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Decomposing the Socio-economic Inequalities in Utilization of Full Antenatal Care in Jharkhand State, India

towards inequalities (Goli, Doshi, and Perianayagam, 2013).
Findings from the analysis also show that place of residence is another important contributing
factor as it caused 15.6% of inequalities in full ANC utilization. Existing literature has revealed that
there are some cultural taboos attached with the health care utilization among women and inadequate
knowledge also aggravates the poor utilization of maternal health services in rural areas (Barnes,
2007; Haq, 2008; Van Hollen, 2003). Besides, health care institutions which are mostly located in
the countryside depict poor conditions of the health system (Pandey, Roy, Sahu et al., 2004) where
doctors and other health workers are absent from centers and medicines are unavailable. The low
skill levels of health professionals, inadequate supervision, and low interest and attitudinal behaviour
of workers are some of the common characteristics of the health system in rural areas (Visaria, Si-
mons, Berman et al., 1997). As a result, women at rural community health centers use fewer com-
ponents of ANC than the areas which have public/private hospitals. Thus, the focus should be made
to those areas where either public/private hospitals are not available or users have less access to
health care (Gage, 2007). However, a study done in southern states rejected this rural-urban divide
(Navaneetham and Dharmalingam, 2002).
The utilization of antenatal services also varies among the social groups. Our results demonstrate
that SC/ST social groups contributed to 5% of inequality in full ANC utilization after considering
other covariates. The caste system in India governs the status of the household. It is evident that
the caste system has a strong association with maternal health (Kavitha and Audinarayan, 1997). An
important study from Jharkhand demonstrated that maternal care was worse among Scheduled Tribe
women than non-tribal women (Agrawal and Agrawal, 2010). Socio-economic inequalities are the
result of dispossession of some segments of population historically, politically, economically and
socially. However, the worst part of these inequalities is reflected in exclusion of some subgroups
from their fundamental right of being healthy. There are social, economic, cultural and spatial im-
pediments which restrain women’s utilization of ANC services (Pallikadavath, Foss, and Stones,
2004a; Sunil, Rajaram, and Zottarelli, 2006). It is ubiquitous that lower caste women lack basic
education, reside in rural areas, and have lesser access to public health programs (Borooah,
Sabharwal, and Thorat, 2012). The minorities (especially Muslims), Scheduled Caste and Tribes are
socially excluded groups. They are vulnerable to differences in access to health services (Sivanand,
2006). However, a study reported diminishing effect of the caste system in India (Subramanian,
Nandy, Irving et al., 2006).
Cautiousness is needed when interpreting the findings of the present study. First, the size of con-
tribution of each socio-economic factor to the differential use of full ANC is relative. In other words,
when other covariates are further controlled in the models, the size of contribution to the use of full
ANC and the ranking order of each socio-economic factor may change. Nevertheless, we are confi-
dent about the robustness of our analysis and most of these socio-economic factors would be the
primary contributors to inequality in the use of full ANC services. Second, the size of contribution of
each socio-economic factor may change over time, especially when full ANC service programs be-
come more accessible. We welcome more research on these themes to verify our findings and spec-
ulations.

5. Conclusion
Some of the existing studies have attempted to shift their approaches from the identification of ma-
ternal health factors to quantification of their contribution in generating health inequalities (Goli,
Doshi, and Perianayagam, 2013; Hosseinpoor, VanDoorslaer, Speybroeck et al., 2006; Kumar and
Singh, 2013; Nawal, Sekher, and Goli, 2013). However, to the best of our knowledge, none of the
studies have looked into the quantification of full ANC determinants in Jharkhand State. In this con-
text, this paper offers several insights to explain the dynamics behind the variation in full ANC utili-
zation among various groups using a decomposition method. Findings obtained in this paper suggest
that inequalities in full ANC utilization can be minimized by focusing on the economic conditions of

102 International Journal of Population Studies | 2016, Volume 2, Issue 2