Contact coverage, content of care and inequality in antenatal care and routine immunisation in rural Uttar Pradesh, India: a repeated cross-sectional analysis of household surveys and direct observations of community health sessions
- 1University of Manitoba, Winnipeg, Manitoba, Canada
- 2India Health Action Trust, Lucknow, Uttar Pradesh, India
- 3Universidade Federal de Pelotas, Pelotas, Brazil
Abstract
Introduction: Community-based primary care aims to reduce geographic and opportunity–cost barriers in rural settings, yet population trends in coverage, content and education-related inequality are poorly described. In rural Uttar Pradesh (UP), monthly community health sessions (Village Health and Nutrition Days (VHNDs)) provide integrated antenatal care (ANC) and routine immunisation (RI). We describe long-term trends in coverage, content and education-related inequality, with direct observation of session readiness.
Methods: We analysed repeated cross-sectional rural UP household survey data from National Family Health Survey (NFHS)-3 (births 2001–2006), NFHS-4 (2011–2016) and NFHS-5 (2018–2020). Outcomes included any and community-level ANC/RI, content-qualified ANC (Antenatal Care Quality (ANCq) ≥8), full RI among children aged 12–23 months and ultrasound use and caesarean birth as facility-dependent comparators. Education-related inequality was quantified using the Slope Index of Inequality and Concentration Index (CIX). Direct observations of 61 133 VHND sessions (2022–2023) described input readiness and observed ANC component delivery.
Results: Between 2001 and 2019, any ANC increased from 51.3% to 94.8% and content-qualified ANC from 3.3% to 53.3%. Any RI remained high throughout; full RI increased from 20.8% (2004) to 71.2% (2019). Gains were largest among women with no formal education. Relative inequality narrowed for every indicator and fell close to zero for services deliverable at community level (CIX 0.502 to 0.059 for ANCq, 0.269 to 0.018 for full RI), while remaining substantial for caesarean birth (0.394 to 0.257). Sessions showed high blood pressure and haemoglobin testing capacity and strong availability for key antigens, with lower but improving urine testing and measles-rubella vaccine supply.
Conclusions: Content-qualified ANC and full immunisation improved markedly, with the largest gains among the least educated women and relative inequality narrowed for every indicator except caesarean birth. Where community-deliverable services have converged across education groups, the remaining gap lies in facility-dependent care. Further gains likely depend on referral, transport and surgical capacity rather than extending first-contact outreach.
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BibTeX
@article{shoemaker2026contact,
title = {{Contact coverage, content of care and inequality in antenatal care and routine immunisation in rural Uttar Pradesh, India: a repeated cross-sectional analysis of household surveys and direct observations of community health sessions}},
author = {Esther Shoemaker and Emma Sandstrom and Ravi Prakash and John Anthony and Fernando C Wehrmeister and Aruni Tennakoon and Lorine Pelly and Bidyadhar Dehury and Amit Kumar Agrawal and Vasanthakumar Namasivayam and Dhanunjaya Rao Chintada and Shajy Isac and Ramesh Banadakoppa Manjappa and James Blanchard and Marissa L Becker},
journal = {BMJ Public Health},
year = {2026},
month = nov,
doi = {10.1136/bmjph-2026-005227},
url = {https://doi.org/10.1136/bmjph-2026-005227},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Contact coverage, content of care and inequality in antenatal care and routine immunisation in rural Uttar Pradesh, India: a repeated cross-sectional analysis of household surveys and direct observations of community health sessions
AU - Esther Shoemaker
AU - Emma Sandstrom
AU - Ravi Prakash
AU - John Anthony
AU - Fernando C Wehrmeister
AU - Aruni Tennakoon
AU - Lorine Pelly
AU - Bidyadhar Dehury
AU - Amit Kumar Agrawal
AU - Vasanthakumar Namasivayam
AU - Dhanunjaya Rao Chintada
AU - Shajy Isac
AU - Ramesh Banadakoppa Manjappa
AU - James Blanchard
AU - Marissa L Becker
PY - 2026
DA - 2026/11/02
JO - BMJ Public Health
DO - 10.1136/bmjph-2026-005227
UR - https://doi.org/10.1136/bmjph-2026-005227
AB - Introduction: Community-based primary care aims to reduce geographic and opportunity–cost barriers in rural settings, yet population trends in coverage, content and education-related inequality are poorly described. In rural Uttar Pradesh (UP), monthly community health sessions (Village Health and Nutrition Days (VHNDs)) provide integrated antenatal care (ANC) and routine immunisation (RI). We describe long-term trends in coverage, content and education-related inequality, with direct observation of session readiness. Methods: We analysed repeated cross-sectional rural UP household survey data from National Family Health Survey (NFHS)-3 (births 2001–2006), NFHS-4 (2011–2016) and NFHS-5 (2018–2020). Outcomes included any and community-level ANC/RI, content-qualified ANC (Antenatal Care Quality (ANCq) ≥8), full RI among children aged 12–23 months and ultrasound use and caesarean birth as facility-dependent comparators. Education-related inequality was quantified using the Slope Index of Inequality and Concentration Index (CIX). Direct observations of 61 133 VHND sessions (2022–2023) described input readiness and observed ANC component delivery. Results: Between 2001 and 2019, any ANC increased from 51.3% to 94.8% and content-qualified ANC from 3.3% to 53.3%. Any RI remained high throughout; full RI increased from 20.8% (2004) to 71.2% (2019). Gains were largest among women with no formal education. Relative inequality narrowed for every indicator and fell close to zero for services deliverable at community level (CIX 0.502 to 0.059 for ANCq, 0.269 to 0.018 for full RI), while remaining substantial for caesarean birth (0.394 to 0.257). Sessions showed high blood pressure and haemoglobin testing capacity and strong availability for key antigens, with lower but improving urine testing and measles-rubella vaccine supply. Conclusions: Content-qualified ANC and full immunisation improved markedly, with the largest gains among the least educated women and relative inequality narrowed for every indicator except caesarean birth. Where community-deliverable services have converged across education groups, the remaining gap lies in facility-dependent care. Further gains likely depend on referral, transport and surgical capacity rather than extending first-contact outreach.
SN - 2753-4294
ER -