Chapt

er-
1

I
NTRODUCTI
ON

Pregnancyandchildbi
rtharespeci
alevent
sinwomen’slivesandi ndeedinthe
l
ivesoft hei
rfami
lies.t
hiscanbeat i
meofgr eathopeandj oyf ulant
ici
pati
onthe
pri
mar yaim ofantenat
alcareistoachi
eve,attheendofpregnancy, ahealt
hy
mot herandhealt
hybaby,thequali
tyofcarei
smor eimpor
tantt hanthequantit
y
,pregnancyrequi
resspecial
i
zedcaregeneral
lyagreedt
oprev entiv
eact i
vi
ty.

Antenatalcareisthesy st
emi cmedi calsupervisi
onofwomendur i
ngpr egnancy
,t
heai mist opreservethephy siol
ogicalaspectofpr egnancyandl abourandt o
preventordetect,asearlyaspossi bl
e,allthati
spat hol
ogical
,earl
ydiagnosisduring
pregnancycanpr eventmat ernalil
l
-heal t
h,inj
ury,medicalmortal
it
y,foetal
death,
i
nfantmor t
alityandmor bidit
y. Hencet heearli
er inpregnancyawomancomes
earl
ierunderthesuper v
isionofanobst etri
cian,wil
lbebetter.

Antenatalcarer ef
erstopr egnancyr el
atedheal thcarepr ov
idedbyadoct orora
healt
hwor keri nmedi calfacili
tyorathome, antenatalcareshouldmoni t
ora
pregnancyf orsignsofcompl i
cati
ondet ectandt reatpre-exi
stingandconcur rent
problemsofpr egnancy.itshoul dalsoprovideadv i
ceandcounsel ingorpreventi
ve
care, di
etdur i
ngpr egnancy, deli
ver
ycar e,postnatalcareandr elatedissues,an
antenatalcarei snecessaryf orensuringaheal t
hymot herandbabyatt heendof
bir
thandpar enthood, becomi ngapar entisat i
meofi ntenselearningbothfor
parentsandf ort hosecloset othem.

Thewor ldhealt
horganizat
ionhasi ssuedanewser i
esofr ecommendat ionsto
i
mpr ovequali
tyofantenatalcaretoreducetheriskofsti
ll
birthsandpr egnancy
compl i
cati
onsandgivewomenaposi ti
vepregnancyexperience, t
hesenew
guidel
inesseektoensur enotonlyahealthpregnancyformot herandbaby, butal
so
anef f
ecti
vetransi
ti
ontoposi t
ivelabourandchil
dbirt
handul timatel
ytoaposi ti
ve
experi
enceofmot herhood.

Promot ionofmat ernal andchil

dheal t
hhasbeenoneoft hemosti mportant
component softhef ami l
ywelfarepr ogrammeoft hegov ernmentofi ndiaandthe
nationalpopulat
ionpol i
cyofmat ernal mortali
tyrat i
oofi ndiahasdecl i
nedby8
point sf
rom 130/100, oooliv
ebi r
thsi n2014- 16t o122/ 100,000liv
ebi rt
hsin2015-17
{6.
2per centdecline}t histr
anslatest o2000addi ti
onal mot her
ssav edannuall
yin
2017ascompar edt o2015.Tot al annualdeat hsdecl inedfrom 32,000mat er
nal
deat hsin2015to30, 000deathsin2017, thi
st ranslatedt oevery20mi nutesa
mot herdyingduet opr egnancyorchi l
dbirthrelatedcause,

Mat er
nalmor tal
it
yisconsideredakeyheal thi
ndicatorandthedirectcausesof
maternaldeathsarewellknownandl ar
gelypreventabl
eandt r
eatable,al
lwomen
needaccesst oantenat
alcareinpr egnancy,ski
ll
edcar edur
ingchil
dbirth,
andcar e
andsupportint heweeksafterchil
dbi r
thallbi
rt
hsshoul dbeassistedbyskill
ed
healt
hprofessional
s,asti
mel ymanagementandt reatmentcanmaket hediff
erence
betweenlif
eanddeat hforbotht hemot herandthebaby…
Thegov ernmentofi ndi
ahasbeenf ocusi
ngoni nit
iat
ivest oimprovemat ernalheal
th
i
ndicators,
Muchpr ogresshasbeenmadei nendingpr eventablemat ernaldeat
hsi nthepast
twodecades: global
lyt
henumberofwomenandgi r
lswhodi eeachy eardue t o
i
ssuesr el
atedt opregnancyandchil
dbirt
hhasdr oppedconsi derabl
yfrom 451,oooin
2000t o295,oooi n2017a38per centdecrease. andini ndiathenumberofwomen
andgirlswhodi eeachy earduetoi
ssuesr elat
edt opr egnancyandchi l
dbirthhas
droppedconsider abl
yfrom 103,
000in20000t o35000i n2017a55per cent
decrease.

