Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine Health Policy

cy and Planning 2014;29:542–559

ß The Author 2013; all rights reserved. Advance Access publication 18 June 2013 doi:10.1093/heapol/czt039

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
Prashant Kumar Singh,1* Chandan Kumar,2 Rajesh Kumar Rai3 and Lucky Singh4
1
International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai 400 088, India, 2Department of Humanities and
Social Sciences, Indian Institute of Technology Roorkee (IITR), Roorkee 247 667, Uttarakhand, India, 3Tata Institute of Social Sciences, V N
Purav Marg, Deonar, Mumbai 400 088, India and 4School of Health Systems Studies, Tata Institute of Social Sciences, V N Purav Marg,
Deonar, Mumbai 400 088, India
*Corresponding author. International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai 400 088, India.

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E-mail: prashant_iips@yahoo.co.in

Accepted 12 May 2013

Background Studies have often ignored examining the role of community- and district-level
factors in the utilization of maternity healthcare services, particularly in Indian
contexts. The Social Determinants of Health framework emphasizes the role of
governance and government policies, the measures for which are rarely
incorporated in single-level individual analysis. This study examines factors
associated with maternal healthcare utilization in nine high focus states in
India, which shares more than half of the total maternal deaths in the country;
accounting for individual-, household-, community- and district-level
characteristics.
Methods The required data are extracted from the third round of the nationally repre-
sentative District Level Household and Facility Survey conducted during 2007–08.
Multilevel analyses were applied to three maternity outcomes, namely, four or
more antenatal care visits, skilled birth attendance and post-natal care after birth.
Findings Results show that along with individual-/household-level factors, community
and district-level factors influence the pattern of utilization of maternal
healthcare services significantly. At the community level, the odds of maternal
healthcare utilization were lower in rural areas and in communities with a high
concentration of poor and illiterate women. Moreover, the average population
coverage of primary health centres (PHCs), availability of labour room in PHC
and percentage of registered pregnancies were significant factors at the district
level that influenced the use of maternity care services. The study also found a
strong association between the extent of previous use of maternal healthcare
and its effect on subsequent usage patterns.
Conclusion This study highlights the role of strengthening public health infrastructure at
district level in the study area, and promoting awareness about available
healthcare services and subsidized schemes in the community. To reach out to
rural and underprivileged communities and to apply a participatory approach
from the programme officials are issues to delve into.
Keywords Antenatal care, skilled birth attendance, post-natal care, community, district,
high focus states, India

542
 MATERNAL HEALTHCARE UTILIZATION IN INDIA 543

KEY MESSAGES
 This study examined factors associated with maternity healthcare utilization in nine high focus states (which share the
utmost burden of maternal mortality in India) accounting for individual-, household-, community- and district-level
factors.

 Along with individual-/household-level factors, communities with high concentration of poor and illiterate women are
disadvantageous in utilizing three recommended maternal healthcare services.

 District-level factors such as average population coverage per PHC, availability of labour room in PHC and the percentage
of registered pregnancies in the district significantly influence the utilization of maternal healthcare services.

 The findings of this study suggest evidence based and targeted interventions that should adopt a multilevel approach to
address barriers to maternity healthcare services utilization beyond individual and household factors.

Background 2009). Followed by women’s education, household economic

status is the most widely discussed factor in public health
India, with more than 1.21 billion population, managed to
research (Ahmed et al. 2010; Viegas Andrade et al. 2012). The
reduce the maternal mortality ratio (MMR) from 600 per

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100 000 live births in 1990 to 200 per 100 000 live births in
2010. However, the country still has the highest (20%) share of
global maternal deaths (total 56 000 in 2010), and the prospect
of achieving the millennium development goal (MDG) 5 target
by 2015 seems bleak (WHO 2012). The north–south variation in
maternal mortality in India is evident (see Figure 1), where
some of the north and central Indian states have persistently
shown poor coverage of key maternal and child healthcare
services (Kumar et al. 2013). On account of the unacceptably
high fertility and mortality indicators, the eight empowered
action group states (Bihar, Chhattisgarh, Jharkhand, Madhya
Pradesh, Orissa, Rajasthan, Uttarakhand and Uttar Pradesh)
and Assam, which account for 45 and 48% of India’s
geographical area and population, respectively, are designated
as ‘High Focus States’ by the Government of India (RGI and CC
2012). These nine states together record a MMR of 308 per
100 000 live births (RGI 2011), which corresponds to the level
in a few African nations such as Burkina Faso (300), South
Africa (300), Timor-Leste (300), Togo (300) and Uganda (310)
(WHO 2012). The prime cause of maternal deaths in India is
haemorrhage, constituting almost 40% of the deaths (RGI
2006). However, the availability, accessibility and affordability
of required healthcare services, as indirect causes, have
considerable influence on maternal health, and there is
evidence of inadequate coverage of maternal healthcare services
utilization in India (Victora et al. 2012; Kumar et al. 2013).
Conventional public health studies assessing the determinants
of utilization of maternal healthcare services in the majority of
developing countries (including India), have mostly focused on
the fixed effect of individual- and household-level factors. Such
studies have often ignored accounting for individual-, house-
hold-, community- and district-level factors in tandem. A
plethora of studies suggest the significance of the mother’s
individual or personal characteristics such as mother’s age at
childbirth (Singh et al. 2012b), parity (Burgard 2004), un-
wanted pregnancy (Ahmed et al. 2012; Singh et al. 2012a),
education (Ahmed et al. 2010) and exposure to specific health
knowledge (Gage 2007), in explaining the utilization of
maternity benefits. Studies demonstrate a strong and dose-
dependent positive effect of level of education on receiving
skilled attendance during childbirth (Gabrysch and Campbell
cost of care seeking is not limited to transportation, medica-
tions, official and unofficial provider fees; rather, opportunity
costs including travel time and waiting time lost from
productive activities also contribute to uptake of recommended
and timely maternity healthcare services (Gabrysch and
Campbell 2009). Studies also empirically show considerable
differences in healthcare coverage across rural and urban areas
(along with regional variations) in India (Kumar et al. 2013). A
few studies have attempted to explore factors such as distance
to health facility, availability of transportation and quality of
available healthcare services in explaining utilization of
healthcare services in developing countries (Kesterton et al.
2010).
The review of extant literature, however, confirms that very
few studies have attempted or examined beyond individual and
household factors of healthcare utilization. Studies are rare,
particularly in Indian contexts, to consider factors related to
governance and government policies in healthcare studies,
which are often measured at higher administrative levels. The
potential implications of this omission could underestimate the
significance of these factors in overall policy and programmatic
agenda, which could adversely influence maternity healthcare
uptake among eligible women. Responding to such a research
gap in health literature, this study examines factors associated
with the utilization of the three components of maternal
healthcare services employing a set of individual-household-,
community- and district-level factors for 14 385 communities in
292 districts across nine high focus states in India. The selected
three components of maternal healthcare services include the
incidence of women having four or more antenatal care (ANC)
visits, had delivery attended by skilled professionals and
received post-natal care (PNC) within 2 days of delivery.
Research design and methods
Conceptual framework
To understand the causes (direct or indirect) of maternal
mortality, Thaddeus and Maine (1994) grouped various factors
into the ‘three delays’ model, which maintains that pregnancy
related mortality is due to delays in seeking required medical
help, seeking a medical facility in time and receiving adequate
544 HEALTH POLICY AND PLANNING
Figure 1 MMR for India and major states, Sample Registration System, 2007–09. Notes: Abbreviations shown for the states are as follows: AP,
Andhra Pradesh; AS, Assam; BR, Bihar; CG, Chhattisgarh; GJ, Gujarat; HR, Haryana; JH, Jharkhand; KA, Karnataka; KL, Kerala; MH, Maharashtra;
MP, Madhya Pradesh; OR, Orissa; PJ, Punjab; RJ, Rajasthan; TN, Tamil Nadu; UK, Uttarakhand; UP, Uttar Pradesh; WB, West Bengal.
care. However, it is important to recognize that the particular
model is probably an oversimplification and that, at each level
of care, there may be a series of complex factors affecting care
(Bhutta 2011). This study adopts the health behaviour model
and its subsequent modifications (Aday and Andersen 1974;
Andersen 1995) along with the Social Determinants of Health
(SDH) framework proposed by the World Health Organisation
(WHO) Commission on SDH (CSDH 2007). The health behav-
ioural model proposed that health seeking behaviour is a
function of three sets of individual characteristics: (1) predis-
posing characteristics, e.g. age, household size, education,
number of previous pregnancies, etc., (2) enabling characteris-
tics, i.e. income, contact to health workers, etc. and (3) need
characteristics, i.e. perceived health status, and expected benefit
from treatments. Moreover, the SDH framework extends the set
of healthcare factors to include the importance of governance,
and government policies. The SDH framework underscores
mainly two sets of factors, i.e. (1) structural and (2) inter-
mediary determinants. The structural determinants include the
socio-economic and political context, as well as indicators of
social position such as education, income, occupation, social
class, gender and ethnicity. The weight and relevance of the
assigned social position is influenced by the socio-economic and
political context, including governmental policies, cultural
values and the macroeconomic conditions. Furthermore, the
impact of these structural determinants on equity in health and
wellbeing is mediated by different intermediary determinants
such as living conditions and exposure that directly influence
health, as well as access to and quality of care received when
encountering the health system (CSDH 2007). This study
considers these healthcare frameworks, and applies a multilevel
approach in explaining the utilization of maternal healthcare
services, where along with an individual’s social position and
other intermediary factors at one level, indicators of governance
and government policies at other levels are examined in tandem
(considering the structure of potential indicators). In particular,
along with the background or predisposing characteristics of
the population at risk, the analysis explicitly delves into the role
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of community position and the health system attributes at
district level.
Data
This study analysed data from the third round of the District
Level Household and Facility Survey (DLHS-3) conducted
during 2007–08 (IIPS 2010). The DLHS is a nationally repre-
sentative cross-sectional survey carried out in 34 states covering
601 districts in India. DLHS-3 questionnaires were canvassed in
720 320 households and from 643 944 ever-married women
aged 15–49 years. The facility survey covered 18 068 sub-centres,
8619 primary health centres (PHCs) and 4162 community
health centres. The broad objective of DLHS-3 was to provide
reproductive and child health outcome indicators at the district
level to monitor and provide corrective measures. The financial
support for DLHS-3 was provided by the Ministry of Health and
Family Welfare (MOHFW), Government of India, United
Nations Population Fund (UNFPA) and United Nations
Children’s Fund (UNICEF).
Sampling techniques and study population
A multi-stage stratified systematic sampling design was em-
ployed in the DLHS-3 survey. In each district, 50 primary
sampling units (PSUs) were selected, which were villages in
rural areas and census enumeration blocks (CEBs) in urban
areas. In rural areas, first, villages were selected by probability
proportional to size (PPS) systematic sampling, and in the
second stage, households were selected by systematic sampling.
For urban areas, first, wards were selected by PPS systematic
sampling, and in the second stage, CEBs were selected by PPS
sampling, and then households were selected by systematic
sampling in the third stage.
The term ‘community’ used throughout this article refers to
the clustering within the same geographical living environment.
These communities were measured based on sharing a common
PSU in the DLHS-3 data. PSUs were census villages in rural
areas and CEBs in urban areas based on the 2001 census.

