Abstract

Background

To further reduce maternal and neonatal mortality, it is essential for mothers and newborns to fully utilize all essential services within the continuum of maternal and newborn care. However, research on maternal and child health services in India has not sufficiently examined geographical disparities in the full utilization of these services and the factors influencing the full utilization, particularly in rural areas. This study aims to address this critical gap.

Methods

Utilizing data from 130,312 mothers collected in the National Family Health Survey-5听(2019鈥�21), this study employed spatial analysis to uncover geographical disparities in the full utilization of the continuum of maternal and newborn healthcare services听in rural India. Additionally, binary logistic regression was used to identify the factors associated with this utilization.

Results

In rural India,听54.3%听mothers recieved听 four or more antenatal care visits, 88.6% received skilled birth attendance, and 75.5% of mothers and 79.8% of newborns received postnatal care within 48听hours of birth. However, only 43.5% mothers-newborn dyads in rural India听utilized all four services of the continuum of maternal and newborn healthcare. There were significant geographical disparities in the full utilization of the continuum of maternal and newborn healthcare听services. Hotspots were primarily identified in districts of southern states, western Maharashtra, and central Odisha, while cold spots were evident in the northeastern states of Arunachal Pradesh, Meghalaya, Assam, and Nagaland, as well as in the Empowered Action Group states of Bihar, Uttar Pradesh, and Jharkhand. Key determinants influencing the full utilization of the continuum of care听in rural India included 听maternal听education, household wealth, parity, health insurance coverage, and exposure to mass media. Specifically, the odds of fully utilizing the continuum of care were significantly lower among women without formal education (adjusted odds ratio鈥�=鈥�0.60, 95% CI鈥�=鈥�0.56鈥�0.65), those from the poorest wealth quintile (0.65, 0.61鈥�0.69), and mothers with six or more children (0.42, 0.37鈥�0.47), compared to mothers with higher education, those in the richest wealth quintile, and mothers with a single child, respectively. Additionally, mothers from the southern region were more than twice as likely (2.11, 1.99鈥�2.20) to fully utilize the continuum of healthcare听services compared to mothers from the northern region.

Conclusion

The significant geographical disparities in the full utilization of maternal and newborn healthcare听services in rural India highlight the necessity for tailored, region-specific interventions. Future programs should focus on addressing the barriers to care by prioritizing vulnerable groups, including those who are poor, uninsured, less educated, adolescents, and women with high parity.

Introduction

Maternal and newborn mortality remains a significant public health challenge globally, particularly in developing countries [1, 2]. Each year, over 4.5听million mothers and newborns lose their lives during pregnancy, childbirth, or in the weeks following birth, which translates to one death every seven seconds [3, 4]. However, these deaths can be significantly reduced through timely and appropriate maternal and newborn care at every stage鈥攆rom preconception through pregnancy, childbirth, and into early childhood [5,6,7]. This approach is known as 鈥渃ontinuum of care鈥� approach in maternal and child health literature and has been acknowledged having a critical role in reducing the maternal and newborn mortality and morbidity [8]. The continuum of care includes a series of essential maternal and child healthcare services, such as at least four Antenatal Care (ANC) visits, delivery by a Skilled Birth Attendant (SBA), and Postnatal Care (PNC) within 48听h for both mothers and newborns. In 2016, the WHO updated its guidelines, recommending a minimum of eight ANC visits to further improve maternal and newborn health outcomes [9,10,11].

In India, significant progress has been made since the government committed to the United Nations Millennium Development Goals (MDGs) in 2000. The Maternal Mortality Ratio (MMR) has declined dramatically, from 560 to 97 per 100,000 live births between 1990 and 2020 [12,13,14]. As the focus shifts to the Sustainable Development Goals (SDGs), India aims to further reduce the MMR to below 70 deaths per 100,000 live births by 2030 [13]. While India successfully met the MDGs related to maternal and child health, challenges persist, particularly in rural areas where accessibility, availability, and affordability of essential healthcare services remain inadequate [15,16,17].

