Prevalence, utilization and determinants of complete postnatal care services among rural women in northern Tamil Nadu

Postnatal care is the care given to the mother and her newborn baby immediately after birth up to (cid:977)irst six weeks after delivery. Receiving 4 complete postnatal visits by healthcare workers helps to decrease the maternal and neonatal mortality rates. The present study was conducted with the aim of assessing the utilization and determinants of post-natal care among mothers who gave birth. This community based cross sectional study was conducted in the rural area of northern Tamilnadu with 210 mothers who delivered a year prior to commencement of study by “30 cluster sampling method”. A pretested, semi-structured data tool was used. Descriptive variables were presented as pro-portions and frequencies. Chi-square test was used to ascertain the associa-tions. Only 78.1% had received their (cid:977)irst postnatal care within 24 hours. The prevalence of complete postnatal care services was found to be 16.2%. The main reason behind it was lack of knowledge / ignorance about the bene(cid:977)its of postnatal services. The present age of the mother, family type, parity, postnatal care counseling and cultural beliefs were signi(cid:977)icantly associated with utilization of post-natal check-ups. As the prevalence and utilization of postnatal care is considerably low, development of health facilities, the promo-tion of service providers, sustainable maternal and child health programs and awareness-raising will further promote better outcomes.


INTRODUCTION
The postnatal period begins from the birth of the baby to 6 successive weeks with the recommended time of visit, i.e. 6-24 hours, 3-6 days and 6 weeks after the birth (WHO, 2014). Although the health of mothers is generally thought to be the health of the society, an estimated 287 000 maternal deaths occurred worldwide (GHO, 2013). Every year, three million neonates die within their irst month of life, representing nearly 40% of all deaths of kids under the age of 5 and the majority newborn deaths are in developing countries (WHO, 2014). An oversized percentage of maternal and neonatal deaths occur during 48 hours after childbirth.
Receiving complete and appropriate postnatal care (PNC) by skilled health care provider during the initial 42 days after childbirth is most vital for signi icantly reducing the maternal and neonatal mortality rate which is shown in several studies conducted in developing countries (WHO, 2014) , (Warren et al., 2006;Baqui et al., 2009). Regardless of demonstrated bene its of complete postnatal care, this is often the foremost ignored domain in most parts of our country. Report shows that the utilization of complete PNC services is meagre with sev-eral factors including maternal age, mother level of education, women and husband occupational status, place of delivery, mode of delivery, total number of births, and perception of obstetric-related danger signs and knowledge of PNC services (Workineh, 2014;Worku et al., 2013). Moreover, within a population the determinants of utilizing PNC programs do not appear to be similar across different communities and socio-economic status.
According to NFHS 4 survey, rate of postnatal care within 24 hours of delivery is just 58.7 % in Tamil Nadu Brahmapurkar (2019). The rural area women are most disadvantaged at this point. Thus, assessing factors affecting utilization of postnatal care service in several setup area is incredibly important to enhance maternal and child health. With this background, our study aimed to produce present-day evidence on postnatal care service coverage by skilled healthcare provider and determinants for availing the PNC services among women who gave birth in rural area of Tamilnadu.

MATERIALS AND METHODS
This community based cross sectional study was conducted from January to March 2020 in the rural ield practice area district (Thiruvallur) of tertiary medical college hospital in a metropolitan city of Tamilnadu. Study comprised of 210 women who gave birth in preceding year from the commencement of study period (i.e. January 2019 to January 2020) residing in the area of study. Thiruvallur district consists of 14 Blocks and 43 village panchayats (Hariharan, 2001). Ethical approval was obtained from institutional ethics committee board.

Sampling Method
Participants were selected through '30*7 clusters sampling' method proposed by WHO was used for rapid assessment of coverage evaluation based on probability proportional to size (PPS) for cluster selection (Chadha, 2006). The list of villages (sam- pling unit) of Thiruvallur district was availed from district panchayat of ice. Cumulative population and cluster interval (CI) was calculated by dividing cumulative population by 30. First cluster (village) was selected by choosing random number from random table; similarly remaining clusters were selected using CI and random numbers. Town panchayats and urban communal were excluded from selection.

