Beyond four: status, wealth-related inequality, and factors associated with eight or more antenatal care visits in India: a secondary analysis of the National Family Health Survey-5

The World Health Organization (WHO) recommends a minimum of eight antenatal care (ANC) visits, as this model is associated with better maternal and perinatal outcomes than the previously endorsed four-visit schedule. However, nationally representative evidence on frequency of eight or more ANC visits in India remains limited. This study aimed to assess the utilization of eight or more ANC visits and examine socioeconomic inequality and factors associated with receiving this level of ANC utilization in India. Data from 165,823 mothers aged 15–49 years from the National Family Health Survey-5 (2019–2021) were analysed. Bivariate associations between background characteristics and eight or more ANC visits were assessed using the chi-square test. Binary logistic regression was performed to identify the factors associated with eight or more ANC visits. Wealth-related inequality was assessed using the Erreygers Concentration Index (ECI) and concentration curve. Although 58.3% (95% CI: 57.7–58.8) of mothers received four or more ANC visits, only 19.2% (95% CI: 18.7–19.7) reported eight or more visits. Higher maternal age, lower birth order, intended pregnancy, previous pregnancy termination, higher education, greater household wealth, urban residence, residence in the Western and Southern regions, and mass media exposure were positively associated with receiving eight or more ANC visits. The ECI (0.194; p < 0.001) indicated significant pro-rich inequality, with the utilization of eight or more ANC visits disproportionately concentrated among wealthier mothers. The reported frequency of eight or more ANC visits remains low in India and is marked by substantial socioeconomic and geographic inequalities. Policies should prioritize women with lower educational attainment, those from poorer households, rural communities, and underperforming regions by strengthening community outreach, health communication, and equitable access to quality ANC to improve adherence to the WHO-recommended ANC schedule.