1. Introduction

Globally, a maternal health issues has been highly prioritized and well recognized in the first decade of twenty first century particularly in the form of Millennium Development Goal 5 and also the continuation of it in Sustainable Development Goals (SDGs) framework ^{[1, 2, 3, 4]}. However, achievements in maternal deaths reduction have been not reached satisfactory level yet ^{[5, 6]}. Still more than 800 women die per day due to pregnancy and childbirth related causes that are highly preventable ^{[7, 8]}. Out of total maternal deaths worldwide, nearly 99% of death happens in low-income countries especially in Sub-Saharan Africa and South Asia ^{[7, 8, 9]}. Rural and poor communities are even more vulnerable to maternal deaths because they do not have access to adequate quality health services on time ^[10]. Furthermore, only one third of all pregnant women in developing countries receive at least four antenatal care visits ^[8]. There is also a huge disparity of maternal health status between urban and rural Settings ^{[4, 11, 12]}. Nepal a resource poor country with high geographic and socio-cultural variation also presents the similar situation ^{[13, 14]}. There is sufficient numbers of evidences reflecting severe and worsening economic inequalities to and use of basic health services including Ante-Natal Care (ANC), unmeet needs for contraceptives, institutional delivery and care received by trained health workers in Nepal ^{[13, 15, 16]}. The regional socio-economic disparity also explicitly shows inequalities in maternal health service utilization and differences in Maternal Mortality Rate (MMR) among various ethnic groups across the country ^{[17, 18, 19]}.

Though Nepal has been honored for remarkable progress in achieving country target of MGDs 5, there are still enormous challenges to reduce alarming MMR among socio-economically disadvantage ethnic groups and various regions within country ^{[3, 18, 20, 21]}. Mothers from disadvantage community like Terai/Madheshi or Terai and hills dalits are most underprivileged ethnic groups in Nepal with very poor maternal health status ^{[11, 18]}. Also, antenatal care has been also determined as one of the essential element of maternal health services that contribute in reducing MMR ^[22], but the coverage of ANC check up with four completed visit among Terai/Madheshi women in Nepal is only about 35% and among Terai/Madheshi dalits is even just 23.4 %, which is relatively very low coverage as compared to national figure ^{[11, 18]}. In addition, considering the institution delivery as financial hardship to poor, government of Nepal initiated Aama Program in 2005 and 4 ANC incentive services in 2009 that includes free institutional delivery and cash incentive scheme to cover travel cost in order to promote institutional delivery ^{[23, 24]}. However the percentage of institution delivery is still just around 35% at national level and situation is even worse among poor and excluded groups ^[18]. For instance, nearly 80% delivery is conducted at home in absence of trained health worker among Terai/Madheshi dalits communities ^{[18, 25, 26]}. Consequently, in order to address maternal health issues among all segments of population across the country, it is crucial to have segregated evidences to develop appropriate policy interventions to tackle the gaps in maternal health outcomes ^{[10, 11]}. In this context, the present study intends to explore the factors influencing ANC dropouts at government run public health facilities on Dhanusa district of Nepal. Dhanusha district is also categorized as one of the low HDI district of Nepal with very low education, health and economic status as compared with other hills and mountain districts in Nepal ^[27].

2. Materials and Methods

This is a descriptive cross sectional study conducted at Dhanusha district of Nepal. A total sample size of 206 women who had received at least 1st ANC check up from the government health facility during March 2014 to March 2015 were selected as study respondent. Sample size was calculated considering the reliability co-efficient for 95% confidence level set at 1.96, proportion of antenatal care services dropout 0.52 according to annual health report ^[28], design effect =2, error=10%, and non response rate 10%. Study respondents were selected using multi-stage sampling procedure. Dhanusha district was stratified into seven electoral constituencies, one Village Development Committee (VDC) from each electoral constituencies was randomly selected and again three wards from each selected VDC were randomly drawn and finally 10 mothers were randomly chosen from each selected wards using safe motherhood register book. Study data was collected using interview method and semi-structure questionnaire was used to gather the study information. The study questionnaire was translated from English language into local language and pre-tested among 10% of actual sample size in similar setting at adjoining Saharba VDC of Mohottari district. The data entry was done in Epi-data 3 and data analysis was carried out through Statistical Package for Social Science (SPSS) 20. Bivariate analysis was done using Chi-Square test to find the association between the selected variables of the study.

