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  • Shreyas Patil, Vidhi Wadhwani, Shreyas Patil, Preeyati Chopra, Pratik Gavhane

Antenatal Care in India - Care that Nurtures: Part 2 of An ASAR Data Story

Updated: Jun 14

By ASAR Blog Team


Ideation & Drafting 

Vidhi Wadhwani, Preeyati Chopra, Shreyas Patil, Pratik Gavhane


 Calculations & Visualisations

Vidhi Wadhwani, Shreyas Patil


Data Extraction 

Shreyas Patil, Preeyati Chopra, Vidhi Wadhwani


Review & Editing 

Parth Sharma

Introduction 


Pregnancy necessitates careful attention to nutrient intake, especially micronutrients such as iron, folate (vitamin B9), and calcium. This is imperative not only to meet the heightened needs of the mother but also to support the optimal development of the growing fetus. Inadequate consumption of these nutrients in pregnancy heightens the risk of neural tube defects in the baby, like in folate deficiency. Insufficient iron levels can lead to anaemia, resulting in various complications, ranging from early fatigue and breathlessness to perinatal infection and pre-eclampsia in mothers. Hence, these nutritional interventions are key in reducing maternal and neonatal morbidity and mortality.


Besides poor nutrition, tetanus is a potentially fatal bacterial infection that can lead to maternal morbidity and mortality in the newborn. Administering tetanus immunisation during pregnancy provides a straightforward and effective means of safeguarding both the mother and the child against this fatal disease. India has eliminated maternal and neonatal tetanus, which is described as a significant milestone in public health. To sustain this success, meticulous monitoring of interstate and inter-district coverage nationwide. Allocating resources to high-priority areas is the imperative step in maintaining the health status of this preventable health threat. 


In this data story, we utilize the Health Management Information System (HMIS) 2019-20 focussing on the coverage of Iron and Folic Acid (IFA), Calcium supplementation, and tetanus toxoid immunization among pregnant women


1. How did the percentage of pregnant women (PW) who received 180 iron and folic acid (IFA) tablets vary across the districts of India in 2019-20? 


According to the HMIS data of 2019-20, the percentage of pregnant women who received 180 iron and folic acid (IFA) tablets varied from 6.5% in the Srinagar district of Jammu & Kashmir to 100% in four districts of Andhra Pradesh– Kurnool, Prakasam, Cuddapah, and Srikakulam; two districts of Maharashtra– Kolhapur and Aurangabad and one each in Chhattisgarh (Narayanpur) and Tamil Nadu (Perambalur).






Only 39.09% of the districts reported that over 90 of every 100 pregnant women received 180 IFA tablets during pregnancy. One in ten districts reported that less than 50 out of every 100 pregnant women received 180 IFA tablets, further highlighting poor coverage of services. Among these districts with poor coverage, 60% belonged to the country's North Eastern region. Data related to 113 districts were excluded as they exceeded 100% raising concerns about the reliability of the HMIS data.


On a closer look, Manipur, Meghalaya, and Nagaland fared poorly. However, a disparity in coverage of services was noticed between HMIS and NFHS. For example in Manipur, HMIS reported that less than 50 every 100 pregnant women received 180 IFA tablets in 66.67% of districts. However, NFHS reported this to be in all the districts. A similar disparity in the coverage of services was noticed in districts in Meghalaya (HMIS - 54.5%  vs NFHS-5 - 100%), and Nagaland  (HMIS - 72.72% vs NFHS-5 - 100%). In addition, disparities in each district-level value were observed for all these states between the HMIS and the NFHS-5 for this parameter.


2. Which districts showcased the highest rise and decline from their respective 2018-19 percentage values for providing iron and folic acid (IFA) tablets?


Figure 2 depicts the regions with the highest increase in consumption of IFA tabs in 2019-20 as compared to 2018-19. Kra Daadi district of Arunachal Pradesh showed the highest rise in the percentage of IFA consumption, with an increase of 79 percentage points. Figure 3 depicts the regions with the highest decline in consumption of IFA tabs in 2019-20 compared to 2018-19. Kolkata in West Bengal showed the highest decline, with a decrease of 65.3 percentage points.









3. How did the percentage of pregnant women who received the Calcium tablets vary across the districts of India in 2019-20?


According to HMIS 2019 data, the percentage of pregnant women receiving calcium tablets varied from 0.2% in Thiruvarur, Tamil Nadu to 100% coverage in Aurangabad, Maharashtra, and Perambalur, Tamil Nadu. (Figure 4


Only 19.5% of districts reported that more than 90 of every 100 pregnant women received calcium tablets during pregnancy. Poor coverage was noted in almost 25% of districts, as less than 50 out of every 100 pregnant women received calcium supplementation. On a closer look, a pattern of low performance was observed in 30% of states from the North Eastern Region.


In the North Eastern region, especially, for every 100 pregnant women in Nagaland, less than 50 received calcium supplementation in all eleven of its districts, according to HMIS data, and none according to the NFHS data. In addition, disparities in individual district-level values were observed for all these states between the HMIS and the NFHS-5 for this parameter as well. 






4. Which districts showcased the highest rise and decline from their respective 2018-19 percentage values for calcium supplementation?


