Spatial inequalities in quality antenatal care in India: a district-level analysis

The study examines the spatial distribution and determinants of quality antenatal care (Q-ANC) utilization across districts of India using data from the National Family Health Survey (NFHS-5, 2019-21). Q-ANC is operationalized as the receipt of at least five out of seven essential antenatal care components, capturing the adequacy of service content during pregnancy. District-level estimates were analyzed using spatial statistical techniques, including Global and Local Moran's I, spatial regression models, and geographically weighted regression (GWR), to identify clustering patterns and spatial heterogeneity in determinants. The findings reveal substantial regional disparities in Q-ANC utilization, with higher coverage concentrated in southern India and lower levels in northern and northeastern districts. Significant positive spatial autocorrelation (Moran's I ≈ 0.60, p < 0.001) indicates strong geographic clustering. Spatial regression results show that intended pregnancy, adverse pregnancy outcomes, mass media exposure, and utilization of public healthcare facilities are positively associated with Q-ANC, whereas higher parity and greater concentration of socially disadvantaged and minority populations are negatively associated. The GWR model demonstrates considerable spatial variation in these relationships, explaining up to 80% of the observed variation across districts. These findings highlight that the determinants of maternal healthcare utilization are not spatially uniform and are shaped by localized socio-demographic and health system factors. The study underscores the need for geographically targeted policy interventions to address persistent regional inequalities in maternal healthcare access and quality in India.