title: Examining inequalities in uptake of maternal health care and choice of provider in underserved urban areas of Mumbai, India: a mixed methods study.
abstract: BACKGROUND
  Discussions of maternity care in developing countries tend to emphasise service uptake and overlook choice of provider. Understanding how families choose among health providers is essential to addressing inequitable access to care. Our objectives were to quantify the determinants and choice of maternity care provider in Mumbai's informal urban settlements, and to explore the reasons underlying their choices.
  
  
  METHODS
  The study was conducted in informal urban communities in eastern Mumbai. We developed regression models using data from a census of married women aged 15-49 to test for associations between maternal characteristics and uptake of care and choice of provider. We then conducted seven focus group discussions and 16 in-depth interviews with purposively selected participants, and used grounded theory methods to examine the reasons for their choices.
  
  
  RESULTS
  Three thousand eight hundred forty-eight women who had given birth in the preceding 2 years were interviewed in the census. The odds of institutional prenatal and delivery care increased with education, economic status, and duration of residence in Mumbai, and decreased with parity. Tertiary public hospitals were the commonest site of care, but there was a preference for private hospitals with increasing socio-economic status. Women were more likely to use tertiary public hospitals for delivery if they had fewer children and were Hindu. The odds of delivery in the private sector increased with maternal education, wealth, age, recent arrival in Mumbai, and Muslim faith. Four processes were identified in choosing a health care provider: exploring the options, defining a sphere of access, negotiating autonomy, and protective reasoning. Women seeking a positive health experience and outcome adopted strategies to select the best or most suitable, accessible provider.
  
  
  CONCLUSIONS
  In Mumbai's informal settlements, institutional maternity care is the norm, except among recent migrants. Poor perceptions of primary public health facilities often cause residents to bypass them in favour of tertiary hospitals or private sector facilities. Families follow a complex selection process, mediated by their ability to mobilise economic and social resources, and a concern for positive experiences of health care and outcomes. Health managers must ensure quality services, a functioning regulatory mechanism, and monitoring of provider behaviour.
authors.affiliation: Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK. g.alcock@ucl.ac.uk.
authors.forename: Glyn
authors.initials: G
authors.lastname: Alcock
authors.affiliation: Society for Nutrition, Education and Health Action (SNEHA), 310, 3rd Floor, Urban Health Center, 60 Feet Road, Dharavi, Mumbai, 400 017, India. sushmita@snehamumbai.org.
authors.forename: Sushmita
authors.initials: S
authors.lastname: Das
authors.affiliation: Society for Nutrition, Education and Health Action (SNEHA), 310, 3rd Floor, Urban Health Center, 60 Feet Road, Dharavi, Mumbai, 400 017, India. neena@snehamumbai.org.
authors.forename: Neena
authors.initials: N
authors.lastname: Shah More
authors.affiliation: Society for Nutrition, Education and Health Action (SNEHA), 310, 3rd Floor, Urban Health Center, 60 Feet Road, Dharavi, Mumbai, 400 017, India. ketaki.hate@snehamumbai.org.
authors.forename: Ketaki
authors.initials: K
authors.lastname: Hate
authors.affiliation: Society for Nutrition, Education and Health Action (SNEHA), 310, 3rd Floor, Urban Health Center, 60 Feet Road, Dharavi, Mumbai, 400 017, India. sharda.more@snehamumbai.org.
authors.forename: Sharda
authors.initials: S
authors.lastname: More
authors.affiliation: Society for Nutrition, Education and Health Action (SNEHA), 310, 3rd Floor, Urban Health Center, 60 Feet Road, Dharavi, Mumbai, 400 017, India. drshpantvaidya@gmail.com.
authors.forename: Shanti
authors.initials: S
authors.lastname: Pantvaidya
authors.affiliation: Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK. d.osrin@ucl.ac.uk.
authors.forename: David
authors.initials: D
authors.lastname: Osrin
authors.affiliation: Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK. a.j.houweling@erasmusmc.nl.|Department of Public Health, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands. a.j.houweling@erasmusmc.nl.
authors.forename: Tanja A J
authors.initials: TA
authors.lastname: Houweling
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D002755:Choice Behavior; D036861:Delivery, Obstetric / Q000523:psychology / Q000706:statistics & numerical data; D004522:Educational Status; D005260:Female; D006297:Health Services Accessibility; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D016304:Hospitals, Private / Q000706:statistics & numerical data; D006801:Humans; D007194:India; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D010298:Parity; D011204:Poverty Areas; D011247:Pregnancy; D012044:Regression Analysis; D012959:Socioeconomic Factors; D062606:Tertiary Care Centers / Q000706:statistics & numerical data; D014505:Urban Population / Q000706:statistics & numerical data*; D035862:Vulnerable Populations / Q000523:psychology / Q000706:statistics & numerical data*; D055815:Young Adult