GeoJournal
https://doi.org/10.1007/s10708-020-10241-0
(0123456789().,-volV)
Geographical variations in postnatal care use and associated
factors in India: evidence from a cross-sectional national
survey
Pintu Paul
 Springer Nature B.V. 2020
Abstract Postnatal care (PNC) period is a critical
phase for survival of mothers and newborn babies.
Understanding spatial heterogeneity is essential for
evidence-based policymaking in high-risk geograph-
ical areas. Moreover, there is a paucity of research on
the utilization of PNC and its geographical inequalities
in India. Therefore, this paper aims to identify the
geographical variations in PNC use and associated
socio-demographic factors among Indian women. A
cross-sectional study was conducted using the
2015–2016 National Family Health Survey (NFHS-
4) data. A total of 190,898 women aged 15–49 years
who had a live birth in the past five years preceding the
survey were utilized in this study. This study assessed
the levels of PNC use across geographical regions,
states, and districts. Moran’s ‘I’ and spatial autocor-
relation were carried out to identify the spatial patterns
of PNC use. Bivariate and multivariate logistic
regressions were employed to examine the factors
associated with PNC utilization. In India, the propor-
tion of PNC usage was 69.1% with marked variations
across geographical regions. Lower use of PNC was
found in the north, central, east, and northeast regions,
while PNC utilization was higher in south, followed by
west region of the country. This study found that
P. Paul (&)
Centre for the Study of Regional Development, School of
Social Sciences, Jawaharlal Nehru University,
New Delhi 110067, India
e-mail: pintupaul383@gmail.com
( 01234567
89().,-volV)
educational attainment of women and household
wealth status was positively correlated with PNC
utilization. Women with higher education were more
likely to receive PNC (adjusted odds ratio [AOR]:
1.57, 95% CI 1.49–1.65) compared to uneducated
women. The odds of PNC use were 2.57 times higher
(AOR: 2.57, 95% CI 2.44–2.70) among the women
from the richest wealth quintile than those from the
poorest wealth quintile. Furthermore, social groups,
religion, women’s age, age at marriage, birth order,
child wantedness, and geographical region had a
significant association with PNC healthcare-seeking.
The findings of this study indicate evidence-based
maternal healthcare programs to mitigate the identi-
fied geographical inequalities in PNC usage. Further-
more, this study suggests state- and region-specific
healthcare interventions and strengthening of existing
policies to improve the utilization of PNC in India.
Keywords Postnatal care (PNC)
Geographical
variations
LISA
India
Introduction
Safe Motherhood has become a global priority to
reduce the incidence of maternal and child deaths.
Maternal mortality is highly prevalent in low- and
middle-income countries (LMICs), particularly
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among sub-Saharan Africa and South Asian countries.
In 2017, around 66% and 20% of the world’s maternal
deaths occurred in sub-Saharan Africa and South
Asian countries, respectively (WHO 2019). Despite
the implementation of several Safe Motherhood
initiatives, a large number of maternal deaths still
occur in India, accounting for approximately 12% of
the global maternal deaths (WHO 2019). The maternal
mortality ratio of India was 122 deaths (per 100,000
live births) with marked regional variations across
states, ranging from 175 deaths in Empowered Action
Group (EAG) states and Assam to 72 deaths (per
100,000 live births) in Southern states in
2015–17 (SRS 2019). Globally, around 2.5 million
children (7000 every day) died within the first month
of life in 2017. Currently, India’s neonatal mortality
rate was 24 deaths (per 1000 live births) (UNIGME
2018). The high maternal and neonatal death of the
country is linked with inadequate utilization of
maternal healthcare services (Thaddeus and Maine
1994; Singh et al 2012a, b). An accelerated improve-
ment in maternal and child healthcare services is
required to achieve the targets of Sustainable Devel-
opment Goal (SDG)-3 by reducing maternal mortality
to less than 70 deaths (per 100,000 live births) and
neonatal mortality to at least as low as 12 deaths (per
1000 live births) by 2030.
Postnatal care (PNC) is an essential component of
maternal healthcare utilization. According to the
World Health Organization (WHO), PNC period is
defined as ‘‘immediately after birth of the baby and
extends up to six weeks (42 days) after birth’’ (WHO
2010). Maternity care during postpartum period is
crucial for survival of mothers and newborn babies.
Most of the maternal and neonatal deaths occur during
postpartum period, and 66% of maternal deaths take
place in the first weeks of delivery (Nour 2008). Active
management and close monitoring of mothers imme-
diately after birth reduce the risk of complications
during postpartum period that can avert a large
proportion of maternal deaths (WHO 2013). WHO
recommended at least 4 PNC checkups in the first
6 weeks. As per WHO guidelines, women should
undergo PNC with two full assessments on the first
day; three additional visits are recommended: day 3
(48–72 h), between days 7–14 and 6 weeks after birth
(WHO 2013). India has made substantial progress in
institutional deliveries over the recent period due to
India’s several maternal healthcare programs
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including conditional cash transfer scheme known as
Janani Suraksha Yojana (JSY) (Gopalan and
Varatharajan 2012). However, the use of PNC remains
unsatisfactory in India. According to the recent
National Family Health Survey (NFHS)-4, about
69% of the women received PNC within 42 days of
delivery in 2015–16 (IIPS and ICF 2017).
Understanding spatial heterogeneity is essential for
evidence-based policymaking in the high-risk geo-
graphical areas. Most of the previous studies did not
account for the role of geography in the use of
maternal healthcare services especially in India
despite its large geographical extension and high
diversity. A few studies in African countries recently
investigated the spatial pattern of PNC service
utilization. For instance, Ononokpono et al. (2020)
carried out a spatial analysis of PNC use in Nigeria
using Bayesian-structured additive regression of the
logit model. Similarly, a study by Sisay et al. (2019)
identified clusters with low rates of PNC use using
STScan and examined socio-demographic determi-
nants of PNC use in Ethiopia. In India, it is evident that
the utilization of maternal healthcare services remains
poor despite the implementation of several reproduc-
tive healthcare programs (Kumar et al. 2013; Patel
et al. 2015). Singh et al. (2012a, b) found a large rich-
poor gap in PNC usage among mothers in India. To
address the inadequate use of maternal health care
services, it is, therefore necessary to identify the
inequity in PNC usage across regions, states, and
districts in the country. Moreover, the geographical
patterns of PNC use and its associated factors have
poorly understood in India. Hence, this study aimed to
examine the geographical variations in the use of PNC
and associated socio-economic, demographic, and
geographical factors in India, using a large-scale
nationally representative dataset.
An overview of previous studies
Studies on the utilization of maternal healthcare
services in India predominantly focused on antenatal
care (ANC) and delivery care. Assessing the utiliza-
tion of PNC largely ignored in previous literature due
to mainly paucity of data. There are an expanding
body of literature on PNC utilization in the field of
public health, which provides evidence for policy-
making in low PNC use settings at the aggregate level.
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However, assessing geographical heterogeneity in
maternal healthcare is scant, especially in India. The
present study has added value in the growing body
literature by examining the geographical variations in
PNC usage and its socio-economic, demographic and
geographic determinants in India.
A few studies have attempted the utilization of PNC
service in India. A cross-sectional study conducted in
Karnataka of South India indicated that urban resi-
dence, secondary or higher education, delivery in a
private hospital, and complications during delivery are
positively associated with PNC check-ups (Bhatia and
Cleland 1995). Mistry et al. (2009) examined the
influence of socio-economic and demographic factors
on maternity care. Their study found that women’s
educational attainment, standard of living, region, and
distance to health facility are significantly associated
with the use of PNC. Similarly, a study conducted
among EAG states in India documented the impor-
tance of individual/household, district- and commu-
nity-level characteristics in the utilization of PNC
(Singh et al. 2013). Furthermore, Paul and Chouhan
(2020) assessed the socio-economic and demographic
factors of maternal healthcare utilization among
reproductive women (aged 15–49 years), using a
nationally representative large-scale sample survey.
They found that women’s education, wealth status,
and women’s exposure to mass media have a strong
positive impact on PNC utilization. Apart from these,
social status, demographic characteristics, and geo-
graphical region also have a significant influence on
PNC utilization. A cross-sectional study conducted in
rural Uttar Pradesh revealed that women’s working
status, exposure to mass media, ANC visits, and
institutional delivery increased the odds of PNC,
whereas social marginalization decreased the likeli-
hood of seeking PNC service (Singh et al. 2019).
Similarly, a qualitative study carried out in the
Karnataka state of India reported that lack of deci-
sion-making power, unavailability of transport facil-
ities, and cost of healthcare are some key barriers of
postpartum healthcare-seeking (Vidler et al. 2016).
