This study has attempted to explore the utilization of maternal health care services among young married women in India by examining the underlying trends and determinants over a period of two and a half decades using nationally representative data sets. Specifically, the study focused on two indicators of maternal health care services, namely, full antenatal care and skilled birth attendance.
Although the utilization of full ANC is showing an upward trend since 1992, there exist a substantial proportion of young women who are not practicing full ANC during pregnancy. Moreover, utilization of full ANC is unacceptably low in EAG states as 72% of young mothers belonging to these states did not go for full ANC during 2015-2016. A remarkable increase in the proportion of young women who had SBA during birth was evident during 2005-2006 and 2015-2016, which may be attributed to a well-funded and well-publicized safe motherhood intervention named Janani Suraksha Yojana (JSY). JSY has led to an extensive and rapid increase in institutional deliveries, from 18% in 2008, to more than 80% 10 years later [34,35]. This trend is also validated by the results from multivariate analyses. Lesser growth in the utilization of full ANC compared to SBA among young women could be due to several facts, such as limited knowledge and understanding about the importance of antenatal care, social restrictions for the young married women, and lack of cash incentives as in the case of SBA. The study has also revealed a number of demographic and socioeconomic predictors of the utilization of maternity care services among young mothers.
Consistent with previous studies [13,36-39], urban women were more likely to use maternal health care services. Regarding state-wise residence, the present study has found that the gap between EAG and Non-EAG states in the utilization of both the maternity care services among young women is much more prominent than the rural-urban gap. Based on multivariate analysis, women belonging to Non-EAG states were almost 5 times and 2.5 times more likely to use full ANC and SBA, respectively, compared to women belonging to EAG states. To the authors’ knowledge, disparity in the use of maternal health care services between EAG and Non-EAG states has not been reported in the literature, however many studies have observed regional inequalities [28,40,41]. There could be many explanations for the low coverage of maternal health care services in EAG states. In India, there is a substantial difference in accessibility and availability of health care from public health facilities between EAG and Non-EAG states [42-44]. EAG states (mostly northern and central region) have a high proportion of population below poverty line and a high proportion of women not exposed to education and mass media [13,45].
Religion and social group of young women also influence the use of maternal health care services among them. This study has found that Muslim women were less likely to opt for full ANC and SBA. Regarding the social group, young women belonging to other than SC/ST group were more likely to use both the maternal health care services. Several studies from India [40,46,47] and other countries [36,37,48,49] showed that the utilization of maternity care services is affected by ethnicity and religion of women. Religion-specific beliefs and traditional practices of Muslim women may lead to lower use of maternity care services among them . The low usage of maternity care services among SC and ST women could be due to lack of access to health care services as women of these social groups have a higher probability of living under adverse circumstances [51,52]. Also, the low coverage of maternal health care services among young Muslim and SC/ST women could be linked to their lower autonomy and lower socioeconomic status [53-55].
The educational status of young women appeared to be a pertinent predictor of the use of full ANC and SBA. A sharp increase in the odds of the utilization of both the maternal health care services was observed as we move from uneducated women to higher educated women. Many previous studies conducted in India [38,56,57] and other developing countries [58-61] have found similar results. Educated women have the capability to access health care information and are more aware of the negative consequences of not practicing maternity care services. Moreover, higher education may empower women to make proper decisions for their health and to use health care inputs accordingly [58,60].
The present study has found a significant disparity in maternal health care service utilization across different economic groups. Young women belonging to wealthier households were more likely to practice maternal health care than those who are from poor households. This rich-poor gap is consistent with the findings of many other studies from India [13,62,63] and elsewhere [58,61,64]. Poor young women are often turned out to be uneducated, unemployed, and detached from social networks; they are thus more difficult to be reached by maternity care programs, and they tend to underestimate the importance of maternal health care services and therefore prioritize spending their limited resources on daily basic needs over maternal health care [65,66].
Our study emphasizes the role of maternal age and birth order on the likelihood of utilizing maternal health care services. We found that adolescent mothers were less likely to use full ANC and SBA than older young mothers. This finding is supported by a study conducted in Kenya on young women . Knowledge and experience of elder women encourage them to get maternity and childbirth care . Additionally, older young women have higher decision making autonomy, which has a positive association with greater use of maternal health care services [55,68]. Therefore, delaying childbearing of young women would be beneficial for greater coverage of maternity care services. Concerning birth order, the likelihood of using full ANC and SBA decreases significantly with the increase in birth order. Several other studies have reported similar finding [38,40,47,69]. Primiparous women may have fear of first pregnancy and are more afraid of complications and difficulties during delivery. Whereas, during higher-order births, women may have developed self-confidence as they have prior experience of birth/births, which makes them less likely to seek maternal health care services [69,70]. The other reasons may be resource constraints due to having more children and prior bad health facility experiences .
In our study, young women with no exposure to any kind of mass media were found to be less likely to use full ANC and SBA. This result concurs with the findings from various other studies in which exposure to mass media had a positive association with the utilization of maternity care services [47,61,71,72]. Mass media is an important source of information on health and existing health care programs or policies. Women, who are exposed to mass media, may have a better understanding of maternal health complications and the importance of antenatal care and skilled birth attendance during delivery. Women’s exposure to mass media may also be associated with other factors like higher wealth quintile, higher education, and urban residence, all of which are positively associated with an increased likelihood of utilizing maternal health care service.
The findings of this study should not be interpreted without acknowledging its limitations. Some of the potential limitations of the study include recall bias, reporting bias, and non-availability of required information in some or all of the survey rounds. The responses on age, antenatal care, skilled birth attendance were self-reported by women and hence are prone to recall and reporting bias. During multivariate analysis, important variables representing women’s decision-making autonomy were excluded due to lack of data on these variables. Since the information on maternal health care indicators was available only for pregnancies that resulted in a live birth, we were not able to analyse the section of population with adverse outcomes i.e. miscarriage, abortion or still birth. Also, there was no data on the quality and accessibility of maternal health care services which could have given a more informed idea on the adequacy of maternity care. Finally, we were forced to relied on studies conducted among adolescents and women aged 15-49 years due to lack of literature on young women aged 15-24 years.