Factors associated with underutilization of antenatal care in India: Results from 2019-2021 National Family Health Survey.

Introduction: Despite progress in recent years, full antenatal care utilization in India continues to be relatively low and inequitable, particularly between states and districts. In 2015-2016, for example, only 51% of women aged 15-49 in India attended antenatal care at least four times during pregnancy. Using data from the fifth iteration of India's National Family Health Survey, our study aims to explore factors related to the underutilization of antenatal care in India.

Materials And Methods: Data from the most recent live birth in the past five years among women aged 15-49 years were included in our analysis (n = 172,702). Our outcome variable was "adequate antenatal care visits", defined as four or more antenatal visits. Utilizing Andersen's behavioral model, 14 factors were identified as possible explanatory variables. We used univariate and multivariate binary logistic regression models to analyze the association between explanatory variables and adequate visits. Associations were considered statistically significant if p<0.05.

Results: Of the 172,702 women in our sample, 40.75% (95% CI: 40.31-41.18%) had an inadequate number of antenatal care visits. In multivariate analysis, women with less formal education, from poorer households and more rural areas had higher odds of inadequate visits. Regionally, women from Northeastern and Central states had higher odds of inadequate antenatal care utilization compared to those from Southern states. Caste, birth order, and pregnancy intention were also among the variables associated with utilization of antenatal care.

Discussion: Despite improvements in antenatal care utilization, there is cause for concern. Notably, the percentage of Indian women receiving adequate antenatal care visits is still below the global average. Our analysis also reveals a continuity in the groups of women at highest risk for inadequate visits, which may be due to structural drivers of inequality in healthcare access. To improve maternal health and access to antenatal care services, interventions aimed at poverty alleviation, infrastructure development, and education should be pursued.