Quality of antenatal care provision in rural villages of Satna district, Madhya Pradesh, India: a quantitative formative study to help the development of an evidence-based contextualised complex health intervention of the CHAMPION2 cluster randomized trial

Quality of antenatal care provision in rural villages of Satna district, Madhya Pradesh, India: a quantitative formative study to help the development of an evidence-based contextualised complex health intervention of the CHAMPION2 cluster randomized trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Quality of antenatal care provision in rural villages of Satna district, Madhya Pradesh, India: a quantitative formative study to help the development of an evidence-based contextualised complex health intervention of the CHAMPION2 cluster randomized trial Siddharudha Shivalli, Ila Fazzio, Diana Elbourne, Sridevi Karnati, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5211700/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Mar, 2026 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 4 You are reading this latest preprint version Abstract Background Since 2005, maternal and newborn deaths have declined in India. Nonetheless, if the current mortality trends continue, India may not achieve the Sustainable Development Goal targets without enhancing the quality of care across the continuum from pregnancy to delivery, particularly in poorly performing states. This study aimed to help the development of an evidence-based contextualised CHAMPION2 trial package of maternal and child health (being implemented in rural villages of Satna district, India) by assessing the quality of, and the factors associated with antenatal care (ANC) provision across four aspects of care and exploring reasons if uptake of care was inadequate. Methods We conducted a cross-sectional study in 50 of 196 villages in the CHAMPION2 cluster randomized trial in Satna district, Madhya Pradesh, India before randomization. We interviewed 792 women, who were eligible for the trial and had given birth in the previous two years from the interview date. We assessed the quality of ANC provision across four aspects of care (i.e., skilled care, timeliness (ANC in first trimester), number of ANC visits (at least four), and content of care) and explored reasons given by women if the uptake of care was inadequate. The quality of ANC provision was considered ‘adequate’ if all the four aspects of care were judged sufficient. We conducted logistic regression analyses to determine the socio-demographic factors associated with the adequate quality of ANC provision. Results Only 21.2% of women received ANC provision of 'adequate' quality (skilled care:98.9%, timeliness: 75.3%, minimum four ANCs: 73.5%, and appropriate content of care: 28.3%). The inadequate quality was primarily due to inappropriate content of care particularly, poor compliance with iron-folate intake for at least 100 days and no counselling by healthcare providers on key ANC issues. The odds of receiving adequate quality ANC were increased when either the woman or husband was educated to at least high school level. Conclusions The quality of ANC provision in the study setting was inadequate. The quality of care was emphasised in refresher training for nurses in the CHAMPION2 trial and health promotion, demand generation, and community mobilisation activities were locally contextualised. antenatal care formative study India quality provision of care rural village Background In the last two decades, India witnessed a significant drop in overall maternal (384 to 97 per 100,000 livebirths from 2000-20) and neonatal (38 to 23·5 per 1000 livebirths from 2000-17) mortality rates [ 1 – 4 ]. This is mainly attributed to substantial improvement in the coverage of essential maternal and child health services[ 5 , 6 ] and various incentive-driven strategic initiatives under the National Health Mission (1,2). However, the magnitude of decline in mortality rates has been below the predicted levels [ 3 , 7 ]. Additionally, there have been growing inequalities in these mortality rates within and across the Indian states [ 3 , 7 ]. If the current mortality trends were to continue, India may not achieve the Sustainable Development Goal targets by 2030 for maternal (< 70/100,000 livebirths) and neonatal (< 12/1000 livebirths) mortality[ 8 ] without further interventions particularly in poorly performing states [ 3 , 7 ]. According to a pooled analysis of nationally representative surveys, 78.1% of maternal deaths in India occurred in facilities, among women who planned to deliver at a health facility and 40.6% of maternal deaths had complications before the onset of labour [ 7 ]. In this analysis, obstetric haemorrhage (47.2%) followed by pregnancy-related infections (12%) and hypertensive disorders of pregnancy (6.7%) were the leading causes of maternal deaths, indicating delayed or missed diagnosis and/or poor management of underlying medical conditions during antenatal care (ANC) [ 7 ]. According to a comprehensive district-level analysis of neonatal mortality trends in India, 80% of neonatal deaths occurred within 7 days of birth [ 3 ]. Low birth weight and short gestation (child and maternal malnutrition) were the predominant risk factors to which 82.8% (95I CI: 77.6–88.4) of the neonatal deaths could be attributed [ 3 ]. In India (and low- and middle-Income countries, LMICs), poor quality of care was an important driver of excess mortality (i.e., mortality in excess of what would be expected relative to the reference case fatality level) in 61% of neonatal conditions[ 9 ] This excess mortality may be addressed by improving the quality of health care across the continuum of care from pregnancy to delivery[ 9 , 10 ] Timely ANC with adequate and comprehensive content is a vital component in the continuum of care of pregnant women and babies for early management of complications, sensitizing women to recognize the danger signs, importance of breastfeeding and institutional delivery. Existing evidence suggests that with adequate coverage and quality of maternal and newborn healthcare, resource limited LMICs like India can avert 71% and 54% of neonatal deaths and maternal deaths, respectively [ 11 ]. Previous studies from India have highlighted the poor quality of maternal and child health care [ 12 – 21 ]. Additionally, the quality of care received is associated with women’s socio-demographic factors such as age, caste category, literacy, and socio-economic status [ 12 – 21 ]. Therefore, to further accelerate reductions in maternal and newborn mortality, it is critical to improve the quality of care while considering these socio-demographic factors in India [ 16 , 22 ]. Given the substantial interstate variations in quality of ANC[ 17 ] and in maternal deaths [ 7 ], state-specific and socio-culturally contextualised strategies are needed [ 23 , 24 ]. A study investigating the effectiveness of a package of maternal and child health interventions (community health promotion and medical provision and impact on neonates (CHAMPION2)) is being implemented in the Satna district of Madhya Pradesh to help inform future strategy in Madhya Pradesh [ 25 ]. CHAMPION2 is a cluster randomized trial wherein 196 villages (clusters) are randomized to receive either the health (CHAMPION2 for pregnant women) or education (STRIPES2 (Support To Rural India’s Public Education) for early primary school children) intervention. Villages receiving the health intervention are controls for the education intervention, and vice versa. Further details of the CHAMPION2/STRIPES2 trial are published elsewhere [ 25 ]. Madhya Pradesh is a state with high maternal (173/1,00,000 live births) and neonatal (29/1000 live births) mortality [ 4 , 26 ]. At the planning stage of the trial, we did not find any studies from Madhya Pradesh (other than a secondary analysis of NFHS-4 (National Family Health Survey-4 2015-16)[ 17 ] comprehensively assessing the quality of ANC provision to help align the ongoing RMNCH + A (Reproductive, Maternal, Newborn, Child, and Adolescent Health) strategy[ 27 ] to the local context in Madhya Pradesh. Given the importance of quality of ANC provision for the success of the intervention, and to help development of a contextualised (i.e., adapting the intervention to fit the specific social, cultural, and economic conditions of the target population or community) the package of interventions in CHAMPION2 [ 25 ], we conducted a cross-sectional study with the following objectives: To assess the quality of provision of ANC in rural villages of Satna district using four aspects of care (i.e., skilled care, timeliness, number and content of ANCs) [ 28 ] To explore reasons given by women if uptake of care was not adequate. To investigate the factors associated with the quality of provision of ANC in rural villages of Satna district. To help inform the development of an evidence-based contextualised package of maternal and child health interventions for the CHAMPION2 trial [ 25 ]. Methods Study setting Satna is one of the 55 districts in Madhya Pradesh state with an estimated population of about 2.62 million. Rural villages constitute 79% of the district’s population with a predominantly agrarian economy. There are 10 Tehsils (administrative subdivision in a district) and 2125 villages in Satna district. The public healthcare system in Satna consisted of 309 sub-centres, 47 primary health centres (PHCs), seven community health centres (CHCs), two civil hospitals (CH), and one district hospital (DH) [ 29 ]. At village level, Auxiliary Nurse Midwives (ANM) and Accredited Social Health Activists (ASHA) render maternal and child health services under the RMNCH + A strategy, which is a key component of the National Health Mission [ 27 ]. Design and participants : This cross-sectional study was conducted in 50 of the 196 villages that were subsequently randomised to receive either the CHAMPION2 (health) or the STRIPES2 (education) intervention in the trial [ 25 ]. The 50 villages were selected using stratified random sampling with stratification according to the nearest Community Health Centre to the village. In the 196 trial villages, a woman was considered eligible for the trial if she was a resident of the village, married, aged less than 50 years, neither she nor her husband had a family planning operation (i.e. tubectomy or vasectomy) and consented to participate. As part of the trial baseline enumeration in 2017 (prior to selection of villages for this study) potentially eligible women had been asked whether they had given birth in the previous year. Approximately one year later we returned to all women in the 50 selected villages, who were both eligible for the trial and had earlier reported a birth in the year prior to enumeration. These women were asked to participate in the present study, and then asked questions relating to their most recent birth. This most recent birth must have been in the two years preceding the date of interview for this study: but could have occurred after the one reported at enumeration. Sample size and sampling framework Pragmatically we aimed to include all the women eligible for this study in 50 randomly selected villages. Assessment of quality of provision of ANC Assessment of the quality of care is complex and requires a multidimensional approach. Using a system-based model, the quality of care is assessed under three domains i.e., structure, process, and outcome [ 30 ]. The World Health Organization (WHO) further expanded the ‘process’ domain into two linked dimensions of ‘provision of care’ and ‘experience of care’ [ 31 ]. Heredia-Pi et al. [ 28 ] used four aspects of ‘provision of care’ to assess the adequacy of ANC in Mexico i.e., skilled care, timeliness, sufficiency, and appropriate content of care. In the present study, to inform the development of a contextualised evidence-based package of maternal and child health interventions in the CHAMPION2 trial [ 25 ], we focused on ‘provision of care’ i.e., skilled care, timeliness, number of ANCs, and appropriate content of care to assess the quality of ANC [ 28 ]. These four aspects were defined as: Skilled care: received ANC by a doctor, ANM, nurse or midwife. Timeliness: received first ANC visit in the first trimester of pregnancy. Number of ANCs: at least four ANCs completed during pregnancy. Content of ANC: Based on the criteria used by previous studies [ 17 , 28 ], we considered that ANC content as “appropriate” if at least 7 out of 8 of the following procedures or processes of care were given to a woman: (1) measurement of weight; (2) blood pressure; (3) urine test (4) abdominal examination (with or without a machine); (5) tetanus vaccination; (6) blood test (to assess anaemia and possibly parasite and other infections); (7) consumed iron-folic acid (IFA) for at least 100 days. (8) counselling on healthy eating, personal hygiene, adequate sleep and rest during the day, and no smoking/drinking alcohol. Outcome measure The quality of provision of ANC was considered as ‘adequate’ if a woman satisfied all the above-mentioned four aspects of care. Data collection We developed a structured questionnaire based on the latest WHO guidelines and manuals by the National Health Mission (NHM), India to assess the ANC details and to explore the factors associated with access to ANC. Two language experts translated the English questionnaire to Hindi and SiS back translated to English. SK, HR, and SiS trained 12 enumerators over a period of 5 days for data collection using the Hindi version of the questionnaire. All the enumerators pilot tested the questionnaire in two non-study villages. Each interview lasted for 30–40 minutes. The trained enumerators conducted face-to-face interviews of eligible women using the structured questionnaire from November to December 2018. Two data entry operators independently entered the data from the completed questionnaires into a data management system set-up by Sealed Envelope Ltd, London ( www.sealedenvelope.com ). A data entry supervisor reviewed and resolved any discrepancies in the entered data. Statistical analysis We used descriptive statistics to summarise the sample characteristics. 