Safe motherhood is a fundamental pillar of public health, emphasizing the need for comprehensive antenatal care (ANC), maternal nutrition, and access to skilled delivery services to ensure the health and well-being of both mother and child. Globally, improvements in maternal health have been central to public health agendas; yet, in many rural and remote areas, including regions of Himachal Pradesh, challenges persist. Despite India's significant strides in reducing maternal mortality rates, rural populations continue to experience disparities in access to quality antenatal and maternal health services, undermining the goal of universal safe motherhood [1-3].

Antenatal care is critical not only for monitoring the health of the mother and fetus but also for providing essential  health  education,   nutritional   counseling,  and early identification of pregnancy-related complications. The World Health Organization recommends a minimum of four ANC visits during pregnancy to optimize maternal and neonatal outcomes. However, in rural Himachal Pradesh, limited health infrastructure, lack of awareness, socio-cultural barriers, and geographic inaccessibility often result in inadequate ANC coverage. Nutrition during pregnancy, another cornerstone of safe motherhood, is frequently compromised by poor dietary practices, food insecurity, and traditional beliefs, contributing to adverse outcomes such as low birth weight and maternal anemia [4-6].

Institutional deliveries—births occurring in healthcare facilities under the supervision of skilled professionals—are crucial in preventing maternal and neonatal deaths. Yet, many women in rural settings still deliver at home without trained assistance, due to factors including limited transportation, financial constraints, mistrust of health systems, and cultural preferences. While government initiatives such as Janani Suraksha Yojana (JSY) and Pradhan Mantri Matru Vandana Yojana (PMMVY) aim to promote institutional deliveries and improve maternal nutrition, their awareness and utilization among rural women remain variable [8-10].

Understanding the current level of public awareness regarding antenatal care, maternal nutrition, and institutional deliveries in rural Himachal Pradesh is vital for identifying gaps and barriers. This study seeks to evaluate the knowledge, attitudes, and practices related to maternal health services among rural women, thereby providing insights to strengthen health education programs and enhance service delivery mechanisms to promote safe motherhood.

Study Design

A descriptive, cross-sectional community-based survey was conducted to assess public awareness of antenatal care (ANC), maternal nutrition, and institutional delivery practices among women residing in rural areas of Himachal Pradesh.

Study Area and Population

The study targeted women aged 18–45 years living in rural villages across selected districts of Himachal Pradesh. Eligible participants included women who were either currently pregnant or had delivered a child within the past two years. Women were required to comprehend Hindi or English to ensure clear communication and understanding of the questionnaire.

Study Duration

Data collection was undertaken over a three-month period, from January to March 2025.

Sample Size and Sampling Technique

Assuming a 50% prevalence of adequate awareness regarding antenatal care practices (due to limited prior regional data), with a 95% confidence interval and a 5% margin of error, the minimum required sample size was calculated as 384. To account for possible incomplete responses, a final target sample size of 420 women was set.

Participants were selected using a multistage random sampling technique:

• First, districts were randomly selected

• Then, within each district, villages were randomly chosen

• Eligible women within selected villages were approached using door-to-door visits with the assistance of local community health workers (ASHAs and ANMs)

Inclusion and Exclusion Criteria

Inclusion Criteria

• Women aged 18–45 years

• Residents of rural Himachal Pradesh for at least one year

• Currently pregnant or had a live birth within the last two years

• Ability to understand Hindi or English

• Willingness to provide informed written consent

Exclusion Criteria

• Women with diagnosed cognitive impairment or severe mental health conditions affecting the ability to respond

• Women unwilling or unable to provide informed consent

Data Collection Instrument

A structured, bilingual (Hindi and English) and pre-tested questionnaire was developed for data collection. The questionnaire consisted of four sections:

• Socio-Demographic Profile: Age, education, marital status, occupation, socio-economic status, and healthcare access

• Antenatal Care Awareness: Number of ANC visits, knowledge of recommended services (e.g., blood pressure monitoring, iron-folic acid supplementation, tetanus immunization)

• Maternal Nutrition: Knowledge of dietary requirements during pregnancy, awareness of nutritional supplements, and understanding of anemia prevention

• Institutional Deliveries: Awareness and attitudes toward delivery in healthcare facilities, knowledge of government programs like JSY and PMMVY, and barriers to institutional deliveries

  • Correct answer: 1 point

The questionnaire underwent pilot testing with 30 women from a non-study village to assess clarity, cultural relevance, and ease of administration. Revisions were made based on feedback before final deployment.