Details of sampling techniques and sampling weights are
available in the DLHS-3 report (IIPS 2010). The study sample
includes 125 721 ever-married women aged 15–49 years in nine
high focus states, who had at least one child during the 3 years
preceding the survey. These sample women hail from 14 385
PSUs (communities) across 292 districts in the study area.
Outcome variables
The study measures three outcome variables such as 4 ANC
visits, skilled birth attendance (SBA) and PNC within 2 days
after delivery as indicators of maternal healthcare utilization.
These three selected indicators of maternal healthcare utiliza-
tion and their components are based on the guidelines
developed by the MOHFW, Government of India and the
World Health Organization (MOHFW 2012). Delivery conducted
either in a medical institution or a home delivery assisted by
doctor/nurse/Lady Health Visitor/Auxiliary Nurse Midwife
(ANM)/other health professionals are termed ‘SBA’ (WHO
2006). The study considered PNC check-up within 2 days of
childbirth as a potential maternal healthcare service indicator.
The recent document by WHO estimated that 77% of maternal
deaths could be averted by providing necessary PNC globally
(WHO 2010).
Exposure variables
A range of individual-household-, community- and district-level
explanatory variables (see Table 1) were used based on their
theoretical and empirical importance applied in international
literature, considering the use of maternal healthcare services
on the one hand, and their availability in the dataset on the
other. The detailed description and references of selected
variables are given below.
Individual-/household-level factors
The study considers a number of potential individual-/house-
hold-level factors such as the mother’s age at childbirth, birth
order, education, awareness of health services, social group
(caste), religion, occupation and economic status. It is well
recognized in public health literature that women’s age and
birth order (Santhya et al. 2008), a mother’s childcare burden
(Gage and Calixte 2006), and a mother’s education (Bloom
et al. 2001; Ahmed et al. 2010) and awareness about health
services (Ghosh 2006) play influential roles in determining the
utilization of maternity care services. The mother’s childcare
burden refers to the number of children below 3 years of age
preceding the current birth, and should not be equated with the
birth order. In India, caste and religious affiliations play a
significant role in determining the access to healthcare and its
utilization, the omission of which could lead to biased estimates
(Navaneetham and Dharmalingam 2002; Nayar 2007). The
growing rich–poor gap in the utilization of maternal healthcare
services is the focus of public health literature at present,
irrespective of world regions (Barros et al. 2012; Mohanty 2012).
Community-level factors
In recent years, the association between shared community (or
contextual/neighbourhood) environment and health outcome
has been frequently discussed in public health studies
(Stephenson et al. 2006; Subramanian et al. 2006; Babalola
MATERNAL HEALTHCARE UTILIZATION IN INDIA 545
and Fatusi 2009). The three community-level indicators such as
type of residence (urban/rural), proportion of illiterate women
in PSU and proportion of women belonging to the poorest
wealth quintile in PSU are considered. The urban health
advantage has often been attributed to the improved modern
healthcare system that facilitates public health interventions
(Fotso 2006). The high concentration of people belonging to the
poor (Gage and Calixte 2006) and illiterate (Kravdal 2004) in
the community could have an impact on health and mortality
outcomes. The theories of social capital (Coleman 1990)
including social networks and relationships (Gage 2007),
community awareness and diffusion (McNay et al. 2003; Gage
and Calixte 2006) provide a framework for understanding the
mechanism through which communities may influence the
utilization of healthcare services.
District-level factors
In the majority of the developing countries like India, the
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district serves as the lowest programme implementation unit in
the overall administrative hierarchy. The review of existing
literature suggests that the role of individual, household and
community factors differs from one geographic setting to
another (Babalola and Fatusi 2009). The programme factors
(Sunil et al. 2006) such as availability of health services, average
population covered by health facilities (Jat et al. 2011) and their
functional status (Nyamtema et al. 2011) significantly deter-
mine the usage pattern of health services. In addition, the
percentage of pregnancies registered has also been included as a
potential factor at the district level.
Analytical strategy
First, bivariate analyses were performed to examine the nature
of association between utilization of maternal healthcare
services and selected background characteristics. To take into
account the hierarchical structure of the data, the study
employed multilevel logistic regression models to examine
factors affecting the utilization of maternal healthcare services.
The DLHS-3 data have a three-level structure—individual
(level 1), within community (level 2) and within district
(level 3). The multilevel structure of the data used in this
analysis is displayed in Figure 2. If we fail to account for the
existing hierarchical structure in data, the estimates of the
observed covariates are likely to be biased (Stephenson et al.
2006). Moreover, in addition to the observed covariates
considered at each of these three levels, there are likely to be
several unobserved or unobservable factors affecting the
utilization of maternal healthcare services, and these may
operate at any level in the hierarchy. There are a number of
unobserved heterogeneities including perception towards
healthcare use made by individuals, cultural practices that
operate at community level, social support, attitudes towards
existing health facilities and prevailing norms about healthcare
which are difficult to capture in data (Stephenson et al. 2006).
These factors in some contexts influence the healthcare decision
independently and in other contexts could act collectively.
The basic idea is that the utilization of maternity services has
community- and district-level determinants, beyond individual/
household traits. The maternal healthcare use experiences of
mothers in the same district, and furthermore in the same
546 HEALTH POLICY AND PLANNING

