To identify the determinants of adequate antenatal care (ANC) utilisation and institutional deliveries among socio-economically disadvantaged migrants living in Delhi, India.
To identify the determinants of adequate antenatal care (ANC) utilisation and institutional deliveries among socio-economically disadvantaged migrants living in Delhi, India.
In a cross-sectional survey, 809 rural–urban migrant mothers with a child aged below 2 years were interviewed with a pretested questionnaire. Data on receiving antenatal, delivery and post-natal services, migration history and other social, demographic and income were collected.
Recent migrants used the services significantly less than settled migrants. ANC was adequate only among 37% (35% of recent migrant women and 39% of settled migrants). Multinomial regression revealed that being a recent migrant, multiparous, illiterate and married to an unskilled worker were significant risk factors for receiving inadequate ANC. Around 53% of deliveries took place at home. ANC seeking has a strong influence on place of delivery: 70% of births to women who received inadequate ANC were at home. Women who are educated, had their first delivery after the age of 20 years and received adequate ANC were more likely to deliver their child in hospital. Post-natal care is grossly neglected among these groups.
Migrant women, particularly recent migrants, are at the risk of not receiving adequate maternal healthcare. Because migration is a continuing phenomenon, measures to mitigate disadvantage due to migration need to be taken in the healthcare system.
Identifier les déterminants de l'adéquate utilisation de la clinique anténatale (CAN) et des accouchements dans les institutions par les migrantes socio-économiquement défavorisées à Delhi, en Inde.
Une enquête transversale sur 809 mères migrantes rurales/urbaines avec un enfant âgé de moins de 2 ans, interviewées au moyen d'un questionnaire pré testé. Les données sur l'obtention de services prénataux, d'accouchement et postnataux, sur l'historique de la migration et sur d'autres facteurs sociaux, démographiques et des revenus ont été recueillies.
Les migrantes récentes ont significativement moins utilisé les services que les migrantes installées. La CAN a été suffisante seulement chez 37% (35% des femmes migrantes récentes et 39% des migrantes installées). La régression multinomiale a révélé que le fait d’être une migrante récente, multipare, analphabète et mariée à un ouvrier non qualifié, étaient des facteurs de risque significatifs pour recevoir une CAN insuffisante. Environ 53% des accouchements ont eu lieu à domicile. Le recours à la CAN a une forte influence sur le lieu de l'accouchement: 70% des naissances chez les femmes qui ont reçu une CAN insuffisante ont eu lieu à la maison. Les femmes instruites ont eu leur premier accouchement après l’âge de 20 ans, ont reçu une CAN adéquate et étaient plus susceptibles d'accoucher à l'hôpital. Les soins postnataux sont grossièrement négligés dans ces groupes.
Les femmes migrantes, en particulier les migrantes récentes, sont à risque de ne pas recevoir des soins de santé maternelle adéquats. Vu que la migration est un phénomène continu, des mesures visant à atténuer les désavantages de la migration doivent être prises dans le système de santé.
identificar los determinantes de la utilización de cuidados prenatales y parto institucional entre inmigrantes con desventajas socioeconómicas viviendo en Delhi, India.
Estudio croseccional, utilizando un cuestionario previamente evaluado, en el que se entrevistó a 809 madres que inmigraron desde zonas rurales a zonas urbanas con un hijo menor de 2 años. Se recolectaron datos sobre el haber recibido cuidados prenatales, los servicios recibidos durante el parto y después de él, la historia de migración y datos demográficos, sociales y sobre ingresos.
Aquellos que habían inmigrado recientemente utilizaban los servicios significativamente menos que quienes ya estaban establecidos. Los cuidados prenatales eran adecuados solo para un 37% (35% de mujeres que habían inmigrado recientemente y 39% de los inmigrantes establecidos). Una regresión multinomial reveló que ser inmigrante, multípara, analfabeta y estar casada con un trabajador no cualificado eran factores de riesgo significativos de recibir cuidados prenatales inadecuados. Cerca del 53% de los partos tuvieron lugar en los hogares. La búsqueda de cuidados prenatales tiene una gran influencia sobre el lugar del parto: 70% de los partos de mujeres que recibieron cuidados prenatales inadecuados se tuvieron lugar en el hogar. Las mujeres con educación, que tenían su primer parto con más de 20 años y que recibieron unos cuidados prenatales adecuados tenían una mayor probabilidad de dar a luz en un hospital. En general los cuidados post parto eran poco comunes entre estos grupos.
