Bridging the Gap: Examining the level, trends and determinants of Adequacy of Quality Antenatal Care in India

doi:10.21203/rs.3.rs-3101720/v1

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Research Article

Bridging the Gap: Examining the level, trends and determinants of Adequacy of Quality Antenatal Care in India

https://doi.org/10.21203/rs.3.rs-3101720/v1

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Background

Antenatal care (ANC) is an important component of the continuum of care for a mother’s health as it is a complete package of not only timely diagnosis of obstetric conditions but it also awares women about the sign of complications due to pregnancy and the importance of family planning and breastfeeding. It has been estimated that by increasing coverage as well as the quality of ANC nearly all maternal deaths are preventable in low- and middle-income countries. However, there have been very few studies with regard to quality antenatal care in India. Therefore, this study attempts to assess the adequacy of quality ANC in India.

Objectives

Firstly, it attempts to understand the trends and patterns in components of quality ANC and secondly it analyses the determinants of quality ANC in India.

Data & Methods:

This study is based on data from National Family Health Survey. The dependent variable is the quality of antenatal care composed of skilled health care, timeliness, sufficiency, and appropriateness in content. Both bivariate and multivariate generalised ordered logit regression analysis has been employed.

Results

The findings indicate that in 2015-16, there were 16% of births without antenatal care, which decreased to just 6% in 2019-21. Despite significant improvement, the components of antenatal care are far from the requirement of Sustainable Development Goals (SDG). The overall quality of antenatal care is just 33% in NFHS-5, rising 10 percentage points from NFHS-4. Southern state has highest utilisation of adequate quality of ANC. The utilisation of adequate quality of ANC increases with women’s education, wealth quintile and decreases with birth order. It is higher in urban areas; those covered by health insurance and have mass media exposure.

Conclusion

Despite some improvements in coverage of antenatal care, the quality of antenatal care is very low in the country and requires urgent attention by policy and program makers.

Antenatal Care

Quality Service

Anderson Behavioural Model

Maternal Health

Adequacy

India

As per Agenda 2030, the world is in a decade of action, but the striking question is whether the steps taken are enough to tread this efforts to sustainability. It is a matter of concern as a lot of interventions have been undertaken across the globe to achieve the Sustainable Development Goals (SDG), but still, there is a long journey to reach the targets. The new Programme of Actions proposed in International Conference on Population and Development (ICPD) of 1994 emphasises the need of meeting the needs of individuals and providing quality of life within the universally recognised framework of human rights rather than merely meeting the demographic targets. The prime objective of this programme of action is that all people should have access to comprehensive reproductive health care, including voluntary family planning, safe pregnancy, and childbirth services, and the prevention and treatment of sexually transmitted infections ^[1]. Despite the efforts to bring quality to forefront of programmes and policies, intervention is more focused towards increasing the coverage, therefore in the process quality is being compromised especially in countries like India, where demographic transition has been very quick and the population is large.

According to World Health Organisation (WHO), almost 800 women died every day in 2020 due to pregnancy-related complications that were preventable and almost 95% of maternal deaths occurred in low and lower-middle-income countries ^[2]. In India, as per the Sample Registration System report (SRS, 2022), the maternal mortality ratio (MMR) is 103 maternal deaths to per lac live birth in 2017–2019 ^[3], which is far from the first target of Sustainable Development Goal-3 i.e. to reduce MMR to less than 70 per 100000 live births. Therefore, there is a need to expand maternal and infant health care services to all regions and communities, but at the same time, it should not be limited to just the provision of availability and accessibility of health care delivered by skilled health personnel during the antenatal period, instead quality should also be attained ^[4].

In India, there has been continuous attempts to increase the coverage of antenatal care and post-natal care, but the quality is still an issue. Studies have found that failure to use antenatal care (ANC) and inadequate receipt of components of ANC pose a significant risk for the pregnant woman and the baby ^[5]. During pregnancy, antenatal care is the first set of interventions that a pregnant woman receives from the health care system to ensure a good start for the newborn as well as a positive pregnancy experience. Antenatal care is an opportunity for the timely diagnosis of obstetric conditions, educating women about the complexities of pregnancy, the benefits of immediate start of breastfeeding and need of family planning, which are vital components of the continuum of care ^[6–7]. The burden of maternal morbidity and mortality due to the lack of adequate ANC services could be tackled by the strategic and effective implementation of healthcare service utilization promotion and healthcare education in routine ANC visits, which goes beyond just ensuring the coverage ^[8].

The coverage of antenatal care services largely depends on various socio-demographic factors, and are significantly associated with women’s empowerment, maternal education, maternal health status, birth order, economic status, and availability of health facilities ^[9–10]. There are many studies on the associated factors of low utilization of ANC in different parts of India but the literature shows that attempts to understand the factors associated with the utilization of quality ANC in India and even in low-and middle-income countries are very rare ^[11].

However, several efforts have been made to measure the adequacy of ANC in different parts of the world. As early as in 1970s, Kessner DM et. al, constructed an index to measure the timeliness of the initial antenatal care intervention ^[12]. Similarly, by combining several indicators, other authors also tried to develop a measure of adequacy. Unfortunately, some of them either failed in providing comprehensiveness or overlooked the process measures ^[13–14]. This study is based on the concept developed by Heredia-Pi et al who introduced four dimensions to measure the adequacy of quality antenatal care based on the Demographic Health Survey data (DHS) for Mexico and overcome the previous methodological limitation ^[15]. They introduced that quality ANC refers to those services, which are provided by skilled healthcare providers on time and are sufficient without ignoring the appropriateness in content.

As per our knowledge, in the Indian context there has been only one major nationwide study, utilising data from NFHS-4 that attempted to understand the adequacy of quality ANC, consisting each of necessary dimension ^[16], which has been missing in other previous or subsequent studies ^{[5, 17–20]}. The present study is an extension to their efforts as it used the most recent data of NFHS-5, shown the trends and added some additional dimensions in looking up for determinants, which were lacking in the previous study. In addition, this study has attempted to explore the determinants of quality care in context of Anderson Behavioural Model.

