Background of The Study

Maternal health refers to the health of women during pregnancy, childbirth and the postnatal period. Each stage should be a positive experience, ensuring women and their babies reach their full potential for health and well-being [1]. In any community, mother and children constitute a priority group; they comprise approximately 71.14% of the population of the developing countries. In India women of the child bearing age constitute 22.2% and children under 15 years of age about 35.3% of the total population together they constitute nearly 57.5% of the total population [2]. Every day in 2017, approximately 810 women died from preventable causes related to pregnancy and childbirth. 94% of all maternal deaths occur in low and lower middle-income countries [3]. Globally, 85% of pregnant women attend at least one ANC visit with a skilled health professional and 58% attend at least 4 ANC visits [4]. Studies shows majority 73.5% mothers were registered after 12 weeks of pregnancy whereas 26.5% of them were registered within first 12 weeks of pregnancy. Around 14% mothers did not receive the recommended minimum three antenatal visits [5]. Only 25.5% mothers received cash benefits under JSY. Awareness and perception regarding JSY were low among mothers Kumar R, Bachloo T et al. [6]. In India, 25% women still hesitate to access health (JSY). facilities for delivery due to out of pocket expenditure during stay at health facilities on drugs, diet and diagnosis and arrangement blood [7]. Evidence shows that in a tribal district of India early registration rates among the ante-natal women were still poor as women were not motivated to come on their own accord for check-ups. Additionally, the quality of ANC was poor [8]. Currently pregnant women and women who had a child aged 5 years or younger, were not aware of the recommended minimum number of antenatal care visits to be made during pregnancy [9].

The guideline of World Health Organization focuses on the core ANC clinical package that all women should receive at routine ANC visits [10]. It recommends pregnant women to have their first contact in the first 12 weeks’ gestation, with subsequent contacts taking place at 20, 26, 30, 34, 36, 38 and 40 weeks’ gestation [10]. A new target to accelerate the decline of maternal mortality by 2030 (SDG 3) includes an ambitious target: “reducing the global MMR to less than 70 per 100 000 births”. The most common direct causes of maternal injury and death are excessive blood loss, infection, high blood pressure, unsafe abortion and obstructed labour, as well as indirect causes such as anaemia, malaria and heart disease. Data from NFHS-4, 2015-16 shows that, 12% of women age 15-19 in Tripura have completed 12 or more years of schooling, compared with 19% of men. The median age at marriage is 19.6 years among women age 20-49 years.33% of women age 20-24 years got married before the legal minimum age of 18 years. More than one-fifth (22%) of users of modern spacing methods discontinued use within the first year after they adopted the method. The main factors that prevent women from receiving or seeking care during pregnancy and childbirth are: poverty, distance to facilities and lack of information, inadequate and poor quality services, cultural beliefs and practices [10].

All the above perspective it is imperative to study the barriers for utilization of reproductive health interventions that will provide a base line data for programming and implementation of the services under government facilities.

Aim

The present study aimed at identifying the actual barriers for availing reproductive health interventions among the rural mothers residing in existence of Tripura.

Objectives

Qualitative identification of the barriers for utilization of reproductive health interventions by the rural mothers residing in existence of Tripura.

Research Design

On the basis of objectives descriptive qualitative approach was selected to conduct the present study.

Data Collection Technique

Formal administrative approval and permission was obtained from the Director of Health Services, Government of Tripura, Agartala for conducting this research study under the entire eight districts of Tripura.

As the purpose of the study was to identify the barriers for utilization of reproductive health interventions investigators decided to obtain the woman’s perception directly from the reproductive age group women by conducting focus group discussion among the Homogenous group of women, either ante-natal or post-natal mothers.

The qualitative data was collected from 30th March’2021 to 30th July’2021.

Development of the Tool

The tool has been developed based on the related literature and relevant to the sample subjects and present study. The item for the FGD guide was also drawn from the sources like Consultation with nursing experts, Discussion with colleagues, Investigators personal experience. To ensure the content validity of the tool it was validated by 5 nursing experts. The criteria for selection of experts were: Those who have been conducted specialization in community health nursing, obstetrical and gynecological nursing.

