Antenatal Care in India: The GoI Model
Comprehensive overview of the current Antenatal Care provision and the role of ASHAs/Doulas
Table of Contents
Introduction to Antenatal Care in India
Antenatal Care (ANC) in India has undergone significant evolution over the past decades as the country aims to improve maternal and infant health outcomes. Despite improvements, India still faces challenges in achieving universal coverage of quality antenatal care services. According to recent data, only about 21% of pregnant women in India receive full antenatal care, with significant variations across states ranging from 2.3% to 65.9%.
ASHA worker providing antenatal care to a pregnant woman in rural India
Key Antenatal Care Statistics in India
- 51.6% of pregnant women have 4 or more ANC visits
- 30.8% consume Iron-Folic Acid (IFA) for at least 100 days
- 91.1% receive one or more doses of tetanus toxoid
- ANC utilization shows inequity across place of residence, caste, and maternal education
Current GoI Model of ANC Provision
The Government of India’s current model for Antenatal Care is implemented through the National Health Mission (NHM), which defines quality antenatal care as care provided by skilled healthcare providers to pregnant women. The model has evolved from focusing on a minimum of four antenatal visits to gradually aligning with WHO’s recommendations of eight contacts.
Core Components of India’s ANC Model
In India, the National Health Mission defines quality antenatal care as consisting of:
- Timely pregnancy registration (ideally in the first trimester)
- A minimum of four antenatal care visits
- Comprehensive physical examination
- Identification and referral for danger signs
- Consumption of at least 100 Iron-Folic Acid tablets
- At least one tetanus toxoid injection
- Blood pressure monitoring and urine testing
- Abdominal examination and fetal heart rate monitoring
| Visit Schedule | Recommended Timing | Key Services |
|---|---|---|
| First Visit | First trimester (as soon as pregnancy is suspected) | Registration, baseline assessment, nutritional counseling, IFA supplementation, tetanus toxoid |
| Second Visit | 4-6 months (around 26 weeks) | Weight monitoring, blood pressure check, abdominal examination, IFA continuation |
| Third Visit | 8th month (around 32 weeks) | Fetal growth assessment, danger sign identification, birth preparedness counseling |
| Fourth Visit | 9th month (36-40 weeks) | Final assessment, delivery planning, postnatal care guidance |
Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)
A significant enhancement to India’s ANC model is the Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), launched by the Ministry of Health & Family Welfare. This flagship program aims to improve the quality and coverage of antenatal care services across the country.
Key Features of PMSMA
- Fixed-day assured, comprehensive, and quality antenatal care provided free of cost
- Services delivered on the 9th day of every month at designated government health facilities
- Special focus on pregnant women in their 2nd and 3rd trimesters
- Identification and management of high-risk pregnancies
- Involvement of private sector practitioners on a voluntary basis
- Guaranteed minimum package of antenatal services
The PMSMA program complements existing antenatal care services by ensuring that every pregnant woman receives at least one comprehensive checkup during the critical second and third trimesters. This approach helps identify and manage high-risk conditions that may have been missed during routine ANC visits.
WHO Guidelines for ANC
While India’s current model focuses on a minimum of four ANC visits, the World Health Organization released updated guidelines in 2016 recommending an increased frequency of antenatal contacts. These guidelines are gradually being incorporated into India’s maternal health programs.
The WHO 8+ Contact Model
The WHO recommends a minimum of eight antenatal care contacts, structured as follows:
| Trimester | Contacts | Timing (weeks of gestation) |
|---|---|---|
| First Trimester | Contact 1 | Up to 12 weeks |
| Second Trimester | Contact 2 | 20 weeks |
| Contact 3 | 26 weeks | |
| Third Trimester | Contact 4 | 30 weeks |
| Contact 5 | 34 weeks | |
| Contact 6 | 36 weeks | |
| Contact 7 | 38 weeks | |
| Contact 8 | 40 weeks (with return for delivery at 41 weeks if not given birth) |
Evidence-Based Rationale: Research indicates that eight or more contacts for antenatal care can reduce perinatal deaths by up to 8 per 1000 births compared to the traditional four-visit model. The increased frequency allows for earlier detection and management of complications.
In India, there is growing recognition of the need to transition from the minimum four-visit model to the WHO-recommended eight-contact model, particularly in regions with high maternal and infant mortality rates. However, implementation challenges remain, including healthcare workforce capacity and infrastructure limitations.
Role of ASHAs in Antenatal Care
Accredited Social Health Activists (ASHAs) are the cornerstone of India’s community health worker program and play a pivotal role in delivering antenatal care services, particularly in rural and underserved areas. As part of the National Rural Health Mission (NRHM), ASHAs serve as the critical link between pregnant women and the formal healthcare system.
Key Functions of ASHAs in ANC
- Early identification and registration of pregnant women in their communities
- Facilitating at least four antenatal check-ups and ensuring hospital deliveries
- Counseling on birth preparedness, importance of safe delivery, and institutional delivery
- Promoting consumption of IFA tablets and ensuring tetanus toxoid immunization
- Identifying danger signs during pregnancy and facilitating timely referral
- Accompanying women to health facilities for antenatal check-ups when required
- Conducting home visits to monitor high-risk pregnancies
- Creating awareness about government schemes like Janani Suraksha Yojana (JSY) and PMSMA
- Mobilizing community support for pregnant women and promoting appropriate care-seeking behavior
ASHA Program in Numbers
Currently, there are approximately 983,032 ASHAs positioned across India against the target of 1,034,630 (95% in position). The program follows the norms of:
- One ASHA for every 1,000 population in rural areas
- One ASHA covering 2,500 population in urban areas
Research studies have shown that exposure to ASHA services is associated with a 17% increase in first antenatal care visits and a 5% increase in women receiving four or more ANC visits. Their community-based approach has been particularly effective in addressing socio-cultural barriers to accessing antenatal care.
