Study on utilization of antenatal care and outcome of pregnancy in a medical  college & hospital of kolkata wb
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Study on utilization of antenatal care and outcome of pregnancy in a medical college & hospital of kolkata wb

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A study on Ante-natal care utilization by the mothers in Calcutta National Medical College & Hospital done by the 3rd Professional (Part I) M.B.B.S. students of Calcutta National Medical College......

A study on Ante-natal care utilization by the mothers in Calcutta National Medical College & Hospital done by the 3rd Professional (Part I) M.B.B.S. students of Calcutta National Medical College under the guidance of the teachers of Community Medicine.

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  • 1. 'Be good to your baby before it is born'. This aphorism serves to emphasize the importance of medical care during pregnancy. The care is so important because, the fetal organs are actively developing during the first 12 weeks of pregnancy. The embryo is highly susceptible to external insults during this time, so that any damage can lead to crippling birth defects.1
  • 2. WHO defines ante natal care as ‘A care which includes recording medical history, assessment of individual needs, advice and guidance on pregnancy and delivery, screening tests, education on self-care during pregnancy, identification of conditions detrimental to health during pregnancy, first-line management and referral if necessary.’ So Antenatal care is the systemic medical supervision of women during pregnancy. It preserves the physiological aspect of pregnancy and labor and to prevent or detect, as early as possible, all that is pathological.1 The primary aim of antenatal care is to achieve, at the end of pregnancy, a healthy mother and baby. The quality of care is more important than the quantity.2 It is the care that mother had received during pregnancy which included IFA tablets, TT, blood, urine tests and ultrasonographic investigations.1
  • 3. According to UNICEF (2012) the IMR is 48 per 1000 live birth which was attributed to primarily low birth weight, severe anemia, high birth rate and low spacing4 . Low birth weight and preterm deliveries in turn are related to adolescent pregnancies and short spacing. The Neonatal mortality rate in West Bengal in 2010 was 24 per 1000 live birth and 19 per 1000 live birth in urban area. The infant mortality rate in West Bengal in 2010 was 32 per 1000 live birth in rural area and 25 per 1000 live birth in urban area.4
  • 4. A very important aspect of antenatal care is to offer information and advice to women about pregnancy and the related complications. It also informs about the care a mother should take for herself and the possible curative measures on early detection of complications and its management. Antenatal care also plays a critical role for preparing a woman and her families for child birth by establishing confidence, further antenatal visits raise the awareness about the need for care during delivery.3
  • 5. Most maternal death to pregnancy related complication can be prevented if pregnant women have access to good quality antenatal care & if certain harmful birth practices are avoided.4 In west Bengal 51.1% women take more than 3 antenatal visits, 47% practice institutional deliveries and 46.6% take 100 IFA tablets.4 High maternal mortality can also be reduced by early registration of pregnancy, taking at least 4 antenatal visits, prevention and treatment of complications like- eclampsia, malpresentations, diabetes and hypertension.
  • 6. Primary aims of antenatal care-  To achieve at the end of the pregnancy a healthy mother & a healthy baby.  To promote, protect &maintain the health of mother during pregnancy.  To foresee complications & prevent them.  To reduce maternal & infant mortality rate.  To teach the mother elements of child care, nutrition, personal hygiene, environmental sanitation & family planning. These can be achieved through a well planned package of antenatal services provided at different health facilities. The desired outcome is having a healthy child out of a healthy mother.
  • 7. AIMS & OBJECTIVES To assess sociodemographic profile of post- natal mother admitted in CNMCH. To find out antenatal care services utilized by them. To determine the outcome of pregnancy. To assess the association of sociodemographic profile & antenatal care utilization with the outcome of pregnancy, if any. Keeping this in mind, a study was conducted among the mothers admitted in post-natal ward of Calcutta National Medical College & Hospital with the following aims and objectives:-
  • 8. Type of Study – Observational, Descriptive, Hospital Based Study Study Design – Cross-sectional .  Place of study – Post-natal ward of Calcutta National Medical College & Hospital, Kolkata.  Study Population – Mothers admitted in postnatal ward of Calcutta National Medical College & Hospital.