Table 1 Exposure variables used in modelling the utilization of maternity healthcare services in nine high focus states in India, DLHS-3 (2007–08)

Selected variables Description

Individual-level variables
Women’s age at birth Based on women’s reporting of year of birth of the last child and current age of women and grouped as
follows: 35–49 (Ref.), 25–34 and 13–24
Birth order Birth order grouped as follows: >3 (Ref.), 2 and 1
Women childcare burden Indicating women’s total number of births in the 3-year period preceding the birth of the index child: no
burden (Ref.) and at least one burden
Women‘s education Defined using years of schooling and they were grouped as: higher secondary (Ref.), middle, primary
and illiterate
Husband‘s education Defined using years of schooling and they were grouped as: higher secondary (Ref.), middle, primary
and illiterate
Heard/seen message on safe Based on women’s reporting whether she seen/heard/read the messages related to the delivery care: yes
delivery (Ref.) and no
Heard/seen message on ANC Based on women’s reporting whether she seen/heard/read the messages related to the ANC: yes (Ref.)
and no
Occupation Identification of women’s occupation based on self-reporting and grouped as follows: professional/
service/production (Ref.), farmer/agricultural and unemployed

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Household-level variables
Social groups
Religion
Household wealth quintile
Community-level variables
Type of residence
Proportion of illiterate women in
PSU
Proportion of women in PSU
from lowest wealth quintile
District-level variables
Average population covered per
PHC in district
Proportion of PHC functional 24 h
in district
Per cent PHC with labour room
available in district
Percentage of pregnancies regis-
tered at district level
States
Identification of the social group was based on the women’s self-reporting as: others (Ref.), Scheduled
Tribes and Scheduled Castes
Based on women’s self reporting religious groups as: Hindu (Ref.), Muslim and others
Index based on household amenities, assets and durables derived by factor analysis used for the
computation of the wealth index. Households were categorized into quintiles as follows: richest (Ref.),
richer, middle, poorer and poorest
Women’s current place of residence: urban (Ref.) and rural
Percentage of illiterate women in the PSU categorized as: 0–25% (Ref.), 26–50% and >50%
Percentage of women in the PSU belonged to the lowest wealth quintile categorized as: 0–25% (Ref.),
26–50%, >50%
Calculated based on facility information at PHC level grouped as: Up to 25 000 (Ref.), 25 000–50 000 and
50 000 and above
Calculated based on facility information whether PHC functional 24 h and grouped as follows: >50%
(Ref.), 25–50% and <25%
Information obtained from facility survey whether PHC has labour room categorized as: >50% (Ref.), 25-
50% and <25%
Number of pregnancies registered out of total number of pregnancies in last 3 years prior to survey:
>50% (Ref.), 25–50% and <25%
State of residence: Uttar Pradesh (Ref.), Uttarakhand, Rajasthan, Bihar, Assam, Jharkhand, Orissa,
Chhattisgarh and Madhya Pradesh

Note: Analytical sample size and percentage distribution for all the exposure variables are presented in Appendix 1.

community and household are likely to be similar since these

women share many characteristics. The multilevel models
adjust for this correlation across units of observation. The
advantage of multilevel modelling is that it recognizes the
existing hierarchical structure of the data and estimates
accordingly (Kravdal 2004; Subramanian et al. 2006). Conse-
quently, the multilevel approach enables assessment of the
relative contributions made by individual and area level effects
on individual healthcare utilization (Ross 2000). In addition, it
provides more accurate standard error estimation by accounting
for the non-independence of the individual observations and
Figure 2 A schematic diagram illustrating the multilevel structure of provides for distinguishing between contextual and compos-
the data. itional effects (Goldstein et al. 2002).

The dependent variable in our analysis is whether a woman
had at least 4 ANC visits (no/yes), had SBA (no/yes) and
received post-natal check-ups (no/yes). Due to the binary
nature of the dependent variable, the multilevel model with
logit link function can be described as follows:
 
picd
ln ¼  þ xicd  þ wcd  þ zd  þ ucd þ vd ,
1  picd
where ln(picd/(1  picd)) is the logit in which picd is the probability
of woman ‘i’ in community (PSU) ‘c’ in district ‘d’ using maternity
healthcare services; xicd , wcd and zd are vectors of individual-/
household-, community- and district-level characteristics; a is a
constant, while ,  and  are vectors of estimated parameter
coefficients; and ucd and vd are unexplained residual terms at the
community and district level, respectively. Thus, a multilevel
model with three levels was fitted to assess the influences of
measured individual-household-, community- and district-level
factors as fixed effects, and community (ucd) and district (vd) as
random effects on the utilization of maternity healthcare services.
The correlations between the probability of maternal health-
care services utilization in the same community and the same
district are represented by variance partition coefficients (VPC),
which are expressed as VPCc and VPCd, respectively (Kiros and
White 2004):
 2c þ  2d  2d
VPCc ¼ and VPCd ¼ 2 ,
 2d 2
þ  c þ 3:29  d þ  2c þ 3:29
where c2 represents the community-level variance, and d2
represents the district-level variance. The multilevel model with
a logistic link function was fitted for the utilization of all three
selected maternity services using MLwiN 2.1 (Rasbash et al. 2009).
We used penalized quasi-likelihood (PQL) approximate estima-
tion procedure, which has been found to be the least biased
(Goldstein and Rasbash 1996) in the case of binary response data.
Since the study considered a range of covariates in the models, we
examined for multicollinearity with variance inflation factors, all
of which were much lower than 2.5, suggesting that the possibility
of high multicollinearity was ostensible. Supplementary analyses
were done using Stata version 10 (StataCorp 2007).
Results
Differentials in maternal healthcare services
utilization
Figure 3 shows considerable variations across states in the
utilization of maternity care services—about 9 of 10 women
utilized all the three maternity services in states such as Tamil
Nadu, Kerala and Goa. On the other hand, unacceptably lower
coverage of all three maternity care services was evident in states
such as Uttar Pradesh, Uttarakhand, Bihar and Jharkhand.
Figure 4 displays that there were 228, 57 and 98 districts where
less than one-quarter of the total sample of women went for 4
ANC visits, received SBA and PNC within 48 h, respectively.
Table 2 presents variations in the utilization of three maternal
healthcare services by selected individual-household-, commu-
nity- and district-level characteristics. Women who were young,
educated and belonged to the Hindu religion as well as women
with first order birth and from the richest wealth quintile
utilized all the three maternal healthcare services in high
MATERNAL HEALTHCARE UTILIZATION IN INDIA 547
proportions. However, women residing in rural areas and in
communities with high concentration of illiterate and poor
women utilized lower proportions of all three maternity care
services. The three maternity care services also varied with
district-level indicators including population coverage per PHC,
functionality of PHC, availability of labour room in PHC and
proportion of registered pregnancies in the district.
Factors associated with the utilization of maternal
healthcare services
In the multilevel models, community (PSU) and district of
residence were modelled to be random. The results of the
random intercept only model (empty model) are shown in
Table 3. There were considerable variations in the utilization
of the three maternal healthcare services across communities
(14–16%) and districts (6–7%) in nine high focus states. Table 4
presents the results of unadjusted (univariate) and adjusted
(multivariate) models when individual-household-, commu-
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nity- and district-level variables were included. When controlled
for all potential factors, the variances attributed to the
differences across communities and districts in the 4 ANC
visits reduced to 7 and 2%, and in receiving skilled attendance
at delivery to 6 and 2%, respectively. The community- and
district-level variances in the adjusted multilevel model for the
utilization of PNC also reduced to 8 and 3%, respectively.
Four or more antenatal care visits (4 ANC visits)
Birth order, women’s education, husband’s education, exposure
to healthcare information/messages, social group and house-
hold wealth significantly predicted 4 ANC visits (Table 4). The
likelihood of women availing themselves of 4 ANC visits was
38% lower among illiterate women compared to women with
higher secondary level of education and above. Similarly, the
likelihood of taking 4 ANC visits was 18% lower among those
women whose husbands were illiterate, than women whose
husbands had completed higher secondary level of education
and above. The odds of 4 ANC visits were 16 and 31% lower
among women who had not heard/seen messages about safe
delivery and ANC services, respectively. Similarly, women
belonging to Scheduled Tribes (17%), Scheduled Castes (10%)
and Muslim religion (9%) were less likely to take 4 ANC visits
compared with women from other social groups and the Hindu
religion, respectively. The odds of 4 ANC visits were 56%
lower among the poorest women compared with women from
the richest wealth quintile. The adjusted model shows that the
type of residence, community education, community impover-
ishment, average population covered per PHC and percentage of
registered pregnancies were significant community- and dis-
trict-level factors associated with 4 ANC visits. The probability
of 4 ANC visits by women was higher in all the states
compared with Uttar Pradesh.
Skilled birth attendance
Women with higher order birth, illiterate, belonging to
Scheduled Tribes and Scheduled Castes, Muslim women and
women who were not exposed to information/messages on safe
delivery and ANC services were less likely to avail themselves of
SBA. Women with 3 order birth were 42% less likely to avail
themselves of SBA compared to women with first order birth.
548 HEALTH POLICY AND PLANNING