Las mujeres inmigrantes, particularlmente imigrantes recientes, están en riesgo de no recibir una atención de salud materna adecuada. Puesto que la migración es un fenómeno continuo, las medidas para mitigar las desventajas debido a la migración deberían incluirse dentro del sistema sanitario.
Migration is an important livelihood strategy, mainly for the poor in many of the world's poorest countries. There has been increased attention on migrant health as illustrated by WHO calling upon its member states to promote migrant-sensitive health policies, equitable access to health promotion, and disease prevention and healthcare programmes for migrants (World Health Organization 2008). The Human Development Report of the United Nations Development Program (UNDP) estimated that there are approximately 740 million internal migrants and 214 million international migrants (United Nations Development Programme 2009). In India, there were 326 million internal migrants in 2007–2008 (i.e. 28.5% of the population) (National Sample Survey Organization 2010).
Against the background of ever-increasing migration and younger age profile of the migrants, reproductive health is of greater importance. It is necessary to understand the existing picture of healthcare access to migrants in order to develop migrant-sensitive strategies for improvement of maternal health. Maternal health indicators are poorer among migrants than natives (Shaokang et al. 2002; Hayes et al. 2011; Heaman et al. 2013). Studies from India (Swain & Mishra 2006; Babu et al. 2010; Kusuma et al. 2010; Singh et al. 2012) and abroad (Hayes et al. 2011; Heaman et al. 2013) reveal that the poor migrants often forego healthcare services. Urban populations exhibit better maternal health indicators than rural populations, attributed to the urban advantage in terms of better health facilities. Despite high concentration of healthcare services in urban areas, inequities in access exist and poor migrants are vulnerable. Hence, disaggregated data are needed to understand the problems of the migrants and their access to healthcare. Identifying determinants of maternal healthcare utilisation among the migrants is important to make the governments understand and recognise them as a specific vulnerable group to provide services. Thus, the objective of this study was to understand maternal healthcare-seeking behaviour in terms of using antenatal care (ANC) services and institutional delivery, and determinants or risk factors for such behaviours among poor migrants in Delhi.
The study was conducted in the Indian National Capital Territory (NCT) of Delhi. In 2006, the population of Delhi increased by 285 000 through migration and by another 215 000 through natural population growth (Government of National Capital Territory of Delhi 2009).
We categorised migrants as (i) recent migrants and (ii) settled migrants. Recent migrants were defined as those who had moved to Delhi from rural villages 6 months to 5 years ago; settled migrants were defined as migrants who had been living in Delhi for at least 5 years. Before starting the study, we walked through several slums informally talking to various community members and leaders. The general perception in the community was that residents up to 5 years are considered as recent, resident for 6 years and longer are considered as not very new but not old either, and those who have been staying for 10 years are considered as old. On the basis of this, as the process of adaptation is continuous, we arbitrarily took 5 years as the cut-off point to classify them into two groups. Both groups are from northern Indian states, mainly Uttar Pradesh and Bihar, and their distribution in terms of place of origin, ethnicity, social class and religion is similar.
Sample size calculation and sampling approach were given elsewhere (Kusuma et al. 2010). Required sample size is 384 for each group. To attain this sample size, mothers with children under 2 years of age were identified from selected clusters and 825 mothers were approached. The purpose of the study was explained to them, and their consent was obtained before data collection. However, 12 mothers refused to participate and data were incomplete for another four mothers. Thus, the final sample available for analysis was 809 (381 recent and 428 settled migrants). The institutional ethics committee approved the study protocol.
Socio-demographic details, migration history, details on various components of ANC, child delivery and post-natal care services were elicited through interviewer-administered questionnaire by trained interviewer.
