A RESEARH PROPOSAL

ON
KNOWLEDGE AND PRACTICE ON UTILIZATION OF
ANTENATAL CARE SERVICE IN KASKI DISTRICT

SUBMITTED BY:

BPH 7th SEMESTER/4th YEAR

PU REGD.NO 091-6-2-04215-2013

SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

IN THE SUBJECT OF THE PUBLIC HEALTH RESEARCH
REPORT(COURSE CODE PSD 408.4 PHRR) FOR DEGREE OF
BACHELOR OF PUBLIC HEALTH

SUBMITTED TO:
PURBANCHAL UNIVERSITY
NATIONAL ACADEMY FOR MEDICAL SCIENCES
DEPARTMENT OF PUBLIC HEALTH
KATHMANDU,NEPAL
2018
 APPROVAL SHEET

National Academy For Medical Sciences

Old Bahneswor, Kathmandu
(Affiliated to Purbanchal University)

Proposal on Knowledge and Practice on utilization of Antenatal care services in Annapurna

Municipality of Kaski District
(For the partial fulfillment of degree of Bachelor in Public Health)

---------------------------------

Research Supervisor/Principle
National Academy for Medical Sciences

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 ACRONYMS

ANC Antenatal visit care

BCC Behaviour change communication
BPH Bachelor in public health
FCHV Female community health volunteers

ICPD International conference on population

development

IEC Information education communication

MMR Maternal mortality rate
SPSS Statistical package of social science
TT Tetanus toxoid
WHO World health organization

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Contents
Acronyms........................................................................................................................................ii
CHAPTER I: INTRODUCTION....................................................................................................1
1.1 General Background..............................................................................................................1
1.2 Statement of the problem.......................................................................................................2
1.3 Rational/justification..............................................................................................................2
1.4 Objectives...............................................................................................................................3
1.4.1 General Objective............................................................................................................3
1.4.2 Specific Objectives..........................................................................................................3
1.5 Research question..................................................................................................................3
1.6 Conceptual framework...........................................................................................................3
Chapter II: Review Of Litrature......................................................................................................4
Chapter III: Methodology................................................................................................................6
3.1 Study design...........................................................................................................................6
3.2 Study variables.......................................................................................................................6
3.3 Study area...............................................................................................................................6
3.4 Study population....................................................................................................................6
3.5 Sample size............................................................................................................................6
3.5 Sampling technique................................................................................................................7
3.6 Tools and technique of data collection..................................................................................7
3.7 Data management, analysis and interpretation procedure.....................................................7
3.8 Validity and reliability of study.............................................................................................8
3.9 Inclusion and exclusion criteria.............................................................................................8
3.10 Ethical consideration............................................................................................................8
3.11 Limitation of the study.........................................................................................................9
3.12 operational definition...........................................................................................................9
REFERENCES..............................................................................................................................10
Annex.............................................................................................................................................11
3.13 Time frame of study...........................................................................................................19

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 CHAPTER I

INTRODUCTION

1.1 General Background

Antenatal care is a planned examination and observation for the women from conception till the
birth. Antenatal care refers to the care that is given to an expected mother from time of
conception is confirmed until the beginning of labor. The care of the pregnant women and her
unborn baby throughout a pregnancy is called ANC. Such care involves regular visit to a doctor
or midwife, who perform abdominal examinations, blood and urine tests, and monitoring of
blood pressure and fatal growth to detect disease or potential problems.WHO recommends a
minimum of four antenatal check-ups at regular intervals to all pregnant women(at the fourth,
sixth, eighth and ninth months of pregnancy). During these visits women should receive the
services and general health check-ups: Blood pressure, weight and foetal heart rate monitoring,
IEC and BCC on pregnancy, childbirth and early newborn care and family planning, Information
on danger signs during pregnancy, childbirth and in the postpartum period, and timely referral to
appropriate health facilities using birth preparedness and complication readiness (BPCR) for
both normal deliveries and obstetric emergencies (plan of delivery by skilled birth attendants,
money, transportation and blood),Early detection and management of complications during
pregnancy, Provision of tetanus toxoid and diphtheria (Td) immunization, iron folic acid tablets
and deworming tablets to all pregnant women, and malaria prophylaxis where necessary.