95% confidence intervals for proportions were constructed using robust (Huber-White) standard errors that allowed for clustering. Logistic regression models, with robust (Huber-White) standard errors that allowed for clustering, were used to separately relate woman’s age at interview (continuous), caste (4-level categorical: scheduled caste, scheduled tribe, other backward class, general category) and education status (5-categorical: No schooling, primary, middle, high school/higher secondary, graduate and above) to a binary variable indicating adequate quality of ANC provision. In India, both women’s and their husbands’ education levels are strongly associated with the quality of ANC provision [ 17 – 20 ]. Women and /or husband with better education level, are more likely receive adequate quality of ANC provision [ 17 – 20 ]. Three measures of education status were considered i) woman’s education, ii) husband’s education and iii) maximal education (highest of i) and ii)). Participants with missing education status were omitted from models. P-values from Wald tests (with joint tests for categorical variables) and from trend tests (education level variables only) were computed. Simultaneous inclusion of woman’s and husband’s education in multivariate models induces collinearity because they are highly associated with one another. Accordingly, we first fitted three multivariable logistic regression models, each including age, caste and one of the three education variables. Each of these was then extended by including a three-level categorical variable indicating the relative education of the couple (husband more educated, same level of education, wife more educated). Participants missing either maternal or husband’s education status were omitted from models. Robust standard errors that allowed for clustering were used in all models. P-values from Wald tests (with joint tests for categorical variables) and from trend tests (education level variables only) were computed. The fits of nested models (i.e., pairs of models where one model contains a subset of the predictor variables in the other model but no additional variables) were compared using Wald tests. The fits of non-nested models (i.e., pairs of models where each model contains at least one predictor variable not included in the other model) were compared using the Quasi-Likelihood information criteria (a variant of Akaike’s information criterion suitable for use with robust standard errors) [ 32 , 33 ]. Stata version 16 (StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC) was used to perform the analyses. Results Of the 1054 eligible women identified in the 50 villages, 797 completed the interview, 128 were not in the village, 115 gave birth more than 2 years before the interview date, 13 did not give consent, and one was a duplicate. Of these 797 women, four did not deliver a live-birth and one reported data on a birth born more two years before the survey, so the analysis is restricted to 792 women. The mean age of these women was 24.3 ± 3.5 years and almost all of them were Hindus by religion (99.6%). Only 14.8% women and 9.2% of husbands, had no schooling. Nearly half of them belonged to either Scheduled Caste or Scheduled Tribe (Table 1 ). Table 1 Socio-demographic profile of women in rural villages of Satna district, Madhya Pradesh, India (N = 792) Mean (SD) Min, Max Woman’s age 24.3 (3.5) 18, 42 Characteristic N % Education status No schooling 117 14.8 Primary 114 14.4 Middle School 301 38.0 High School 179 22.6 Higher-secondary School 53 6.7 Graduate 18 2.3 Postgraduate 9 1.1 Not Known 1 0.1 Religion Hindu 789 99.6 Muslim 3 0.4 Caste-category Scheduled Caste 164 20.7 Scheduled Tribe 222 28.0 Other Backward Class 315 39.8 General category 91 11.5 Husband’s education No schooling 73 9.2 Primary 138 17.4 Middle School 263 33.2 High School 193 24.4 Higher Secondary School 75 9.5 Graduate 33 4.2 Postgraduate 12 1.5 Not Known 5 0.6 Table 2 Quality of antenatal care (ANC) provision to women in rural villages of Satna district, Madhya Pradesh, India (N = 792) Aspect of quality of ANC provision Number % (95% CI) Skilled health care 783 98.9 (97.9, 99.8) Timeliness (ANC in first trimester) 596 75.3 (71.1, 79.4) Number of ANCs (at least four visits) 582 73.5 (69.1, 77.8) Appropriateness in ANC content 224 28.3 (23.3, 33.2) Overall adequacy of quality of ANC provision 168 21.2 (16.8, 25.6) Most of the women (770, 97.2%) sought ANC from the public (government) healthcare facilities. Table 2 shows the various aspects of quality of ANC provision. Only 21.2% (95% CI 16.8, 25.6) of the women had ‘adequate’ quality of ANC provision i.e., received ANC from a skilled health personnel, first ANC visit within the first trimester, completed at least 4 ANC visits and with appropriate ANC content. This inadequate quality of ANC provision was mainly due to insufficient procedures or processes of care received during ANC (28.3%, 95% CI 23.3, 33.2). The following proportions of women received the various procedures or processes of care received during ANC: weight measured (95.2%), blood pressure recorded (92.3%), abdomen examined (with or without a machine) (72.9%), received tetanus vaccination (98.6%), urine tested (68.3%), blood tested (89.3%), consumed IFA for at least 100 days (17.0%) and counselled on key ANC issues (30.4%). Only two women did not seek any care from a skilled health person for ANC. Of these, one woman stated that the nearest health facility was too far away, and a vehicle was not available. The other woman stated that she was in a different town for work. The following reasons were given by the women who did not complete their first ANC within the first trimester and/or attended less than four ANC visits: they didn’t think they needed early or more ANC (51% and 64%, respectively), they didn’t know they could go (37.6% and 18.1%), they didn’t have time (11.3% and 17.6%), the health facility was too far away (11.3% and 15.7%) and they were out of the village (13.9% and 13.3%). The reasons were not mutually exclusive. Poor compliance with 100 days of IFA tablet intake was mainly attributed to the fact that women were not given the IFA supplements (34%) and did not feel well when they started taking them (42%). Other reasons for poor compliance with IFA intake were as follows (not mutually exclusive): the woman was not told to take IFA for at least 100 days (14.7%), she received the tablets but forgot to take them (14%), she did not feel IFA intake was necessary (8.1%), and she reported that that she had a previous bad experience with IFA intake (5%). Table 3 shows the unadjusted associations between socio-demographic characteristics and the binary ‘quality of ANC provision’ indicator. There was no statistically significant evidence of an association with age but there was borderline statistically significant evidence of an association with caste, and strong evidence of an association with education, whether that of the woman or husband. In the analysis of the maximal (amongst woman and husband) education level, the odds of adequate quality of ANC provision were similar in the three lowest education categories and markedly increased in those receiving at least high school education. Table 3 Unadjusted associations between socio-demographic characteristics of women and adequate quality of ANC provision in rural villages of Satna district, Madhya Pradesh, India (N = 792) Socio-demographic characteristic Category Adequate quality of provision of ANC Odds ratio (95% CI) p-value Yes (N = 168) No (N = 624) Mean SD Mean SD Woman’s age (years) 24.4 3.3 24.3 3.5 1.01 (0.97, 1.05) 0.72 N % N % Caste-category Scheduled Caste 40 23.8 124 19.9 1 0.0591 (joint test) Scheduled Tribe 31 18.5 191 30.6 0.50 (0.29, 0.88) Other Backward Class 71 42.3 244 39.1 0.90 (0.60, 1.35) General category 26 15.5 65 10.4 1.24 (0.65, 2.35) Woman’s education status No schooling 17 10.1 100 16.0 0.61 (0.35, 1.04) 0.0084 (joint test) 0.0007 (trend test) Primary 13 7.7 101 16.2 0.46 (0.25, 0.85) Middle 66 39.3 235 37.7 1 High/higher secondary 60 35.7 172 27.6 1.24 (0.88, 1.75) Graduate and above 12 7.1 15 2.4 2.85 (1.09, 7.44) Missing 0 0.0 1 0.16 Husband’s education status No schooling 10 6.0 63 10.1 0.75 (0.36, 1.57) 0.0001 (joint test) 0.0029 (trend test) Primary 24 14.3 114 18.3 0.99 (0.59, 1.66) Middle 46 27.4 217 34.8 1 High/higher secondary 72 42.9 196 31.4 1.73 (1.24, 2.42) Graduate and above 16 9.5 29 4.6 2.60 (1.46, 4.64) Missing 2 0 0.0 5 0.8 Maximal education status No schooling 6 3.6 32 5.1 1.11 (0.45, 2.75) < 0.0001 (joint test) 0.0138 (trend test) Primary 11 6.5 66 10.6 0.99 (0.50, 1.95) Middle 40 23.8 237 38.0 1 High/higher secondary 91 54.2 246 39.4 2.19 (1.51, 3.18) Graduate and above 20 11.9 37 5.9 3.20 (1.69, 6.08) Missing 2 0 0.0 6 1.0 The odds ratio for age relates to a one-year increase in age. Omitted from analyses. In the education adjusted analyses relating socio-demographic characteristics to the binary ‘quality of ANC provision’ indicator there was no statistically significant evidence of an association with age or with caste after adjustment for education, whether that of the woman, husband, or the maximal level. As measured using the quasi-likelihood information criteria (QIC), the best fitting of the adjusted models included the maximal level of education along with age and caste (Table 4 ). As in the unadjusted analysis, the odds of the adequate quality of ANC provision were similar in the three lowest education categories and markedly increased in those receiving at least high school education. In an extended model there was no evidence that odds of adequate quality of ANC provision differed if just the woman or husband had received the maximal education level (odds ratio = 1.02 (95% CI 0.71, 1.49) for the comparison between families where just the woman had reached this level and families where both had; odds ratio = 0.91 (95% CI 0.60, 1.40) for the comparison between families where just the husband had reached this level and families where both had). Models where just the woman’s education (QIC = 812.375) and just the husband’s education (QIC = 814.531) was included fitted less well than the model with their maximal level of education (QIC = 808.21). For both such models, extensions provided some evidence that where the other partner had a higher level of education the odds of adequate quality of ANC provision were increased, providing additional support for the hypothesis that is the maximal level of education among the couple that is key. Table 4 Mutually adjusted associations between socio-demographic characteristics of women and adequate quality of ANC provision in rural villages of Satna district, Madhya Pradesh, India (N = 786) Socio-demographic characteristic Category Odds ratio (95% CI) p-value Woman’s age (years) 1.02 (0.98, 1.07) 0.28 Caste-category Scheduled Caste 1 0.63 (joint test) Scheduled Tribe 0.67 (0.36, 1.25) Other Backward Class 0.92 (0.60, 1.40) General category 0.98 (0.53, 1.81) Maximal education status No schooling 1.11 (0.40, 3.04) 0.0041 (joint test) 0.0537 (trend test) Primary 1.05 (0.53, 2.08) Middle 1 High/higher secondary 2.06 (1.35, 3.13) Graduate and above 2.83 (1.47, 5.48) Discussion This study provides deeper insights concerning the quality of ANC provision across four aspects of the process of care in a high priority district of Madhya Pradesh, India. The following salient findings emerged from our analysis. First, only 21.2% of women in rural villages of Satna district received ANC that was of 'adequate' quality. Second, inadequate quality of ANC provision was primarily due to inappropriate ANC content (i.e., various procedures and processes) delivered by care providers. Notably, women’s poor compliance with IFA intake for at least 100 days and lack of counselling by care providers on the key aspects of ANC emerged as the main issues. Women with no early and/or fewer than four ANCs thought they didn’t need ANC sufficiently early or frequently, or not knowing they could access ANC. Third, a woman educated to at least high school level (or whose husband had been) was more likely to receive adequate quality of ANC provision than a woman from a family when neither had been educated to this level. A previous survey[ 5 ] and some studies[ 18 – 20 ] reported ‘full ANC’ if a woman had four or more ANCs, received at least one tetanus injection, and took IFA for 100 or more days. However, unlike the present study, ‘full ANC’ criteria do not consider ‘skilled care’, ‘timeliness’, and ‘appropriate content of care’ while assessing the quality of provision of ANC, which is an important limitation. Similar to the present study, a secondary analysis of NFHS-4 data using all the four aspects of care reported that very low proportion (about 16%) of women in Madhya Pradesh received adequate quality of ANC provision [ 17 ]. As in this study, appropriate ANC content was the least satisfied aspect care provision in other studies in India [ 17 , 21 ]. Although nearly three-quarters of women had at least 4 ANC visits, only 28.2% of women received ANC with appropriate content, suggesting missed opportunities by the healthcare providers or women to render or receive all the procedures/process of ANC. Pregnant women’s poor compliance to IFA intake for at least 100 days is a pan-India issue (30.3% in NFHS-4 (2015-16) and 54% in NFHS-5 (2019-21)) [ 6 ], with compliance worse in rural areas (40.2% in NFHS-5 (2019-21)) [ 6 ]. In the latest nationwide survey (NFHS-5), compliance to IFA intake during pregnancy in Satna district was 41.3% (urban and rural combined) [ 34 ], which is much higher than in our study (where all villages are rural) (17%). Our study findings suggest that in rural villages of Satna district IFA compliance has multiple causes i.e., lack of adequate supply (input indicator of quality of care), lack of counselling of pregnant women regarding the importance of IFA intake and the fact that initial side effects of IFA are reversible, and that women forgot to take them (process indicators of quality of care). Given that gestational anaemia is a major public health issue in Madhya Pradesh (prevalence of 52.8%) [ 6 ] and postpartum haemorrhage is the most common cause of