Since, there has been very few studies with regard to quality antenatal care in India. Therefore, this study aims to assess the adequacy of quality ANC in India and its determinants so that the policy and programme makers go beyond just the coverage of ANC service utilisation and ensure adequate quality ANC to all. The major objective of this study is to firstly, understand the trends and patterns in components of quality ANC and secondly, to analyse the determinants of quality ANC in India. This study will be a contribution to the Indian maternal health programme in order to achieve SDG targets through convergence of upscaling the utilisation of programme as well as quality provision of services.

Data Source

This study is based on secondary data obtained from the fifth round of the National Family & Health Survey (NFHS) conducted in 2019-21. In addition, for comparison, the fourth round of NFHS conducted in 2015-16 is also analysed. It is a nationally representative cross-sectional retrospective survey following the Demographic Health Survey (DHS) guidelines. The prime objective of NFHS is to provide information on population, health and nutrition for India, covering each of the 28 states, 8 union territories and 707 districts. The survey is conducted under Ministry of Health and Family Welfare (MoHFW), and International Institute for Population Sciences (IIPS), Mumbai is the nodal agency. The sample design, methodology, and findings are available in the national report (IIPS & ICF, 2021) ^[21].

The focus of this study is reproductive and maternal health services, which is covered in woman’s questionnaire employed to all eligible sampled women aged 15–49. Women having at least one child in five years preceding the survey were questioned about their birth history including their utilisation of maternal and child health services. The unit of analysis for this study is the most recent birth to surveyed mothers whom questions on utilisation of antenatal care services were asked. A total of 176,843 samples in NFHS-5 and 190,797 samples in NFHS-4 are taken into consideration for the present study.

Variables

Outcome Variable

The major outcome variable of this study is quality Antenatal Care (QANC). There is lack of consensus about definition of quality antenatal care. Therefore, in the present study, the methodology given by Heredia, Servan-Mori, Darney et.al (2016) to measure adequacy of antenatal health care in Mexico, is followed to compute the outcome variable and modified as per the availability of data in Indian context. In this study, quality antenatal care is composed of four major dimensions as given below:

ANC provided by Skilled Health Care Providers: Antenatal care provided by doctors, auxiliary nurse midwives (ANM), nurses, midwives, or lady health visitors are considered as skilled health care providers.
Timeliness: It is computed using two indicators i.e. antenatal care visit during the first trimester (0-3months) and pregnancy registration during the first trimester.
Sufficiency: According to WHO, at least four antenatal care visits are must for a pregnant woman. So, mothers who had four or more ANC visits are considered into the sufficiency dimension for adequacy.
Appropriateness of component of ANC: During antenatal care visits, a lot of health services are being provided to the mother for a healthy newborn. In this study eight components are considered as per the availability of data. The eight components are weight measurement, blood pressure measurement, urine sample taken, blood sample taken, at least two doses of tetanus injection, consuming IFA tablets for at least 100 days, abdominal examination, and receiving counselling. A score is generated using all these eight indicators, where appropriate ANC is considered only if a mother has received at least seven out of these eight components.

Finally, the quality antenatal care variable is computed through combining these four dimensions into three categories i.e. received adequate ANC consisting adequacy of all four dimensions, received inadequate ANC consisting inadequacy in any of these four dimensions and no ANC consisting those who have not received any of the components of these four dimensions.

Independent Variable

In the present study, independent variables are selected based on the Anderson Behavioural Model, which provides a multilevel framework for personal and environmental determinants of healthcare utilisation ^[22].

Conceptual Framework showing the linkage between selected independent variables and dependent variable based on Anderson Behavioural Model

At community level, region (states classified as North, Central, East, North-East, South, West) and place of residence (rural, urban) is considered. Among predisposing factors, socio-demographic indicators include mother’s age at last birth, mother’s education level, social group, religion, wealth index & birth order and health knowledge related indicator includes mass media exposure. Further, enabling factors include health insurance coverage, relationship with head of households and type of facility for ANC. Lastly, need factor includes desire for pregnancy and adverse previous pregnancy outcome.

Statistical Analysis

The analysis is undertaken into three major phases. Firstly, univariate analysis is conducted for understanding the trends and patterns of each components and dimension of quality antenatal care through percent distribution, graphical representation and mapping. Secondly, bivariate analysis is conducted to understand the distribution of quality antenatal care by independent variables and state. Lastly, since, the categories of outcome variable is following a certain rank/ order therefore ordered logistic regression is applied but proportional odds assumption is violated, therefore generalised ordered logistic regression is used as multivariate analysis technique to identify the determinants of quality antenatal care ^[23]. The proportional odds assumption is tested using Brant Test (Additional File 1).

Trends in components and dimensions of Quality Antenatal Care

Comparison of two most recent rounds of NFHS reveals substantial improvement in every aspects of quality antenatal care (Table 1). ANC by skilled health care providers increased from 79 percent in 2015-16 to 85 percent in 2019-21. The ANC visits during the first trimester increased from 59 percent to 70 percent and the registration of pregnancy in the first trimester increased from 67 to 80 percent, which contributed to increase in the percentage of overall timeliness to 64 percent from 50 percent in India, over the same time-period. However, the sufficiency of ANC i.e., at least four ANC visits during the pregnancy improved slightly from 51 percent to 59 percent. Overall appropriateness based on eight components of ANC witnessed an increase of 19 percentage points between NFHS-4 and NFHS-5.

All the eight aspects encompassing appropriateness have witnessed a significant growth. Six aspects are surpassing 80 percent with two major exceptions, firstly consumption of IFA tablets minimum for 100 days, which is merely 44 percent and percentage of women who received counselling, which is only 65 percent.