Prenatal care, also known as antenatal care, refers to the regular medical and nursing care
recommended for women during pregnancy. Prenatal care is a type of preventive care with the
goal of providing regular check-ups that allow doctors or midwives to treat and prevent
potential health problems throughout the course of the pregnancy and to promote healthy
lifestyle that benefit both mother and child.

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Maternal mortality remains one of the biggest public health problems in Nepal. Lack of access to
basic maternal healthcare, difficult geographical terrain, poorly developed transportation and
communication systems, poverty, illiteracy, women's low status in the society, political conflict,
and shortage of health care professional and under utilization of currently available services are
major challenges to improving maternal health in Nepal. Improving health facilities, mother’s
nutrition, women’s position in the society such as freedom of movement, providing education to
female children, integrating Traditional Birth Attendants into local health services can play a vital
role in the improvement of mothers’ health. Maternal mortality is one of the key indicators of the
status of reproductive health care service delivery and utilization, but it also can be an indicator of
women’s status in a society. Maternal mortality, currently an issue of concern on the international
health agenda, remains one of the most important public health problems in developing countries.

Globally, while 86 per cent of pregnant women access antenatal care with a skilled health
personnel at least once, only three in five (62 per cent) receive at least four antenatal visits. In
regions with the highest rates of maternal mortality, such as sub-Saharan Africa and South Asia,
even fewer women received at least four antenatal visits (52 per cent and 46 per cent,
respectively).

The main reasons that hinder the use of Antenatal Care are different from Country to Country. But
the reason experienced in developing countries are nearly similar such as; hemorrhage, followed by
eclampsia, infection, abortion complications and obstructed labor. Other 2 issues are lack of
knowledge and preparedness about reproductive health in the family, community and health
provider.
To alleviate such factors, Antenatal Care is the most important method for detecting pregnancy
problems in the early period. Because Antenatal care is the best mechanism to minimize maternal
mortality, and give a good information for pregnant women about their birth and how to prevent
related problems. The best and most advantage of Antenatal Care is to protect the health of women's
and their infants as well as indicating the danger signals that will be occurred and needs to be further
treated by advanced health professionals
A number of studies indicate that the Antenatal Care utilization rate is still low due to many factors
that need to be examined such as socio demographic factors, knowledge of social support. They

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conclude that eliminating such factors is important to increase the women's participation in
Antenatal Care.
When we come to Nepal, although, access to health care services is improving, the country has
faced challenges in increasing health care utilization and the proportion of women who give birth
with the assistance of skilled attendants is the lowest in South East Asia.

1.2 Statement of the problem

An estimated 515,000 women die of pregnancy-related causes, a rate of over 1,400 maternal
deaths each year. The overwhelming majority of these deaths and complications occur in
developing countries. Effective antenatal care(ANC), appropriate emergency treatment of
complications and competent referral level encompass the most effective answers to reduction of
maternal deaths.

Every minute, at least one woman dies from complications related to pregnancy or child birth
that means 529 000 women a year. In addition, for every woman who dies in childbirth, around
20 more suffer injury, infection or disease approximately 10 million women each year. Studies
reveal that the cause of maternal mortality in developing countries is mostly due to poor
accessibility to maternal health’s service poor referral to appropriate antenatal and delivery care
unit, and inadequacies of available care. These studies suggested that most of the maternal deaths
were preventable with improved coverage of antenatal care, safe delivery and postpartum care.
There are regional variations in antenatal care utilization rate basically due to differences in the
availability of health care facilities, among the regions during 1985-1990, antenatal coverage rate
for the whole Africa was 60% compared to 99% for developed countries.

Based on NDHS 2011 report, in Nepal the maternal mortality rate has been estimated to be 258
per 100,000 live births. In addition women's reproductive health problems are a timely and
serious matter of concern, for any health professionals, the government as well as the society.