maternal mortality in India [ 7 ], co-existing anaemia (particularly ‘severe’ anaemia) increases the risk of death or maternal near miss [ 35 – 37 ]. Hence, it is vital to ensure IFA compliance in pregnancy to improve maternal and child health outcomes. In addition, lack of counselling on key ANC related issues was another major issue in this and one other study [ 21 ] during ANC, this being vital in empowering women to take necessary actions for a positive pregnancy experience and to prevent adverse birth outcomes [ 38 ]. In this and other studies [ 16 – 19 ], at least four ANC visits during pregnancy was considered as adequate according to the national guidelines. The new WHO ANC model recommends at least eight ANC visits during pregnancy [ 38 ]. However, based on the inadequacy in quality of ANC provision in this and other studies in India [ 17 , 21 ], increasing the minimum number of ANC visits may not translate into the desired health outcomes unless the quality of ANC provision is addressed [ 39 ]. In our study, woman’s age (as a continuous variable) showed “small and non-significant” association with receiving ANC of adequate quality. Older women may have had more babies (the fact that we don’t consider parity in our analysis is a limitation) and could impact on our result in several ways. Previous studies in India reported that women of adolescent age were less likely to receive ANC of adequate quality [ 17 , 18 ]. Similarly, when compared to primigravidae, multiparous women were less likely to receive ANC of adequate quality [ 17 , 18 ]. Miteniece et al,[ 40 ] reported increased confidence from previous pregnancy and childbirth experience, constraints of time and resources, poor prior experience with the health system and financial barriers as potential reasons for inadequate ANC quality provision in multiparous women. Regarding woman’s caste, we did see some evidence (albeit not normally statistically significant) of an association but, adjustment for education renders the effects smaller and not statistically significant, suggesting that education plays a mediating role here. In this study, woman/husband with higher education were more likely to receive ANC of adequate quality. Previous Indian studies have highlighted those women with higher education status (or whose husband has higher education status) are more likely to receive ANC of adequate quality [ 17 , 18 , 41 ]. According to Das et al., women and/or their husband who had a higher level of education were more likely to seek ANC from competent health professionals when compared to those with lower educational levels [ 42 ]. A secondary analysis of NFHS-4 data[ 41 ] in five Indian states including Madhya Pradesh reported that the interaction of husband’s higher education with women’s primary education shows a ‘substitution effect’ in the use of ANC services. Another secondary analysis of NFHS-5 data reported that quality of maternal and newborn care in India displayed a greater variation between smaller areas within districts [ 43 ]. One of the mechanisms could be clustering of these key socio-demographic characteristics (education, wealth, caste, etc.), which tend to cluster more densely at the household or small area level [ 43 ]. Despite the statistical significance of the association between higher education and receipt of adequate ANC, only around a third of women (111/394) who had (or whose husband had) been educated to at least High/Higher secondary level received adequate quality of ANC provision, suggesting that any intervention aimed at improving ANC should not be restricted to those with lower levels of education. Contextualising the CHAMPION2 intervention: Maternal and child health intervention package in the CHAMPION2 trial [ 25 ] consisted of community health promotion, community mobilisation with women’s groups in the form of participatory learning and action (PLA), provision of nurse-led fixed-day services and participatory discussion groups (PDGs) with pregnant women, and facilitation of referrals of mothers and neonates to community health centres or civil hospitals. After randomisation of villages in the CHAMPION2 trial, the intervention team conducted quantitative and qualitative appraisals in the intervention villages to help identify key areas in need of improvement through interviews and focus groups with local women, healthcare providers and village elders. These appraisals by the intervention team and the findings of this study substantiated our approach in contextulisation of key components of CHAMPION2 intervention. For health promotion and demand generation, a health awareness campaign was launched in the villages, targeting all the community members to promote maternal and neonatal health knowledge. Focus groups and Nukkad Nataks (village-level street plays) were conducted for the campaign, which were adapted based on local customs to convey important maternal and child health messages to communities. Further, we planned to allow all the village women to participate in the PLA sessions focussing on improving women’s health knowledge, encouraging greater use of available services, other key aspects of maternal and child health, and providing women with a forum to discuss solutions to important maternal and neonatal health issues. As a part of CHAMPION2 intervention, refresher training of nurses was conducted to improve the implementation of various components of ANC content. Nurses were also trained to conduct participatory discussion groups (PDGs) with pregnant women during ANC sessions to discuss key issues. In refresher training for nurses, we emphasised on all the processes/procedures of ANC, ensuring an adequate IFA supply and counselling on various key ANC issues including IFA compliance (i.e., explaining and reassuring initial temporary side effects and benefits of daily intake). PDGs included various key topics including the importance of ANC, diet in pregnancy and after delivery, importance of IFA intake, etc. Nurses were advised to share the relevant information with PLA teams based on their experiences or events during ANC and PDG sessions so that these could be discussed at the next PLA session with village women. Strength and limitations The study’s main strength was the comprehensive assessment of the quality of ANC provision across all four aspects of care in the eligible population. A limitation was that the quality of ANC provision assessment was based on women’s recall. Hence, we could not verify all the responses. We did not collect data on women’s parity at the time of this study, which may be associated with quality of ANC provision. Also, this study focussed only on the quality of ANC provision as insufficient information was available for postnatal and neonatal care provision across all the four aspects of care. Conclusions Overall, the quality of ANC provision in rural villages of Satna district was inadequate, which was primarily due to inappropriate content of ANC. The education level women or their husbands of at least high school and above increased the odds of receiving adequate quality of ANC. Findings of this study substantiated our approach in contextualisation of key components of maternal and child health intervention package in the CHAMPION2 cluster randomised trial. It is likely that inadequate quality of ANC provision in similar settings will also be related to content of ANC, and that contextualised health promotion, demand generation, and community mobilisation activities as well as refresher training will be helpful in improving the quality of ANC provision in similar rural settings. Abbreviations ANC antenatal care ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activist CH civil hospitals CHAMPION2 community health promotion and medical provision and impact on neonates CHC community health centres DH district hospital EAG Empowered Action Group PHC primary health centre RMNCH + A (Reproductive, Maternal, Newborn, Child, and Adolescent Health STRIPES2 support to rural India’s public education system and impact on numeracy and literacy scores WHO World Health Organization Declarations Ethics approval and consent to participate The ethics committees of L V PRASAD Eye Institute, Hyderabad, India (LEC 02-16-008) and the London School of Hygiene and Tropical Medicine (LSHTM Ethics Ref: 10482) have approved this study as a part of the CHAMPION2/STRIPES2 cluster randomized trial protocol. We have obtained the necessary approvals from Indian Council of Medical Research (ICMR), New Delhi, and from the Department of Health & Family Welfare of the government of Madhya Pradesh. The study complies with the Declaration of Helsinki, local laws, and the International Conference on Harmonisation Good Clinical Practice (ICH-GCP). We obtained written informed consent (signature or thumbprint) from all the women participants for their voluntary participation. Consent for publication All the participants agreed that all individual information collected during interviews would be used only for research purposes and in ways that would not reveal their identity. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available as the main study (CHAMPION2/STRIPES2 trial) is not yet complete but, will later be available from Ila Fazzio ( [email protected] ) on reasonable request. Competing interests PB is the Executive Chair of EI; IF is a paid employee of EI but has no competing interests. DE and CF received research grants funding from EI but have no competing interests. SS is employed on this research grant but has no competing interests. SK and HR receive research funding from EI but have no competing interests. PR, RN, and MG declare a potential competing interest due to the involvement of the NICE Foundation (an independent organization) which is involved in programs intervening with women and children in rural and urban Telangana (previously Andhra Pradesh) and Rajasthan. Funding Effective Intervention NGO Effective Intervention, Centre for Economic Performance, London School of Economics, UK. Email: [email protected] Authors' contributions All authors contributed extensively to the design of the study, and have contributed to, commented on, and approved the final manuscript. In addition, SK, HR, and SiS provided training, field, and data support for designing the research component. CF performed the statistical analysis. SiS prepared the first version of the manuscript. CF, DE, and IF revised the manuscript. Acknowledgements We would like to acknowledge the work of Mr. A Jaipal Reddy (for his work during data collection), all the teams of supervisors and enumerators (who conducted the interviews), the data entry team (who processed all the paper forms) and Sealed Envelope team: Tony Brady and Piotr Gawron (for designing the database). References World Health Organization. India has achieved groundbreaking success in reducing maternal mortality. https://www.who.int/southeastasia/news/detail/10-06-2018-india-has-achieved-groundbreaking-success-in-reducing-maternal-mortality . Accessed 16 Feb 2024. Bhatia M, Dwivedi LK, Banerjee K, Bansal A, Ranjan M, Dixit P. Pro-poor policies and improvements in maternal health outcomes in India. BMC Pregnancy Childbirth. 2021;21. Dandona R, Kumar GA, Henry NJ, Joshua V, Ramji S, Gupta SS, et al. Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000-17. Lancet. 2020;395:1640–58. Office of the Registrar General & Census Commissioner, India. SAMPLE REGISTRATION SYSTEM (SRS)-SPECIAL BULLETIN ON MATERNAL MORTALITY IN INDIA 2018-20. In: SAMPLE REGISTRATION SYSTEM-MATERNAL MORTALITY BULLETIN. Office of the Registrar General & Census Commissioner, India. 2022. https://censusindia.gov.in/nada/index.php/catalog/44379 . Accessed 3 Apr 2024. International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-4), 2015-16: India. Mumbai: IIPS; 2017. International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), 2019-21: India: Volume II. Mumbai: IIPS; 2021. Meh C, Sharma A, Ram U, Fadel S, Correa N, Snelgrove JW, et al. Trends in maternal mortality in India over two decades in nationally representative surveys. BJOG. 2022;129:550. Ministry of Health and Family Welfare, India. Indicator Framework. In: SDG Health India. Ministry of Health and Family Welfare, India. 2023. https://sdghealthindia-mohfw.in/indicator-framework . Accessed 15 Jun 2023. Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet. 2018;392:2203–12. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018;6:e1196–252. Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet. 2014;384:347–70. Mony PK, Krishnamurthy J, Thomas A, Sankar K, Ramesh BM, Moses S et al. Availability and Distribution of Emergency Obstetric Care Services in Karnataka State, South India: Access and Equity Considerations. PLoS ONE. 2013;8. Wendt AS, Stephenson R, Young MF, Verma P, Srikantiah S, Webb-Girard A et al. Identifying bottlenecks in the iron and folic acid supply chain in Bihar, India: A mixed-methods study. BMC Health Serv Res. 2018;18. Sabde Y, Diwan V, Randive B, Chaturvedi S, Sidney K, Salazar M et al. The availability of emergency obstetric care in the context of the JSY cash transfer programme in Madhya Pradesh, India. BMC Pregnancy Childbirth. 2016;16. Arsenault C, Jordan K, Lee D, Dinsa G, Manzi F, Marchant T, et al. Equity in antenatal care quality: an analysis of 91 national household surveys. Lancet Glob Health. 2018;6:e1186–95. O’Neil S, Naeve K, Ved R. An Examination of the Maternal Health Quality of Care Landscape in India. Cambridge, MA; 2017. Singh L, Dubey R, Singh S, Goel R, Nair S, Singh PK. Measuring quality of antenatal care: a secondary analysis of national survey data from India. BJOG. 2019;126:7–13. Kumar G, Choudhary TS, Srivastava A, Upadhyay RP, Taneja S, Bahl R, et al. Utilisation, equity and determinants of full antenatal care in India: analysis from the National Family Health Survey 4. BMC Pregnancy Childbirth. 2019;19:327. Singh P, Singh KK, Singh P. Maternal health care service utilization among young married women in India, 1992–2016: trends and determinants. BMC Pregnancy Childbirth. 2021;21. Singh L, Bubey R, Singh PK, Nair S, Rai RK, Rao MVV et al. Coverage of Quality Maternal and Newborn Healthcare Services in India: Examining Dropouts, Disparity and Determinants. Ann Glob Health. 