Abstract

Objective

To investigate the socio-economic differentials in the quality (clinical and interpersonal) of antenatal care and also the correlation between differentials in the quality and utilization of antenatal care.

Design

The study uses cross-sectional, nationally representative data from National Family Health Survey (1998–99).

Setting

Four south Indian states (Andhra Pradesh, Karnataka, Kerala and Tamil Nadu) and four north Indian states (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh).

Main outcomes measured

More than four antenatal care visits for utilization, and index of clinical, information and interpersonal quality of care.

Results

Lower than desired quality of antenatal care was observed in both north and south Indian states, though the quality was significantly better in south India compared with north India, especially among the disadvantaged women. Significant socio-economic differentials in the quality of care were evident in both north and south India, but were more glaring in north India. A significantly positive relationship was observed between the quality and utilization of antenatal care in the rural areas from village-level multivariate analysis.

Discussion

Poor quality of antenatal care is likely to reduce its utilization. Policy and program interventions to improve the quality of care of antenatal care, especially for the poor and other disadvantaged population groups, more so in north India, are essential to improve maternal health outcomes. The India's National Rural Health Mission (NRHM), launched in 2005, should lay greater emphasis on improving the quality of antenatal care, among other things, to increase utilization of antenatal care and achieve better maternal health outcomes.

Introduction

Antenatal care is the ‘care before birth’ to promote the well-being of mother and fetus, and is essential to reduce maternal morbidity and mortality, low-weight births and perinatal mortality [1–2]. However, the content and quality of antenatal care and the availability of effective referral and essential obstetric care are important for antenatal care to be effective [2].

Although utilization of antenatal care (proportion of pregnant women receiving one or more consultations with trained health workers) is regularly monitored in most settings, and has improved considerably in developing countries in 1990s, there is little evidence on the content and quality of antenatal care in these settings [3]. In fact, the weak relationship, observed in some studies, between antenatal care utilization and maternal health outcomes may be partly due to failure to take into account the content and quality of antenatal care provided [4–5].

In addition, there is very sparse evidence on socio-economic differentials in the quality of antenatal care in developing countries [6]. Most of the studies in India [7–10] and in other developing countries [11–13] have attributed socio-economic differentials in antenatal care utilization to a combination of poor access to health services, low education levels and poor demand. Few studies examined the socio-economic differentials in the quality of antenatal care and its association with utilization. Some studies, however, have suggested poor quality, unfriendly treatment and less information sharing by health providers to the poor and disadvantaged women [14–16]. These studies also suggested that the perception of poor quality of care may lead to under-utilization of health services by the poor women.

Drawing upon a nationally representative survey data from India, the study investigates: (i) quality of antenatal care and socio-economic differentials in the content and self-reported technical and interpersonal quality of antenatal care in four north Indian and four south Indian states; and (ii) correlation between quality of antenatal care and utilization of antenatal care services.

Methods

The data from the National Family Health Survey-2 (NFHS-2), implemented nationwide between November 1998 and December 1999, were used in this study. NFHS-2 is a nationally representative, cross-sectional survey using a systematic, two-stage, cluster sample of households [17]. A 3-year retrospective pregnancy history was obtained from married women, aged 15–49 years, who gave birth in the 3 years preceding the survey. However, to reduce recall bias, the sub-sample for this study is limited to only those who gave births in the 6 months preceding the survey. The analysis focused on the four north and four south Indian states to provide a comparative perspective, as two regions differ substantially in utilization of preventive health services. These criteria yielded a final sub-sample of 840 women from the four south Indian states (Andhra Pradesh, Karnataka, Kerala and Tamil Nadu) and 2970 women from the four north Indian states (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh).

Dependent variables

Utilization of antenatal care

Utilization of antenatal care is measured as at least one antenatal consultation with a trained provider (doctor/nurse); at least four antenatal consultations; and whether the women initiated antenatal consultation in the first trimester.

Clinical quality

Three different aspects of quality of care are generally assessed: structure, process and outcome [18–19]. The ‘clinical quality’ of antenatal care was measured by ever performance of essential physical examinations, tests and services by the provider (measurement of weight, height, blood pressure; urine and blood testing; abdomen examination; provision of iron/folic acid supplementation and tetanus toxoid immunization; and provision of information on nutrition, danger signs of pregnancy, delivery care, newborn care and family planning). Two separate summative indexes were created to measure the overall level of quality of ‘clinical care’ and the quality of ‘information provided’, both ranging from 0 to 5. The data on quality of clinical care are available by the type of provider (doctor and nurse) but not by the affiliation of the providers (i.e. public or private sector).

Interpersonal quality of care

The ‘interpersonal’ quality of care was assessed by whether the provider spent enough time with the client; spoke nicely to the woman; and respected the need for client's privacy. The data on interpersonal quality of care were available by the type of facility visited (public and private).

Independent variables

Wealth quintiles (based on household wealth index), caste and educational status were the main socio-economic status indicators to examine the socio-economic differentials in the utilization and the quality of antenatal care.

Statistical methods

Bivariate analysis is used to examine the socio-economic differentials in the utilization and the quality of antenatal care. Pearson's chi-square test is used to test the significance of differences in the dependent variable across two categories. The two sample mean test is used to test the statistical significance of difference in means of quality of care indexes across two categories.

Two multivariate linear regression models were used to examine the adjusted relationships: (i) the first model used summative quality of care indexes as dependent variable to calculate the adjusted relationship of quality of antenatal care with various socio-economic variables; and (ii) the second was fitted with the proportion of women in a village seeking four or more antenatal visits as the dependent variable to examine the independent relationship of the quality of care with antenatal care utilization after controlling for access to health services and other state level variables. (Since the quality of antenatal care data is available only for women who utilized antenatal care, the only way to examine this relationship was to do a village-level analysis. Urban areas are excluded from the second regression, as the access is assumed to be universal in urban areas.)

