“Pathways to care among antenatal women in South India - A sequential explanatory mixed-method study”

ABSTRACT

Introduction:

Poor access to effective antenatal care (ANC) is identified as one of the key challenges in reducing maternal mortality. Antenatal women seek ANC through different pathways, including primary health centers (PHCs), private clinics/hospitals, and tertiary care facilities, influenced by factors such as perceived quality of care, financial constraints, proximity, and cultural preferences. The study aimed to determine the pathways antenatal women choose to seek ANC, reasons for preferring such point of care or facilities, and the out-of-pocket expenditure (OOPE) incurred for an ANC visit.

Methods:

This tertiary hospital-based mixed-method study was conducted among 303 antenatal women in South India. The study was conducted in 2019. A pretested semistructured questionnaire was used to gather data on sociodemographic and obstetric characteristics, utilization of ANC services, reasons for choosing each facility, and the costs incurred during an ANC visit. Among some participants, in-depth interviews were conducted to explore the facilitators and barriers to using ANC services at primary healthcare centers, private healthcare facilities, and tertiary care facilities. Collected quantitative data were analyzed using SPSS version 20 (IBM Corp). In-depth interviews were transcribed and analyzed using an inductive content analysis approach. Codes were grouped to form similar categories which in turn were grouped to themes.

Results:

Out of 303, 279 pregnant women registered in their respective PHCs, the remaining 24 participants (7.9%) did not register or seek ANC from a PHC. Most of them mentioned the lack of facilities and unawareness about a PHC in their locality as the reasons for not using ANC services at PHC. The highest OOPE incurred was at a private facility, where the median cost per visit was INR 1400 (990-2115) compared with PHC, which was INR 100 (20-360).

Conclusion:

Appropriate action has to be implemented at PHCs to improve the utilization rate and to reduce OOPE incurred.

Introduction

Maternal mortality is regarded as an essential health indicator because the direct causes of maternal death are well understood and, in most cases, preventable and curable.[1]

Maternal mortality remains predominantly high in low- and middle-income countries, particularly in sub-Saharan Africa and South Asia. The Sustainable Development Goal (SDG) Target 3.1 seeks to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.[2] However, as per a simulation study, only 30% of low- and middle-income countries are currently on track to achieve this target.[3] The significant complications that account for nearly two-thirds of all maternal deaths are severe bleeding (primarily after childbirth), infections (typically after childbirth), high blood pressure throughout pregnancy (preeclampsia and eclampsia), delivery complications, and unsafe abortions.[1]

India has been striving hard to reduce maternal mortality by addressing the root causes of death and morbidity among women and providing solutions to eradicate these causes.[4] As a result, India’s Maternal mortality ratio (MMR) has decreased from 384 per 1,00,000 live births in 2000 to 97 in 2020.[5] Further reduction in MMR requires ensuring proper obstetric care and attention for mothers during the antenatal period.

A subsequent increase of 58.02% of ANC coverage in India is also reported. The decrease in maternal and neonatal mortality is associated with an increase in institutional delivery, which is currently at 88.6%.[6] This increase covers significant disparities among India’s socioeconomic classes and states.

Primary Health Centres (PHC’s) handle uncomplicated cases allowing the secondary and tertiary facilities to focus on complicated and high-risk cases. Skipping of PHC’s for antenatal care (ANC) a phenomenon known as “bypassing” can result in lack of quality of care as secondary and tertiary centers become overcrowded.[7] Bypassing a PHC can have an effect on antenatal mothers by increasing the amount of time to reach the alternative source of care and the transport cost.[8] A study conducted in Gujarat found that 37.6% of women bypassed their PHCs for ANC services.[9] while in Madhya Pradesh 25.7% did so.[10] The increased use of maternal care from private health centers can be attributed to a variety of factors, including improved quality of care and accessibility of private health centers, the lack of availability of health services and drugs at public centers, and an improvement in the population’s standard of living.[11,12]

High expenses on ANC are often reported as barriers for utilization of health care facilities during pregnancy. The Out-of-Pocket Expenditure (OOPE) for ANC was found to be more than the cost of delivery alone.[13] The expenses incurred during child bearing also differed with the place of seeking maternal care. This means that availing ANC at a private facility would increase the expenditure on maternal health care.

According to a study by Nihal et al.,[14] 67% of women in Puducherry received ANC services that were of adequate quality. This implies that a sizable fraction of expectant mothers might not be getting comprehensive ANC. Considering Puducherry’s 100% institutional delivery rate, it is essential we investigate this matter by conducting studies to examine the specific pathways women undertake to access ANC services in India. Understanding these pathways, including the reasons behind facility preferences and the direct and indirect costs incurred, is essential for informing targeted interventions to improve maternal healthcare access and outcomes.

