Factors affecting pregnancy registration in India: does the pregnancy intention matter?

Maternal mortality continues to be high in India, although remarkable improvements have recently been noticed [1]. With a prevalence of 120 per 1000 live births, severe maternal morbidities indicate the equally bad maternal health status of Indian women [2]. Antenatal care (ANC), institutional delivery, and appropriate postnatal care (PNC) are the deterrent factors of maternal morbidity and mortality [3, 4]. An early ANC visit allows for the most effective screening and tests, including correct gestational age determination for proper preterm labor treatment, genetic and congenital diseases screening, folic acid supplementation to lower iron deficiency anemia, and sexually transmitted infections screening and treatment [5]. It is thus critical to identify and register women early in their pregnancies to ensure the utilization of suggested ANC services [6]. Early pregnancy registration is the starting point of Indian government’s maternal healthcare delivery system [7]. Delays in pregnancy registration influence obtaining appropriate treatment, immunization, and vitamin supplementation, all critical in reducing pregnancy-related problems. Policy initiatives to increase pregnancy registration are well in place universally in India. Pregnant women are given Mother and Child Protection (MCP) Cards and safe motherhood booklets [7], and some states have added initiatives along with this MCP card to increase pregnancy registration. For example, Karnataka has introduced the Thayi card and the mother and child tracking systems (MCTS). Pregnant women get the Thayi card with a unique identification number when registered with a female health assistant in their area, enabling socioeconomically disadvantaged women to avail of ANC and delivery services from registered private hospitals free of cost [8]. Similarly, Tamil Nadu has a Pregnancy and Infant Cohort Monitoring and Evaluation System (PICME) both in urban and rural areas [9].

Women in low-and-middle-income countries disguise their pregnancy during the first few months due to various socio-cultural behaviors and attitudes that make early pregnancy registration difficult [10, 11]. According to a study in Maharashtra, fear of losing the baby owing to black magic and the casting of evil eyes by jealous neighbors and those with malicious intentions are the causes of delayed disclosure and registration of pregnancy [12]. Women are again reluctant to inform the grassroot level health workers i.e., Accredited Social Health Activist (ASHA) and Anganwadi Worker (AWW) about their pregnancy at an early stage, as it would require them to attend the village health facility and thus, make their pregnancy evident to everyone, which they did not want [12]. ASHA, a selected trained female member from the community, works as an interface between the community and the public health system. AWW, also known as Integrated Child Development Services (ICDS) workers, are grassroots workers within the Integrated Child Development Services scheme, which aims to meet the essential health and nutritional needs of children, adolescent girls, and lactating mothers. The ASHA and AWW are the first contact points for health care seeking, mainly for women living in rural areas. Impolite health staff who do not respect confidentiality are barriers to early ANC utilization [10]. Literature reveals that women’s education is critical in obtaining early pregnancy registration [13, 14]. The average gestational age at registration and first-trimester appointment is closely connected for women with lower parity and those that have previously experienced stillbirths [13]. However, some studies show no link between a previous unfavorable obstetric history and the length of pregnancy at registration [15]. Morbidity in the index pregnancy and nulliparity favor early appointment considerably [15]. Despite considering pregnancy registration in the first trimester important, many women do not practice it, especially with increasing parity [16]. A 2009 study found that women with unplanned or mistimed pregnancies were more likely to delay starting prenatal care until after the first trimester than planned pregnancies [17]. The role of the husband behind the failure of pregnancy registration also become crucial as women are often dependent on their husband’s decisions [12]. A recent study found that socially marginalized groups, i.e., Scheduled Caste (SC), Scheduled Tribe (ST), and Other Backward Classes (OBC) have taken a longer time and late initiated the first ANC check-up (registration of pregnancy) than Non-SC/ST/OBC [18]. Most tribal women from East Khasi Hills failed to receive full ANC because they did not register early enough [19]. This late enrollment in the first ANC services among the lower caste groups might result in high infant and maternal morbidity and mortality [20]. One of the main causes of India’s unequal access to healthcare, low utilization of health services, and poor health outcomes are caste-based exclusion and discrimination [21, 22].

Early pregnancy registration contributes to improved maternal and child health. However, to our knowledge, no empirical study using nationally representative data has explored the correlates of pregnancy registration in India. Moreover, the relationship between pregnancy intention of last birth and pregnancy registration is inadequately explored. This study assesses the determinants of pregnancy registration, especially the role of the intention of the last birth in the country.