Optimizing Maternal Healthcare Access: A Mixed Method Study on Dual Utilization of Public and Private Antenatal Care Services in Puducherry, India

Abstract

Background:

Access to antenatal care (ANC) services has improved. However, it is also noted that some antenatal women seek multiple healthcare services. Exploring this practice will identify gaps in service provision and pave the path toward improving the quality of services.

Objective:

This study aimed to measure the concurrent use of public and private healthcare services for various components of ANC and understand the reasons for the dual utilization.

Methodology:

This explanatory mixed-method study enrolled 177 mothers residing in Puducherry, who had given birth in the last three years. A pretested, semi-structured questionnaire was administered, and six key informant interviews were conducted. Integration was performed in the interpretation stage, and a joint display was used to depict the results. We adopted the Donabedian model during the analysis and organized the codes under these major themes[1] Access;[2] Delivery of the Services;[3] and Quality of Care.

Result:

Most pregnant women (81.9%, 95% CI = 75.2%–86.8%) sought care from both public and private healthcare facilities, however, they preferred public facilities for delivery (74.6%, 95% CI = 67.6%–80.4%). The qualitative analysis revealed three major themes[1] Access;[2] Delivery of the Services;[3] and Quality of Care. Primary reasons for opting for private facilities included perceived superior ANC quality, organized care evident in scheduled appointments, reduced waiting time, frequent ultrasounds, personalized medication, and enhanced rapport with family. Women also believed that visits to government facilities are essential to avail the monetary benefits and have a seamless admission during delivery. They felt that government hospitals perform fewer cesarean sections.

Conclusion:

Strengthening public-private partnerships could enhance antenatal care utilization, benefiting pregnant women and streamlining healthcare delivery.

INTRODUCTION

The current sustainable development goal (SDG) is to reduce the maternal mortality ratio (MMR) to 70 per 100,000 live births by 2030.[1] Antenatal care (ANC) plays a vital role in reducing maternal mortality.[2] Essential ANC includes risk identification, prevention and management of pregnancy-related diseases, health education, and promotion. The percentage of expecting mothers, who had at least four ANC visits increased from 51.2% in NFHS-4 (2014–15) to 58.1% in NFHS-5 (2019–20).[3]

The Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH) Programme by MoHFW (The Ministry of Health and Family Welfare) recommends that every antenatal mother should receive at least four ANC checkups, iron-and-folic acid (IFA) tablets, calcium tablets, tetanus injections (TT), weight monitoring, blood pressure checks, abdominal examinations, and counseling from a frontline health worker.[4] There is variation in ANC use; some pregnant women do not use it, while others visit multiple healthcare providers at multiple times.[5] The behavior of seeking multiple healthcare facilities for ANC has not been studied. Understanding the proportion seeking such various care facilities and the reasons for such behavior will identify the gaps in the provision of quality care services. In addition, it adds to the out-of-pocket expenditure (OOPE) of antenatal women. Such healthcare spending during pregnancy and childbirth hinders access to high-quality treatment, particularly for low-income women.[6]

The current study aims to describe the dual use of public and private healthcare services for various components of ANC and understand the reasons for the dual utilization. The findings of this study will give valuable insights for policy formulation to enhance the efficiency and effectiveness of ANC services. In addition, identifying the benefits and limitations of public and private healthcare could suggest interventions to maximize the public-private partnership.[7]

MATERIALS AND METHODS

Study design

We used an explanatory mixed-method design (QUAN→qual) to give a comprehensive enhanced picture of the care-seeking behavior of antenatal women. The quantitative component was a cross-sectional study. For the qualitative component, we used key informant interviews (KIIs). The study data collection period was from July 2021 to Dec 2022

The flow of study is the visual diagram in Figure 1.

Figure 1.

The flow chart depicting the study procedure

Study setting

Puducherry has a population of about 12 Lakhs. Puducherry has two government medical colleges, seven private medical colleges, thirty-nine primary health care (PHC), four CHCs, and eight district hospitals. Puducherry provides good mother and childcare and shows improvement in the ANC indicators, institutional births, distribution of IFA tablets, monitoring of high-risk pregnancies, and provision of postnatal and infant care (NFHS 4 and 5). In Puducherry, 44% of women had four ANC examinations. Private clinics and nursing homes also offer ANC services besides the government health facility. Almost all deliveries occurred in institutions, 77% of which were in public health facilities, according to HMIS 2019–20.[8]

Study participants

Quantitative part: All mothers delivered from July 2018 to June 2021 registered in the selected Anganwadi were included in the study.

