Pregnancy and childbirth complications are the leading causes of maternal mortality worldwide, as an estimated 830 women lose their lives daily from preventable pregnancy- and/or childbirth-related causes. Over 99% of those maternal deaths occur in low- and middle-income countries (LMICs, including India) [1
]. Antenatal care (ANC) provides a unique opportunity for screening and diagnosis, health promotion, and disease prevention among pregnant women, and their families and communities [2
]. Appropriate utilisation of ANC services corresponds to improved maternal and newborn health, as well as a reduction in maternal deaths during pregnancy and childbirth [3
]. Based on the benefits of ANC, the World Health Organisation (WHO) recommends that pregnant women should attend at least four ANC visits to increase opportunities for risk stratification and/or the identification, prevention, and management of pregnancy and/or comorbidities, as well as health promotion [2
Worldwide, approximately 64% of women had attended four or more ANC visits in 2016. However, the attainment of the recommended ANC visits varied between and within countries, with LMICs reporting lower percentages [2
]. In India, previous reports have indicated that the proportion of women who had four or more ANC visits has increased by approximately 38% over a 10-year period, from 37% in 2006 [6
] to 51% in 2016 [7
]. While this improvement in ANC service use may be commendable, it also suggests that many Indian women do not achieve the recommended four or more ANC visits, a proxy for comprehensive maternal care during pregnancy [2
]. This lack of access to appropriate ANC may have potentially adverse short- and long-term impacts on Indian women and newborns. These adverse effects may include maternal death or health loss from haemorrhage, hypertensive disorders, sepsis, and abortion [4
], as well as stillbirth and neonatal death [9
Past nationally representative studies conducted based on the 2005–2006 India Demographic and Health Survey (DHS) data elucidated a number of factors associated with the underutilization of ANC services. These factors included low parental education, urban residence, a lack of mass-media exposure [10
], lower household wealth, the region of residence, and belonging to Scheduled Castes, Scheduled Tribes, and the other backward class [11
]. In addition, previous subnational studies suggested that financial and cultural issues, as well as a lack of awareness of the benefits of ANC among women and their partners, were also barriers to appropriate ANC service use [12
]. Nevertheless, it is uncertain whether these factors have changed in the past 10 years in India, given the improvements in household economic and educational status [14
], social mobility of women [15
], and the implementation of the Government of India maternal and child health interventions. These programs included the National Rural Health Mission (2005), the National Urban Health Mission (2008), and the Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A) Strategy, introduced in 2013 to improve maternal and child health outcomes, including promotion of ANC service use [17
]. Understanding the contextual factors that influence a mother’s decision to attend, or not to attend ANC is crucial to healthcare practitioners and policymakers, as it can offer relevant information and opportunities for targeted policy interventions.
Additionally, findings from the 2005–2006 India DHS may also differ from those obtained from the 2015–2016 DHS, the data source for the present study, due to variations in the sample size and methods used. The 2015–2016 India DHS collected data from 601,509 households, drawn from about 1.2 billion people [7
], compared to 110,000 households in the 2005–2006 DHS, drawn from approximately 1 billion people [6
]. Also, the 2015–2016 DHS methodology now forms the foundation for future national household surveys in India [7
]. The availability of improved methodology for health information gathering and data also suggests the need for up-to-date evidence on the determining factors of ANC service use to guide national maternal health efforts. Therefore, the study aimed to investigate the enablers and barriers to ANC service use in India.
The present study showed that 16.6% of Indian women had no ANC visits, 31.7% had between one and three ANC visits, and just over half received the recommended four or more ANC visits (51.7%). The study demonstrated that higher household wealth status and parental education, belonging to other tribes or castes, a woman’s autonomy to visit the health facility, residence in Southern India, as well as exposure to the media were enablers of the recommended ANC service use (≥4 visits). The recommended four or more ANC attendance was also associated with contraceptive use and a woman’s desire for pregnancy. In contrast, lower household wealth, a lack of woman’s autonomy, and residence in Eastern and Central India were barriers to appropriate ANC use.
The study indicated that mothers who resided in Southern India were more likely to attend at least four ANC visits, as recommended by the WHO compared to their counterparts in Northern India [2
]. In contrast, mothers who resided in the East, Northeast, and Central India were less likely to attend at least four ANC visits compared to those who reside in Northern India. To the authors’ knowledge, region-specific determinants of ANC service use have not been elucidated in India; however, possible reasons for the regional variations in ANC use may be due to region-specific differences in economy, education, access and distance to health facilities, as well as the quality of service provision [30
]. Studies that assess region-specific determining factors of ANC uptake may be needed to inform a more equitable distribution of maternal and child health (MCH) resources and policies at the sub-national level in India.
