Assessment of maternal healthcare utilization and continuum of care among reproductive-age women in Gujarat: a cross-sectional study

Abstract

Background

A healthcare system’s efficacy is demonstrated by safe motherhood, which is an essential aspect of women’s health. Preconception, pregnancy, labor, and the postoperative phase are all included in this continuum of care. There are still gaps in maternal healthcare awareness, use, and continuity, especially during preconception and the early postnatal stages, even though India has made great strides in lowering maternal mortality through national health programs and better access to institutional deliveries and antenatal care. The purpose of this study was to evaluate Gujarati women’s knowledge, availability, and use of maternal health services, with an emphasis on preconception care, prenatal care, delivery procedures, and postnatal follow-up.

Methodology

The study used a descriptive cross-sectional methodology and included 318 reproductive-age women from semi-urban, urban, and rural areas using a structured pre-validated questionnaire. Both quantitative information about maternal health practices and experiences were gathered through in-person interviews and Google Forms and analyzed using descriptive statistics including frequencies and percentages in Microsoft Excel.

Results

Among the 318 respondents, 75.5% were aged 18–30 years and 50% resided in rural areas. Awareness regarding preconception health checkups was reported by 71.1% of women, whereas 28.9% lacked such awareness. Antenatal care utilization was high, with 87.1% attending antenatal checkups, the majority receiving tetanus toxoid immunization and iron–folic acid supplementation, and 97.3% undergoing institutional deliveries with skilled birth assistance. However, only 58.2% of women received postnatal care within 48 hours after delivery. Nutritional counseling was reported by 41% of respondents, while 55.2% received breastfeeding counseling. Significant gaps were found in preconception health information, early postnatal follow-up, and emotional support, especially among rural women.

Conclusion

The study highlights the need to shift focus from service availability to continuity and quality of maternal care. Strengthening preconception education, ensuring timely postnatal follow-up through community health workers, expanding counseling services, and promoting family engagement are essential to improving maternal and neonatal health outcomes.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12913-026-15063-3.

Introduction

A woman’s physical, psychological, and social well-being is profoundly influenced by motherhood, making pregnancy and childbirth pivotal events in her life course. Ensuring safety and dignity during the preconception period, pregnancy, childbirth, and the postnatal phase is therefore a fundamental public health priority. The concept of safe motherhood emphasizes every woman’s right to accessible, timely, and respectful maternal healthcare throughout the continuum of reproductive life, particularly in low- and middle-income countries where maternal morbidity and mortality remain disproportionately high despite notable progress [1].

Globally, maternal health has been recognized as a key indicator of health system performance, social development, and gender equity. Although maternal mortality ratios have declined over the past two decades, a substantial proportion of maternal deaths continue to occur due to preventable causes related to inadequate antenatal care, delayed access to skilled birth attendance, and insufficient postnatal follow-up [2, 3]. International agencies have consistently highlighted that a comprehensive continuum of care—including preconception counseling, quality antenatal services, institutional delivery, and early postnatal care—is essential for reducing avoidable maternal and neonatal deaths [4].

In response to the global burden of maternal mortality, the Safe Motherhood Initiative was launched to promote evidence-based interventions aimed at improving maternal outcomes. These strategies focus on strengthening antenatal care, ensuring clean and safe delivery, providing essential obstetric services, and improving postnatal care, including family planning [5]. Subsequent global frameworks, including the Sustainable Development Goals, further reinforced maternal health as a priority area by emphasizing the reduction of preventable maternal deaths and the promotion of well-being for women and newborns [6].

India has demonstrated significant progress in maternal health outcomes through sustained policy attention and the implementation of national programs such as the National Health Mission, Janani Suraksha Yojana, Janani Shishu Suraksha Karyakram, Pradhan Mantri Surakshit Matritva Abhiyan, and the LaQshya initiative. These programs have contributed to increased institutional deliveries, improved antenatal care coverage, and wider availability of skilled obstetric services [7, 8]. As a result, maternal mortality has declined substantially over time, reflecting improved access to facility-based care and emergency obstetric services [9].