Selection of study participants and data collection
Each cluster was randomly divided into quadrants for better representation of study population. Using a team of 5 member's data was collected. The irst house in each cluster was chosen from random direction using tip of pen method. Women who are residing within the study area for at least a year were chosen. From each cluster 7 mothers were chosen, i.e. 2 from each quadrant and 1 from last quadrant. House -house data collection was performed until the desired sample size was attained. A pretested semi-structured questionnaire was used to collect data containing the demographic details, obstetric characteristics, utilization of postnatal services and the other information required. Pilot testing was performed with investigators in the ield for uniformity. All data were cross-checked by principal investigator at ield level and mistakes were recti ied immediately to maintain the quality of data. Written informed consent was obtained after informing the participants regarding the aim of study, bene its, procedure and con identiality of the research study in the local language.

Study tool and Study variables
The study instrument consisted of three components,

Section-I
Sociodemographic Details which incorporates Age (in years), Education of mother, Education of father, Occupation of mother, type of family, Income, Socioeconomic status and Number of children.

Section-II
Obstetrics Characteristics of women including Par-ity, Nature of last pregnancy, ANC visits, Course of pregnancy, Mode of delivery, type of labor.

Section-III
utilization and components of postnatal care services like Total number of PNC visits, Feeding practices, Immunization status, PNC counseling, Postdelivery seclusion.

Statistical Analysis
Data was tabulated in Microsoft Excel 365 and analyzed by Statistical Package for Social Sciences (SPSS) Software 21.0. Descriptive Statistics were calculated for all the variables in frequencies and percentages. Analytical statistics like chi-square tests were applied to elicit the factors in luencing complete postnatal care services

Sociodemographic characteristics
A total of 210 mothers were included for analysis. The mean age of the mothers was 24.9±2.7. An average family size was found to be 4.8. Among the mothers who completed high school, 72(52.9%) of them perceived undergraduate courses and the remaining 64(47%) broken with schooling. Out of these, the majority 138(65.7%) of them belong to socioeconomic class II and some 58(27.8%) belongs to class III. Only few 7(3.3%), 5(2.3%), 2(0.9%) belongs to class I, IV and V respectively. (Table 1)

Obstetric characteristics
More than half of mothers were primi and among the multiparous woman 3(4.1%) of them with birth order of 3, conducted home delivery. Almost all mothers had there ANC checkups among which maximum 127(57.6%) pregnancies were unplanned but was supported. Out of 124 mothers, 95(45.2%) of them faced complication during antenatal period like anemia, GDM, hypertension, PROM etc., few 5(2.3%) mothers during their natal period like labor dystocia and the remaining 24(11.4%) during their postnatal period like postpartum hemorrhage, perineal tears etc. Term pregnancy mainly consists of vaginal 48(41.3%) and instrumental delivery 28(24.1%) and in some cases cesarean 40(34.4%). (Table 2)

Utilization of postnatal care services
Most of the mothers 164(78.1%) had received their irst postnatal care within 24 hours but only 17(8.1%) of them had there last postnatal visit between 4-7 days, many 147(70%) had received within 6 weeks and the remaining did not attend their next visit. About the mothers who were given complete postnatal care counseling nearly 76(49%) of them received neonatal care which includes exclusive breast feeding, birth registration, umbilical cord care, immunization etc., and the remaining mothers received maternal care like nutrition, contraception, personal hygiene etc. Among those women who attended postnatal counseling, nearly 150(71.4%) of them exclusively breastfed their babies for the irst 6 months. Nearly half 110(52.7%) of the mothers proposed that there was a social and cultural faith called "Seclusion" which prevents them from coming out of home after delivery among those 48(22.8%) of them had food restrictions and were given improper diet. (Table 3) Figure 1 shows the postnatal services received by the mothers where majority 78.9% of the women were not taught about correct breast feeding technique and skin to skin contact to keep the baby warm. Figure 2 tells us the various reasons for not attending the postnatal services after delivery and also various social disturbances. Also, most of them 65.9% had hindrances from mother-in-law on autonomy of availing healthcare services. Table 3, post natal care can be affected by several factors. It was observed that, education of mothers (P= 0.003) was important contributing factor with utilization of postnatal care (OR =2.545; 95%CI: 1.375-4.714), and mother, who were house wives, utilized PNC 2.980 times more (95%CI: 1.600-5.548) (P=.000). Table 4, post-natal care can be affected by several factors. It was observed that, age of mothers was important contributing factor with utilization of postnatal care (OR =2.45; 95%CI: 1.32-9.98), and mother, who were living in nuclear family, utilized PNC more (95%CI:1.12 -7.34).