Antenatal Care related problem parameters are very sensitive because it have directly related
with maternal morbidity and mortality, and loss of fetus. It is a necessary component of maternal
health in order to identify complications.Regular Antenatal Care visits can provide some benefits
for the women such as a care provider that can result in reducing complications during

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pregnancy the absence of this activity affects millions of mothers in the rural as well as urban
areas.

Many women from different studies have mentioned that women’s are embarrassed when
visiting an ANC. With improved knowledge about the benefits of ANC and the importance of a
positive attitude toward it, these women will come to understand that ANC’s medical procedures
and interventions will do much to save their lives and improve their children’s health. In this way
they will be motivated enough to overcome their reluctance. In many ways, changing attitudes
and behavior are the most challenging tasks, but are also the least costly. Proper educational
campaigns and the improved dissemination of information are investments for the long-term.
Most previous studies done on knowledge and attitude of women toward ANC were community
based done on general women of child bearing age. Until now little has been known about
knowledge and practice of women who are currently using ANC services. Therefore this study
will help to know how much percentage of women came to benefit from this important service of
women’s health know about it and have good practice about antenatal care services. The aim of
this study is to assess knowledge and Practice of pregnant women regarding the benefits of
Antenatal care utilization in Annapurna municipality of kaski district.

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1.3 Rational/justification
Having good knowledge and practice is the most valuable precondition for any healthy behavior
including ANC service. Different studies have shown that women who had a good knowledge
towards ANC had a higher proportion of ANC visits . Therefore knowing about prevalence of
women who has good knowledge and practice and identifying the associated factors in a given
society has important contribution in addressing maternal health need of the women. This study
is intended to extract out the knowledge and practice of pregnant women and mothers on the
benefits of ANC utilization during antenatal visit. The findings of this study will serve as a
reference for giving intervention accordingly by the health care providers and others who
concerned; for conducting further researches; the findings of this study will have importance for
health care providers because it will serve as base line for filling gaps of the actual practices on
antenatal care.

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1.4 Objectives
1.4.1 General Objective
 To assess the knowledge and practice on utilization of antenatal care services in
Annupurna municipality of Kaski district

1.4.2 Specific Objectives

 To identify the knowledge of pregnant women and mothers towards utilization of
antenatal care services
 To assess practice of pregnant women and mothers on utilization of antenatal care
services

1.5 Research question

 What is the knowledge on utilization of antenatal care services?
 What is the practice on utilization of antenatal care services?

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 1.6 Conceptual framework
Independent Variables Dependent Variables

Sociodemographic characterstics
Age
Religion Knowledge
Ethnicity
Education
Practice

Socioeconomic information and

media exposure
Source of income
Monthly income
Family support

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 CHAPTER II: REVIEW OF LITRATURE

Health knowledge is considered to be one of the key factors that enable women to be aware of
their right and health status in order to seek appropriate health services. Study conducted in
different part of the world has discovered that level of knowledge of mothers toward ANC is
important for utilizing ANC service. The level of knowledge of pregnant mother also varies in
deferent part of the world.

An institutional based cross sectional study conducted in north central Nigeria to investigate
knowledge and utilization of ANC service has revealed that 87.7% of women in child bearing
age were aware of the benefits of antenatal care out of which 25.9% had fair knowledge about
the activities carried out during the antenatal care services, 69.9% had good knowledge while
only 4.2% had poor knowledge(10, 5). Similarly a study that was conducted in Tunisia to
investigate mothers’ knowledge about preventive care indicated that 95% of women knew the
importance of antenatal examination.

Different to these findings a cross-sectional study conducted using two-stage cluster sampling at
24 selected villages in the Kham District, Nagoya, Japan found that most of the respondents
73.9%, lacked sufficient knowledge towards ANC . In another cross-sectional study conducted in
Metekel zone, North West Ethiopia, 65.6% of women interviewed knew at least half of the
knowledge questions on ANC and so labeled as knowledgeable.