However, improved service availability alone does not guarantee comprehensive or high-quality maternal care. Evidence indicates that gaps persist in critical areas such as preconception health awareness, nutritional counseling, early postnatal care within the first 48 hours, and emotional and psychosocial support following childbirth [10, 11]. Many women enter pregnancy without adequate health assessments or counseling, increasing the risk of complications during pregnancy and delivery. Additionally, postnatal care often remains neglected despite being a period of heightened vulnerability for both mother and newborn [12].

Family and community involvement play a decisive role in maternal health outcomes, particularly in sociocultural contexts where healthcare decision-making is influenced by household dynamics. Studies suggest that limited family engagement may delay care-seeking behavior and reduce adherence to medical advice, whereas inclusive, family-centered approaches can improve service utilization and maternal outcomes [13, 14].

Despite policy advances and improved coverage of maternal health services, disparities in awareness, utilization, and continuity of care persist across rural, urban, and semi-urban populations. These gaps underscore the need to view safe motherhood as an ongoing process rather than a series of isolated interventions. Strengthening preconception education, enhancing the quality of antenatal and postnatal counseling, and ensuring continuity of care across all stages of maternity are essential for further improving maternal and newborn health outcomes in India [15].

Maternal health is an essential indicator of healthcare quality, social development, and women’s well-being [16]. Despite substantial reductions in maternal mortality globally, preventable maternal complications and deaths remain significant public health concerns, particularly in low- and middle-income countries [17]. Limited awareness, delayed healthcare-seeking behavior, inadequate antenatal and postnatal care, and poor continuity of maternal healthcare services continue to affect maternal and neonatal outcomes [18]. Therefore, a comprehensive continuum of care including preconception counseling, antenatal care, safe institutional delivery, and timely postnatal follow-up is crucial for ensuring safe motherhood and improving maternal health outcomes [19].

India has implemented several national maternal health initiatives, including the National Health Mission (NHM), Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), and LaQshya, which have contributed to increased institutional deliveries and improved antenatal healthcare utilization [20–24]. However, despite improved service accessibility, important gaps still persist in preconception health awareness, nutritional and emotional counseling, family involvement, and early postnatal care, especially among women residing in rural and semi-urban settings [25, 26].

Community health workers and family support systems play an important role in influencing maternal healthcare utilization and continuity of care [27]. Nevertheless, disparities in awareness, accessibility, and utilization of maternal healthcare services continue to exist across different residential populations [28]. In this context, the present study was conducted to assess the awareness, accessibility, and utilization of maternal healthcare services among reproductive-age women in Gujarat across preconception, antenatal, delivery, and postnatal stages of care [29, 30].

In a similar vein, one of the most vulnerable times for both the mother and the baby is the postnatal period, particularly the first 48 hours following delivery [31]. Early problem detection, breastfeeding start, nutritional support for mothers, and emotional and psychological care are all crucial during this time [32]. Even while postnatal care is crucial, it is frequently disregarded after birth, especially when patients are released from medical facilities [33]. Women often receive little advice on diet, mental health, postpartum care, and baby care, which leads to lost chances for early assistance and intervention [34].

The role of family and community support is another crucial aspect of safe motherhood. In many Indian homes, husbands and in-laws are among the family members who have an impact on the healthcare choices made for women [35]. While a lack of involvement or false information may operate as a barrier to service usage, supportive family involvement can favorably promote prompt care-seeking and adherence to medical recommendations [36]. Therefore, enhancing community involvement and family participation is crucial to enhancing maternal health outcomes and guaranteeing continuity of treatment [37].

Maternal health services are available, but there are still shortages in follow-up treatment, emotional support, counseling quality, and awareness [38]. In rural and semi-urban settings, where access to healthcare resources and information may be uneven, these disparities are frequently more noticeable [39]. Designing responsive, people-centered maternal health treatments requires an understanding of these gaps from the viewpoint of the women themselves [40].

In light of this, the current study was conducted to evaluate Gujarati women’s knowledge, availability, and use of maternal healthcare services during the preconception, prenatal, and postnatal phases. The study intends to offer useful insights for public health professionals, legislators, and healthcare administrators by analyzing current procedures, finding gaps, and investigating obstacles to successful care. Bolstering community-based support networks, promoting family involvement, strengthening counseling services, and increasing postnatal follow-up.

