Antenatal Care Utilization of Savara Tribe Women: A Most Vulnerable Tribe of Andhra Pradesh

 

K. L. Narayana¹*, L. Giridhar¹ and K. Harika²

 

ABSTRACT:

This paper examines the patterns of antenatal health care utilization among the Savara Tribe Women of Andhra Pradesh. The aim of this study was to identify the knowledge, attitude and accessibility related to the utilization of antenatal care (ANC) service among Savara tribe women in the Srikakulam district, Data for this cross-sectional study were using a multi-stage random sampling strategy from 6 selected mandals in Srikakulam district. A total of 600 married women of reproductive age who had at least one child and had delivered the last child within two years from the date of data collection were interviewed using structured questionnaires. To get the antenatal check-ups, majority of the women were attended by traditional healers at their homes. During the antenatal care, the pregnant women were tested for body weight, blood pressure, hemoglobin, abdominal check-ups, haemogram and HIV/AIDS, but nearly 10.0% of Savara women have not received any one of these services. Almost all the pregnant tribal women have received 2 TT injections. Due to various reasons majority of the women are not consuming the IFA tablets, it needs more awareness about the importance of consumption of IFA tablets and the health workers and other family members should monitor the intake of IFA tablet by the pregnant women.

 

 

INTRODUCTION:

The risk of maternal death in developing countries is estimated to be one in 61, while for the developed countries it is about one in 2800 (WHO, UNICEF and UNFPA 2004). Complications during pregnancy and child-birth are the leading cause of death and disability among women of reproductive age in developing countries. There are an estimated 529,000 maternal deaths each year, of which 99% occur in developing countries (WHO, 2005).Millions of women in these countries lack access to adequate care during pregnancy. In adequate access and under utilization of modern healthcare services are major reasons for poor health in the developing countries (Amin et al.1989). This inequality in the health and wellbeing of women in the developing and the developed world is a growing concern.

 

 

Antenatal care is an essential safety net for healthy motherhood and childbirth, where the well-being of both the prospective mother and her offspring can be monitored(UNO, 2008).MDG 5 focuses on improving maternal health (WHO, 2008). A substantially lower proportion of pregnant women receive the standard set of four visits recommended by WHO and UNICEF. Many health problems among pregnant women are preventable, detectable or treatable through visits with trained health workers before birth. These enable women to receive important services, such as tetanus vaccinations and screening and treatment for infections, as well as potentially life - saving information on warning signs during pregnancy (UNO, 2009). Antenatal care is an opportunity to promote the benefits of skilled attendance at birth and to encourage women to seek postpartum care for themselves and their newborns (USAID, 2014).

 

Antenatal care is an important determinant of safe delivery. Although certain obstetric emergencies cannot be predicted through antenatal screening, women can be educated to recognize and act on symptoms leading to potentially serious conditions; this is one strategy for reducing maternal mortality (Simkhada, B. et al, 2008). One of the most important functions of ANC is to offer health information and services that can significantly improve the health of women and their infants (WHO and UNICEF 2003). In addition, ANC during pregnancy appears to have a positive impact on the utilization of postnatal healthcare services.

 

Savara, numbering about 4.92 lakhs are one of the most populus tribes of the country. They presently inhabit in Orissa, Andhra Pradesh, Madhya Pradesh, West Bengal, Tripura, Bihar and Assam. However, the present Orissa state contains nearly three-fourths of the total population of the Savara. In Orissa, their number is about 3,42 lakhs and are distributed in 13 districts. In this State they are mostly concentrated in Ganjam and Koraput districts. Their population in these two districts account for more than one-third of the total Savara population in the country. In Andhra Pradesh, the Savara account for about 5.14% of its total tribal population. They occupy a continuous belt in the Vizianagaram and the Srikakulam districts bordering the Orissa State.

