hospitals, 79.3% did so at government facilities. Similar result was found by researchers in other developing countries. , In India, most studies suggested private facilities as the preferred ones for institutional delivery, but findings in favor of public hospitals are also available. ,,,,, In 2009, Population Council documented that two-third of all institutional deliveries were being conducted at Public facilities in rural UP. 
In the present study, Hindus were found to be more likely to deliver at government hospitals. This is, although in contradiction to Bhatia, consistent with the other studies. ,, Caste has earlier been established for deciding the choice of place of delivery. , The tendency among higher castes for delivering at private facilities was again revealed in our study, although not significant after controlling for other variables.
The tendency of the late registered women to go for public set-up might be attributed to their adherence to health workers late in their pregnancies. Late registration itself is not appreciable, but counseling at a time near to their deliveries might have affected their decision for choosing government facilities over private ones. This indirectly points toward the need of constant motivation as the pregnancy is approaching toward expected date of delivery. In contrary to the previous studies, which revealed education, age, parity or number of ANC visits as factors responsible for institutional deliveries, the present one could not find any of them as a predictor for institutional deliveries at government facilities. ,,,,
A preference for private hospitals among economically sound beneficiaries was clear in our study. More demonstrated a steady increase in preferring private set-up over public ones among affluent sections.  The findings from the previous studies also support similar view. ,,,, People willingly go for private sector, when affordable. Bhatia found that people belonging to higher economic strata were 3 times more likely to go for private set up than lower ones.  Poor reputation and suboptimal quality of the government hospitals as well as the perception that private hospitals are equipped with best amenities are the driving factors for a decision in favor of private institutions. 
The study has certain limitations. Retrieving the lists of RDWs from health workers, recall bias, not considering any complication during the pregnancy are some of them. Considering the fact that the study was not limited to only delivery practices, sample size determination was based on utilization of ANC services. Utilization of the government sector for delivery practices would be more appropriate for such calculation, which may be considered for future research.
On the other hand, evaluation of NRHM at the grass root level through a community based approach and elicitation of predictors for institutional deliveries at government hospitals are some of the strengths of the study. Unlike other studies, which addresses home versus institutional deliveries, this one took the fact into account that deliveries at private hospitals won't be considered to be success for the mission.
To summarize, there are, no doubt, improvement in institutional deliveries but public sector is still missing more than 20% of the clients who preferred hospital set-up during deliveries. Private sector is still preferable for a group of RDWs due to proximity in location and shorter queues, particularly if the women is economically well-off. Religious factors should also be considered. Early registration is of no value if it does not ensure a continuum of care and institutional delivery. All these are vital in achieving higher coverage at government establishments in terms of institutional deliveries. Until there are improvements in terms of quality-of-care as well as the highlighted issues, this is difficult to get a better picture of maternal health in rural India.
| References|| |
|1.||WHO/UNICEF/UNFPA/The World Bank. Estimates of maternal mortality 2008. Available from: http://www.childinfo.org/maternal_mortality_indicators.php. [Last accessed on 2012 Jan 13]. |
|2.||International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-06: India. Vol. I. Mumbai: IIPS; 2007. |
|3.||Thind A, Mohani A, Banerjee K, Hagigi F. Where to deliver? Analysis of choice of delivery location from a national survey in India. BMC Public Health 2008;8:29. |
|4.||Devadasan N, Elias MA, John D, Grahacharya S, Ralte L. A conditional cash assistance programme for promoting institutional deliveries among the poor in India: process evaluation results. In: Richard F, Witter S, De Brouwere V, eds. Reducing financial barriers to obstetric care in low-income countries. Antwerp. Belgium: ITG Press, 2008. p. 257-73. |
|5.||International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), India, 2005-06: Uttar Pradesh. Mumbai: IIPS; 2008. |
|6.||NIHFW. Survey instruments for collection of information from house hold developed by NIHFW for collaborative activity of the National Consortium of Public Health. New Delhi: NIHFW; 2003. |
|7.||Government of India & International Institute for Population Science. District Level Household and Facility Survey (DLHS-3), 2007-08. Mumbai: Ministry of Health and Family Welfare, Government of India; 2008. |
|8.||Department of Medical Health and Family Welfare. Baseline facts - Uttar Pradesh, Concurrent assessment of health and family welfare programme and technical assistance to districts of UP. Lucknow: Department of Medical Health and Family Welfare, 2007. |
|9.||Wu Z, Viisainen K, Li X, Hemminki E. Maternal care in rural China: A case study from Anhui province. BMC Health Serv Res 2008;8:55. |
|10.||D'Ambruoso L, Abbey M, Hussein J. Please understand when I cry out in pain: Women's accounts of maternity services during labour and delivery in Ghana. BMC Public Health 2005;5:140. |
|11.||Dabral S, Malik SL. Demography study of Gujjars of Delhi: V. Maternal and child health care practices. J Hum Ecol 2005;17:1-12. |
|12.||Garg R, Shyamsunder D, Singh T, Singh PA. Study on delivery practices among Women in rural Punjab. Health Popul Perspect Issues 2010;33:23-33. |
|13.||More NS, Alcock G, Bapat U, Das S, Joshi W, Osrin D. Tracing pathways from antenatal to delivery care for women in Mumbai, India: Cross-sectional study of maternity in low-income areas. Int Health 2009;1:71-7. |
|14.||Munjial M, Kaushik P, Agnihotri S. A comparative analysis of institutional and noninstitutional deliveries in a village of Punjab. Health Popul Perspect Issues 2009;32:131-40. |
|15.||Varma DS, Khan ME, Hazra A. Increasing institutional delivery and access to emergency obstetric care services in rural Uttar Pradesh. J Fam Welf 2010;56:23-30. |
|16.||Bhatia JC, Cleland J. Determinants of maternal care in a region of south India. Health Transit Rev 1995;5:127-42. |
|17.||Anita P, Jain RB, Punia MS, Vidya R, Kalhan M. Pattern of deliveries in rural areas of a district in Haryana, India. Internet J Epidemiol 2010;9. |
|18.||Kesterton AJ, Cleland J, Sloggett A, Ronsmans C. Institutional delivery in rural India: The relative importance of accessibility and economic status. BMC Pregnancy Childbirth 2010;10:30. |
|19.||Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health 2011;10:31. |