The formal approval of study was taken from Nepal Health Research Council Ethical Review Board (national ethical clearance board) at national level and study approval from District Public Health Office (DPHO), Dhanusha and District Development Committee (DDC), Dhanusa at local level. Verbal informed consent was taken from each respondent prior to interview. None of the respondent was forced to participate in the study and confidentiality of information gathered was assured.

3. Results

Table 1. Socio-demographic variables of study respondents

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View next table

The Table 1 finding presents, out of total 206 respondents, majority were 21-24 years of age with mean age of 23.62 years ± 3.95. Similarly, 29.52%, 27.14%, and 27.62% respondents were Madheshi dalit women, disadvantage Janjati and disadvantage non-dalits respectively. About 78.57% of respondents were illiterate and from poor economic background. Also majority of respondents were housewife (75.71%) and 22.38% were farmer. Likewise, out of total study participants, 104 (49.52%) respondents have completed 4 ANC visits and 106 (50.47%) respondents have not completed 4 ANC visits.

Table 2. Availability of health worker and Comfortability in receiving ANC services at HFs

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

View next table

Table 2 shows, out of total about respondents 28.10% of respondents response unavailability of health worker during the time of ANC visit at health facility and 36.19% of respondents felt uncomfortable in receiving ANC care during visit.

In present study, out of total respondents 106 (50.47%) ANC dropouts respondents, majority 42.45%, 39.62%, 27.36%, and 21.70% responded lack of trust on public health facilities, unsatisfactory ANC counseling, relatively good health services at private clinics and afraid of demanding X-ray and other services charges respectively as major reasons for not attending ANC visit at public health facility (multiple responses). Similarly 97.37% of respondent responded unreceptive attitude of health staffs and 15.79% responded presence of male staff during ANC check up for not attending ANC services at health facility.

Table 3. Chi-square test of association of selected study variables with ANC visit dropouts and 4 ANC visit completed among respondents

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

View next table

Table 3 presents the bivariate analysis of selected variables with ANC visit dropout. The results shows, education status of respondents, economic status of respondent, satisfaction with the information provided at local government health facilitates, satisfaction with behavior aspects of health worker, satisfaction with ANC care received at government health facilities and discomfort in receiving ANC services were significantly associated (p-value < 0.05) with the ANC visit dropout.

Table 4 presents the results of binary logistic regression analysis showing odds of association between ANC drop out with some selected study variables. Variables such as economic status of respondents, education status of respondents, satisfaction with the health services provided at public health facilities, satisfaction with the health information provided during ANC visit and behavioral aspects of health workers were significantly associated to ANC dropout among individual visiting public/government health facilities. Respondents who were illiterate were about 2.22 times less likely to complete 4 ANC visit as compared to literate respondents; this result was statistically significant (OR= 2.22, 95% CI= 1.264-3.917). Respondents with poor economic status were also 2.37 times less likely to attend 4 ANC visit (OR= 2.37, 95% CI= 1.264-4.462). Similarly satisfaction with the health service received at health facilities, information provided during ANC visit and behavior of health worker were also statistically significant with ANC dropout among individuals visiting to government/public health facilities.

Table 4. Binary logistic regression analysis showing odds of association between ANC dropouts with some selected study variables

Download as

PowerPoint Slide

Larger image(png format)

• Tables index

Veiw figure

View current table in a new window

View previous table

4. Discussion

In the present study majority women of childbearing age were (16-28) years of age. In Nepal and similar low-income countries in Southeast Asia and Sub-Saharan African countries, childbearing age of women is between (15- 25) ^[7]. High proportion of women gets pregnant in early age especially in resource poor countries is due to high prevalence of early and child marriage ^[30]. However, the childbearing age among the women of developed countries ranges between 28-38 years of age ^[7].

The current study illustrates 71.90% of respondents responded the availability of health staffs during time of ANC visit, however presence of health worker at health facilities was not only enough to encourage pregnant women to complete at least 4 ANC visits during pregnancy. Nearly 50% of those who reported the availability of health workers at health facilities have not completed 4 ANC visit. Like wise similar studies conducted in different region of Nepal revealed quality of ANC services at local health facilities as major factor associated to low utilization of maternal health services ^{[17, 31]}. Moreover traditional beliefs, customs and social system in Nepalese society are equally responsible for poor utilization of maternal health services in rural areas ^{[32, 33]}. The mother-in-low usually make decision regarding workload, health care seeking during pregnancy and delivery process in rural part of Nepal ^[32] where as husbands in Uganda and traditional birth attendants in rural Bangladesh influences seeking and receiving antenatal care ^[34].

