The findings of this analysis are of concern as despite efforts of the Indian government during the last two decades, only one fifth of pregnant women utilised full ANC. Half of the women did not receive the minimum recommended 4 ANC visits, which are a conservative expectation when compared to the recent recommendations of the World Health Organisation (WHO), a minimum of 8 visits. In 17 out of 36 states/UTs, less than 30% of the pregnant women received full ANC. Inequity in full ANC utilisation was higher in states with low rates of full ANC coverage.
The proportion of women with 4 or more ANC visits is considerably lower than the global average of 61.8% and implementing the recent WHO recommendation of a minimum of 8 ANC visits will be a major challenge for the national programme in India . The number of ANC visits may also be critical to the delivery of other components of ANC and to provide adequate follow-up of pregnant women closer to delivery. The high proportion of mothers with at least one tetanus toxoid immunisation can be achieved even in a single visit during any trimester. In contrast, 100 days of IFA consumption is possible only if multiple visits are made as currently the supplies are given for 1 month at each visit and lower number of visits may be a reason for low utilisation for100 days of IFA.
Registration of pregnancy, utilisation of benefits from the government’s ICDS program and having health insurance were associated with higher odds of full ANC utilisation. Lower maternal education, lower wealth quintile(s), higher birth order, father not accompanying for the ANC visit, teenage pregnancy and unintended pregnancy were associated with lower odds of full ANC utilisation.
Economic status and maternal education were highly associated with utilisation of ANC, which corroborates with previous literature [19,20,21]. Younger maternal age at conception is also common among these women. In LMICs including South East Asia, women from the highest wealth quintile have higher financial and social access to health care services in general, which may lead to higher utilisation of full ANC as seen in the current analysis .
Unintended pregnancy, which may be due to lack of awareness or, a reflection of inadequate or inaccessible family planning services has been associated with lower ANC utilisation previously and our findings also suggest the same [22,23].
Lower ANC utilisation among women of higher parity can be due to increased confidence from previous pregnancy and childbirth experience, constraints of time and resources, poor prior experience with the health system and financial barriers to ANC utilisation .
Equity in states with low ANC utilisation is expected to be lower as those who are better-off are more likely to utilise the services. This finding is critical to account for while redesigning of strategies for increasing ANC utilisation at national and subnational level. As India prepares for achieving universal health coverage, equity in utilisation of essential maternal healthcare services like ANC should be ensured.
Child’s father presence during any ANC visit was associated with higher utilisation of full ANC, this is of special interest in the context of a patriarchal society like India. Child’s father presence during ANC visit, may reflect greater spousal care and support, joint decision making and a more caring environment at home [24,25]. We found a positive association between health insurance coverage and full ANC utilisation in the adjusted analysis. However, only 20% women were covered by health insurance or health schemes and majority of these were beneficiaries of central or state government health insurance schemes . This finding is relevant to the current health policy as majority of the private insurance players and even the recently launched National Health Protection Scheme (“Ayushman Bharat”) do not cover ANC services . Higher utilisation of government’s ICDS services, implemented through Anganwadis which are the focal point of community outreach sessions for antenatal care, health education and nutrition support during pregnancy and lactation was associated with higher odds of full ANC as it acts as a bridging platform for different government schemes like Janani Suraksha Yojna (JSY) and Pradhan Mantri Matru Vandana Yojna (PMMVY) [14,27].
Strengths and limitations
The findings from this analysis should be interpreted considering the following strengths. Our analysis uses data from the most recent survey with a large, nationally representative sample, and is based on a more comprehensive indicator i.e. full ANC (minimum of 4 ANC visits, consumption of 100 or more days of IFA and at least 1 dose of tetanus toxoid), as against the total number of ANC visits used in previous studies. Some limitations are as follows. Lack of information on pregnancies which did not result in a live birth i.e. abortion, miscarriage or still birth restricts us from commenting on the utilisation of ANC in this subset with adverse outcomes. The responses pertaining to the individual components of full ANC, were self-reported and therefore prone to recall bias, although the subgroup analysis restricted to births in the one year preceding the survey yielded similar results. We are unable to comment on some factors like care seeking behaviour, health literacy, distance from the health care facility, provider discrimination and other system side factors for which information was not collected in NFHS-4.