Mat er nalcarei
ncludescar eduringpregnancyandshoul dbeginfrom theear l
y
stagesofpr egnancy.womencansuccessant ent
alcareservi
ceeitherbyv ist
inga
healt hcentersuchservi
cesar eavail
ableorf r
om healt
hwor ker
sdur ingtheir
domi cli
aryvi
sits,
oneoft hemosti mpor tantcomponent sofantenatalcareistoof f
er
i
nf ormat ionandadv i
cetowomenaboutpr egnancyrel
atedcompl i
cat i
onand
possi blecurati
vemeasur esf orearl
ydet ecti
onandmanagementofcompl i
cation
,ant enatalcarecanalsopl ayacr i
ti
calroleinprepar
ingawomanandherf amilyfor
birthbyest abli
shingconfidencebet weent hewomanandherheal thcar eprovider
andbyi ndivi
duali
zingpromot ionalheal
thmessages,

Eff
ectiveantenatalcarecani mprovethehealt
hofthemot herandgiveherachance
todeli
veraheal t
hybaby, regularmonitori
ngduri
ngpr egnancycanhel pdetectthe
complicat
ionatt heearlystagebeforetheybecomel i
fe–t hreateni
ngemer gency
,howev er,
onemustr eali
zet hateventhemostef f
ectivescanningtoolscurrent
ly
avai
lableonecannotpr edictwhichwilldevel
oppregnancyr el
atedcompl i
cati
on
hence,everypregnantwomenneedsspeci al
care..

Descr i
bedt hatpregnancyli
nksmotherandfetustoget
herandisthebasisfor
regenerat
ingt hegenerati
on,mostpr
egenanciesendwithbir
thofal i
vebabytoa
healt
hymot her,forsomehowev erchi
ldbir
thisnotthejoy
ousev ent,
butatimeof
pain,f
ear, sufferi
ngandev endeath,

Explai
nedt hatever
yy eart
han200mi l
l
ionwomanbecomepr egnant,
pregnancyis
consider
edt obeanor malpsychol
ogi
calst
ateasperthesci
entif
icvi
ew,toal ay
personitisacommonphenomenonoccur r
inginawomenaf t
ermar ri
age,accordi
ng
togeneticsiti
stheprocessofprocr
eati
on,butabov
eallf
orwomeni tisajoyand
sati
sfacti
on,

Anent alcarereferstothecarethatisgiventoanexpect antmot herfr

om thet i
met he
concept i
oni sconfirmedunt i
lthebeginningoflabourinaddi ti
ont omonitori
ngt he
progressoft hepregnancy,themainai m ofant
enat alcareistomai ntai
nwi th
physiologyofpr egnancyandt opreventortodet ectattheear l
iestandtot r
eatand
untowar dcompl icati
onthatmayar i
se,thepromot ionofheal thandmai ntenanceof
healthylif
estyleshav ebecomeobjectivesofutmosti mpor tancetohealthcare
profession,empower i
ngpopulati
onstobecomeeducat edheal thcareconsumer s
andt oadoptawel lnessperspect
iveisagoal ofhealthcar ereform.
 Theaim ofantenat
alheal
theducat
ionistocreat
eawarenessamong
expect
antmot her
sandmot ivat
ethei
rhealt
hstatustopromot
ethewellbei
ngof
bothmotherandfetus,

Definedthatantenatalcareisthatwhichcompr isessy st
emat ic,medicalsupervi
sion
ofapr egnantwoment hroughoutpregnancy, theout comeoft hegoodant enatal
careshoul dbeaheal t
hymot herandaheal thybabyandav oidanceofmat ernaland
peri
natalmor tal
it
yandmor bi
dity,
explai
nedt hepr egnancyi sanor mal physi
ologi
cal
event,knowingawomani spregnantisthebegi nningofcar einpr egnancy,howev er
pregnancyi snotfor
mal l
yannouncedi nmostoft heI ndianfamili
esbi r
thisatimef or
j
oyandcel ebrati
onat i
mef orcongratulati
ons, good
andgi f
ts,sadlynotall
birthsarehappyoccasi ons, thatisbecausenopr opercare
wasgi vendur i
ngthepregnancy, t
heant enatalcarei scompl etewhenheal th
i
nformat i
oni simpart
ed. .