Methodology

Study design

In order to evaluate women’s knowledge, accessibility, and use of maternal healthcare services, this study used a descriptive cross-sectional research methodology. Because it enables data collection at a single point in time and offers a clear snapshot of current maternal health practices across various stages of parenthood, the cross-sectional technique was deemed appropriate. In terms of preconception, prenatal, delivery, and postnatal care, the design was very helpful in detecting prevalent gaps, patterns, and service consumption trends.

Study setting

The survey, which covered rural, urban, and semi-urban areas, was carried out in the Indian state of Gujarat. Gujarat was chosen because of its active national maternal health program implementation and comparatively robust healthcare infrastructure, which makes it a good place to assess both the progress and shortcomings in safe motherhood practices. Variability in sociodemographic traits, healthcare access, and service consumption patterns was ensured by including women from a range of residential origins. Participants were categorized into rural, urban, and semi-urban settings based on self-reported residential locality and administrative classification of their area of residence. The categorization was performed to assess differences in maternal healthcare awareness, accessibility, and utilization across populations with varying healthcare infrastructure and service availability. Although geographical variations may exist within rural settings, the present study primarily focused on broader residential classification for comparative assessment. These inclusion of diverse residential settings enabled comparative assessment of disparities in maternal healthcare practices and continuum of care.

Study population

Women who were of reproductive age, had given birth, and lived in Gujarat at the time of data collection made up the study population. In order to gain a thorough picture of maternal health awareness and behaviors across communities, women from a variety of educational backgrounds, age groups, and residential situations were included.

Sample size

The sample size was calculated using Cochran’s formula for cross-sectional studies considering a 95% confidence interval, 5% margin of error, and estimated prevalence from previous maternal healthcare utilization studies. The minimum required sample size was calculated and rounded to 318 participants to improve representation. This figure was deemed practical given the study’s timeframe and available resources, and it allowed for the observation of differences among rural, urban, and semi-urban people.

Sampling technique

A non-probability convenience sampling technique was used. Eligible participants from rural, urban, and semi-urban areas of Gujarat who met the inclusion criteria were approached through community outreach and Google Forms. Women willing to participate and providing informed consent were enrolled in the study. The method enabled respondents to freely express their experiences and promoted community involvement [41].

Inclusion criteria

Participants were eligible for inclusion in the study if they met the following criteria:

1. Women aged 18–45 years who had experienced at least one childbirth.

2. Individuals holding Indian nationality and residing in Gujarat.

3. Participants who were willing to participate and provided written informed consent prior to data collection.

Exclusion criteria

Participants were excluded from the study based on the following criteria:

1. Women who declined or were unwilling to participate in the study.

2. Questionnaires that were incomplete, partially filled, or contained missing responses that could compromise data validity and reliability.

Data collection tools and techniques

Data were collected using a structured and pre-validated questionnaire specifically developed for the present study. The questionnaire was designed to comprehensively assess multiple dimensions of maternal healthcare, including: knowledge regarding birth spacing and preconception health; antenatal care practices (such as timing of the first antenatal visit, total number of visits, receipt of tetanus toxoid immunization, and consumption of iron–folic acid supplements); place and mode of delivery; postnatal care practices, including follow-up within 48 hours of delivery; availability of emotional support and nutritional counseling; and the role of family members and community health workers in maternal healthcare decision-making. Content validity of the questionnaire was assessed by subject experts in public health and maternal healthcare. A pilot study was conducted among 20 participants to assess clarity, comprehensibility, and consistency of responses. Necessary modifications were made prior to final data collection. The questionnaire consisted of both closed-ended items to facilitate quantitative analysis and a limited number of open-ended questions to capture insights into participants’ personal experiences, perceived barriers, and perspectives related to maternal health services.