DISCUSSION
Postnatal care is signi icant in maintaining and helping the woman and the baby to improve the health, by providing an opportunity for the healthcare professionals to identify and treat the health conditions, which might develop in the mother and new-born during the postnatal period because majority of the deaths occurs in this period. Utilization of postnatal care services plays a very important role in the health of the mother and the newborn.
This study was aimed to identify the utilization of postnatal care services prevalence among the mothers and the factors affecting them to perceive complete utilization of the services.
Among women involved in the study, only 16.2% received complete postnatal care i.e. at least 4 vis-  its within six weeks of delivery. Women were more likely to receive postnatal care if they knew about care, lived in urban areas, received more than secondary education, had caesarean births, had at least four antenatal visits, and were ascertained if pregnancy was supported (Bhattacherjee et al., 2013). Our outcome shows a very less proportion of women obtained postnatal care compared to previous studies done in Darjeeling which was 18.8% (Bhattacherjee et al., 2013). This may be due to the fact that the postnatal care was considered unimportant by the mother and their family and also home visits and counseling by health care workers was not suf icient to make people understand in this regard (Bhattacherjee et al., 2013).
Almost 97.8% mothers in our survey received the full ANC services during their pregnancy, which is higher than a study conducted in Northwest Ethiopia that reported 76.6% of women received ANC service during their last pregnancy (Akibu et al., 2018).
Place of delivery was one of the sturdiest interpreters of postnatal care service utilization. Almost all except 3 mothers, gave birth to their last child at institutions whereas in comparison only 75% of the   (Tesfahun et al., 2014).
This may be attributed to the fact that women are enrolled for maternity bene it schemes in the study area. Among the mothers, only 3(4.1%) of them with birth order of 3, conducted home delivery and in comparison 30(15%) delivered at home in an article done in urban slum of Mumbai (Landge et al., 2017).
The con iguration of postnatal care usage is consistent with previous studies. Of all postnatal care participants, 78.1 per cent attended with 4-24 hours of birth. This is more when compared to a study in Northwest Ethiopia where 34% of women who attended postnatal care visits attended early postnatal care (Tesfahun et al., 2014). Due to the fact that, most deliveries were institutional in our study.
Overall 144 (68.5%) of mothers received the partial postnatal care counseling including exclusive breast feeding (99.1%) and immunization status (98.9%) but on breast feeding technique and keeping baby warm and checking umbilical cord was only 67.9%. whereas similar study made in Western Rajasthan reveals that immunization (98.87%), exclusive breast feeding (98.87%) and others was 79.1% (Uppadhaya et al., 2016). This implies that complete and proper counseling was not given to the mothers in the current study.
Half of the mothers (52.3%) believed post-delivery seclusion which restrained them from attending visits is far better when compared to other study which shows 76.3% of mothers considered cultural belief more than their checkups (Landge et al., 2017). Cultural practices have been associated with nonutilization of postnatal care in studies conducted in rural, Bangladesh (Winch et al., 2005). Con inement of the mother and the newborn is most strongly observed before the noai ceremony on day 7 or 9, and involves restrictions on movement outside the home, sleeping where the birth took place rather than in the mother's bedroom, and sleeping on a mat on the loor. Newborns are seen as vulnerable to cold air, cold food or drink (either directly or indirectly through the mother) and malevolent (Winch et al., 2005).
With regards to determinants, present age of the mother, family type, parity, postnatal care counseling and cultural beliefs had signi icant relationship with the utilization of complete PNC services. Conversely literacy, socioeconomic class, occupation of mothers had signi icant relationship with the utilization of complete postnatal services in other study (Uppadhaya et al., 2016).

Limitations
Potential recall bias, as the mothers were asked about events that occurred a year back prior to the study. Cultural issues could not be addressed completely, as it was quantitative study. Qualitative studies may throw light on this aspect. Study area is limited to one district, which is restricting the scope and relevance.

CONCLUSIONS
This study highlights the low prevalence and utilization of complete postnatal care services among the study population and also determinants like age, parity, family type, cultural practices and PNC counseling during delivery had signi icant associations. These indings implies the fact that increasing awareness on postnatal care services, preventing complications and adhering the mothers to national postnatal care protocol strictly is the need of the hour.