(Table 1)

Table 1

Percent distribution of dimensions & components of quality Antenatal Care in India
Indicators	NFHS-5 2019-21		NFHS-4 2015-16
Indicators	%	95% CI	%	95% CI
ANC by skilled health care provider	85.1	[84.88 - 85.32]	79.3	[79.07 - 79.56]
Timeliness in ANC	63.8	[63.49 - 64.12]	50.0	[49.65 - 50.32]
ANC visit during the first trimester (0-3months)	70.0	[69.74 - 70.34]	58.6	[58.30 - 58.95]
Pregnancy registered during the first trimester	80.0	[79.71 - 80.24]	66.6	[66.26 - 66.88]
Sufficiency (Four or more ANC)	58.5	[58.17 - 58.81]	51.2	[50.87 - 51.53]
Overall appropriate ANC (at least 7 out of 8 component)	64.3	[63.97 - 64.59]	45.3	[44.95 - 45.62]
Weight measurement	91.1	[90.91 - 91.28]	75.6	[75.32 - 75.83]
Blood Pressure measured	90.3	[90.16 - 90.53]	74.7	[74.44 - 74.96]
Urine sample taken for test	87.9	[87.68 - 88.09]	73.5	[73.20 - 73.73]
Blood sample taken for morbidity and sugar level	88.5	[88.26 - 88.66]	72.9	[72.67 - 73.21]
At-least two doses of tetanus injection during pregnancy	83.1	[82.90 - 83.37]	83.0	[82.75 - 83.24]
Consumed IFA tablet at least for 100 days	44.1	[39.95 - 40.58]	30.3	[29.99 - 30.64]
Abdominal examination	86.9	[86.66 - 87.09]	74.0	[73.75 - 74.29]
Counselling received or not	64.6	[64.29 - 64.93]	44.8	[44.44 - 45.11]
N	176843		190797

Further, in 2015-16, out of every 100 eligible surveyed mothers 18 were not getting any component of ANC, 59 were getting inadequate ANC and only 23 were getting adequate ANC. However, in 2019-21, out of every hundred women only eight were not getting any ANC, 60 were getting inadequate and 32 were receiving adequate quality of ANC. The percentage of mothers receiving adequate quality of ANC has increased between NFHS4 and NFHS5 but it is still very low, as only one-third of the mothers are receiving the adequate quality of ANC in 2019-21 (Fig. 1).

(Fig. 1)

The independent coverage of each of the dimensions indicates that the proportion of mothers is highest for the skilled healthcare provider and increases over both rounds of NFHS. The percentage is lowest for appropriateness of the content of ANC (45%) in NFHS-4 but for NFHS-5 out of all the four dimensions, it is lowest for sufficiency (59%). The analysis on conditional coverage highlights that out of every hundred women who received at least four ANC from a skilled health care provider within the right time, only 70 were getting appropriate ANC as per NFHS-4 and the figure is 80 as per NFHS-5. This reflects that there is still a huge gap in the delivery of quality ANC (Table-2).

(Table 2)

Table 2

Independent and conditional coverage of the dimensions of Quality ANC in India
Dimension of ANC	NFHS-4 (2015-16)				NFHS-5 (2019-21)
	Independent coverage		Conditional coverage		Independent coverage		Conditional coverage
	%	95% CI	%	95% CI	%	95% CI	%	95% CI
Skilled health care(antenatal care provided by doctors, auxiliary nurse midwives, nurses, midwives or lady health visitors)	79.32	[79.07–79.56]	79.32	[79.07–79.56]	85.10	[84.88–85.32]	85.1	[84.88–85.32]
Timeliness(first ANC visit and registration during the first trimester of pregnancy)	49.99	[49.65–50.32]	60.31	[59.93–60.68]	63.80	[63.49–64.12]	68.62	[68.29–68.96]
Sufficiency(at least four antenatal care visits completed during pregnancy)	51.20	[50.87–51.53]	70.11	[69.68–70.54]	58.49	[58.17–58.81]	70.61	[70.23–70.99]
Appropriateness in content(an indicator summarising the procedures and processes of care provided during antenatal check-up)	45.30	[44.97–45.65]	70.05	[69.51–70.60]	64.28	[63.97–64.59]	79.48	[79.06–79.90]

Spatial Heterogeneities in Quality Antenatal Care

The state wise distribution of quality of antenatal care highlights that Nagaland, Arunachal Pradesh, Mizoram, Sikkim, and Bihar are the states where one out of every five mothers are not getting any component of ANC in 2019-21 (Fig. 2). Uttar Pradesh (78 percent), Bihar (72 percent), and Jharkhand (72 percent) are the states, where proportion of women receiving inadequate ANC is highest. The utilization of adequate quality ANC is lowest in Nagaland and Bihar where out of every 11 mothers only one is getting adequate ANC, while it is highest in states of Kerala and Tamil Nadu, where nearly 10 out of every 16 eligible women is getting adequate ANC. Among Union Territories (UTs), Lakshadweep (75 percent) and Puducherry (67 percent) are best performing UTs in terms of adequate quality of ANC.

(Fig. 2)

Further, the district-wise distribution of adequate quality antenatal care shows that along with interstate variation, there is variation within states but despite that, there is clustering of higher percentage of mothers who are utilising adequate quality of ANC in districts in southern part of India. The clustering of lower utilisation of adequate quality of ANC is in the districts of northern plain and north-eastern India (Map1).

(Map1)

Adequacy of quality ANC by socio-demographic characteristics

There is not a huge difference in sample distribution for each categories of quality antenatal care by background characteristics except for few variables like maternal education, mass media exposure, place of ANC and wealth quintile (Additional File 2).

The coverage of quality ANC by independent variables in 2019-21 indicates that adequacy of quality ANC is highest in 22–39 years age group of mothers at the last delivery with 33 percent whereas no ANC is highest among mothers of 40–49 years with 15 percent. In each of the age group, inadequate ANC is nearly 60 percent. In terms of mother’s education level, 44 percent of mothers having higher education is receiving adequate antenatal care but it is a serious concern as mother’s education is one of the crucial determinants of mother and child’s health but even among them adequate quality is received only by half of the mothers. Further, mothers having more than four children have lowest percentage of receiving adequate quality ANC, however it is highest for first birth with 39 percent. Adverse outcome of previous pregnancy has slightly higher percentage of women receiving adequate antenatal care, but just 1.5 percentage points higher.

