By ASAR Blog Team
Ideation & Drafting
Shreyas Patil, Vidhi Wadhwani, Preeyati Chopra, Pratik Gavhane
Calculations & Visualisations
Shreyas Patil, Vidhi Wadhwani
Data Extraction
Preeyati Chopra, Vidhi Wadhwani, Shreyas Patil
Review & Editing
Parth Sharma
“Pregnancy should be a positive experience for all women and they should receive care that respects their dignity.”
- Dr Ian Askew
India reports roughly 48.5 million pregnancies resulting in nearly 25 million child births every year. The antenatal period, which spans from the time of conception to the birth of a baby is a crucial period in a woman’s life. Traditional beliefs and practices in India significantly influence maternal care during pregnancy. However, antenatal care (ANC) at healthcare institutions is pivotal to ensure a safe and positive pregnancy experience.
Antenatal care (ANC) aims to reduce maternal and neonatal morbidity and mortality through a variety of interventions. The World Health Organisation (WHO) recommends a minimum of four ANC checkups provided by a Doctor, an Auxiliary Nurse Midwife (ANM), or a Nurse. Ideally, a woman should have her first ANC checkup either when she first notices a missed period or during the first three months of pregnancy. ANC registration in India is done during the first visit of the expecting mother to a healthcare facility. Registration thus serves as an indicator of a pregnant woman’s first contact with the healthcare system. Early and regular ANC check ups have been shown to improve pregnancy outcomes and have thus attracted the attention of policymakers. Effective ANC thus is the backbone of optimal maternal and child health.
Maternal and child mortality rates occupy a prominent place in the Sustainable Development Goals for Health (SDG 3). The decline in Maternal Mortality Rate from 113 in 2016-18 to 97 in 2018-20, and Under-5 Mortality Rate from 45 in 2014 to 32 in 2020 shows that India is well placed to achieve the SDG target by 2030. However, national level figures do not accurately reflect the progress made at the state, and subsequently the district level.
In this ASAR data story, we look at Health Management Information System (HMIS) data on 704 Indian districts for the period of 2019-20, to highlight disparities in ANC services. As the National NFHS follows a more stringent methodology for collection of representative data, we compared information provided by HMIS to NFHS to ascertain the validity of HMIS data. In the first part of this data story, we look at the patterns of timely ANC registration and adequate ANC visits.
1. How did the percentage of early antenatal care (ANC) registration (registration in the first trimester) vary across the districts of India in 2019-20?
According to the HMIS data of 2019-20, the percentage of early ANC registrations ranged from 13.6% in Papum Pare, Arunachal Pradesh to 99.6% in Budgam, Jammu & Kashmir (Figure 1). It was seen that more than 90 out of every 100 ANC registrations were in the recommended time in only 123/704 (17.5%) districts. On the other end, in 70/704 (9.9%) districts, less than 50 out of 100 pregnancies were registered in the recommended time period. Among these 70 districts, 38 (54.3%) districts belong to the North East region of the country.
Upon a closer look, it was seen that certain northeastern states i.e. Arunachal Pradesh, Nagaland and Meghalaya fared poorly. For every 100 ANC registrations, more than 50 were registered in the first trimester in just 7/20 (35%) districts of Arunachal Pradesh. However, as per the National Family Health Survey 5 NFHS-5, 2019-21) early registration was reported in 13/20 (65%) districts of the state raising concerns regarding the reliability of HMIS report. Similarly, as per HMIS report in Nagaland no district had more than 50 early registrations for every 100 ANC registrations as compared to 5/11 (45.5%) districts according to the NFHS-5. The discordance was noted for Meghalaya as well.
Figure 1. https://www.datawrapper.de/_/HAtdL/
2. Which districts showcased the highest rise and decline from their respective 2018-19 percentage values for early ANC registrations?
Looking at regions with significant rises in the percentage of early ANC registration helps us identify successful strategies. On the other hand, regions with large declines serve as target areas for focused actions. This ensures more equitable healthcare and improves maternal and child health outcomes.
Figure 2. depicts the top ten districts with the highest rise in the share of early ANC registrations in 2019-20 compared to 2018-19. Pratapgarh and Unnao districts in Uttar Pradesh showcased the highest rise in the percentage of early ANC registrations, with increases of 43.1 and 29.7 percentage points respectively.
Figure 2. https://www.datawrapper.de/_/XITq3/
The top ten districts with the highest decline in the share of early ANC registrations in 2019-20 compared to 2018-19 are seen in Figure 3. Meerut in Uttar Pradesh had the highest decline of 19.5 percentage points, followed by Jogulamba Gadwal in Telangana with a decline of 18.3 percentage points.