Numerous studies in India have investigated the utilization and determinants of maternal and child healthcare services [18,19,20,21,22,23,24,25,26]. However, many of these studies tend to focus on specific components鈥攕uch as ANC visits, institutional deliveries, deliveries by SBAs, and PNC鈥攔ather than examining these services as a听continuum of care [19]. Previous research has highlighted factors influencing the delivery by SBA, home deliveries, PNC, breastfeeding, and vaccinations [23]. Some studies have highlighted socioeconomic and biodemographic disparities in maternal healthcare utilization across various geographical regions [16, 21]. However, research specifically examining the full utilization of the continuum of maternal and newborn healthcare services in India is limited, especially in rural areas, where over two-thirds of the population resides. It is important to note that rural mothers face unique challenges, including limited accessibility, affordability issues, inadequate healthcare infrastructure, and rising poverty, all of which can hinder their ability to fully utilize these essential services [27, 28].

To address this gap, this study seeks to investigate the geographical disparities and determinants affecting the full utilization of the continuum of maternal and newborn healthcare services in rural India, utilizing data from the most recent National Family Health Survey (NFHS). By identifying districts with suboptimal performance and examining the factors that influence healthcare utilization, our findings will contribute to the formulation of policies designed to enhance both access to and the outcomes of maternal and newborn healthcare in rural areas. This research is vital for advancing equitable healthcare delivery and supporting rural development initiatives.

Methods

Data source

This study leverages data from the NFHS-5, conducted between 2019 and 2021. The NFHS serves as a vital resource for understanding key indicators related to health and well-being across India, focusing on areas such as demographics, socioeconomic status, maternal and child health, reproductive health, and family planning. The sampling methods used in this survey are detailed in the official national report available online [29]. In NFHS-5, interviews were conducted with 724,115 women aged 15鈥�49, gathered from a total of 636,669 households. This extensive coverage included data from 28 states and 8 Union Territories (UTs), representing 707 districts, with a response rate of 97% [29].

In this study, we concentrated on 176,843 mothers from the 724,115 women interviewed, who reported having a live birth in the five years preceding the survey, specifically focusing on their most recent live birth. To ensure a rural focus, we excluded 37,975 mothers residing in urban areas, resulting in a sample of 138,868 rural women. We further eliminated 8,556 mothers due to missing data on age at marriage and social group. Consequently, our final sample consisted of 130,312 mothers aged 15鈥�49 years from rural India.

Dependent variable

The dependent variable in this study is defined as the full utilization of the continuum of maternal and newborn healthcare services, as outlined by the Ministry of Health and Family Welfare, Government of India, and supported by existing literature [20, 29,30,31]. This continuum includes four critical components: a minimum of four ANC visits, delivery assisted by a SBA, and PNC provided within 48听hours of delivery for both the mother and the newborn. Full utilization is indicated by mothers reporting receipt of all these essential components of maternal and newborn healthcare services.

For this analysis, we recoded the continuum variables into binary format. The number of ANC visits was transformed so that a code of 鈥�1鈥� was assigned if a mother completed four or more visits, while 鈥�0鈥� was assigned if she had fewer than four visits. Similarly, delivery by a SBA was coded as 鈥�1鈥� if the delivery was assisted by a doctor, auxiliary nurse midwife, nurse, midwife, or lady health visitor, and 鈥�0鈥� otherwise [29]. PNC for mothers was coded as 鈥�1鈥� if the mother received a postnatal checkup within 48听hours of delivery by a skilled provider, which includes doctors, auxiliary nurse midwives, nurses, midwives, and lady health visitors; it was coded as 鈥�0鈥� if she did not receive such care [29]. Similarly, PNC for newborns was coded as 鈥�1鈥� if the newborn received a postnatal checkup within 48听h of birth听by a skilled provider, and 鈥�0鈥� if not [29]. Mothers and newborns who reported receiving all four components of care were assigned a code of 鈥�1,鈥� indicating full utilization of the continuum of maternal and newborn healthcare services, while those who did not receive all four components听or missed any of these components were coded as 鈥�0.鈥�

Independent variables

We have considered a range of socioeconomic and biodemographic variables such as social group (Scheduled Caste (SC), Scheduled Tribe (ST), Other Backward Classes (OBC), and Others), mothers'听education level (no education, primary, secondary, and higher), religion (Hindu, Muslim, Christian, others), household听wealth quintile (poorest, poorer, middle, richer, richest), mother鈥檚 age in years (15鈥�19 years, 20鈥�24 years, 25鈥�29 years, 30鈥�34 years, 35鈥�39 years, 40鈥�44 years, 45鈥�49 years), age at marriage (married after听18 years, married on or before听18 years, which is also considered as child marriage), mother鈥檚 age at birth (less than 20, 20鈥�34, 35鈥�49 years), parity (1, 2鈥�3, 4鈥�5, 6 or higher), child desired (then, later, no more), ever had terminated pregnancy (no, yes), covered by health insurance (no, yes), frequency of reading newspaper/magazine (no, yes), frequency of listening to radio (no, yes), frequency of watching televisions (no, yes), and region of residence (north, central, east, north east, west, south). The choices of these variables are guided by existing literature on the continuum of maternal and newborn healthcare services utilization [20, 32,33,34].

