2025
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PublicationArticle Association between flood-prone geographies and incomplete ANC in India: Implications for equitable maternal care access(Elsevier Ltd, 2025) Rakesh Chandra; Jeetendra Kumar Patel; Sonal Srivastava; Saradiya Mukherjee; Aditya P. SinghThis study examines the association between floods and incomplete antenatal care (ANC) visits in India to assess the impact of floods on ANC utilization, particulary among vulnerable groups. Data from the National Family Health Survey (2019–20) and Vulnerability Atlas of India (2019) were used and merged to create individual-level data. Binary logistic regression was employed to analyze the odds of incomplete ANC visits, adjusting for relevant variables. Interaction terms were incorporated to investigate the moderating effects of wealth (poor and non-poor) and social groups [Scheduled Caste (SC)/Scheduled Tribes (ST) and non-SC/ST]. Flood-prone districts showed a 50 % higher likelihood of incomplete ANC visits. When examining the interaction effects, wealth was found to be insignificant in flood-prone regions. Women from SC/ST households in flood-prone areas were two times more likely to have incomplete ANC visits compared to the rest. Floods have a significant association with poor ANC utilization in India. The heightened odds of incomplete ANC visits in flood-prone districts underscore the need for targeted interventions. Moreover, the amplified disparity between SC/ST and non-SC/ST women in flood-prone areas emphasizes the urgency of addressing inequities. We suggest policymakers and healthcare providers to develop inclusive strategies that ensure equitable access to maternal healthcare amid the increasing risks posed by floods and other extreme events associated with climate change, with a strong emphasis on effectively prioritizing vulnerable populations. © 2025 The AuthorsPublicationBook Chapter Full Antenatal Care Service Utilization Among Tribal Mothers in India: A Multilevel Analysis(Springer Nature, 2025) Aditya P. Singh; Mahashweta Chakrabarty; Sourav Chowdhury; Vineet Kumar; Rakesh Chandra; Shivani Paratap SinghScheduled Tribes (ST) are one of the most disadvantaged socioeconomic groups in India, with a significant maternal mortality and morbidity burden. The coverage of full antenatal care (ANC) is low among ST mothers, leading to poor maternal and child health outcomes. We analyzed the data from the fourth round of the National Family Health Surveys (NFHS-4), conducted in 2015–2016. A multilevel binary logistic regression model was used to examine the factors associated with full ANC among ST mothers in India. Only one in every six tribal mothers in India received full ANC. Although 46% of ST mothers had four or more ANC visits and about 88% received one or more tetanus toxoid (TT) injections, only 27% consumed 100 or more iron–folic acid (IFA) tablets/equivalent amount of IFA in syrup during their pregnancy. Household wealth, maternal education, pregnancy registration, and spouse’s presence at the last ANC visit were associated with higher odds of receiving full ANC. High parity and undergoing the first ANC visit in the second or third trimester were associated with lower odds of receiving full ANC. India’s northern and central regions reveal a deplorable condition compared to southern and western regions in terms of the utilization of full ANC. To improve the coverage of full ANC, the government should prioritize reaching out to poor, illiterate, and high-parity ST women and encourage early registration of preganacy and a timely first ANC visit. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024.PublicationBook Chapter Individual-and Community-Level Determinants of Maternal Healthcare Utilization in Afghanistan(Springer Nature, 2025) Aditya P. Singh; Sayed Attaullah Saeedzai; Ajit Kumar Jaiswal; Shivani Paratap Singh; Rakesh ChandraTo increase the utilization of maternal healthcare services, the factors that affect must first be identified. However, national-level studies on this topic in the country are lacking. Therefore, this chapter aims to identify and examine the factors affecting maternal healthcare utilization in Afghanistan. This chapter uses data from the first Demographic and Health Survey conducted in Afghanistan in 2015 to examine the factors associated with the utilization of maternal healthcare services among ever-married women (aged 15–49) who have had at least one birth during the 5 years preceding the survey. Multilevel binary logistic regression analyses were carried out to understand the net effect of predictor variables on the utilization of maternity care. The results show that the utilization of maternal health services is considerably low in Afghanistan. Only about 18%, 48%, and 33% Afghan mothers had availed themselves of antenatal care (ANC), safe delivery, and postnatal care (PNC) services, respectively. Findings have indicated a considerable amount of variation in the use of maternity care depending on education, wealth, ethnicity, parity, and place of residence. Maternal care in Afghanistan is associated with a woman and her partner’s education, ethnicity, wealth, parity, exposure to mass media, and place of residence. The chapter finds a strong association between the utilization of antenatal care and both safe delivery and postnatal care. Exposure to mass media and mothers’ participation in health expenditure decision-making are positively associated with maternal care utilization in Afghanistan. These results suggest the need to adopt a targeted approach to reduce differentials in the utilization of maternal care in Afghanistan. In the short term, the government should focus on promoting antenatal care and the use of mass media. In the long term, the government should promote girl’s education and reduce wealth inequalities. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024.PublicationBook Chapter Inadequate Iron–Folic Acid Consumption Among Pregnant Mothers in India: A Spatial Analysis(Springer Nature, 2025) Aditya P. Singh; Mahashweta Chakrabarty; Sourav Chowdhury; Shivani Paratap Singh; Rakesh ChandraDespite guidelines recommending that every expectant mother take 100 iron–folic acid (IFA) tablets or an equivalent amount of syrup for 100 days, over 70% of Indian mothers do not adhere to this recommendation. Understanding the geographical distribution of insufficient IFA intake and the factors influencing it is crucial for developing targeted prevention and intervention strategies. However, prior to this chapter, research exploring the geographic disparities in IFA consumption and its determinants in India has been limited. Therefore, this chapter aims to address this research gap by examining the spatial patterns of inadequate IFA consumption at the district level and identifying the factors explaining these district-level spatial patterns. This chapter analyzed data from 141,875 married women aged 15–49, using the fourth round of the NFHSs (2019–2021). The dependent variable, inadequate IFA, was defined as consuming fewer than the recommended 100 IFA tablets or equivalent syrup. A district-level prevalence map was prepared to assess the spatial pattern of inadequate IFA consumption. Further, spatial clustering in IFA consumption was evaluated by using Moran’s I statistic and bivariate local indicators for spatial association (BiLISA) maps. Finally, the correlates of inadequate IFA consumption were examined by using ordinary least squares, spatial lag, and spatial error models. The overall prevalence of inadequate IFA consumption in India was 70%, with substantial spatial heterogeneity across different regions, districts, and even socioeconomic groups. The statistically significant spatial autocorrelation value for inadequate IFA consumption indicated the existence of clustering in the distribution of inadequate IFA consumption across the districts of India. Further analysis revealed that several clusters of high values of inadequate IFA were concentrated primarily in the districts of empowered action group (EAG) states—i.e., Bihar, Uttar Pradesh, Madhya Pradesh, Jharkhand, and Rajasthan. BiLISA analysis revealed that the districts with high rates of inadequate IFA consumption also had high rates of poverty and illiteracy, a higher number of Scheduled Caste (SC) and Scheduled Tribe (ST) mothers, high rates of early marriage, the inadequate coverage of antenatal care (ANC), and low levels of mass-media exposure. Among the three regression models applied, the spatial error model was the best. The results of the model suggested that inadequate IFA consumption at the district level was positively associated with ANC visits and negatively associated with a respondent’s education. Considerable spatial heterogeneity exists at the district level in the consumption of inadequate IFA among expectant mothers in India. Redirecting resources to vulnerable subgroups and geographical areas that were identified as lagging in this study would be critical to ensuring equitable progress in reducing IFA deficiency-related anemia among expectant mothers across the country. In addition, appropriate interventions need to be introduced to increase the average number of ANC visits in districts where IFA consumption is substantially low. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024.PublicationArticle Why Do Working Women Experience More Violence Than Non-Working Women in India? A Decomposition Analysis Using Nationally Representative Survey Data(SAGE Publications Inc., 2025) Rakesh Chandra; Sonal Srivastava; Jeetendra Kumar Patel; Saradiya Mukherjee; Aditya P. SinghIn India, multiple studies highlight that the prevalence and odds of intimate partner violence (IPV) is higher among working women than non-working women. Such evidence, though counterintutive, dismantles the notion that women’s employment substantially reduces IPV or acts as a protective factor. To explore this anomaly, our study utilizes data from the National Family Health Survey (2019-21) and quantitatively examines the factors of IPV in relation with women’s employment status in the Indian context. In the first step, a logistic regression model has been deployed to analyse the factors of IPV among women in India. This analysis is followed by Fairlie Decomposition to investigate the factors that contribute to higher IPV prevalence among working women in India. The decomposition model explained 49% of the gap in IPV across working status of women. Men’s controlling behavior (−32.3%) and alcohol consumption (−32.3%), which are significant risk factors of IPV, collectively contributed about 65% in this explained gap in IPV, reducing the IPV gap between working and non-working women. Other significant contributors were women’s justification of IPV (−14.17%), women’s education (−11.08%), household wealth (−8.05%), religion (−17.92%), region (−3.52%), number of children (−3.89%), and internet use (−2.39%) reducing the gap whereas residence (3.57%) and caste category (2.62%) contributed to widening the gap. The current study finds an explanation for the uncharacteristic role of employment in relation to IPV, exposing men’s characteristics such as controlling behavior and alcoholism as the main drivers of IPV across working and non-working women overriding the preventive effects of employment. Policies related to violence against women are recommended to shift and gear their focus on targeted interventions with men to address the perpetration behavior alongside women’s education, social categories, residence, etc., to prevent IPV among women in India. © The Author(s) 2025PublicationArticle WASH, Women, and Violence: Investigating the Associations Between Households’ Access to WASH Facilities and Intimate Partner Violence in India(SAGE Publications Inc., 2025) Rakesh Chandra; Ajay Dutta; Sonal Srivastava; Saradiya Mukherjee; Aditya P. SinghPoor access to water, sanitation, and hygiene (WASH) facilities heightens women's vulnerability to partnered and non-partnered violence and disproportionately impacts their health and well-being. However, no national-level study in India explores the links between WASH access and violence against women. This research examines household WASH access and its connection with intimate partner violence (IPV) against women in India. Utilizing 46,667 married women samples from National Family Health Survey (NFHS)-5 pan-India survey, the study analyses association of IPV with WASH indicators alongside other socio-economic variables. All WASH indicators in the study significantly associate with IPV, emphasizing an urgent need for gender-sensitive WASH research and policymaking. © The Author(s) 2025PublicationArticle Understanding the drivers of urban–rural divide in women’s internet use in India: a decomposition approach(Springer Nature, 2025) Anshika Singh; Rakesh Chandra; Aditya P. Singh; Utkarsh Jain; Shivani Paratap SinghDespite SDG 9’s target of universal internet access, many women, particularly in rural India, remain offline. While digital infrastructure has expanded rapidly, sharp rural–urban disparities in women’s internet use persist, with limited research on their scale and drivers. This study addresses that gap by analysing the determinants of rural–urban differences in women’s internet use in India. We used nationally representative data from the fifth round of the National Family Health Survey (2019–21). The analysis included 1,03,119 women aged 15–49 (25,483 urban; 77,636 rural). Logistic regression identified predictors of internet use, while Fairlie decomposition quantified contributions to the rural–urban gap. Overall, 33% of women in India use the internet, with higher prevalence in urban (51.7%) than rural (24.8%) areas. Goa has the highest rural prevalence and West Bengal the lowest; in urban areas, Sikkim leads and Andhra Pradesh lags. The rural–urban gap is widest in Mizoram, Jharkhand, and Himachal Pradesh, but narrowest in Goa, Kerala, and Manipur. Education and household wealth are strong predictors of women’s internet use, with educated women and those from wealthier households more likely to be online. Decomposition analysis shows that wealth (67.4%), education (25.8%), and social group (4.5%) are the major contributors to the rural–urban gap. A pronounced rural–urban digital divide persists among Indian women, driven mainly by wealth, education, and social group. Addressing this gap requires policies that strengthen rural digital infrastructure and economic opportunities, alongside education and digital literacy initiatives. Targeted measures for disadvantaged social groups will further promote equitable and inclusive internet use. © The Author(s), under exclusive licence to Springer Nature Switzerland AG 2025.PublicationArticle Spatial disparities in death registration across states and districts of India, 2019-21(BioMed Central Ltd, 2025) Aditya P. Singh; Ananya Kundu; Sumit Ram; Rakesh Chandra; Arabindo Tanti; Shivani Paratap Singh; Vineet KumarBackground: The persistent issue of incomplete death registration in India, with a significant number of deaths going unrecorded, underscores the critical need for a granular understanding of spatial variations. Given the nation’s vast geographic and demographic diversity, this granular understanding, particularly at the district level, is crucial for effective interventions. This analysis, therefore, aims to examine spatial disparities in death registration at both the state and district levels across India. Data and methods: Using data from the fifth round of the National Family Health Survey (NFHS-5) conducted in 2019-21, this study analyzed information on 79,449 deaths occurring in the three years preceding the survey, across 707 districts in India. The study explored spatial patterns and identified clusters of death registration using Moran’s I and univariate Local Indicators of Spatial Association (LISA) maps. Additionally, spatial regression models were employed to examine the factors influencing death registration at the district level. Results: In 2019-21, only 71% of deaths in India were registered, with significant variations across states and districts. The univariate Moran’s I value of 0.69 (p < 0.001) indicated strong spatial clustering in death registration at the district level. Two notable ‘cold spots’—districts with low death registration rates surrounded by other low-registration districts—were identified across 152 districts, primarily in the eastern states of Uttar Pradesh, Jharkhand, Bihar, and the northeastern regions of Arunachal Pradesh, Nagaland, and parts of Manipur. Results from regression models revealed that factors such as the proportion of poor households, rural households, Muslim and Scheduled Tribe (ST) households, and households with at least one uneducated member were negatively associated with death registration at the district level. Conclusions: The findings suggest the necessity for region-specific focused interventions to improve death registration in India, taking the social determinants of death registration into consideration and raising societal awareness about it. © The Author(s) 2025.PublicationArticle Examining the unfair concentration of non-institutional deliveries among poor households in India: a study of predictors and wealth-based inequality(BioMed Central Ltd, 2025) Rakesh Chandra; Jeetendra Kumar Patel; Sonal Srivastava; Saradiya Mukherjee; Aditya P. SinghBackground: Non-institutional deliveries, defined as childbirth outside healthcare facilities, remain a significant global concern. It poses serious maternal and child health problems and significantly contributes to maternal and infant mortality. India witnessed a sustained decrease in non-institutional deliveries in thepast 20 years. However, the rate of decline has tapered recently while the country still has a sizeable number of women delivering out of the facility. To better understand the enduring proportions of non-institutional deliveries, this study preliminarily analyses its predictors. The prime objective of the study is to unravel the inequality in the prevalence of non-institutional deliveries and understand if they are unfairly concentrated among certain households in India. It also aims to provide policy-relevant insights into the socioeconomic factors contributing to its concentration among specific households and their implications for maternal and child health. Methodology: Using the National Family Health