Two outcome measures were considered. The first outcome variable is the odds of a mother receiving inadequate/somewhat adequate ANC (the categorical dependent variables being 1 = adequate care, 2 = somewhat adequate care and 3 = inadequate care). Adequate care is defined as receiving a minimum of four ANC visits, the first visit being in the first trimester and receiving a minimum of 100 iron folic acid (IFA) tablets. Somewhat adequate care is defined as late initiation of ANC visits (either during second or third trimester), fewer than four visits, receiving fewer than 100 IFA tablets. Inadequate care is reception of none of the above components. The second outcome variable is the likelihood of a mother delivering the child at a health facility, with two categorical variables, namely: 1 = mother delivered child at home and 2 = in health facility.
Various socio-economic and demographic characteristics were considered as independent variables. Individual-level independent variables were respondent's (mother's) age (categorised as 1 = below 20 years, 2 = 20–24 years, 3 = 25–29 years, 4 = 30–34 years), age at marriage (1 = got married before reaching 18 years; 2 = married at 18 years or later), age at first delivery (1 = delivered at or when younger than 20 years; 2 = delivered at 21 years or later), educational status (1 = no formal schooling, 2 = 1–5 years of schooling, 3 = 6 or more years of schooling), occupational status (1 = home maker, 2 = working to earn) and parity (1 = one pregnancy; 2 = 2–3 pregnancies, 3 = four or more pregnancies). The household-level characteristics were her husband's educational status (1 = no formal schooling, 2 = 1–5 years of schooling, 3 = 6–10 years of schooling, 4 = more than 10 years of schooling); occupation of the head of the household (1 = unskilled worker, 2 = skilled worker, 3 = small business, 4 = salaried job); household income per month [in Indian rupees (INR), (1 INR = US$ 0.02); 1 = earning less than INR 2000, 2 = INR 2001-4000, 3 = INR 4001-6000, 4 = more than INR 6000]; social class (1 = scheduled caste or tribe, 2 = other backward castes, 3 = uncategorised castes); and migration status (1 = recent migrants, 2 = settled migrants). The Government of India has categorised some socio-economically less developed ethnic groups into scheduled castes, scheduled tribes and backward castes to enforce positive discrimination in education, employment and other developmental opportunities.
Two types of regression analyses were considered for the two outcome variables. For analysis of determinants of adequate ANC utilisation, multinomial logistic regression analysis was carried out. To identify the independent variables for the regression analyses, initially, each independent variable was regressed against dependent variable. Those variables with a minimum P-value of 0.25 were included for multiple logistic regression analyses following Hosmer and Lemeshow (2000) and Mickey and Greenland (1989). The model selected for carrying out the multinomial logistic regression analysis was main effects model, and log likelihood ratio test was considered as a goodness-of-fit test.
The second analysis is for determinants of place of delivery. To examine the association of place of delivery, a multiple logistic regression was carried out. Similar procedures as above were carried out to identify the independent variables for final regression analysis. Multiple logistic regression analyses were carried out by backward likelihood ratio method. The fit of this model was tested by Hosmer and Lemeshow goodness-of-fit tests. All analyses were carried out using SPSS 20.0 (IBM Corp., Armonk, NY, USA).
Recent migrants were characterised by younger ages and significantly lower mean age (t = 8.76, P = 0.000) than their settled migrant counterparts (Table 1). More than half of the respondents did not receive any formal schooling. Around 80% of husbands were educated, with a majority up to 10 years of schooling. 80% were affiliated to lower social class. Women were mainly homemakers, and only 10% were working to earn. Only 14% of household heads had a salaried/permanent job. The majority reported to earn less than INR 4000 (US$ 80) per month. Around 20% of the women (29% of recent migrants and 11% of settled migrants) had so far experienced one pregnancy; 45% of settled migrant women had more than four pregnancies. These differences in parity are due to the younger ages of recent migrant women.