Role of Doulas in Indian Context
Unlike ASHAs who are integrated into the government health system, doulas in India represent an emerging complement to formal maternal healthcare, particularly in urban settings. Doulas provide non-medical emotional, physical, and informational support during pregnancy, childbirth, and the postpartum period.
Doulas in the Indian Healthcare Landscape
The concept of professional doula services is relatively new in India but is gaining recognition, especially among urban, middle to upper-class families. While traditional birth companions have existed in various forms across different communities in India, professional doulas with formal training are more recent additions to the maternal support system.
Differentiating Doulas from ASHAs and Medical Providers
It’s important to note that doulas do not replace medical care or the role of ASHAs. Their role is complementary and focuses on:
- Providing continuous emotional and physical support during labor
- Offering evidence-based information to help women make informed decisions
- Using comfort measures and positioning techniques during labor
- Advocating for the mother’s wishes in clinical settings
- Supporting breastfeeding and early bonding
In India, doulas typically charge between ₹15,000 to ₹35,000 per client and may serve one to three clients at a time. They typically undergo training workshops provided by international organizations from the US, Canada, or Australia that offer certification.
While doulas are not formally integrated into India’s public health system, they represent a growing trend in personalized maternal care that may influence future policies and programs around childbirth support. Organizations like The Doula Collective in India are working to provide culturally sensitive doula training that respects the diverse traditions and practices across the country.
Challenges and Gaps in ANC Services
Despite significant progress, India continues to face several challenges in providing comprehensive antenatal care to all pregnant women. Understanding these challenges is crucial for nursing professionals working within the system.
| Challenge Area | Specific Issues | Impact on ANC |
|---|---|---|
| Coverage and Equity | Wide disparities across states, rural-urban divide, socioeconomic factors | Variable ANC utilization from 2.3% to 65.9% across states |
| Quality of Care | Focus on quantity over quality, incomplete service delivery | With only 2 of 10 ANC visits deemed of adequate quality |
| Workforce Issues | Shortage of skilled providers, inadequate training, high workload | Compromised quality and comprehensiveness of care |
| Infrastructure and Resources | Inadequate facilities, equipment, and supplies | Inability to provide complete ANC package |
| Cultural and Social Barriers | Traditional beliefs, gender norms, decision-making power | Delayed care-seeking and non-compliance |
Nursing Insight
Understanding these challenges helps nurses adapt their care approach when working with pregnant women from diverse backgrounds. Nurses should be particularly attentive to women who may face multiple barriers to accessing care, such as those from rural, low-income, or marginalized communities.
Best Practices and Recent Updates
Based on emerging evidence and policy directions, here are three best practices and recent updates in antenatal care provision in India:
1. Integration of Digital Health Solutions
India is increasingly leveraging digital technologies to enhance antenatal care services. Mobile health applications and telemedicine platforms are being used to:
- Track and monitor pregnant women’s health parameters
- Send appointment reminders and health information through SMS
- Enable virtual consultations in areas with limited access to specialists
- Improve data collection and analysis for better program planning
The PMSMA program now incorporates digital tracking systems to monitor high-risk pregnancies identified during the monthly clinics, ensuring timely interventions.
2. Transition to the 8+ ANC Contact Model
India is gradually moving toward adopting WHO’s recommended 8+ antenatal contacts model:
- Pilot programs implementing the 8+ contact model are being evaluated in several states
- Enhanced focus on quality during each contact rather than just increasing the number of visits
- Revised training modules for healthcare providers emphasizing comprehensive assessments
- Integration of the expanded visit schedule into existing programs like PMSMA
This transition acknowledges the evidence that more frequent, quality contacts can significantly reduce perinatal mortality.
3. Enhanced Role of Midwifery in ANC
India has recently launched initiatives to strengthen midwifery services as part of improving maternal and newborn care:
- Introduction of professional midwifery services through the Midwifery Initiative of India
- Development of midwifery training programs aligned with international standards
- Integration of midwives as key providers of antenatal care, particularly for low-risk pregnancies
- Emphasis on woman-centered, respectful care during the antenatal period
This development represents a significant shift toward recognizing the value of dedicated maternal care specialists in improving birth outcomes.
Conclusion
The Government of India’s model for antenatal care provision continues to evolve, incorporating global best practices while addressing country-specific challenges. The complementary roles of ASHAs as community health workers within the formal system and doulas as personalized support providers represent different approaches to ensuring women receive comprehensive care during pregnancy.
For nursing students and professionals, understanding these models and the ongoing transitions in antenatal care delivery is essential for providing evidence-based, contextually appropriate care. As India works toward improving maternal health outcomes, the focus is increasingly on not just increasing coverage but also enhancing the quality of antenatal care services.
Key Takeaways for Nursing Practice
- Recognize the importance of early registration and regular antenatal check-ups
- Collaborate effectively with ASHAs for community outreach and follow-up
- Understand the complementary role that doulas can play in providing emotional support
- Stay updated on evolving guidelines, particularly the transition to the 8+ contact model
- Focus on providing quality care that addresses both physical and psychosocial needs
- Be sensitive to cultural, social, and economic factors that influence antenatal care-seeking behaviors