Data collection was conducted through both online and offline modes. Google Forms were distributed through community networks and social platforms, while face-to-face interviews were conducted in local community settings for participants with limited digital literacy. A total of 342 eligible women were approached for participation through online and community-based recruitment methods. Among them, 325 women responded to the questionnaire. After exclusion of incomplete and partially filled responses, 318 questionnaires were considered complete and included in the final analysis, resulting in a response rate of 95.4%.

Data collection period

From February to March, 2026, a two-month period, the study was carried out. This time frame ensured response consistency while providing sufficient time for participant recruitment, data collection, and verification.

Data management and analysis

Quantitative data were analyzed using descriptive statistical methods including frequencies and percentages to summarize maternal healthcare utilization patterns. Comparative assessment across rural, urban, and semi-urban populations was additionally performed to identify variations in awareness and service utilization trends. Microsoft Excel was used for data organization and statistical interpretation. In order to supplement quantitative findings and offer a deeper understanding of current gaps, obstacles, and women’s lived experiences, responses gathered through in-person conversations and open-ended questions were examined and thematically analyzed.

The study’s dependent variables were maternal health practices during the preconception, prenatal, delivery, and postnatal stages; for contextual understanding, demographic traits such as age, place of residence, and level of education were considered independent variables.

Ethical considerations

The study was conducted in strict accordance with established ethical guidelines. Prior to data collection, informed consent was obtained from all participants, and their participation was entirely voluntary. The objectives and purpose of the study were clearly explained to each respondent, and they were assured that the information provided would be used solely for academic and research purposes. Ethical approval was obtained from the Institutional Ethics Committee (Approval No. ECR/702/Inst/GJ/2015/RR-21/10206). Confidentiality and privacy were rigorously maintained throughout the study. No personally identifiable information was collected, and all responses were anonymized prior to analysis. The data were securely stored and accessed only by the research team. As the study involved no invasive procedures, clinical interventions, or experimental treatments, it posed no physical risk to participants. Despite providing valuable insights into maternal health knowledge and practices, the study has certain limitations. The use of voluntary response sampling may limit the generalizability of the findings to the broader population. Additionally, as data were self-reported, the responses may have been subject to recall bias or social desirability bias, potentially influencing the accuracy of reported practices and experiences. Nevertheless, the descriptive cross-sectional design was appropriate for achieving the study objectives and for identifying critical gaps in the continuum of maternal healthcare, particularly in preconception and early postnatal stages.

Results

The study’s findings are used to characterize the respondents’ sociodemographic profile as well as their knowledge of and use of maternal healthcare services throughout the preconception, prenatal, delivery, and postnatal stages of care. The results are based on replies from 318 women who live in Gujarat’s rural, urban, and semi-urban districts.

Socio-demographic characteristics of respondents

A total of 318 women participated in the study. Among them, 50.0% (n = 159) were from rural areas, 39.3% (n = 125) from urban areas, and 10.7% (n = 34) from semi-urban areas. The majority of participants belonged to the 18–30 years age group (75.5%, n = 240), while 24.5% (n = 78) were aged 31–45 years. Most respondents were married (99.4%, n = 316). Regarding educational status, 62.3% (n = 198) had completed secondary education, 24.5% (n = 78) had higher secondary education, 10.1% (n = 32) had primary education, and 3.1% (n = 10) were graduates or above.

Variable	Category	Frequency (n)	Percentage (%)
Residence	Rural	159	50.0
	Urban	125	39.3
	Semi-urban	34	10.7
	Total	318	100
Age Group (Years)	18–30	240	75.5
	31–45	78	24.5
	Total	318	100
Marital Status	Married	316	99.4
	Unmarried	2	0.6
	Total	318	100
Educational Status	Primary Education	32	10.1
	Secondary Education	198	62.3
	Higher Secondary	78	24.5
	Graduate and Above	10	3.1
	Total	318	100

Preconception health awareness

71.1% (n = 226) of respondents said they were aware of preconception health check-ups. On the other hand, 28.9% (n = 92) said they knew very little or nothing about the significance of health evaluation prior to pregnancy. Compared to their urban counterparts, women from rural areas had relatively lower awareness levels. Birth spacing and family planning knowledge varied by place of residence, with urban women having greater awareness than rural and semi-urban women.