In India, this is one of the very few studies done to explore the pathways chosen by antenatal women to seek ANC, assess the factors influencing facility preferences, and estimate the economic implications of ANC utilization.

Methodology

Study setting

Puducherry, a union territory in South India, has a maternal mortality ratio (MMR) of 45 per 100,000 live births,[15] with 86.9% of mothers receiving at least four ANC visits and institutional births reaching 100%.[6] This study was conducted in a tertiary hospital in Puducherry, specifically in the Obstetrics and Gynaecology department, which serves both urban and rural populations. The hospital receives a high volume of antenatal cases, with an outpatient department (OPD) footfall of 5,000–8,000 pregnant women per month. All antenatal mothers without high risks are scheduled to follow-up once in 4 weeks till 28 weeks of gestation, once in 2 weeks until 36 weeks of gestation and weekly once after 36 weeks of gestation until delivery. High risk pregnancies are advised to come based on their complications and whenever there is a need for immediate attention. The duration of data collection was 3 months.

Quantitative component

Study participants

This study included antenatal women aged ≥18 years who were seeking care in the outpatient department (OPD) of a tertiary hospital in South India, irrespective of their trimester. Participants were recruited during their ANC visits. Antenatal women who were employees, who lived nearby the tertiary hospital and those with cognitive impairment were excluded.

Sample size and sampling technique

Sample size was calculated using OpenEpi version 3.0 (Emory University, Atlanta, GA, USA). Assuming the anticipated proportion of antenatal mothers seeking ANC from PHC’s as 37.6%,[9] alpha error of 5%, confidence level of 95%, absolute precision of 5.4%, the required sample size was found to be 307. Owing to constraints related to the duration of the study and the logistical aspects of data collection, we were able to collect data from 303 participants. Consecutive sampling was done to include the eligible participants

Study procedure

Information regarding sociodemographic characteristics, obstetrics characteristics, registration in a PHC, total number of ANC visits made in a PHC, types of antenatal services received from PHC, reasons for choosing each facility and the direct and indirect costs incurred during an ANC visit were collected using a pretested semistructured questionnaire. Antenatal women who had visited their local PHCs for at least four times were considered as “availing ANC services from PHC” Details on direct cost included cost spent on doctor fee, medicines, laboratory investigations, registration fee and admission fee for the antenatal woman alone. For the indirect costs details on the cost spent for transport, food, stay, and loss of wages of both the participant as well as her caregiver was included.

Qualitative component

Sampling and sample size

For the qualitative component, purposive sampling was done to choose eight antenatal women for in-depth interviews (IDIs). IDIs were conducted among women who were willing to participate in further interviews.

The interviewer explained the purpose of the study. IDIs were performed until point of theoretical saturation. Interviews were conducted in places convenient to participants. A semistructured pretested interview guide was used to collect the data. After obtaining written informed consent, we conducted IDIs in English or Tamil depending on the respondents’ preference. The interviews were audio-recorded, and field notes were taken throughout the process. At the conclusion of each interview, participants were provided with a debrief summarizing the key points discussed. The interviews were transcribed, translated, and subsequently back-translated into English. The translation into English was done to ensure accessibility for the research team and consistency in the analysis.

Statistical analysis

Data capturing was done using Epicollect5, and the quantitative analysis was done using SPSS version 20 (IBM Corp). Continuous variables were summarized as Mean (SD) and Median (IQR) based on the normality of distribution. Categorical variables were summarized as proportions. The audio recordings were transcribed in verbatim format. Manual content analysis was performed using inductive approach. Codes were grouped to form similar categories which in turn were grouped to themes.

Results

Baseline characteristics of the participants

A total of 303 participants were included in this study. Around 55.1% of the antenatal women were in the age group of 21–25 years. About 59.1% were graduates and 87.5% were home makers. The median monthly income of the family was 10000 INR (2000–100,000). Around 78.5% participants were in their third trimester; 53.8% were primi mothers. 37.9% had at least one live birth, and about 18.5% of participants had a history of at least one abortion [Table 1].

Table 1.