Survey-5 (NFHS-5) data (N = 1,75,569 deliveries), we developed a regression model to understand the existing non-institutional deliveries and their predictors. We employed the Erreygers’ Concentration Index (ECI) to quantify the degree of concentration (inequality) of non-institutional deliveries among households. Furthermore, a decomposition analysis was run to analyse the factors contributing to the concentration of non-institutional deliveries in a particular groups of households. It breaks down the overall inequality at population level into its constituent parts to identify the sources of inequality. This approach helps discover prime causes of inequality, such as differences in income, education, or other relevant factors. Findings: Out of the total sampled deliveries in the reference period, around 14% were non-institutional. Inequality analysis (ECI=-0.2174; p-value < 0.0001) suggests that non-institutional deliveries were unequally and unfairly concentrated in low-income households. The concentration of non-institutional deliveries in poor households was majorly contributed by factors like education (13.85%), wealth (13.91%), mass media exposure (12.27%) region (9.76%), birth order (3.17%), distance to health facilities (2.77%), caste (2.82%), timing of first ANC visit (1.07%), and women considering having to take transport as a problem (1.60%). Conclusions: This research employs inequality analyses of non-institutional deliveries and contributes to the existing literature by establishing its unfair concentration among poor households in India. It expands our understanding of the factors driving non-institutional deliveries among the disadvantaged. The findings highlight the importance of targeted interventions and policies to reduce the concentration of last-mile non-institutional deliveries among vulnerable women living in marginalized households. © The Author(s) 2025.PublicationArticle Trends and determinants of obesity among ever-married women aged 15–49 in India: insights from National Family Health Surveys (NFHS 1998–2021)(BioMed Central Ltd, 2025) Aditya P. Singh; Sadanand Karun; Mahashweta Chakrabarty; Rakesh Chandra; Shivani Paratap SinghBackground: Obesity has emerged as a significant public health concern in India, particularly among ever-married women of reproductive age (EMWRA). This study analyses trends in obesity among EMWRA across India and its states from 1998 to 2021 and explores the factors contributing to obesity in this group. Methods: Data from four National Family Health Survey (NFHS) rounds, spanning 1998-99 to 2019-21, were pooled to create a dataset of 1,117,433 participants. We analysed obesity trends in India and its states and assessed β- and σ-convergence in obesity rates during this period. Additionally, we examined changes in socioeconomic differentials in obesity over this period. Binary logistic regression was used to explore the association of obesity with socioeconomic, demographic, and temporal factors. Results: Over the study period, obesity among ever-married women of reproductive age (EMWRA) in India has shown a startling increase, tripling from 5.1% (95% CI: 4.7–5.5) in 1998-99 to 15.7% (15.4–15.9) in 2019-21. While obesity rates have surged across all states, the degree of increase varies significantly (ranging from 22.9% points in Tamil Nadu to 2.6 in Meghalaya). Presently, two prominent regions in the country exhibit high obesity rates: the southern region, including Tamil Nadu (29%), Kerala (25%), Goa (25%), and Andhra Pradesh (23%), and the northwestern region, encompassing Delhi (33%), Punjab (31%), and Haryana (24%). Moreover, the disparity in obesity rates across states has widened over time, with states initially showing higher rates experiencing a faster growth rate compared to those with lower initial rates, as highlighted by the β- and σ-convergence analyses. There was substantial variation in obesity rates across education, wealth, place of residence, and social group categories. The risk of obesity is higher among older, educated, wealthy, non-Hindu EMWRAs and TV watchers, but lower among those living in rural areas, the southern region, smaller households, and belonging to SC, ST, and OBC social groups. Conclusion: The surge in obesity among Indian ever married women of reproductive age calls for immediate public health measures. Customized strategies, acknowledging regional differences, are vital to tackle diverse obesity rates across states. Prioritizing vulnerable groups, including the poor, uneducated, and urban populations, is critical for ensuring fair health outcomes. © The Author(s) 2025.