 

The Savara are one of the most primitive tribes of AndhraPradesh. They are mainly found in the picturesque Palakonda hill ranges (part of Eastern Ghats) of Srikakulam and Vizianagaram districts. They are also found scattered in the district of Vishakhapatnam of Andhra Pradesh. About 9o% of Savara in Andhra Pradesh are concentrated in Srikakulam and Vizianagaram districts. They belong to Proto-Australoid racial stock. On the basis of physical features the Savara habitat can be divided into two distinct zones: (1) the hill settlements and (2) the foothill settlements. The hill settlements, as the name suggests, are mainly in mountainous country, of late large number of these settlements are accessible by road. The second zone, the smaller of the two in terms of population and number of settlements, consists of the foothill settlements  of  Savara along the Eastern Ghats. These settlements came in touch with outsiders much earlier than the hill settlements, and these contacts have increased in the last two decades due to the migration of non-tribal into tribal areas. The Savara of these settlements cultivate terraced land with ploughs, like the Jatapu of the foothill settlements.

 

RATIONAL FOR THE STUDY:

The present study will expected to bring out the various levels of antenatal health care practices in relation to social environment among Savara tribal community in Srikakulam district of Andhra Pradesh. Due to the poor perception levels of the health care providers towards the Reproductive and child health (RCH) programme and also due to the lack of proper motivation and other administrative problems they are unable to scatter the services to the needy tribals and also failed to motivate the tribal people towards modern health care services because of the deep rooted traditional belief systems of the people. In the present study aimed to identify the awareness towards RCH programme and the gaps in delivering antenatal health care services with main objective of To study the current pattern of utilization of antenatal care services among the woman of Savara tribal community.

 

METHODOLOGY:

The present study is aimed to assess the health care practices among Savara tribe of Srikakulam district. Systematic sampling procedures were followed in the selection of the sample size from different tribal mandals of Srikakulam district. The study on tribes was carried out in 6mandals which were selected at random from a total of 14 tribal mandals of the district. The villages in the present study were on the belt of Eastern Ghat mountainous ranges and their adjoin places. The villages were selected considering their accessibility and Savara dominance. Though other tribes and castes are living together in the selected villages, the study was conducted only on the “Savara” tribes. Ethnic group wise stratification of the population of the villages was followed to maintain the ethnicity of the tribe. Most of the villages are selected which are relatively interior and far away (10-45 Kms) from Mandal headquarters. In the second phase of stratification, in total 95 villages are selected and from each village 5-8 available nursing mothers who are in the age range between 15-49 years are considered as the respondents. After field investigation, data were processed and analyzed in accordance with the outline laid down for the purpose. Both qualitative and quantitative data from field survey were collected and analyzed with appropriate measures.

 

DISCUSSION:

Antenatal care refers to care provided to women during pregnancy by a medical practitioner or health worker at medical facility or at home. The number of antenatal visits and timing of antenatal checkup is important for the health of the mother and even to the foetus. For proper monitoring of the pregnancy, the first checkup is mandatory, immediately on confirmation or at least before twenty weeks of gestation; a minimum of three checkups are essential. The reproductive and child health programme recommends that as a part of antenatal care, women receive two doses of tetanus toxoid vaccine, at least 100 IFA tablets or syrup to prevent and treat anaemia and at least three antenatal check-ups that include blood pressure checks and other procedures to detect pregnancy complications. (MOHFW, 1997).

 

1.      Antenatal check-ups:

Proper antenatal care can help ensure a favourable pregnancy outcome, a healthy mother and a healthy baby, but the coverage of antenatal care should be evaluated in many populations. In the present study, the details regarding the number of antenatal visits, place of antenatal care, antenatal care provider and the knowledge towards antenatal care of both the populations are evaluated and presented in the Table-1. About 83.2% of women have the knowledge about antenatal check-ups; whereas 16.8% of women have no knowledge in utilizing the antenatal care services.

 

The present study women have the knowledge and positive attitude to make at least three antenatal care visits but about 41.3% of women have put it in practice to receive the antenatal care services 3 and more than 3 times. The tribal women who have received 3 or more than 3 ANC services were more among the tribes of Vizianagaram (89.4%) studied by Sambasiva Rao (2008), Visakhapatnam (95.8%) and also by the same (2008a) and Koya Dora tribe of West Godavari district (90.2%) by Sambasiva Rao, et.al., (2011) when compared to the present Gadaba and Konda Dora populations. Low coverage (32.1%) (3 or more than 3 ANC) was reported by Mallikarjuna Rao (2008) among the tribes of Andhra Pradesh. But the Scheduled Tribes of Rajasthan studied by Bhardwaj and Tungdim (2010) reported very low coverage of ANC more than 3 visits (3.6%).