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Figure 3 State-wise variations in the utilization of three maternal healthcare services, DLHS-3 (2007–08). Notes: Abbreviations shown for the states
are as follows: AP, Andhra Pradesh; AR, Arunachal Pradesh; AS, Assam; BR, Bihar; CG, Chhattisgarh; CH, Chandigarh; DL, Delhi; GJ, Gujarat; GO,
Goa; HP, Himachal Pradesh; HR, Haryana; JH, Jharkhand; JK, Jammu and Kashmir; KA, Karnataka; KL, Kerala; MG, Meghalaya; MH,
Maharashtra; MN, Manipur; MP, Madhya Pradesh; MZ, Mizoram; OR, Orissa; PJ, Punjab; RJ, Rajasthan; SK, Sikkim; TN, Tamil Nadu; TR, Tripura;
UK, Uttarakhand; UP, Uttar Pradesh; WB, West Bengal.

The odds of SBA seemed to decline significantly with the
reduction in the level of women’s education. Women who had
not seen or heard about the safe delivery services were less
likely to have SBA [odds ratios (OR) ¼ 0.75; 95% confidence
interval (CI) ¼ 0.73–0.77], compared with women who were
aware about the delivery services. The likelihood of SBA was
43% lower among the poorest women compared with the
richest. Rural women were 22% less likely to avail themselves
of SBA compared with their urban counterparts. The results
suggest that the increasing number of illiterate women and of
women belonging to the poorest wealth quintile at the
community level were negatively associated with SBA. Except
Uttarakhand, the odds of SBA were higher in all states
compared with Uttar Pradesh. SBA declined with the decreas-
ing proportion of PHC with labour room availability and
registered pregnancies in the district. Women who did not
take 4 ANC visits were less likely to have SBA compared with
women who had 4 ANC visits.
Post-natal care
In the full adjusted multilevel model, individual-/household-
level variables such as birth order, women’s education, aware-
ness of information/messages related to ANC and safe delivery
services, and household economic status (wealth quintile)
transpired as significant predictors of PNC services utilization.
The odds of PNC were lower among women with 3 order birth
(OR ¼ 0.58; 95% CI ¼ 0.56–0.59) compared to women with first
order birth. PNC seemed to decline with the decrease in the
level of women’s education, and household economic status.
Women who were not exposed to messages related to delivery
services (OR ¼ 0.90; 95% CI ¼ 0.88–0.93) and ANC (OR ¼ 0.91;
95% CI ¼ 0.88–0.94) were less likely, respectively, to utilize PNC
services compared with women who had heard/seen messages
related to delivery and ANC services. At the community and
district levels, type of residence, average population covered per
PHC, per cent PHC with labour room facility and percentage of
registered pregnancies were significantly associated with the
 MATERNAL HEALTHCARE UTILIZATION IN INDIA 549

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Figure 4 Spatial variation of the utilization of three maternal healthcare services across 292 districts in nine high focus states in India, DLHS-3
(2007–08). (A) Location of the study area. (B) Percentage of women taken 4 ANC visits. (C) Percentage of women received skilled attendance at
delivery. (D) Percentage of women received PNC. Notes: Abbreviations shown for the states are as follows: AS, Assam; BR, Bihar; CG, Chhattisgarh;
JH, Jharkhand; MP, Madhya Pradesh; OR, Orissa; RJ, Rajasthan; UK, Uttarakhand; UP, Uttar Pradesh.

utilization of PNC services. Previous experiences with the use of
maternal care services appeared to have strong influence on the
utilization of PNC services.
Discussion
Despite the progress that has been made towards improving the
utilization of maternal healthcare services during the last two
decades, MMR remains unacceptably high in these nine high
focus states. Although widely published evidence from India
has highlighted the factors that contribute to the utilization of
maternity healthcare services, few studies have exemplified it
by using a comprehensive framework using potential factors at
different levels. This study investigates factors associated with
three maternal healthcare outcomes (namely, 4 ANC visits,
SBA and PNC within 2 days after delivery) in nine high focus
states by applying a multilevel approach considering a range of
potential individual-household-, community- and district-level
covariates.
The results show a number of individual-, household-,
community- and district-level factors that significantly influ-
ence the decision to utilize the three maternal healthcare
services. The individual/household characteristics found to be
particularly important are birth order, women’s education,
knowledge about maternity care services, social and religious
affiliations and household economic conditions. Studies from
developing countries have shown an inverse relationship
between birth order and maternal healthcare utilization (Bell
et al. 2003). Since the lower parity women are inexperienced
with pregnancy-related activities and perceive greater health
risks, they tend to heed skilled delivery (Raj et al. 2009).
However, time and resource constraints faced by those with
larger families among higher parity women could restrict their
use of maternity healthcare services (Singh et al. 2012b).
Many hypotheses have been proposed for the mechanism
through which increased education could lead to reduction in
maternal and child mortality rates, through timely use of
healthcare services, economic advantages, high autonomy and
improved status in family and society (Levine and Rowe 2009).
This finding is particularly imperative for these nine high focus
states in the wake of the fact that nearly three in five women in
these states had no or below primary level education. According
to the 2011 Census, of 292 districts in the study area, 72
districts recorded female literacy of <50%, while only 1 district
had male literacy of below 50% (RGI and CC 2011). Lack of
550 HEALTH POLICY AND PLANNING

Table 2 Percentage of women who had at least one live birth during Table 2 Continued
the last 3 years preceding the survey by usage pattern of maternity
Background characteristics 4 ANC SBA PNC
healthcare services and by background characteristics, high focus states visits
in India, DLHS-3 (2007–08)
Community-level variables
Background characteristics 4 ANC SBA PNC Type of residence
visits
Urban 30.6 63.0 52.6
Individual-household-level variables
Rural 11.3 32.6 28.1
Mother’s age at child birth
Proportion of illiterate women in PSU
35–49 6.8 23.5 22.5
0–25% 32.5 51.6 35.2
25–34 13.3 33.9 29.9
26–50% 16.5 43.4 34.8
13–24 15.4 40.9 33.9
>50% 7.7 33.1 29.9
Birth order
Proportion of women in PSU from lowest wealth quintile
1 21.9 52.8 40.8
0–25% 18.3 42.7 37.7
2 17.3 40.9 34.4
26–50% 9.5 32.4 26.4
3 7.3 25.4 24.6
>50% 11.9 26.2 22.2
Mother’s childcare burden
District-level variables
No burden 15.4 37.8 31.9
Average population covered per PHC in district