2022;88. Dandona R, Majumder M, Akbar M, Bhattacharya D, Nanda P, Kumar GA et al. Assessment of quality of antenatal care services in public sector facilities in India. BMJ Open. 2022;12. World Health Organization. Quality of care. In: Health topics – India. World Health Organization. 2023. https://www.who.int/india/health-topics/quality-of-care . Accessed 23 May 2023. Horwood G, Opondo C, Choudhury SS, Rani A, Nair M. Risk factors for maternal mortality among 1.9 million women in nine empowered action group states in India: secondary analysis of Annual Health Survey data. BMJ Open. 2020;10:e038910. Kumar S. Reducing maternal mortality in India: policy, equity, and quality issues. Indian J Public Health. 2010;54:57–64. Agarwal A, Banerji R, Boone P, Elbourne D, Fazzio I, Frost C, et al. Protocol for a cluster randomised trial in Madhya Pradesh, India: community health promotion and medical provision and impact on neonates (CHAMPION2); and support to rural India’s public education system and impact on numeracy and literacy scores (STRIPES2). Trials. 2020;21:569. International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), India, 2019-21: Madhya Pradesh. Mumbai: IIPS; 2021. National Health Mission. RMNCH + A. In: National Health Mission. https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=794&lid=168 . Accessed 23 May 2023. Heredia-Pi I, Servan-Mori E, Darney BG, Reyes-Morales H, Lozano R. Measuring the adequacy of antenatal health care: a national cross-sectional study in Mexico. Bull World Health Organ. 2016;94:452–61. Directorate of Health Services, Government of Madhya Pradesh. Health Institutions. In: Directorate of Health Services, Government of Madhya Pradesh. https://www.health.mp.gov.in/en/department-section/health-institutions . Accessed 23 May 2023. Donabedian A. The quality of care. How can it be assessed? 1988. In: PubMed. https://pubmed.ncbi.nlm.nih.gov/9372740/ . Accessed 23 May 2023. World Health Organization. Standards for improving quality of maternal and newborn care in health facilities. WHO. 2016. ISBN: 9789241511216. Pan W. Akaike’s information criterion in generalized estimating equations. Biometrics. 2001;57:120–5. Cui J. QIC program and model selection in GEE analyses. Stata J. 2007;7(2):209–20. https://doi.org/10.22004/ag.econ.119269 . International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), India, 2019-21: Satna. Mumbai: IIPS; 2021. Mansukhani R, Shakur-Still H, Chaudhri R, Bello F, Muganyizi P, Kayani A, et al. Maternal anaemia and the risk of postpartum haemorrhage: a cohort analysis of data from the WOMAN-2 trial. Lancet Glob Health. 2023;11:e1249–59. Stevens G, Paciorek C, Flores-Urrutia M. et. National, regional, and global estimates of anaemia by severity in women and children for 2000–19: pooled analysis of population-representative data. Lancet Glob Health. 2022;10:e627–39. World Health Organization. Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health. ISBN 978 92 4 150222 1. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: World Health Organization; 2016. PMID: 28079998. Hodgins S, D’Agostino A. The quality-coverage gap in antenatal care: toward better measurement of effective coverage. Glob Health Sci Pract. 2014;2:173–81. Miteniece E, Pavlova M, Shengelia L, Rechel B, Groot W. Barriers to accessing adequate maternal care in Georgia: a qualitative study. BMC Health Serv Res. 2018;18. Yadav A, Sahni B, Kumar D, Bala K, Kalotra A. Effect of Women’s and Partners’ Education on Maternal Health-care Services Utilization in Five Empowered Action Group States of India: An analysis of 13,443 Women of Reproductive Age. Int J Appl Basic Med Res. 2021;11:231. Das J, Gertler PJ. Variations in practice quality in five low-income countries: a conceptual overview. Health Aff (Millwood). 2007;26. Lee HY, Rana MJ, Kim R, Subramanian SV. Small Area Variation in the Quality of Maternal and Newborn Care in India. JAMA Netw Open. 2022;5. Additional Declarations Competing interest reported. PB is the Executive Chair of EI; IF is a paid employee of EI but has no competing interests. DE and CF received research grants funding from EI but have no competing interests. SS is employed on this research grant but has no competing interests. SK and HR receive research funding from EI but have no competing interests. PR, RN, and MG declare a potential competing interest due to the involvement of the NICE Foundation (an independent organization) which is involved in programs intervening with women and children in rural and urban Telangana (previously Andhra Pradesh) and Rajasthan. Cite Share Download PDF Status: Published Journal Publication published 23 Mar, 2026 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 07 Oct, 2024 Editor assigned by journal 07 Oct, 2024 Submission checks completed at journal 07 Oct, 2024 First submitted to journal 06 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5211700","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":363140773,"identity":"73bfab5d-9aa3-4a80-8ff3-8551c6f005d7","order_by":0,"name":"Siddharudha Shivalli","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABNUlEQVRIie3RMUvDQBTA8XccxOWySiTYfoVXAqXSgl/lDocsRQpdOkiIBNIltGuLX8JsjikP6uIHCEREv0EmaRDEXEXBtNrV4f4QSCA/7h0PwGT6j3FAd/uS1w8LHYAjHmblCOTXH3iYcBauFghS/EbgJ4Et4eIP0p7ytBhdPalZET2z6q6n5hG7pgEGl+fHGSs3QF7zCLLG/cV6rJaPa+T2g6MWxEIaIo2FK/lJAtRtEi66rrCkus0lchY7HnySTCWuhHpmGjQHizR518QvWVWTtiY9DDThb3sIUE3sWJMhgh07LdSkPl0TS5+yM5i+iz2T3jIfjkiTTk1WCZJKChWfJeg3r9+eU1qIV3k6y/30pYoD0bqPqNxMAjW9uaB8M+l3wt3FfJc1vvWa9izSZDKZTAf7AIRecvRxl1X+AAAAAElFTkSuQmCC","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":true,"prefix":"","firstName":"Siddharudha","middleName":"","lastName":"Shivalli","suffix":""},{"id":363140774,"identity":"bdb93116-706d-4a55-a674-a5abb615bc07","order_by":1,"name":"Ila Fazzio","email":"","orcid":"","institution":"Effective Intervention, London","correspondingAuthor":false,"prefix":"","firstName":"Ila","middleName":"","lastName":"Fazzio","suffix":""},{"id":363140775,"identity":"44df6aa0-5f2e-4363-8c25-7d7d0c7b2e16","order_by":2,"name":"Diana Elbourne","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Diana","middleName":"","lastName":"Elbourne","suffix":""},{"id":363140777,"identity":"09618d05-7251-4948-a99e-e67973c2d396","order_by":3,"name":"Sridevi Karnati","email":"","orcid":"","institution":"GH Training and Consulting, Hyderabad","correspondingAuthor":false,"prefix":"","firstName":"Sridevi","middleName":"","lastName":"Karnati","suffix":""},{"id":363140778,"identity":"35b36f59-0d8b-44f5-a65a-2ac5eb6fcba7","order_by":4,"name":"Harshavardhan Reddy","email":"","orcid":"","institution":"GH Training and Consulting, Hyderabad","correspondingAuthor":false,"prefix":"","firstName":"Harshavardhan","middleName":"","lastName":"Reddy","suffix":""},{"id":363140779,"identity":"aa326af5-7ef0-415a-ac74-bbefb37b3908","order_by":5,"name":"Padmanabh Reddy","email":"","orcid":"","institution":"NICE Foundation, Hyderabad","correspondingAuthor":false,"prefix":"","firstName":"Padmanabh","middleName":"","lastName":"Reddy","suffix":""},{"id":363140780,"identity":"5a374919-428d-47bf-b248-68e5db842176","order_by":6,"name":"Rakhi Nair","email":"","orcid":"","institution":"NICE Foundation, Hyderabad","correspondingAuthor":false,"prefix":"","firstName":"Rakhi","middleName":"","lastName":"Nair","suffix":""},{"id":363140781,"identity":"e82b3779-1a2e-4774-b09d-339a9dd71fef","order_by":7,"name":"Madan Gopal","email":"","orcid":"","institution":"NICE Foundation, Hyderabad","correspondingAuthor":false,"prefix":"","firstName":"Madan","middleName":"","lastName":"Gopal","suffix":""},{"id":363140782,"identity":"28c15afb-7f4c-49ad-b735-a48786788bef","order_by":8,"name":"Peter Boone","email":"","orcid":"","institution":"Effective Intervention, London","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Boone","suffix":""},{"id":363140783,"identity":"77478700-2528-4f5e-91ac-6b44a61c5b18","order_by":9,"name":"Chris Frost","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Chris","middleName":"","lastName":"Frost","suffix":""}],"badges":[],"createdAt":"2024-10-06 07:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5211700/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5211700/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-026-08925-5","type":"published","date":"2026-03-23T16:12:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":105756118,"identity":"10c0dd61-1b92-4d34-992a-df8c0c34e3df","added_by":"auto","created_at":"2026-03-30 16:35:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1219113,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5211700/v1/f433b5d7-c964-4c3b-a11d-bd499cbb9161.pdf"}],"financialInterests":"Competing interest reported. PB is the Executive Chair of EI; IF is a paid employee of EI but has no competing interests. DE and CF received research grants funding from EI but have no competing interests. SS is employed on this research grant but has no competing interests. SK and HR receive research funding from EI but have no competing interests. PR, RN, and MG declare a potential competing interest due to the involvement of the NICE Foundation (an independent organization) which is involved in programs intervening with women and children in rural and urban Telangana (previously Andhra Pradesh) and Rajasthan.","formattedTitle":"Quality of antenatal care provision in rural villages of Satna district, Madhya Pradesh, India: a quantitative formative study to help the development of an evidence-based contextualised complex health intervention of the CHAMPION2 cluster randomized trial","fulltext":[{"header":"Background","content":"\u003cp\u003eIn the last two decades, India witnessed a significant drop in overall maternal (384 to 97 per 100,000 livebirths from 2000-20) and neonatal (38 to 23\u0026middot;5 per 1000 livebirths from 2000-17) mortality rates [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This is mainly attributed to substantial improvement in the coverage of essential maternal and child health services[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and various incentive-driven strategic initiatives under the National Health Mission (1,2). However, the magnitude of decline in mortality rates has been below the predicted levels [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, there have been growing inequalities in these mortality rates within and across the Indian states [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. If the current mortality trends were to continue, India may not achieve the Sustainable Development Goal targets by 2030 for maternal (\u0026lt;\u0026thinsp;70/100,000 livebirths) and neonatal (\u0026lt;\u0026thinsp;12/1000 livebirths) mortality[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] without further interventions particularly in poorly performing states [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to a pooled analysis of nationally representative surveys, 78.1% of maternal deaths in India occurred in facilities, among women who planned to deliver at a health facility and 40.6% of maternal deaths had complications before the onset of labour [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In this analysis, obstetric haemorrhage (47.2%) followed by pregnancy-related infections (12%) and hypertensive disorders of pregnancy (6.7%) were the leading causes of maternal deaths, indicating delayed or missed diagnosis and/or poor management of underlying medical conditions during antenatal care (ANC) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to a comprehensive district-level analysis of neonatal mortality trends in India, 80% of neonatal deaths occurred within 7 days of birth [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Low birth weight and short gestation (child and maternal malnutrition) were the predominant risk factors to which 82.8% (95I CI: 77.6\u0026ndash;88.4) of the neonatal deaths could be attributed [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In India (and low- and middle-Income countries, LMICs), poor quality of care was an important driver of excess mortality (i.e., mortality in excess of what would be expected relative to the reference case fatality level) in 61% of neonatal conditions[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] This excess mortality may be addressed by improving the quality of health care across the continuum of care from pregnancy to delivery[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTimely ANC with adequate and comprehensive content is a vital component in the continuum of care of pregnant women and babies for early management of complications, sensitizing women to recognize the danger signs, importance of breastfeeding and institutional delivery. Existing evidence suggests that with adequate coverage and quality of maternal and newborn healthcare, resource limited LMICs like India can avert 71% and 54% of neonatal deaths and maternal deaths, respectively [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Previous studies from India have highlighted the poor quality of maternal and child health care [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Additionally, the quality of care received is associated with women\u0026rsquo;s socio-demographic factors such as age, caste category, literacy, and socio-economic status [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Therefore, to further accelerate reductions in maternal and newborn mortality, it is critical to improve the quality of care while considering these socio-demographic factors in India [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the substantial interstate variations in quality of ANC[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and in maternal deaths [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], state-specific and socio-culturally contextualised strategies are needed [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A study investigating the effectiveness of a package of maternal and child health interventions (community health promotion and medical provision and impact on neonates (CHAMPION2)) is being implemented in the Satna district of Madhya Pradesh to help inform future strategy in Madhya Pradesh [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. CHAMPION2 is a cluster randomized trial wherein 196 villages (clusters) are randomized to receive either the health (CHAMPION2 for pregnant women) or education (STRIPES2 (Support To Rural India\u0026rsquo;s Public Education) for early primary school children) intervention. Villages receiving the health intervention are controls for the education intervention, and vice versa. Further details of the CHAMPION2/STRIPES2 trial are published elsewhere [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMadhya Pradesh is a state with high maternal (173/1,00,000 live births) and neonatal (29/1000 live births) mortality [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. At the planning stage of the trial, we did not find any studies from Madhya Pradesh (other than a secondary analysis of NFHS-4 (National Family Health Survey-4 2015-16)[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] comprehensively assessing the quality of ANC provision to help align the ongoing RMNCH\u0026thinsp;+\u0026thinsp;A (Reproductive, Maternal, Newborn, Child, and Adolescent Health) strategy[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] to the local context in Madhya Pradesh. Given the importance of quality of ANC provision for the success of the intervention, and to help development of a contextualised (i.e., adapting the intervention to fit the specific social, cultural, and economic conditions of the target population or community) the package of interventions in CHAMPION2 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], we conducted a cross-sectional study with the following objectives:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo assess the quality of provision of ANC in rural villages of Satna district using four aspects of care (i.e., skilled care, timeliness, number and content of ANCs) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo explore reasons given by women if uptake of care was not adequate.