FIELD OF THE INVENTION
[001] The present invention relates to the field of medical science, and more particularly, the present invention relates to a community-based study on barriers to the utilization of antenatal care services by currently married women in rural areas.

BACKGROUND FOR THE INVENTION:
[002] The following discussion of the background to the invention is intended to facilitate an understanding of the present invention. However, it should be appreciated that the discussion is not an acknowledgment or admission that any of the material referred to is published, known, or part of the common general knowledge in any jurisdiction as of the priority date of the application. The details provided herein the background if belongs to any publication is taken only as a reference for describing the problems, in general terminologies or principles or both of science and technology in the associated prior art.
[003] In 2015, approximately 303 000 women died all over the world during and following pregnancy and childbirth. Almost all of these deaths occurred in low to middle-income countries and most of these deaths could have been averted as the necessary medical interventions exist and are well known. Over the past few decades, though India has made significant progress in maternal health, this decline has decelerated and the country continues to contribute almost one-quarter of maternal deaths globally. It is a well-known fact that most of matern the al deaths are avertible, as access to good antenatal care (ANC) in pregnancy, skilled care during delivery, and care and support in the postpartum period can avert many complications.
[004] As a child’s health is very closely linked to its mother’s, right from conception through to birth, an effective care during the antenatal period decreases the chance of a negative outcome of the pregnancy. The World Health Organization (WHO) recommends at least four ANC visits during pregnancy to check for the wellbeing of the mother and fetus, providing counselling to mothers about the care they should take during pregnancy and also in preparation for childbirth. Itensures birth preparedness and complication readiness as well as provides other essential services which ensure the wellbeing of mother and baby. However, utilization of these services is not universal, even in settings where they are widely available. Data show that the utilization of ANC services in India has increased substantially over time, 66% to 77% from National Family Health Survey-2 (NFHS-2) to NFHS-3.
[005] According to NFHS-4, 34.9 % of pregnant women received at least 4 ANC visits in the state of Uttarakhand. As antenatal care is crucial for the health of both the mother and the new born, it is important to analyses the possible factors acting as a barrier to its utilization, if any. Therefore, this paper aims to identify factors associated with the utilization of ANC services as well as possible barriers to it. This is a smaller part of the project supported by the department of Health Research, Government of India.
[006] In light of the foregoing, there is a need for acommunity-based study on barriers to the utilization of antenatal care services by currently married womenthat overcomes problems prevalent in the prior art.

OBJECTS OF THE INVENTION:
[007] Some of the objects of the present disclosure, which at least one embodiment herein satisfies, are as follows.
[008] The principal object of the present invention is to overcome the disadvantages of the prior art by providing acommunity-based study on barriers to the utilization of antenatal care services by currently married women.
[009] An object of the present invention is to provide acommunity-based study on barriers to the utilization of antenatal care services by currently married women that help in knowing the extent of antenatal care serviceutilization by the currently married women of ruralUttarakhand during their last pregnancy.
[010] Another object of the present invention is to provide acommunity-based study on barriers to the utilization of antenatal care services by currently married womenthat find the barriers for utilization of ANC services.
[011] Yet another object of the present invention is to provide acommunity-based study on barriers to the utilization of antenatal care services by currently married womenthat correlate the socio-demographic variables with thenon-utilization of ANC services.
[012] Other objects and advantages of the present disclosure will be more apparent from the following description, which is not intended to limit the scope of the present disclosure.

SUMMARY OF THE INVENTION:
[013] The present invention provides a community-based study on barriers to the utilization of antenatal care services by currently married women.
[014] In another aspect of the present invention, the community-based study is conducted in rural areas of 3 randomly selected districts in Uttarakhand.
[015] In another aspect of the present invention, multistage stratified and simple random samplings are used for area selection and the PPS technique is used to recruit the participants. Overall, 637 currently married women (CMW) who delivered in the last 5 years prior to the survey, are interviewed by trained social workers.
[016] In another aspect of the present invention, the Chi-square test is used to ascertain the association between variables, and regression analysis is done to adjust for confounding associations. Overall, 496 (77.9%) women availed one or more ANC services during their last pregnancy, but the complete package is availed by only 210 (33%) of the CMW.
[017] In another aspect of the present invention, the majority of the women who did not avail of any ANC services are older, illiterate, laborers, spouses of laborers/ unemployed persons, and belonged to lower socio-economic status.
[018] In another aspect of the present invention, unawareness is the most commonly cited reason for not availing of ANC services followed by financial issues and unfelt need.
[019] In another aspect of the present invention, the women in Uttarakhand are pliant to ANC services, but there is a need to create demand for it by increasing awareness and improving the quality of ANC services.