All the point estimates were weighted to provide representative estimates. In addition, the standard errors were adjusted for the clustered multistage sampling design (Huber-white standard error estimates) to give efficient confidence intervals. The statistical analysis was carried using the Stata 8.0 statistical software [20].

Results

Differentials in antenatal care utilization

The women in south India utilized antenatal care significantly more than those in the north India for all the utilization indicators, with sharpest differences observed for ‘four or more antenatal visits’ (Table 1). The differences in the utilization between north and south were significantly wider in the disadvantaged social groups than among the better-off for all the three indicators. For instance, while the gap between North and South in the poor population quintile for at least one antenatal care visit was 56% (82% in the North versus 26% in the South), it was only 13.8% in the wealthiest population quintile (Table 1). The socio-economic differentials within each region and between the North and the South were even more acute for ‘four or more antenatal care consultations’. Similar differences were observed by caste and education. In addition, majority of women, especially in the South, chose doctors than nurses as providers of antenatal care.

Table 1

Differentials in antenatal care utilization rates by socio-economic characteristics of women who had birth in the last 6 months of the survey

Background characteristic of the woman Antenatal care utilization by any trained provider (%) Antenatal care utilization: doctors (%) Antenatal care utilization: nurse (%) 4+ Antenatal care visits (%) Antenatal care visit in the first trimester (%) 
 North South North South North South North South North South 
 Overall 43.1 93.4 26.1 82.3 14.1 27.1 9.6 69.6 17.1 59.3 
Household Wealth           
 Poorest 20% 26.3 82.2 13.1 62.3 8.6 31.0 NS 2.8 47.5 7.3 33.6 
 Second poorest 36.2 89.6 18.6 76.9 13.3 23.6 3.5 55.5 10.7 48.0 
 Middle 45.1 96.2 27.2 81.6 14.2 30.0 5.4 69.1 16.7 55.7 
 Second richest 57.2 98.9 37.8 95.1 20.6 29.5 16.5 84.7 24.7 74.2 
 Richest 86.2 100.0 66.4 97.4 22.4 16.5 45.5 95.9 53.4 92.5 
Caste           
 Scheduled caste 37.8 94.6 18.4 74.1 16.5 NS 33.7 4.4 59.9 10.5 48.1 
 Scheduled tribe 41.0 61.9 18.9 44.6 12.2 15.7 5.5 35.9 14.2 37.4 
 Other backward 41.0 95.3 25.9 86.1 12.5 33.2 9.2 72.2 16.2 62.6 
 General 49.4 94.2 34.2 88.1 14.5 11.9 15.1 78.3 23.5 66.4 
Education           
 No education 34.0 83.0 18.0 67.4 11.6 23.0 4.3 50.0 10.5 40.0 
 Primary 56.0 98.4 34.0 87.1 21.5 37.7 11.6 65.3 19.9 54.2 
 Secondary or higher 73.0 99.2 55.9 91.7 19.9 26.3 31.1 85.7 43.7 75.3 
Residence           
 Rural 37.7 91.5 21.3 79.3 12.8 28.0 NS 6.1 64.9 13.3 54.3 
 Urban 73.9 98.9 54.3 915 219 24.6 29.6 83.5 38.7 74.2 
Background characteristic of the woman Antenatal care utilization by any trained provider (%) Antenatal care utilization: doctors (%) Antenatal care utilization: nurse (%) 4+ Antenatal care visits (%) Antenatal care visit in the first trimester (%) 
 North South North South North South North South North South 
 Overall 43.1 93.4 26.1 82.3 14.1 27.1 9.6 69.6 17.1 59.3 
Household Wealth           
 Poorest 20% 26.3 82.2 13.1 62.3 8.6 31.0 NS 2.8 47.5 7.3 33.6 
 Second poorest 36.2 89.6 18.6 76.9 13.3 23.6 3.5 55.5 10.7 48.0 
 Middle 45.1 96.2 27.2 81.6 14.2 30.0 5.4 69.1 16.7 55.7 
 Second richest 57.2 98.9 37.8 95.1 20.6 29.5 16.5 84.7 24.7 74.2 
 Richest 86.2 100.0 66.4 97.4 22.4 16.5 45.5 95.9 53.4 92.5 
Caste           
 Scheduled caste 37.8 94.6 18.4 74.1 16.5 NS 33.7 4.4 59.9 10.5 48.1 
 Scheduled tribe 41.0 61.9 18.9 44.6 12.2 15.7 5.5 35.9 14.2 37.4 
 Other backward 41.0 95.3 25.9 86.1 12.5 33.2 9.2 72.2 16.2 62.6 
 General 49.4 94.2 34.2 88.1 14.5 11.9 15.1 78.3 23.5 66.4 
Education           
 No education 34.0 83.0 18.0 67.4 11.6 23.0 4.3 50.0 10.5 40.0 
 Primary 56.0 98.4 34.0 87.1 21.5 37.7 11.6 65.3 19.9 54.2 
 Secondary or higher 73.0 99.2 55.9 91.7 19.9 26.3 31.1 85.7 43.7 75.3 
Residence           
 Rural 37.7 91.5 21.3 79.3 12.8 28.0 NS 6.1 64.9 13.3 54.3 
 Urban 73.9 98.9 54.3 915 219 24.6 29.6 83.5 38.7 74.2 

Differences across all the background characteristics are statistically significant at P < 0.05 except where indicated; NS, not significant.