Figure 3. https://www.datawrapper.de/_/9sDO4/
3. How did the percentage of pregnant women who received four or more antenatal care (ANC) checkups vary across the districts of India in 2019-20?
The percentage of pregnant women who received four or more ANC check ups varied from 4.9% in Tuensang, Nagaland to 100%, seen in three districts; (1) Aurangabad, Maharashtra, (2) Kolhapur, Maharashtra and (3) Saharanpur, Uttar Pradesh (Figure 4). 65/646 (10%) districts reported that less than 50 out of 100 pregnant women had received four or more ANC check ups. Of these 65 districts, 43 (66.1%) belong to the North East region of the country. On the other end, at least 90 out of every 100 pregnant women received four or more ANC check ups in 150/646 (23.2%) districts.
On a closer look, a pattern of low performance was observed in Arunachal Pradesh, Manipur, Mizoram, and Nagaland. For every 100 pregnant women in Arunachal Pradesh, less than 50 received four or more ANC check ups in 16/20 (80%) districts as per the HMIS, and in all 20 (100%) districts as per the NFHS-5. In Manipur, less than 50 out of 100 pregnant women received four or more check ups across all districts according to the HMIS while the NFHS-5 data shows a better picture with just one district showcasing this level of performance. A similar situation was observed in 6/8 (75%) districts of Mizoram as per the HMIS, and in 4/8 (50%) districts as per the NFHS-5. Less than 50 out of 100 pregnant women had received the recommended amount of ANC check ups in Nagaland for all 11 (100%) districts as per the HMIS but the NFHS-5 data shows that this was seen in 6/11 (54.5%) districts. In addition, disparities in individual district level values were observed for all these states between the HMIS and the NFHS-5 for this parameter. Percentage data for 58 districts were excluded in this analysis as they exceeded 100% in HMIS again raising concerns regarding the reliability of the data.
Figure 4. https://www.datawrapper.de/_/6xyHJ/
4. Which districts showcased the highest rise and decline from their respective 2018-19 percentage values for pregnant women who received four or more antenatal (ANC) check ups?
Figure 5 displays the top ten districts with the highest rise in the percentage of women who received 4 or more ANC check ups in 2019-20 compared to 2018-19. Jehanabad in Bihar showcased the highest rise of 52.2 percentage points, followed by Nainital in Uttarakhand with 46.8 percentage points.
Figure 5. https://www.datawrapper.de/_/d5OBW/
The top ten districts with the highest decline in percentage values of 2019-20 compared to 2018-19 are seen in Figure 6 Wanaparthy and Vikarabad in Telangana displayed the highest declines of 64 and 42.3 percentage points respectively. Percentage data of 87 districts were omitted during this analysis as one or both percentage points exceeded 100%
Figure 6. https://www.datawrapper.de/_/jupbp/
Accuracy of data in the HMIS
The HMIS has multiple mechanisms to ensure that the data entered into it are accurate. One of these mechanisms is the compare option, which allows the user to compare the current data with the data of the previous month, to detect any significant deviations or errors. Apart from this, the HMIS contains data validation checks based on inbuilt data validation rules.
As per these rules the number of pregnant women with early ANC registration (within 12 weeks) should be less than or equal to the number of pregnant women with ANC registration. It was seen that none of the data points violated this rule and all values were retained. Another rule states that the number of pregnant women with four or more antenatal checkups should be less than or equal to the number of pregnant women with ANC registration. Based on this rule, we had to drop data related to four or more antenatal check ups for 87 districts.. Two districts in Telangana, Siddipet and Mancherial reported percentage values as high as 276.5% and 254.5% respectively.
Conclusion
High quality of data in the HMIS is crucial as they serve as the basis for monitoring and evaluation of health programmes. The presence of data points that violate validation rules is therefore concerning. In addition, disparities were noted between the data in the HMIS and the NFHS-5, a nationally representative survey. These must also be looked at in order to improve data quality.
Analysis of the HMIS data reveals that coverage of antenatal registrations and antenatal visits across India’s districts is not uniform. Promisingly, at least half of the registrations were early and at least half of the pregnant women received four or more ANC check ups in most districts. However, pockets of poor performance exist, notably concentrated in the North East region of the country. Specific and targeted measures to bridge these gaps are necessary if India is to achieve the SDGs on maternal and child mortality by 2030.
Cite this article as:
Patil S, Wadhwani V, Chopra P, Gavhane P, Sharma P. 2023 Dec 5; Available from: