antenatal care ( anc ) services are considered to be the key element in the primary health care delivery system of a country , which aims for a healthy society . over the past 60 years , the maternal health situation in the country has been staggering despite several changes in a rapidly evolving socioeconomic environment . the roles and responsibilities of primary care physicians have also been revised continuously in this context . under their leadership , different cadres of health workers have been appointed to address the problem . as deadline for millennium development goals is approaching , the need for improving the standard of maternal care is more than ever . in the last decade , as per the national data , health indicators keeping in view the gap between the target and reality , national rural health mission ( nrhm ) was launched in april 2005 , to improve the rural health care delivery system and health status of the people . accredited social health activists ( ashas ) were introduced at the village level for motivating the beneficiaries to utilize the antenatal care services provided by the government health facilities . under supervision of auxillary nurse midwives ( anm ) and physicians at primary health care level , ashas were planned to play the role of a connecting bridge between community and first level government health sector . these groups of health care providers , along with anganwadi workers ( aww ) , build the base line of rural health services in the country . they , under the mission , seek to provide universal access to equitable , affordable and quality maternal health care , as well as to bring about an improvement in the health status of the pregnant women belonging to underprivileged sections of the society . in this perspective , the present study aimed to find out the determinants of utilization of antenatal care services by the beneficiaries in rural lucknow . the present study , cross - sectional in nature , was conducted among rural beneficiaries in lucknow district from august 2009 to july 2010 . lucknow , a district in uttar pradesh ( up ) , north india , is having 33.3% of the population living in rural area . the rural part of the district has a literacy rate of 61.8% overall and 52.3% among the females . a rdw was defined as a post natal woman who had delivered a baby during the period from january 2009 till june 2010 . the percentage of women attending antenatal care was 64.2% in rural up , based on the findings of nfhs-3 . sample size was calculated with a relative precision of 10% and a design effect of 1.5 . sample size calculation was done using formula to estimate a proportion requirement for 95% confidence . considering non - response , an additional list of rdw ( comprising of 10% of the sample size ) was kept ready for every village . in case of absence or unwillingness of the rdw , the list was utilized . multistage random sampling was used for selecting villages . in the first stage , out of nine community health centers ( chcs ) in lucknow , two were chosen randomly . in the second stage , two primary health centers ( phcs ) were selected randomly from each chc , thus four phcs were included in the study . under each phc , two sub centers were taken within five km and two sub centers were taken more than five km away from the respective phc . in each of the sub centers thus selected , two villages were selected , one in which sub centre is located and any other village , selected via random sampling . thus , the study covered 32 villages , which includes equal ( 16 each ) number of sub centre villages ( scv ) and non - sub centre villages ( nscv ) . list of rdws was collected from ashas and awws and then systematic random sampling was followed to pick up the requisite number of beneficiaries . the study was conducted after clearance from the institutional ethical committee and permission from the superintendents of the concerned chc . a pretested structured interview schedule was used to collect required information . among independent variables , age , religion , caste , type of family , education , socio economic status ( ses ) , parity , and timing of registration were considered . for calculating ses , modified pareek 's classification for rural area data entry and analysis were done using pasw statistics version 19.0 ( spss inc . , fisher 's exact test were used to compare the rdws who took at least three antenatal care visits and who did not . results were expressed in terms of odd 's ratio ( or ) and confidence interval ( ci ) . independent variables that were significant at univariate level were included in multivariate model for avoiding confounding . backward logistic model , based on likelihood ratio , was used to find predictors for institutional deliveries at government hospitals . the fit of final model was assessed using hosmer - lemeshow goodness - of - fit test . multistage random sampling was used for selecting villages . in the first stage , out of nine community health centers ( chcs ) in lucknow , two were chosen randomly . in the second stage , two primary health centers ( phcs ) were selected randomly from each chc , thus four phcs were included in the study . under each phc , two sub centers were taken within five km and two sub centers were taken more than five km away from the respective phc . in each of the sub centers thus selected , two villages were selected , one in which sub centre is located and any other village , selected via random sampling . thus , the study covered 32 villages , which includes equal ( 16 each ) number of sub centre villages ( scv ) and non - sub centre villages ( nscv ) . list of rdws was collected