Differentials in the quality of clinical care

North–South differentials

Only 40% of the women who received antenatal care in the North compared with 87% in the South reported their blood pressure being measured during antenatal visit (Table 2). Less than one-third of the women in the North reported their weight being measured in at least one of the visits compared with 80% in the South. Similar differentials were observed for other components of care also—blood examination (40 versus 79%) and urine examination (38 versus 77%). The overall summative index of clinical quality on a scale of 0–5 varied significantly from 2.1 in the North to 4.1 in the South (Table 2). Major deficiencies were observed in the provision of essential information in both South and North but more so in the later. Only 23% of the women in the North and 44% of women in the South reported receiving information on danger signs during pregnancy and delivery care. The overall index of information provided on a scale of 0–5 varied from 1.5 in north India to 2.7 in south India. Besides the poor clinical and information quality, women in the North were also significantly less likely to receive iron and folic acid supplementation than their counterparts in the South (60 versus 91%), though the differences for the tetanus toxoid vaccination were not significant (89 versus 95%).

Table 2

Percentage of women (who had at least one antenatal consultation) reporting ever performance of different components of antenatal care in north and south India by the type of provider

 Doctor only Nurse only Any provider 
 North (n = 612) South (n = 370) North (n = 533) South (n = 93) North (n = 1363) South (n = 786) 
Clinical quality of care       
 Blood pressure measured (%) 53.5 93.0 19.7 48.1 40.3 87.4 
 Weight taken (%) 33.0 83.1 16.0 58.9 27.1 79.6 
 Blood examination (%) 49.2 84.6 22.2 41.6 40.4 78.6 
 Urine examination (%) 47.2 85.5 19.2 35.5 37.9 77.1 
 Abdomen examination (%) 69.1 94.5 48.6 66.1 62.7 89.7 
 Overall index of clinical quality (0–5) 2.52 4.40 1.26 2.5 2.1 4.1 
Information provided       
 Diet (%) 65.5 76.7 43.4 69.6 56.6 79.9 
 Danger signs (%) 28.8 47.6 16.5 34.1 23.3 44.1 
 Delivery care (%) 33.0 49.8 16.2 46.8 27.3 53.9 
 New born care (%) 28.7 41.5 12.4 40.5 23.6 47.6 
 Family planning (%) 15.9 35.6 12.2 54.7 14.7 43.3 
Overall index of information given (0–5) 1.7 2.5 1.0 2.5 1.5 2.7 
Prophylactic treatment       
 Antenatal tetanus toxoid (%) 90.1 95.9 90.3 86.3 89.2 95.1 
 Antenatal iron/folic acid supplementation (%) 67.3 87.6 50.9 82.9 60.2 88.0 
 Doctor only Nurse only Any provider 
 North (n = 612) South (n = 370) North (n = 533) South (n = 93) North (n = 1363) South (n = 786) 
Clinical quality of care       
 Blood pressure measured (%) 53.5 93.0 19.7 48.1 40.3 87.4 
 Weight taken (%) 33.0 83.1 16.0 58.9 27.1 79.6 
 Blood examination (%) 49.2 84.6 22.2 41.6 40.4 78.6 
 Urine examination (%) 47.2 85.5 19.2 35.5 37.9 77.1 
 Abdomen examination (%) 69.1 94.5 48.6 66.1 62.7 89.7 
 Overall index of clinical quality (0–5) 2.52 4.40 1.26 2.5 2.1 4.1 
Information provided       
 Diet (%) 65.5 76.7 43.4 69.6 56.6 79.9 
 Danger signs (%) 28.8 47.6 16.5 34.1 23.3 44.1 
 Delivery care (%) 33.0 49.8 16.2 46.8 27.3 53.9 
 New born care (%) 28.7 41.5 12.4 40.5 23.6 47.6 
 Family planning (%) 15.9 35.6 12.2 54.7 14.7 43.3 
Overall index of information given (0–5) 1.7 2.5 1.0 2.5 1.5 2.7 
Prophylactic treatment       
 Antenatal tetanus toxoid (%) 90.1 95.9 90.3 86.3 89.2 95.1 
 Antenatal iron/folic acid supplementation (%) 67.3 87.6 50.9 82.9 60.2 88.0 

The north–south differences are statistically significant at 95% level for all the indicators except for antenatal tetanus toxoid for doctor, nurse and any provider. The differences between doctor and nurse is also statistically significant at 95% level within north and south India except for information on new born care and delivery care in South India.

Differentials by provider (doctor/nurse)

In general, women who consulted a nurse reported significantly lower level of clinical quality than those who consulted a doctor, differences being significantly larger in north India (Table 2). The overall index of clinical quality of care varied from 1.3 for a nurse to 2.5 for a doctor in north India and from 2.5 for a nurse to 4.4 for a doctor in south India (Table 2). Nurses were likely to provide significantly lower levels of information than doctors in the North (the index of information given is 1.0 versus 1.7), the differences were not significant in the South (the index of information given is 2.5 versus 2.5).

Differentials by socio-economic indicators

Significant differentials were observed in the clinical and information quality by the household wealth, caste, education and residence in both north and south India. However, the differentials were much wider in the north than in south India for some of the indicators (e.g. the richest/poorest difference in clinical quality of care was 1.8 in North compared with 1.1 in South).

The North–South differentials in the quality of care were observed in all the population groups, with women at the same socio-economic level in the South likely to receive significantly better clinical quality and information than in the North. For instance, women in the poorest population quintile in the South received significantly better clinical quality of care (index of clinical quality of care was 3.7 versus 1.8) and much better information (index of information given 2.8 versus 1.3) than their counterparts in the North from doctors. The North–South differences were more profound among the disadvantaged groups of women than among the better-off groups (e.g. the North–South difference in the poorest quintile for clinical quality of care index for doctors was 1.9 compared with 1.2 in the richest quintile). Similar differences were seen for nurses as well and by the education and caste of women (Table 3). The North–South and socio-economic differentials were the narrowest for the tetanus toxoid vaccination, an interesting finding explored further in the discussion.