Several studies from low- and middle-income
countries have investigated socio-demographic factors
of the utilization of PNC service. Rai et al. (2012)
assessed the socio-economic and demographic factors
of maternal healthcare services in Nigeria and found
that educational attainment of women and wealth
status of the household have a significant positive
influence on the utilization of PNC. Their study also
found that ANC visits play a crucial role in seeking
PNC service among Nigerian women. In another
study, Rai et al. (2013) examined the factors influenc-
ing utilization of maternal healthcare services among
adolescent women aged 15–19 years in Malawi where
women’s education, religion, ethnic group, birth order
and interval, ANC visits and to some extent personal
barrier are significantly associated with PNC utiliza-
tion. Similarly, Somefun and Ibisomi (2016) deter-
mined the factors associated with non-utilization of
PNC in Nigeria. Their study demonstrated that the risk
of non-utilization decreased with an increasing level
of education. Similarly, wealth status also has a strong
negative association with non-utilization of PNC
service. In contrast, the risk PNC non-utilization
increased with higher birth order. Neupane and Doku
(2013) identified several socio-demographic factors
influencing PNC use among Nepalese women, using a
nationally representative sample survey. Their study
highlights the importance of mother’s education on the
utilization of PNC service. However, father’s educa-
tion appears to be less important in seeking PNC than
the mother’s education. Besides education, occupa-
tion, economic status, and sufficient advice emerged
as key predictors of PNC utilization. In Bangladesh,
Mosiur Rahman et al. (2011) identified a number of
predisposing factors, enabling factors and need factors
that influencing utilization of postpartum care among
mothers aged 15–24 years. The findings of this study
indicated that education, sufficient ANC, and delivery
at health facility are important predisposing factors for
seeking postpartum care. Household wealth status and
exposure to mass media are found to be strong
enabling factors of postpartum care. Furthermore,
distance to health facility, permission to go to the
health center alone, and husband/family concern about
pregnancy complications have a significant impact on
postpartum care. In Uganda, women’s secondary and
higher level of education is important for receiving
PNC within two days of delivery. Additionally, ANC
attendance, delivery at public and private health
facility, and access to media massages have a strong
positive correlation with early postnatal care (Ndugga
et al. 2020).
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Methods
Data source
The present study is based on secondary data from the
fourth round of the National Family Health Survey
(NFHS-4), conducted in 2015–16 under the steward-
ship of the Ministry of Health and Family Welfare
(MoHFW), Government of India and coordinated by
the International Institute of Population Sciences
(IIPS), Mumbai.
Data collection and sample design
The NFHS-4 is a large-scale nationally representative
sample survey of 601,509 households, 699,686
women aged 15–49 years with a response rate of
97%, and 112,122 men aged 15–54 years with a
response rate of 92%. The primary objective of this
survey was to provide updated and reliable informa-
tion on fertility, mortality, family planning methods,
utilization of maternal healthcare services, breastfeed-
ing practices, nutritional status of women and young
children, child immunization, childhood morbidity
and mortality, awareness and behavior regarding HIV/
AIDS and other sexually transmitted infections. The
sample was selected using a stratified two-stage
sampling design comprising of 28,586 clusters;
8,397 in urban, 20,059 in rural, and 130 from slums
list provided by Municipal Corporation Offices
(MCOs). In the first stage, clusters were selected
using probability proportional to clusters size. In the
second stage, 22 households from each cluster were
selected with an equal opportunity systematic selec-
tion from the household listing. The sampling frame
used for the NFHS-4 was the 2011 Indian Population
and Housing Census. A detailed description of the
sampling design and survey procedures is provided in
the national report NFHS-4 (IIPS and ICF 2017). The
present study is based on 190,898 ever-married
women aged 15–49 years who had a birth in the past
five years preceding the survey. All participants were
provided informed consent to participate and allow
their data to be used for research.
Data management
The present study extracted relevant data from the
Demographic Health Surveys (DHS) program into
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STATA version 12.1. The data were weighted using
the sample weights of each sample. The variables with
multiple categories were recoded into desired groups.
The use of PNC is considered as the outcome
variable in this study. Women receiving PNC within
42 days of delivery were taken into account in this
study as per recommendation of the World Health
Organization (WHO 2013).
The following variables were extracted from the
NFHS-4 dataset to assess the factors associated with
PNC utilization:
Socio-economic factors
1. Social groups—Scheduled Caste (SC), Scheduled
Tribe (ST), Other Backward Classes (OBC), and
others.
2. Religion—Hindu, Muslim, and others. Others
include Christian, Sikh, Buddhist/neo-Buddhist,
Jain, Jewish, Parsi/Zoroastrian, no religion, and
others.
3. Women’s education—no education, primary, sec-
ondary, and higher.