Knowledge of the women towards ANC service can be influenced by different factors. In study
done on knowledge and practice of ante-natal care in an urban area of India revealed that the
primipara had more knowledge than the multipara although it was not statistically significant.
This study also reviled that women having adequate knowledge on ANC were found to be
statistically associated with their educational status, religion, age at marriage and house
ownership. With increase in the educational status, the adequacy of knowledge also increased
correspondingly (12). However, the multipara were found to have poorer knowledge on ANC in
a study done in Shanghai, China.

In study done in Metekel Zone, Northwest Ethiopia, Among the socio-demographic factors;
being in urban residence, possessing radio and educational status of secondary school and above

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8 were more than 4 times, two times, and three times more likely to be knowledgeable about
ANC.
It could be in realization that knowledge of pregnant mothers is a major factor in determining the
extent of utilization of antenatal services. Reports from different part of the world have indicated
that increased level of pregnant mothers toward ANC care service has an influence on its
utilization.

Study done in Copper belt Province of Zambia to identify factors associated with late antenatal
care attendance in selected rural and urban communities found that inadequate knowledge about
ANC resulted into 2.2 times high odds for late ANC attendance than women who had adequate
knowledge in urban district. The perception of no benefits derived from commencement of ANC
early was associated with 4 times likelihood of late attendance in the urban district .

According to report from study done in Kham District, Xiengkhouang Province, Nagoya, Japan,
the levels of education and knowledge were the most important predictors of ANC utilization.
Educated women were 6.8 times more likely to receive ANC services than those who had no
education, and women who were highly knowledgeable were 6.5 times more likely to do so than
those who were deficient in knowledge.

A cross- sectional study was conducted in Dhankuta municipality from 28th March to 10th
april,2013 to find out the antenatal care practice and its impact on birth outcome among the
residents of where 246 households were taken as subjects. Convenient purposive sampling
technique was applied. Semi-structured questionnaire was used and face to face interview was
conducted. Almost 88% of participants attended ANC visits. The findings revealed that even
though the fourth ANC visit was (82.4%),almost 82.5% of the pregnant women took the TT
injections , about 81.7% received iron tablets and nearly 57.7% received albendazole. Women
with SLC and higher education level are more likely to ANC visits (95.4%) than women with
below SLC (87.9%) and no education (66.7%).Hindu women are more likely to have ANC visits
(91.2%) compared to women of other religion (47.4%).We conclude that the women of the
surveyed communities have placed antenatal care as priority. Lack of money and educational led
some of the participants not to attend the recommended antenatal care visits. Antenatal care
checkup is important for favourable birth outcome.

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 CHAPTER III: METHODOLOGY
3.1 Study design
Study design will be descriptive cross sectional quantitative study design.
3.2 Study variables
Study variables will be independent and dependent

Independent variables Dependent variables

Age Knowledge

Religion Practice

Ethnicity

Education

Source of income

Monthly income

Family support

3.3 Study area

Study area will be Annapurna municipality of Kaski district
3.4 Study population
Study population will be pregnant women and mothers.
3.5 Sample size
The sample size will be determined by using the following formula as shown below;
Sample Size (n) = [z2.p (1-p)]/d2
Where,
z = critical value which is equal to 1.96 in two-tailed test
p = prevalence 57%
d = absolute sampling error 10%
The total sample size for the study will be 94

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3.5 Sampling technique
Sampling technique for study will be purposive sampling technique.

3.6 Tools and technique of data collection

Tools and techniques of data collection will be:

Tools Techniques Respondent

Structured questionnaire Face to face interview Pregnant women and
mothers

3.7 Data management, analysis and interpretation procedure

Data entry and analysis will be in Microsoft office excel and SPSS.
3.8 Validity and reliability of study

 Validity and reliability will be maintained by pre-test and necessary modifications.

 Consultation will be done with the supervisors / guide / subject experts.

 Field work will be carried out by the researcher herself and necessary help could be taken
from the experts.

 Data will be gathered promptly after collecting the data.