Sociodemographic and obstetric details of antenatal mothers attending the obstetrics OPD of a tertiary health care center in Puducherry (n=303)

Characteristics	Frequency (n)	Percentage (%)
Age (years) Mean (SD)	24±3.5
Education (years)
No formal education	1	0.3
1-10	67	22.2
11-12	56	18.5
Graduate and above	179	59.1
Occupation
Home maker	265	87.5
Employed	38	12.5
Husband’s education (years)
No formal education	10	3.3
1-10	98	32.4
11-12	40	13.2
Graduate and above	155	51.2
Gestational age
First trimester	6	2.0
Second trimester	59	19.5
Third trimester	238	78.5
Gravida
Primi	163	53.8
Multi	140	46.2
Parity
Nil	16	5.3
One	185	61.1
More than two	102	33.7
Live child/children
Nil	188	62.0
One	104	34.3
More than two	11	3.6
Abortion
Nil	247	81.5
One	49	16.2
More than two	7	2.3

About half (44.2%) of the pregnancies were confirmed at home: one fourth confirmed their pregnancies in a PHC and the other one fourth in a private health facility. Around 279 (92.1%) had a Mother Child Tracking System (MCTS) card, 274 (90.4%) received Td injections, 227 (74.9%) consumed IFA tablets from PHC, and 224 (73.9%) had minimum four ANC visits.

First point of care is depicted in green [Figure 1]. Around 149 (49.2%) had directly walked into a PHC and 133 (43.9%) had sought initial ANC services from private health facilities as their first point of care, whereas 21 (6.9%) sought ANC directly from district hospital and tertiary care center together. Second point of care is denoted in yellow, here 149 (49.2%) participants who went to a PHC as first point of care, of which 72 participants went to tertiary care center, 68 went to private facilities, and nine went to district hospital and out of 133 who went to private facilities as first point of care, 120 shifted to seek ANC from PHCs, and 12 went to tertiary care center. Third point of care is depicted in blue. In the third point of care, we can see that a majority section of participants that is 121 from PHC’s and 68 participants from private health facilities went to seek ANC services from tertiary care center. The fourth point of care denoted by the red figures, two participants from private health facilities, one participant from PHC and one participant from district hospital went to tertiary care center to seek ANC services [Figure 1].

Figure 1.

Pathways undertaken to seek antenatal care by antenatal mothers visiting a tertiary care Centre, Puducherry

Out of a total of 303, 279 pregnant women registered in their respective PHCs, the rest of the 24 participants (7.9%) did not register or seek ANC from a PHC. Among these 24 participants, the most commonly reported reasons for not registering were the lack of facilities at the PHC (25%) and a lack of awareness about the availability of a PHC in their locality (25%) [Figure 2].

Figure 2.

Reasons given for not registering at their local PHCs by antenatal mothers attending the obstetrics OPD of a tertiary health care centre in Puducherry (n=24)

The OOPE incurred during one visit to a PHC is INR 100 (20-360). OOPE during one visit to a tertiary care center was INR 560 (360–800). The highest OOPE incurred was at a private facility where the median cost was INR 1400 (990–2115). The OOPE was calculated for only one visit in this study as the total number of visits could not be calculated for complete pregnancy duration because the antenatal mothers were interviewed in different periods of gestation [Table 2].

Table 2.

Out of pocket expenditure of one antenatal visit made among antenatal mothers attending the obstetrics OPD of a tertiary health care Centre in Puducherry, (n=303)

Point of care	n (%)*	Direct cost per visit** (INR) Median (IQR)	Indirect cost per visit*** (INR) Median (IQR)	Total Cost per visit (INR) Median (IQR)
PHC	279 (92.1)	0 (0,0)	100 (20-360)	100 (20-360)
Private	204 (67.3)	1200 (900-1937)	40 (25-80)	1400 (990-2115)
District hospital	21 (6.9)	0 (0-0)	80 (40,455)	80 (40-455)
Tertiary care Centre	303 (100)	0 (0,0)	560 (360-800)	560 (360-800)

*The total number of visits exceeds the total sample size (n=303) because some antenatal mothers sought care at multiple healthcare facilities. Hence, the percentages do not sum to 100% within the column **Doctors’ fee, registration fee, laboratory, investigation fees and medicines. *** Includes food cost, transport, stay and loss of wages for antenatal mother and her attendant

More than one third (37.6%) of antenatal mothers reported that the reason they chose a PHC for seeking ANC was because they wanted to register there. Some women believed that they would be denied care in tertiary center if they did not register in a PHC and some believed that registering in a PHC is a rule that everyone should follow. About one fourth of the women also reported that a PHC is more easily accessible and affordable than other facilities because of the short distance from their residence and free services. About half (47.1%) women said that they preferred a Private health facility over a PHC because of the availability of scanning facilities that most PHCs lack. The main reasons when asked for choosing a tertiary center were preference of mode of delivery (40.9%)

Qualitative results

A total of eight in-depth interviews were conducted. Three overarching themes emerged from these in-depth interviews and a conceptual framework was developed [Figure 3].

Figure 3.

