Maternal mortality remains a pressing public health challenge in India, which bears approximately 12% of the global maternal deaths. According to the Sample Registration System (SRS) 2018–20, India's Maternal Mortality Ratio (MMR) stands at 97 per 100,000 live births nationally, with Uttar Pradesh recording an MMR of 167—nearly double the national average. Sustainable Development Goal (SDG) 3.1 mandates a global MMR below 70 per 100,000 live births by 2030, a target that demands urgent action, particularly in high-burden states like Uttar Pradesh.

Antenatal care (ANC) constitutes a critical continuum of preventive, promotive, and curative services offered to pregnant women, aimed at detecting and managing pregnancy complications, promoting healthy behaviours, and preparing families for safe delivery and postnatal care. The World Health Organization (WHO), in its 2016 guidelines, recommends a minimum of eight ANC contacts, upgrading from the earlier four-visit model, to maximise reduction in perinatal mortality. India's Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) strategy prescribes at least four ANC visits with specific content at each visit.

Urban areas of India are witnessing rapid population growth accompanied by significant socioeconomic stratification. Urbanization has not uniformly translated into improved maternal health outcomes; urban slums and peri-urban settlements frequently report ANC utilization comparable to or worse than rural benchmarks. Lucknow, the capital city of Uttar Pradesh with a population exceeding 3.5 million (Census 2011), presents a paradigmatic example of such urban heterogeneity—with high-end tertiary care facilities coexisting with underserved urban primary health centres (UPHCs) catering to migrant and low-income populations.

The National Family Health Survey-5 (NFHS-5, 2019–21) reports that while 71.5% of women in Uttar Pradesh received ANC from a skilled provider, only 28.6% completed four or more visits, and merely 21.6% had their first ANC in the first trimester. Urban areas within the state perform marginally better, yet significant gaps in quality and content of care persist. Understanding the determinants and barriers specific to the urban context is essential for designing targeted interventions.

Few studies have rigorously examined ANC utilization specifically within the urban zones of Lucknow, integrating both coverage and quality indicators alongside socio-demographic predictors. The present study was therefore undertaken with the following objectives: (i) to determine the level of ANC registration and utilization; (ii) to assess the content and quality of ANC services received; (iii) to identify socio-demographic determinants of adequate ANC utilization; and (iv) to document barriers to ANC uptake among urban women in Lucknow.

A community-based cross-sectional study was conducted over a period of six months in the urban field practice area of the Department of Community Medicine, King George's Medical University (KGMU), Lucknow. The study area encompasses four administrative zones of the Lucknow Municipal Corporation (LMC): North, South, East, and West. Each zone contains a mix of planned residential colonies, unplanned settlements, and notified slums, ensuring heterogeneity of socioeconomic strata.

2.2 Study Population and Eligibility

The study population comprised women who had delivered a live or stillborn baby within the 12 months preceding the date of data collection and who were residing in the selected urban areas. Inclusion criteria were: (a) age 18–45 years; (b) permanent resident of the selected ward for ≥6 months; (c) willingness to participate. Exclusion criteria included women with severe physical or mental illness precluding an interview and those who had migrated to the area post-delivery.

2.3 Sample Size and Sampling

The sample size was calculated using the formula n = Z²pq/d², where Z = 1.96 (95% confidence level), p = 71.5% (proportion receiving skilled ANC, NFHS-5 UP), q = 1 − p = 0.285, and d = 5% allowable error. This yielded n = 313; accounting for a 20% non-response rate and design effect of 1.5, the final sample size was 400 women. A multi-stage sampling approach was employed: (i) one UPHC from each of the four zones was selected by simple random sampling; (ii) from the ASHA workers' household registers of the selected UPHCs, eligible women were enumerated; (iii) systematic random sampling was used to select 100 women per zone (total 400). The sampling interval was calculated based on the total eligible population in each zone's list.

2.4 Data Collection

Data were collected by four trained field investigators (medical interns) using a pretested, structured interview schedule after obtaining informed written consent. The questionnaire was developed based on the WHO ANC model, DLHS-4, and NFHS-5 modules, and was translated into Hindi and back-translated for validation. A pilot study of 40 women (10%) in a non-selected zone was conducted to refine the tool; minor modifications were made in language and sequencing.