from ashas and awws and then systematic random sampling was followed to pick up the requisite number of beneficiaries . the study was conducted after clearance from the institutional ethical committee and permission from the superintendents of the concerned chc . a pretested structured interview schedule was used to collect required information . among independent variables , age , religion , caste , type of family , education , socio economic status ( ses ) , parity , and timing of registration were considered . for calculating ses , modified pareek 's classification for rural area data entry and analysis were done using pasw statistics version 19.0 ( spss inc . , fisher 's exact test were used to compare the rdws who took at least three antenatal care visits and who did not . results were expressed in terms of odd 's ratio ( or ) and confidence interval ( ci ) . independent variables that were significant at univariate level were included in multivariate model for avoiding confounding . backward logistic model , based on likelihood ratio , was used to find predictors for institutional deliveries at government hospitals . the fit of final model was assessed using hosmer - lemeshow goodness - of - fit test . about half ( 54.5% ) of the rdws were above the age of 25 years . overall , 85.5% of the rdws took at least three anc services during their pregnancy ( 95% ci : 81.8% - 88.9% ) and 53.7% of them got registered during the first trimester of pregnancy ( 95% ci : 49.1% - 59.1% ) . chcs and anganwadi centers ( awc ) were the most common ( 50.9% and 48.6% , respectively ) sources of antenatal care services for them . for scv , sub centre was the most common ( 52.3% ) source followed by chc ( 45.5% ) for antenatal care services . for nscv , awc was the most common ( 63.1% ) source followed by chc ( 56.3% ) , for the same services [ table 1 ] . distribution of rdws according to the source of antenatal care during their last pregnancy * at the comparison between the profiles of the women who went for three anc visits and who did not , significant difference was found in terms of age , ses , and timing of registration . about 89.1% rdw above the age of 25 years took three or more such visits . majority ( 91% ) of the pregnant women who got them registered early went for more number of antenatal visits . the influence of religion , caste , education , family type or parity was not prominent though higher utilization was seen with increasing education [ table 2 ] . comparison of the profile of the rdws based on three antenatal care visits on simple logistic regression , no significant relation was found between three anc visits and religion , caste , education , family type or parity of the rdws . however , significant relation was found between three ante natal care visits and age ( or = 1.189 , 95% ci = 1.029  3.433 ) , ses ( or = 1.888 , 95% ci = 1.009  3.533 ) , and timing of antenatal registration ( or = 2.667 , 95% ci = 1.427  4.984 ) . women with age more than 25 years , higher ses , and early registration were found to be more likely to get three or more number of antenatal visits [ table 3 ] . factors associated with three antenatal care visits by the rdws on simple logistic regression at multivariate level , significant variables in the model were age of woman ( or = 2.107 , 95% ci = 1.132  3.923 ) and timing of registration ( or = 2.817 , 95% ci= 1.487  5.338 ) [ table 4 ] . the result of hosmer - lemeshow goodness - of - fit test was not significant ( p = 0.683 , df = 6 ) . overall correct classification result indicated that 85.5% of the rdws are predicted rightly about their number of antenatal visits . the study found that all the studied beneficiaries got themselves registered for antenatal care services . however , the findings are different from the observation of murthy , which showed that for phc / sc villages , the coverage was more than other villages . no such difference was found in the present study with regard to presence of sub centre in the village and this could be attributed to presence of asha in every village . majority of the beneficiaries attended three or more anc check - up and they got themselves registered most commonly in the first trimester of pregnancy . it was observed in the present study that chc and awc were the most common sources of antenatal care services for the beneficiaries . this is not consistent with a previous study , which found that most of the pregnant females went to sub centre or phc . preference for chc in the present study might be due to provision of lab facilities , while awcs were chosen due to their presence in every village . among different factors , less age has earlier been established as the determinant for three or more anc visits . in contrary to these studies , the present study suggests that increased age is associated with at least three antenatal visits . this might be due to increased awareness and more familiarity with the health workers with increasing age . the doctors at the phc and chc level should be more elaborate to the young pregnant ladies , as the latter , many a times , lack sufficient information . as per our study , ses was associated with adequate number of anc visits although after controlling for other variables , it could not come out as significant . previous studies also pointed towards economic factor as a predictor . in an area where three fourth of the population survive in a low standard of living , economic factors providing free care or conditional cash transfer will continue to be weighed against loss of daily wages in financially staggering part of the society . without an overall improvement in the standard