Table 3

Differentials in the quality of antenatal care by socio-economic characteristics of women from north and south India separately by type of provider (for women who had births in the last 6 months of the survey)

 Clinical quality of care (0–5) Information given (0–5) Antenatal tetanus toxoid (%) Iron/folic acid (%) 
 Doctors Nurses Doctors Nurses Doctors Nurses Doctors Nurses 
 North South North South North South North South North South North South North South North South 
Household wealth                 
 Poorest 1.8*** 3.7** 0.9*** 2.5* 1.3*** 2.8 0.9* 2.46 80.1*** 89.5 90.1 85.8 53.8*** 74.2** 43.7** 88.1 
 Second poorest 1.7 4.1 1.0 1.6 1.4 2.3 1.0 2.16 80.5 95.5 86.5 82.6 42.7 85.1 42.4 74.3 
 Middle 2.3 4.4 1.0 2.7 1.5 2.4 0.9 2.57 91.2 95.7 90.3 84.1 70.6 92.3 52.7 76.2 
 Second richest 2.6 4.6 1.7 3.2a 1.9 2.4 1.1 2.87a 91.9 96.1 93.6 100.0a 74.6 89.9 63.3 100.0a 
 Richest 3.6 4.8 2.4 3.8a 2.2 2.8 1.4 2.11a 100.0 100.0 95.7 100.0a 84.0 90.0 63.9 100.0a 
Caste                 
 Scheduled caste 2.2*** 4.1 1.3 2.3 1.5 2.4 1.3** 3.05*** 87.5** 98.0 91.1 89.4 60.0*** 81.8 47.5* 84.5 
 Scheduled tribe 1.8 4.3 0.9 2.3a 1.5 1.5 0.9 1.38a 75.7 82.6 87.4 85.5a 56.0 73.2 61.3 85.7a 
 Other backward 2.3 4.5 1.2 2.8 1.8 2.6 1.1 2.52 89.8 95.1 91.4 85.5 63.2 91.9 43.3 83.4 
 General 2.9 4.4 1.5 2.2a 1.8 2.5 0.8 1.07a 94.0 96.7 91.8 81.0a 75.5 86.7 58.0 75.5a 
Education                 
 No education 1.9*** 3.8 1.1 2.3 1.4 2.5 1.0** 2.03*** 85.3*** 90.0*** 88.6* 85.0 59.6*** 79.4** 44.3*** 83.3 
 Primary 2.4 4.1 1.5 1.8 1.4 2.3 1.0 2.66 88.2 97.9 91.7 82.8 63.3 90.5 61.1 75.9 
 Secondary/higher 2.5 4.7 1.5 3.2 2.2 2.5 1.1 2.96 97.3 98.0 96.0 90.2 79.5 90.6 68.0 86.2 
Residence                 
 Rural 2.2** 4.3 1.1** 2.4 1.7 2.5 0.9 2.3** 87.1 95.0 89.9 85.8 61.4** 86.3 47.3** 86.8 
 Urban 3.1 4.6 2.3 2.9 1.8 2.5 1.3 3.1 95.9 97.5 97.4 88.7 79.0 90.1 68.3 64.3 
 Clinical quality of care (0–5) Information given (0–5) Antenatal tetanus toxoid (%) Iron/folic acid (%) 
 Doctors Nurses Doctors Nurses Doctors Nurses Doctors Nurses 
 North South North South North South North South North South North South North South North South 
Household wealth                 
 Poorest 1.8*** 3.7** 0.9*** 2.5* 1.3*** 2.8 0.9* 2.46 80.1*** 89.5 90.1 85.8 53.8*** 74.2** 43.7** 88.1 
 Second poorest 1.7 4.1 1.0 1.6 1.4 2.3 1.0 2.16 80.5 95.5 86.5 82.6 42.7 85.1 42.4 74.3 
 Middle 2.3 4.4 1.0 2.7 1.5 2.4 0.9 2.57 91.2 95.7 90.3 84.1 70.6 92.3 52.7 76.2 
 Second richest 2.6 4.6 1.7 3.2a 1.9 2.4 1.1 2.87a 91.9 96.1 93.6 100.0a 74.6 89.9 63.3 100.0a 
 Richest 3.6 4.8 2.4 3.8a 2.2 2.8 1.4 2.11a 100.0 100.0 95.7 100.0a 84.0 90.0 63.9 100.0a 
Caste                 
 Scheduled caste 2.2*** 4.1 1.3 2.3 1.5 2.4 1.3** 3.05*** 87.5** 98.0 91.1 89.4 60.0*** 81.8 47.5* 84.5 
 Scheduled tribe 1.8 4.3 0.9 2.3a 1.5 1.5 0.9 1.38a 75.7 82.6 87.4 85.5a 56.0 73.2 61.3 85.7a 
 Other backward 2.3 4.5 1.2 2.8 1.8 2.6 1.1 2.52 89.8 95.1 91.4 85.5 63.2 91.9 43.3 83.4 
 General 2.9 4.4 1.5 2.2a 1.8 2.5 0.8 1.07a 94.0 96.7 91.8 81.0a 75.5 86.7 58.0 75.5a 
Education                 
 No education 1.9*** 3.8 1.1 2.3 1.4 2.5 1.0** 2.03*** 85.3*** 90.0*** 88.6* 85.0 59.6*** 79.4** 44.3*** 83.3 
 Primary 2.4 4.1 1.5 1.8 1.4 2.3 1.0 2.66 88.2 97.9 91.7 82.8 63.3 90.5 61.1 75.9 
 Secondary/higher 2.5 4.7 1.5 3.2 2.2 2.5 1.1 2.96 97.3 98.0 96.0 90.2 79.5 90.6 68.0 86.2 
Residence                 
 Rural 2.2** 4.3 1.1** 2.4 1.7 2.5 0.9 2.3** 87.1 95.0 89.9 85.8 61.4** 86.3 47.3** 86.8 
 Urban 3.1 4.6 2.3 2.9 1.8 2.5 1.3 3.1 95.9 97.5 97.4 88.7 79.0 90.1 68.3 64.3 