Identified Gap	Recommendation
Preconception Awareness	28.9% (92) of women lacked knowledge; awareness campaigns should be intensified
Early Postnatal Care	Only 58% (153) received 48-hour follow-up; ASHA home visits should be strengthened
Family Involvement	Many reported “sometimes” support; encourage husbands and in-laws to participate actively
Counseling & Mental Health	55.2% (174) received breastfeeding counseling; expand postnatal counseling sessions
Healthcare Facilities	Limited awareness of affordable services; promote awareness and alternatives for costly medicines

Antenatal care utilization

Prenatal care services were used by a large percentage of respondents. During pregnancy, 87.1% (n = 277) went to a medical facility for prenatal exams. The majority of women reported taking iron-folic acid (IFA) pills and having tetanus toxoid (TT) injections, demonstrating adequate coverage of standard prenatal treatments.

Prenatal visit attendance was high, although there were differences in the number of suggested visits and the time of the first prenatal visit, especially among respondents who lived in rural areas. Pregnancy-related counseling on emotional health, nutrition, and warning indicators was shown to vary by environment.

Delivery care practices

78.9% (n = 251) of respondents gave birth in either public or private healthcare facilities, indicating a very high incidence of institutional deliveries. The majority of women reported skilled birth attendance, which is indicative of better availability to qualified medical professionals and efficient execution of maternal health initiatives.

While urban women were more likely to use private healthcare facilities, both rural and urban respondents indicated similar trends in institutional delivery. The results show that home deliveries are significantly declining in all residential categories.

Postnatal care utilization

Use of postnatal care revealed significant disparities. Just 48.1% (n = 153) of respondents said they had a postnatal examination within 48 hours after giving birth, which is crucial for detecting problems with the mother and the newborn. For the remaining responders, there was either no postnatal check-up at all or a delayed follow-up.

Maternal nutrition and counseling [42]

Maternal healthcare indicator distribution among urban, semi-urban, and rural populations (N = 318). Key maternal health services, such as preconception checkups, family planning, antenatal care (ANC), tetanus toxoid (TT) immunization, iron-folic acid (IFA) supplementation, institutional delivery, skilled birth assistance, and postnatal care (PNC) within 48 hours, are represented by values. Nutritional advice after birth was reported by 41% (n = 129) of those surveyed. 55.2% (n = 174) of the mothers got breastfeeding-related counseling. There was little emotional and mental health counseling throughout the postpartum period, and many women reported receiving little help other than acute physical recuperation.

Family and community support

There were reports of varying levels of family involvement in maternal healthcare decisions. Many women said they only “sometimes” received support from their husbands and family members, whereas some reported constant support. Particularly in rural regions, community health workers—such as ASHA and Anganwadi workers—were shown to be important providers of information and support.

Rural–urban differences in maternal health services

Table 1 demonstrates differences in maternal healthcare utilization across rural, semi-urban, and urban populations. Urban women showed comparatively higher awareness regarding preconception care, family planning, and antenatal service utilization. Rural women benefited substantially from community healthcare support; however, lower utilization of postnatal care within 48 hours was observed across all residential categories, indicating persistent gaps in continuity of maternal healthcare services.

Table 1.

Rural–urban differences in maternal healthcare utilization among respondents (N = 318)

Maternal Healthcare Indicator	Rural n (%) (n = 159)	Semi-urban n (%) (n = 34)	Urban n (%) (n = 125)	Total n (%)
Awareness of Preconception Check-ups	104 (65.4)	24 (70.6)	98 (78.4)	226 (71.1)
Awareness of Birth Spacing & Family Planning	111 (69.8)	25 (73.5)	96 (76.8)	232 (73.0)
First Trimester ANC Visit	139 (87.4)	26 (76.5)	112 (89.6)	277 (87.1)
≥4 ANC Visits	117 (73.6)	26 (76.5)	114 (91.2)	257 (80.8)
TT Immunization Received	133 (83.6)	33 (97.1)	110 (88.0)	276 (86.8)
IFA Supplementation	149 (93.7)	33 (97.1)	122 (97.6)	304 (95.6)
Institutional Delivery	118 (74.2)	33 (97.1)	103 (82.4)	254 (79.9)
Skilled Birth Assistance	116 (73.0)	33 (97.1)	102 (81.6)	251 (78.9)
Postnatal Care Within 48 Hours	66 (41.5)	21 (61.8)	66 (52.8)	153 (48.1)