Experts were requested to judge the items of FGD guide for clarity, relatedness and meaningfulness.

Tools and Description of the Tool

A semi structured questionnaire for conducting focus group discussion was developed which consists of 17 items to obtain the in-depth information.

The Study Setting

Community-Based Study in entire eight districts of Tripura.

Population

In the present study population comprised of all rural mother residing in existence of Tripura.

The Sample

Rural mothers in age group (18 – 45 year).

Sample Size

100

Sampling Technique

Multistage sampling technique is used for accomplishing the aim and objective of the present study.

At first, the Total-8 District has been selected with the permission obtained from the State Government. A comprehensive list of all ante-natal and post-natal rural mothers in age (18 to 45 years) group collected from the Sub-centre under each eight district and eight PHCs by simple random method.

Data Collection Procedure

Focus group discussions (one group in each eight District) has been conducted among the Reproductive age (18 – 45 years) group women (homogenous group of women, i.e, Ante-natal and post-natal mothers) by the investigators using semi-structured questionnaire to identify the barriers of partially or not utilizing the services. 

A group of 10 reproductive age (18 – 45years) group women from each selected eight Sub-centre under each selected eight PHCs of eight District were randomly selected for Focus Group Discussion.

A semi-structured FGD guide was used to facilitate FGDs including open-ended questions regarding the awareness of different government health facilities. Informed consent was taken from the mothers. Explanation was given to the mothers about the project and confidentiality was assured.

The FGD was conducted by both the investigators in each eight districts separately in the working day to facilitate the availability of all field workers. Audio Tape recorder was used to conduct the whole session of FGD.

A Nurse graduate, who was trained by the principal investigator and one of the Multi-Purpose supervisors in each eight districts, facilitated the discussions as a moderator. The principal investigator acted as a field note-taker and operated the tape-recorder and noted the observations of interaction between participants as well as group dynamics including non-verbal communications also. Time taken for each FGD varied from 30 to 50 minutes.

Plan for data Analysis

After collection of audio recordings and the field notes from each FGD both the investigators prepared Transcripts. Two investigators have performed the verbatim data analysis separately and then discuss their results and obtain consensus. The transcribed verbatim were examined thoroughly and highlighted the specific word and sentence to name these as meaning units. Then its relevancy to each research question were identified and summarized as codes. Codes were then sorted by similarities and dissimilarities and abstracted into categories and were discussed under different themes. Finally, these emergent categories were used to create themes. The investigators cross-checked each step of content analysis in order to establish authenticity and truthfulness of the present research study and ensured that the interpretation are clear to the readers according to the available data.

A total number of 100 women participated in all 10 FGDs (FGD1: 10, FGD2: 10, FGD3: 10, FGD4: 10, FGD5: 10, FGD6: 10, FGD7: 10, FGD8: 10, FGD9: 10, FGD10: 10,). Majority 65(65%) of the participants were in the age group of 18 to 27 years 24(24%) under 27 to 36 years and 11(11%) in the age group of 36 to 45 years. All were married (100%) women (Table 1).

Table 1: Frequency and Percentage Showing Demographic Characteristics of the Focus Group Participants N = 100

The socio demographic information related to the study participants was analyzed in relation to religion, educational level, occupation, type of family and number of family members. The responses were summarized in frequencies and percentages (Table 1).

The Table 1 revealed that 65(65%) participants were in the age group of 18 to 27 years, 24(24%) under 27 to 36 years and 11(11%) in the age group of 36 to 45 years.

Majority 63(63%) of total participants were belongs to Hindu whereas 27(27%) are Muslim community and 10(10%) Christian.

Regarding the level of education 38(38%) undergone up to high school, 26(26%) up to middle level, 12(12%) up to Primary education, 14(14%) under below primary level of education and 10(10%) illiterate.

Out of total participants 78(78%) were engaged in house hold activities, 10(10%) independent profession, 10 (10%) are service holder and 2(2%) of them are having business. 