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At least one burden 10.5 34.1 30.2
Up to 25 000 18.0 36.8 29.7
Mother’s education
25 000–50 000 15.5 41.7 30.3
Higher secondary and above 37.3 69.1 51.4
50 000 and above 11.9 32.8 32.6
Middle 19.1 47.6 38.7
Proportion of PHC functional 24 h in district
Primary 13.5 37.6 32.0
>50% 14.1 37.2 33.2
Illiterate 6.3 24.9 23.2
25–50% 14.2 36.1 28.1
Husband’s education
<25% 11.6 34.3 28.3
Higher secondary and above 23.3 52.2 42.4
Per cent PHC with labour room available in district
Middle 12.7 37.1 31.7
>50% 14.5 39.1 34.9
Primary 9.4 29.6 26.8
25–50% 13.0 33.9 27.3
Illiterate 5.6 21.5 20.4
<25% 12.4 28.4 19.2
Heard/seen message on delivery services
Percentage of pregnancies registered at district level
Yes 16.9 42.8 36.0
>50% 16.9 39.1 34.6
No 6.6 21.6 20.0
25–50% 9.5 33.4 28.2
Heard/seen message on ANC
<25% 9.3 32.5 23.3
Yes 16.6 40.6 34.5
High focus states
No 3.9 18.9 17.4
Uttar Pradesh 8.3 30.0 32.2
Social groups
Uttarakhand 17.5 35.3 30.0
Others (Non-SC/ST) 15.9 40.4 34.6
Rajasthan 16.7 52.5 37.1
Scheduled Tribes (ST) 10.6 26.7 23.2
Bihar 10.3 31.7 25.4
Scheduled Castes (SC) 9.8 31.4 26.8
Assam 23.1 40.0 30.3
Religion
Jharkhand 16.1 24.8 28.9
Hindu 14.5 38.4 31.9
Orissa 33.7 50.7 27.0
Muslim 10.7 29.5 30.2
Chhattisgarh 25.6 29.3 38.0
Others 13.9 24.5 24.5
Madhya Pradesh 19.6 49.7 35.5
Occupation
Previous maternal service use
Professional/service/production 17.6 25.7 24.6
At least 4 ANC visits na
Farmer/agricultural 13.2 34.0 28.6
4 visits 71.7 59.7
Unemployed 7.2 43.1 35.6
<4 visits 39.8 34.5
Household wealth quintile
No ANC visit 19.2 16.5
Richest 39.3 74.2 62.3
SBA na na
Richer 20.9 50.4 42.0
Yes 63.8
Middle 13.1 38.2 32.1
No 12.6
Poorer 8.4 28.9 25.0
Total 13.9 36.7 31.4
Poorest 6.0 20.9 19.1
Chi-squared test applied for each variable and were significant at P < 0.001;
(continued) na, not applicable.

Table 3 Parameter coefficients for the multilevel model (random intercept only model, without covariates) for various
indicators of the use of maternal healthcare services, high focus states in India, DLHS-3 (2007–08)
Random effects
Community (PSU) random variance (SE)
Community (PSU) VPC (%)
District random variance (SE)
District VPC (%)
Notes: PSU ¼ Primary Sampling Unit; SE ¼ Standard Error; VPC ¼ Variance Partition Coefficient.
knowledge about the messages related to the safe delivery and
ANC have shown a negative effect on the utilization of
maternal healthcare services, which highlights the importance
of disseminating specific healthcare knowledge that brings
about changes in people’s attitude towards timely utilization of
skilled healthcare services (Ghosh 2006).
The significant impact of religion (Hazarika 2011) and castes
(Saroha et al. 2008) is in keeping with the findings from other
studies in India. Although very few attempts have been made
to explore the association between religion and healthcare use,
a few studies have suggested that the lower utilization of
healthcare services among Muslim women is attributed to the
lower level of educational attainment and poor socio-economic
status (Singh et al. 2012b). It has also been argued that certain
practices within the community, such as the ‘purdah’ system,
could restrict Muslim women’s tendency towards utilizing
healthcare benefits (Hazarika 2011). On the other hand, lack
of knowledge and awareness, coupled with poor socio-economic
status and segregated habitation particularly in rural areas
(Nayar 2007) could be some reasons for the relative underutil-
ization of healthcare services among women belonging to
Scheduled Castes and Scheduled Tribes.
The results suggest a lower probability of 4 ANC visits and
SBA among women who were involved in professional and
agricultural occupations. In two south Indian states (Navanee-
tham and Dharmalingam 2002) and in Nepal (Sharma et al.
2007), working women were found less likely to use healthcare
services compared with non-working women. The low use of
healthcare services among farming women has been linked to
limited financial resources since working is poverty-induced in
the context of many developing countries (Gabrysch and
Campbell 2009), whereas women who are employed in profes-
sional work have time constraints that restrict their utilization
of healthcare services.
This study shows that a substantial poor–rich gap exists in
the utilization of maternity healthcare services, which is in
concordance with the findings from earlier studies in India
(Viegas Andrade et al. 2012) and other developing countries
(Ahmed et al. 2010). According to the 2009–10 poverty
estimates, while 30% of India’s population were below the
poverty line, the estimates were as high as 50% in Bihar and
Chhattisgarh (Planning Commission 2012). To overcome eco-
nomic barriers in the provision of maternal healthcare services,
the Government of India launched a conditional cash transfer
scheme in 2005, namely, the ‘Janani Suraksha Yojana’ (JSY)
under the broad umbrella of the National Rural Health Mission
(NRHM). According to the scheme, eligible women could
receive Indian National Rupees (INR) 1000 in urban and INR
MATERNAL HEALTHCARE UTILIZATION IN INDIA 551
4 ANC visits SBA PNC
0.354 (0.009) 0.308 (0.006) 0.317 (0.006)
16.1 14.0 15.0
0.278 (0.024) 0.229 (0.020) 0.261 (0.022)
7.1 6.0 6.8
1400 in rural areas after delivering in a government or
accredited private health facility. However, a few recent
evaluation studies show that the poorest and illiterate women
have not always been benefited by the JSY scheme (Lim et al.
2010). For instance, a study in Rajasthan has documented that
more than 50% of the eligible women were not benefited from
the JSY, and that the reach of JSY remained inequitable for
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women living in rural areas, and those who were poor and
illiterate (Santhya et al. 2011).
This study found a considerable difference in the probability
of healthcare utilization among women in rural and urban
residences, and in the vicinity of illiterate and poor women in
the community. The social and service environment (Koblinsky
et al. 2006), poor accessibility and communication, substandard
infrastructural facilities, comparatively high poverty, coupled
with traditional beliefs extensively render the lower utilization
of healthcare services in rural areas. In 2005, acknowledging
the rural health needs, the Government of India launched the
NRHM with the objective of reducing maternal and child
mortality by providing universal access to equitable, affordable,
accountable and effective primary healthcare services to women
in rural areas (MOHFW 2006). However, according to the Rural
Health Statistics 2010, the nine high focus states alone
contributed a shortfall of 75, 57 and 69% in sub-centres
(19 590), PHCs (4252) and CHCs (2115), respectively, at
national level (MOHFW 2010). Similarly, out of the total
shortage of female health workers/ANM (15 079) and doctors at
PHCs (2433) in rural areas, a shortage of nearly 10 687 female
health workers and 2187 doctors were estimated in just five
states (of the high focus states), namely Uttar Pradesh, Bihar,
Chhattisgarh, Orissa and Madhya Pradesh.
Studies show a strong relationship between ‘poor and
uneducated community, and utilization of maternal healthcare
services’ (Montgomery and Hewett 2005; Gage and Calixte
2006; Mahmud et al. 2006). It has been argued that commu-
nities with a low concentration of educated women point to the
lower awareness of the need for care during childbirth. In
traditional societies, lower levels of education among females
also indicate lower autonomy, high teenage marriages and
childbearing, which correspond to the overall lower status of
women in society restricting access to essential healthcare
benefits. The higher concentration of poor households in a
community may lead to lower community collective effective-
ness, as a poor community may not attract resources to sustain
quality healthcare (Gage and Calixte 2006; Mahmud et al.
2006). It can also be understood through the hypothesis of the
diffusion of innovative behaviour that operates at community
level (Cleland 2001).
Table 4 Results of the multilevel analysis showing OR with 95% CI for receiving maternity care services among women who had at least one live birth during the last 3 years preceding the survey,
552

high focus states in India, DLHS-3 (2007–08)