of living , nothing more it is thought to pave way for longer period of contact between rdw and health workers . that explains higher tendency of early registered women to go for three or more number of anc visits . this finding is important , since it implies that encouraging early registration will ensure better maternal health in a long run . although it was not statistically significant , it is worth noting as several other studies in the past recorded the role of education in deciding health seeking attitude of pregnant women . education , on the other hand , by imparting awareness and autonomy to the women , encourages utilization of maternal services and leads to demand for maternal health care services . to sum up more importantly , the introduction of ashas at the rural level seemed to have influenced the health care seeking attitude of the rdws . it 's too early to say that ashas have changed the face of primary health care over past few years . setbacks are still there but it has been proved that ashas could play a pivotal role in improvising the health seeking attitudes of rural population . primary care physicians should also motivate the rdws for regular ante natal visits . at this stage of pregnancy , women are usually more receptive to their advices . this opportunity should be utilized today for the sake of a better maternal health tomorrow . evaluation of nrhm at the grass root level through a community - based approach , meticulously collected data and finding out the predictors for three anc visits are few strengths of this study . on the other hand , dependence of the sampling procedure on the completeness of the lists of rdws , retrieved from asha and aww , second , recall bias was not an impossible factor as the clients were asked regarding their pregnancies in this cross sectional study . third , we did not ask for the reasons for getting less number of antenatal care visits . elicitation of such causes would have revealed the views of the rdws in this regard . in addition , a longitudinal study will help in better understanding of the role of socio demographic as well as behavioral factors for sufficient antenatal care . evaluation of nrhm at the grass root level through a community - based approach , meticulously collected data and finding out the predictors for three anc visits are few strengths of this study . on the other hand , dependence of the sampling procedure on the completeness of the lists of rdws , retrieved from asha and aww , is one of the limitations . second , recall bias was not an impossible factor as the clients were asked regarding their pregnancies in this cross sectional study . third , we did not ask for the reasons for getting less number of antenatal care visits . elicitation of such causes would have revealed the views of the rdws in this regard . in addition , a longitudinal study will help in better understanding of the role of socio demographic as well as behavioral factors for sufficient antenatal care . elder rdws and those with early registration were found to be more likely to have at least three antenatal care visits . encouraging early registration and more focus on young mothers should be the thrust areas in maternal health program . younger mothers are easily convincible , personal interaction with them on part of asha could bring in successful changes in behavior . counseling for early registration should also get priorities , as it would be the first step for sufficient antenatal care visits to the health facility . under nrhm , there is improvement in anc coverage but health sector is yet to get 15% of the clients convinced , who are availing less care during their pregnancy . besides , conditional cash transfer has certain limitations in indian perspective , corruption being on of them . until there are improvements in terms of quality of care and community participation , it will remain challenging to achieve higher coverage of anc in rural areas . it is , therefore , recommended to focus on the predictors at individual as well as community level to bring about development in maternal health care utilization .
background : antenatal care services are the first steps towards ensuring the health of mothers and the newborn . 
 this is the key component for achieving millennium development goals by 2015 . but 
 india 's performance continues to be poor in providing antenatal care services to its huge population , particularly in the rural areas.objective:to assess the determinants of utilization of antenatal services by rural beneficiaries in lucknow , a district of north india.materials and methods : the study , cross - sectional in design , was conducted from august 2009 to july 2010 . 
 multistage random sampling was used for selecting villages . 
 a total of 352 recently delivered women were selected following systematic random sampling . 
 logistic regression was used to find out the determinants of three antenatal care services.results:overall , 85.5% of the beneficiaries surveyed were found to receive at least three antenatal care services from any health facility . 
 community health centre was the most common source for such care . 
 significant difference was found between beneficiaries who took three antenatal care visits and who did not in terms of age , socio economic status , and timing of registration . on multiple regression , only age ( or = 2.107 , 95% ci = 1.132  3.923 ) and timing of registration ( or = 2.817 , 95% ci = 1.487  5.338 ) were found to be the predictors for three antenatal care visits.conclusion:intervention should be focused on young and late registered women for ensuring sufficient care during pregnancy .