Discussion

The present study provides useful insights into Gujarati women’s knowledge and utilization of maternal health services across the preconception, antenatal, delivery, and postnatal phases. The findings indicate substantial progress in service uptake, particularly in antenatal care and institutional deliveries, alongside persistent gaps that limit the overall effectiveness of safe motherhood practices. Although improved healthcare access is evident, deficiencies in preconception awareness, early postnatal follow-up, counseling quality, and family involvement highlight the need for a more integrated and continuous maternal healthcare approach. High utilization of antenatal services was a key positive outcome, with most women reporting regular checkups, iron–folic acid supplementation, and tetanus toxoid immunization, consistent with national trends under the National Health Mission [43]. Community health workers, especially ASHA workers, appear to play a significant role in promoting service utilization, particularly in rural areas [44]. However, inconsistencies in counseling related to nutrition, pregnancy danger signs, and mental well-being suggest that the quality of antenatal care requires further improvement beyond routine clinical monitoring [45]. Institutional deliveries were also notably high, reflecting successful implementation of programs such as the Janani Suraksha Yojana and improved healthcare infrastructure [46]. While this shift reduces risks associated with home births, it may inadvertently overshadow the importance of postnatal care, which remains underutilized. Preconception care emerged as one of the most neglected components, with nearly one-third of women unaware of its importance, largely due to sociocultural factors and limited targeted communication. Postnatal care, especially within the first 48 hours after delivery, represented a major gap, despite its critical role in detecting maternal and neonatal complications. Deficiencies in postpartum counseling, particularly related to mental health and emotional support, further highlight the need to integrate psychosocial care into maternal health services. Variability in family involvement also suggests that family-centered strategies could enhance timely care-seeking and adherence to health advice.

Overall, the study emphasizes that safe motherhood should be approached as a continuous process, requiring strengthened preconception education, improved postnatal follow-up, high-quality counseling, and greater family engagement to achieve sustainable maternal health outcomes.

Conclusion

The study demonstrates significant advancements in safe motherhood in Gujarat, notably in better use of prenatal care and institutional births, which are indicative of the beneficial effects of maternal health initiatives and fortified healthcare systems. These improvements show that rural, urban, and semi-urban areas have improved access to basic services.

Despite high utilization of antenatal care services and institutional deliveries, important gaps were identified in preconception health awareness, nutritional and emotional counseling, family involvement, and timely postnatal care utilization. Lower uptake of postnatal follow-up services and variability in maternal healthcare awareness across rural, semi-urban, and urban settings indicate the need for strengthened community-based maternal healthcare education and continuity of care interventions. Timely postnatal care utilization within the recommended 48-hour period remains suboptimal among a considerable proportion of participants. Comprehensive care is further undermined by inadequate diet, breastfeeding, and emotional health counseling.

The results highlight the necessity of a people-centered, continuum-based strategy that goes beyond prenatal and delivery treatments. Existing gaps can be filled by enhancing holistic counseling, postnatal follow-up, preconception education, and family and community involvement, especially through community health workers. These observations can help health administrators and legislators create focused plans to enhance maternal and newborn health outcomes and promote safe motherhood.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

The authors confirm their contribution to the paper as follows: U.A., S. G.: Methodology, data collection, data analysis, interpretation of results and drafted the manuscript. P.S., K.S., P.K., K.R., E.M., P.G.: Conceptualization and Technical Advice. All authors reviewed the results and approved the final version of the manuscript.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Parul University - Institutional Ethics Committee approval on Human Research no. ECR/702/Inst/GJ/2015/RR-21/10206. All procedures involving human participants/data were conducted in accordance with institutional ethical standards and the Declaration of Helsinki. Ethical approval was obtained from the Institutional Ethics Committee, and informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.