Qualitative: KII among Anganwadi workers (AWWs), ANMs, and mothers.

Sample size calculation

Taking the prevalence based on a prior study conducted, Kumar et al. utilization of ANC services in Tamil Nadu was 45%, with a relative precision of 20% (absolute precision of 9%) at 95% CI, the sample size was calculated to be 118, with OpenEpi 3.01. Considering a design effect of 1.5, owing to cluster sampling, the final sample size was 177.

Sampling

A multistage cluster random sampling was used to select the participants. Anganwadi centers were the clusters, and 15 (70% urban and 30% rural) out of 683 Anganwadi centers were selected randomly. From each Anganwadi area, 12 mothers were selected using a systematic random sampling method, and every second house with eligible participant was selected. All mothers of under three year old child delivered from July 2018 to June 2021 were eligible for the study.

For the qualitative part, six KIIs were done among six purposively selected mothers of under three year old child,[2] AWWs,[2] (n=2) and ANM[2] at a time convenient to them. Among the AWWs those who were vocal, had more than three year’s experience and who were able to give time were selected. Based on the availability of the time ANMs were interviewed. Mothers who received multiple health care and who had a good rapport with other community members were purposively selected with the help of AWW. Mothers were asked to opine about the general practice in the community rather than their own beliefs and practices.

Data collection

Quantitative

The investigator selected Anganwadis and eligible mothers. Participants who could not be interviewed after two visits were excluded from the study. Pre-structured questionnaire was administered by the principal investigator. The information about the latest pregnancy was noted. The questionnaire was used to collect information on socio-demographic characteristics, utilization patterns for ANC services, and place of care for various services. Private facilities include private clinics, private medical college hospitals, and nursing homes.

Qualitative

KII was conducted using the interview guide. The interview guide was made by the first author and reviewed by the research team. The interview was conducted by the first author who was trained in qualitative research in Anganwadi centers. It was conducted using an interview guide, using probes wherever necessary. At the end of the interview, the key points were discussed with participants to validate the information summarized. The session was audio-recorded and important statements were noted. Audio-recorded interviews were transcribed into English.

Data Analysis: Data was collected using Epicollect5 and analyzed using SPSS version 22. Categorical variables such as religion, education status, occupation, and various components of ANC were expressed as frequency and proportions. A biplot was generated through correspondence analysis to illustrate the utilization patterns of antenatal from the various types of health facilities by the study participants. Manual thematic analysis was carried out using an inductive approach. It was done by two persons and reviewed by another person who has experience in qualitative research and has been working at the study site for around 15 years. Statements were the units of study, and codes were grouped into categories. We adapted the Donabedian Model during the analysis and organized the codes under these major themes:[1] Access;[2] Delivery of the Services;[3] and Quality of Care.

Integrative phase

Integration was performed through combined display analysis, yielding insight into what could be achieved from the data obtained independently based on quantitative and qualitative findings.

RESULTS

Quantitative components

A total of 177 women, who delivered in the last three years, were included in the quantitative component of the study. The mean age of the participants was 28 (Standard Deviation = 4.1) years. More than one-third were postgraduates (43.5%), and the majority of the participants were homemakers (81.9%). The median (Inter Quartile Range) monthly family income was INR 15000 (10000–30000). [Table 1]

Table 1.

Socio-demographic characteristics and pattern of utilisation of dual health care services for the various components of antenatal care during the last pregnancy among mothers residing in Puducherry (n=177)