Statistical analysis

We employed chi-squared test to analyze differences in the full utilization of the continuum of maternal and newborn healthcare services based on selected socioeconomic and biodemographic characteristics in rural India. To identify the factors associated with full utilization of continuum, we used multivariable logistic regression, as our response variable was dichotomous [35]. The level of statistical significance was set at 5%. Variables that were found to be significant in the chi-squared test (p-value鈥�<鈥�0.05) were included in the final logistic regression model, ensuring that no important variables were excluded. The results of the logistic regression are presented as Adjusted Odds Ratios (AOR) alongside their corresponding p-values and 95% Confidence Intervals (CI), with statistical significance defined as p鈥�=鈥�0.05. We assessed multicollinearity among independent variables using Variance Inflation Factors (VIF), confirming that all VIF values were below the threshold of 5, indicating multicollinearity was not an issue (see supplementary file 1). Consequently, all variables were included in the final model. All estimates were adjusted for the sample weights, considering the complex survey design of the NFHS-5. The 鈥荣惫测蝉别迟鈥� command in Stata 16 was used to obtain these estimates.

To assess geographical disparities in the full utilization of continuum of maternal and newborn healthcare services, we utilized a range of spatial statistical methods with the help of ArcGIS 10.5 software. In particular, we applied Global Moran鈥檚 I to detect spatial clustering and autocorrelation within the dataset. This metric evaluates spatial dependence by determining whether similar values are located near each other geographically. A positive Moran鈥檚 I (>鈥�1) indicates a clustered pattern, suggesting that areas of high (or low) utilization are concentrated together, whereas a negative value (<听1)听suggests a dispersed pattern, where high (or low) utilization areas are more evenly distributed across the region.

Next, to identify statistically significant clusters of low utilization in the continuum of maternal and newborn healthcare services, we employed Local Moran鈥檚 I for Cluster and Outlier analysis. This method revealed distinct spatial patterns within the dataset, categorizing districts into four main groups:

Hot spots (high-high clusters)

Districts with high utilization rates that are surrounded by neighboring districts with similarly high rates.

Cold spots (low-low clusters)

Districts with low utilization rates surrounded by neighboring districts with similarly low rates.

High-low outliers

Districts with high utilization rates but located among neighboring districts with low utilization rates.

Low-high outliers

Districts with low utilization rates that are surrounded by neighboring districts with high utilization rates.

Results

Profile of the respondents

Table听1 shows the weighted percentage distribution of mothers who delivered their last child within the five years preceding the survey, categorized by selected background characteristics. The majority of mothers identified as Hindu (77.1%), and approximately half had completed secondary education. About 40% of mothers belonged to OBC. Additionally, about 88% of mothers were aged 20鈥�34 years at the time of childbirth. More than half of the mothers had 2鈥�3 children, and most expressed a desire for children during their pregnancies. Furthermore, approximately 25% had health insurance coverage, while over 75% reported no exposure to newspapersor magazines.

Table 1 Percentage distribution of mothers who reported a live birth within the preceding five years of survey by background characteristics in rural India, NFHS-5 (2019鈥�21)

Differentials in the full utilization of continuum of maternal and newborn healthcare services in rural India

Table听2 provides important insights into maternal and newborn healthcare听services utilization in rural India, based on NFHS-5 data (2019-21). Notably, in rural India听88.6% of deliveries were attended by SBA, indicating good access to skilled care during childbirth. However, only 54.3% of women had the recommended four or more ANC visits, and 75.5% of mothers, along with 79.8% of newborns, received PNC within 48听hours of delivery. Despite these figures, the overall rate of full utilization of the continuum of maternal and newborn healthcare services stands at just 43.5%听in rural India.