(Table 3)

Table 3: Percent distribution of Adequacy of Quality ANC by background characteristics of sampled eligible women in India, 2019-21
Background characteristics	No ANC		Inadequate ANC		Adequate ANC		N (Weighted)
Background characteristics	%	95% CI	%	95% CI	%	95% CI	N (Weighted)
Mother's age at the time of most recent delivery
Under 21years	8.0	[07.61 - 08.37]	60.0	[59.31 - 60.63]	32.0	[31.41 - 32.68]	43726
22-29 years	7.1	[06.86 - 07.29]	59.8	[59.37 - 60.21]	33.1	[32.73 - 33.54]	104038
30-39 years	8.8	[08.35 - 09.28]	58.1	[57.28 - 58.96]	33.1	[32.25 - 33.88]	27733
40-49 years	15.4	[12.47 - 18.25]	61.5	[57.98 - 65.06]	23.1	[20.15 - 26.09]	1347
Mother's education Level
No Education	14.2	[13.68 - 14.65]	68.2	[67.59 - 68.84]	17.6	[17.11 - 18.12]	34515
Primary	8.6	[08.05 - 09.10]	64.8	[63.94 - 65.71]	26.6	[25.78 - 27.43]	20749
Secondary	6.1	[05.83 - 06.29]	57.9	[57.43 - 58.34]	36.1	[35.61 - 36.50]	91047
Higher	4.3	[03.98 - 04.66]	51.4	[50.47 - 52.25]	44.3	[43.43 - 45.21]	30534
Birth Order
1st order	5.7	[05.45 - 06.02]	54.8	[54.25 - 55.41]	39.4	[38.87 - 40.01]	60612
2nd or 3rd order	7.3	[07.10 - 07.57]	60.5	[60.02 - 60.91]	32.2	[31.77 - 32.63]	93363
4th or more	13.9	[13.35 - 14.51]	68.6	[67.81 - 69.38]	17.5	[16.83 - 18.12]	22868
Previous adverse pregnancy outcomes
No	7.8	[07.64 - 08.03]	59.6	[59.26 - 59.97]	32.6	[32.20 - 32.89]	148447
Yes	6.6	[06.17 - 07.00]	59.4	[58.62 - 60.25]	34.0	[33.19 - 34.78]	28397
Relationship with the head of households
Herself or any one from her maternal side	9.5	[08.90 - 09.99]	61.1	[60.19 - 61.91]	29.5	[28.65 - 30.28]	25630
Husband	8.4	[08.15 - 08.71]	59.7	[59.19 - 60.22]	31.9	[31.37 - 32.36]	75284
In Laws	6.2	[05.98 - 06.48]	59.0	[58.49 - 59.45]	34.8	[34.33 - 35.26]	75929
Type of facility exposed for ANC utilization
Home only or not utilized any ANC	45.4	[44.51 - 46.31]	41.1	[40.23 - 42.04]	13.5	[12.80 - 14.11]	25648
Public	1.3	[01.20 - 01.41]	65.6	[65.17 - 65.97]	33.1	[32.73 - 33.52]	98748
Private	1.1	[00.93 - 01.24]	57.4	[56.70 - 57.99]	41.6	[40.92 - 42.21]	52448
Mass Media Exposure
No Exposure	13.4	[13.01 - 13.82]	68.3	[67.76 - 68.87]	18.3	[17.80 - 18.74]	47322
Have Exposure	5.5	[05.34 - 05.72]	56.4	[56.01 - 56.79]	38.1	[37.69 - 38.46]	129522
Intended Pregnancy
Yes	7.2	[06.98 - 07.34]	59.1	[58.76 - 59.44]	33.7	[33.41 - 34.07]	54895
No	13.1	[12.37 - 13.91]	65.2	[64.05 - 66.26]	21.7	[20.73 - 22.69]	3068
Covered with health insurance
No	8.3	[08.06 - 08.48]	61.0	[60.60 - 61.36]	30.8	[30.38 - 31.11]	134693
Yes	5.6	[05.33 - 05.91]	55.1	[54.51 - 55.74]	39.3	[38.65 - 39.86]	42151
Wealth Quintile
Poorest	13.8	[13.35 - 14.24]	67.1	[66.46 - 67.64]	19.2	[18.66 - 19.65]	40270
Poorer	8.1	[07.69 - 08.47]	64.8	[64.16 - 65.45]	27.1	[26.52 - 27.71]	37210
Middle	5.6	[05.22 - 05.90]	59.1	[58.37 - 59.81]	35.4	[34.64 - 36.06]	34620
Richer	4.9	[04.53 - 05.21]	54.2	[53.37 - 54.98]	41.0	[40.17 - 41.75]	34015
Richest	4.4	[04.04 - 04.84]	50.0	[49.13 - 50.93]	45.5	[44.63 - 46.42]	30728
Social Group
SC	8.1	[07.71 - 08.49]	61.6	[60.88 - 62.26]	30.3	[29.66 - 30.99]	40057
ST	8.9	[08.38 - 09.39]	59.2	[58.28 - 60.01]	32.0	[31.15 - 32.78]	17479
OBC	7.2	[06.93 - 07.44]	60.5	[60.05 - 61.00]	32.3	[31.83 - 32.74]	76048
Others	7.5	[07.11 - 07.88]	56.3	[55.54 - 57.01]	36.2	[35.52 - 36.95]	43261
Religion
Hindu	7.1	[06.95 - 07.33]	60.0	[59.64 - 60.37]	32.9	[32.50 - 33.20]	140715
Muslim	9.5	[09.02 - 10.05]	59.1	[58.21 - 59.94]	31.4	[30.57 - 32.21]	28145
Others	9.7	[08.82 - 10.56]	54.0	[52.56 - 55.42]	36.3	[34.90 - 37.74]	7983
Place of Residence
Urban	6.3	[05.52 - 06.29]	52.8	[52.06 - 53.53]	41.3	[40.57 - 42.02]	49876
Rural	8.5	[08.12 - 08.51]	62.3	[61.91 - 62.60]	29.4	[29.10 - 29.76]	126968
Region
North	6.5	[06.19 - 06.85]	56.3	[55.68 - 56.99]	37.2	[36.51 - 37.78]	24028
Central	6.0	[05.75 - 06.27]	72.0	[71.47 - 72.46]	22.0	[21.57 - 22.49]	47131
East	12.5	[12.02 - 12.91]	60.9	[60.24 - 61.58]	26.6	[26.00 - 27.25]	45619
North East	9.1	[08.61 - 09.53]	63.7	[62.81 - 64.54]	27.3	[26.43 - 28.07]	7169
West	7.6	[06.93 - 08.29]	51.5	[50.31 - 52.76]	40.9	[39.66 - 42.04]	22855
South	3.4	[03.14 - 03.74]	45.9	[45.07 - 46.75]	50.7	[49.80 - 51.50]	30045