4. Wealth quintile—wealth quintile/index was
assessed by collecting data regarding possession
of durable assets (e.g. radios, televisions, refrig-
erators, cars, bicycles), housing characteristics
(e.g. toilet facilities, number of rooms, materials
used for roof and floor), and accessibility to
services (e.g. source of drinking water and elec-
tricity supply). A score has been generated for
each individual using principal component anal-
ysis and categorized into five quintiles, each
represents 20% of the respondents, between 1
(poorest) and 5 (richest).
Demographic factors
5. Women’s age—15–19 years, 20–34 years, and
35–49 years.
6. Age at marriage—below 18 years and 18 years or
above.
7. Birth order—first, second, and third or more.
8. Child wantedness—wanted then, wanted later,
and wanted no more.
Geographical factors
9. Place of residence—urban and rural.
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10. Geographical region—Indian states and union third of women’s (33.6%) most recent birth was their
territories are grouped into six regions based on first child. Over 90% of the women reported that they
geographical locations and cultural settings. wanted children. Most of the sample women (70.3%)
These regions are north, central, east, northeast, were residing in rural areas. Participants were pre-
west, and south. dominantly from central region (25.7%), followed by
east (25.4%), and south region (18.7%) (Table 1).
Data analysis
PNC usage by socio-demographic characteristics
This study assessed the levels of PNC usage by rural–
About 69.1% of women reported that that they
urban residence, regions, states, and union territories.
received PNC within 42 days of delivery. Socio-
District-level variations in PNC usage were estimated
demographic factors, such as social groups, religion,
for all the 640 districts of the country and presented it
education, wealth quintile, women’s age, age at
spatially. Furthermore, Moran’s ‘I’ was calculated and
marriage, birth order, child wantedness, place of
spatial autocorrelation map (LISA) was prepared to
residence, and geographical region were significantly
show the spatial clustering of PNC use across all the
associated with PNC usage (p \ 0.01). PNC usage
districts. Spatial analyses were carried out using Arc-
was lower among Scheduled Tribe (63.7%), Muslim
GIS version 10.2 and GeoDa version 1.14.
(63.2%), uneducated (54.8%), and poorest (52.2%)
This study examined the socio-demographic and
women. The proportion of PNC use was also lower
geographical factors of PNC use. Tests of association
among women age 35–49 (65.8%) and those who were
between PNC use and socio-demographic factors were
married before 18 years (63%). A higher proportion of
performed using Pearson’s Chi-square test. Bivariate
women received PNC who had most recent first
and multivariate logistic regression was carried out to
(75.6%) or second child (72.2%), compared with
examine the factors associated with PNC usage. The
women who had third or higher-order child (59%).
independent variables were checked for collinearity
The percentage of women receiving PNC was higher
before running to the multivariate analysis. The results
among the women who wanted child then (69.9%) or
of regression analysis are presented by unadjusted and
wanted child later (68.4%), compared with women
adjusted odds ratios (ORs) with 95% confidence
who wanted no more children (56.5%) (Table 2).
intervals (CIs). All statistical analyses were carried
out using STATA version 12.1 (StataCorp LP, College
Geographical variations in PNC use
Station, TX, USA).
The proportion of PNC use was higher in urban areas
as compared to rural areas (76.5 vs. 66%). The usage
Results
of PNC was significantly varied across geographical
regions. The highest proportion of women receiving
Respondent’s characteristics
PNC was found in south (82.7%), followed by west
(78.4%), while east region (60.9%) had the lowest
A total of 190,898 ever-married women aged
usage of PNC service (Table 2). Furthermore, inter-
15–49 years with most recent birth in the past five
actions of region and rural–urban residence showed
years preceding the survey were utilized in the present
marked differences in PNC use between rural and
study. Majority of respondents were Hindu (78.9%)
urban women in all the regions. The rural–urban
and belonged to Other Backward Classes (45.7%).
differences in PNC use were considerably larger
Over one-fourth of women (27.6%) had no formal
among the regions of low PNC use (i.e., central, east,
education, while only 12% of them had a higher level
and north-east) (Fig. 1).