  • 9.  Study Duration – 23rd May 2013 to 19th June2013 → 28 Days  1st week- •Topic Selection •Discussion •Schedule preparation 2nd week- •Data Collection 3rd week- •Data Entry •Data Analysis 4th week- •Report writing •Presentation
  • 10. Sampling Technique – Complete enumeration was done. All the mothers admitted in the postnatal ward during the period of data collection was included in the study.  Exclusion criteria – Those mothers who didn’t give consent to participate. Those mothers who were severely ill.  Sample Size – thus the total sample size was160. Study Technique - Interview method – of the patients. Record review method.
  • 11.  Study Tools –  A pretested, predesigned, semi-structured schedule. Antenatal Card  Bed Head Tickets with special investigation reports  Prescription (if available.)
  • 12. Variables included in the study - Age . Religion. Residence. Education of patients & their husbands. Occupation of patients and their husbands. Socio-economic status. Type of family. Parity Number of living children. Number of ANC visits. Time of registration for ANC. Investigations done. Prophylaxis given. Advices given. Practices during pregnancy. Outcome of pregnancy.
  • 13. ♦ Study Procedure ♦ The topic was chosen & Discussed. Schedule was prepared with the help of teachers. Pretesting of the schedule was done on 10 subjects & necessary corrections done. After taking informed consent from the patients study was conducted by interviewing the mothers admitted in the postnatal ward. Additional information were noted after consulting the necessary records. The data thus collected, were compiled & analysed using MS Excel & Word. Report was prepared & presented.
  • 14. Table 1 : Distribution of study population according to age (n= 160) Age (yrs) Number percentage <20 27 16.87 20-25 93 58.13 26-30 32 20.00 >30 8 5.00 Total 160 100  COMMENT : Majority of the study population were within the age group of 20 to 25 years.  COMMENT : Majority of the study population were within the age group of 20 to 25 years.
  • 15. Table no 2 : Distribution of study of population according to religion (n= 160) Religion Number Percentage Hindu 80 50.00 Muslim 76 47.50 Christian 4 2.50 Total 160 100  COMMENT : Most of the study population (50%) are Hindus.
  • 16. Table no. 3 : Distribution of study population according to residence (n=160) Residence Number Percentage Rural 100 62.50 Urban 60 37.50 Total 160 100  COMMENT : 62.5% belong to the rural area. COMMENT : 62.5% belong to the rural area.
  • 17. Table no 4: Distribution of study population according to education (n=160 ) Education Wife Husband Illiterate 16 (10.00%) 16 (10.00%) Just literate 16 (10.00%) 15 (9.37%) Primary 42 (26.25%) 36 (22.50%) Mid School 43 (26.87%) 37 (23.12%) Secondary 32 (20.00%) 27 (16.88%) Higher secondary 7 (4.38%) 20 (12.50%) Graduate & Above 4 (2.50%) 9 (5.63%) Total 160 (100%) 160 (100%)  COMMENT : Most of the study population (53.12%) & their husbands (45.62%) were educated up to Mid school & primary level.
  • 18. TableNo 5 : Distribution Of Study Population According To Patients Occupation (n = 160) OCCUPATION NO % SERVICE 1 0.63 SKILLED WORKER 3 1.80 UNSKILLED WORKER 6 3.75 HOME MAKER 150 93.75 TOTAL 160 100 COMMENTS – Majority arehomemaker
  • 19. OCCUPATION NO % SERVICE 6 3.75 SMALL BUSINESS 33 20.62 SKILLED WORKER 48 30.00 UNSKILLED WORKER 72 45.00 UNEMPLOYED 1 0.63 TOTAL 160 100 COMMENTS- Majority areunskilled worker
  • 20. SOCIOECONOMIC STATUS NO % UPPER MIDDLE 10 6.25 LOWER MIDDLE 39 24.38 POOR 84 52.50 VERY POOR 27 16.88 TOTAL 160 100  COMMENTS – Majority of the study population (52.5%)are poor, whereas people from high & upper high class were not found during the study.
  • 21. TYPE OF FAMILY Number % JOINT 85 53.13 NUCLEAR 75 46.88 TOTAL 160 100  COMMENTS – Majority are from joint families..
  • 22. TABLE 9 : Distribution Of Study Population According To spacing from last child birth (n = 54) SPACING (in years) No. % < 3 48 88.89 ≥3 6 11.11 TOTAL 54 100  COMMENT : Majority ( 88.89%) of the study population was pregnant within 3 years of last child birth. (106 patients were primi para & 3 of them have no living issues)
  • 23. TABLE no. 10 : Distribution Of Study Population According to Parity. (n = 160) Parity Number % 1 109 68.12 2 44 27.50 ≥3 7 4.38 TOTAL 160 100  COMMENT : Majority (68.12%) of the study population are primi Para.