Surprisingly, the adequacy of quality ANC is highest in those households where In-Laws are head of the household with 39 percent, in contrast where woman herself is head of household or her parents are head, the percentage is 29.5. Further, in comparison to utilisation of public facility for accessing ANC, the adequacy is higher in private facility with 42 percent. In terms of mass media exposure, those having the exposure to television, radio or newspaper have higher percentage of women receiving adequate quality ANC by 20 percent points. Also, mothers having unintended pregnancy have lower percentage of receiving adequate quality of antenatal care. Coverage by health insurance indicates higher percentage of adequacy in ANC by eight percentage points as compared to those who are not covered. As expected mothers from richer quintile have higher percentage in receiving adequate quality of ANC with 45 percent. Distribution by social groups shows that the percentage of adequate quality of ANC is higher among “others” with 36 percent and lowest among scheduled caste with 30 percent. In addition, distribution by religions shows that “others” have higher percentage of adequacy in receiving quality ANC and lowest is among Muslims with 31 percent and 33 percent of Hindus are receiving adequate quality of ANC. In terms of place of residence, higher percentage of mothers in urban areas have received adequate quality of ANC as compared to mothers in rural areas and the difference is of 12 percent points. Among regions of India, in southern region, almost half of the mothers are receiving adequate quality of care. This percentage is lowest for mothers in central region with just 22 percent (Table 3).

Determinants of adequate quality of ANC

The adjusted odds of getting adequate quality of ANC in comparison to no ANC and inadequate ANC is significantly associated with mother’s age at time of delivery, mother’s education level, birth order, previous adverse pregnancy outcome, relationship with head of households, type of facility for ANC, mass media exposure, intended pregnancy, coverage by health insurance, wealth quintile, social group, religion, place of residence and region. Mothers of age group 30–39 years at the time of last birth is 1.31 times more likely to receive adequate ANC than mothers giving their most recent birth at less than 21 years age. Further, the odds of receiving adequate quality of ANC increases with the level of education among mothers and it is 1.55 times more among mothers having higher education than mothers with no education. The association with birth order indicates that with increasing number of births, the adequacy of quality ANC decreases. The experience of adverse previous pregnancy outcome is 1.07 times more likely to have adequate quality of ANC.

(Table 4)

Table 4: Generalised Ordered logistic model of Quality ANC with key independent variables in India, 2019-21

Background variables	No ANC vs inadequate & adequate ANC		No ANC & inadequate ANC vs adequate ANC
Background variables	Odds ratio	[95% Conf. Int.]	Odds ratio	[95% Conf. Int.]
Mother's age at the time of last delivery
Under 21	1.00		1.00
22–29	1.14**	[1.05–1.25]	1.14***	[1.10–1.19]
30–39	1.19**	[1.06–1.35]	1.35***	[1.27–1.43]
40–49	1.02	[0.72–1.45]	1.31**	[1.07–1.60]
Mother's education Level
No Education	1.00		1.00
Primary	1.32***	[1.19–1.46]	1.33***	[1.26–1.41]
Secondary	1.48***	[1.36–1.61]	1.54***	[1.47–1.61]
Higher	1.4***	[1.21–1.61]	1.55***	[1.46–1.65]
Birth Order
1st order	1.00		1.00
2nd or 3rd order	0.81***	[0.75–0.89]	0.75***	[0.72–0.77]
4th or more	0.67***	[0.60–0.76]	0.53***	[0.50–0.56]
Previous adverse pregnancy outcomes
No	1.00		1.00
Yes	1.05	[0.96–1.16]	1.07**	[1.03–1.12]
Relationship with the head of households
Herself or any one from her maternal side	1.00		1.00
Husband	1.11*	[1.01–1.22]	1.18***	[1.12–1.23]
In Laws	1.18**	[1.08–1.30]	1.11***	[1.06–1.17]
Type of facility exposed for ANC utilization
Public	1.00		1.00
Home only or not utilized any ANC	0.02***	[0.01–0.02]	0.28***	[0.27–0.30]
Private	0.98	[0.83–1.16]	1.06**	[1.02–1.09]
Mass Media Exposure
No Exposure	1.00		1.00
Have Exposure	1.33***	[1.23–1.44]	1.51***	[1.45–1.58]
Intended Pregnancy
Yes	1.00		1.00
No	0.66***	[0.60–0.72]	0.69***	[0.65–0.74]
Covered with health insurance
No	1.00		1.00
Yes	1.12**	[1.04–1.21]	1.26***	[1.21–1.30]
Wealth Quintile
Poorest	1.00		1.00
Poorer	1.14**	[1.04–1.24]	1.11***	[1.05–1.16]
Middle	1.26***	[1.13–1.40]	1.24***	[1.18–1.31]
Richer	1.18*	[1.04–1.34]	1.36***	[1.28–1.44]
Richest	1.13	[0.95–1.33]	1.48***	[1.38–1.59]
Social Group
OBC	1.00		1.00
SC	1.15**	[1.05–1.24]	1.08***	[1.04–1.12]
ST	1.07	[0.97–1.19]	1.36***	[1.29–1.43]
Others	1.21***	[1.11–1.33]	1.16***	[1.11–1.21]
Religion
Others	1.00		1.00
Hindu	1.64***	[1.43–1.90]	1.14***	[1.06–1.22]
Muslim	1.67***	[1.42–1.97]	1.26***	[1.17–1.37]
Place of Residence
Rural	1.00		1.00
Urban	0.94	[0.85–1.04]	1.08***	[1.04–1.13]
Region
South	1.00		1.00
North	0.39***	[0.35–0.45]	0.58***	[0.55–0.61]
Central	0.61***	[0.54–0.69]	0.36***	[0.34–0.38]
East	0.46***	[0.40–0.52]	0.57***	[0.54–0.60]
North East	0.43***	[0.37–0.50]	0.44***	[0.41–0.47]
West	0.78**	[0.67–0.92]	0.79***	[0.74–0.85]
_cons	44.7***	[35.26–56.66]	0.29***	[0.26–0.32]

In terms of relationship with head of households, mothers are more likely to receive adequate quality of ANC if the head of household is their husband with an odds of 1.18. In comparison to exposure to public facility for receiving adequate quality of ANC, those having experience of private facility for ANC is 1.06 times more likely to receive adequate quality of ANC. The mass media exposure and coverage by health insurance increases the likelihood of receiving adequate quality of ANC by 1.51 times. Unintended pregnancy decreases the likelihood of receiving adequate quality of ANC by 0.31 times. The association with wealth quintile shows that the likelihood of receiving adequate quality of ANC increases by increasing wealth quintile as richest quintile are 1.48 times more likely to receive adequate ANC than poorest quintile. Further, scheduled tribes are 1.36 times more likely to receive adequate quality of ANC than OBC and scheduled caste are 1.08 times more likely to receive adequate QANC. Muslims are 1.26 times more likely to receive adequate quality of ANC as compared to others, but Hindus are 1.14 times more likely to receive adequate quality of ANC. Mothers in urban areas are 1.08 times more likely to receive adequate quality of ANC than mothers in rural areas. Lastly, in terms of regions, all the regions have negative association with adequate quality of ANC as compared to southern region (Table 4).