everyyearabout6mi ll
i
onwomenbecomepr egnant5mi l
l
ionofthesepregnanci
es
l
eadt othebir
thofthechi l
danadequat euseofant enatal
healt
hser vi
cesis
associat
edwithimpr ovedmat ernalandneonatalhealthstat
us,pregnancycare
expectedtoaffectt
hedev el
opmentoft hefet
usandt hebabyaswel lasthemother
,earl
ybookingandr egularvi
sitati
onofantenatalcarecanonlyachievethis,

theANCpr ov i
desanest imateofessent i
al healthissues, i
ncludi
nghealt
hpr omot i
on
,diseasepr eventi
on, screeninganddi agnosi s,allstr
ugglescommencedt opr eserve
thephy si
cal andment al well–bei ngofthemot hers,t
opr eventprematur
elabor, t
o
predictdi
f f
icult
iesandcompl icationsatbi r
th, ensuresdecr easenumberofmat er
nal
mor tal
it
yandmor bidityknowl edgeofpr egnantmot hersmaybemaj orf
actorin
determiningt heextentofant enatalservicesuse, report
sf rom vari
ouspartoft he
wor l
dhav eshownt hati ncreasedl evel
sofpr egnantmot her sint
ermsofant enatal
carehav eani mpactont heirunt i
l
izati
on.

Jananishishusurakshakaryakar
am thisschemeencompassesfr
eemat erni
ty
serv
icesforwomanandchi ldr
en,anati
onwidescal
e–upofemergencyreferr
al
syst
emsandmat ernaldeat
haudits,andimprov
ementsi
nthegovernanceand
managementofheal thserv
icesatal
l l
evel
s,

Toachievetheglobalofimprovi
ngmaternalheal
thandtosavewomen’sli
veswe
needtodomor etoreachthosewhoaremostatr i
sk,suchaswomeninruralareas
,urbansli
ms,poorerhouseholds,
adol
escentmothers,womenfr
om minori
tiesand
tr
ibalschedul
edcasteandscheduledtr
ibegroups…..
NEEDFORSTUDY:

Mat ernalheal thisanat ion’sweal th.Womenar et hepr imar ycar etakers, f i

rst
educat ors, bear ersandnur tur esoft henextgener ati
on.Theyar et henucl eusofoursoci ety.
Ourdest i
nyl i
eswi ththewel lbeingofwomen’ sheal th.Pr egnancyi st heper i
odwhenwomen
needmor eat tent i
onandcar e.Wor ldwi de, anest i
mat ed515, 000womendi eofcauses
relatedt opr egnancyandchi ldbir t
heachy ear,andt hei rdeat hsl eav eonemi ll
ionchi ldren
mot herless. 2Ov er99%oft hesedeat hsoccuri ndev el opi ngcount ri
es.I nI ndia,inev eryf ive
mi nut esonewomandi esf rom compl icationsr elatedt opr egnancyandchi l
dbi r
th.Thi s
meansmor et han1, 00,000womendi eeachy earduet opr egnancyr elat edcauses
. Ant enat al careisani mpor t
anti nter vent i
onf ort hewel lbei ngoft hepr egnantmot her
andt heex pect edi nfant,especi allyinr egionswher emat ernal andi nfantmor t
alityratesar e
high.Themai nr easonf orhi ghmat er nal mor talityinI ndi ai st hatmanywomenar enotawar e
oft hemeasur est hatar eav ailablet opr ev entdi seasesi npr egnancyaswel lasbasi c
i
nf ormat i
oni nsel fcar edur i
ngpr egnancy .Manydonotr ecei vet i
mel yhel peitherbecause
theyar eunawar eoft hehel pav ailabl eorhel pi snotwi thi nt her easonabl edi stance.
Acr osssect ionalsur veywasconduct edondet er mi nant sofant enat al care
util
iz ati
onamong5344pr egnantwomenf rom 14st atesofI ndi a.Fort hesur veyat hree
stagest ratifiedr andom cl ust ersampl i
ngwasadopt ed, anddat acol l
ect edusi ng
quest i
onnai r e, resul t
sshowst hat73. 9%hadatl eastoneant enat alcont actwi thaaux i
liary
nur semi dwi v es51. 7%oft hewomenwhor ecei vedant enat al car epr ef erredi nstituti
onal
deliver yascompar edto27. 6%oft hosewhohadnotav ai ledant enatal car e
ser vices.Findi ngssuggest sthatawar enessofcar edur i
ngpr egnancyandknowl edgeof
pregnancyr elat edcompl icationswer eassoci atedwi thi ncr easedut i
lizat ionofant enat al
car eser vices, ov erallthesur veyshowedt heneedf ori mpr ov ingawar enessonant enat al
heal thandf ormot ivati
ngwoment out il
izeant enat alcar eser vices