Conceptual framework regarding facilitators and barriers in utilization of PHCs among antenatal women

Theme 1: Reasons related to utilization of Tertiary care services functioning under the government (public)

Category 1: Facilitators for utilization of tertiary care services functioning under the government (public)

Pregnant mothers who chose the tertiary hospital among their pathway to ANC were influenced by their family members. They also mentioned that they seek ANC from the tertiary care centre because they trust the quality of care here which gives them the assurance that they are safe. They also believe that they will not have any complications during their pregnancy or delivery and even if it arises the center will be able to handle it. The hospitable environment of the tertiary care centre compared to PHCs also plays an important role.

• “My family members (in-laws) perceive that PHC is a small care centre, care won’t be good enough there. And since this is my first pregnancy they want me to have a proper antenatal care from here (tertiary care centre) and deliver here itself.” - 22 year old primi mother who did register in PHC but preferred tertiary care centre

• “Here in tertiary hospital, doctors only conduct deliveries so the care is good. Compared to my place the quality of care is very good here.” - 27 year old pregnant mother of one child who did not register in her PHC and hailing from a place of approximately 105 km away from the tertiary care centre

• “During my first pregnancy I did all my antenatal checkup from PHC, there they said that everything was fine and that I need not worry, but when I reached 8 and a half months of pregnancy, I had heavy bleeding and the umbilical cord prolapsed. The PHC referred me to a private hospital where they did caesarean. I don’t want to go through the same thing this time. So for precaution my husband and I decided to seek antenatal checkup and deliver here in tertiary care hospital…” -25 year old pregnant woman who did not complete ANC visits in PHC

• “The people from my native place, said that if I don’t register and take antenatal checkup from here they will not allow me to come for delivery….” – 26 year old pregnant woman who skipped PHC

Category 2: Barriers for utilization of tertiary health care services functioning under the government (public)

In the tertiary care centre pregnant women have to wait in a long queue as the hospital is usually crowded. Sometimes women experienced differential preference over other clients who are employees of the hospital and their relatives

• “We all wait in line from early morning for checkup but first preference is usually given to the people known by the nurses and other people working in the hospital….”- 25-year-old pregnant woman who did not complete 4ANC visits in PHC

Theme 2: Reasons related to utilization of primary health care services

Category 1: Facilitators for utilization of primary health care services

Most of the participants reported that their local PHC were not very far away from their residence and that it is easier to access the PHC as it is near. Antenatal mothers mentioned about choosing a PHC over a private facility for affordability. They also expressed that incentives are another reason for them to avail antenatal services from their local PHCs

• “A small hospital (PHC), is very close by to my home which makes it more convenient for me to visit. Also, there are times when Sister (PHC nurse) comes home to check up on me….” – 24-year-old pregnant woman who seeks ANC from both PHC and tertiary hospital

• “We spend more money at private hospitals, whereas if I go to my local PHC it is at a walkable distance and we don’t spend money for travel and other things like doctor fees, medicines or even for tests….” -25-year-old pregnant mother of 1 child

Category 2: Barriers for utilization of primary health care services

Some mothers expressed their dissatisfaction of unavailability of doctors in PHC. Mothers emphasized on the poor infrastructure at the PHC mentioning small details like the condition of the floor and the toilets which are most often neglected. Lack of laboratory investigations was also mentioned by mothers. Attitude of health care workers was also reported as a barrier.

• “Doctors are not sufficient. I think if there are more doctors it would upgrade the quality of PHCs and more antenatal mothers would go for antenatal checkup there…”– 24 years old primi mother who had registered in PHC and completed 4 ANC visits

• “In PHC doctors don’t conduct deliveries, they are not there for fulltime (whole day). Even in time of emergencies only nurses are available and they only conduct deliveries.” - 27-year-old pregnant, mother of 2 children who had not registered in her local PHC.

• “The Aarambasugatharanilayam (PHC) near my home is very small and does not have enough facilities…”– 26 year old pregnant mother with one child

• “In my PHC only HIV testing and hemoglobin test are done, other blood investigations and scan are not available, so I prefer going to private hospitals or come to tertiary care hospital where every facilities are available.” - 26 year old pregnant mother with one child who enrolled herself in PHC to avail an MCT card and skipped ANC visits in PHC.