Main Findings

This study attempts to understand the scenario of adequacy in quality of ANC in India and identify its determinants. The foremost and most worrying finding is that although there is a significant increase in percentage of women receiving ANC, majority of them are receiving inadequate quality of ANC, with a marginal increase in percentage of women receiving adequate quality of ANC between NFHS-4 and NFHS-5. Only one-third of the women attended by skilled health personnel get timely sufficient and appropriate ANC in India. Further, the findings reveal that there is interstate and intrastate variations in provision of adequate quality of ANC, where southern India is performing much better than the state and districts in northern and north-eastern India. Another major finding is that the adequacy in quality of antenatal care increases with higher education of women, wealth status, and mass media exposure and decreases with the increasing number of births. Further, it is higher among urban women, having health insurance coverage, adverse outcome in previous pregnancy, intended pregnancy and exposed to private facilities. Additionally, Scheduled Tribes and Muslims are more likely to receive adequate quality of ANC as compared to OBC and others respectively. However, it is important to highlight that this study has found that none of the socio-demographic category consist half of its mother receiving adequate quality of ANC, whether its richest quintile or women having higher education. Quality is found to be a serious and universal concern in the Indian context.

Interpretations of Findings

The present study is based on a comprehensive but understudied approach that attempts to highlight the complete scenario of the quality of antenatal care delivered by the healthcare system in India. Despite the fact that maternal mortality reduced significantly in the last decade in India, India is still on the list of most vulnerable countries in terms of the burden of maternal deaths, the majority of which are preventable. This study reflects that to achieve the target of SDG goals 3.1 and 3.2, there is a need to accelerate the service delivery system which should be delivered by skilled healthcare providers easily accessible and affordable to all, that too, timely and should be appropriate in content.

The findings of this study on the socio-economic and regional disparity of adequate quality of ANC are consistent with other studies analysing utilisation of ANC. The percentage of mothers receiving adequate quality ANC increases from lower to the higher wealth quintile, no education to higher education, and is quite high in urban areas. In southern & western regions of India, the proportion of utilization of adequate quality of ANC is higher as compared to the Central and Eastern regions of India. Ogbo et.al 2019 also found that the enablers of the recommended ANC visits are higher household wealth status and parental education, residence in Southern India but, residence in East and Central India were barriers to appropriate ANC service use ^[24]. Further, this study highlights that younger women are less likely to receive the adequate quality ANC and it decreases with an increase in the parity of women but increases if the mother has experienced adverse pregnancy outcomes previously, which is very much similar to the well-established associations found in other studies on utilisation of ANC ^{[9, 25–26]}. Studies in context of neighbouring countries, like Nepal, also supports the findings of this study ^[27].

There are several possible explanations for the associations established in this study for adequate quality of ANC. The lower reception of adequate quality of ANC is explained by distant location of facilities, deficiency of facility resources, indifferent attitude, non-availability of the staff, and lack of client awareness ^[28]. Further, a study in Ethiopia found that the lower quality of ANC provision is very much associated with structural element of health facility and skills of health care providers ^[29].The present study points out that even among women with higher education, nearly half of the women are not receiving adequate quality of ANC. The probable causes could be lack of knowledge of all the components of quality ANC or that the aware women are worried about the burden of expenditure in private facilities, and long queues and waiting time in public facilities, resulting in lesser utilisation of ANC ^[30–31]. The exposure to private facility for ANC increases the odds of utilisation of adequate quality of ANC due to the interplay of the better infrastructure as well as accountability of health care providers. Therefore there is need to prioritise the public healthcare infrastructure on an immediate basis along with strengthening the interventions so that women from lower quintiles could receive adequate quality of ANC. The rural-urban gap in quality ANC utilization can be explained as the difference in economic status and accessibility of services, exposure to mass media, and awareness about policies and programs ^{[25, 32]}. Women covered with health insurance have higher utilisation of adequate quality of ANC, this is probably because in Indian context health insurance are mostly taken by those who can afford, particularly from private agencies and they can easily access private facilities ^[33]. However, a recent study in Bihar showed that due to the availability of cash incentives under the JSY scheme institutional delivery got a boost but ANC care utilization is too low due to no financial coverage ^[34]. This study also reveals that women belonging to the southern region are more likely to receive adequate ANC services compared to other regions. Another recent study based on NFHS-5 data argued that low utilization of ANC services in any region can be attributed to little or no access to media, low levels of education, and less availability of health facilities and skilled health personnel, which is clearly reflected in terms of findings of this study as women from southern region are more likely to receive adequate ANC services ^[5]. Similarly, one literature emphasized the importance of maternal healthcare policies and higher political commitment, as an explanation to such regional disparities. ^[35]

The present study points out to major findings, which are quite different from the existing literature. Unlike the other studies, which presents that Hindus are more likely to utilize health care services than Muslims ^{[16, 36]} and SC/ST are less likely to utilise health services ^[37], this study found that the odds of receiving adequate quality of ANC among Muslims is higher than that of Hindus when compared to others. Further, the odds of utilizing adequate ANC are highest among ST women than its counterparts when compared to others backward class. The probable explanation for this finding needs exploration, as it is different from the existing literatures.

Limitations of the study

Despite all these significant contributions of this study, there are certain limitations. This study is limited to evaluate only some features of the supply of antenatal care that too reported by the respondent only. It does not evaluate some of the additional quality dimensions proposed by other theoretical frameworks, such as technical quality, interpersonal quality and amenities ^[38–39]. Additionally, recall bias may affect this study because some women may not be able to remember about all the components that she received during pregnancy. Other major limitation is that for appropriateness all the components got equal weightage in our analysis, as there is no available literature, which prioritized the components of appropriateness. Lastly, since this study is based on cross sectional data, cause and effect cannot be determined, hence it is limited to the assessment of associations.