|Variable||Recent migrants (n = 381) n (%)||Settled migrants (n = 428) n (%)||Both (n = 809) n (%)|
|Age group of participants|
|≤19 years||38 (10.0)||18 (4.2)||56 (6.9)|
|20–24 years||200 (52.5)||135 (31.5)||335 (41.4)|
|25–29 yeas||108 (28.3)||176 (41.1)||284 (35.1)|
|≥30 years||35 (9.2)||99 (23.1)||134 (16.6)|
|Mean ± SD (years)||23.7 ± 3.8||26.4 ± 4.4||25.1 ± 4.3|
|Participant's educational status|
|No formal education||199 (52.2)||225 (52.6)||424 (52.4)|
|1–5 years||64 (16.8)||71 (16.6)||135 (16.7)|
|6–10 years||100 (26.2)||113 (26.4)||213 (26.3)|
|≥11 years||18 (4.7)||19 (4.4)||37 (4.6)|
|Participant's age at marriage|
|≤14 years||82 (21.5)||118 (27.6)||200 (24.7)|
|15–17 years||154 (40.4)||170 (39.7)||324 (40.0)|
|≥18 years||145 (38.1)||140 (32.7)||285 (35.2)|
|Occupation of the participant|
|Home maker||343 (90.0)||378 (88.3)||721 (89.1)|
|Working||38 (10.0)||50 (11.7)||88 (10.9)|
|Educational status of husband (of the participant)|
|No formal education||73 (19.4)||85 (20.0)||158 (19.7)|
|1–5 years||59 (15.6)||79 (18.6)||138 (17.2)|
|6–10 years||214 (56.8)||218 (51.3)||432 (53.9)|
|≥11 years||31 (8.2)||43 (10.1)||74 (9.2)|
|Occupation of the head of the household|
|Unskilled worker||75 (19.7)||77 (18.0)||152 (18.8)|
|Skilled worker||84 (22.0)||83 (19.4)||167 (20.6)|
|Small business||58 (15.2)||75 (17.5)||133 (16.4)|
|Temporary job||109 (28.6)||132 (30.8)||241 (29.8)|
|Permanent job||55 (14.4)||61 (14.3)||116 (14.3)|
|Scheduled castes/tribes||149 (39.1)||178 (41.6)||327 (40.4)|
|Backward castes||155 (40.7)||165 (38.6)||320 (39.6)|
|Others||77 (20.2)||85 (19.9)||162 (20.0)|
|Hindu||355 (93.2)||394 (92.1)||749 (92.6)|
|Other than Hindu||26 (6.8)||34 (7.9)||60 (7.4)|
|Family income per month in Indian Rupees (INR)|
|≤INR 2000||66 (17.3)||77 (18.0)||143 (17.7)|
|INR 2001–4000||196 (51.4)||224 (52.3)||420 (51.9)|
|INR 4001–6000||65 (17.1)||68 (15.9)||113 (14.0)|
|INR 6001 and above||54 (14.2)||59 (13.8)||113 (14.0)|
|1 pregnancy||110 (28.9)||49 (11.4)||159 (19.7)|
|2–3 pregnancies||201 (52.8)||188 (43.9)||389 (48.09|
|≥4 pregnancies||70 (18.4)||191 (44.6)||261 (32.3)|
Around 82% of recent migrants and 85% of settled migrants received at least one ANC visit (Table 2). 70% of recent and 74% of settled migrants sought ANC from government health facilities. Only 10% reported to have had a health worker's visit at home. Sixteen percent of recent migrant women relied on private practitioners, whereas 9% of settled migrants did. Although 84% of the women contacted the health systems for ANC, a high proportion did not continue to seek adequate ANC. The differences between recent and settled migrants are striking. Similar results were found for other components of ANC services. Around 10% of recent migrants reported that they were not aware of the services or location, 5% felt no need for them. Seven percent of settled migrants did not use the services because they felt them to be unnecessary. Other reasons for not using ANC were lack of time, shyness, health workers’ behaviour to women, financial problems, illness during pregnancy, health facility far away and sought care from a non-allopathic provider.
