"Pathways to care among antenatal women in South India - A sequential explanatory mixed-method study".

Introduction: Poor access to effective antenatal care (ANC) is identified as one of the key challenges in reducing maternal mortality. Antenatal women seek ANC through different pathways, including primary health centers (PHCs), private clinics/hospitals, and tertiary care facilities, influenced by factors such as perceived quality of care, financial constraints, proximity, and cultural preferences. The study aimed to determine the pathways antenatal women choose to seek ANC, reasons for preferring such point of care or facilities, and the out-of-pocket expenditure (OOPE) incurred for an ANC visit. Methods: This tertiary hospital-based mixed-method study was conducted among 303 antenatal women in South India. The study was conducted in 2019. A pretested semistructured questionnaire was used to gather data on sociodemographic and obstetric characteristics, utilization of ANC services, reasons for choosing each facility, and the costs incurred during an ANC visit. Among some participants, in-depth interviews were conducted to explore the facilitators and barriers to using ANC services at primary healthcare centers, private healthcare facilities, and tertiary care facilities. Collected quantitative data were analyzed using SPSS version 20 (IBM Corp). In-depth interviews were transcribed and analyzed using an inductive content analysis approach. Codes were grouped to form similar categories which in turn were grouped to themes. Results: Out of 303, 279 pregnant women registered in their respective PHCs, the remaining 24 participants (7.9%) did not register or seek ANC from a PHC. Most of them mentioned the lack of facilities and unawareness about a PHC in their locality as the reasons for not using ANC services at PHC. The highest OOPE incurred was at a private facility, where the median cost per visit was INR 1400 (990-2115) compared with PHC, which was INR 100 (20-360). Conclusion: Appropriate action has to be implemented at PHCs to improve the utilization rate and to reduce OOPE incurred.