Antenatal care is the most important aspect to improve maternal as well as child health and not only to avoid mortalities but also to avoid long term consequences other than mortality which may occur due to pregnancy. Findings indicate that despite some improvements in coverage of antenatal care, the quality of antenatal care is very low in the country and requires urgent attention in maternal health related policies and programmes. This study shows that the mere availability of schemes may not affect the comprehensive utilization of all services of maternity care; instead, implementation needs to be focused to ensure quality so that the objectives of the national health mission are fulfilled. Special attention needs to be given to vulnerable groups consisting young women with no education, belonging to the poorest quintile & scheduled caste, residing in rural areas, having higher parity, no mass media exposure & not being covered by health insurance. It should also be noted that even among the women having higher education, not even half of them are receiving adequate quality of antenatal care. So, there is need to expand awareness about the components of antenatal care and making health services affordable to all. Lastly, lessons can be learned from the districts in southern state where quality is comparatively ensured along with coverage of ANC.

SDG

Sustainable Development Goals

ICPD

International Conference on Population and Development

WHO

World Health Organisation

SRS

Sample Registration System

MMR

Maternal Mortality Ratio

ANC

Antenatal Care

DHS

Demographic Health Survey

NFHS

National Family and Health Survey

MoHFW

Ministry of Health and Family Welfare

IIPS

International Institute for Population Sciences

QANC

Quality Antenatal Care

UTs

Union Territories

ANM

Auxiliary Nurse Midwives

IFA

Iron-Folic Acid

OBC

Other Backward Class

JSY

Janani Suraksha Yojana

Scheduled Caste

Scheduled Tribes

Confidence Interval

Ethical approval

The study is based on the National Family Health Survey (NFHS) – conducted during 2015-16 and 2019-21, which are available in the public domain with no identifiable information on the survey participants. Therefore, no ethics statement is required for this work.

Consent for publication

Not applicable.

Availability of data and materials

The NFHS data can be downloaded from www.dhsprogram.com.

Competing interests

The authors declare that they have no competing interests.

Funding

There is no funding received for this study.

Author’s contributions

SN conceptualized and designed the study. SN conducted the data analysis and drafted the manuscript. SN has read and approved the manuscript.

Acknowledgements

This research paper is made possible by the generous support of Professor T.V Sekher through his valuable comments and guidance in various stages of the manuscript. The contents of this manuscript are the sole responsibility of the author and do not necessarily reflect the views of the reviewers.

Author information

¹International Institute for Population Sciences (IIPS), Mumbai, India.