Characteristics	All participants n	%
Total	177	100
Age in years, mean (SD)	28	4.1
Women’s Educational status
No formal education	1	0.6
Higher secondary	65	36.7
Graduate and above	111	62.7
Husband’s Education
No formal education	1	0.6
Higher secondary	60	33.9
Graduate and above	116	65.5
Women’s occupational status
Homemaker	145	81.9
Employed	32	18.1
Husband’s occupational status
Employed in private sector*	127	71.8
Employed in Government sector	20	11.3
Self employed	30	16.9
Residence
Urban	129	72.9
Rural	48	27.1
Religion
Hindu	165	93.2
Christian	8	4.5
Muslim	4	2.3
PMMVY benefits received†
Yes	84	47.5
No	93	52.5
Obstetrics history
Gravida
Primi	72	40.7
2nd gravida	76	42.9
3rd and 4th gravida	29	16.4
Previous Abortion
No	142	80.2
Yes	35	19.8
Healthcare facilities visited for ANC service	n	%
Type of healthcare facilities visited for antenatal services
Only Public	24	13.6
Only Private	8	4.5
Both	145	81.9
Urine pregnancy test‡
Only Public	55	31.1
Only Private	77	43.5
Both	41	23.1
Not tested	4	2.3
Ultrasonography imaging
Only Public	13	7.4
Only Private	125	71.6
Both	39	22.0
Td Injection§
Only Public	158	89.3
Only Private	14	7.9
Both	5	2.8
Received Iron and folic acid supplementation
Only Public	59	33.3
Only Private	24	13.6
Both	94	53.1
Laboratory Investigations†
Only Public	86	48.6
Only Private	76	42.9
Both	9	5.1
Not done	6	3.4
Nutritional counselling received
Only Public	120	67.8
Only Private	11	6.2
Both	12	6.8
Did not received	34	19.2
Type of Health facility for last delivery
Public	132	74.6
Private	45	25.4

*Employed in private sector includes organized and unorganized sector. ^†Pradhan Mantri Matru Vandana Yojana-Cash incentive of Rs 5000 in three instalments. ^‡Self-test 129 (72.9 ^†urine and blood investigation (any), excluding urine pregnancy test. ^§Tetanus and adult diphtheria Injection

Most of the antenatal women (81.9%; 95% CI=75.2%-86.8%)sought care from both public and private healthcare facilities for at least one component of ANC. Around 13.6% of respondents sought care at only government-run health facilities, while 4.5% of respondents chose private facilities only. Table 1 describes the distribution of healthcare service utilization of women in their last pregnancy. Notably, 53% (95% CI = 47.4%–62.2%), received Iron and Folic acid supplements from both healthcare facilities. In addition, 23% underwent urine pregnancy tests in both public and private facilities. Around 48.6% (95% CI = 42.8%–57.7%) sought public health facilities for investigations, whereas 42% choose private facilities for investigations. A median of 12 scans were taken by the mothers during their pregnancy. The Td injection was predominantly taken from public facilities, for 89% (95% CI = 87.4%–95.5%) women. Nutritional counseling was majorly given by public health facilities (67%, 95% CI = 62.9%–76.5%), whereas only 6.2% received counseling from both public and private providers. About 74.6% (95% CI = 67.6%–80.4%) of participants delivered at public hospitals. [Table 1] Univariate and multivariate analysis was conducted to identify the factors associated with receiving dual care and a statistically significant association was identified only with gravidity (primi/multi). Primi gravida were 1.15 times more likely to receive dual care as compared to multi-gravida. However, even this association was not statistically significant in the adjusted analysis (not depicted in the Table).

Biplot indicates that participants preferred public health facilities for nutrition counseling, Td immunization, and other medications related to common ailments or chronic diseases. Conversely, private health facilities were preferred for blood investigations and obtaining ultrasonography (USG) scans. Additionally, a combination of private and public health care systems (Dual health care) was utilized for acquiring Iron-Folate and Calcium supplementations. [Figure 2]

Figure 2.

Illustrating utilization pattern of antenatal care: The correspondence analysis biplot

Qualitative component

The qualitative analysis revealed three major themes under the global theme ‘driver for availing ANC in multiple health care facilities’[1]; Access;[2] Delivery of the Services;[3] and Quality of Care. [Figure 3]

Figure 3.

Thematic analysis of reasons for availing public-private facilities for antenatal

Access

Better geographic accessibility, familiarity, and free services at the PHC encouraged to seek ANC from the public health facility. The public tertiary care center is usually crowded, and pregnant women must wait in a long line. In contrast, private healthcare facilities always respect patients’ time and facilitate consultations by scheduling appointments in advance. Hence, private facilities had better accessibility to the time dimension. It was also noted that rich women prefer private health facilities. A comment by an AWW:

“An advantage of a private hospital is there won’t be any crowd, and no need to wait for a longer time.” (52 years old, female, 30 years of work experience as an AWW)

The conditional cash transfer schemes of the Government are additional motivators for pregnant women to register at PHCs and have at least four visits. Regardless of where women had their ANC, they chose public facilities for delivery where birth services are free of cost.