|Variable||Recent migrants (n = 381) (%)||Settled migrants (n = 428) (%)||Both (n = 809) (%)|
|Visited health facility for ANC at least once||82.4||85.3||83.9|
|ANC sought from (χ2 = 8.57, P = 0.014); (χ2 for Government vs. Private Care = 7.99, P = 0.005)|
|Government health facility||69.8||74.1||72.1|
|Qualified private practitioner||15.7||8.8||12.1|
|Not applicable/did not receive ANC||17.6||14.7||16.1|
|First ANC visit made/received (χ2 = 3.21, P = 0.201)|
|Did not visit at all||17.6||14.7||16.1|
|Number of ANC visits made (χ2 = 9.44, P = 0.009)|
|4 or more visits||49.9||60.5||55.5|
|Reception of iron folic acid tablets (χ2 = 0.627, P = 0.428)|
|Received ≥100 tablets||63.2||75.5||69.7|
|Consumption of iron folic acid tablets (χ2 = 4.90, P = 0.086)|
|Consumed ≥100 tablets||46.5||57.0||52.0|
|Reception of other services|
|Measured body weight (χ2 = 13.1, P = 0.000)||55.4||67.8||61.9|
|Measured height (χ2 = 0.456, P = 0.499)||20.5||23.1||21.9|
|Measured blood pressure (χ2 = 6.85, P = 0.009)||62.5||71.5||67.2|
|Abdominal examination (χ2 = 3.66, P = 0.056)||70.8||77.3||74.3|
|Blood test for haemoglobin carried out (χ2 = 2.17, P = 0.140)||60.1||66.4||63.4|
|Received treatment for anaemia (χ2 = 13.1, P = 0.000)||17.1||18.0||17.6|
|Received pregnancy-related advices (χ2 = 7.79, P = 0.005)||58.5||68.0||63.5|
|Ultra sonography test carried out (χ2 = 1.79, P = 0.109)||37.5||43.2||40.5|
|Received tetanus toxoid injection (χ2 = 9.82, P = 0.002)||87.7||89.5||88.6|
|Received one tetanus toxoid injection||6.0||5.6||5.6|
|Received two tetanus toxoid injections||76.9||80.6||78.9|
|Received more than two tetanus toxoid injections||4.7||3.3||4.0|
Table 3 presents details of reception of various levels of adequacy of ANC by various socio-demographic variables and corresponding adjusted odds ratios (AOR) with 95% confidence intervals (CI) based on multinomial regression analysis. Recent migrants (AOR 1.988, 95% CI 1.242–3.181), mothers who had no formal education (AOR 3.127, 95% CI 1.701–5.748) and wives of unskilled workers (AOR 2.268, 95% CI 1.259–4.087) were at risk of receiving inadequate care. Women with single (AOR 0.343, 95% CI 0.140–0.840) or 2–3 parity (AOR 0.481, 95% CI 0.270–0.856) were less likely to receive inadequate care; thus, multiparous women (with four or more pregnancies) were at the risk of receiving inadequate ANC. Contrary to expectation, households with lower levels of income (INR 2001-4000 and INR 4001-6000) were less likely to receive somewhat adequate care than households with income >INR 6000 per month. The log likelihood ratio test indicates that the model is a good fit.