Covariates 4 ANC visits SBA PNC

Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Individual-household-level variables
Mother’s age at child birth
35–49 (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
25–34 2.09 (1.91–2.27)*** 1.02 (0.97–1.08)ns 1.67 (1.59–1.76)*** 1.02 (0.96–1.08)* 1.47 (1.39–1.55)*** 1.00 (0.96–1.04)ns
13–24 2.47 (2.27–2.68)*** 0.95 (0.90–1.01)ns 2.26 (2.14–2.37)*** 0.98 (0.94–1.01)ns 1.77 (1.66–1.86)*** 0.96 (0.92–1.01)ns
Birth order
1 (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
2 0.75 (0.72–0.78)*** 0.83 (0.80–0.85)*** 0.62 (0.60–0.64)*** 0.68 (0.66–0.69)*** 0.76 (0.74–0.78)*** 0.93 (0.91–0.96)***
HEALTH POLICY AND PLANNING

3 0.30 (0.29–0.31)*** 0.68 (0.66–0.70)*** 0.30 (0.29–0.31)*** 0.58 (0.56–0.59)*** 0.47 (0.46–0.49)*** 0.90 (0.87–0.92)***
Mother’s childcare burden
No burden 1.00 1.00 1.00 1.00 1.00 1.00
At least one burden 0.65 (0.63–0.67)*** 1.01 (0.98–1.04)ns 0.95 (0.88–0.99)** 0.94 (0.85–1.01)** 0.92 (0.90–0.95)*** 1.01 (0.99–1.03)ns
Women’s education
Higher secondary and above (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
Middle 0.40 (0.38–0.42)*** 0.77 (0.74–0.79)*** 0.41 (0.39–0.42)*** 0.77 (0.74–0.79)*** 0.53 (0.51–0.55)*** 0.90 (0.87–0.94)***
Primary 0.26 (0.25–0.28)*** 0.70 (0.67–0.73)*** 0.27 (0.26–0.28)*** 0.71 (0.69–0.73)*** 0.39 (0.38–0.41)*** 0.89 (0.86–0.92)***
Illiterate 0.11 (0.11–0.12)*** 0.62 (0.60–0.64)*** 0.15 (0.14–0.15)*** 0.67 (0.65–0.70)*** 0.25 (0.24–0.26)*** 0.87 (0.84–0.90)***
Husband’s education
Higher secondary and above (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
Middle 0.48 (0.46–0.50)*** 0.90 (0.88–0.93)*** 0.54 (0.52–0.56)*** 0.93 (0.91–0.96)*** 0.63 (0.61–0.65)*** 0.98 (0.95–1.01)ns
Primary 0.34 (0.33–0.36)*** 0.84 (0.81–0.87)*** 0.38 (0.37–0.40)*** 0.90 (0.87–0.92)*** 0.50 (0.48–0.52)*** 0.99 (0.96–1.03)ns
Illiterate 0.20 (0.19–0.21)*** 0.82 (0.79–0.85)*** 0.25 (0.24–0.26)*** 0.85 (0.83–0.88)*** 0.35 (0.34–0.36)*** 0.93 (0.90–0.96)***
Heard/seen message on delivery services
Yes (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
No 0.35 (0.33–0.36)*** 0.84 (0.81–0.87)*** 0.37 (0.36–0.38)*** 0.75 (0.73–0.77)*** 0.44 (0.43–0.46)*** 0.90 (0.88–0.93)***
Heard/seen message on ANC
Yes (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
No 0.21 (0.20–0.22)*** 0.69 (0.65–0.72)*** 0.34 (0.33–0.35)*** 0.85 (0.81–0.89)ns 0.40 (0.38–0.42)*** 0.91 (0.88–0.94)***
Social groups
Others (Non-SC/ST) (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
Scheduled Tribes (ST) 0.63 (0.60–0.66)*** 0.83 (0.80–0.87)*** 0.54 (0.52–0.56)*** 0.83 (0.80–0.86)*** 0.57 (0.55–0.59)*** 0.91 (0.88–0.95)***
Scheduled Castes (SC) 0.58 (0.55–0.60)*** 0.90 (0.87–0.92)*** 0.67 (0.65–0.69)*** 0.91 (0.89–0.94)*** 0.69 (0.67–0.72)*** 0.98 (0.96–1.01)ns

(continued)

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Table 4 Continued
Covariates 4 ANC visits SBA PNC
Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Religion
Hindu (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
Muslim 0.71 (0.68–0.75)*** 0.91 (0.87–0.95)*** 0.67 (0.65–0.69)*** 0.91 (0.88–0.94)*** 0.93 (0.89–0.99)*** 0.96 (0.93–1.00)*
Others 0.95 (0.87–1.04)ns 0.99 (0.92–1.07)ns 0.52 (0.49–0.56)*** 0.93 (0.87–0.99)* 0.69 (0.64–0.74)*** 0.96 (0.89–1.04)ns
Occupation
Professional/service (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
Farmer/agricultural 0.51 (0.48–0.54)*** 0.91 (0.88–0.95)*** 0.67 (0.64–0.70)*** 0.96 (0.93–0.99)** 0.81 (0.78–0.85)*** 1.03 (1.00–1.07)*
Unemployed 1.42 (1.34–1.49)*** 1.03 (0.99–1.06)ns 1.47 (1.42–1.52)*** 1.07 (1.04–1.10)*** 1.38 (1.33–1.43)*** 1.00 (0.97–1.04)ns
Household wealth quintile
Richest (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
Richer 0.40 (0.38–0.42)*** 0.70 (0.68–0.73)*** 0.35 (0.39–0.37)*** 0.72 (0.69–0.74)*** 0.44 (0.41–0.45)*** 0.88 (0.84–0.91)***
Middle 0.23 (0.22–0.24)*** 0.58 (0.55–0.60)*** 0.22 (0.21–0.23)*** 0.65 (0.63–0.67)*** 0.28 (0.27–0.29)*** 0.86 (0.82–0.89)***
Poorer 0.14 (0.13–0.15)*** 0.50 (0.48–0.53)*** 0.14 (0.14–0.14)*** 0.61 (0.59–0.63)*** 0.20 (0.19–0.21)*** 0.84 (0.80–0.88)***
Poorest 0.10 (0.09–0.10)*** 0.46 (0.44–0.49)*** 0.10 (0.09–0.011)*** 0.57 (0.55–0.60)*** 0.14 (0.13–0.14)*** 0.85 (0.81–0.89)***
Community-level variables
Type of residence
Urban (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
Rural 0.29 (0.28–0.30)*** 0.79 (0.75–0.82)*** 0.28 (0.27–0.29)*** 0.78 (0.75–0.80)*** 0.35 (0.34–0.36)*** 0.86 (0.82–0.91)***
Proportion of illiterate women in PSU
0–25% (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
26–50% 0.41 (0.39–0.43)*** 0.89 (0.84–0.94)*** 0.49 (0.47–0.50)*** 0.90 (0.87–0.93)*** 0.62 (0.59–0.64)*** 0.99 (0.95–1.04)ns
>50% 0.17 (0.17–0.18)*** 0.83 (0.78–0.88)*** 0.24 (0.23–0.25)*** 0.83 (0.80–0.86)*** 0.37 (0.36–0.38)*** 0.98 (0.93–1.03)ns
Proportion of women in PSU from lowest wealth quintile
0–25% (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
26–50% 0.47 (0.45–0.49)*** 0.99 (0.95–1.02)ns 0.50 (0.49–0.52)*** 0.96 (0.93–0.98)*** 0.54 (0.52–0.55)*** 0.99 (0.95–1.03)ns
>50% 0.35 (0.34–0.37)*** 0.89 (0.85–0.94)*** 0.31 (0.29–0.32)*** 0.82 (0.79–0.85)*** 0.35 (0.33–0.36)*** 0.95 (0.90–1.00)**
District-level variables
Average population covered per PHC in district
Up to 25 000 (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
25 000 to 50 000 0.85 (0.80–0.89)*** 0.97 (0.86–1.11)ns 1.23 (1.18–1.28)*** 1.06 (0.93–1.30)ns 1.03 (0.98–1.07)ns 0.46 (0.37–0.56)***
50 000 and above 0.62 (0.59–0.65)*** 0.78 (0.67–0.92)*** 0.84 (0.80–0.87)*** 0.74 (0.61–0.85)ns 1.14 (1.09–1.19)*** 0.52 (0.46–0.70)***
Proportion of PHC functional 24 hrs in district
MATERNAL HEALTHCARE UTILIZATION IN INDIA