The statistical significance (P-values) indicates that the differentials within a particular sub-group (household wealth, caste, education and residence) are significant. These do not indicate the statistical significance comparing a particular population sub-group across north or south India. *P < 0.10; **P < 0.05; ***P < 0.001. aEstimates should be interpreted with caution due to small sample size (n < 159).

Differentials in the interpersonal quality of care

Table 4 presents the levels and socio-economic differentials, separately by public and private facility, in the self-reported interpersonal quality of care during the last visit to a health facility for antenatal care. As with quality of clinical care and information provided, the socio-economic differentials in the interpersonal quality of care were observed in both north and south India and in both public and private sectors, although women in both north and south India reported better interpersonal quality of care in the private sector. However, women at the same socio-economic levels were likely to report better interpersonal quality in the South and in the private sector than in the North and in the public sector, respectively. Almost all women—both from poor and rich households—in both north and south India reported providers spending enough time during their visit in private facilities.

Table 4

Differentials in the self-reported interpersonal quality of care from north and south India separately for public and private providers

 Provider spoke nicely (%) Did not respect the need for privacy (%) Spent enough time (%) 
 Public Private Public Private Public Private 
 North (n = 420) South (n = 228) North (n = 346) South (n = 486) North (n = 420) South (n = 228) North (n = 346) South (n = 486) North (n = 420) South (n = 228) North (n = 346) South (n = 486) 
Overall 48.8 67.9 70.1 86.4 20.5 11.6 10.3 3.4 92.7 92.7 97.6 98.9 
Household wealth             
 Poorest 20% 52.1 61.2 60.3 91.7** 28 19.3 7.8 1.9 92.2 84.6 96.1 98.7 
 Second poorest 57.6 59.7 70.7 75.5 13 9.9 7.1 5.4 94.2 100 94.8 97.1 
 Middle 51.3 69.5 76.2 83.6 24.9 12 12.8 91.2 92.5 97.7 100 
 Second richest 48.8 74.9 67.9 83.9 17.3 5.8 9.9 4.4 96.5 94.2 100 100 
 Richest 38.7 70.1 71.4 93.3 21.9 11.2 13.3 2.3 88.3 94.2 97.1 98.5 
Caste             
 Scheduled caste 38.3*** 62.8* 65.3 86.2 22.5 19.9*** 11.6 79.6*** 92.1 94.6 98.9 
 Scheduled tribe 50.2 33.5 71 84 19.5 49.4  7 0.0 97.6 75.7# 100 100.0# 
 Other backward 47 77.9 68.4 86.1 26.7 4.6 8.7 5.4 95.5 94.8 95.3 98.1 
 General 55.3 59.9 72.4 86.9 14 7.5 11.2 1.1 95.4 92.5 99.4 100 
Education             
 No education 41.0** 58.7* 57.6*** 74.7*** 24.2* 16.6* 17.5*** 4.5*** 89.9** 89.7* 95.7 98.7 
 Primary 54.7 72.9 85.3 85.1 12.3 6.8 2.3 1.4 93.3 95.1 100 99 
 Secondary/higher 65.8 73.8 80.4 91.2 16.7 9.4 4.2 2.4 100 94.3 98.4 98.9 
Residence             
 Rural 41.3*** 73.2** 69.6 86.6 25.1*** 11.7 10.9 4.3 90.0*** 95.1** 96.3 98.8 
 Urban 69.0 51.9 71.3 86.1 7.9 11.3 9.1 1.6 100.0 85.5 99.6 99.0 
 Provider spoke nicely (%) Did not respect the need for privacy (%) Spent enough time (%) 
 Public Private Public Private Public Private 
 North (n = 420) South (n = 228) North (n = 346) South (n = 486) North (n = 420) South (n = 228) North (n = 346) South (n = 486) North (n = 420) South (n = 228) North (n = 346) South (n = 486) 
Overall 48.8 67.9 70.1 86.4 20.5 11.6 10.3 3.4 92.7 92.7 97.6 98.9 
Household wealth             
 Poorest 20% 52.1 61.2 60.3 91.7** 28 19.3 7.8 1.9 92.2 84.6 96.1 98.7 
 Second poorest 57.6 59.7 70.7 75.5 13 9.9 7.1 5.4 94.2 100 94.8 97.1 
 Middle 51.3 69.5 76.2 83.6 24.9 12 12.8 91.2 92.5 97.7 100 
 Second richest 48.8 74.9 67.9 83.9 17.3 5.8 9.9 4.4 96.5 94.2 100 100 
 Richest 38.7 70.1 71.4 93.3 21.9 11.2 13.3 2.3 88.3 94.2 97.1 98.5 
Caste             
 Scheduled caste 38.3*** 62.8* 65.3 86.2 22.5 19.9*** 11.6 79.6*** 92.1 94.6 98.9 
 Scheduled tribe 50.2 33.5 71 84 19.5 49.4  7 0.0 97.6 75.7# 100 100.0# 
 Other backward 47 77.9 68.4 86.1 26.7 4.6 8.7 5.4 95.5 94.8 95.3 98.1 
 General 55.3 59.9 72.4 86.9 14 7.5 11.2 1.1 95.4 92.5 99.4 100 
Education             
 No education 41.0** 58.7* 57.6*** 74.7*** 24.2* 16.6* 17.5*** 4.5*** 89.9** 89.7* 95.7 98.7 
 Primary 54.7 72.9 85.3 85.1 12.3 6.8 2.3 1.4 93.3 95.1 100 99 
 Secondary/higher 65.8 73.8 80.4 91.2 16.7 9.4 4.2 2.4 100 94.3 98.4 98.9 
Residence             
 Rural 41.3*** 73.2** 69.6 86.6 25.1*** 11.7 10.9 4.3 90.0*** 95.1** 96.3 98.8 
 Urban 69.0 51.9 71.3 86.1 7.9 11.3 9.1 1.6 100.0 85.5 99.6 99.0 