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo investigate the factors associated with the quality of provision of ANC in rural villages of Satna district.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo help inform the development of an evidence-based contextualised package of maternal and child health interventions for the CHAMPION2 trial [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSatna is one of the 55 districts in Madhya Pradesh state with an estimated population of about 2.62 million. Rural villages constitute 79% of the district\u0026rsquo;s population with a predominantly agrarian economy. There are 10 \u003cem\u003eTehsils\u003c/em\u003e (administrative subdivision in a district) and 2125 villages in Satna district. The public healthcare system in Satna consisted of 309 sub-centres, 47 primary health centres (PHCs), seven community health centres (CHCs), two civil hospitals (CH), and one district hospital (DH) [\u003cspan\u003e29\u003c/span\u003e]. At village level, Auxiliary Nurse Midwives (ANM) and Accredited Social Health Activists (ASHA) render maternal and child health services under the RMNCH\u0026thinsp;+\u0026thinsp;A strategy, which is a key component of the National Health Mission [\u003cspan\u003e27\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign and participants\u003c/strong\u003e: This cross-sectional study was conducted in 50 of the 196 villages that were subsequently randomised to receive either the CHAMPION2 (health) or the STRIPES2 (education) intervention in the trial [\u003cspan\u003e25\u003c/span\u003e]. The 50 villages were selected using stratified random sampling with stratification according to the nearest Community Health Centre to the village. In the 196 trial villages, a woman was considered eligible for the trial if she was a resident of the village, married, aged less than 50 years, neither she nor her husband had a family planning operation (i.e. tubectomy or vasectomy) and consented to participate. As part of the trial baseline enumeration in 2017 (prior to selection of villages for this study) potentially eligible women had been asked whether they had given birth in the previous year. Approximately one year later we returned to all women in the 50 selected villages, who were both eligible for the trial and had earlier reported a birth in the year prior to enumeration. These women were asked to participate in the present study, and then asked questions relating to their most recent birth. This most recent birth must have been in the two years preceding the date of interview for this study: but could have occurred after the one reported at enumeration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size and sampling framework\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePragmatically we aimed to include all the women eligible for this study in 50 randomly selected villages.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of quality of provision of ANC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAssessment of the quality of care is complex and requires a multidimensional approach. Using a system-based model, the quality of care is assessed under three domains i.e., structure, process, and outcome [\u003cspan\u003e30\u003c/span\u003e]. The World Health Organization (WHO) further expanded the \u0026lsquo;process\u0026rsquo; domain into two linked dimensions of \u0026lsquo;provision of care\u0026rsquo; and \u0026lsquo;experience of care\u0026rsquo; [\u003cspan\u003e31\u003c/span\u003e]. Heredia-Pi et al. [\u003cspan\u003e28\u003c/span\u003e] used four aspects of \u0026lsquo;provision of care\u0026rsquo; to assess the adequacy of ANC in Mexico i.e., skilled care, timeliness, sufficiency, and appropriate content of care.\u003c/p\u003e\n\u003cp\u003eIn the present study, to inform the development of a contextualised evidence-based package of maternal and child health interventions in the CHAMPION2 trial [\u003cspan\u003e25\u003c/span\u003e], we focused on \u0026lsquo;provision of care\u0026rsquo; i.e., skilled care, timeliness, number of ANCs, and appropriate content of care to assess the quality of ANC [\u003cspan\u003e28\u003c/span\u003e]. These four aspects were defined as:\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eSkilled care: received ANC by a doctor, ANM, nurse or midwife.\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003eTimeliness: received first ANC visit in the first trimester of pregnancy.\u003c/p\u003e\n\u003c/span\u003e\u003cspan\u003e\n \u003cp\u003eNumber of ANCs: at least four ANCs completed during pregnancy.\u003c/p\u003e\n\u003c/span\u003e\u003cspan\u003e\n \u003cp\u003eContent of ANC: Based on the criteria used by previous studies [\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e28\u003c/span\u003e], we considered that ANC content as \u0026ldquo;appropriate\u0026rdquo; if at least 7 out of 8 of the following procedures or processes of care were given to a woman: (1) measurement of weight; (2) blood pressure; (3) urine test (4) abdominal examination (with or without a machine); (5) tetanus vaccination; (6) blood test (to assess anaemia and possibly parasite and other infections); (7) consumed iron-folic acid (IFA) for at least 100 days. (8) counselling on healthy eating, personal hygiene, adequate sleep and rest during the day, and no smoking/drinking alcohol.\u003c/p\u003e\n\u003c/span\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome measure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe quality of provision of ANC was considered as \u0026lsquo;adequate\u0026rsquo; if a woman satisfied all the above-mentioned four aspects of care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe developed a structured questionnaire based on the latest WHO guidelines and manuals by the National Health Mission (NHM), India to assess the ANC details and to explore the factors associated with access to ANC.\u003c/p\u003e\n\u003cp\u003eTwo language experts translated the English questionnaire to Hindi and SiS back translated to English. SK, HR, and SiS trained 12 enumerators over a period of 5 days for data collection using the Hindi version of the questionnaire. All the enumerators pilot tested the questionnaire in two non-study villages. Each interview lasted for 30\u0026ndash;40 minutes. The trained enumerators conducted face-to-face interviews of eligible women using the structured questionnaire from November to December 2018.\u003c/p\u003e\n\u003cp\u003eTwo data entry operators independently entered the data from the completed questionnaires into a data management system set-up by Sealed Envelope Ltd, London (\u003cspan\u003e\u003cspan\u003ewww.sealedenvelope.com\u003c/span\u003e\u003c/span\u003e). A data entry supervisor reviewed and resolved any discrepancies in the entered data.\u003c/p\u003e\n\u003cdiv id=\"Sec2\"\u003e\n \u003ch2\u003eStatistical analysis\u003c/h2\u003e\n \u003cp\u003eWe used descriptive statistics to summarise the sample characteristics. 95% confidence intervals for proportions were constructed using robust (Huber-White) standard errors that allowed for clustering.\u003c/p\u003e\n \u003cp\u003eLogistic regression models, with robust (Huber-White) standard errors that allowed for clustering, were used to separately relate woman\u0026rsquo;s age at interview (continuous), caste (4-level categorical: scheduled caste, scheduled tribe, other backward class, general category) and education status (5-categorical: No schooling, primary, middle, high school/higher secondary, graduate and above) to a binary variable indicating adequate quality of ANC provision.\u003c/p\u003e\n \u003cp\u003eIn India, both women\u0026rsquo;s and their husbands\u0026rsquo; education levels are strongly associated with the quality of ANC provision [\u003cspan\u003e17\u003c/span\u003e\u0026ndash;\u003cspan\u003e20\u003c/span\u003e]. Women and /or husband with better education level, are more likely receive adequate quality of ANC provision [\u003cspan\u003e17\u003c/span\u003e\u0026ndash;\u003cspan\u003e20\u003c/span\u003e]. Three measures of education status were considered i) woman\u0026rsquo;s education, ii) husband\u0026rsquo;s education and iii) maximal education (highest of i) and ii)). Participants with missing education status were omitted from models. P-values from Wald tests (with joint tests for categorical variables) and from trend tests (education level variables only) were computed.\u003c/p\u003e\n \u003cp\u003eSimultaneous inclusion of woman\u0026rsquo;s and husband\u0026rsquo;s education in multivariate models induces collinearity because they are highly associated with one another. Accordingly, we first fitted three multivariable logistic regression models, each including age, caste and one of the three education variables. Each of these was then extended by including a three-level categorical variable indicating the relative education of the couple (husband more educated, same level of education, wife more educated). Participants missing either maternal or husband\u0026rsquo;s education status were omitted from models. Robust standard errors that allowed for clustering were used in all models. P-values from Wald tests (with joint tests for categorical variables) and from trend tests (education level variables only) were computed. The fits of nested models (i.e., pairs of models where one model contains a subset of the predictor variables in the other model but no additional variables) were compared using Wald tests. The fits of non-nested models (i.e., pairs of models where each model contains at least one predictor variable not included in the other model) were compared using the Quasi-Likelihood information criteria (a variant of Akaike\u0026rsquo;s information criterion suitable for use with robust standard errors) [\u003cspan\u003e32\u003c/span\u003e, \u003cspan\u003e33\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eStata version 16 (StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC) was used to perform the analyses.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 1054 eligible women identified in the 50 villages, 797 completed the interview, 128 were not in the village, 115 gave birth more than 2 years before the interview date, 13 did not give consent, and one was a duplicate. Of these 797 women, four did not deliver a live-birth and one reported data on a birth born more two years before the survey, so the analysis is restricted to 792 women. The mean age of these women was 24.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5 years and almost all of them were Hindus by religion (99.6%). Only 14.8% women and 9.2% of husbands, had no schooling. Nearly half of them belonged to either Scheduled Caste or Scheduled Tribe (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic profile of women in rural villages of Satna district, Madhya Pradesh, India (N\u0026thinsp;=\u0026thinsp;792)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMin, Max\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWoman\u0026rsquo;s age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.3 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18, 42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eEducation status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigher-secondary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot Known\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHindu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e789\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eCaste-category\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScheduled Caste\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScheduled Tribe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther Backward Class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral category\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eHusband\u0026rsquo;s education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigher Secondary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot Known\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eQuality of antenatal care (ANC) provision to women in rural villages of Satna district, Madhya Pradesh, India (N\u0026thinsp;=\u0026thinsp;792)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspect of quality of ANC provision\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkilled health care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e783\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98.9 (97.9, 99.