Figure 5 displays the top ten districts with the highest rise in the percentage of women who received calcium supplementation in 2019-20 compared to 2018-19. Tiruvannamalai, Tamil Nadu showed the highest increase by 90.2 percentage points. Figure 6 displays the top ten districts with the highest decline in the percentage of women who received calcium supplementation in 2019-20 compared to 2018-19. Ganderbal, Jammu & Kashmir showed the highest decline by 60.7 percentage points. 








5. How did the percentage of pregnant women who received the second dose of tetanus (TT2) or tetanus-toxoid (TT) booster vary across the districts of India in 2019-20?


According to HMIS 2019-20 data, the percentage of pregnant women receiving second dose of tetanus (TT2) or tetanus-toxoid (TT) booster varied from 6.5% in Shimla, Himachal Pradesh to 100% in three districts of Maharashtra– Hingoli, Aurangabad and Kolhapur; three in Andhra Pradesh– Cuddapah, Nellore and East Godavari; and one district, Sundargarh in Odisha. (Figure 7


In 51.3% of districts, more than 90 of every 100 pregnant women received a second dose of tetanus or tetanus-toxoid (TT) booster during pregnancy. In contrast, 16.2% of districts reported less than 50 out of every 100 pregnant women receiving a second dose of tetanus or tetanus-toxoid (TT) booster. Among the districts reporting less than 1 in 4 women receiving tetanus vaccine coverage, 12.5% were from the North Eastern States and 9.4% belonged to regions of Delhi, with South East Delhi performing the poorest with only 13.3%. Similar data on coverage for the second dose of tetanus or tetanus toxoid from NFHS-5 was not available for comparison with HMIS data. 


We were unable to find a data validation rule for this variable, i.e. the percentage of pregnant women who received either the second dose of tetanus toxoid (TT-2) or the tetanus toxoid (TT) booster. So we hypothesised that even if all women received the second dose of tetanus, that number could still not surpass the ANC registrations. Hence, any values above 100 were omitted. We excluded 124 district values based on this rationale. This is also explained later under ‘HMIS Data Quality Concerns’. 






6. Which districts showcased the highest rise and decline from their respective 2018-19 percentage values for the second dose of tetanus (TT2) or tetanus-toxoid (TT) booster?


Figure 8 displays the top ten districts with the highest rise in the percentage of women who received a second dose of tetanus (TT2) or booster in 2019-20 compared to 2018-19. Dibang Valley of Arunachal Pradesh showed the highest increase in coverage with an increase of 39 percentage points. Figure 9 displays the top ten districts with the highest decline in the percentage of women who received the second dose of tetanus (TT2) or booster in 2019-20 compared to 2018-19. Shimla, Himachal Pradesh showed the highest decline of 82 percentage points.










HMIS Data Quality Concerns 


The exclusion of data was carried out per the validation rules of the HMIS. Data from 160 districts were omitted while assessing the coverage of IFA tablets, and 93 districts were excluded while assessing the coverage of calcium tablets due to these data points surpassing the 100% threshold.


In the case of the IFA tablets, we observed that Jangaon and Siddipet districts in Telangana reported percentage values of 611.1% and 506.1%, respectively, during the 2018-19 period. These values far exceeded the possible upper limit of 100%. Similar irregularities were identified for the calcium tablets, with Mancherial in Telangana reporting the highest percentage value (370.7%), followed by Lucknow, Uttar Pradesh (283.9%).


We were unable to find a data validation rule for our fifth variable, i.e. the percentage of pregnant women who received either the second dose of tetanus toxoid (TT-2) or the tetanus toxoid (TT) booster. So, to validate this data, we calculated the percentage of pregnant women receiving either TT-2 or TT booster divided by the total number of women registered for antenatal care. In any case, the number of pregnant women receiving the booster cannot exceed ANC registrations, hence this percentage should be less than or equal to 100. 


In a realistic setting, not all women may receive the first dose, let alone the second dose or booster (if immunised previously within 3 years). Even under ideal conditions, the percentage should not surpass 100%. During analysis, we noted that districts with percentage values exceeding 100% for this variable tended to exhibit similar patterns in the other variables discussed earlier, validating this hypothesis. Consequently, based on this rationale, we omitted data points for a total of 124 districts.


Conclusion


In conclusion, the analysis of HMIS 2019-20 data to assess the coverage of essential maternal health interventions across districts in India reveals significant discrepancies. Our findings highlight that coverage of relevant maternal health services in India still has significant scope for improvement, especially in the North Eastern and Northern states of the country.


Concerns about data reliability, as evidenced by discrepancies between HMIS and National Family Health Survey (NFHS) data, highlight the necessity for robust and accurate reporting mechanisms to inform effective policymaking. Ultimately, to improve maternal outcomes in India, there is a need for high-quality data to guide decision-making. It is also important to understand regional nuances in the best and worst-performing states to understand the barriers and facilitators to good coverage of maternal services in India.


Cite this article as:

Wadhwani V, Chopra P, Patil S, Gavhane P, Sharma P.

Antenatal Care in India - Care that Nurtures: Part 2 of An ASAR Data Story

2024 June 10; Available from:



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