of education. Nearly one-fourth of respondents
Among the states, the highest usage of PNC was
(23.4%) were from the poorest wealth quintile. More
found in Goa (92.6%), followed by Punjab (90.9%),
than two-thirds of women (68.9%) were in the age
Kerala (89.3%) and Tamil Nadu (87.6%), whereas
group of 20–34 years. Nearly 40% of women were
lowest usage of PNC was observed in Nagaland
married before 18 years (before legal age). About one-
(25.2%), followed by Arunachal Pradesh (35.6%), and

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Table 1 Socio-economic, demographic and geographical Table 1 continued

characteristics of the study participants, NFHS-4 (2015–16)
Variables Number (n) Percentage (%)
Variables Number (n) Percentage (%)
South 19,907 18.7
Social groups Total 190,898 100.0
Scheduled Caste 35,170 22.2
Scheduled Tribe 37,889 10.8
Other Backward Classes 74,060 45.7
Others 34,705 21.3
Religion
Hindu 138,343 78.9
Bihar (48.6%). Among the union territories, Pondi-
Muslim 29,309 16.1
cherry had the highest usage of PNC service (93.4%),
Others 23,246 5.0
followed by Lakshadweep (92.7%), and Chandigarh
(91.2%), while the lowest PNC use was found in
Women’s education
Daman and Diu with a proportion of 65.6% (Table 3).
No education 55,165 27.6
District-level estimates showed a heterogeneous
Primary 26,712 13.5
pattern of PNC usage across the country. The districts
Secondary 88,871 46.9
with higher usage of PNC service were found in south
Higher 20,150 12.0
and south-eastern coastal districts of India. The PNC
Wealth quintile
usage was also higher in Punjab and several patches of
Poorest 46,782 23.4
the country. Conversely, lower usage of PNC was
Poorer 43,739 21.2
found in north, central, and north-eastern parts of the
Middle 38,393 19.9
country (Fig. 2).
Richer 33,212 19.0
Richest 28,772 16.6
Spatial clustering of PNC use
Women’s age
15–19 5,899 3.4 The spatial autocorrelation analysis revealed cluster-
20–34 126,352 68.9 ing patterns of PNC usage in the districts of India
35–49 58,647 27.7 (Moran’s I = 0.649). LISA cluster map showed that
Age at marriage out of 640 districts, 135 districts were high-high
Below 18 years 69,751 39.5 clusters and 85 districts were low-low clusters of PNC
18 years or above 117,078 60.5 use. On the contrary, 400 districts had no significant
Birth order autocorrelation with their neighboring districts. The
First 61,807 33.6 clusters of higher PNC use were mostly found in
Second 62,484 34.5 Kerala, Tamil Nadu, and Andhra Pradesh from south
Third or more 66,607 31.9 region, Maharashtra from west region, Orissa from
Child wantedness east region, and Punjab from north India. Low clusters
Wanted then 173,407 90.8 of PNC use were observed in Arunachal Pradesh,
Wanted later 7,918 4.1 Nagaland, north Bihar, eastern Uttar Pradesh, and
Wanted no more 9,472 5.1 some parts of Madhya Pradesh (Fig. 3).
Place of residence
Urban 47,833 29.7 Factors associated with PNC use
Rural 143,065 70.3
Region Various socio-economic, demographic, and geograph-
North 36,079 13.2 ical variables were included to examine the factors
Central 52,952 25.7 associated with PNC use (Table 4). Women belonged
East 39,243 25.4 to Scheduled Tribe (AOR: 0.91, 95% CI 0.88–0.94)
Northeast 28,825 3.9 and Other Backward Classes (AOR: 0.93, 95% CI
West 13,892 13.1 0.91–0.96) were less likely to receive PNC service

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Table 2 Distribution of postnatal care use by socioeconomic, demographic and geographical characteristics of women in India,
NFHS-4 (2015–16)
Variables Postnatal care use p-value
No Yes
n (%) n (%)

Social groups \ 0.01

Scheduled Caste 11,615 (31.2) 23,555 (68.8)
Scheduled Tribe 15,852 (36.3) 22,037 (63.7)
Other Backward Classes 23,892 (31.1) 50,168 (68.9)
Others 9383 (26.1) 25,322 (73.9)
Religion \ 0.01
Hindu 43,932 (30.3) 94,411 (69.7)