  • 24. Table 11: Distribution of study population according to time of registration (n= 160) Time of registration Number Percentage ≤ 12 Weeks 128 80.00 > 12 Weeks 32 20.00 TOTAL 160 100  COMMENT : Majority (80%) of the study population have registered within 12 weeks.
  • 25. Table 12: Distribution of study population according to place of visit. (n= 160) Place of visit Number Percentage Government Sub-Centre 17 10.63 Primary Health Centre 39 24.38 Govt. Hospitals 95 59.38 Private 14 8.75 COMMENT : Most of the study population visited Govt. institution for their antenatal care.
  • 26. Antenatal Care Utilization Number Percentage I. No. of antenatal visit 1 3 1.88 2 11 6.87 3 30 18.74 4 37 23.13 >4 79 49.38 II. No. of time BP measured 0 3 1.88 1 8 5.00 2 14 8.75 3 38 23.75 ≥4 97 60.62 III. No. of time weight measured 0 4 2.50 1 6 3.75 2 19 11.87 3 28 17.50 ≥ 4 103 64.38
  • 27.  COMMENT : Majority (72.51%) of study population took 4 or more antenatal visits. Weight & blood pressure was measured 4 times or more in 64.38% and 60.25% of the study population respectively.
  • 28. Table 14: Distribution of study population according to different blood investigations done (n=160) Investigations Done Results Frequency Percentage Hb% 137 85.63 VDRL 92 57.50 HIV 88 55.00 HbsAg 79 49.37 ABO group 131 81.87 Rh typing 131 81.88 Sugar 86 53.75 Comment : Majority of study population has done investigation of Hb%, ABO grouping, Rh typing ; whereas in around 50% cases VDRL, HIV, Sugar testing are done .
  • 29. Table 15 : Distribution of study population according to different other investigations done . (n=160) Investigations done Results Urine RE C&S Frequency Percentage 27 16.86 4 2.50 Stool 5 3.12 USG 149 93.12 Comment : In majority of cases USG is done, while frequency of doing other investigations are low .
  • 30. Table 16: Distribution of study population according to iron & folic acid tablet intake (n=160) No. Of Tablets taken Frequency Percentage < 100 72 45.00 100 – 200 70 43.75 > 200 2 1.25 Nil 16 10.00 Total 160 100 Comment : 43.75% subjects have taken 100-200 tablets, while 10% subjects did not take anything .
  • 31. Table 17: Distribution of study population according to their history of tetanus toxoid (n=160 ) Tetanus Toxoid Frequency Percentage Only TT1 2 1.25 TT1 & TT2 154 96.25 Booster 2 1.25 Nil 2 1.25 Total 160 100 Comment : Majority of study population has received both TT1 and TT2 , whereas 1.25% cases does not receive any dose of toxoid .
  • 32. TABLE 18: Distribution of study population on the basis of the advices given (n=160) ADVICES GIVEN FREQUENCY PERCENTAGE REST 145 90.63 DIET 150 93.75 PLACE OF DELIVERY 123 76.88 BREAST FEEDING 143 89.38 CONTRACEPTION 47 29.38 PERSONAL HYGINE 139 86.88 ADDICTION 101 63.13 DRUG ADVICE 109 68.13 COUNTING FOETAL MOVEMENTS 124 77.50
  • 33. Most of the mothers were given advices on rest, diet, breast feeding & place of delivery. Only 30% of the study population was given advice regarding contraception.  COMMENT –
  • 34. ADVICES GIVEN ( DANGER SIGNS) FREQUENCY PERCENTAGE GEN. SWELLING 99 61.88 BLEEDING P.V. 88 55.00 HEADACHE 93 58.13 BLURRING OF VISION 75 46.88 PAIN ABDOMEN 98 61.25 CONVULSION 88 55.00 WATERY DISCHARGE P.V. 80 50.00 PALPITATION 86 53.75 BREATHLESSNESS 102 63.75 REDUCED FOETAL MOVEMENT 70 43.75 TABLE 19: Distribution of study population on the basis of the advices regarding Danger Signs. (n=160)
  • 35.  COMMENT –  Around 60% of the study population were given advices on BREATHLESSNESS , Gen. Swelling and PAIN ABDOMEN.  Rest of the danger signs were informed to about 50% of the study population.