BRIEF DESCRIPTION OF DRAWINGS:
[020] Reference will be made to embodiments of the invention, examples of which may be illustrated in accompanying figures. These figures are intended to be illustrative, not limiting. Although the invention is generally described in the context of these embodiments, it should be understood that it is not intended to limit the scope of the invention to these particular embodiments.
[021] Figure 1 shows a respondent by ANC visits during the last pregnancy.
[022] Figure 2 shows nonusers by reasons for not availing antenatal care.

DETAILED DESCRIPTION OF DRAWINGS:
[023] While the present invention is described herein by way of example using embodiments and illustrative drawings, those skilled in the art will recognize that the invention is not limited to the embodiments of drawing or drawings described and are not intended to represent the scale of the various components. Further, some components that may form a part of the invention may not be illustrated in certain figures, for ease of illustration, and such omissions do not limit the embodiments outlined in any way. It should be understood that the drawings and the detailed description thereto are not intended to limit the invention to the particular form disclosed, but on the contrary, the invention is to cover all modifications, equivalents, and alternatives falling within the scope of the present invention as defined by the appended claim.
[024] As used throughout this description, the word "may" is used in a permissive sense (i.e. meaning having the potential to), rather than the mandatory sense, (i.e. meaning must). Further, the words "a" or "an" mean "at least one” and the word “plurality” means “one or more” unless otherwise mentioned. Furthermore, the terminology and phraseology used herein are solely used for descriptive purposes and should not be construed as limiting in scope. Language such as "including," "comprising," "having," "containing," or "involving," and variations thereof, is intended to be broad and encompass the subject matter listed thereafter, equivalents, and additional subject matter not recited, and is not intended to exclude other additives, components, integers, or steps. Likewise, the term "comprising" is considered synonymous with the terms "including" or "containing" for applicable legal purposes. Any discussion of documents, acts, materials, devices, articles, and the like are included in the specification solely for the purpose of providing a context for the present invention. It is not suggested or represented that any or all these matters form part of the prior art base or are common general knowledge in the field relevant to the present invention.
[025] In this disclosure, whenever a composition or an element or a group of elements is preceded with the transitional phrase “comprising”, it is understood that we also contemplate the same composition, element, or group of elements with transitional phrases “consisting of”, “consisting”, “selected from the group of consisting of, “including”, or “is” preceding the recitation of the composition, element or group of elements and vice versa.
[026] The study area comprised of three randomly selected blocks in three districts of the state. Uttarakhand is a hilly state which can be broadly divided into three geographic zones, the upper Himalayas, the mid Himalayas and the foothills. From each zone, one district is selected randomly (i.e. three districts in all). Then one block CHC.
[027] The present invention is described hereinafter by various embodiments with reference to the accompanying drawing, wherein reference numerals used in the accompanying drawing correspond to the like elements throughout the description. This invention may, however, be embodied in many different forms and should not be construed as limited to the embodiment set forth herein. Rather, the embodiment is provided so that this disclosure will be thorough and complete and will fully convey the scope of the invention to those skilled in the art. In the following detailed description, numeric values and ranges are provided for various aspects of the implementations described. These values and ranges are to be treated as examples only and are not intended to limit the scope of the claims. In addition, several materials are identified as suitable for various facets of the implementations. These materials are to be treated as exemplary and are not intended to limit the scope of the invention.
[028] The present invention provides a community-based study on barriers to the utilization of antenatal care services by currently married women.
[029] This study is carried out as a research project approved and funded by the Department of Health and Research (DHR), Government of India. It is a correlational study, conducted amongst currently married women of the reproductive age group (15-49 years) of Uttarakhand state to know their general and reproductive health-seeking behavior and perceived barriers to it. The eligible women are recruited by using multistage stratified and simple random sampling with probability proportional to size (PPS). A sample size of 1600 is calculated by assuming the prevalence of health-seeking behavior as 50%, as studies from this area related to health-seeking behavior are scarce. Sample size is calculated by using formula 4pq/l2 (Where p= prevalence, q= 100-p and l= 5% of p).
[030] area followed by one PHC area is selected randomly in each district. The study population (currently married women in reproductive age group) of the selected PHC area are line listed and then the sample size is reached by using PPS technique (in different age groups). For data collection, a tool (schedule) is developed to gather information related to socio-demographic details, reproductive health, health seeking behaviour and barriers to it etc. Social workers are trained by investigators in interview and Focus Group Discussion techniques. Pretesting of the data collection tool is done. Trained social workers interviewed the respondents by using finalized pretested structured data collection tool after taking consent. Those not giving consent are excluded from the study. From time-to-time supervision is done by the investigators in the field and minimum 10% of the forms are checked randomly in all the three areas to check authenticity of data. Data so collected is entered in SPSS 22.0 software programme by the data entry operator. Suitable statistical tests are applied to the data to find out the significance of association between variables. A significant p-value is set at 0.05.
[031] This paper presents the findings on the antenatal care services seeking behaviour of currently married women (CMW) in the reproductive age along with its barriers, if any, in selected areas of the state of Uttarakhand. Overall, 534 CMWs in the reproductive age are interviewed from each of the three districts namely Pauri, Uttarkashi andUdham Singh Nagar, thus completing the sample size of 1602. Women are selected in different age groupaccording to their proportions in districts. For this research publication we analyzed data from 637 CMW, who conceived/delivered in the past 5 years preceding the survey. The finding related to their last pregnancy are being presented in this paper. ANC services are availed by 496 (77.9%) women in their last pregnancy. It is seen that only 33.0% of theresponders (210 women) received full ANC care and 286 (44.9%) received incomplete ANC care during their last pregnancy. The mean age of women who did not use any ANC services during their last pregnancy is 30.86 ± 7.837 years, which is higher than those who took ANC services (26.14 ± 4.246 years). It is clear from (Table-1) that younger women availed ANC services more as compared to older women during their last pregnancy and this difference is found to be highly significant statistically.