Muslim 10,814 (36.8) 18,495 (63.2)
Others 9221 (21.7) 14,025 (78.3)
Women’s education \ 0.01
No education 25,589 (45.2) 29,576 (54.8)
Primary 10,098 (35.0) 16,614 (65.0)
Secondary 24,646 (24.8) 64,225 (75.2)
Higher 3634 (17.1) 16,516 (82.9)
Wealth quintile \ 0.01
Poorest 22,742 (47.8) 24,040 (52.2)
Poorer 16,939 (35.4) 26,800 (64.6)
Middle 11,300 (26.1) 27,093 (73.9)
Richer 7797 (21.4) 25,415 (78.6)
Richest 5189 (17.9) 23,583 (82.1)
Women’s age \ 0.01
15–19 2073 (31.3) 3826 (68.7)
20–34 40,571 (29.5) 85,781 (70.5)
35–49 21,323 (34.2) 37,324 (65.8)
Age at marriage \ 0.01
Below 18 years 27,748 (37.0) 42,003 (63.0)
18 years or above 33,931 (26.4) 83,147 (73.6)
Birth order \ 0.01
First 16,289 (24.4) 45,518 (75.6)
Second 19,081 (27.8) 43,403 (72.2)
Third or more 28,597 (41.0) 38,010 (59.0)
Child wantedness \ 0.01
Wanted then 56,883 (30.1) 116,524 (69.9)
Wanted later 2617 (31.6) 5301 (68.4)
Wanted no more 4366 (43.5) 5106 (56.5)
Place of residence \ 0.01
Urban 12,152 (23.5) 35,681 (76.5)
Rural 51,815 (34.0) 91,250 (66.0)
Geographical region \ 0.01
North 9903 (27.7) 26,176 (72.3)
Central 19,596 (37.7) 33,356 (62.3)
East 15,125 (39.3) 24,118 (60.7)

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Table 2 continued
Variables
Northeast
West
South
90 Urban
80 Rural
Postnatal care (%)
70
60
50
40
30
20
10
0
North Central East North-east
Region
Fig. 1 Postnatal care use (%) by region and rural–urban
residence in India, NFHS-4 (2015–16)
compared with Scheduled Caste women. The odds of
PNC use were lower among the women affiliated to
Muslim (AOR: 0.80, 95% CI 0.77–0.83) and ‘others’
religion (AOR: 0.79, 95% CI 0.76–0.82) than those
affiliated to Hindu religion. Maternal education was
found to be a strong predictor of PNC use. Compared
with women who had no education, women who
attained primary (AOR: 1.22, 95% CI 1.18–1.26),
secondary (AOR: 1.40, 95% CI 1.36–1.44) and higher
level of education (AOR: 1.57, 95% CI 1.49–1.65)
were more likely to have PNC service. Similarly, the
use of PNC significantly increased from poorest to
richest wealth group of households. Compared with
women belonged to poorest households, women from
richer (AOR: 2.08, 95% CI 1.99–2.16) and richest
households (AOR: 2.57, 95% CI 2.44–2.70) were
more than twice as likely to receive PNC service.
Women aged 20–34 years (AOR: 1.07, 95% CI
1.01–1.14) and 35–49 years (AOR: 1.14, 95% CI
1.07–1.22) were more likely to use PNC service than
the women in younger age group (15–19 years).
Women who married below 18 years were less likely
to use PNC service (AOR: 0.87, 95% CI 0.85–0.89)
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Postnatal care use p-value
No Yes
n (%) n (%)
12,385 (38.1) 16,440 (61.9)
3249 (21.6) 10,643 (78.4)
3709 (17.3) 16,198 (82.7)
compared with those who married at 18 years or older.
Women who had a second-order child (AOR: 0.84,
95% CI 0.82–0.86) and third or higher-order child
(AOR: 0.71, 95% CI 0.69–0.73) were associated with
a lower likelihood of PNC usage compared with
women who had first order child. Women who wanted
no more children were less likely to receive PNC
service (AOR: 0.80, 95% CI 0.77–0.84) than those
women who wanted children.
West South Place of residence was significantly correlated with
PNC utilization in crude analysis. However, after
controlling for socio-demographic factors in multi-
variate analysis, rural–urban residence had no signif-
icant association with PNC usage. Geographical
regions of the country also had a strong influence on
PNC service utilization. Compared with women from
north region, women from central (AOR: 0.88, 95% CI
0.85–0.91), east (AOR: 0.95, 95% CI 0.92–0.98) and
northeast (AOR: 0.70, 95% CI 0.67–0.73) were less
likely to use PNC and women from west (1.32, 95% CI
1.26–1.39) and south (AOR: 1.63, 95% CI 1.55–1.70)
were more likely to receive PNC service.