 

It is quite interesting to note here that 25.0% of the Savara women have visited the homes of the traditional healers for antenatal check-ups. Nearly 28.0% of Savara women had their antenatal care check-ups at their homes. Though the women know the availability of antenatal care services at government health facilities, but about 34.7% women received antenatal check-ups at government hospitals and only 12.0% visited the private health facilities. The antenatal visits to government health facilities in this tribe is very low when compared to the tribes of Vizianagaram (57.5%) studied by Sambasiva Rao (2008), but the antenatal check-ups at private health facilities are very low (1.7%) in Vizianagaram district also. Whereas the tribes of Andhra Pradesh studied by MallikarjunaRao (2008) revealed that they had antenatal care provided at home (30%) followed by private health facility (17%) and government health facility (16%).

 

Table-1: Antenatal care particulars among Savara women

 

Traditional healers and Dais (32.8%) have provided the antenatal care for Savara women, whereas the government doctors are the providers of antenatal care to 31.7% of women. Though a considerable number of both the communities visited the private health facilities, only around 2.0% of these respondents were provided with antenatal care by the private practitioner. The other antenatal care providers are Local quack doctor, Multi-Purpose Health workers (MPHW), Auxiliary Nurse Mid-wife (ANMs) and other health workers.

 

2.      Tests and examinations:

Data were collected on the type of tests and examinations conducted during antenatal check-ups to the pregnant women and are presented in Table-2. The results revealed that 28.5% of present Savara women had the abdominal check-ups, 16.4% reported that they had urine examinations. Only 5.1% of Savara women were tested for blood examination. Body weight, blood pressure, haemoglobin levels and HIV/AIDS tests were recorded to a limited number of Savara women, such as 10% for each test. The other tests conducted for these women are body weight (12.7%), blood pressure (12.5%), Hb levels (12.5%), HIV/AIDS (12.4%), blood analysis (7.5%) and scanning (0.2%).Only abdominal check-ups are done by Dais but other ethno medical practitioners and traditional healers are not advised for conducting tests and examinations because these women are un-educated and un-touched by the men.

 

The tests and examinations conducted during antenatal visits to the present Savara women are 82.0% and these levels are lesser when compared to the studies conducted by SambasivaRao, et.al., (2011) and Mallikarjuna Rao (2008) on the tribes of Koya Dora tribe of West Godavari district (98.2%) and the tribes of Andhra Pradesh (98.3%). But 50% of the tribes of Rajasthan studied by Iyengar and others (2009) have undergone the tests and examinations. Body weight, blood pressure and Hb estimation are very poorly covered in the present study tribes when compared to the tribes of Vizianagaram (Sambasiva Rao 2008), Koya Doras of West Godavari district (Sambasiva Rao, et.al., 2011), tribes of Andhra Pradesh (Mallikarjuna Rao, 2008) and Khasi tribes of Meghalaya (Deb, 2007). During the first visit stool examination, complete blood grouping, serological examinations, ABO and Rh blood grouping are recommended, but are poorly covered or not at all covered in the present study populations and also in other studies on the tribes of India. Variation in blood pressure, hemoglobin and weight gain are the common physical examination should conduct in all the subsequent visits, but the health facilities are failing to provide these services in majority of the situations.

 

Table-2: Tests and examinations conducted during ANC care among the women

 

3.      Iron-folic acid tablets:

As a part of antenatal care interventions, the distribution of Iron Folic Acid (IFA) tablets among pregnant women is almost mandatory in rural and tribal areas. The practice of utilizing IFA distribution service with regard to consumption, it varies from tribe to tribe and also between individuals. The following are some of the practices observed among Gadaba and Konda Dora women regarding the consumption of IFA tablets.