  • 36. Table 20 : Distribution of study population according to dietary practice during pregnancy (n=160) Dietary practice Number Percentage Increased 74 46.25 Same 53 33.12 Reduced 33 20.63 Total 160 100 Comment : Majority of the population have increased diet during their pregnancy period.
  • 37. Table no. 21: Distribution of study population according to activity during pregnancy (n=160) Strenuous activity Number Percentage Yes 31 19.38 No 129 80.62 Total 160 100  Comment : Majority of the population (80.625%) did not perform any strenuous activity during pregnancy .
  • 38. Table no. 22 : Distribution of study population according to addiction during pregnancy (n= 160 ) Addiction Number Percentage Yes 5 3.12 No 155 96.88 Total 160 100  Comment : Majority of the population (96.875%) didn’t have any addiction history during pregnancy . (The main addiction was tobacco chewing.)
  • 39. Table no. 23 : Distribution of study population according to outcome of pregnancy (n= 160 ) Outcome Number % Live birth NBW 104 65.00 LBW 51 31.88 Premature 1 0.62 Still birth 1 0.62 Neonatal Death 1 0.62 Abortion 2 1.26 Total 160 100
  • 40. Education Live birth Still birth [No.(%)] Abortion [No.(%)] Neonatal death [No.(%)] Total [No.(%)] Normal birth weight [No.(%)] Low Birth Weight [No.(%)] Illiterate 6 (37.50) 10(62.5) 16 (100) Just literate 10(66.67) 5(33.33) 15 (100) Primary 14(33.33) 24(57.14) 1(2.30) 2(4.70) 1(2.30) 42 (100) Mid school 18(45.00) 22(55.00) 40 (100) Secondary 15(46.88) 16(50.00) 1(3.12) 32 (100) H.S & Above 8(53.32) 7(46.67) 15 (100) Table No 24 : Distribution Of Study Population According To Educational Status And Outcome Of Pregnancy (n =160)  COMMENT – Occurrence of low birth weight is much higher among the illiterate population.
  • 41. SOSCIOECONOMIC STATUS LIVE BIRTH STILL BORN [No.(%)] ABORTION [No.(%)] NEONATAL DEATH [No.(%)] TOTAL [No.(%)] Normal birth weight [No.(%)] Low Birth Weight [No.(%)] UPPER MIDDLE 10(100) - - - - 10(100) LOWER MIDDLE 32(82.05) 7(17.95) - - - 39(100) POOR 45(53.57) 37(44.05) 1(1.19) 1(1.19) - 84(100) VERY POOR 19(70.37) 6(22.22) - 1(3.70) 1(3.70) 27(100) COMMENTS– Adverseoutcomesof pregnancy (Low Birth weight, Abortion, Still Birth, Neonatal death) weremorecommon in poor & very poor families.
  • 42. SPACING LIVE BIRTH STILL BIRTH ABORTION NEONATAL DEATH TOTAL Normal birth weight [No.(%)] Low Birth Weight [No.(%)] <3 33(68.75%) 14(29.17) 0 0 1(2.08%) 48(100%) ≥3 5(83.33%) 1(16.67) 0 0 0 6(100%) TABLE 26: Distribution Of Study Population according to spacing from last child birth and pregnancy outcome (n =54)  COMMENT : Proportion of normal birth weight babies was more in cases where spacing from the last child birth was more than 3 years.
  • 43. PARITY LIVE BIRTH STILL BIRTH ABORTION NEONATAL DEATH TOTAL Normal birth weight [No.(%)] Low Birth Weight [No.(%)] 1 92(84.42%) 15(13.76%) 1(0.91) 1(0.91) 0 109(100%) 2 16(36.36%) 27(61.37%) 0 0 1(2.27) 44 ≥3 4(57.14%) 3(42.86%) 0 0 0 7 TOTAL 121 45 1 1 1 160 TABLE 27 : Distribution of study population according to parity & pregnancy outcome (n = 160)  COMMENT : Majority of the study population have normal birth weight baby.
  • 44. Prophylaxis taken Outcome of pregnancy Live birth Still birth Abortion Neonatal death Total Normal Birth weight Low birth weight Iron and folic acid tablets <100 19(46.66%) 24(50.00%) 0 2 1(3.33%) 30(100%) ≥100 46(40%) 68(59.13%) 1(0.86%) 0 0 115(100%) Tetanus Nil 0 1(50%) 0 1(50%) 0 2(100%) Only TT1 70(44.02%) 86(54.08%) 1(0.62%) 1(0.62%) 1(0.62%) 159(100%) TT2/Booster 67(43.79%) 85(54.90%) 2(0.65%) 0 1(0.65%) 153(100%)
  • 45.  COMMENT : Most of the study population who have taken <100 IFA tablets gave birth low birth weight baby, 1 having neonatal death.