Discussion
The present study has investigated the spatial patterns
of PNC use and its socio-economic, demographic and
geographical determinants. In India, the usage of PNC
is 69.1% with marked regional variations. Overall,
women from north, central, east, and north-eastern
parts have lower usage of PNC as compared to south
and west regions of the country. Spatial analysis
(LISA) showed that clusters with high rates of PNC
use are found in south and south-eastern coastal
districts, while other parts of the country have clusters
with low rates of PNC use. The observed pattern in
seeking PNC could be due to unequal access and
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Table 3 Postnatal care use (%) by states and union territories achievement in the use of PNC service from an
of India, NFHS-4 (2015–16) estimated 41% in 2005–06 to 69% in 2015–16 (IIPS
Regions States and union territories Postnatal care (%) and ICF 2017). This is attributed to India’s several
maternal health programs envisaged to provide quality
North Chandigarha 91.2 and affordable healthcare among socio-economically
a
Delhi 67.6 disadvantaged mothers.
Haryana 73.4 Multivariate analysis this study found that various
Himachal Pradesh 80.5 socio-economic, demographic and geographic factors
Jammu & Kashmir 78.4 are significantly associated with the use of PNC
Punjab 90.9 service. Educational attainment of women is found to
Rajasthan 66.6 be a strong predictor of PNC use. Women with higher
Uttarakhand 61.8 education are 1.57 times more likely to have PNC
Central Chhattisgarh 74.2 service compared to uneducated women. This finding
Madhya Pradesh 59.5 is consistent with several other studies conducted in
Uttar Pradesh 61.7 India and low- and middle-income countries (Babalola
East Bihar 48.6 and Fatusi 2009; Mistry et al. 2009; Neupane and
Jharkhand 52.4 Doku 2013; Singh et al. 2013; Paul and Chouhan
Odisha 82.3 2020). This could be explained by the fact that
West Bengal 71.5 education enhances decision-making ability on health-
Northeast Arunachal Pradesh 35.6 care and increases access to healthcare information,
Assam 62.6 which leads to better health-seeking behavior. Simi-
Manipur 69.3 larly, women from the richest wealth quintile are
Meghalaya 67.0 found to be associated with an increased likelihood of
Mizoram 68.8 PNC use compared to those from the poorest wealth
Nagaland 25.2 quintile. This finding is similar to earlier studies
Sikkim 80.6 conducted in India (Mistry et al. 2009; Singh et al.
Tripura 65.3 2013; Paul and Chouhan 2020). The possible expla-
West Dadra & Nagar Havelia 78.8 nation is that wealthier women generally have greater
Daman & Diua 65.6 access to healthcare information and facilities.
Goa 92.6 Women who married during childhood are less likely
Gujarat 70.8 to receive PNC service compared to those who
Maharashtra 82.2 married as adults. Studies have indicated that child
South Andaman & Nicobar Islandsa 77.8
married women have lower educational attainment
Andhra Pradesh 85.6
and lack of autonomy, which further results in lower
Karnataka 67.8
access to healthcare information and facilities (Paul
and Chouhan 2019; Singh et al. 2012a, b). Our study
Kerala 89.3
a also found that marginalized caste and Muslim women
Lakshadweep 92.7
are less likely to receive PNC service. Women in
Puducherrya 93.4
socially backward communities have lower access to
Tamil Nadu 87.6
healthcare compared to forward caste women (Nava-
Telangana 86.3
neetham and Dharmalingam 2002). This could be due
a
Union territories to discrimination in social and economic opportunities
of these backward communities. Furthermore, reli-
gious beliefs and norms may restrict women from
healthcare-seeking. Women with a higher number of
distribution of healthcare services. Moreover, poverty,
children often cause resource constraints, which leads
lack of adequate information, and unavailability of
to lower utilization of healthcare (Bhatia and Cleland
healthcare facilities are the main barriers to PNC
1995). In support of this argument, our present study
healthcare-seeking. India has made a considerable

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Fig. 2 Spatial patterns of postnatal care use (%) by the districts of India, NFHS-4 (2015–16)
also revealed that women with higher parity decreased
the likelihood of using PNC service.
It is noteworthy that place of residence has a
significant association with PNC use in crude analysis.
However, after controlling for socio-demographic
characteristics in multivariate analysis, this associa-
tion becomes insignificant. This finding is consistent
with other studies conducted in Nepal (Neupane and
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GeoJournal
Doku 2013), Malawi (Rai et al. 2013), and Nigeria
(Ononokpono et al. 2020). However, Babalola and
Fatusi (2009) found that urban women are more likely
to have PNC compared with rural women, even after
controlling for individual, household, and community-
level characteristics in Nigeria. The influence of
geographical region on PNC utilization showed that
women from central, east, and north-east regions are
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Fig. 3 Spatial clustering of postnatal care use in India, NFHS-4 (2015–16): a LISA cluster map; b LISA significance map

123
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Table 4 Socio-economic, demographic and geographical factors associated with postnatal care use in India, NFHS-4 (2015–16)
Variables Crude OR 95% CI Adjusted OR 95% CI
Lower Upper Lower Upper

Social groups
Scheduled Caste (Ref.)