Similarly, 36.19% of respondents reported that they experienced uncomfortable environment during receiving ANC services at local government health facilities. Majority of respondents i.e. 97.37% among dropout group responded unreceptive attitude of health staffs and 15.79% of respondents among dropout group responded presence of male staff during ANC check up for not attending ANC services at government health facility. A systematic review conducted by Mannava et al. (2015) also mirrors negative behaviors of heath workers during delivery of ANC services such as physical abuse towards women, absenteeism or unavailability of providers, corruption, lack of regard for privacy, poor communication, unwillingness to accommodate, traditional practices, and authoritarian or frightening attitudes ^{[35, 36]}. It also documented that such behavior of health worker are influence by health service provider workload, long working hours, poor relations with co-workers, insufficient salaries, lack of equipment’s and supplies, patients’ attitudes and behaviors, provider beliefs and prejudices, and feelings of superiority among health professionals ^{[35, 37, 38]}. These negative behaviors of health workers in turn underestimate clients health care seeking and over all clients well being ^{[35, 39]}. Consistent results in comparable studies from Africa ^{[40, 41, 42]}, the present study shows majority 42.45%, 39.62%, 27.36%, and 21.70% responded lack of trust on public health facilities, unsatisfactory ANC counseling, relatively good health services at private clinics and afraid of demanding X-ray and other services charges respectively as major reason for not attending ANC visit at public health facility. Even women are informed about maternal incentive schemes, they may not use maternal health services until they feel confident in overcoming hurdles and if trust on public health facility and satisfaction of care are not assured ^{[14, 31, 43]}.

In the current study, Chi-square test of association explicitly shows, antenatal care visit drop out is significantly associated with the education status of respondents (p>0.05, OR=2.25, CI= 1.26-3.91), economic status of respondent (p<0.05, OR= 2.37, 95% CI: 1.26-4.46), information provided at local government health facilitates during ANC visit (p<0.05, OR=6.00, 95% CI: 3.30-10.19), satisfaction with behavior aspects of health worker (p<0.05, OR= 3.76, 95% CI: 2.09-6.76), satisfaction with ANC care received at government health facilities (p<0.05,OR=17.48, 95% CI: 8.76-34.88) and Comfortability in receiving ANC services at government health facilities ( P<0.05, OR=0.37, 95% CI: 0.20-0.67). Similar study conducted in eastern Nepal also shows women from wealthy family had higher chance (OR: 2.3, 95% CI: 1.1-5.3) of attending 4 ANC services as compared to women who belongs to poor and disadvantage ethnic group ^[15]. Access to financial resources, autonomy of movement and decision making regarding their health would have empower those women to utilize antenatal care services ^{[44, 45]}. Also women education level was found to have strong association with ANC services utilization ^{[15, 46]}. Moreover, study carried out in Xien Khouang Province Lao. PDR presented education, income, knowledge, availability of public transport; cost of transport and cost of services were significant predicators of ANC services utilization ^{[38, 47]}. Likewise, the present study also shows no association of antenatal care visit dropout with the health staff availability at health facilities during ANC visit (p.0.05, OR=0.81, 95% CI: 0.44-1.48), ANC incentive schemes (p>0.05, OR=0.55, 95% CI: 0.26-1.17) and ANC visit at different type of government health facility at community level (p>0.05, OR= 0.97, 95% CI: 0.53-1.77). A similar result has been reflected in the study conducted in the Madhya Pradesh state of India ^[48]. Furthermore binary logistic regression analysis also shows statistically significant association of ANC dropout with respondents’ education status (OR= 2.22, 95% CI= 1.264-3.917), economic status (OR= 2.37, 95% CI= 1.264-4.462) and the satisfaction with behavioral aspects of health workers at public health facility (OR= 3.76, 95% CI=2.095-6.769). These findings are consistent with studies carried out in different part of Nepal, Indonesia, Uganda, India, Nigeria and Zambia ^{[14, 40, 47, 49, 50, 51]}.