Table 2 Utilization of components of continuum of maternal and newborn healthcare services in rural India, NFHS-5 (2019-21)

We also examined how full utilization of continuum of maternal and newborn healthcare services in rural India varied among mothers from different socioeconomic and biodemographic groups (see Table听3). The full utilization of continuum of maternal and newborn healthcare services was lower among mothers who had no formal education (26.3%) than those with higher education (57.9%). Utilization increased with household wealth; for instance, only 26.5% of mothers in the poorest wealth quintile reported full utilization, compared to 58.7% among those in the richest quintile. Among the four social groups, the full utilization of continuum was lowest among the SCs mothers (41%). Nearly half of the mothers who had access to radio, newspapers, or television utilized the full continuum of services. Furthermore, full utilization of听continuum of maternal and newborn healthcare services听decreased with higher parity. For example, the full utilization of the continuum among mothers with six or more children was only 19.4% compared to 51.5% among mothers with one child. Geographically, full utilization of the continuum of these healthcare services was higher in the southern region (69.4%) as compared to the central region (33.3%).

Table 3 Determinants of full utilization of continuum of maternal and newborn healthcare services in rural India, NFHS-5 (2019-21)

Geographic disparities in the full utilization of continuum of maternal and newborn healthcare services in rural India

In rural India, the overall rate of full utilization of maternal and newborn healthcare services is only听43.5%. However, this figure masks significant disparities across different states and UTs (see Fig.听1). Tamil Nadu, a state in the southern part of the country, leads with an impressive 89% of mothers fully utilizing the continuum of maternal and newborn healthcare services. Notably, the full utilization of continuum was below 40% in six of the eight northeastern states, with Nagaland having the lowest at just 7%. The situation is similarly concerning in the Empowered Action Group states, where low rates of full utilization are evident: Bihar at 16%, Jharkhand at 24%, and Uttar Pradesh at 28%. Among the union territories, Lakshadweep stands out with the highest utilization rate at 94%, while Chandigarh records the lowest at 40%.

Fig. 1

State-wise distribution of听full utilization of continuum of maternal and newborn healthcare services in rural听India, NFHS-5 (2019鈥�21)

To examine the detailed spatial patterns, we prepared a district-level map of the full utilization of continuum of maternal and newborn healthcare services among mothers in rural India (see Fig.听2). This illustration reveals significantly greater variation in the full utilization of the continuum at the district level compared to the broader state-level patterns. The full utilization of maternal and newborn healthcare services varied widely across districts, with rates ranging from less than 1% in Balrampur (Uttar Pradesh) and Sahibganj (Jharkhand) to over 80% in Coimbatore (Tamil Nadu) as well as in the Palakkad and Wayanad districts of Kerala.

Fig. 2

District-wise disparities in听full utilization of continuum of maternal and newborn healthcare services in rural India, NFHS-5 (2019鈥�21)

Overall, most districts in Bihar and Nagaland exhibited particularly low utilization rates, with many falling below 20%. Specifically, less than 20% utilization was observed in 64 districts, while 204 districts had a utilization rate between 20 and 40% (see supplementary file 2). In 217 districts, the utilization ranged from 40 to 60%, and 147 districts demonstrated utilization between 60 and 80%. Finally, 65 districts showed high utilization rates of over 80%.

Results of cluster and outlier analysis

To evaluate spatial clustering in the full utilization of continuum across Indian districts, we calculated the Global Moran鈥檚 I value, which yielded an index of 0.66 (p-value鈥�<鈥�0.001) (see supplementary file 3). The index value suggests a strong presence of spatial autocorrelation. To further identify the clusters of high and low utilization, we carried out a cluster and outlier analysis. Figure听3 illustrates the statistically significant hot spots, cold spots, and spatial outliers. Notably, a distinct north-south divide emerges, with southern districts displaying hot spots of full utilization, while central and northeastern districts predominantly exhibit cold spots.

Fig. 3

Spatial clusters and outliers of full utilization of continuum of maternal and newborn healthcare services in听rural India, NFHS-5 (2019-21)

Overall, our analysis identified 115 districts as high-high clusters (hot spots) and 148 districts as low-low clusters (cold spots), with 430 districts categorized as not significant. Additionally, 8 districts were classified as low-high outliers and 6 districts as high-low outliers. Specifically, high-high clusters or hot spots were prevalent in the southern states such as Tamil Nadu, Kerala, southern parts of Karnataka and Andhra Pradesh. There were three other significant high-high clusters covering several districts of coastal Maharashtra, Goa, northwestern coastal Karnataka, western Gujarat, and central Odisha. Conversely, two major low-low clusters or cold spots were observed in northeastern states; one covering large swaths of Arunachal Pradesh and the second covering the districts making the shared border of Meghalaya and Assam and the entire Nagaland. A large continuous cold spot was located in Bihar, Uttar Pradesh, Jharkhand, and some districts in the Bundelkhand region of Madhya Pradesh.