The schedule covered: (i) socio-demographic characteristics; (ii) obstetric history; (iii) ANC registration—timing and facility type; (iv) number and content of ANC visits (BP measurement, weight monitoring, haemoglobin estimation, urine examination, ultrasound, TT immunization, IFA supplementation); (v) counselling received; and (vi) barriers to ANC utilization using a pre-coded checklist validated in prior Indian studies. Socioeconomic status was classified using the Modified BG Prasad Classification updated.

2.5 Operational Definitions

Adequate ANC was defined as ≥4 ANC visits as per the existing Indian RMNCH+A schedule. Early registration was defined as first ANC contact before 12 completed weeks of gestation (first trimester). Complete ANC content at each visit was assessed against the RMNCH+A checklist. Quality of ANC was operationalized as the proportion of prescribed service components received at each contact.

2.6 Statistical Analysis

Data were entered in EpiData 3.1 and analysed using SPSS version 26.0. Descriptive statistics—frequencies, proportions, means, and standard deviations—were computed for all variables. For association between socio-demographic variables and adequate ANC utilization, Pearson's chi-square test was applied. Odds ratios with 95% confidence intervals were computed for significant variables on univariate logistic regression. A p-value of <0.05 was considered statistically significant.

Table 1 presents the socio-demographic characteristics of the 400 study participants. The majority (73%) of women were in the reproductive age group of 20–29 years. A substantial proportion (24%) had education only up to primary or middle school level. Most women (77%) were homemakers. Hindus constituted 74% of the sample, while Muslims comprised 22%. One-third of women (33%) belonged to the lower-middle socioeconomic class (Class III, BG Prasad), and 32% were from lower or upper-lower classes (Class IV and V). Nuclear family structure predominated (63%).

Table 1: Socio-demographic Characteristics of Study Participants (n=400)

As shown in Table 2, 92.0% of women had registered for ANC. However, only 53% registered during the first trimester (before 12 weeks). The proportion receiving adequate ANC (≥4 visits) was 66.0%, while only 22% completed the newer WHO-recommended ≥8 visits. Tetanus toxoid immunization was received by 88% of women. IFA tablets (≥100 tablets) were received by 79%.

High coverage was observed for ultrasound (86%), haemoglobin estimation (80%), and blood pressure measurement (72%). However, counselling services were markedly deficient—less than half (49%) received birth preparedness counselling, only 45% were counselled about danger signs, and 40% had a delivery plan discussed with them.

Table 2: ANC Utilization Indicators among Study Participants (n=400)

Table 3 presents the association between selected socio-demographic variables and adequate ANC (≥4 visits). Education was significantly associated—73.3% of women with secondary education or above received adequate ANC compared to only 47.8% of illiterate/primary-educated women (χ²=18.42, p<0.001). Higher socioeconomic status (Class I and II) was strongly associated with adequate ANC (82.9%) compared to Class IV and V (53.1%) (χ²=22.67, p<0.001). First-trimester registration was the strongest predictor: 92.5% of early registrants received ≥4 visits versus only 35.8% of late registrants (χ²=112.4, p<0.001). Husband's support and lower parity were also significantly associated with adequate ANC (p<0.001).

Table 3: Association between Socio-demographic Factors and Adequate ANC (≥4 Visits)

Among the 136 women with inadequate ANC (<4 visits), barriers were explored (Table 4). The most frequently cited barrier was long waiting time at the health facility (47.8%), followed by the perception that ANC is unnecessary when feeling well (41.8%). Unawareness of the ANC schedule (35.8%), distance and transport difficulty (29.9%), financial constraints (26.9%), and lack of family support (23.9%) were other significant barriers. Provider attitude and work commitments were cited by approximately 18–21% of women.

Table 4: Barriers to Adequate ANC Utilization among Women with Inadequate ANC (n=136)

This study provides a comprehensive assessment of ANC utilization in urban Lucknow, highlighting both the progress achieved and the persistent gaps in maternal health services. The overall ANC registration rate of 92% is encouraging and exceeds the NFHS-5 figure of 81.4% for urban UP, suggesting improving awareness and demand-generation efforts in the city. However, the more critical metric—timing of first ANC registration—reveals a stark gap: only 53% registered in the first trimester. Late registration has well-documented consequences including missed opportunities for early detection of ectopic pregnancy, pre-eclampsia risk stratification, nutritional supplementation, and first-trimester screening.