  • 46. Table 29: Distribution of study population according to ANC utilization and outcome of pregnancy (n=160) ANC Utilization Outcome Of Pregnancy Live Birth Still Birth Abortion Neonatal Death Total Normal Birth weight Low Birth weight No. of visit <4 24(51.07%) 20 (42.55%) 0 2(4.26%) 1(2.12%) 47(100%) ≥4 46(40.35%) 67(58.77%) 1(0.88%) 0 0 114(100%) Time of Registration In weeks ≤12 27(39.13%) 40(57.97%) 0 2(2.89%) 0 69(43.13%) >12 38(41.37%) 52(57.47%) 1 0 1(1.14%) 87(54.37%)
  • 47.  COMMENT :
  • 48. PRACTICES DURING PREGNANCY LIVE BIRTH STILL BORN NO(%) ABORTION N0(%) NEONATA L DEATH NO(%) TOTAL NO(%) Normal birth weight [No.(%)] Low Birth Weight [No.(%)] 1.DIET DURING PREGNANCY:- a. Increased 27(50.94) 22(41.50) 1(1.80) 2(3.77) 1(1.80) 53(100) b. Same 59(79.72) 15(20.27) - - - 74(100) c. Decreased 19(57.57) 14(42.42) - - - 33(100) 2.ANY STRENUUS ACTIVITY DURING PREGNANCY:- a. Yes* 24(80.00) 4(13.33) 1(3.33) 1(3.33) 30(100) b. No* 82(63.07) 46(35.38) - 2(1.54) - 130(100) Table no. 30 : Distribution Of Study Population According To Practices During Pregnancy And Outcome Of Pregnancy. (n=160) CONTINUED……..
  • 49. PRACTICES DURING PREGNANCY LIVE BIRTH STILL BORN NO(%) ABORTIO N [No(%)] NEONATAL DEATH NO(%) TOTAL NO(%)Normal birth weight [No.(%)] Low Birth Weight [No.(%)] 3.ADDICTION:- a. Yes 5(100) - - - - 5(100) b. No 101(65.16) 50(32.26) 1 (0.65) 2 (1.29) 1 (0.65) 155(100)
  • 50.  COMMENT- 51% of mothers who have taken increased diet during pregnancy gave birth to normal birth weight babies. 63% of mothers who have not done any strenuous activity during pregnancy conceivenormal birth weight baby. 65% mothers who have no addiction gave birth to normal birth weight babies  COMMENT- 51% of mothers who have taken increased diet during pregnancy gave birth to normal birth weight babies. 63% of mothers who have not done any strenuous activity during pregnancy conceivenormal birth weight baby. 65% mothers who have no addiction gave birth to normal birth weight babies
  • 51.  Under the guidance of community medicine dept. and gynecology dept. A descriptive, observational, Cross Sectional study with the title of “THE UTILIZATION OF ANTE NATAL CARE AND OUTCOME OF PREGNANCY” was undertaken on the mothers admitted in the postnatal ward of CNMC&H from 28th May to 19th June, in 2013.  The objectives of the study are :  To assess sociodemographic profile of post- natal mother admitted in CNMCH.  To find out antenatal care services utilized by them.  To determine the outcome of pregnancy.  To assess the association of sociodemographic profile & antenatal care utilization with the outcome of pregnancy, if any. The data were collected interviewing all the mothers after taking their informed consent and also by reviewing records.  Findings of the study are as follows :  . Majority of the study population were within the age group of 20 to 25 years
  • 52.  Majority of study population (50%) were Hindus & belong to rural area(62.5%)  Most of the study population (53.12%) & their husbands(45.62%) were educated up to Mid school & primary level.  Majority of them were home makers &their husbands were unskilled workers.  Majority were from joint families with poor socioeconomic status  Majority (68.25%) of the study population are primi Para :  88.89% of the multipara mothers were pregnant within 3 years of last child birth.  Majority (75%) have registered within 12 weeks & 94 % visited Govt. institution for their antenatal care.