Scheduled Tribe 0.69** 0.67 0.71 0.91** 0.88 0.94
Other Backward Classes 1.04* 1.01 1.06 0.93** 0.91 0.96
Others 1.33** 1.29 1.37 1.01 0.97 1.05
Religion
Hindu (Ref.)
Muslim 0.80** 0.78 0.82 0.80** 0.77 0.83
Others 0.71** 0.69 0.73 0.79** 0.76 0.82
Women’s education
No education (Ref.)
Primary 1.42** 1.38 1.47 1.22** 1.18 1.26
Secondary 2.25** 2.2 2.31 1.40** 1.36 1.44
Higher 3.93** 3.78 4.09 1.57** 1.49 1.65
Wealth quintile
Poorest (Ref.)
Poorer 1.50** 1.46 1.54 1.32** 1.28 1.35
Middle 2.27** 2.2 2.33 1.72** 1.66 1.78
Richer 3.08** 2.99 3.18 2.08** 1.99 2.16
Richest 4.30** 4.15 4.45 2.57** 2.44 2.70
Women’s age
15–19 (Ref.)
20–34 1.15** 0.98 1.02 1.07* 1.01 1.14
35–49 0.95 0.67 0.71 1.14** 1.07 1.22
Age at marriage
Below 18 years 0.62** 0.61 0.63 0.87** 0.85 0.89
18 years or above (Ref.)
Birth order
First (Ref.)
Second 0.81** 0.79 0.83 0.84** 0.82 0.86
Third or more 0.48** 0.46 0.49 0.71** 0.69 0.73
Child wantedness
Wanted then (Ref.)
Wanted later 0.99 0.94 1.04 0.98 0.93 1.03
Wanted no more 0.57** 0.55 0.6 0.80** 0.77 0.84
Place of residence
Urban (Ref.)
Rural 0.60** 0.59 0.61 1.01 0.99 1.04
Region
North (Ref.)
Central 0.64** 0.63 0.66 0.88** 0.85 0.91
East 0.60** 0.58 0.62 0.95** 0.92 0.98
Northeast 0.50** 0.49 0.52 0.70** 0.67 0.73

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Table 4 continued
Variables Crude OR 95% CI
Lower
West 1.24** 1.18
South 1.65** 1.58
OR Odds ratio; CI Confidence interval; Ref Reference category
**
p \ 0.01, *p \ 0.05
less likely to use PNC, and women from west and
south region are more likely to receive PNC than the
north region of the country. Mistry et al. (2009) found
a similar finding in a study conducted in rural India.
The higher use of PNC in southern states is attributed
to better women’s status and healthcare system.
The main strength of this study is that it is a
nationally representative study with a large number of
samples. This study examined regional variations in
PNC use, which would help stakeholders to under-
stand the problem of PNC use at a spatial scale.
However, this study is not free from limitations, and
thus, the study results should be interpreted with
caution. Due to self-reported and retrospective nature
of data, recall bias might have been introduced. This is
a cross-sectional study, and therefore, cause-effect
relationship between PNC usage and its predictor
variables cannot be assumed from this study. Another
limitation of this study is that NFHS-4 does not
provide accessibility-related information on health-
care or quality of healthcare services, which might
influence the utilization of PNC service.
Conclusion
This study has found marked variations in PNC use
across geographical regions, states, and districts of
India. Cluster analysis shows that lower usage of PNC
is found in north, central, and north-eastern regions.
Multivariate analysis of this study indicates that
women with no education, poor economic back-
ground, social marginalization, and lower age at
marriage are less likely to receive PNC service.
Therefore, policymakers and stakeholders should
initiate effective maternal healthcare programs to
mitigate the identified geographical inequalities in
PNC use. Interventions should target socio-
Adjusted OR 95% CI
Upper Lower Upper
1.3 1.32** 1.26 1.39
1.72 1.63** 1.55 1.7
economically vulnerable women to increase PNC
service utilization. Furthermore, this study suggests
state- and region-specific healthcare policies to
improve the use of PNC service in India.
Funding The author did not receive any financial assistance
for conducting this research.
Compliance with ethical standards
Conflict of interest The author has no conflict of interest.
Ethical approval This study is based on publicly available
secondary data. Therefore, separate ethical is not required for
conducting this research.
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