|Variable/characteristic||Inadequate ANC (n = 132) (%)||Somewhat adequate ANC (n = 378) (%)||Adequate ANC (n = 132) (%)||Adjusted odds ratio (AOR) [95% confidential interval (CI) for adequate vs. inadequate ANC]||AOR (95% CI) for somewhat adequate ANC vs. inadequate ANC|
|Age of the mother|
|<20 years||12.5||50.0||37.5||0.766 (0.233–2.631)||1.122 (0.479–2.630)|
|20–24 years||11.6||48.4||40.0||0.605 (0.287–1.274)||0.938 (0.535–1.644)|
|25–29 years||18.0||45.1||37.0||0.677 (0.361–1.270)||0.840 (0.506–1.396)|
|Age at marriage|
|Married < 18 years||18.1||46.4||35.5||1.035 (0.621–1.726)||0.914 (0.642–1.299)|
|Married ≥ 18 years||13.0||47.4||39.6||Reference||Reference|
|Recent migrants||17.8||47.5||34.6||1.988 (1.242–3.181)**||1.289 (0.924–1.798)|
|Educational status of mother|
|No formal education||23.1||47.5||20.5||3.127 (1.701–5.748)***||1.554 (1.057–2.284)*|
|1–5 years||8.9||48.1||43.0||1.158 (0.508–2.643)||1/205 (0.756–1.923)|
|6–10 year and above||8.1||44.5||47.5||Reference||Reference|
|Educational status of husband|
|No formal education||26.2||48.2||25.6||1.995 (0.761–5.229)||1.707 (0.886–3.288)|
|1–5 years||20.9||50.4||28.8||1.871 (0.710–4.928)||1.681 (0.876–3.227)|
|6–10 year||12.0||45.8||42.1||0.886 (0.369–2.132)||1.117 (0.649–1.924)|
|Occupation of the head of the household|
|Unskilled worker||25.0||46.7||28.3||2.268 (1.259–4.087)**||1.408 (0.892–2.221)|
|Skilled worker||18.0||47.9||34.1||1.299 (0.724–2.331)||1.207 (0.795–1.831)|
|Small business||12.8||51.1||36.1||1.162 (0.593–2.277)||1.312 (0.845–2.038)|
|Household income per month in Indian Rupees (INR)|
|< INR 2000||14.7||49.7||35.7||0.557 (0.230–1.350)||0.595 (0.332–1.065)|
|INR 2001–4000||16.4||45.0||38.6||0.675 (0.319–1.430)||0.548 (0.337–0.890)*|
|INR 4001–6000||21.8||41.4||36.8||1.082 (0.468–2.501)||0.548 (0.306–0.979)*|
|> INR 6000||11.5||55.8||32.7||Reference||Reference|
|1||10.1||46.5||43.4||0.343 (0.140–0.840)**||0.623 (0.341–1.138)|
|2–3||13.1||47.8||39.1||0.481 (0.270–0.856)**||0.794 (0.517–1.220)|
The details of delivery and post-natal care services among mothers who have had a full-term pregnancy in the last 2 years are provided in Table 4. Hospital deliveries were significantly more common among those who had four or more ANC visits, irrespective of migration duration. Eighty-five percent of the women reported no complications during delivery (results not shown in table). Some of the complications reported were excess bleeding (2.5%), prolonged labour and delayed placenta delivery (0.6% and 0.7%, respectively). Around one-fourth of the mothers received a health worker's visit at home after delivery. Around 40% of recent migrant women did not receive any advice, whereas more than 80% of settled migrant women did.
|Variable||Neo-migrants (n = 330)||Settled migrants (396)|
|Received ≤ 3 visits (n = 157) n (%)||Received ≥ 4 visits (n = 173) n (%)||Total (n = 330) n (%)||Received ≤ 3 visits (n = 151) n (%)||Received ≥ 4 visits (n = 245) n (%)||Total (n = 396) n (%)|
|Type of delivery|
|Normal||152 (96.8)||164 (94.8)||316 (82.9)||149 (88.2)||227 (87.7)||376 (94.9)|
|Caesarean||5 (3.2)||9 (5.2)||14 (4.2)||2 (1.3)||18 (7.3)||20 (5.1)|
|Place of delivery†|
|Home||110 (70.1)||70 (40.5)||180 (54.5)||106 (70.2)||105 (42.9)||211 (53.3)|
|Health facility||47 (29.9)||103 (59.5)||150 (45.5)||45 (29.8)||140 (57.1)||185 (46.7)|
|Reception of health worker's visit at home after delivery|
|Received visit||48 (30.6)||43 (42.2)||91 (27.6)||41 (12.4)||65 (26.5)||106 (26.7)|
|Reception of advises on the following|
|On family planning||51 (32.5)||75 (43.4)||126 (38.2)||55 (36.4)||150 (61.2)||205 (51.8)|
|On breast feeding||50 (31.8)||101 (58.4)||151 (45.8)||61 (40.4)||163 (66.5)||224 (56.6)|
|On immunisation||65 (41.4)||110 (63.6)||175 (53.0)||79 (52.3)||190 (77.6)||269 (67.9)|
|All the above||31 (19.7)||58 (33.5)||89 (27.0)||38 (25.2)||121 (49.4)||159 (40.2)|
|Did not receive any advises||86 (54.7)||46 (26.6)||132 (40.0)||66 (43.7)||43 (17.6)||109 (27.5)|
Table 5 reveals that mothers who had their first delivery after the age of 20 years (AOR 1.439, 95% CI 1.001–2.069), those educated to high school or higher level (AOR 1.986, 95% CI 1.381–2.844), those who received four or more ANC visits (AOR 1.745, 95% CI 1.132–2.676), and mothers who had adequate ANC (AOR 4.224, 95% CI 2.065–8.641) or even somewhat adequate care (AOR 3.304, 95% CI 1.816–6.012) were more likely to deliver their children at a health facility. Hosmer and Lemeshow statistic indicates that the model is a good fit.