5. Conclusion

The findings of this study confirmed that women’s poor education, week economic status, dissatisfaction with the health service provided at public health facilities, dissatisfaction with the information provided during ANC visit and unreceptive attitude of health worker were major hindering factors among respondents for not attending four ANC visit at government/public health facilities in Dhanusha district of Nepal. Further, the study explicitly indicates even women are informed about maternal incentive schemes and maternal health services they may not use maternal health services until they are empowered to overcome hurdles and if trust on government health facilities are not assured from provider side. Therefore, promotion of positive attitude and behavior of health workers towards clients and building trust on government health facilities from health care provider side are equally important to increase antenatal service utilization among rural pregnant women.

Statement of Competing Interests

The authors have no competing interests to report.

List of Abbreviations

ANC: Antenatal Care

SDGs: Sustainable Development Goals

MDGs: Millennium Development Goals

MMR: Maternal Mortality Rate

HDI: Human Development Index

VDC: Village Development Committee

HFs: Health Facilities

CI: Confidence Interval

OR: Odds Ratio.

References

[1]	U. Nations, “The Millennium Development Goals Report: 2015,” New York, USA2015.
	In article
[2]	U. Nations, “Sustainable Development Goals and Targets,” New York2015.
	In article
[3]	U. Nations, “Nepal Millennium Development Goals Progress Report 2013,” Kathmandu, Nepal 2013.
	In article
[4]	V. Khanal, M. Adhikari, R. Karkee, and T. Gavidia, “Factors associated with the utilisation of postnatal care services among the mothers of Nepal: analysis of Nepal demographic and health survey 2011,” BMC Womens Health, vol. 14, p. 19, 2014.
	In article
[5]	P. P. Ndola Prata, Amita Sreenivas & Caitlin Elisabeth Gerdts, “Maternal mortality in developing countries: challenges in scaling-up priority interventions,” Women's Health, vol. 6, pp. 311-327, 2010.
	In article
[6]	M. Islam, “Progress towards achieving Millennium Development Goal 5 in South-East Asia,” BJOG, vol. 118 Suppl 2, pp. 6-11, Sep 2011.
	In article
[7]	WHO, “Trends in Maternal Mortality: 1990 to 2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division,” Geneva, Switzerland 2015.
	In article
[8]	WHO, “Maternal mortality: fact sheet,” Department of Reproductive Health and Research, Geneva 2014.
	In article
[9]	C. Ronsmans and W. J. Graham, “Maternal mortality: who, when, where, and why,” The Lancet, vol. 368, pp. 1189-1200, 2006.
	In article
[10]	T. A. J. Houweling, C. Ronsmans, O. M. R. Campbell, and A. E. Kunst, “Huge poor–rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries,” Bulletin of the World Health Organization, vol. 85, pp. 745-754, 2007.
	In article
[11]	B. Lynn, Dahal, D R., and Govindasamy, P. , “NEPAL FURTHER ANALYSIS:Caste, Ethnic and Regional Identity in Nepal: Further Analysis of the 2006 Nepal Demographic and Health Survey,” Calverton, Maryland, USA 2008.
	In article
[12]	D. B. Thomas, Stephen.;, Dahal, Kapil.; Grellier, Rachel.; Jha, Chhaya.; Prasai, Sitaram.; Subedi, Hom Nath. , “Voices from the Community: Access to Health Services A Rapid Participatory Ethnographic Evaluation and Research (PEER) Study, Nepal,” Government of Nepal, Population Division, MoHP, Kathamndu, Nepal 2012.
	In article
[13]	N. E. Ministry of Health and Population (MOHP) [Nepal], and ICF International Inc, “Nepal Demogrpahic Health Survey 2011,” Calverton, Maryland2012.
	In article