United Nations Population Fund. International Conference on Population and Development [Internet]. UNFPA. [Cited 2023 Feb 23]. Available from: https://www.unfpa.org/icpd
World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience [Internet]. 2016 Nov [cited 2023 Feb 18]. Available from: https://www.who.int/publications/i/item/9789241549912
Office of the Registrar General & Census Commissioner India (ORGI). Sample Registration System (SRS)-Special Bulletin on Maternal Mortality in India 2017-19 [Internet]. Delhi; 2022 Mar [cited 2023 Feb 28]. Available from: https://censusindia.gov.in/nada/index.php/catalog/40525/study-description
Austin A, Langer A, Salam RA, Lassi ZS, Das JK, Bhutta ZA. Approaches to improve the quality of maternal and newborn health care: An overview of the evidence. Reprod Health. 2014 Sep 4; 11.
Nagdev N, Ogbo FA, Dhami MV, Diallo T, Lim D, Agho KE, et al. Factors associated with inadequate receipt of components and non-use of antenatal care services in India: a regional analysis. BMC Public Health. 2023 Jan 3; 23(1):6.
Tunçalp Ӧ., Pena-Rosas JP, Lawrie T, Bucagu M, Oladapo OT, Portela A, et al. WHO recommendations on antenatal care for a positive pregnancy experience-going beyond survival. BJOG. 2017 May; 124(6):860–2.
Wang W, Hong R. Levels and determinants of continuum of care for maternal and newborn health in Cambodia-evidence from a population-based survey. BMC Pregnancy Childbirth. 2015 Dec 19;15(1):62.
World Health Organization. Maternal mortality [Internet]. 2023 Feb [cited 2023 Mar 1]. Available from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
Rustagi R, Basu S, Garg S, Singh M, Mala Y. Utilization of antenatal care services and its sociodemographic correlates in urban and rural areas in Delhi, India. Eur J Midwifery. 2021 Sep 10;5(September):1–5.
Kumar G, Choudhary TS, Srivastava A, Upadhyay RP, Taneja S, Bahl R, et al. Utilisation, equity and determinants of full antenatal care in India: analysis from the National Family Health Survey 4. BMC Pregnancy Childbirth. 2019 Dec 5;19(1):327.
Alexander GR, Cornely DA. Prenatal care utilization: its measurement and relationship to pregnancy outcome. Am J Prev Med. 1987;3(5):243–53.
Kessner DM, Singer J, Kalk CE, Schlesinger ER. Infant death: an analysis by maternal risk and health care. Institute of Medicine. National Academy of Sciences, Washington, DC. 1973;97:1950-68.
Kotelchuck M. The Adequacy of Prenatal Care Utilization Index: its US distribution and association with low birthweight. Am J Public Health. 1994 Sep;84(9):1486–9.
Kogan MD. The Changing Pattern of Prenatal Care Utilization in the United States, 1981-1995, Using Different Prenatal Care Indices. JAMA. 1998 May 27;279(20):1623.
Heredia-Pi I, Servan-Mori E, Darney BG, Reyes-Morales H, Lozano R. Measuring the adequacy of antenatal health care: a national cross-sectional study in Mexico. Bull World Health Organ. 2016 Jun 1;94(6):452–61.
Singh L, Dubey R, Singh S, Goel R, Nair S, Singh PK. Measuring quality of antenatal care: a secondary analysis of national survey data from India. BJOG. 2019 Aug;126 Suppl 4:7–13.
Radovich E, Chaudhry M, Penn-Kekana L, Raju KRK, Mishra A, Vallabhuni R, et al. Measuring the quality of antenatal care in a context of high utilisation: evidence from Telangana, India. BMC Pregnancy Childbirth. 2022 Nov 25;22(1):876.
Upadhyay AK, Singh A, Srivastava S. New evidence on the impact of the quality of prenatal care on neonatal and infant mortality in India. J Biosoc Sci. 2020 May 9;52(3):439–51.
Khan REA, Raza MA. Utilization of Quality Source of Prenatal-Care in India: An Evidence from IDHS. Soc Indic Res. 2017 Apr 4;131(3):1163–78.
Dandona R, Majumder M, Akbar M, Bhattacharya D, Nanda P, Kumar GA, et al. Assessment of quality of antenatal care services in public sector facilities in India. BMJ Open. 2022 Dec 1;12(12):e065200.
International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5) [Internet]. India; 2022 Mar [cited 2023 Mar 5]. Available from: http://rchiips.org/nfhs/
Andersen R, Newman JF. Societal and Individual Determinants of Medical Care Utilization in the United States. Vol. 51, Source: The Milbank Memorial Fund Quarterly. Health and Society. Winter; 1973.
Williams R. Understanding and interpreting generalized ordered logit models. Journal of Mathematical Sociology. 2016 Jan 1;40(1):7–20.
Ogbo FA, Dhami MV, Ude EM, Senanayake P, Osuagwu UL, Awosemo AO, et al. Enablers and Barriers to the Utilization of Antenatal Care Services in India. Int J Environ Res Public Health. 2019 Aug 29;16(17):3152.
Singh PK, Rai RK, Alagarajan M, Singh L. Determinants of Maternity Care Services Utilization among Married Adolescents in Rural India. PLoS One. 2012 Feb 15;7(2):e31666.
Ghosh-Jerath S, Devasenapathy N, Singh A, Shankar A, Zodpey S. Ante natal care (ANC) utilization, dietary practices and nutritional outcomes in pregnant and recently delivered women in urban slums of Delhi, India: an exploratory cross-sectional study. Reprod Health. 2015 Dec 20;12(1):20.
Joshi C, Torvaldsen S, Hodgson R, Hayen A. Factors associated with the use and quality of antenatal care in Nepal: a population-based study using the demographic and health survey data. BMC Pregnancy Childbirth. 2014 Dec 3;14(1):94.
Majrooh MA, Hasnain S, Akram J, Siddiqui A, Memon ZA. Coverage and Quality of Antenatal Care Provided at Primary Health Care Facilities in the ‘Punjab’ Province of ‘Pakistan.’ PLoS One. 2014 Nov 19;9(11):e113390.
Defar A, Getachew T, Taye G, Tadele T, Getnet M, Shumet T, et al. Quality antenatal care services delivery at health facilities of Ethiopia, assessment of the structure/input of care setting. BMC Health Serv Res. 2020 Dec 1;20(1):485.
Goli S, Moradhvaj, Rammohan A, Shruti, Pradhan J. High Spending on Maternity Care in India: What Are the Factors Explaining It? PLoS One. 2016;11(6):e0156437.
Kavitha N. Are Young Mothers in India Deprived of Maternal Health Care Services? A Comparative Study of Urban and Rural Areas. J Health Manag. 2015 Jun 8;17(2):204–20.
Singh PK, Kumar C, Rai RK, Singh L. Factors associated with maternal healthcare services utilization in nine high focus states in India: a multilevel analysis based on 14 385 communities in 292 districts. Health Policy Plan. 2014 Aug 1;29(5):542–59.
Yadav MK, Mohanty PC. Determinants of choice of health insurance: Empirical evidence from responses of Indian households. Int J Health Plann Manage. 2021 Sep 24;36(5):1809–29.
Prasad RD, Arora S, Salve PS, Goli S, James KS, Pallikadavath S, et al. Why there is underutilization of four and more antenatal care services despite the colossal rise in institutional deliveries in Bihar, India. Journal of Social and Economic Development. 2022 Dec;24(2):355–78.
Rani M, Bonu S, Harvey S. Differentials in the quality of antenatal care in India. International Journal for Quality in Health Care. 2007 Nov 16;20(1):62–71.
Sanneving L, Trygg N, Saxena D, Mavalankar D, Thomsen S. Inequity in India: the case of maternal and reproductive health. Glob Health Action. 2013 Dec 2;6(1):19145.
Sridharan S, Dey A, Seth A, Chandurkar D, Singh K, Hay K, et al. Towards an understanding of the multilevel factors associated with maternal health care utilization in Uttar Pradesh, India. Glob Health Action. 2017 Jan 6;10(1):1287493.
Donabedian A. The Role of Outcomes in Quality Assessment and Assurance. QRB Qual Rev Bull. 1992 Nov;18(11):356–60.
Donabedian A. Evaluating the Quality of Medical Care. Milbank Quarterly. 2005 Dec;83(4):691–729.

Map 1 is available in the Supplementary Files section.

No competing interests reported.

AdditionalFile1.pdf
Additional File 1 (pdf format): Title of data- Appendix 1: Brant test for parallel regression assumption Description of data- It shows the result of Brant test for checking assumptions of ordered logistic regression
AdditionalFile2.pdf
Additional File 2 (pdf format): Title of data- Appendix 2: Sample distribution by background characteristics for quality of antenatal care in India, 2019-21 Description of data- It shows the sample distribution by background characteristics for quality of antenatal care in India in 2019-21.
3.jpg
Map 1: Distribution of Adequate Quality of Antenatal Care in districts of India, 2019-21

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Bridging the Gap: Examining the level, trends and determinants of Adequacy of Quality Antenatal Care in India

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Version 1

Abstract

Background

Objectives

Data & Methods:

Results

Conclusion

Figures

Background

Materials and Methods

Data Source

Variables

Outcome Variable

Independent Variable

Statistical Analysis

Results

Trends in components and dimensions of Quality Antenatal Care

Spatial Heterogeneities in Quality Antenatal Care

Adequacy of quality ANC by socio-demographic characteristics

Determinants of adequate quality of ANC

Discussions

Main Findings

Interpretations of Findings

Limitations of the study

Conclusion

Abbreviations

Declarations

References

Map 1

Additional Declarations

Supplementary Files

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