>50% (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00

25–50% 1.01 (0.97–1.04)ns 1.05 (0.96–1.15)ns 0.95 (0.93–0.98)*** 0.99 (0.91–1.07)ns 0.78 (0.76–0.80)*** 0.91 (0.79–1.05)ns
553

(continued)

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Table 4 Continued
554

Covariates 4 ANC visits SBA PNC

Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
<25% 0.76 (0.72–0.82)*** 1.05 (0.91–1.20)ns 0.88 (0.84–0.92)*** 1.05 (0.92–1.19)ns 0.79 (0.76–0.83)*** 1.00 (0.80–1.27)ns
Per cent PHC with labour room available in district
>50% (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
25–50% 0.87 (0.84–0.91)*** 1.05 (0.95–1.16)ns 0.80 (0.78–0.82)*** 0.99 (0.91–1.09)ns 0.70 (0.68–0.77)*** 0.80 (0.67–0.94)**
<25% 0.83 (0.78–0.88)*** 0.98 (0.85–1.13)ns 0.62 (0.59–0.64)*** 0.82 (0.72–0.93)*** 0.44 (0.42–0.46)*** 0.78 (0.62–0.92)***
Percentage of pregnancies registered at district level
>50% (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
25–50% 0.52 (0.50–0.54)*** 0.74 (0.67–0.81)*** 0.78 (0.76–0.80)*** 0.89 (0.75–0.93)** 0.74 (0.72–0.76)*** 0.90 (0.77–1.06)*
<25% 0.51 (0.48–0.53)*** 0.75 (0.62–0.90)*** 0.75 (0.73–0.78)*** 0.79 (0.67–0.83)*** 0.57 (0.55–0.59)*** 0.69 (0.51–0.93)***
HEALTH POLICY AND PLANNING

Nine high focus states

Uttar Pradesh (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
Uttarakhand 2.46 (2.25–2.70)*** 1.21 (0.98–1.49)* 1.27 (1.19–1.36)*** 0.80 (0.66–0.97)** 0.90 (0.84–0.96)*** 0.85 (0.60–1.20)ns
Rajasthan 2.12 (2.00–2.26)*** 1.54 (1.33–1.78)*** 2.59 (2.48–2.69)*** 1.94 (1.71–2.21)*** 1.24 (1.19–1.29)*** 0.86 (0.68–1.10)ns
Bihar 1.24 (1.16–1.31)*** 2.42 (2.00–2.93)*** 1.08 (1.04–1.12)*** 1.23 (1.04–1.46)** 0.71 (0.69–0.74)*** 0.85 (0.62–1.16)ns
Assam 3.43 (3.22–2.65)*** 2.28 (1.98–2.64)*** 1.56 (1.49–1.63)*** 1.15 (1.01–1.31)** 0.91 (0.87–0.96)*** 0.53 (0.41–0.66)***
Jharkhand 2.06 (1.93–2.20)*** 2.92 (2.48–3.44)*** 0.77 (0.73–0.81)*** 1.04 (0.90–1.20)ns 0.85 (0.81–0.89)*** 0.91 (0.70–1.19)ns
Orissa 5.84 (5.49–6.21)*** 2.96 (2.56–3.42)*** 2.39 (2.28–2.52)*** 1.53 (1.35–1.75)*** 0.77 (0.73–0.82)*** 0.53 (0.42–0.67)***
Chhattisgarh 3.55 (3.30–3.81)*** 2.40 (2.00–2.88)*** 0.96 (0.91–1.02)ns 0.90 (0.76–1.06)ns 1.29 (1.22–1.36)*** 1.52 (1.12–2.05)**
Madhya Pradesh 2.54 (2.40–2.69)*** 1.95 (1.72–2.21)*** 2.30 (2.22–2.39)*** 1.73 (1.55–1.94)*** 1.16 (1.11–1.20)*** 0.73 (0.60–0.90)***
Previous maternal service use
ANC visits
4 visits (Ref.) na na 1.00 1.00 1.00 1.00
<4 visits 0.26 (0.25–0.27)*** 0.61 (0.59–0.63)*** 0.35 (0.34–0.37)*** 0.73 (0.71–0.76)***
No visit 0.09 (0.08–0.10)*** 0.36 (0.35–0.37)*** 0.13 (0.13–0.14)*** 0.53 (0.52–0.55)***
SBA
Yes (Ref.) na na na na 1.00 1.00
No 0.08 (0.07–0.09)*** 0.17 (0.17–0.18)***
Random effects
Community (PSU) random variance (SE) 0.163 (0.006) 0.135 (0.004) 0.180 (0.007)
Community (PSU) VPC (%) 6.8 5.7 7.6
District random variance (SE) 0.077 (0.077) 0.063 (0.005) 0.091 (0.020)
District VPC (%) 2.2 1.8 2.6

Level of significance ***P < 0.001; **P < 0.05; *P < 0.10; (Ref.) ¼ reference categories are indicated in parentheses after the names of the characteristics being considered. na, not applicable; ns, not significant.
Likelihood ratio (LR) tests for multilevel logistic vs ordinary logistic regression model: for 4 ANC (2 ¼ 4315.44, P < 0.001); for SBA (2 ¼ 6715.68, P < 0.001); for PNC (2 ¼ 14267.03, P < 0.001). These LR tests are
conservative and provided only for reference; calculations are based on the Laplacian approximation. Final models are based on penalized quasi likelihood estimation that does not provide LR test.
Sample size: at level 1 (individual) ¼ 125 721; level 2 (community) ¼ 14 385; level 3 (district) ¼ 292.

