Family Gatekeeping in Antenatal care Decision-Making: A Qualitative Study among Women in Rural Sangareddy District, Telangana, India

Abstract Background: Family members, particularly mothers-in-law and husbands, play crucial roles in maternal healthcare decisions in rural India. Understanding these dynamics is essential for designing effective maternal health interventions in Telangana, where maternal mortality remains a public health challenge. Objectives: To explore the role of family members in antenatal care (ANC) decision-making among women in rural Telangana and identify multi-level factors influencing maternal healthcare access. Methods: A qualitative descriptive study was conducted in rural Telangana from June 2025 to October 2025. Twenty women who had delivered in the past six months were purposively sampled (20 of 25 women approached). In-depth interviews were conducted in Telugu (mean: 65 minutes), audio-recorded, transcribed, and analyzed using Braun and Clarke’s six-phase thematic analysis. Inter-coder reliability was achieved (Cohen’s κ =0.82, substantial agreement). Ethical approval was obtained (IEC/2025/045, May 15, 2025). Results: Four major themes emerged: (1) Individual-level factors — knowledge gaps about ANC importance and prior negative healthcare experiences; (2) Interpersonal influences — mother-in-law as primary decision-maker (most participants), husband’s financial control (majority of participants), and severely limited women’s autonomy (nearly all participants); (3) Community-level factors — cultural norms favoring traditional practices, Accredited Social Health Activist (ASHA) worker support; and (4) Healthcare system barriers — distance, cost, and provider attitude concerns (reported by 16 of 20 participants). Joint families showed stronger mother-in-law influence compared to nuclear families. Conclusion: Traditional family hierarchies significantly constrain women’s autonomy in maternal healthcare decisions in rural Telangana. Family-centered interventions targeting mothers-in-law and husbands, integrated with existing state programs, are essential to improve ANC utilization.