The association between household wealth status and ANC service utilisation has been documented in LMICs [32
], and was a key factor in the present study. We found that mothers from wealthier households were more likely to attend ANC services compared to those from poorer households, and this association was stronger in those who attended at least four ANC visits. These findings are consistent with previous studies conducted in India [34
], as well as other LMICs, including Nigeria [18
], Pakistan [36
], and Kenya [37
]. Mothers who belonged to lower wealth quintiles may have greater financial challenges in accessing ANC services, as reported in studies from regional India [12
]. Although ANC is almost free in most public hospitals in India, issues such as poor infrastructure, health professional absenteeism, and a shortage of medications in public hospitals, particularly in rural areas, may have pushed pregnant women to seek private ANC services [38
]. Similarly, the costs associated with attending private maternity facilities [39
] and the cost of transportation [40
] have also been described as key barriers to accessible ANC in India.
In recent years, India has implemented a number of MCH interventions to tackle the expenses associated with maternity care services. Most notable of these is the Janani Suraksha Yojana (JSY) scheme, which was implemented by the National Rural Health Mission (NRHM) in 2005 to provide underprivileged pregnant women with cash assistance [41
]. Nevertheless, the costs associated with accessing ANC remains significantly higher than the subsidies provided by programs such as the JSY program [42
]. To improve ANC uptake among Indian women and other MCH outcomes, the Government of India has recently launched new MCH schemes, including the Pradhan Mantri Matru Vandana Yojana, Pradhan Mantri Surakshit Matritva Abhiyan, and LaQshya programmes [43
]. While these initiatives are useful and required, the assessment of how successful and impactful these programs are may need to be documented in the scientific literature, consistent with a previous program [17
], to guide future MCH programmes in India.
Higher maternal education level is an important enabler of ANC utilisation in the present study, as mothers with secondary or higher schooling were more likely to attend at least four ANC visits. The dose-response relationship between maternal education and ANC service use observed in this study is consistent with previous studies conducted in India [10
], Indonesia [45
], Bangladesh [46
], and Turkey [47
]. Higher maternal education may have a synergistic effect with other enablers of ANC utilisation, as women with higher education may be more likely to live in urban areas, gain employment, possess more wealth, and have a better understanding of the benefits of attending ANC [24
]. This association was mirrored in the partner education levels, potentially due to similar reasons. Furthermore, higher education may empower parents to make informed decisions about their health and take action on health promotion initiatives. Our study highlights the importance of targeting low education mothers with health promotion messages, as the majority of mothers who did not attend ANC had no education. More broadly, the Government of India may need to ensure that young girls and boys have access to inclusive and quality education, and ensure a higher completion rates, as articulated in Sustainable Development Goal–4 [48
], which may subsequently lead to greater utilisation of ANC service in the long-term.
Consistent with previous reports [18
], the present study indicated that women who considered access to enabling factors (e.g., household decision-making power, autonomy to attend ANC, and requiring a companion to attend ANC) a big problem, had a corresponding underutilization of ANC services in India. In particular, women who were not involved in household decision-making were less likely to attend between one and three ANC visits, and even less likely to attend four or more ANC visits compared to their counterparts. Similarly, women who reported needing to seek permission from their partners to attend ANC and those who were not usually accompanied to health facilities were also less likely to attend the recommended number of ANC visits. These findings suggest that a woman’s autonomy and support from their partner play important roles in ANC service use.
Contrary to past studies [37
], distance to health facilities was not associated with ANC service use in our study. The Government of India health initiative (the National Rural Health Mission) [17
] that expanded MCH services to disadvantaged rural areas may have played a role in our finding. Women’s exposure to mass media (newspapers or magazines and television) was associated with ANC service use, and this is consistent with past studies [10
]. A lack of exposure to these media outlets may have resulted in women missing out on health promotion messages relating to the benefits of ANC. Additionally, the ownership of media devices may be a direct result of higher household wealth, which was also related to ANC service use. Our research underpins the need to improve women’s autonomy in the household, as well as increase the reach and impact of health promotion campaigns and access to media sources for vulnerable women.
Past studies have suggested that the use of ANC services is influenced by a woman’s desire for pregnancy, as women who carry unplanned pregnancies were less likely to attend ANC [37
]. This finding was demonstrated in our study, where women who had no desire for pregnancy were less likely to attend the recommended four or more ANC visits compared to those who had no desire for pregnancy. Similarly, women who did not use contraceptives were less likely to attend four or more ANC visits. These findings indicate the need for a scale-up of accessible family planning to women of reproductive age, as well as greater access to contraceptive methods and education in India.
Study Limitations and Strengths
This study had limitations. First, the study was based on cross-sectional data, which makes an assessment of a clear temporal relationship between the study factors and ANC attendance impossible. Second, the ANC data collected during the NFHS-4 would have been subjected to recall bias, as it relied on self-reporting. This may have resulted in misclassification measurement bias, and subsequently, led to either an over- or under-estimation of the effect size between the study factors and ANC service use. Third, there was a lack of assessment of other potential confounders (e.g., data on health care access or health status of pregnant women), which may have provided additional information with the enablers and barriers to ANC service use in India. The study also had strengths. First, the large representative sample, with a high response rate (approximately 98%). This implies that selection bias may be unlikely to affect the observed results. Second, trained personnel with validated questionnaires were used to collect data in the NFHS-4, which would have strengthened the internal validity of the study. Lastly, the study provides insight into key determinants of ANC visits in India, and thus, provides an opportunity for policymakers and public health practitioners to design and implement focused MCH interventions.