 

Nearly 99% of tribal women belong to have received the IFA tablets, but 53.0% of women have consumed the required number of IFA tablets. But majority (47.2%) of the women though they have received the IFA tablets, they have not consumed all the tablets distributed by the health workers. Further, information regarding the number of tablets consumed were gathered and found that 40.4% of women have consumed 61-90 IFA tablets. About 40.4% women have consumed 31-60 IFA tablets. Less than 30 IFA tablets were consumed by 19.1% of women. No women in this community have consumed more than 90 IFA tablets (Table-3).

Table-3: IFA tablets’ distribution, source, consumption

The distribution of IFA tablets to the pregnant women of the present study populations received between 99.0%. The distribution of IFA tablets was relatively low (82.1) among the tribes of Andhra Pradesh (MallikarjunaRao, 2008), Khasi tribe of Meghalaya (80.0%) (Deb, 2008) and Bhumija tribe of Orissa (55.8%) (Goswamy, 2009). But very low distribution of IFA tablets was recorded among the tribes of Rajasthan (48%), Bhils of Madhya Pradesh (36%) and Santhali, Munda and Oraon of Jharkhand (24.3%) studied by Gandhi ManavKalyan (2007), Ravender Sharma (2010)and Maiti, et.al., (2005). Though the distribution of IFA tablets at population level records high, but the consumption of the IFA tablets was not satisfactory. The consumption of IFA tablets among the tribes of Visakhapatnam (78.1%) (SambasivaRao, 2008a), KoyaDoras of West Godavari district (70.8%) (SambasivaRao, et.al., 2011) was higher than the present study populations.

 

The Khasis of Meghalaya studied by Deb in 2008 show very appreciable level of consumption of IFA tablets i.e. 79.3% were consumed out of 80% distributed. Even in the study conducted by Lakshmi (2011), only 17.5% of Savaras and 25% of Jatapus have consumed 61-90 IFA tablets. There is no proper monitoring on the consumption levels of IFA tablets by the health care providers. Lakshmi (2011) reported that nearly 98-99% of tribal women in Srikakulam district have received the IFA tablets, but 39.0% of Savara and 64.0% of Jatapu women have consumed the required number of IFA tablets.The present study tribal women have the practice of collecting the IFA tablets from various sources like anganwadicentres, ANMS, Government health facilities like PHC and private health facilities. IFA tablets at Primary Health Centers, sub-center level and anganwadi center level distributed by the health workers, ANMs, CHWs and anganwadi workers to the pregnant women (92.5%). Very negligible percentages (0.1%) of these women have received the IFA tablets from private health centres.

 

The distribution of IFA tablets mostly carried out by ANM/ CHW and anganwadi workers in the present study population mostly from PHCs and its sub-centers. Similar trend was found among the tribes of Vizianagaram (SambasivaRao, 2008) and KoyaDoras of West Godavari district (SambasivaRao, et.al., 2011) where the distribution of anganwadi and ASHA workers are relatively less. The private health facilities are also distributed IFA tablets to the tribal women and was found not only in the present study, but also among the populations studied by SambasivaRao, et.al., (2011) and SambasivaRao (2008) among KoyaDoras of West Godavari district and the tribes of Vizianagaram district. The distribution of IFA tablets mostly carried out by anganwadi and ASHA workers in the Savara and Jatapu tribal women mostly from PHCs and its sub-centers as reported by Lakshmi (2011).

 

4.      Tetanus toxoid injections:

To prevent the infections caused during delivery time due to unhygienic practices and also in case of episiotomy, Tetanus Toxoid (TT) injection will be given to the pregnant women. It also takes-care the newborn against neonatal jaundice due to improper care provided in cutting the umbilical cord. Usually 2 doses of TT injections will be provided to the pregnant women; the first preferably during the first trimester and the second may be given after observing a gap of minimum one month. In the present study populations, the first dose of TT injection was given not only in second trimester but also during 1^st and 3^rd trimesters (Table-4). In majority of the cases the second dose of TT injection was given after a span of one month to four months period. Further, it is also observed that every tribal woman in both the study populations was given 3 doses of TT injections during their 1^st pregnancy. Similarly, during their second pregnancy another two doses of TT injections were given. Actually as per the guide lines of WHO, one dose of TT injection may be sufficient during second pregnancy period, if the birth space is less than 3 years.