|Variable||Place of delivery||Adjusted odds ratio (95% confidential interval)|
|Home (%)||Health facility (%)|
|Age of the mother|
|Scheduled castes and Scheduled tribes||56.6||43.4||–|
|Age at marriage|
|Age at first delivery|
|≥21 years||46.1||53.9||1.439 (1.001–2.069)*|
|Educational status of mother|
|No formal education||62.7||37.3||Reference|
|1–5 years||50.4||49.6||1.380 (0.891–2.137)|
|6–10 years and above||39.5||60.5||1.987 (1.387–2.847)***|
|Educational status of husband|
|No formal education||64.1||35.9||–|
|Occupation of head of the household|
|Number of ANC visits|
|≥4 visits||41.9||58.1||1.745 (1.135–2.682)**|
|Adequacy of ANC***|
|Somewhat adequate||54.9||45.1||3.304 (1.816–6.012)***|
The present study demonstrated that the utilisation of maternal healthcare services by poor migrants, particularly recent migrants, was far below that of the general population of Delhi (International Institute for Population Sciences (IIPS) & Macro International 2009) and urban India's average utilisation rates (International Institute for Population Sciences (IIPS) & Macro International 2007). For instance, Delhi's and urban India's averages for receiving 3 or more ANC visits was reported to be 75.1% and 74.7%, respectively (vs. 62.8% for present study migrants). Similarly, Delhi's average for first ANC check-up in the first trimester was around 64% vs. 44% for the present study migrants). A minimum of two tetanus toxoid (TT) injections for Delhi was 90.3% vs. 83% among the present study migrants. Hospital deliveries are 64% in Delhi in general vs. 54% in the present study migrants. The above-mentioned referred utilisation rates for Delhi cover all sections including slum dwellers. Utilisation of various ANC services is far below the state's average, and thus, we infer that less utilisation of services by migrants, particularly recent migrants, is contributing to the state's averages, which are lower than those of other states of India. Although a good proportion of women reported to have had at least one contact with the health systems, the data on ANC visits and reception of various components of ANC reveal that the care was largely inadequate for these migrant women and more so for recent migrants.
This lower service utilisation can be attributed to both individual- and health system-level factors. Only 10% of households receiving health worker visits indicates a lack of motivational efforts of the health system. Behaviour of the healthcare staff towards the poor and disadvantaged is reported as one of the deterring factors. Higher mobility discourages these people from continued care, and some faced problems in continuing care at another health facility. Women cannot continue care as they lack an accompanying person, coupled with hesitation to go alone, and care of younger children at home. Tetanus injection is considered more important by the community than the other components of ANC, and one or two visits can be attributed to this. Not using ANC services, it may be a reflection of native cultural beliefs surrounding pregnancy care as these migrants mainly belong to the states where ANC utilisation is very low, and this behaviour continues even after migrating to the city. Recent migrants were not aware of the location of the health facility. A considerable proportion of recent migrant women accessing ANC from nearby private healthcare providers indicates that they were not familiar with the government health system in the new urban environment.