Theme 3: Reason related to utilization of Private facilities services (clinics and hospitals)

Category 1: Facilitators for utilization of private facilities services (clinics and hospitals)

Access to essential medical diagnostic services was reported as one of the main facilitators for utilization of private facilities services

• “I went to private only for scan as there is no scan facilities in my PHC but I seek antenatal care from PHC and from here (tertiary hospital)…”- 26 year old pregnant mother with one child who sought care in a private hospital

Category 2: Barriers for utilization of private facilities services (clinics and hospitals)

While private facilities offer good services and infrastructure, barriers such as apprehension surrounding delivery methods deter patients from using these services. Antenatal mothers feel that private hospitals urge people to undergo caesarean section rather than attempting natural deliveries.

• “In a private hospital they don’t wait or try for normal delivery, they immediately go for caesarean…”- a pregnant woman who did not register in PHC, when asked why did she discontinue antenatal care from private hospital”

Discussion

Majority of the antenatal women in our study had registered with their local PHC and received at least one ANC visit there before seeking care at the tertiary hospital. More than two third had sought ANC from private facilities, less than one tenth sought ANC from district hospital.

In our study, however, 43.9% chose private sectors as their first point of care. In the second point of care, 90.2% of the 43.9% shifted to PHCs to avail ANC which is much more than the findings from a cross-sectional study by More et al.[16] The difference could be due to availability of the healthcare facilities and the quality of antenatal services and the same was revealed by our qualitative findings.

The barriers reported for not seeking ANC from a PHC and preferring a tertiary care center and private health facility over PHC’s were that PHC’s showcased poor quality of care and unavailability of healthcare providers which was consistent to findings reported by Mohanty et al.[11]

• “In PHC sisters (PHC nurses) are the ones conducting deliveries and not the doctors.” - a 25 years old pregnant woman who had not registered in her PHC and sought ANC from private facility and tertiary care hospital

• “The Aarambasugatharanilayam (PHC) near my home is very small and does not have enough facilities”– a 26 years old pregnant mother with one child

The facilitators for preferring PHC’s as the point of care for ANC services was the belief among the participants to have a mother and child tracking card without which they cannot avail ANC elsewhere, monetary benefits and the affordability of PHC’s. Most of the women sought care from private and tertiary care facilities because of the availability of ultrasonography which PHC’s did not have similar to the findings of a qualitative study by Akowuah et al.[17] These finding stresses the need to improve the accessibility of PHCs by ensuring they are located within acceptable distances of the communities they serve and also provide regular training to healthcare providers to enhance the quality of care at PHC’s.

Our study also observed that the number of antenatal mothers who registered at a PHC were those who were in their first and second trimester and those who registered in the tertiary hospital were mostly in their second and third trimester consistent with National Family Health Survey-5 (2019-2021).[6] Our study found that the median OOPE per ANC visit was INR 100 (USD 1.42) at PHCs, INR 560 (USD 7.94) at tertiary care centres, and INR 1400 (USD 19.85) at private healthcare facilities. Although studies specifically comparing OOPE per ANC visit across different facility types are limited, our findings provide valuable insights into the cost variations at different levels of care. According to Gunarathne et al.’s[18] systematic review and meta-analysis, the pooled OOPE for a single ANC visit in LMICs was USD 12.93 (95% CI: 4.54–21.31). This estimate highlights that ANC costs can vary greatly across settings, although it does not differentiate between facility types

Our study also reported that the highest median cost for OOPE in private facilities was reported for direct costs such as laboratory, investigation fees and medicines which were similar to study by Gupta et al.[19] The high OOPE highlights the gaps in implementation of policy interventions and schemes such as JSY, hence the finding calls for regular monitoring and evaluation. The fact that OOPE for ANC was determined per visit is one of the study’s limitations. We were unable to determine the total number of ANC visits per pregnancy because interviewees were at varying gestational stages. As a result, since our OOPE estimates do not account for the total cost of the pregnancy, this restriction may compromise their accuracy.

Being a mixed-method study, it provided a holistic understanding of the pathways chosen by antenatal women and the reasons behind their choices, thereby strengthening the overall findings. The study was prone to recall and social desirability bias. We have guidelines in place proposed by Ministry of Health and Family Welfare that has set priorities for enhancing the quality of care at PHC’s yet the implementation of the guidelines remains challenging at ground level. It’s time action is taken to improve the quality of infrastructure and services in PHC’s which will improve its utilization and also reduce OOPE. Awareness generation about the ANC services available at PHC’s should be done.

Conclusion

In our study, a fairly satisfactory number of antenatal mothers had registered in PHC and were using ANC services. The OOPE incurred by antenatal mother was least in a PHC than in tertiary hospitals or district hospitals. The results stresses on the need for strengthening the PHC’s for obstetric care management which will prevent overcrowding of tertiary care center and increase the utilization of antenatal services at PHC.

Ethical clearance

Ethical approval was obtained from the Institutional Ethics Committee (JIPMER)

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.