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Introduction <p>Antenatal care (ANC) is central to improving maternal and neonatal outcomes; however, substantial geographic inequalities in utilisation persist in India, particularly at sub-state levels. Evidence on spatial clustering of four or more ANC visits (ANC4+) at the district level remains limited.</p> Purpose/Significance <p>This study examines district-level spatial patterns of ANC4 + coverage in Assam and Tamil Nadu and explores associations with maternal care pathway and socio-demographic factors across contrasting health system contexts.</p> Materials &amp; Methods <p>A cross-sectional ecological analysis was conducted using district-level data from NFHS-5 (2019–21). Global Moran’s I assessed spatial autocorrelation, and Local Indicators of Spatial Association (LISA) identified local clusters. Spearman’s correlation examined non-spatial associations.</p> Results <p>Mean ANC4 + coverage was 52.3% (SD = 12.9) in Assam and 90.6% (SD = 5.4) in Tamil Nadu. Assam demonstrated strong positive spatial autocorrelation (Moran’s I = 0.623), with significant high-high and low-low clusters. Tamil Nadu demonstrated weak, non-significant positive spatial autocorrelation (Moran’s I = 0.124), with only limited localized clustering. In Assam, ANC4 + correlated positively with early ANC initiation (r<sub>s</sub>=0.679) and postnatal care within 2 days (r<sub>s</sub>=0.588), and negatively with early marriage (r<sub>s</sub>=–0.542). In Tamil Nadu, insurance coverage (r<sub>s</sub>=0.657) and postnatal care within 2 days (r<sub>s</sub>=0.614) were significant ecological correlates, while anaemia showed a negative association (r<sub>s</sub>=–0.525).</p> Discussion and Conclusion <p>ANC4 + coverage demonstrated marked spatial inequality in Assam, whereas Tamil Nadu showed relatively more homogeneous coverage with limited evidence of statewide spatial clustering. Ecological associations with maternal care pathway and socio-demographic indicators differed across states and were consistent with contrasting health system contexts. These findings support geographically targeted, district-level approaches to identify residual inequities and strengthen continuity of maternal care.</p>

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Spatial Inequalities in Utilisation of Four or More Antenatal Care Visits: A District-level Comparative Analysis of Assam and Tamil Nadu

  • 期刊论文

  • 发表日期：

    2026年6月29日

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  • Vaibhav Patwardhan,
  • Apurvakumar Pandya,
  • Priya Kotwani,
  • Geetika Madan Patel

摘要

Introduction

Antenatal care (ANC) is central to improving maternal and neonatal outcomes; however, substantial geographic inequalities in utilisation persist in India, particularly at sub-state levels. Evidence on spatial clustering of four or more ANC visits (ANC4+) at the district level remains limited.

Purpose/Significance

This study examines district-level spatial patterns of ANC4 + coverage in Assam and Tamil Nadu and explores associations with maternal care pathway and socio-demographic factors across contrasting health system contexts.

Materials & Methods

A cross-sectional ecological analysis was conducted using district-level data from NFHS-5 (2019–21). Global Moran’s I assessed spatial autocorrelation, and Local Indicators of Spatial Association (LISA) identified local clusters. Spearman’s correlation examined non-spatial associations.

Results

Mean ANC4 + coverage was 52.3% (SD = 12.9) in Assam and 90.6% (SD = 5.4) in Tamil Nadu. Assam demonstrated strong positive spatial autocorrelation (Moran’s I = 0.623), with significant high-high and low-low clusters. Tamil Nadu demonstrated weak, non-significant positive spatial autocorrelation (Moran’s I = 0.124), with only limited localized clustering. In Assam, ANC4 + correlated positively with early ANC initiation (rs=0.679) and postnatal care within 2 days (rs=0.588), and negatively with early marriage (rs=–0.542). In Tamil Nadu, insurance coverage (rs=0.657) and postnatal care within 2 days (rs=0.614) were significant ecological correlates, while anaemia showed a negative association (rs=–0.525).

Discussion and Conclusion

ANC4 + coverage demonstrated marked spatial inequality in Assam, whereas Tamil Nadu showed relatively more homogeneous coverage with limited evidence of statewide spatial clustering. Ecological associations with maternal care pathway and socio-demographic indicators differed across states and were consistent with contrasting health system contexts. These findings support geographically targeted, district-level approaches to identify residual inequities and strengthen continuity of maternal care.