Thus, migrants, particularly recent migrants, are at the risk of not accessing maternal healthcare services. It may be argued that this behaviour can be attributed to lower educational attainment and poor social and economic conditions as observed in several Indian studies (Khan et al. 2009; Jat et al. 2011; Rustagi et al. 2011; Varma et al. 2011; Adamson et al. 2012). We argue that migration to the cities exacerbates their vulnerability and recent migration itself is a risk factor for not accessing services. This is obvious as both the groups are similar in their personal characteristics and share a locality; thus, as healthcare is available to both, recent migration emerged as a significant contributor for low access. The results are consistent with the earlier studies across the world. Migrants were often reported to utilise ANC to a significantly lesser extent than either the natives or longer-settled migrants (Zulkifli et al. 1994). Based on a systematic review, Heaman et al. (2013) concluded that migrant women are more likely to receive inadequate prenatal care. Shaokang et al. (2002) revealed that insufficient ANC is one of the main determinants for poor maternal health outcomes and that migrants are using ANC services significantly less than permanent residents.
Strengthening the outreach services may be helpful in increasing the coverage and utilisation rates. In urban areas of India, domiciliary visits by the health workers are aimed at motivating women to visit the nearby health facility to seek care. Our study shows that even these visits were less performed. Also, anganwadi childcare and mothercare centres were set up for every 1000 population, and each centre is manned by a worker and a helper from the community. Usually, an auxiliary nurse–midwife visits on specified day in week and provides ANC services. Provision of health education and pregnancy care is one of the objectives of the anganwadi centres; however, the pregnant women rarely utilised this facility for ANC. We think that improving outreach services and strengthening anganwadi services with active involvement of anganwadi workers in identifying and motivating pregnant women for seeking care would be helpful in bringing equitable access to the services. Training anganwadi workers, motivating them and improving their sense of responsibility towards the population they serve would help improving the service outreach. Simultaneously, raising awareness in the community through regular and consistent health and healthcare information via appropriate media would improve access. Certain locations, such as squatter settlements, footpath dwellings and dwellings near construction sites, where many recent migrants live, are likely to miss out on health system's attention and services. A strategy to reach these migrants is needed to achieve equitable access to healthcare and thereby improve the utilisation of maternal health services.
Poverty and social inequality have harmful effects on people's health, because they affect access to care, adequate food, suitable housing and healthy environment (Craig et al. 2012). Healthcare utilisation is influenced by multifaceted dimensions, which are often interlinked and range from individual level to the broader system-level factors. For example, in rural areas of India, ANC services are domiciliary in nature, and women who have come from rural villages are used to this type of service delivery. In cities, health workers make domiciliary/community visits mainly to inform and motivate women to access the services at a nearby facility. These differences may have a bearing on accessing the services. Poor women often suffer from compromised living and working conditions, low educational attainment and livelihood insecurity. Thus, accessing healthcare is influenced by multiple dimensions with migration as a distinct determinant. Hence, by understanding the problem, concerted efforts both at the community- and system-levels can be made to improve maternal health. The present study has implications as the upcoming national urban health mission of India aimed at tackling the inequities in health and healthcare access. Usually, the urban poor living in slums are considered for various interventions and often migrants and slum dwellers are seen synonymously. The present study identifies recent migrants as a specific vulnerable group and that healthcare access is inequitable to migrants in general and recent migrants specifically. As a long-term measure, investments are needed in education, development and ensuring livelihoods. The same applies to other low- and middle-income countries where internal migrants constitute a considerable proportion of urban population.
Our study had some limitations. It was based on data collected from mothers in the community and did not collect detailed data on supply side barriers. Also, questionnaire-based surveys provide little information about the context. Despite these limitations, the present study has methodological strengths such as comparing two groups of migrants with data collected from representative samples using a pre-tested questionnaire by trained interviewer. Also, the study is specifically designed to capture socio-economically disadvantaged migrants to understand their maternal healthcare-seeking behaviour.
This study received financial support from the All India Institute of Medical Sciences (AIIMS), New Delhi, India in the form of Grant out of the Institute Research Funds.