  • 53.  Majority of study population took 4 or more antenatal visits. Weight & blood pressure was measured 4 times or more in 64.38% and 60.25% of the study population respectively:  42.55 % of study population who had visited <4 times to antenatal care unit had low birth weight babies .  57.6% of study population who had registered after 12 weeks had low birth weight babies  Most of study population had done investigation of Hb%, ABO grouping, Rh typing ; whereas in around 50% cases VDRL, HIV, Sugar testing are done . : In majority of cases USG is done :  45% subjects had taken ≥100 IFA tablets, while 10% subjects did not take any tablet Majority of study population has received both TT1 and TT2 or TT booster.  Most of the mothers were given advices on rest, diet, breast feeding & place of delivery.
  • 54.  Only 30% of the study population was given advice regarding contraception & around 50-60% of the study population were given advices on different danger signs  Majority(65%) of the study population have normal birth weight baby & 32% had low birth weight babies .  Regarding practice , majority of the population have increased diet & did not perform any strenuous activity during their pregnancy period  Adverse outcomes of pregnancy (Low Birth weight, Abortion, Still Birth, Neonatal death) were more common in poor & very poor families and among illiterates and mothers with spacing <3 years from last child  51% of mothers who have taken increased diet & 63% of mothers who have not done any strenuous activity during pregnancy gave birth to babies having normal birth weight .
  • 55. Analyzing the data collected during d study it is observed that outcome of pregnancy is indeed related to ANC taken by the mother during pregnancy. Form the study, it is concluded that – 1. Receiving & utilizing Antenatal Care plays a major role in outcome of pregnancy. In the cases where Antenatal Care utilization is not up to the mark (i.e. delayed registration, <4 ANC visits, <100 IFAs intake), which is seen in considerable no. of mothers, the outcome of pregnancy have shown adverse results. 2. Mothers who had good practice during pregnancy have shown better outcome. 3. SES also play an important role in the study as it is observed that adverse outcomes of pregnancy were more common in poor and very poor family & among illiterates.
  • 56. Hence, form the study it is observed that SES of the parents, their general awareness about the maternal health & ANC utilization – all contribute to the outcome of pregnancy. So, to improve the total picture, these areas should be looked upon to be improved.
  • 57. RECOMMENDATION 1)Outcome of pregnancy can be improved by improving educational status of the mothers. 2)To educate the community by the village level workers like ASHA, AWW regarding early registration of pregnancy, adequate number of ANC visits. 3)Counseling of mothers in each antenatal visit regarding rest, diet, danger signs, institutional delivery, taking iron and FA, TT by the Antenatal Care providers. 4)Counseling on contraception should be done for proper birth spacing. 5)Improvement of the facility for investigations like VDRL, Hep.B, HIV testing etc. by proper implementation of RCH II Programme. 6)There should be a gap of at least 3 years between 2 children.
  • 58. We heartily thank all the patients of the post natal ward for their fine co- operation for providing us all the necessary information for smooth conduction of our project. We acknowledge our respected HOD of community Medicine, Prof. (Dr.) Salil Kumar Bhattacharcharya and all the teachers of the department. We thank our guides Dr. Sharmila Mallik, Dr. Soma Chakrabarti and Dr. Manufa Bilkis for their huge help in completing this project. And finally we would like to acknowledge our Principal Prof. Dr. Samir Chandra Ghosh Roy. We extend our acknowledgement to HOD of GYNAECOLOGY & OBSTRETICS, Prof. (Dr.) Arati Biswas and other teachers of the department for their help in conducting the project.
  • 59. REFERENCES 1. Dr. Manjula G. Kadapatti, Dr. A.H.M. Vijayalaxmi, Antenatal Care the Essence of New Born Weight and Infant Development, International Journal of Scientific and Research Publications, Volume 2, Issue 10, October 2012 1 ISSN 2250-3153. 2. C.S.Metgud*,S.M.Katti, M.D.Mallapur and A.S.Wantamutte, Utilization Patterns of Antenatal Services Among Pregnant Women: A Longitudinal Study in Rural Area of North Karnataka, Al Ameen J Med Sci (2009)2 (1 ) : 58 – 62. 3. Nomita Chandhiok, Balwan S Dhillon, Indra Kambo, Nirakar C Saxena, Determinants of antenatal care utilization in rural areas of India : A cross-sectional study from 28 districts (An ICMR task force study), J Obstet Gynecol India Vol. 56, No. 1 : January/February 2006 Pg 47-52 4. K. Park, Textbook of Preventive and Social Medicine, 22e (2013)