Determinants of full utilization of continuum of maternal and newborn healthcare services听in rural India

Table听3 presents the results of binary logistic regression, revealing key factors associated with full utilization of continuum of maternal and newborn healthcare services in rural India. Education emerged as a significant determinant, with women lacking formal education had 40% lower odds (AOR=鈥�0.60, 95% CI=鈥�0.56鈥�0.65) of fully utilizing continuum of these healthcare听services compared to mothers with higher education. Mothers in the poorest wealth quintile were 35% less likely (0.65, 0.61鈥�0.69) to fully utilize the continuum of maternal and newborn healthcare听services than those in the richest quintile. Additionally, child marriage was negatively associated with the full utilization of the continuum of healthcare听services. Women who married after 18 years of age had 13% higher odds of full utilization of the continuum of these services than those married before 18 (1.13, 1.09鈥�1.17). Older mothers (35鈥�49 years) were 33% more likely to fully utilize the continuum of services compared to adolescent mothers, indicating an increase in services utilization with age. In contrast, mothers with six or more children showed significantly lower odds compared to those with only one child (0.42, 0.37鈥�0.47). Health insurance coverage turned out to be a positive determinant, with insured mothers having 28% higher odds of full utilization of continuum of maternal and newborn healthcare services (1.28, 1.23鈥�1.33). Mothers in the southern region had twice the odds of fully utilizing these services than those in the northern region (2.11, 1.99鈥�2.24).

Discussion

This study examined geographic disparities in the full utilization of continuum of maternal and newborn healthcare services in rural India and attempted to explore factors associated with it. The findings revealed that despite high coverage of delivery听by SBA and PNC for mothers and newborns, the full utilization of continuum of maternal and newborn healthcare services by mothers was disappointingly low in rural India. Less than half of the rural mothers fully utilized the continuum of these services. Furthermore, the study noted significant geographical disparities in the full utilization of the continuum of services at both state and district level. The study also identified several cold spots covering large swaths of northeastern states of Arunachal, Nagaland, Assam, and Meghalaya and central Indian states of Bihar, Jharkhand, and Uttar Pradesh. Additionally, the study revealed that mother鈥檚 education, household wealth, child marriage, parity, desire of child, health insurance coverage, exposure to mass media, and region of residence were found statistically associated with the full utilization of continuum of services in rural India.

Among the various factors, mother鈥檚 education emerged as a critical determinant of utilization of continuum of maternal and newborn healthcare services, with women with higher educational attainment demonstrating a greater likelihood of full utilization of continuum of these services. This could be attributed not only to enhanced health literacy but also to greater autonomy in decision-making within the household and an increased capacity to navigate the intricacies of healthcare system [24, 34, 36,37,38]. Additionally, educated women may be more aware to the benefits of preventative care and more adept at overcoming traditional or cultural barriers to seeking medical assistance, a phenomenon observed in studies across low- and middle-income countries [39, 40].

The study revealed that mothers from poor households were less likely to fully utilize the continuum of maternal and newborn healthcare services听in rural India. Several factors contribute to this issue, primarily revolving around financial constraints. Beyond the direct costs of care, families face significant expenses related to transportation and childcare during health visits, which can deter them from seeking necessary services [41, 42]. Moreover, economic hardship often leads families to prioritize urgent needs, such as food and housing, over healthcare, resulting in inadequate access to essential services. This finding is in line with the previous studies that have noted economic inequalities in the maternal and child healthcare utilization in India [4, 16, 43, 44].

Women who marry before the age of 18 are less likely to utilize the full continuum of maternal and newborn healthcare compared to those who marry later. This finding aligns with existing literature that links early marriage to lower healthcare utilization among women. The reduced utilization among early brides may stem from their lower levels of education, limited income, and diminished autonomy within the household [45, 46]. Additionally, early marriage can restrict access to familial or social support, which is vital for navigating complex healthcare systems鈥攁 theme frequently discussed in studies focused on adolescents [47, 48]. These factors collectively hinder their ability to seek and receive essential healthcare services.