. Theinvesti
gatorwit
hherexperienceandobser vati
onanalyzedthatmanymot hers
camet othehospit
al,whentheyhadsomecompl i
cationsl i
kelossoffetal mov ements,gross
anemiaorwi t
hsignsofinfect
ion.I
twasdi f
ficul
ttosav et he5mot herandt hebabyinsuch
condit
ion.Thecausewasmai nlyduetomot her’signoranceandl ackofinf ormation
regar
dingproperantenatal
care.I
nv i
ewoft hisitwasf eltthatanantenatal careeducati
on
shouldbemadeav ai
labl
etoprimigravi
dawomen.ASI M wi l
lbeveryusef ul f
ortheprimi
gravi
dwoment ogainknowledgeregardi
ngant enatalcare

Thepur poseoft hestudyist oident i

fytheknowledgeandpr acti
cesofpr egnant
womenr egardi
ngdi f
ferentaspectsofant enatalcaresuchasdi et
,antenatal checkups,
i
mmuni zat i
on,adequatesleepandr est,exercise,hygi
ene,breastcare,breastfeedingthe
heal
thpr oblemsandcompl icat
ionsofpr egnancyt omaker ecommendat i
onst oenhancet he
knowledgeandpr acti
cesofant enatalcar ebyi mprovi
ngthedel i
veryofant enatal
serv
ices(bot hqualit
yandquant i
ty)iftheyar eless;andtocont i
nuewi ththepr esent
ant
enat
alser
vicer
ender
ingst
atusi
ftheknowl
edgeandpr
act
icesar
eadequat
e

.Ast udyconduct edatSaf dar j

angHospi talNewDel hi byICMRr evealedt hatas
42.6%ofper inataldeathcoul dbeat tributedt opr ev entablecauseswhi char edi rectlyor
i
ndi r
ect lyrelatedt omat ernal disease, compl icat i
onsofpr egnancyandmet hodsofdel iver
y.A
sampl eof310mot hersbelongi ngt olowSoci oeconomi cclassf r
om anant enatal clini
cof
anur banheal t
hcent erandanot hersampl eof180mot hersbel ongingtohi ghSoci o-
economi cclassat tendingnear l
ynur singhomecl inicwer est udiedandcl assifiedi nto3
groupsbasedonr i
sk.Twot hirdwer ecl assifi
edasl owr i
sk, 5%ashy br
iskandt her estas
moder ater i
sk
Ast udycanal sohel pust ocompar et hel evelsofknowl edgeandpr acticeof
primigr avidaandmul t
iparas.Thi shel psust oassesst hestressgi ventopr event iveobst et
ric
carewi thint heheal t
hcar esy st em aswel last hedi ssemi nat i
onofknowl edgei nt he
communi ty.Suchast udycoul dal sopot entiall
yhel pusf i
ndt hesour ceofknowl edgeof
thosewhohav ei tandt ointensi fytheusepr opagandat hroughsuchmedi a
.
Poorut il
izati
onofser vicesr ef l
ectscul turalandsoci o–economi cconst raintsas
wel l
asper cepti
onsr egardingaccessi bilit
yoff acili
tiesandqual i
tyofcar e.Near ly64. 00%of
womenwhodi dnotut i
li
zeant enat alser vi
cesconsi deritunnecessar yref l
ectingbot hthe
tradi
tional noti
ont hatchildbear ingi snotanev entwor thyofmedi calattent.

Asampleof310mothersbelongingtolowSocioeconomicclassfr
om anantenat
al
cl
inicofanurbanheal
thcent
erandanot hersampleof180mot herbel
ongi
ngt ohi
ghsocio-
economicclassat
tendi
ngnearl
ynursinghomecl i
nicwerestudi
edandclassif
iedi
nto3
groupsbasedonrisk,
twothi
rdwerecl assi
fi
edaslowrisk5%asandt herestasmoderate
ri
sk..

