title: Factors associated with maternal healthcare services utilization in nine high focus states in India: a multilevel analysis based on 14 385 communities in 292 districts.
abstract: BACKGROUND
  Studies have often ignored examining the role of community- and district-level factors in the utilization of maternity healthcare services, particularly in Indian contexts. The Social Determinants of Health framework emphasizes the role of governance and government policies, the measures for which are rarely incorporated in single-level individual analysis. This study examines factors associated with maternal healthcare utilization in nine high focus states in India, which shares more than half of the total maternal deaths in the country; accounting for individual-, household-, community- and district-level characteristics.
  
  
  METHODS
  The required data are extracted from the third round of the nationally representative District Level Household and Facility Survey conducted during 2007-08. Multilevel analyses were applied to three maternity outcomes, namely, four or more antenatal care visits, skilled birth attendance and post-natal care after birth.
  
  
  RESULTS
  Results show that along with individual-/household-level factors, community and district-level factors influence the pattern of utilization of maternal healthcare services significantly. At the community level, the odds of maternal healthcare utilization were lower in rural areas and in communities with a high concentration of poor and illiterate women. Moreover, the average population coverage of primary health centres (PHCs), availability of labour room in PHC and percentage of registered pregnancies were significant factors at the district level that influenced the use of maternity care services. The study also found a strong association between the extent of previous use of maternal healthcare and its effect on subsequent usage patterns.
  
  
  CONCLUSIONS
  This study highlights the role of strengthening public health infrastructure at district level in the study area, and promoting awareness about available healthcare services and subsidized schemes in the community. To reach out to rural and underprivileged communities and to apply a participatory approach from the programme officials are issues to delve into.
authors.affiliation: International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai 400 088, India, Department of Humanities and Social Sciences, Indian Institute of Technology Roorkee (IITR), Roorkee 247 667, Uttarakhand, India, Tata Institute of Social Sciences, V N Purav Marg, Deonar, Mumbai 400 088, India and School of Health Systems Studies, Tata Institute of Social Sciences, V N Purav Marg, Deonar, Mumbai 400 088, India prashant_iips@yahoo.co.in.
authors.forename: Prashant Kumar
authors.initials: PK
authors.lastname: Singh
authors.affiliation: International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai 400 088, India, Department of Humanities and Social Sciences, Indian Institute of Technology Roorkee (IITR), Roorkee 247 667, Uttarakhand, India, Tata Institute of Social Sciences, V N Purav Marg, Deonar, Mumbai 400 088, India and School of Health Systems Studies, Tata Institute of Social Sciences, V N Purav Marg, Deonar, Mumbai 400 088, India.
authors.forename: Chandan
authors.initials: C
authors.lastname: Kumar
authors.affiliation: International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai 400 088, India, Department of Humanities and Social Sciences, Indian Institute of Technology Roorkee (IITR), Roorkee 247 667, Uttarakhand, India, Tata Institute of Social Sciences, V N Purav Marg, Deonar, Mumbai 400 088, India and School of Health Systems Studies, Tata Institute of Social Sciences, V N Purav Marg, Deonar, Mumbai 400 088, India.
authors.forename: Rajesh Kumar
authors.initials: RK
authors.lastname: Rai
authors.affiliation: International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai 400 088, India, Department of Humanities and Social Sciences, Indian Institute of Technology Roorkee (IITR), Roorkee 247 667, Uttarakhand, India, Tata Institute of Social Sciences, V N Purav Marg, Deonar, Mumbai 400 088, India and School of Health Systems Studies, Tata Institute of Social Sciences, V N Purav Marg, Deonar, Mumbai 400 088, India.
authors.forename: Lucky
authors.initials: L
authors.lastname: Singh
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D007194:India / Q000453:epidemiology; D000067010:Literacy; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008428:Maternal Mortality; D008875:Middle Aged; D055361:Multilevel Analysis; D011203:Poverty; D011247:Pregnancy; D012111:Residence Characteristics; D012424:Rural Population; D055815:Young Adult
keywords: Antenatal care; India; community; district; high focus states; post-natal care; skilled birth attendance