[032] Hindu women had maximum utilization of ANC services, while least use is seen in Muslim women. (Figure-1) Significantly higher proportion of women who are illiterate, labourer by occupation, spouse of illiterate, living in nuclear families and belonging to lower most socio-economic status did not avail any ANC services.
[033] ANC services are not availed by 141 interviewed women. When they are asked about the reason for not availing these services, unawareness about availability and importance of ANC services is the most commonly cited reason by 46 women (33%). About 30% of the women (41) reported having problems with arranging money (for transportation as well as other expenses) to go for the ANC services, while 22% (31) felt no need for ANC services (Figure-2). About 8% of the women (11) claimed that they could not go for ANC because of the lack of easy availability of transport facilities to the service providers. Few women also cited uncordial behaviour of the health personnel for not wanting to go the health centres. Unawareness regarding significance of antenatal services is found to be increasing in older age group (Table-2).

[034] Younger women, who did not avail ANC services are either not willing for it (despite of being aware) or quoted financial constraints as the main limitation. Lack of awareness is the main reason for non-availment of ANC services in Hindu women, while Muslim and Sikh women held their financial status accountable for this. Womenwhoare illiterate or had education upto 5 years, areeither not aware of the need for ANC services or had financial constraints, while women with higher education felt no need for it. There is no significant difference in the reasons for non-availment of ANC services according to the occupational status of respondents, type of families or Socio-economic status. On doing regression analysis, age, education of respondent and spouse, religion, caste and type of family are found to be significantly associated with the utilization of antenatal care (Table-3).