 

Table-4: The time gap between first and second dose of TT injections among present study pregnant women

 

But the age at first conception* among the study population was 18.24 years (n=426) and the second conception at the age of 22.48 years, so the duration between two conceptions was around 4.24 years and hence the two doses of TT injections during the second pregnancy is justifiable (*The mean values were calculated to the women those who have more than 1 conception).

 

It is also revealed from the present study analysis that majority of the women have provided with 1^st dose of TT injection during 4^th (30.8%) and 5^th (40.1%) months. Quite interestingly some (0.5%) of the women were provided with 1^st dose of TT injection in 2^nd month and 12.9% of women in their 3^rd month, which is very early and others (7.2%) were given during 7^th and 8^th month of pregnancy (Table-5).

 

The present study Savara women were provided with 2 TT injections during the pregnancy period is 95.7%. Whereas the studies conducted by MallikarjunaRao (2008) among the tribes of Andhra Pradesh (80%), Gandhi ManavKalyan (2007) study on the tribes of Rajasthan (71.43%) and Deb’s study (2008) on Khasis of Meghalaya (83.3%) reported relatively higher percentages of single dose of TT injection when compared to the present study savara tribe. The KoyaDoras of West Godavari district and the tribes of Vizianagaram district (SambasivaRao, et. al., 2011 and SambasivaRao 2008) reported higher TT injection coverage with more than 2 TT injections i.e. 97.3% and 96.9%, respectively. Nearly 60% of Bhumija women of Orissa (Goswamy 2009) have received atleast one TT injection during their pregnancy period. Exclusively single dose of TT injection coverage was found among the Savara (6.1%) and Jatapu (13.6%) tribal women of Srikakulam district as reported by Lakshmi (2011). While the study conducted by SambasivaRao (2008) on the tribes of Vizianagaram records with less percentage (0.4%) of women who received the single dose of TT injection.

 

The antenatal check-ups received by the present tribal women are less in the younger age group (19-24 years-70.5%) than the subsequent age groups upto the age of 36 years (25-30 yrs-19.8% and 30-36 years-9.7%). In the older age groups after 30 years, the antenatal care received by the women is relatively low. Regarding the quantity of IFA Tablets received and the TT injections taken by the women are more among the younger women when compared to their older counterparts.

 

Table-5: The particulars of TT injections among the present women

 

This is in agreement with the studies conducted by Bhatia and Cleland (1995a) and Goswamy (2009). The finding of the present study is in accordance with the findings of NFHS-2 (1998-99), IIPS-ORG-Macro (2000) where the percentage of women who received the antenatal check-ups decreases with the advancement of age. The women receiving the TT and IFA Tablets also show a similar trend. Gilany and Aref (2000) have also reported that utilization of antenatal care might depend on the enthusiasm or anxiety of the mother, which is greater among young women than older women.

 

Table-6: Utilization of ANC check-ups, IFA tablets and TT injections according to the age of the respondents.

 

Thus the acceptance of antenatal care is more in women of the younger age group which indicates that they have understood and availed the existing health care facilities in a better way. This is also possible due to the introduction of Janani Suraksha Yojana (JSY) scheme in 2005 which has an impact on the rate of antenatal check-ups and immunization of the poor pregnant women (Goswamy, 2009).

 

Out of 600 women, 499(83.2%) women have the knowledge about antenatal check-ups; whereas 101(16.8%) of women have no knowledge in utilizing the antenatal care services (Table-12). Regarding the IFA tablets and TT injections, the number of IFA tablets consumed were gathered and found that 314 (52.7%) of women have consumed and 281(47.2%) have not consumed the IFA tablets during their pregnancy stage. Majority of the women (574-95.7%) have provided with two doses of TT injections and 26(4.3%) of women have not received two doses of TT injections.