Downloaded from http://heapol.oxfordjournals.org/ by guest on May 24, 2016


This study also found the average population covered per
PHC, proportion of PHC with labour room availability and
percentage of registered pregnancies at the district level as
significant influencing factors. According to the guidelines of
the Indian Public Health Standards a PHC covers 20 000 to
30 000 population, but due to a huge shortage of PHCs in the
study area, it has adverse implications for quality assurance and
maintenance (Rai et al. 2011). Since the launch of the JSY
scheme, the government health facilities have become over-
crowded. A study conducted in Jharkhand, India found that the
majority of the women were discharged within 24 h, and 50%
of them within 3 h due to lack of resources in hospitals (Rai
et al. 2011). In addition, SBA and PNC were also determined by
the percentage of PHCs equipped with a labour room in the
district. A recent evaluation has registered lower availability of
labour rooms in PHCs in the nine high focus states ranging
from the highest of 28% in Rajasthan to the lowest in
Jharkhand (4%), compared with the national average of 40%
(IIPS 2012).
To date, no study has included pregnancy registration as a
potential factor to examine the utilization of maternal
healthcare services. It was estimated that despite improvements
in the vital registration (when nearly 81 countries now have
adequate systems with high coverage), only 27% births were
registered globally (Goudar et al. 2012). The under-reporting of
pregnancies can mislead the effective planning of health
infrastructure and facilities at district level. As maternal and
child deaths are under-reported (Shah et al. 2008), particularly
in resource poor settings (Raj et al. 2012), establishing effective
health surveillance system at the district (or at sub-district)
level provides reliable statistics towards monitoring and
strengthening ongoing programmatic efforts. Recent evidence
from Nepal has demonstrated the successful establishment of a
surveillance site at the district level to collect accurate and
reliable data (Raj et al. 2012).
As observed in previous studies (Titaley et al. 2010), this study
confirms the strong association of previous uses of maternity
care services on subsequent services utilization. Moreover,
the study also provided strong evidence of considering ANC
visits as a viable entry point for subsequent maternal healthcare
use in the study area. Frequent visits to health facilities during
pregnancy could enhance confidence among women and family
members towards the health system (Thind et al. 2008). Health-
promotion counselling during each visit substantially influences
perceptions and acts as an impetus for obtaining appropriate
and timely delivery care (Gage 2007). The significance of PSU
(community) and district random variances after controlling for
individual-household-, community- and district-level factors in
the study area indicate that the models did not fully explain the
community- and district-level variation in assessing the utiliza-
tion of maternity healthcare services.
Potential limitations of this study
This study reports some potential limitations that must be
understood in the light of the results. Information on the use of
three maternity healthcare services is not exempt from recall
bias. Since information was collected retrospectively, women
may overlook or may not accurately recall the number or timing
of prenatal care, location, and attendant of birth, or PNC during
MATERNAL HEALTHCARE UTILIZATION IN INDIA 555
the interview. However, many studies have examined maternal
healthcare use retrospectively even up to the last 5 years period;
the present study minimized these errors while considering
births up to 3 years period. Not all predictors of maternal
healthcare services use were included in the study due to
limitations of the data and scope of the study. For instance,
healthcare use could be determined by certain community
norms including cultural practices related to pregnancy care
etc., that were difficult to measure from the available dataset.
This study also acknowledges the limitation in considering
measures of quality of healthcare services such as waiting time,
staff attitudes and behaviour, which may influence women’s
decisions on whether or not to make use of given facilities.
However, the district-level variables included in this study
provide some scope to assess the structural features of health
facilities available in the study area. This study defined
community based on PSUs and CEBs in rural and urban
areas, respectively, and these boundaries may not conform to
Downloaded from http://heapol.oxfordjournals.org/ by guest on May 24, 2016
respondents’ perceptions about the extent of their own
community. Despite these limitations, the study provides
important information on the utilization of maternal healthcare
services in nine high focus states in India. The analysis has
highlighted the importance of structural determinants of
maternity care services accounting for individual and household
factors along with contextual factors.
Conclusion and policy implications
The Government of India, through its National Population
Policy 2000 and National Health Policy 2002, set the goal to
substantially expand maternity care, by increasing institutional
deliveries to 80% and having 100% of deliveries attended by
a trained person. However, this target seems bleak in nine high
focus states and indeed a steep road lies ahead to achieve these
objectives. This study empirically addresses the influence of
community- and district-level factors on the utilization of
maternal healthcare services, adjusting for individual- and
household-level determinants in the nine high focus states in
India. The findings from this study have pertinent implications
for India’s efforts towards achieving MDG 5.
The results of this study provide a basis for a number of
policy recommendations. In a broader context, the findings of
this study clearly suggest evidence based and targeted inter-
ventions that should adopt a multilevel approach to address
the constraints in the coverage of maternal healthcare services.
More specifically, greater efforts from the local health activists
are essential to reach illiterate, higher parity and poor women
to ensure appropriate and timely maternal healthcare utiliza-
tion. Considering the lower educational attainment among
women in the study area, education reforms still need to
focus extensively on reducing the barriers and instigating
measures that could effectively enhance women’s education
level. Similarly, poor women need to be informed about
the maternity benefits and schemes that are specifically
designed to offer assistance for those who are economically
vulnerable. The ongoing maternal healthcare interventions
should intensify efforts and need to be more inclusive to
reduce disparities in healthcare utilization across social and
religious groups.
556 HEALTH POLICY AND PLANNING
The findings also highlight the need to look beyond individ-
ual- and household-level factors while assessing the determin-
ants of maternal healthcare services use. To increase the
utilization of maternal healthcare services, focus on commu-
nity- and district-level interventions is critical. There is an
immense need to engage directly with communities, including
women, men, community leaders and other stakeholders
towards raising awareness about the adverse consequences of
lower or indeed untimely utilization of maternal healthcare for
women and their newborns. A clear evidence of benefit from
the greater focus on infrastructural development at district level
has appeared from the present analysis. Expanding basic health
facilities such as increasing number of PHCs to reduce the
burden from existing facilities, and ensuring labour room
availability at PHCs are some of the key steps to strengthen
district level health infrastructure. Exploring strategies to
enhance the district level pregnancy registration is another
essential aspect that significantly affects current and future
demand and supply side dimensions of maternity care services
in these nine high focus states. The significant association
between previous and subsequent maternity services use leads
to significant programmatic implications. Utmost efforts are
required from the health providers to ensure that eligible
women should utilize recommended ANC visits (4).
Moreover, each ANC visit by women should be effectively
exploited and managed to raise awareness about benefits of
subsequent services use, and to offer appropriate counseling
regarding any misconceptions, not restricted to women alone;
rather, other family members should also be included.
Besides, future research should work to gauge those factors
that may account for the unexplained community and district
variations in the use of maternal healthcare services in the
selected nine high focus states. In addition, during the last few
years, there is a growing consensus among policy makers in
addressing health needs at local level; the presence of residual
variance at the community/PSU level observed in this study
could act as a guide for agencies responsible for data collection
to improve the extent of the information base at the commu-
nity level.
Acknowledgements
The authors thank the editor and anonymous reviewers for their
helpful comments and feedback on an earlier draft of this article.
Funding
P.K.S. is supported by the Government of India/National
Eligibility Test (GOI/NET) Doctoral Fellowship Award from
the Ministry of Health and Family Welfare, Government of
India. C.K. is supported by the Doctoral Fellowship granted by
Ministry of Human Resource Development, Government of
India. However, the funders have no specific role in the
preparation of this paper.
Conflict of interest
None declared.
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Appendix 1 Percentage distribution of women who had Poorer 33 009 26.3

at least one live birth during the last 3 years preceding the Poorest 35 842 28.5
survey by background characteristics, high focus states in India, Type of residence
DLHS-3 (2007–08) Urban 16 797 13.4
Rural 108 924 86.6
Background characteristics n % Proportion of illiterate women in PSU
Mother’s age at child birth 0–25% 21 476 17.1
35–49 8981 7.1 26–50% 28 287 22.5
25–34 53 538 42.6 >50% 75 958 60.4
13–24 63 202 50.3 Proportion of women in PSU from lowest wealth quintile
Birth order 0–25% 69 013 54.9
1 35 449 28.2 26–50% 32 268 25.7
2 29 127 23.2 >50% 24 440 19.4
3 61 145 48.6 Average population covered per PHC in district
Mother’s childcare (<5 years) burden Up to 25 000 11 581 9.2
No burden 88 288 70.5 25 000–50 000 50 264 40.0
At least one burden 37 433 29.5 50 000 and above 63 876 50.8
Mother’s education Proportion of PHC functional 24 h in district
Higher secondary and above 20 529 16.4 >50% 81 665 65.0
Middle 15 461 12.3 25–50% 33 951 27.0
Primary 17 514 13.9 <25% 10 105 8.0
Illiterate 72 217 57.4
(continued)
(continued)
 MATERNAL HEALTHCARE UTILIZATION IN INDIA 559

Continued
Background characteristics n %
Per cent PHC with labour room available in district
>50% 81 818 65.1
25–50% 30 958 24.6
<25% 12 945 10.3
Percentage of pregnancies registered at district level
>50% 75 915 60.4
25–50% 32 082 25.5
<25% 17 724 14.1
High focus states
Uttar Pradesh 37 260 29.6
Uttarakhand 4113 3.3
Rajasthan 12 428 9.9
Bihar 21 138 16.8
Assam 9882 7.9

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Jharkhand 11 294 9.0
Orissa 7634 6.1
Chhattisgarh 6092 4.8
Madhya Pradesh 15 880 12.6
Total 125 721 100.0