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTimeliness (ANC in first trimester)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e596\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.3 (71.1, 79.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of ANCs (at least four visits)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e582\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73.5 (69.1, 77.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppropriateness in ANC content\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e224\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.3 (23.3, 33.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall adequacy of quality of ANC provision\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e168\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e21.2 (16.8, 25.6)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMost of the women (770, 97.2%) sought ANC from the public (government) healthcare facilities. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the various aspects of quality of ANC provision. Only 21.2% (95% CI 16.8, 25.6) of the women had \u0026lsquo;adequate\u0026rsquo; quality of ANC provision i.e., received ANC from a skilled health personnel, first ANC visit within the first trimester, completed at least 4 ANC visits and with appropriate ANC content. This inadequate quality of ANC provision was mainly due to insufficient procedures or processes of care received during ANC (28.3%, 95% CI 23.3, 33.2). The following proportions of women received the various procedures or processes of care received during ANC: weight measured (95.2%), blood pressure recorded (92.3%), abdomen examined (with or without a machine) (72.9%), received tetanus vaccination (98.6%), urine tested (68.3%), blood tested (89.3%), consumed IFA for at least 100 days (17.0%) and counselled on key ANC issues (30.4%).\u003c/p\u003e \u003cp\u003eOnly two women did not seek any care from a skilled health person for ANC. Of these, one woman stated that the nearest health facility was too far away, and a vehicle was not available. The other woman stated that she was in a different town for work. The following reasons were given by the women who did not complete their first ANC within the first trimester and/or attended less than four ANC visits: they didn\u0026rsquo;t think they needed early or more ANC (51% and 64%, respectively), they didn\u0026rsquo;t know they could go (37.6% and 18.1%), they didn\u0026rsquo;t have time (11.3% and 17.6%), the health facility was too far away (11.3% and 15.7%) and they were out of the village (13.9% and 13.3%). The reasons were not mutually exclusive.\u003c/p\u003e \u003cp\u003ePoor compliance with 100 days of IFA tablet intake was mainly attributed to the fact that women were not given the IFA supplements (34%) and did not feel well when they started taking them (42%). Other reasons for poor compliance with IFA intake were as follows (not mutually exclusive): the woman was not told to take IFA for at least 100 days (14.7%), she received the tablets but forgot to take them (14%), she did not feel IFA intake was necessary (8.1%), and she reported that that she had a previous bad experience with IFA intake (5%).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the unadjusted associations between socio-demographic characteristics and the binary \u0026lsquo;quality of ANC provision\u0026rsquo; indicator. There was no statistically significant evidence of an association with age but there was borderline statistically significant evidence of an association with caste, and strong evidence of an association with education, whether that of the woman or husband. In the analysis of the maximal (amongst woman and husband) education level, the odds of adequate quality of ANC provision were similar in the three lowest education categories and markedly increased in those receiving at least high school education.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eUnadjusted associations between socio-demographic characteristics of women and adequate quality of ANC provision in rural villages of Satna district, Madhya Pradesh, India (N\u0026thinsp;=\u0026thinsp;792)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSocio-demographic characteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eAdequate quality of provision of ANC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eYes (N\u0026thinsp;=\u0026thinsp;168)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eNo (N\u0026thinsp;=\u0026thinsp;624)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoman\u0026rsquo;s age (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.01\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e (0.97, 1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eCaste-category\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScheduled Caste\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.0591\u003c/p\u003e \u003cp\u003e(joint test)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScheduled Tribe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.50 (0.29, 0.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther Backward Class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.90 (0.60, 1.35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral category\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.24 (0.65, 2.35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eWoman\u0026rsquo;s\u003c/p\u003e \u003cp\u003eeducation\u003c/p\u003e \u003cp\u003estatus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.61 (0.35, 1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.0084\u003c/p\u003e \u003cp\u003e(joint test)\u003c/p\u003e \u003cp\u003e0.0007\u003c/p\u003e \u003cp\u003e(trend test)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.46 (0.25, 0.85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh/higher secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.24 (0.88, 1.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGraduate and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.85 (1.09, 7.44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eHusband\u0026rsquo;s education\u003c/p\u003e \u003cp\u003estatus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.75 (0.36, 1.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003cp\u003e(joint test)\u003c/p\u003e \u003cp\u003e0.0029\u003c/p\u003e \u003cp\u003e(trend test)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.99 (0.59, 1.66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh/higher secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.73 (1.24, 2.42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGraduate and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.60 (1.46, 4.64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eMaximal\u003c/p\u003e \u003cp\u003eeducation\u003c/p\u003e \u003cp\u003estatus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.11 (0.45, 2.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003cp\u003e(joint test)\u003c/p\u003e \u003cp\u003e0.0138\u003c/p\u003e \u003cp\u003e(trend test)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.99 (0.50, 1.95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh/higher secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.19 (1.51, 3.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGraduate and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.20 (1.69, 6.08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eThe odds ratio for age relates to a one-year increase in age.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eOmitted from analyses.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn the education adjusted analyses relating socio-demographic characteristics to the binary \u0026lsquo;quality of ANC provision\u0026rsquo; indicator there was no statistically significant evidence of an association with age or with caste after adjustment for education, whether that of the woman, husband, or the maximal level. As measured using the quasi-likelihood information criteria (QIC), the best fitting of the adjusted models included the maximal level of education along with age and caste (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). As in the unadjusted analysis, the odds of the adequate quality of ANC provision were similar in the three lowest education categories and markedly increased in those receiving at least high school education. In an extended model there was no evidence that odds of adequate quality of ANC provision differed if just the woman or husband had received the maximal education level (odds ratio\u0026thinsp;=\u0026thinsp;1.02 (95% CI 0.71, 1.49) for the comparison between families where just the woman had reached this level and families where both had; odds ratio\u0026thinsp;=\u0026thinsp;0.91 (95% CI 0.60, 1.40) for the comparison between families where just the husband had reached this level and families where both had). Models where just the woman\u0026rsquo;s education (QIC\u0026thinsp;=\u0026thinsp;812.375) and just the husband\u0026rsquo;s education (QIC\u0026thinsp;=\u0026thinsp;814.531) was included fitted less well than the model with their maximal level of education (QIC\u0026thinsp;=\u0026thinsp;808.21). For both such models, extensions provided some evidence that where the other partner had a higher level of education the odds of adequate quality of ANC provision were increased, providing additional support for the hypothesis that is the maximal level of education among the couple that is key.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMutually adjusted associations between socio-demographic characteristics of women and adequate quality of ANC provision in rural villages of Satna district, Madhya Pradesh, India (N\u0026thinsp;=\u0026thinsp;786)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocio-demographic characteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoman\u0026rsquo;s age (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.02 (0.98, 1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eCaste-category\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScheduled Caste\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003cp\u003e(joint test)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScheduled Tribe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.67 (0.36, 1.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther Backward Class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.92 (0.60, 1.40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral category\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.98 (0.53, 1.81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eMaximal education status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.11 (0.40, 3.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.0041\u003c/p\u003e \u003cp\u003e(joint test)\u003c/p\u003e \u003cp\u003e0.0537\u003c/p\u003e \u003cp\u003e(trend test)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.05 (0.53, 2.08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh/higher secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.06 (1.35, 3.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGraduate and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.83 (1.47, 5.48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides deeper insights concerning the quality of ANC provision across four aspects of the process of care in a high priority district of Madhya Pradesh, India. The following salient findings emerged from our analysis. First, only 21.2% of women in rural villages of Satna district received ANC that was of 'adequate' quality. Second, inadequate quality of ANC provision was primarily due to inappropriate ANC content (i.e., various procedures and processes) delivered by care providers. Notably, women\u0026rsquo;s poor compliance with IFA intake for at least 100 days and lack of counselling by care providers on the key aspects of ANC emerged as the main issues. Women with no early and/or fewer than four ANCs thought they didn\u0026rsquo;t need ANC sufficiently early or frequently, or not knowing they could access ANC. Third, a woman educated to at least high school level (or whose husband had been) was more likely to receive adequate quality of ANC provision than a woman from a family when neither had been educated to this level.\u003c/p\u003e \u003cp\u003eA previous survey[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and some studies[\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] reported \u0026lsquo;full ANC\u0026rsquo; if a woman had four or more ANCs, received at least one tetanus injection, and took IFA for 100 or more days. However, unlike the present study, \u0026lsquo;full ANC\u0026rsquo; criteria do not consider \u0026lsquo;skilled care\u0026rsquo;, \u0026lsquo;timeliness\u0026rsquo;, and \u0026lsquo;appropriate content of care\u0026rsquo; while assessing the quality of provision of ANC, which is an important limitation. Similar to the present study, a secondary analysis of NFHS-4 data using all the four aspects of care reported that very low proportion (about 16%) of women in Madhya Pradesh received adequate quality of ANC provision [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. As in this study, appropriate ANC content was the least satisfied aspect care provision in other studies in India [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although nearly three-quarters of women had at least 4 ANC visits, only 28.2% of women received ANC with appropriate content, suggesting missed opportunities by the healthcare providers or women to render or receive all the procedures/process of ANC.