The statistical significance (P-values) indicates that the differentials within a particular sub-group (household wealth, caste, education and residence) are significant. These do not indicate the statistical significance comparing a particular population group across north or south India; *P < 0.10; **P < 0.05; ***P < 0.001.

In both public and private sector, no statistically significant differences were observed by household wealth, except for the indicator of ‘provider speaking nicely’ in the South in the private sector; however, we do not see any consistent increasing or decreasing trend. No significant differences were seen by caste in the private sector, though the differences were significant in the public sector in both north and south India. Significant differences were seen by women's level of education. Illiterate women reported significantly poorer interpersonal quality of care for all the three indicators in both the North and the South. Significant differentials were also seen by rural–urban residence in the pubic sector, especially in the North (Table 4).

Multivariate analysis

Adjusted association between quality of care indexes and socio-economic variables

The differentials in the quality of clinical care and information provided persisted by region, household wealth, education of the women, urban/rural residence (not significant for information provided) and by the type of provider after adjusting the effect of other variables in the model (Table 5). However, the differentials in interpersonal care were statistically significant only by the region, education and the type of the provider (public/private).

Table 5

Results of multivariate linear regression to predict adjusted relationship between the quality of care and women's socio-economic, demographic and healthcare background factors

 Clinical quality of care Information provided Interpersonal quality of care 
 Coeff. 95% CI Coeff. 95% CI Coeff. 95% CI 
Region (South) −1.51*** −1.67 to −1.35 −0.91*** −1.09 to −0.73 −0.19*** −0.26 to −0.12 
Wealth quintile (poorest)       
Second poorest 0.02 −0.23 to 0.28 0.00 −0.24 to 0.24 0.04 −0.06 to 0.14 
Middle 0.22* −0.01 to 0.45 0.05 −0.17 to 0.27 0.03 −0.06 to 0.12 
Second richest 0.48*** 0.22 to 0.73 0.20 −0.05 to 0.45 0.07 −0.02 to 0.17 
Richest 0.93*** 0.62 to 1.24 0.49*** 0.16 to 0.81 0.00 −0.10 to 0.10 
Caste (scheduled castes)       
Scheduled tribes −0.03 −0.31 to 0.26 −0.36 −0.67 to −0.05 0.10 −0.09 to 0.29 
Other backward 0.06 −0.13 to 0.25 −0.07** −0.28 to 0.13 0.07 −0.02 to 0.17 
General 0.01 −0.21 to 0.22 −0.39*** −0.60 to −0.19 0.09* −0.01 to 0.19 
Education (none)       
Primary 0.14 −0.05 to 0.33 0.17 −0.05 to 0.39 0.24*** 0.14 to 0.33 
Secondary 0.61*** 0.41 to 0.80 0.34 0.14 to 0.54 0.24*** 0.17 to 0.31 
Urban (rural) 0.24*** 0.07 to 0.41 0.08 −0.12 to 0.27 0.03 −0.03 to 0.09 
Provider (only nurse)       
Both doctor and nurse 1.36*** 1.15 to 1.57 0.70 0.47 to 0.93   
Only doctor 1.09*** 0.91 to 1.28 0.40 0.23 to 0.56   
Visit to public facility (private) NA  NA NA −0.24*** −0.31 to −0.17 
Constant 3.81 3.43 to 4.20 2.91 2.51 to 3.30 2.78 2.63 to 2.92 
 Clinical quality of care Information provided Interpersonal quality of care 
 Coeff. 95% CI Coeff. 95% CI Coeff. 95% CI 
Region (South) −1.51*** −1.67 to −1.35 −0.91*** −1.09 to −0.73 −0.19*** −0.26 to −0.12 
Wealth quintile (poorest)       
Second poorest 0.02 −0.23 to 0.28 0.00 −0.24 to 0.24 0.04 −0.06 to 0.14 
Middle 0.22* −0.01 to 0.45 0.05 −0.17 to 0.27 0.03 −0.06 to 0.12 
Second richest 0.48*** 0.22 to 0.73 0.20 −0.05 to 0.45 0.07 −0.02 to 0.17 
Richest 0.93*** 0.62 to 1.24 0.49*** 0.16 to 0.81 0.00 −0.10 to 0.10 
Caste (scheduled castes)       
Scheduled tribes −0.03 −0.31 to 0.26 −0.36 −0.67 to −0.05 0.10 −0.09 to 0.29 
Other backward 0.06 −0.13 to 0.25 −0.07** −0.28 to 0.13 0.07 −0.02 to 0.17 
General 0.01 −0.21 to 0.22 −0.39*** −0.60 to −0.19 0.09* −0.01 to 0.19 
Education (none)       
Primary 0.14 −0.05 to 0.33 0.17 −0.05 to 0.39 0.24*** 0.14 to 0.33 
Secondary 0.61*** 0.41 to 0.80 0.34 0.14 to 0.54 0.24*** 0.17 to 0.31 
Urban (rural) 0.24*** 0.07 to 0.41 0.08 −0.12 to 0.27 0.03 −0.03 to 0.09 
Provider (only nurse)       
Both doctor and nurse 1.36*** 1.15 to 1.57 0.70 0.47 to 0.93   
Only doctor 1.09*** 0.91 to 1.28 0.40 0.23 to 0.56   
Visit to public facility (private) NA  NA NA −0.24*** −0.31 to −0.17 
Constant 3.81 3.43 to 4.20 2.91 2.51 to 3.30 2.78 2.63 to 2.92 

NA, not applicable; coeff., coefficient; CI, confidence interval; *P < 0.10; **P < 0.05; ***P < 0.001.