66(66%) of the participants were belongs to the joint family whereas 24(24%) are from nuclear family.

Majority 76(76%) of their family size is up to 5 members and 24(24%) having above 5 members.

The data presented in Table 2 shows that 100% of the mothers were aware about the availability of health agency, personnel and services in and around their village. 

Table 2: Frequency and Percentage Distribution of the Participants by Their Awareness Regarding Health Agency, Health Personnel, Distance of the Health Agency, Types of services available. N=100

For 81% of them health agency was accessible within 3 kms, distance, whereas only for 19% it was within 5 kms Distance.

Total 10 FGD was conducted separately in entire eight districts of Tripura. Homogenous group of ante-natal (10 participants in each group) and post-natal (10 participants in each group) was selected in each district using simple random method. Each FGD session was performed in an around the area of Sub-centre. The responses of the participants were thematically analyzed to identify the barriers and described in Table 3 and Table 4.

Table 3: Thematic Analysis of the Statements According to the Responses of Ante-Natal Mothers to Identify Barriers for Utilization of ANC N = 50

Table 4: Thematic Analysis of the Statements According to the Responses of Post-Natal Mothers to Identify Barriers for Utilization of PNC N = 50

Majority 50(50%) ante-natal mothers never heard the word “Exclusive breast feeding” (Lack of knowledge regarding EBF).

Majority 60(60%) mothers believed that, only cleanliness is the main concern to remain healthy (Lack of knowledge regarding hygiene, diet, rest and sleep during ante-natal period).

Majority 75(75%) were responding about the diet whatever available food prepared for all family members (Less aware about gain in weight, HB%, prevention of minor ailments during pregnancy).

85(85%) participants were discussing their minor ailments along with the mother-in-law and use home remedy to rid of them (Less support from husband).

Majority 90(90%) participants do not know about the anaemia (Lack of knowledge regarding APH, PPH). These findings are also supported by S Nagraj, L Hinton, D Praveen, et al., [11].

92(92%) participants heard about Colostrum feeding is good for their new born but still some of them are not practicing whereas 8(8%) were believe in the culture of family (Lack of knowledge about the importance of colostrum).

80(80%) participants were explaining about the transport fair, 15(15%) don’t aware about the visit as there is no health problem related to pregnancy and 5(5%) due to fear of COVID-19 Pandemic and getting infection (Expensive transport, Ignorance and less confident on health).

This finding are also supported by Vidler, M., Ramadurg, U., Charantimath, U. et al., [12], Jesca Mutowo, Mariatha Yazbek *, Annatjie van der Wath, Carin Maree [13].

62(62) participants were depends on the decision of family members as some of the mother-in-law were practicing Dai (Lack of self-confident and immaturity to take decision).

95(95%) participants were responded about the supportive care to the new mother only for taking care of her baby (Lack of knowledge regarding the post-natal complication, causes of maternal morbidity and mortality). Evidence from the study of Ilankoon IMPS, Goonewardena CSE, Fernandopulle RC, Perera PPR, Vidler, M., Ramadurg, U., Charantimath, U. et al., [14].

The findings are also consistent with Jesca Mutowo, Mariatha Yazbek, Annatjie van der Wath, Carin Maree [15]. Majority 85(85%) participants adopted the choice of oral pill (Men perceived contraception is women’s business). These are consistent with findings of The International Planned Parenthood Federation (IPPF), Gupta S, Bernays S, et.al. [3]. Arupendra Mozumdar, et al., 2016 reported that Very few users of health services under RSBY overall and the use of FP/RH services was negligible.

95(95%) participants were consult with ASHA workers as they are free enough to discuss with female personnel.The findings are also consistent with Jesca Mutowo, Mariatha Yazbek, Annatjie van der Wath, Carin Maree [13] they revealed in their study that women are uncomfortable with being examined by a male midwife.

Recommendation

More study can be carried on community level in comparison with rural and urban mothers.

These descriptive qualitative study findings revealed there is Lack of knowledge regarding EBF, hygiene, diet, rest and sleep during ante-natal period, less aware about gain in weight, HB%, prevention of minor ailments during pregnancy, Lack of knowledge about the importance of colostrum among the rural mothers. Post-natal care is almost lacking. It is suggested that, there is an urgent need for improvement of health education programme during the ANC visits and ante-natal contacts (first contact in the first 12 weeks’ gestation, with subsequent contacts taking place at 20, 26, 30, 34, 36, 38 and 40 weeks’ gestation, [10], postpartum follow up and continuous monitoring of maternal health services. To improve quality of care health care practitioner must use the available resources for organizing community outreach programs to facilitate the utilization of maternal healthcare services.

1. World Health Organization. “Maternal Health.” World Health Organization, https://www.who.int/health-topics/maternal-health#tab=tab_1.

2. Sahoo, Swagatika et al. “A descriptive study to assess the knowledge and attitude on Janani Suraksha Yojana among mothers in village Mendhasala, Khurda, Odisha.” Asian Journal of Nursing Education and Research, vol. 7, no. 4, October–December 2017, pp. 515–518. https://doi.org/10.5958/2349-2996.2017.00101.X.

3. World Health Organization. “Maternal mortality.” World Health Organization, https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.

4. Maternal Health Task Force. “Antenatal care.” Maternal Health Task Force, https://www.mhtf.org/topics/antenatal-care/.

5. Kumar, R. et al. “Utilization and perception of health services under janani suraksha Yojna among mothers in a rural area of Ambala District, Haryana.” International Journal of Medical Science and Public Health, vol. 5, 2016, pp. 1639–1643.

6. Bhaisare, K.A. et al. “Study of utilization of antenatal care services in Tribal Area of Thane District.” International Journal of Reproduction, Contraception, Obstetrics and Gynecology, vol. 4, 2015, pp. 378–383.

7. Nisar, Y.B. et al. “Qualitative exploration of facilitating factors and barriers to use of antenatal care services by pregnant women in Urban and rural settings in Pakistan.” BMC Pregnancy and Childbirth, vol. 16, 2016, p. 42. https://doi.org/10.1186/s12884-016-0829-8.

8. Nagraj, S. et al. “Women's and healthcare providers' perceptions of long-term complications associated with hypertension and diabetes in pregnancy: A qualitative study.” BJOG: An International Journal of Obstetrics and Gynaecology, vol. 126, suppl. 4, August 2019, pp. 34–42. https://doi.org/10.1111/1471-0528.15847.

9. Vidler, M. et al. “Utilization of maternal health care services and their determinants in karnataka State, India.” Reproductive Health, vol. 13, suppl. 1, June 2016, p. 37. https://doi.org/10.1186/s12978-016-0138-8.

10. Mutowo, Jesca et al. “Barriers to using antenatal care services in a Rural District in Zimbabwe.” International Journal of Africa Nursing Sciences, vol. 15, 2021, p. 100319. https://doi.org/10.1016/j.ijans.2021.100319.

11. Ilankoon, I.M.P.S. et al. “Vaginal discharge assessment form for utilization by primary health care workers in a community setting.” Journal of Gynecology and Women’s Health, vol. 9, no. 3, 2018, p. 555763. https://doi.org/10.19080/JGWH.2018.09.555763.

12. Charantimath, U. et al. “Facilitators and challenges to exclusive breastfeeding in Belagavi District, Karnataka, India.” PLOS ONE, vol. 15, no. 5, 2020, e0231755. https://doi.org/10.1371/journal.pone.0231755.

13. Gupta, S. et al. “Community attitudes and gendered influences on decision making around contraceptive implant use in rural Papua New Guinea.” Reproductive Health, vol. 17, no. 1, September 2020, p. 136. https://doi.org/10.1186/s12978-020-00985-w.

14. Inspirajournals. “Study PDF.” Inspirajournals, https://www.inspirajournals.com/uploads/Issues/344445970.pdf.

15. World Health Organization. “Maternal mortality (Update).” World Health Organization, https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.