[14]	S. Sharma, E. Teijlingen, J. M. Belizan, V. Hundley, P. Simkhada, and E. Sicuri, “Measuring What Works: An Impact Evaluation of Women's Groups on Maternal Health Uptake in Rural Nepal,” PLoS One, vol. 11, p. e0155144, 2016.
	In article
[15]	K. K. Deo, Y. R. Paudel, R. B. Khatri, R. K. Bhaskar, R. Paudel, S. Mehata, et al., “Barriers to Utilization of Antenatal Care Services in Eastern Nepal,” Front Public Health, vol. 3, p. 197, 2015.
	In article
[16]	K. Johnson and S. Bradley, “Trends in Economic Differentials in Population and Health Outcomes: Further Analysis of the 2006 Nepal Demographic and Health Survey.,” Calverton, Maryland, USA 2008.
	In article
[17]	B. Choulagai, S. Onta, N. Subedi, S. Mehata, G. P. Bhandari, A. Poudyal, et al., “Barriers to using skilled birth attendants' services in mid- and far-western Nepal: a cross-sectional study,” BMC Int Health Hum Rights, vol. 13, p. 49, 2013.
	In article
[18]	J. P. Pandey, Dhakal, M R.,Karki, S., Poudel, P.,and Pradhan, M S., “Maternal and Child Health in Nepal: The Effects of Caste, Ethnicity, and Regional Identity:Further Aalysis of the 2011 Nepal Demographic and Health survey,” Calverton, Maryland, USA2013.
	In article
[19]	DFID, “Unequal Citizens: Gender, Caste and Ethnic Exclusion in Nepal,” Kathmandu2006.
	In article
[20]	U. Nations, “The Global Campaign for the Health Millennium Development Goals 2010 : Putting the Global Strategy for Women’s and Children’s Health into action,” Oslo, Norway 2010.
	In article
[21]	T. D. Bhandari, G., “Maternal Mortality: Paradigm Shift in Nepal,” Nepal Journal of Obstetrics and gynaecology, vol. 7, pp. 3-8, 2012.
	In article
[22]	M. S. Di, et al. , “What is the effectiveness of antenatal care?,” WHO Regional Office for Europe, Denmark2005.
	In article
[23]	P. T. Lamichane, Suresh., “Progress Report on the Aama/4ANC : Demand Side Financing Programme,” Kathmandu2012.
	In article
[24]	S. Witter, S. Khadka, H. Nath, and S. Tiwari, “The national free delivery policy in Nepal: early evidence of its effects on health facilities,” Health Policy Plan, vol. 26 Suppl 2, pp. ii84-91, Nov 2011.
	In article
[25]	T. Powell-Jackson and K. Hanson, “Financial incentives for maternal health: impact of a national programme in Nepal,” J Health Econ, vol. 31, pp. 271-84, Jan 2012.
	In article
[26]	S. R. Adhikari, Prasai, D R., and Sharma, S K., “A REVIEW OF DEMAND SIDE FINANCING SCHEMES IN THE HEALTH SECTOR IN NEPAL,” Kathmandu2011.
	In article
[27]	Government of Nepal and UNDP, “Nepal Human Development Report 2014: Beyond Geography Unlocking Human Potential,” Kathmandu2014.
	In article
[28]	M. Department of Health Services “Annual Report, Department of Helath Services: 2013/2014,” Teku, Kathmandu 2013/2014.
	In article
[29]	G. o. N. NPCS, “National Population and Housing Census 2011 (National Report),” Kathmandu , Nepal 2012.
	In article
[30]	UNFPA, “GIRLHOOD, NOT MOTHERHOOD: Preventing Adolescent Pregnancy,” New York2015.
	In article
[31]	P. M. S. Pradhan, S. Bhattarai, I. S. Paudel, K. Gaurav, and P. K. Pokharel, “Factors Contributing to Antenatal Care and Delivery Practices in Village Development Committees of Ilam District, Nepal,” Kathmandu University Medical Journal, vol. 11, 2014.
	In article
[32]	B. Simkhada, M. A. Porter, and E. R. van Teijlingen, “The role of mothers-in-law in antenatal care decision-making in Nepal: a qualitative study,” BMC Pregnancy Childbirth, vol. 10, p. 34, 2010.
	In article
[33]	R. Adhikari, “Effect of Women's autonomy on maternal health service utilization in Nepal: a cross sectional study,” BMC Womens Health, vol. 16, p. 26, 2016.
	In article
[34]	J. O. Parkhurst, S. A. Rahman, and F. Ssengooba, “Overcoming access barriers for facility-based delivery in low-income settings: insights from Bangladesh and Uganda,” J Health Popul Nutr, vol. 24, pp. 438-45, Dec 2006.