Maternal age was positively related to with the full utilization of continuum of maternal and newborn healthcare services. This was likely reflective of several factors, including increased life experience, higher autonomy within the family, and greater social and familial stability [49, 50]. Older women might also have accumulated more health knowledge over time, enabling them to recognize the importance of fully utilizing the continuum of maternal and newborn care [43, 51]. In contrast, the negative association between higher parity and the full utilization of the continuum of services suggests that mothers with many children may face significant resource constraints. Our study also identified health insurance coverage was positively associated with the full utilization of continuum of services, reducing out-of-pocket expenses and providing a safety net that encourages women to seek care [52].

Exposure to mass media, particularly through radio and television, emerged as a crucial factor positively associated with full utilization of continuum of maternal and newborn healthcare services. Previous studies have highlighted the crucial role of mass media in disseminating health-related information effectively especially in remote rural areas [53, 54]. Community radio stations have proven to be a powerful tool in disseminating health-related information. For instance, the initiative by Radio Namaskar in Odisha broadcasts health messages specifically aimed at rural communities, including maternal and child health information [55].

The last decade has seen a significant surge in mobile phone ownership and internet access in India, creating new opportunities to enhance awareness and improve health service utilization in rural and remote areas. By integrating digital mass media such as mobile phone with traditional platforms such as radio and television, health initiatives can more effectively reach underserved populations. mHealth programs such as Mobile Kunji (mobile guide), Mobile Academy, and Kilkari (a joyful cry of a baby) have proven effective in disseminating vital health information to healthcare workers and mothers. In states such as Rajasthan, Uttar Pradesh, and Karnataka, the Mother and Child Tracking System (MCTS) serves as a vital tool for engaging mothers in their healthcare. By sending timely reminders for health check-ups, immunizations, and other essential services, MCTS enhances communication between healthcare providers and mothers [56]. The adoption of such innovative technological solutions has helped improve the uptake of maternal and child healthcare services in these states [57,58,59,60].

The findings revealed significant geographical disparities in the full utilization of healthcare services at the state level in India, particularly highlighting a clear north-south divide. Southern states generally exhibited higher utilization rates, which could be attributed to better healthcare infrastructure and more effective implementation of government health programs. In contrast, states with lower utilization, such as Bihar, Jharkhand, Uttar Pradesh, and the northeastern states like Arunachal Pradesh, Assam, Meghalaya, and Nagaland, often struggle with inadequate health system resources, limited access to healthcare facilities, and challenges in program execution [22, 61]. The northeastern states face additional obstacles due to geographical isolation, limited connectivity, and rugged terrain [62]. Furthermore, the district-level analysis uncovers notable disparities within states themselves, underscoring the need for targeted interventions that address local needs and barriers to access to maternal and child healthcare services.

A significant strength of our study lies in its emphasis on the full utilization of the continuum of maternal and newborn healthcare, rather than examining individual components such as utilization of services during听pregnancy, delivery, or postnatal services in isolation. Additionally, the use of a NFHS-5 with a large sample size ensures the robustness of our findings and allows for detailed sub-national analyses. Moreover, our employment of cluster and outlier analysis alongside multivariate logistic regression, enables a nuanced understanding of both the coverage and the determinants influencing the full utilization of continuum of maternal and newborn healthcare services听in rural India.

Our study has a few limitations. First, because the NFHS-5 dataset is cross-sectional, we can only identify associations rather than establish causal relationships. Additionally, since the utilization of maternal and newborn healthcare services is self-reported, there is a risk of recall bias. The dataset also lacks information on supply-side factors, such as the accessibility, availability, and quality of healthcare services, which can greatly influence how fully individuals utilize the continuum of care. Understanding these aspects is crucial for gaining a complete picture of healthcare utilization and for pinpointing barriers that may hinder access to essential services. Addressing these gaps in data is vital for enhancing maternal and newborn health outcomes in the future.

Conclusion

The full utilization of the continuum of maternal and newborn healthcare services remains considerably low in rural India, marked by pronounced geographical disparities at both the state and district levels. This reality underscores the urgent need for targeted interventions that specifically address these geographical disparities. Future efforts should prioritize vulnerable populations, including poor, uninsured, less educated, adolescent, and high-parity women, who are often at a greater risk of getting dropped from the continuum of care. Expanding health insurance coverage and strengthening mass media outreach are crucial strategies for improving awareness of available services and enhancing access to care. By tackling these disparities, we can ensure that all women receive the comprehensive support necessary for improved maternal and child health outcomes.