 

5.      Health complications:

When the tribal women have any pregnancy related health problems, majority has approached the health facility or the health workers to get treated for their complications and the details are presented in the Table-7. Out of 600 respondents from the Savara tribe, 22.2% of the pregnant women have suffered with Oedema. The signs of anaemia were expressed by 21.8% of the tribal women. And the other significant complications are blood pressure (15.4%), convulsions without fever (12.3%). Other complications observed are visual disturbance, vomiting, lower abdominal pain, malaria, general fever and bleeding, respectively.

 

Complications during pregnancy may affect both women’s health and the outcome of the pregnancy adversely. Early detection of complications during pregnancy and their management are important components of safe motherhood programme. Due to the various RCH schemes initiated by the Government from time to time, with the constant effort to improve the health of the mother and the child in rural and tribal areas, the younger women are now coming forward leaving behind their cultural constraints. However, this is not seen in the women of the higher age group. There may be several reasons for this change. Firstly, older women consider pregnancy as a normal phenomenon and believe that no special care is required for this. Secondly, they have a strong belief in traditional practices and are more culture oriented. After the Janani Suraksha Yojana (JSY) was launched under National Rural Health Mission (NRHM) in 2005, the Accredited Social Health Activist (ASHA) has been assigned ten other duties beside institutional delivery. She plays the role of a facilitator and informant, where she facilitates a pregnant mother and links her to medical officer or institution. Thus the ANM together with ASHA concentrates on antenatal check-up and immunization of the women.

 

Table-7: Pregnancy related health complications among the women

*Multiple responses

 

About 74.0% the present study tribal women have the knowledge in receiving the treatment for the pregnancy complications. Their attitude is very clear to avail the health services from the government health centres. And hence, nearly 93.0% have taken the treatment mostly from government health facility like PHC, CHC, district government hospitals and sub-centres. Private health facility is another source to provide the antenatal check-ups for 1.8% of women and 4.8% of women taken treatment from traditional practitioner. For 95.4% of pregnant women, health care providers have given the treatment, 3.9% of women approached the traditional healers and 0.9% of women have received the treatment from quack doctors who are available in their villages.

 

Oedema, vaginal bleeding, lower abdominal pain, headache and back pain, weakness and visual disturbances are the complications suffered by Bhumija women of Orissa (Goswamy, 2009). Anaemia and Malaria are the complications reported by Singh and others (1998) among the pregnant tribal women of Madhya Pradesh. The study from Bangladesh by (Akther, et.al., 1986) revealed that the major causes of morbidity are urinary problems; oedema, vaginal bleeding and lower abdominal pain are the common complications among the pregnant women.

 

Table-8: Information about treatment of health problems among tribal women

 

CONCLUSION:

Traditional healers and Dais have provided the antenatal care for Savara women, whereas the government doctors are the providers of antenatal care to women. The other antenatal care providers are Local quack doctor, Multi-Purpose Health workers (MPHW), Auxiliary Nurse Mid-wife (ANMs) and other health workers. During the first visit stool examination, complete blood grouping, serological examinations, ABO and Rh blood grouping are recommended, but are poorly covered. Variation in blood pressure, hemoglobin and weight gain are the common physical examination should conduct in all the subsequent visits, but the health facilities are failing to provide these services in majority of the situations. All most all of tribal women belong to have received the IFA tablets, but half of women have consumed the required number of IFA tablets. But majority of the women though they have received the IFA tablets, they have not consumed all the tablets distributed by the health workers. The distribution of IFA tablets mostly carried out by ANM/ CHW and anganwadi workers in the present study population mostly from PHCs and its sub-center and the distribution of IFA tablets mostly carried out by anganwadi and ASHA workers in the Savara tribal women mostly from PHCs and its sub-centers as reported.

 

Study found Savara women were provided with 2 TT injections during the pregnancy period and exclusively single dose of TT injection covered. After 30 years, the antenatal care received by the women is relatively low. Regarding the quantity of IFA Tablets received and the TT injections taken by the women are more among the younger women when compared to their older counterparts. They have suffered with Oedema, anaemia and the other significant complications are blood pressure and convulsions without fever during the pregnancy period.

 

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