Association between quality of services and antenatal care utilization levels

The percentage of women receiving four or more antenatal consultations at the village level has a statistically significant positive association with all the three indices for quality of care in the multivariate analysis after controlling the effects of other potentially confounding factors (Table 6). Although this analysis assumes that all the women in the village receive the same level of quality (which is certainly not true considering significant differentials in the quality of services), the result do provide some idea of relative importance of quality vis-à-vis access. The results show that the quality is a more significant predictor of utilization (clinical quality of index P < 0.001 and interpersonal quality index P < 0.001) of utilization of antenatal care than access (proximity to public or private facility, which was statistically insignificant) (Table 6).

Table 6

Unadjusted and adjusted (multivariate linear regression) estimates at a village level predicting percent of women who had four or more antenatal consultations

Independent variables Unadjusted Adjusted 
 Coeff. 95% CI Coeff. 95% CI 
State (Uttar Pradesh) −0.247*** −0.285 to −0.209   
 Andhra Pradesh 0.375*** 0.313 to 0.436 0.423*** 0.384 to 0.463 
 Bihar −0.205*** −0.249 to −0.162 −0.016 −0.044 to 0.012 
 Karnataka 0.347*** 0.284 to 0.410 0.387*** 0.348 to 0.425 
 Madhya Pradesh 0.764*** 0.698 to 0.830 0.596*** 0.535 to 0.657 
 Rajasthan −0.175*** −0.221 to −0.128 0.072*** 0.044 to 0.100 
 Tamil Nadu −0.155*** −0.202 to −0.108 0.089*** 0.061 to 0.117 
 Kerala 0.474*** 0.411 to 0.536 0.462*** 0.417 to 0.506 
Population of the village 0.000*** 0.000 to 0.000 0.000 0.000 to 0.000 
Distance from district headquarter 0.000 −0.001 to 0.001 −0.001*** −0.001 to 0.000 
All weather road within 2 km 0.111*** 0.077 to 0.145 0.007 −0.015 to 0.028 
Percentage of population within 2 km of nearest transport service 0.128*** 0.094 to 0.162 0.001 −0.021 to 0.022 
Public health facility (other than sub − center) with 5 km 0.149*** 0.116 to 0.183 0.009 −0.010 to 0.028 
Private clinic/hospital with 5 km 0.112*** 0.078 to 0.147 −0.006 −0.025 to 0.013 
Percentage of women with >8 years of schooling 1.540*** 1.428 to 1.651 0.408*** 0.314 to 0.503 
Clinical quality of index 0.136*** 0.128 to 0.144 0.035*** 0.027 to 0.042 
Information quality index 0.137*** 0.124 to 0.151 0.009* −0.001 to 0.019 
Interpersonal quality index 0.238*** 0.222 to 0.254 0.023*** 0.008 to 0.037 
Independent variables Unadjusted Adjusted 
 Coeff. 95% CI Coeff. 95% CI 
State (Uttar Pradesh) −0.247*** −0.285 to −0.209   
 Andhra Pradesh 0.375*** 0.313 to 0.436 0.423*** 0.384 to 0.463 
 Bihar −0.205*** −0.249 to −0.162 −0.016 −0.044 to 0.012 
 Karnataka 0.347*** 0.284 to 0.410 0.387*** 0.348 to 0.425 
 Madhya Pradesh 0.764*** 0.698 to 0.830 0.596*** 0.535 to 0.657 
 Rajasthan −0.175*** −0.221 to −0.128 0.072*** 0.044 to 0.100 
 Tamil Nadu −0.155*** −0.202 to −0.108 0.089*** 0.061 to 0.117 
 Kerala 0.474*** 0.411 to 0.536 0.462*** 0.417 to 0.506 
Population of the village 0.000*** 0.000 to 0.000 0.000 0.000 to 0.000 
Distance from district headquarter 0.000 −0.001 to 0.001 −0.001*** −0.001 to 0.000 
All weather road within 2 km 0.111*** 0.077 to 0.145 0.007 −0.015 to 0.028 
Percentage of population within 2 km of nearest transport service 0.128*** 0.094 to 0.162 0.001 −0.021 to 0.022 
Public health facility (other than sub − center) with 5 km 0.149*** 0.116 to 0.183 0.009 −0.010 to 0.028 
Private clinic/hospital with 5 km 0.112*** 0.078 to 0.147 −0.006 −0.025 to 0.013 
Percentage of women with >8 years of schooling 1.540*** 1.428 to 1.651 0.408*** 0.314 to 0.503 
Clinical quality of index 0.136*** 0.128 to 0.144 0.035*** 0.027 to 0.042 
Information quality index 0.137*** 0.124 to 0.151 0.009* −0.001 to 0.019 
Interpersonal quality index 0.238*** 0.222 to 0.254 0.023*** 0.008 to 0.037 

*P < 0.10; ***P  <  0.001.