Antenat
alcarehavesuchattr
acti
vebenefi
tsandstrat
egies,everyyear,
atl
easthal
fa
mill
i
onwomenandgi rl
sdiebecauseofcomplicat
ionsduri
ngpr egnancy,chil
dbi
rt
horthesix
weeksf
oll
owingdeli
very,
almostall
99%ofthesedeathsoccurindev el
opingcountr
ies,
thi
s
showst
hattheantenat
alcareact
ivi
tyisver
yweaki ndevel
opingcount r
y.

Whorecommendst hatwomenst artantenat

al car
eatagest at
ionalageoflessthan
12weeks–t hisisrefer
redtoas“ ear
lyantenatalcare‘ear
lyantenat
alcareisacrit
ical
opportuni
tyf
orhealthprovi
derstodeliv
ercar eandsuppor tandtogiveinformati
on, t
o
pregnantwomeni nthefir
sttr
imesterofpregnancy, despi
tethi
sar ecentstudyshowst hat
manyoft hepoorestwomenst il
ldonothav eequal accesstothehigh–qual i
tyearl
y
antenatal
car
et hatcanhelptoensuretheirhealthandwel l
-bei
ng,

Geneva–t hewor ldhealthor ganizati

onhasi ssuedanewser i
esofpr egnancy
–relat
eddeathsanddi seasesr emai nunacceptablyhigh,in2015anest imat ed303,000
womendi edfrom pregenancyr elatedcauses2. 7mill
ionbabi esdiedduringt hefir
st28days
ofli
feand2.6mi ll
ionsbabi eswer est il
lborn,
whi l
esubstantialprogresshasbeenmadeov er
thepasttwodecades, increasedaccesst oanduseofhi gher–qual i
tyhealthcar eduri
ng
pregnancyandchildbir
thcanpr ev entmanyoft hesedeat hsanddi seases,aswel lasimprove
womenandadol escentgirl’
sexper ienceofpr egnancyandchi l
dbir
th,gl
obally,however,onl
y
64%ofwomenr eceiveantentalcar ef ourormor eti
mest hroughoutt heirpregnancy
 Atthetel
anganawhogav ebi
rt
hinthef i
veyear spr
ecedingt hesur
very,
95percent
receivedantenatalcarefortheirlastbi
rt
hf rom askill
edprovider{86%from adoctorand9%
from anaux i
ll
arynur seandmi dwi fel
adyhealthvisi
torAnd92per ecentofmot her
s
regist
eredthepr egnancyforthei rmostrecentli
vebirthinthefi
vey earspr
ecedingthe
survery,
amongt her egist
eredpr egnanci
esreceived89per centreceivedamotherandchil
d
protecti
oncard

Fourormor
eant
ent
alcar
evi
sit
sbydi
str
ictandper
cent
ageofl
astbi
rt
hsi
nthepastf
ive
year

1..
hyder
abad-
86%

2.War
angal
-85%

3.Khammam %79%

4.Rangar
eddy-
75%

5.Tel
angana75%

6.Kar
imnagar-
74%

7.Nal
gondA–73%

8.NI
ZAMABAD–71%

9.MEDAK–68

10.ADI
LABAD-
68%

11.MAHBUNAGAR-
60%

Amongwomenwi thalivebirthinthefiveyearsprecedi
ngt hesur
veywhomet
withacommuni tyheal
thworkerinthel astthr
eemont hsofpregnancyforthei
r
mostr ecent,l
i
vebirthabouttwo–t hir
dsormor ereceiv
edadviceoneachoff i
ve
diff
erentareas(93%recei
vedadviceonbr east
feedi
ng, 87%onkeepingthebabywarm
,80%ont heimpor t
anceofinst
it
utional deli
ver
y,68%oncor dcare,and64%onf amil
y
planning..

t
hepardhanmant risur
akshi
tmat ri
tvaabhiyanhasbeenlaunchedbythe
ministr
yofhealt
h&f amilywelf
aregovernmentofi ndia,
theprogr
am aimstoprov
ided
assured,comphrensiveandquali
tyantenatalcar
e, f
reeofcosrt,
uni
versal
l
ytoall
pregnantwomenont he9thOFEVERYMONTH
Datai
ndicat
esthatMat
ernalMor
tal
it
yRatio(MMR)inI
ndi
awasveryhi
ghint
hey ear
1990with556womendy i
ngdur
ingchil
dbirt
hperhundr
edt
housandli
vebi
rthsas
comparedtothegl
obal
MMRof385/ lakhl
ivebi
rt
hs.