\u003c/p\u003e \u003cp\u003ePregnant women\u0026rsquo;s poor compliance to IFA intake for at least 100 days is a pan-India issue (30.3% in NFHS-4 (2015-16) and 54% in NFHS-5 (2019-21)) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], with compliance worse in rural areas (40.2% in NFHS-5 (2019-21)) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In the latest nationwide survey (NFHS-5), compliance to IFA intake during pregnancy in Satna district was 41.3% (urban and rural combined) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], which is much higher than in our study (where all villages are rural) (17%). Our study findings suggest that in rural villages of Satna district IFA compliance has multiple causes i.e., lack of adequate supply (input indicator of quality of care), lack of counselling of pregnant women regarding the importance of IFA intake and the fact that initial side effects of IFA are reversible, and that women forgot to take them (process indicators of quality of care). Given that gestational anaemia is a major public health issue in Madhya Pradesh (prevalence of 52.8%) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and postpartum haemorrhage is the most common cause of maternal mortality in India [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], co-existing anaemia (particularly \u0026lsquo;severe\u0026rsquo; anaemia) increases the risk of death or maternal near miss [\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Hence, it is vital to ensure IFA compliance in pregnancy to improve maternal and child health outcomes. In addition, lack of counselling on key ANC related issues was another major issue in this and one other study [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] during ANC, this being vital in empowering women to take necessary actions for a positive pregnancy experience and to prevent adverse birth outcomes [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this and other studies [\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], at least four ANC visits during pregnancy was considered as adequate according to the national guidelines. The new WHO ANC model recommends at least eight ANC visits during pregnancy [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. However, based on the inadequacy in quality of ANC provision in this and other studies in India [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], increasing the minimum number of ANC visits may not translate into the desired health outcomes unless the quality of ANC provision is addressed [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, woman\u0026rsquo;s age (as a continuous variable) showed \u0026ldquo;small and non-significant\u0026rdquo; association with receiving ANC of adequate quality. Older women may have had more babies (the fact that we don\u0026rsquo;t consider parity in our analysis is a limitation) and could impact on our result in several ways. Previous studies in India reported that women of adolescent age were less likely to receive ANC of adequate quality [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, when compared to primigravidae, multiparous women were less likely to receive ANC of adequate quality [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Miteniece et al,[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] reported increased confidence from previous pregnancy and childbirth experience, constraints of time and resources, poor prior experience with the health system and financial barriers as potential reasons for inadequate ANC quality provision in multiparous women.\u003c/p\u003e \u003cp\u003eRegarding woman\u0026rsquo;s caste, we did see some evidence (albeit not normally statistically significant) of an association but, adjustment for education renders the effects smaller and not statistically significant, suggesting that education plays a mediating role here. In this study, woman/husband with higher education were more likely to receive ANC of adequate quality. Previous Indian studies have highlighted those women with higher education status (or whose husband has higher education status) are more likely to receive ANC of adequate quality [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. According to Das et al., women and/or their husband who had a higher level of education were more likely to seek ANC from competent health professionals when compared to those with lower educational levels [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. A secondary analysis of NFHS-4 data[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] in five Indian states including Madhya Pradesh reported that the interaction of husband\u0026rsquo;s higher education with women\u0026rsquo;s primary education shows a \u0026lsquo;substitution effect\u0026rsquo; in the use of ANC services. Another secondary analysis of NFHS-5 data reported that quality of maternal and newborn care in India displayed a greater variation between smaller areas within districts [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. One of the mechanisms could be clustering of these key socio-demographic characteristics (education, wealth, caste, etc.), which tend to cluster more densely at the household or small area level [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Despite the statistical significance of the association between higher education and receipt of adequate ANC, only around a third of women (111/394) who had (or whose husband had) been educated to at least High/Higher secondary level received adequate quality of ANC provision, suggesting that any intervention aimed at improving ANC should not be restricted to those with lower levels of education.\u003c/p\u003e \u003cp\u003eContextualising the CHAMPION2 intervention: Maternal and child health intervention package in the CHAMPION2 trial [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] consisted of community health promotion, community mobilisation with women\u0026rsquo;s groups in the form of participatory learning and action (PLA), provision of nurse-led fixed-day services and participatory discussion groups (PDGs) with pregnant women, and facilitation of referrals of mothers and neonates to community health centres or civil hospitals. After randomisation of villages in the CHAMPION2 trial, the intervention team conducted quantitative and qualitative appraisals in the intervention villages to help identify key areas in need of improvement through interviews and focus groups with local women, healthcare providers and village elders. These appraisals by the intervention team and the findings of this study substantiated our approach in contextulisation of key components of CHAMPION2 intervention. For health promotion and demand generation, a health awareness campaign was launched in the villages, targeting all the community members to promote maternal and neonatal health knowledge. Focus groups and \u003cem\u003eNukkad Nataks\u003c/em\u003e (village-level street plays) were conducted for the campaign, which were adapted based on local customs to convey important maternal and child health messages to communities. Further, we planned to allow all the village women to participate in the PLA sessions focussing on improving women\u0026rsquo;s health knowledge, encouraging greater use of available services, other key aspects of maternal and child health, and providing women with a forum to discuss solutions to important maternal and neonatal health issues.\u003c/p\u003e \u003cp\u003eAs a part of CHAMPION2 intervention, refresher training of nurses was conducted to improve the implementation of various components of ANC content. Nurses were also trained to conduct participatory discussion groups (PDGs) with pregnant women during ANC sessions to discuss key issues. In refresher training for nurses, we emphasised on all the processes/procedures of ANC, ensuring an adequate IFA supply and counselling on various key ANC issues including IFA compliance (i.e., explaining and reassuring initial temporary side effects and benefits of daily intake). PDGs included various key topics including the importance of ANC, diet in pregnancy and after delivery, importance of IFA intake, etc. Nurses were advised to share the relevant information with PLA teams based on their experiences or events during ANC and PDG sessions so that these could be discussed at the next PLA session with village women.\u003c/p\u003e\n\u003ch3\u003eStrength and limitations\u003c/h3\u003e\n\u003cp\u003eThe study\u0026rsquo;s main strength was the comprehensive assessment of the quality of ANC provision across all four aspects of care in the eligible population. A limitation was that the quality of ANC provision assessment was based on women\u0026rsquo;s recall. Hence, we could not verify all the responses. We did not collect data on women\u0026rsquo;s parity at the time of this study, which may be associated with quality of ANC provision. Also, this study focussed only on the quality of ANC provision as insufficient information was available for postnatal and neonatal care provision across all the four aspects of care.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOverall, the quality of ANC provision in rural villages of Satna district was inadequate, which was primarily due to inappropriate content of ANC. The education level women or their husbands of at least high school and above increased the odds of receiving adequate quality of ANC. Findings of this study substantiated our approach in contextualisation of key components of maternal and child health intervention package in the CHAMPION2 cluster randomised trial. It is likely that inadequate quality of ANC provision in similar settings will also be related to content of ANC, and that contextualised health promotion, demand generation, and community mobilisation activities as well as refresher training will be helpful in improving the quality of ANC provision in similar rural settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eantenatal care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAuxiliary Nurse Midwife\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASHA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAccredited Social Health Activist\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecivil hospitals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHAMPION2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecommunity health promotion and medical provision and impact on neonates\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecommunity health centres\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003edistrict hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEAG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmpowered Action Group\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eprimary health centre\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRMNCH\u0026thinsp;+\u0026thinsp;A\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e(Reproductive, Maternal, Newborn, Child, and Adolescent Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTRIPES2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esupport to rural India\u0026rsquo;s public education system and impact on numeracy and literacy scores\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ethics committees of L V PRASAD Eye Institute, Hyderabad, India (LEC 02-16-008) and the London School of Hygiene and Tropical Medicine (LSHTM Ethics Ref: 10482) have approved this study as a part of the CHAMPION2/STRIPES2 cluster randomized trial protocol. We have obtained the necessary approvals from Indian Council of Medical Research (ICMR), New Delhi, and from the Department of Health \u0026amp; Family Welfare of the government of Madhya Pradesh. The study complies with the Declaration of Helsinki, local laws, and the International Conference on Harmonisation Good Clinical Practice (ICH-GCP). We obtained written informed consent (signature or thumbprint) from all the women participants for their voluntary participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the participants agreed that all individual information collected during interviews would be used only for research purposes and in ways that would not reveal their identity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available as the main study (CHAMPION2/STRIPES2 trial) is not yet complete but, will later be available from Ila Fazzio ([email protected]) on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePB is the Executive Chair of EI; IF is a paid employee of EI but has no competing interests. \u0026nbsp;DE and CF received research grants funding from EI but have no competing interests. \u0026nbsp; \u0026nbsp;SS is employed on this research grant but has no competing interests. SK and HR receive research funding from EI but have no competing interests. PR, RN, and MG declare a potential competing interest due to the involvement of the NICE Foundation (an independent organization) which is involved in programs intervening with women and children in rural and urban Telangana (previously Andhra Pradesh) and Rajasthan.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEffective Intervention NGO\u003c/p\u003e\n\u003cp\u003eEffective Intervention, Centre for Economic Performance, London School of Economics, UK. Email: [email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed extensively to the design of the study, and have contributed to, commented on, and approved the final manuscript. In addition, SK, HR, and SiS provided training, field, and data support for designing the research component. CF\u0026nbsp;performed\u0026nbsp;the statistical analysis. SiS prepared the first version of the manuscript. CF, DE, and IF revised the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the work of Mr. A Jaipal Reddy (for his work during data collection), all the teams of supervisors and enumerators (who conducted the interviews), the data entry team (who processed all the paper forms) and Sealed Envelope team: Tony Brady and Piotr Gawron (for designing the database).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. India has achieved groundbreaking success in reducing maternal mortality. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/southeastasia/news/detail/10-06-2018-india-has-achieved-groundbreaking-success-in-reducing-maternal-mortality\u003c/span\u003e\u003cspan address=\"https://www.who.int/southeastasia/news/detail/10-06-2018-india-has-achieved-groundbreaking-success-in-reducing-maternal-mortality\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 16 Feb 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatia M, Dwivedi LK, Banerjee K, Bansal A, Ranjan M, Dixit P. Pro-poor policies and improvements in maternal health outcomes in India. BMC Pregnancy Childbirth. 2021;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDandona R, Kumar GA, Henry NJ, Joshua V, Ramji S, Gupta SS, et al. Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000-17. Lancet. 2020;395:1640\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOffice of the Registrar General \u0026amp; Census Commissioner, India. SAMPLE REGISTRATION SYSTEM (SRS)-SPECIAL BULLETIN ON MATERNAL MORTALITY IN INDIA 2018-20. In: SAMPLE REGISTRATION SYSTEM-MATERNAL MORTALITY BULLETIN. Office of the Registrar General \u0026amp; Census Commissioner, India. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://censusindia.gov.in/nada/index.php/catalog/44379\u003c/span\u003e\u003cspan address=\"https://censusindia.gov.in/nada/index.php/catalog/44379\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 3 Apr 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-4), 2015-16: India. Mumbai: IIPS; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), 2019-21: India: Volume II. Mumbai: IIPS; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeh C, Sharma A, Ram U, Fadel S, Correa N, Snelgrove JW, et al. Trends in maternal mortality in India over two decades in nationally representative surveys. BJOG. 2022;129:550.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health and Family Welfare, India. Indicator Framework. In: SDG Health India. Ministry of Health and Family Welfare, India. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sdghealthindia-mohfw.in/indicator-framework\u003c/span\u003e\u003cspan address=\"https://sdghealthindia-mohfw.in/indicator-framework\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 15 Jun 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKruk ME, Gage AD, Joseph NT, Danaei G, Garc\u0026iacute;a-Sais\u0026oacute; S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet. 2018;392:2203\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018;6:e1196\u0026ndash;252.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet. 2014;384:347\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMony PK, Krishnamurthy J, Thomas A, Sankar K, Ramesh BM, Moses S et al. Availability and Distribution of Emergency Obstetric Care Services in Karnataka State, South India: Access and Equity Considerations. PLoS ONE. 2013;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWendt AS, Stephenson R, Young MF, Verma P, Srikantiah S, Webb-Girard A et al. Identifying bottlenecks in the iron and folic acid supply chain in Bihar, India: A mixed-methods study. BMC Health Serv Res. 2018;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSabde Y, Diwan V, Randive B, Chaturvedi S, Sidney K, Salazar M et al. The availability of emergency obstetric care in the context of the JSY cash transfer programme in Madhya Pradesh, India. BMC Pregnancy Childbirth. 2016;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArsenault C, Jordan K, Lee D, Dinsa G, Manzi F, Marchant T, et al. Equity in antenatal care quality: an analysis of 91 national household surveys. Lancet Glob Health. 2018;6:e1186\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Neil S, Naeve K, Ved R. An Examination of the Maternal Health Quality of Care Landscape in India. Cambridge, MA; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh L, Dubey R, Singh S, Goel R, Nair S, Singh PK. Measuring quality of antenatal care: a secondary analysis of national survey data from India. BJOG. 2019;126:7\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar G, Choudhary TS, Srivastava A, Upadhyay RP, Taneja S, Bahl R, et al. Utilisation, equity and determinants of full antenatal care in India: analysis from the National Family Health Survey 4. BMC Pregnancy Childbirth. 2019;19:327.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh P, Singh KK, Singh P. Maternal health care service utilization among young married women in India, 1992\u0026ndash;2016: trends and determinants. BMC Pregnancy Childbirth. 2021;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh L, Bubey R, Singh PK, Nair S, Rai RK, Rao MVV et al. Coverage of Quality Maternal and Newborn Healthcare Services in India: Examining Dropouts, Disparity and Determinants. Ann Glob Health. 2022;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDandona R, Majumder M, Akbar M, Bhattacharya D, Nanda P, Kumar GA et al. Assessment of quality of antenatal care services in public sector facilities in India. BMJ Open. 2022;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Quality of care. In: Health topics \u0026ndash; India. World Health Organization. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/india/health-topics/quality-of-care\u003c/span\u003e\u003cspan address=\"https://www.who.int/india/health-topics/quality-of-care\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 23 May 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHorwood G, Opondo C, Choudhury SS, Rani A, Nair M. Risk factors for maternal mortality among 1.9 million women in nine empowered action group states in India: secondary analysis of Annual Health Survey data. BMJ Open. 2020;10:e038910.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar S. Reducing maternal mortality in India: policy, equity, and quality issues. Indian J Public Health. 2010;54:57\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgarwal A, Banerji R, Boone P, Elbourne D, Fazzio I, Frost C, et al. Protocol for a cluster randomised trial in Madhya Pradesh, India: community health promotion and medical provision and impact on neonates (CHAMPION2); and support to rural India\u0026rsquo;s public education system and impact on numeracy and literacy scores (STRIPES2). Trials. 2020;21:569.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), India, 2019-21: Madhya Pradesh. Mumbai: IIPS; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Health Mission. RMNCH\u0026thinsp;+\u0026thinsp;A. In: National Health Mission. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nhm.gov.in/index1.php?lang=1\u0026amp;level=1\u0026amp;sublinkid=794\u0026amp;lid=168\u003c/span\u003e\u003cspan address=\"https://nhm.gov.in/index1.php?lang=1\u0026amp;level=1\u0026amp;sublinkid=794\u0026amp;lid=168\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 23 May 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeredia-Pi I, Servan-Mori E, Darney BG, Reyes-Morales H, Lozano R. Measuring the adequacy of antenatal health care: a national cross-sectional study in Mexico. Bull World Health Organ. 2016;94:452\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDirectorate of Health Services, Government of Madhya Pradesh. Health Institutions. In: Directorate of Health Services, Government of Madhya Pradesh. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.health.mp.gov.in/en/department-section/health-institutions\u003c/span\u003e\u003cspan address=\"https://www.health.mp.gov.in/en/department-section/health-institutions\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 23 May 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonabedian A. The quality of care. How can it be assessed? 1988. In: PubMed. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/9372740/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/9372740/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 23 May 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Standards for improving quality of maternal and newborn care in health facilities. WHO. 2016. ISBN: 9789241511216.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePan W. Akaike\u0026rsquo;s information criterion in generalized estimating equations. Biometrics. 2001;57:120\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCui J. QIC program and model selection in GEE analyses. Stata J. 2007;7(2):209\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.22004/ag.econ.119269\u003c/span\u003e\u003cspan address=\"10.22004/ag.econ.119269\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), India, 2019-21: Satna. Mumbai: IIPS; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMansukhani R, Shakur-Still H, Chaudhri R, Bello F, Muganyizi P, Kayani A, et al. Maternal anaemia and the risk of postpartum haemorrhage: a cohort analysis of data from the WOMAN-2 trial. Lancet Glob Health. 2023;11:e1249\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStevens G, Paciorek C, Flores-Urrutia M. et. National, regional, and global estimates of anaemia by severity in women and children for 2000\u0026ndash;19: pooled analysis of population-representative data. Lancet Glob Health. 2022;10:e627\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health. ISBN 978 92 4 150222 1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: World Health Organization; 2016. PMID: 28079998.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHodgins S, D\u0026rsquo;Agostino A. The quality-coverage gap in antenatal care: toward better measurement of effective coverage. Glob Health Sci Pract. 2014;2:173\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiteniece E, Pavlova M, Shengelia L, Rechel B, Groot W. Barriers to accessing adequate maternal care in Georgia: a qualitative study. BMC Health Serv Res. 2018;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYadav A, Sahni B, Kumar D, Bala K, Kalotra A. Effect of Women\u0026rsquo;s and Partners\u0026rsquo; Education on Maternal Health-care Services Utilization in Five Empowered Action Group States of India: An analysis of 13,443 Women of Reproductive Age. Int J Appl Basic Med Res. 2021;11:231.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas J, Gertler PJ. Variations in practice quality in five low-income countries: a conceptual overview. Health Aff (Millwood). 2007;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee HY, Rana MJ, Kim R, Subramanian SV. Small Area Variation in the Quality of Maternal and Newborn Care in India. JAMA Netw Open. 2022;5.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"antenatal care, formative study, India, quality, provision of care, rural, village","lastPublishedDoi":"10.21203/rs.3.rs-5211700/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5211700/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSince 2005, maternal and newborn deaths have declined in India. Nonetheless, if the current mortality trends continue, India may not achieve the Sustainable Development Goal targets without enhancing the quality of care across the continuum from pregnancy to delivery, particularly in poorly performing states. This study aimed to help the development of an evidence-based contextualised CHAMPION2 trial package of maternal and child health (being implemented in rural villages of Satna district, India) by assessing the quality of, and the factors associated with antenatal care (ANC) provision across four aspects of care and exploring reasons if uptake of care was inadequate.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a cross-sectional study in 50 of 196 villages in the CHAMPION2 cluster randomized trial in Satna district, Madhya Pradesh, India before randomization. We interviewed 792 women, who were eligible for the trial and had given birth in the previous two years from the interview date. We assessed the quality of ANC provision across four aspects of care (i.e., skilled care, timeliness (ANC in first trimester), number of ANC visits (at least four), and content of care) and explored reasons given by women if the uptake of care was inadequate. The quality of ANC provision was considered \u0026lsquo;adequate\u0026rsquo; if all the four aspects of care were judged sufficient. We conducted logistic regression analyses to determine the socio-demographic factors associated with the adequate quality of ANC provision.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOnly 21.2% of women received ANC provision of 'adequate' quality (skilled care:98.9%, timeliness: 75.3%, minimum four ANCs: 73.5%, and appropriate content of care: 28.3%). The inadequate quality was primarily due to inappropriate content of care particularly, poor compliance with iron-folate intake for at least 100 days and no counselling by healthcare providers on key ANC issues. The odds of receiving adequate quality ANC were increased when either the woman or husband was educated to at least high school level.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe quality of ANC provision in the study setting was inadequate. The quality of care was emphasised in refresher training for nurses in the CHAMPION2 trial and health promotion, demand generation, and community mobilisation activities were locally contextualised.\u003c/p\u003e","manuscriptTitle":"Quality of antenatal care provision in rural villages of Satna district, Madhya Pradesh, India: a quantitative formative study to help the development of an evidence-based contextualised complex health intervention of the CHAMPION2 cluster randomized trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-29 16:13:25","doi":"10.21203/rs.3.rs-5211700/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-07T12:29:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-07T04:33:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-07T04:31:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-10-06T07:19:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"80dbf752-cf9c-484a-9987-2356fbec42fb","owner":[],"postedDate":"October 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T16:35:40+00:00","versionOfRecord":{"articleIdentity":"rs-5211700","link":"https://doi.org/10.1186/s12884-026-08925-5","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2026-03-23 16:12:43","publishedOnDateReadable":"March 23rd, 2026"},"versionCreatedAt":"2024-10-29 16:13:25","video":"","vorDoi":"10.1186/s12884-026-08925-5","vorDoiUrl":"https://doi.org/10.1186/s12884-026-08925-5","workflowStages":[]},"version":"v1","identity":"rs-5211700","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5211700","identity":"rs-5211700","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}