Long-term trend in socioeconomic inequalities and geographic variation in the utilization of antenatal care service in India between 1998 and 2015

Objective: To investigate the temporal trend of socioeconomic and rural-urban disparities and geographical variation in the utilization of antenatal care (ANC) services in India before and throughout the Millennium Development Goals era. Data Sources/Study Setting: For this temporal analysis, secondary data from the Indian National Family Health Surveys between 1998 and 2015 (Waves 2, 3, and 4) were used. Study Design: We analyzed the trend in inequality for at least one and four ANC visits to a health care professional (ANC1+ and ANC4+, respectively) by education, wealth, and residence type. Multilevel logistic regression models were used to assess the temporal trend and the relative contribution of communities and states to the overall variation in ANC1+ and ANC4+. Data Collection/Extraction Methods: Data on utilization of ANC services for the last birth of women aged 15-49 years during the three or five years preceding the survey (depending on the survey year) were used. Principal Findings: Educational and wealth inequality in ANC1+ and ANC4+ worsened between 1998 and 2005 and improved between 2005 and 2015 (for ANC4+, OR [95% CI] = 0.22 [0.19-0.25] in Wave 2; OR [95% CI] = 0.19 [0.17-0.22] in Wave 3; and OR [95% CI] = 0.38 [0.36-0.40] in Wave 4 for the poorest). Rural-urban inequality showed a consistent decline (for ANC4+, OR [95% CI] = 0.59 [0.54-0.64] in Wave 2; OR [95% CI] = 0.63 [0.59-0.68] in Wave 3; and OR [95% CI] = 0.82 [0.79-0.85] in Wave 4 for rural area). The relative contribution of the community to the total geographic variation in the utilization of ANC services increased more than four times during the study period. Conclusions: The use of ANC services remains disproportionately lower among women with low socioeconomic status. Efforts to directly target these women are necessary to tackle inequality in ANC utilization in India.