 
AsperRGI-SRS(2011-13)
,MMRofI ndi
ahasnowdecl i
nedt o167/l
akhli
vebir
thsagai
nsta
gl
obalMMRof216/ lakhli
vebi
rt
hs(2015).I
ndiahasregist
eredanoveral
ldecl
i
neinMMRof
70%between1990and2015i ncomparisontoaglobaldecl
ineof44%.

WhileIndiahasmadeconsi derableprogressinthereducti
onofmat ernalandi nf
antmor t
ali
ty,
everyyearappr oxi
mately44000womenst i
l
ldi
eduet opregnancy -r
elatedcausesand
approximat el
y6.6lakhinfant
sdi ewithi
nt hefi
rst28daysofl i
fe.Manyoft hesedeathsare
preventabl
eandmanyl ivescanbesav edifquali
tycareisprovidedtopr egnantwoment hei
r
antenatalperi
odandhi ghr i
skfactorssuchassev ereanemi a,
pr egnancy -
inducehyper
tensi
on
etcaredet ectedontimeandmanagedwel l
…

 AMINIMUM ofei
ghtcontact
sarerecommendedt
oreduceper
inat
almor
tal
i
ty
andi
mprov
ewomen’ sexperi
enceofcar
e

 Counsel
i
ngaboutheal
thyeat
ingandkeepi
ngphy
sical
l
yact
ivedur
ingpr
egnancy

 Dail
yorali
ronandfolicaci
dsupplementat
ionwit
h30mgt o60mgofelemental
iron
and400ug{ 0.4mg}foli
cacidf
orpregnantwoment opr
eventmat
ernal
anaemia
,puer
peralsepsi
s,l
owbi rt
hweight,
andpreter
m bi
rt
h,

 Tetanust
oxoidvacci
nat
ionisr
ecommendedforal
lpregnantwomen,
dependingon
previ
oustet
anusvacci
nati
onexposur
e,t
opr
eventneonatalmor
tal
i
tyf
rom t
etanus.
  Oneul t
rasoundscanbefore24weeksgest ati
on{ear
lyult
rasound}isrecommended
forpregnantwoment oesti
mat egest
ational
age,improvedetect
ionoffetal
anomal i
esandmulti
plepregnanci
es,r
educeinducti
onoflabourforpost–t er
m
pregnancy,andi
mprov eawoman’ spregnancyexper
ience,

 Heal
th–car eprov
idersshoul
daskal
lpregnantwomenaboutt
heiruseofalcohol
andothersubst
ances{pastandpr
esent}asearl
yaspossi
blei
nthepregnancyand
atev
eryantenat
alvisi
t.

St
atementoft
hepr
obl
em:

Assesstheeff
ect
ivenessofst
ructur
edteachi
ngprogr
ammeonknowledger
egardi
ng
ant
enatalcar
eamongpr imigr
avidmothersatthesel
ect
edhospi
tal,
Hyder
abad,t
elangana.

OBJECTI
VES:

1.Toassesst
hepr
e-t
estknowl
edger
egar
dingant
enat
alcar
eamongpr
imi
grav
id
mot
hers.

2.Tocompar
etheknowl
edgescor
eonant
ent
alcar
ebef
oreandaf
terst
p,

3.Totesttheassoci
ati
onbet
weenpost–testknowl
edgepost–testknowl
edgescor
e
andselect
edbackgroundfact
orsamongprimigr
avi
dmothers.

4.Toexpl
oreanddescr
ibetheheal
thseeki
ngpr
act
icesofprimigr
avi
daewhost
art
ed
at
tendi
ngant
enat
alcl
ini
catthelevel
1tri
mest
erofpregnancy
5.Tomakerecommendat
ionwit
htheint
ent
ionofencour
agi
ngpr
imi
grav
idaet
oini
ti
ate
ant
enat
alcar
eint
heirf
ir
stt
ri
mester,

OPERATI
ONSDEFI
NITI
ONS:

ASSESS:ITrefer
stothemethofofest
imat
ingt
helev
elofknowl
edge,
i
nthi
sst
udyand
l
evelofknowledgewasassessedbyknowl
edgest
ool.

Knowl
edge:
i
tref
erst
orel
evanti
nfor
mat
ionandawar
enessr
egar
dinganenat
alcar
es