The proportion of women receiving adequate ANC (≥4 visits) at 66% is above the NFHS-5 urban UP figure of approximately 45% but falls considerably short of the WHO's updated 2016 recommendation of ≥8 contacts, achieved by only 22% in our study. This gap between coverage and quality is a recurring theme in Indian ANC literature. Studies from Agra (Bajpai et al., 2021) and Varanasi (Mishra et al., 2020) reported similar findings of high registration but poor follow-through, underscoring structural and behavioural barriers that persist even in urban settings.

The content of ANC visits shows a clear divergence between clinical investigations and counselling services. Coverage of TT immunization (88%), ultrasound (86%), and haemoglobin estimation (80%) was relatively high, in part attributable to subsidized services at UPHCs and a strong push under the Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA). However, counselling on birth preparedness (49%) and danger signs (45%) was grossly inadequate. Similar findings were reported by Kumari et al. (2021) from urban Bihar, where biomedical services outpaced health education components. This imbalance is clinically significant because delayed recognition of danger signs is a major proximate cause of maternal mortality—approximately 40% of which could be averted by timely care-seeking.

The determinant analysis revealed that education and socioeconomic status were independently and significantly associated with adequate ANC (p<0.001). These findings align with the Social Determinants of Health framework: women with higher education are better equipped to understand the importance of ANC, navigate health systems, and resist household-level barriers. Low SES compounds the problem through financial constraints on transportation, loss of daily wages, and low prioritization of preventive care in the context of immediate survival needs. Husband's supportive attitude was a significant predictor—underscoring the role of male engagement in maternal health, an aspect increasingly recognized in RMNCH+A programming.

The most powerful predictor of adequate ANC was first-trimester registration, with an odds ratio exceeding 20 in univariate analysis. This 'gateway effect'—where early registration predicts completion of subsequent visits—has been consistently observed in the Indian literature. It suggests that demand-generation and awareness campaigns must specifically target the first trimester, particularly in communities with low education and low health literacy. ASHA workers, who are the primary community-level link workers, can be instrumental in achieving this through home visits around the time of missed menstrual period and early pregnancy confirmation.

Barriers to ANC completion were predominantly healthcare system-related (long waiting times, provider attitude) and demand-related (perceived low necessity, unawareness of schedule). Long waiting times at UPHCs—a perennial challenge in urban public health facilities—can be addressed through appointment systems, Saturday PMSMA clinics, and redeployment of staff. The 35.8% who were unaware of the required number of ANC visits highlights a critical knowledge deficit that ASHA-led counselling and community-level IEC activities can address. Financial barriers—cited by 26.9%—despite the availability of free ANC under Janani Suraksha Yojana (JSY) suggest that opportunity costs (transport, workday loss) rather than direct facility costs are the primary economic deterrent, demanding facility-level solutions such as flexible clinic timings and transport vouchers under JSY.

The present study has several strengths: a community-based design avoiding facility-based selection bias; a multi-stage sampling frame ensuring representativeness across four city zones; and a comprehensive assessment integrating both coverage and quality indicators. Limitations include the cross-sectional design precluding causal inference; recall bias in reporting of visits, particularly for events 6–12 months prior; and social desirability bias that may lead to overreporting of compliant behaviours.

Antenatal care registration in urban Lucknow is high; however, first-trimester registration, completeness of visits, and quality of counselling services require substantial improvement. Education, socioeconomic status, early registration, and husband's support are the key determinants of adequate ANC utilization. Barriers are multi-factorial, spanning health system inefficiencies and demand-side knowledge deficits. Evidence-based recommendations include:

• Strengthening demand-generation activities specifically targeting first-trimester registration through ASHA workers and community mobilization.
• Addressing supply-side barriers—long waiting times, provider attitudes, and quality of counselling—through facility management improvements and periodic sensitization training for health workers.
• Integrating male partner engagement and family counselling into ANC programmes to leverage the proven influence of husband's support.
• Implementing context-specific IEC campaigns targeting low-literacy and low-SES urban communities to increase awareness of the ANC schedule and danger signs.
• Utilizing the PMSMA platform to improve coverage of quality ANC components, especially comprehensive birth preparedness counselling.

Achieving SDG 3.1 targets and eliminating preventable maternal deaths in Uttar Pradesh will require a paradigm shift from mere coverage metrics toward quality of care, with targeted action for the urban vulnerable—the invisible face of urban health inequity.

CONFLICT OF INTEREST AND FUNDING

The authors declare no conflict of interest. This study received no external funding and was conducted as part of a departmental research initiative.

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