[035] ANC services ensure good care of the mother’s health as well as the development of the unborn baby. They allow for the promotion of good health of mother and foetus duo as well as early detection and treatment of complications. Inadequate care during pregnancy interferes in the continuum of care, and affects both mother and the baby. In our study population, the ANC services are availed by 78% of the women in their last pregnancy, which is similar to NFHS-4 findings for Uttarakhand state. However, this is lower than the NFHS -4 survey records in India, where the proportion of women (age 15-49) who received ANC, has risen from 77% in NFHS-3 to 84 % in NFHS-4. Likewise in a survey done in recently delivered women in urban slums of Delhi, it is seen that almost 80% women received some form of ANC. As far as number of ANC visits are concerned, only about 33% of the surveyed women reported having received 4 or more ANC visit which is in concordance with Uttarakhand data (31%) from NFHS-4. Rejoice and Ravishankar reported in their analysis of NFHS-3 findings, that 9.4% of the women in Karnataka did not receive any kind of ANC during their pregnancy, while it is only 0.9% in Tamil Nadu. In a study from rural Lucknow, it is found that 85.5% of the beneficiaries surveyed received at least three antenatal care services from any health facility, which is much higher than our study.
[036] In Nigeria, 2013 Nigeria Demographic and Health Survey (DHS) revealed that the overall ANC coverage stood at 61% but 54% of the women received full antenatal care. Similarly, in Nepal, DHS 2011 findings revealed that 85% of the surveyed women had at least one ANC visit and almost half of those had four or more visits. The reason for lower full ANC coverage in our study may be that in hilly areas it is difficult to go for frequent ANC visits, owing to the non-availability of health facility nearby, lack of health personnel posted at health facilities due to difficult terrain or difficulty in getting transport as well in arranging money for transport. It is found that distance of health facility and hence problem in getting transport facilities is a big factor in non-availment of ANC services in our study.
[037] Although, the factors deterring the utilization of health services are associated with the characteristics or quality of the services, but often it is also linked to the characteristics of the users and circumstances and hence vary from pl-ace to place. These may relate to the sociodemographic, economic and environmental characteristics of the individuals. ANC behaviour in our study is significantly determined by age of the respondent, literacy status, lower earning occupation of the woman as well as the spouse and lower socio-economic status.
[038] A statistically significant reduction is observed in the proportion of women obtaining ANCservices with increasing parity and number of living children. We report that lack of knowledge, finance related problems (for transportation as well as other expenses) for the ANC services and no felt need for ANC services are the main reasons for non-availment of ANC services among CMW in our study. Srivastava A et al concluded that maternal health care service utilization in their study is significantly associated with small family size, lower birth order, nuclear family, higher socio-economic status, woman’s education and husband’s occupation. A meta-analysis from the DHS conducted in Bangladesh, India, Pakistan, Kenya, Nigeria, and Tanzania revealed that within each country, the poorer, less educated and rural women had higher unmet need for maternal care services. Service-related factors (accessibility in terms of cost and distance) and sociocultural factors (e.g., did not perceive the need for the services and objections from husband and family) also posed as barriers to antenatal care and institutional delivery.
[039] Similar to our study, social status and distance of the health facility are found to be barriers towards seeking antenatal care especially among poor women who could not afford transportation fee to health facilities in Nigeria.
[040] Also, increasing utilization of maternal health services is found among younger women, low parity women and women with high income husbands. In yet another study from Nigeria, authors concluded that three reasons central to non-utilization of ANC services are: “Problems with getting money to go to health facilities”, “Farness of ANC service providers” and “Unavailability of transport to reach the ANC providers” quite similar to our study.
[041] The coverage of ANC services in the studies area is found to be about 78%, which is similar to NFHS-4 data for Uttarakhand, but full coverage is still low. Increasing age, illiteracy, and poverty are found to be strongly associated with the non-availment of ANC services. Unawareness is the most commonly cited reason for not availing of ANC services, followed by financial issues and unfelt need. A few women also cited the uncordial behavior of the health personnel for not wanting to go to the health centers.
[042] There is a need to create demand for the availment of ANC services among women of Uttarakhand. This can be done by spreading awareness about the importance of ANC services for the welfare of the mother as well as for the development of the child. For this, we must focus on addressing financial barriers and improving the quality of ANC services. This will lead to improved client satisfaction, thus ensuring maximal contacts between women and ANC providers.
[043] The disclosure has been described withreference to the accompanying embodiments herein and the various features and advantageous details thereof are explained with reference to the non-limiting embodiments in the following description. Descriptions of well-known components and processing techniques are omitted so as to not unnecessarily obscure the embodiments herein.
[044] The foregoing description of the specific embodiments so fully revealed the general nature of the embodiments herein that others can, by applying current knowledge, readily modify and/or adapt for various applications such specific embodiments without departing from the generic concept, and, therefore, such adaptations and modifications should and are intended to be comprehended within the meaning and range of equivalents of the disclosed embodiments. It is to be understood that the phraseology or terminology employed herein is for the purpose of description and not of limitation. Therefore, while the embodiments herein have been described in terms of preferred embodiments, those skilled in the art will recognize that the embodiments herein can be practiced with modification within the scope of the embodiments as described herein.

We Claim:

1) A community-based study on barriers to the utilization of antenatal care services by currently married women, the community-based study is conducted in rural areas of 3 randomly selected districts in Uttarakhand;
- wherein multistage stratified and simple random samplings are used for area selection and the PPS technique is used to recruit the participants. Overall, 637 currently married women (CMW) who delivered in the last 5 years prior to the survey, are interviewed by trained social workers.
2) The community-based study as claimed in claim 1, wherein the Chi-square test is used to ascertain the association between variables and regression analysis is done to adjust for confounding associations. Results: Overall 496 (77.9%) women availed one or more ANCservices during their last pregnancy, but the complete package is availed by only 210 (33%) of the CMW.
3) The community-based study as claimed in claim 1, wherein the majority of the women who did not avail of any ANC services are older, illiterate, laborers, spouses of laborers/ unemployed persons, and belonged to lower socio-economic status.
4) The community-based study as claimed in claim 1, wherein unawareness is the most commonly cited reason for not availing of ANC services followed by financial issues and unfelt need.
5) The community-based study as claimed in claim 1, wherein the women in Uttarakhand are pliant to ANC services, but there is aneed to create demand for it by increasing awareness and improving the quality of ANC services.