Delivery of the services

Under the theme ‘delivery of the services’, we identified four categories namely consultation facility, medicines and vaccines, investigations, and USG. Key informants felt that women prefer public facilities for delivery because of the belief that cesarean section rates are low in government facilities. Hence, they availed ANC from the same public health facility. Few mothers also felt that doctors at government tertiary health centers are highly experienced.

“Government hospitals are the best. Many senior health professionals are available in government hospitals.” (38 years old, female, 12 years of work experience as an AWW)

Women felt that personalized medications are given by private doctors, whereas in the Government set up it is the same medication for all. They also felt that the iron tables provided by the private practitioners were more palatable. Reports from private facility was also reviewed by the public health facility. It put the women at ease. In addition, mothers reported that using public facilities required them to navigate between different buildings, especially for investigations. Hence, preferring private facilities enabled them to receive services from one place. Another reason for visiting private hospitals is because of the availability of ultrasound scans and regular testing with immediate provision of reports. In this regard, a mother said:

“The only reason we visit a private hospital is to find out about the unborn child’s health. You can get a scan at a private hospital and find out how the baby is doing. The treatment could be improved.” (A 32 years old mother of two children)

Quality of care

Pregnant women often visit multiple health facilities for checkups owing to the perceived inadequacy of care provided by public facilities, whereas they are satisfied with the care received at private facilities as they are patient and family-friendly. Likewise, private hospitals schedule routine checkups within a specific period and notify patients in advance. Mothers consider their baby’s health more important than anything else. The interview divulged that the baby’s health took priority over spending money and they sought care privately irrespective of their financial status.

The key informants felt that seeking multiple healthcare facilities does not affect ANC. “There won’t be any difficulties or confusion (when they seek multiple facilities for antenatal care) because they show all the reports and results from where they took the first treatment. So that they can continue the remaining treatment with respect to the previous test reports”. (A 25 year old, mother of a 2-year-old child)

Very few mothers utilized diphtheria-tetanus (Td) vaccination and laboratory investigation in both facilities. The reasons for the same would be unique for each person, and they did not emerge during the KII.

Integrative phase

The integration of the quantitative and qualitative findings along with the inference are presented in Table 2 as a joint display.

Table 2.

Joint display of reasons for seeking antenatal care from multiple health care providers

Quantitative Constructs 81% of mothers availed ANC services from public and private health centres, while 74% delivered at public health facilities.	Qualitative Constructs: Women go to nearby primary health care centre (PHC), so that they can avail the monetary benefits given to antenatal women. In addition, they also have good rapport with the ANM of that area. However, the concern for the unborn child’s health makes them go to private practitioner who are experienced in maternity care due to their experience or degree. Many of these private practitioners work in government hospital. For delivery, women go to Government hospital mostly the same hospital in which the private practitioner whom they consulted worked. Delivery cost at private facility would be huge and they could not afford it. Caesarean sections are done more frequently in private facility, whereas government sector avoids unnecessary caesarean sections.
Meta-inference Expanded. Women perceived that quality of antenatal care services are good in private as the doctor is experienced in antenatal care. But the delivery services are good in public hospital. Low quality of delivery services in private facility is noted in literature also.
Quantitative Constructs Around 71% of mothers had taken ultrasound scans in private healthcare facilities. In contrast, only 7% of mothers had scanned at public facilities.	Qualitative Constructs: Expanded In private, ultrasound is done a regular interval and this gives the mother the reassurance that the child is healthy. In Government ultrasound is done only when it is absolutely essential and it is not available in primary health centres.
Meta-inference The concern of the unborn child and confidence given by doing ultrasound makes the mother go to private care facility. Additionally, ultrasound is not listed as essential service in the Indian Public Health Standards for PHC.
Quantitative Constructs Approximately 53% of the mothers consumed IFA tablets from public and private facilities and 33% from public facilities.	Qualitative Constructs: (Medicines and vaccines) Expanded The tablets given in private is more palatable and causes less side effects. In Government the health worker delivers the drugs at home and free of cost. Women don’t refuse the medicines given by the health care workers to fulfil the social expectation.
Meta-inference Expanded The behaviour is in alignment with the behaviour observed in literature among antenatal women in India

