Why there is underutilization of four and more antenatal care services despite the colossal rise in institutional deliveries in Bihar, India

Despite the colossal rise in institutional delivery (from 20% in 2005–2006 to 64% in 2015–2016), the state of Bihar shows the poorest performance in the country for utilization of four or more antenatal care services (4 or more ANCs) (14%). In this background, the present paper aims to investigate the factors associated with the low uptake of ANCs in Bihar, India. The study analyses a sample of 16,822 women aged 15–49 in Bihar from the fourth round of the National Family Health Survey (NFHS-4) conducted during 2015–2016. Bivariate and multivariate logistic and linear regression analyses are employed to identify the factors associated with the underutilization of 4 or more ANCs in Bihar. Five out of 38 districts of Bihar have more than 20% uptake of 4 or more ANCs while 13 districts have only 7 to 12% of uptake. However, 79% of women had institutional delivery without having 4 or more ANCs. The results from the logistic regression model suggest that mothers who belonged to the richest wealth index (OR = 3.90; 99% CI: 2.98–5.08) and a higher level of education (OR = 3.35; 99% CI: 2.74–4.08) have a greater likelihood of receiving 4 or more ANCs. In order of their importance, focusing on economic, education, and caste inequalities, awareness of pregnancy registration with MCP cards, and avoiding higher-order births are likely to improve the uptake of 4 or more ANCs in Bihar.