	In article
[35]	P. Mannava, K. Durrant, J. Fisher, M. Chersich, and S. Luchters, “Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review,” Global Health, vol. 11, p. 36, 2015.
	In article
[36]	A. H. L. Rajendra Karkee, Colin W Binns, “Why women do not utilize maternity services in Nepal: a literature review,” WHO South-East Asia Journal of Public Health, vol. 2, pp. 135-41, 2013.
	In article
[37]	K. Afsana and S. F. Rashid, “The challenges of meeting rural Bangladeshi women's needs in delivery care,” Reprod Health Matters, vol. 9, pp. 79-89, Nov 2001.
	In article
[38]	Y. Ye, Yoshida,Y., Haran-OR-Rashid,MD., and Sakamoto, J., “Factors Affecting The Utilization Of Antenatal Care Services Among Women In Kham District, Xiengkhouang Province, LAO PDR,” Nagoya Journal of Medical Science vol. 23, 2010.
	In article
[39]	B. O. Akin-Otiko and B. R. Bhengu, “Client education experiences and expectations of women at the first level of maternal and child care in Kaduna state, Nigeria,” Midwifery, vol. 28, pp. e893-9, Dec 2012.
	In article
[40]	Banda I, C. Michelo, and A. Hazemba, “Factors Associated with late Antenatal Care Attendance in Selected Rural and Urban Communities of the Copperbelt Province of Zambia,” Medical Journal of Zambia, vol. 39, pp. 29-36, 2012.
	In article
[41]	C. O. Izugbara and D. P. Ngilangwa, “Women, poverty and adverse maternal outcomes in Nairobi, Kenya,” BMC Womens Health, vol. 10, p. 33, 2010.
	In article
[42]	L. A. Lubbock and R. B. Stephenson, “Utilization of maternal health care services in the department of Matagalpa, Nicaragua,” Rev Panam Salud Publica/Pan Am J Public Health vol. 24, pp. 75-84, 2008.
	In article
[43]	C. Sialubanje, K. Massar, D. H. Hamer, and R. A. Ruiter, “Understanding the psychosocial and environmental factors and barriers affecting utilization of maternal healthcare services in Kalomo, Zambia: a qualitative study,” Health Educ Res, vol. 29, pp. 521-32, Jun 2014.
	In article
[44]	S. Ahmed, A. A. Creanga, D. G. Gillespie, and A. O. Tsui, “Economic status, education and empowerment: implications for maternal health service utilization in developing countries,” PLoS One, vol. 5, p. e11190, 2010.
	In article
[45]	L. Sado, A. Spaho, and D. R. Hotchkiss, “The influence of women's empowerment on maternal health care utilization: evidence from Albania,” Soc Sci Med, vol. 114, pp. 169-77, Aug 2014.
	In article
[46]	A. Sohag, S. Memon, M. Bhatti, and A. A. Muhammad, “Factors Affecting Utilization of Antenatal Care- the Opinion of Pregnant Women,” Pakistan Journal of Physiology, vol. 9, 2013.
	In article
[47]	I. O. Ajayi, D. C. Osakinle, and E. O. Osakinle, “Quality assessment of the practice of focused antenatal care (FANC) in rural and urban primary health centres in Ekiti State,” Open Journal of Obstetrics and Gynecology, vol. 03, pp. 319-326, 2013.
	In article
[48]	T. R. Jat, N. Ng, and M. San Sebastian, “Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis,” Int J Equity Health, vol. 10, p. 59, 2011.
	In article
[49]	Y. Agus and S. Horiuchi, “Factors influencing the use of antenatal care in rural West Sumatra, Indonesia,” BMC Pregnancy Childbirth, vol. 12, p. 9, 2012.
	In article
[50]	P. C. Kawungezi, D. AkiiBua, C. Aleni, M. Chitayi, A. Niwaha, A. Kazibwe, et al., “Attendance and Utilization of Antenatal Care (ANC) Services: Multi-Center Study in Upcountry Areas of Uganda,” Open J Prev Med, vol. 5, pp. 132-142, Mar 1 2015.
	In article
[51]	S. Gupta, and Nandeshwar, S., “Status of Maternal and Child Health and Services Utilization Patterns in the Urban Slums of Bhopal, India.,” National Journal of Community Medicine vol. 3, pp. 330-332, 2012.
	In article