Long-Term Trend in Inequalities by Socioeconomic Status and Residence Type and Geographic Variation in the Utilization of Antenatal Care Service in India: Result from the National Family Health Survey 1998-2015
30 Pages Posted: 12 Mar 2019More...
Background: India has been making long-term efforts toward increasing antenatal care (ANC) to reduce maternal and neonatal mortality and morbidity. We aimed to investigate the temporal trend of socioeconomic and rural-urban disparities and geographical variation in utilization of ANC services before and throughout the MDG era.
Methods: Using a series of National Family Health Survey between 1998 and 2015 (Wave II, III, and IV), we analyzed the trend in inequality for at least one and four ANC visits to health care professional for ANC (ANCS1, ANCS4) by education, wealth, and residence type. Multilevel logistic regression models were used to assess the trend in relative contribution of various geographical levels (states and communities). Age at pregnancy, history of terminated pregnancy, marital status, religions, birth order, caste were adjusted for.
Findings: Educational and economic inequality in ANCS1 and ANC4 worsened in between 1998 and 2005. However, there was a huge decrease in inequality between 2005 and 2015 that compensated for increase in inequality during preceding half period. Educational inequality narrowed down more than wealth inequality(e.g., ORs of the poorest and the least educated for ANC4 are 0.23, 0.20, and 0.38 and 0.26, 0.28 and 0.58 in wave II, III, and IV. P values for all are <0.001). Rural-urban inequality showed consistent decline during the study period without any fluctuation(e.g., ORs of the rural area for ANC4 are 0.58, 0.63,and 0.82 in wave II, III, and IV. P values for all are <0.001). Relative contribution of community to the total variation in utilization of ANC increased more than four times while contribution of states decreased.
Interpretation: Despite the long history of maternal and child health care interventions in India, the inequality in utilization of ANC started to decline only after special efforts were made for disadvantaged and vulnerable populations. Strengthening community factors such as community health workers and further efforts to remove economic barriers are necessary to tackle the persisting inequality in ANC utilization in India.
Funding Statement: The authors have no support of funding to report.
Declaration of Interests: We declare no competing interests.
Ethical Approval: NFHS data are free to download through Demographic Health Survey (DHS) data distribution system and can be used after registration. The procedures and questionnaires for standard DHS survey have been reviewed and approved by ICF Institutional Review Board(IRB). Additionally, NFHS was approved by the international Institute for Population science (IIPS) Institutional Review Board. Each respondent's informed consent for participation in the survey was obtained. The results presented in this study are based on the analysis of existing survey data which do not contain any identifying information on patients.
Keywords: India, Multilevel, Antenatal care, Inequality, Socioeconomic status, Geography
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