This study deepens our awareness about the wide-ranging and persistent factors of inequality in the utilization of maternal healthcare services. We attempted to measure the inequalities in the utilization of maternal health care services among rural women in India by capturing the dimension of full antenatal care, skill attendants at birth, and postnatal care. We found clear evidence of inequalities in the utilization of full ANC, SBA, and PNC at the state level as well as by the various explanatory variables. India is a country with huge diversity, and the states differ enormously in terms of geography, demography, language, and social norms. Regional disparities among India’s major states are both large and persistent [
23]. A study found the strong indications of a pervasive increase in economic inequality during the nineties in India [
24]. A study [
25] examined the pattern of regional inequalities in India during 1970–92 and found the inter-state inequalities to be rising in India in the economic sphere. Another study [
26] analyzed inequality and poverty in India within the context of caste-based discrimination and found the caste-driven inequalities in India. A study [
27] explored the patterns of economic discrimination faced by Dalits and minorities like Muslims in India and analyzed the discrimination in access to education and primary health-care services.
Inequalities in the utilization of full ANC, SBA & PNC
We have found clear evidence of inequalities in the utilization of full antenatal care. Mother’s education is one of the important factors contributing to the inequality in the utilization of full ANC. The utilization of full antenatal care increases with the increase in the levels of mother’s education. Higher educated women are more likely to use full ANC than uneducated women. A study [
10] on rural adolescent women in India found that women with higher education were three times more likely to utilize the full antenatal care than uneducated women. Many studies conducted in India [
28‐
30], and other countries [
31‐
33] have found that mother’s education is one of the most important determinants of antenatal care utilization. High education standards among women enhance the likelihood of communication with the husband and other family members on health-related issues [
12], and this helps in the higher utilization of antenatal care services. Educational attainment is critical in imparting the feelings of self-worth and self-confidence which are critical in bringing the changes in health-related behaviour [
34]. Accumulation of wealth in the household is another factor contributing to the inequality in the utilization of full antenatal care. Our result suggests that the women in richest wealth quintile are more likely to utilize the full antenatal care than the women in poorest wealth quintile. The utilization of full antenatal care is higher among the subsequent wealth quintile as compared to the previous category of wealth quintile. This evidence is consistent with the other studies [
35‐
37]. Another study in the Indian context also found that women in the richest wealth quintile were more likely to use full antenatal care than the poorest women [
10].
We have found that social factors like religion and caste also play an important role in promoting inequalities in the utilization of antenatal care services. The study found that Muslim women and Scheduled caste women are less likely to utilize the antenatal care services. Our findings are in line with other studies [
10,
12]. A study [
13] conducted in rural North India found the widespread caste-wise inequalities in the utilization of antenatal care; another study [
38] found the same level of caste-wise inequalities in South India. Our study highlights the role of birth order in determining the inequality in the utilization of antenatal care. The higher the birth order, the lower will be the antenatal care. A study [
39] highlighted the limited care during the antenatal period for the second and higher order births than for the first birth. Another study [
12] have also shown this relationship between birth order and the utilization of maternal healthcare services. A study found higher parity to be associated with the reduced use of antenatal care [
13]. This can be attributed to the fear of first birth. Women, delivering the baby for the first time, are more cautious about their pregnancy and are more likely to face difficulties during the labour than women with high parity [
40]. A study concludes that women with higher parity develop confidence after delivering the first birth, and they use their experience and knowledge from previous pregnancies [
10], thus limiting the use of maternal healthcare services for the higher birth order.
We have found that exposure to mass media has a positive association with the utilization of antenatal care services. Our study accords with other studies from Bangladesh [
41], Nepal [
42], and India [
43,
44] where exposure to mass media had positive influence with an increased antenatal care visit. A study [
12] found that women with a high degree of exposure to mass media were more likely to received antenatal check-up. We found the inter-state inequalities in the utilization of full antenatal care. The utilization of full antenatal care is higher among the women in the Southern states of India as compared to women in other states of India. A study also found the regional variation where full antenatal care utilization was found to be less likely in other states of India as compared to the Southern states of India [
10]. Various studies in India found that the utilization of antenatal care services is higher among the mothers in the Southern states of India as compared to women in other states [
28].
Our study found the clear evidence of inequalities in the utilization of skilled attendants at birth. Increasing age of the mother and increasing birth order have a negative association with the utilization of SBA, whereas, increasing education level among women and exposure to mass media have a positive association with the utilization of SBA. The inequalities in the use of SBA are more prominent among uneducated women as compared to women with higher education and among the women who have no access to mass media than to the women who have access to mass media. About one-third of the inequality in the utilization of SBA is contributed by the exposure to mass media among women. Thus it can be understood that mass media exposure is the main contributor to the inequality in the utilization of SBA. A study conducted in Nepal found that mass media information were partially successful in increasing the use of maternal health services [
45]. Another study based on Uttarakhand, a state in India, found that a higher percentage of women with exposure to mass media opted for safe delivery than women who were not exposed to mass media [
46]. The exposure to mass media is positively associated with the utilization of maternal healthcare services. The exposure to mass media mitigate against the cultural barriers for using healthcare services, and it is one of the important sources of information regarding the beneficial impact of care for maternal and child health [
47].
The result of our study suggests that a higher percentage of richest women utilize SBA than the poorest women. Wealth is one of the strongest determinants of skilled birth attendant’s use, with the poor people being at a disadvantage [
48]. Our result is consistent with other studies related to the inequalities in the utilization of SBA and wealth distribution [
49]. Social factors like religion and caste are significant factors affecting utilization of skill attendants at birth. Our study found the religion-wise inequalities in the utilization of skill attendants at birth, where Muslim women are least likely to utilize this service. A study opined that the possibility of the purdah system may be a significant contributor to the low level of utilization of SBA among Muslim women [
48]. Purdah system is a physical segregation of the sexes, where women are required to cover their bodies and conceal their form [
50]. Our study also found caste-wise inequalities in the utilization of SBA, where lesser women from Scheduled Caste, Scheduled Tribes, and Other Backward Classes utilize the SBA. Previous studies have also shown that fewer women from SC, ST, and OBC had an attendant present at birth [
12,
29,
51] as compared to women from other caste. Our study found that with the higher order of birth, the utilization of SBA declines which is consistent with other study [
48].
The findings show women’s age, birth order, education level, and mass media exposure as significant factors of inequality affecting postnatal care utilization. The results found that with an increase in women’s age and birth order, the likelihood of utilization of postnatal care decreases; whereas with an increase in education level, wealth, and access to mass media exposure, the likelihood of utilization of postnatal care increases. The result found that mass media exposure is the biggest contributor to the inequalities in the utilization of postnatal care. A study conducted in Indonesia found that low household wealth index and low maternal education levels are the factors affecting poor response to postnatal care [
52]. A study in India found that women’s education, social group, mass media exposure, wealth quintile, birth order are the significant factors affecting postnatal care utilization [
53]. Our study found that religion and caste are also important factors in determining the inequalities in the utilization of postnatal care. A study found that women from Scheduled Caste, Scheduled Tribes, and Other Backward Classes were less likely to seek postnatal care [
53].