Discussion

The findings should be interpreted within the context of few limitations of the data. The utility of each of the component of antenatal care in ensuring successful maternal and child outcomes even when performed properly is equivocal [21]. Therefore, the study attempts only to examine the performance of standard components of antenatal care as suggested by technical committee of the World Health Organization [1]. Measuring the clinical quality only by enquiring about the ever performance of each component of antenatal care may not capture the quality dimension completely without assessing regular, consistent and proper performance of each component during each visit, which must inevitably affect the effectiveness of the procedures that require regular attendance [21]. The systematic differentials in recall of performance of different components of antenatal care by socio-demographic characteristics may yield false differentials in the quality of care by socio-economic characteristics. To assess the magnitude of this potential source of bias, the responses of the women who gave births in the last 6 months were compared with the women who gave births in the last 3 years. No significant differences were observed between the two samples, alleviating some of our apprehensions on this count. Secondly, consistent reporting of significantly higher quality of care by women in the South at the same education level as in the North does alleviate some of the concerns that illiterate women may not be able to recall the components performed during antenatal visits.

Almost one-third of the women, especially the poor women, in north India reported antenatal care not necessary or customary as the reason of non-utilization of antenatal care. This is consistent with the findings in other household surveys whereby quality or access to services is rarely mentioned as a reason for non-utilization. Simplistic interpretation of these data often leads to conclusions that the lack of demand or information is the main reason for the lower utilization of services often leading, in turn, to inappropriate policy choices of spending resources in educating women about the importance of antenatal care. However, poor quality of services—both clinical and interpersonal—women receive, e.g. in north India, may partly shape some of the attitudes leading to underutilization of antenatal care. A previous qualitative study in India also noted that simple provision of services did not ensure utilization; women had to first perceive the benefits of service to outweigh the cost [22].

The relatively poorer quality of antenatal care received by the poor and illiterate women especially in north India confirms the ‘inverse health care law’, where persons who need it the most get the least [23]. The Working Group on Health of Women and Children for the Government of India highlighted the missed targets on maternal and infant mortality rate in the 10th Plan period (2002–2007) mainly due to poor performance in north Indian states [24]. Since the utilization of antenatal care is nearly universal among better-off groups with much better quality of care, any further gains in infant and maternal mortality will come from improvement in quality and coverage in the disadvantaged groups with higher mortality rates. The much better quality of antenatal care in the southern states for the disadvantaged group of women suggests that better quality for disadvantaged women can also be achieved in the northern states.

It is also difficult to ascertain whether the socio-economic differentials within each region are due to active discrimination by the providers or due to greater empowerment of the better-off women to demand higher quality services from the providers. Recent quantitative study from Mexico shows active discrimination of providers toward disadvantaged women [16]. The first scenario demands active programs to sensitize the providers and action against erring providers. The second scenario suggests the need for continued investment in women's empowerment programs and policies to make them demand better quality of antenatal care.

Past comparative researches in India have highlighted significant differences in health service utilization between north and south Indian states [25] and attributed these north–south differentials to differences in culture, economy, politics and history [26]. This study examined another potential explanatory factor—the quality of health services—with specific reference to antenatal care, for the observed differentials in the utilization of health care services. Overall better quality of clinical and interpersonal care assisted by right attitude of providers irrespective of women's socio-economic status may increase the utilization of health services.

The NRHM of the Government of India, launched in 2005, also rightly prioritizes north Indian states for concerted efforts to improve maternal health [27]. Rural health care, in most of these states, is marked by absenteeism of doctors/health providers, low levels of skills, shortage of medicines, inadequate supervision/monitoring and callous attitudes [24]. If the quality of services was as significant as the availability of the services in ensuring better utilization and improved outcomes, it would be prudent for NHRM to endorse concurrent strategies aimed at enhancing both access and quality.

The results show that nurses provided poor quality of services than doctors, and were bypassed by majority of women in favor of much less accessible doctors. One of the core strategies of NHRM is to promote access to improved healthcare though the female health activist (called as ASHA). Theoretically, nurses should be as competent as doctors in providing basic primary health care such as antenatal care. However, the data (especially the narrow north–south differentials in tetanus toxoid immunization) suggest that although nurses, even in North, are able to provide clearly defined services that can be provided even in non-clinical setting (e.g. tetanus toxoid immunization, distribution of iron/folic acid tablets), they provide poor clinical services that require regular examination and follow-up of women. Strategies to improve access through increasing deployment of health workers such as ASHA by NRHM will be successful only if the quality of services provided by them is good.

The findings reflect on the wider health systems also, as the quality of antenatal care cannot be poor in isolation [28]. Two of the states in the northern region—Uttar Pradesh and Bihar—have lowest rates of utilization of public health services [29]. Hopefully, some of the key strategies adopted under NHRM including establishing ‘Public Health Standards’ and community participation through decentralized planning will improve the overall quality of health services, especially for disadvantage women in north India.

The next NFHS data (2005–2006) are likely to be available soon [30]. It would be important to investigate how the quality of antenatal care and the utilization have improved since 1998–99, especially given the scaling-up of the Reproductive and Child Health program implementation and the rapid economic growth that has taken place in India since 1998–99. Our study results would provide important baseline in assessing the trends in the quality of care and the utilization of antenatal care.

Acknowledgment and disclaimer

The authors thank the anonymous reviewers and the editor for their valuable comments and revisions, which led to significant improvement of the manuscript. The findings, interpretations and conclusions expressed in this paper are entirely those of the authors, and do not necessarily represent the views of the organizations/institutions they work for. No financial assistance was obtained from any source for this work. The research was done while pursuing doctoral studies at the Johns Hopkins Bloomberg School of Public Health, and was not part of the duties of the organizations for which they currently work for.

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