DISCUSSION

In this mixed-method study, most antenatal women (81.9%) used both public and private healthcare facilities for ANC. Public facilities were preferred for Td immunization and counseling services, while private facilities were chosen for undergoing ultrasound examinations and other lab investigations. The majority (74.6%) delivered at public hospitals. The qualitative analysis of the study revealed three major themes as reasons for availing ANC from multiple healthcare facilities[1]: Access,[2] Service components, and[3] Quality of Care.

In our study, many women sought ANC from multiple sources. A similar trend was observed in a study from a low-middle-income region in Brazil. Notably, Women seeking care from multiple healthcare facilities did not report any significant challenges for it. However, this practice leads to OOPEs, even though the amounts spent are relatively low. These indicate a clear need for fostering stronger public-private partnerships in the healthcare sector to improve the continuity of care.

Approximately, 71% underwent ultrasound scans in private health facilities was the major reason to seek private care in addition to their regular visits to primary health centers. This behavior was driven by their concerns about their child in the womb. On an average mothers underwent one to twelve scans during pregnancy, similar to that observed in a study from Kerala, India.[9] The implementation of a new recommendation of offering ultrasound services by trained persons in the Primary Health Centre under the Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) is a right move by the Ministry of Health and Family Welfare.[10] This will improve universal health coverage by decreasing unnecessary OOPEs. The private healthcare facilities were preferred by participants for IFA supplement consumption, mainly due to the perception of better taste.[5,11]

In our qualitative data analysis, pregnant women reported feeling more at ease and safe during private facilities checkups. They appreciated the convenience of comprehensive services in one location, thereby shortening the waiting time. Conversely, at tertiary-level public hospitals women faced the challenging of navigating different areas, insufficient waiting space, limited availability of certain services, and delays in provision of test results. Women increasingly seek compassionate, evidence-based care.[12] Government facilities should prioritize empathy and address the unique needs of women with sensitivity. Under the LaQshya, respectful maternity care should be expanded to ANC.[13] There is a pressing need to enhance service quality, especially in providing empathetic care to antenatal women. This echoes a study in Uttar Pradesh, emphasizing the priority of user satisfaction in healthcare quality improvement projects.[14]

Our findings, consistent with a study using Swabhimaam project data, highlight that nutritional counseling during pregnancy primarily originates from Government healthcare personnel.[5] This underscores the public sector’s superiority in preventive care. However, patients attending private facilities are less likely to receive essential nutritional counseling. Therefore, the program should focus on training and encouraging private providers to offer counselling on nutrition, contraception, danger signs, and birth preparedness.

According to qualitative results, the conditional maternity cash transfer schemes motivate some women to attend public facility[7] even though they prefer to use private healthcare facilities, resulting in multiple healthcare utilization. Pregnant women, who are eligible for support, are given financial aid and belong to lower socio-economic strata. However, visiting multiple facilities will incur additional costs, which differs from the program’s objective. A private-public partnership such as the National Tuberculosis Elimination Program[15] and the Chiranjeevi Scheme in Gujarat would decrease OOPE and improve patient satisfaction.

The study’s strengths were the utilization of a pragmatic approach, integrative quantitative and qualitative results, and the inclusion of multiple stakeholders to give complete insight to policymakers and healthcare providers to improve healthcare services. The study’s applicability is limited to settings characterized by relatively favorable health indicators. The study had the limitation of not including the perspective of program managers and medical officers.

CONCLUSION

Most mothers often seek ANC services from multiple facilities, leading to duplication and added expenses. To achieve universal health coverage, the government can establish public-private partnerships, regulating a mixed system of services. Incorporating a dedicated section in the mother and child protection card to record private facility services would prevent duplication and integrate complementary services. The private sector should prioritize health education for antenatal women and promote government facility utilization, especially among lower socio-economic groups.

Ethics approval

Institute Ethics Committee approved the study (JIP/IEC/2021/157). Participants were interviewed after obtaining informed written consent in their local language (Tamil).

Conflicts of interest

There are no conflicts of interest.

Funding Statement

It was funded by the JIPMER Intramural fund Nil.