 Scientific tools and techniques will be apply for the collection of data

 Necessary help and support will be taken from the experts and supervisors.

3.9 Inclusion and exclusion criteria

Inclusion criteria
 All the pregnant women and mothers of Annapurna municipality

Exclusion criteria

• Mentally retarded or handicapped mothers.

• Women who are severely ill, could not speak.

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3.10 Ethical consideration

 Approval letter will be taken from college.

 Approval will be taken from district public/ health office.

 Informed consent will be taken from the respondent before starting data collection
process.

 The results will be only for study purpose.

 Confidentiality will maintain unless no legal issues.

 The study group will also be protected from physical and emotional harm during the
study.

 Participants will not force for the participation for the study .i.e. voluntarily participation
and they are able to withdrawal at any time.
3.11 Limitation of the study
 It is focused on exploring their Knowledge and Practice on utilization of Antenatal care
service .
 Time of this study is limited to 6 months only and limited budget hindered the inclusion
of larger sample size.
 May be limited by its cross sectional nature of the data hence the results will be carefully
interpreted
 This study is carried out as an academic exercise to learn about conduction of research.
Hence, only the simple analytical tools will be used for better understanding of the
situation.

3.12 Operational definition

Knowledge

Possession of the fact about the Antenatal Care Services

Practice

Daily and ritual action

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Utilization

It refers to antenatal services used by pregnant women for observation and examination of fetus
e.g.to check blood pressure, weight, condition of fetus and deworming.

ANC Services

It refers to examination and observation for the pregnant women from conception till the birth.

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 REFERENCES
1. Joshi R, Khadilkar S, Patel M. Global trends in use of long-acting reversible and
permanent methods of contraception: Seeking a balance. Int J Gynecol Obstet [Internet].
2015 [cited 2017 May 3];131:S60–3. Available from:
http://www.sciencedirect.com/science/article/pii/S002072921500226X
2. Department of Health services D. Annual Report: Department of Health Services 2071/72
(2014/2015). 2015;71:iii,iv. Available from: http://www.spp.org/documents/28682/ar-
2014 04302015.pdf
3. WHO | Maternal mortality. WHO [Internet]. 2016 [cited 2017 May 3]; Available from:
http://www.who.int/mediacentre/factsheets/fs348/en/
4. Survey H. Nepal. 2011;
5. Apanga PA, Adam MA. Factors influencing the uptake of family planning services in the
Talensi District, Ghana. Pan Afr Med J [Internet]. 2015 [cited 2017 May 3];20. Available
from: http://www.panafrican-med-journal.com/content/article/20/10/full/
6. Shrestha DR, Shrestha a, Ghimire J. Emerging challenges in family planning programme
in Nepal. J Nepal Health Res Counc [Internet]. 2012;10(2):108–12. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/23034371
7. Curtis KM, Peipert JF. Long-Acting Reversible Contraception. Solomon CG, editor. N
Engl J Med [Internet]. 2017 Feb 2 [cited 2017 May 3];376(5):461–8. Available from:
http://www.nejm.org/doi/10.1056/NEJMcp1608736
8. Keyal N, Moore M. Contraception in Eastern Nepal: A Study of Knowledge and Use. J
Univers Coll Med Sci. 2014;2(2):15–20.

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 ANNEX

3.13 Time frame of study

Time frame for the study will be six months. It will start from Magh 2074 and will end at
Shrawan 2075.

S.N Activities

1 Topic selection and

presentation

2 Literature review

3 Questionnaire develop,
proposal submission

4 Proposal presentation

5 Pretesting the question

and data collection

6 Data analysis and

interpretation and draft
report writing

7 Submission of final
research

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Budget

S.N. Description Amount (Rs.)

1 Stationery( pen, pencil, eraser, questionnaire) & anthropometric 2500.00

instruments cost

2. Pretesting cost 1000.00

3 Travel cost 10000.00

4 Report print and binding cost 2500.00

5. Mics. 2000.00

Total 18000.00

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