Data Collection Procedure

Data were collected through face-to-face interviews conducted by trained female investigators and supervised by senior researchers. Each interview was conducted in the local language, ensuring comprehension and comfort for the participants. Informed written consent was obtained prior to participation, and privacy was maintained during the interviews to encourage honest responses.

Scoring and Categorization

Responses to knowledge-based questions were scored as follows:

• Incorrect or "Don't Know" answer: 0 points

• Knowledge scores were categorized into four levels

• Very Good Awareness: ≥80% correct responses

• Good Awareness: 60–79% correct responses

• Fair Awareness: 40–59% correct responses

• Poor Awareness: <40% correct responses

Separate scores were also computed for ANC awareness, maternal nutrition knowledge, and understanding of institutional delivery importance.

Data Analysis

Collected data were entered into Microsoft Excel and analyzed using IBM SPSS Statistics Version 26.0. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize demographic details and awareness levels. 

Ethical Considerations

Written informed consent was obtained from all participants prior to data collection. Confidentiality and anonymity were strictly maintained, and participation was voluntary, with participants allowed to withdraw at any point without any consequences.

The socio-demographic profile of the 420 women surveyed revealed that the majority were between 26–35 years of age (39.3%), followed by 18–25 years (35.2%) and 36–45 years (25.5%). A significant majority of participants (90.0%) were married, with only 10.0% being widowed or divorced. Educationally, most respondents had attained secondary school (36.2%) or undergraduate degrees (34.0%), while a smaller proportion had postgraduate education (10.2%), primary schooling (12.6%), or no formal education (6.9%). In terms of occupation, more than half of the women (56.0%) were homemakers, with others engaged in agricultural work (19.5%), self-employment (16.0%), or being unemployed (8.6%). Socio-economically, a considerable percentage of participants belonged to low-income households (45.0%), followed by middle-income (42.4%) and high-income groups (12.6%), reflecting a predominantly modest rural economic background (Table 1).

Table 1: socio-demographic characteristics of participants

The study findings revealed an encouraging overall awareness regarding antenatal care and maternal health services among participants. Approximately 80.0% correctly identified the WHO-recommended minimum of four ANC visits, while 83.8% knew that blood pressure monitoring is a crucial component of ANC. Knowledge about iron-folic acid supplementation (76.0%) and the association between poor maternal nutrition and low birth weight (81.2%) was substantial. Awareness of tetanus vaccination during pregnancy was slightly lower (72.6%). The importance of institutional delivery was recognized by a high 85.7% of participants, while 82.6% understood ANC’s role in detecting pregnancy complications early. However, awareness regarding government programs like Janani Suraksha Yojana (63.8%) and Pradhan Mantri Matru Vandana Yojana (60.7%) was relatively modest, indicating a gap in knowledge about available financial support schemes. Nutrition-related knowledge, such as the importance of protein-rich diets (70.0%), calcium supplementation (66.4%), and the risk of anemia (74.3%), was reasonably good but still left room for improvement. Moreover, participants showed strong awareness that skilled birth attendance is critical (84.0%) and that ANC should include health education like breastfeeding counseling (71.9%) (Table 2)

Table 2: awareness and knowledge of antenatal care and maternal health services among participants

Based on their knowledge scores, 46.2% of the participants demonstrated a "Good" level of awareness, correctly answering between 60%–79% of the questions. Notably, 29.3% exhibited "Very Good" awareness with scores of 80% or above, indicating a considerable proportion of well-informed women. However, 19.0% of participants fell into the "Fair" knowledge category (40%–59% correct answers), and 5.5% were classified as having "Poor" awareness with less than 40% correct responses. These results emphasize that although overall awareness was commendable among the rural women surveyed, there remains a critical segment of the population requiring targeted educational interventions to ensure universal understanding and application of safe motherhood practices (Table 3).

Table 3: knowledge score classification

This study provides critical insights into the current awareness levels and knowledge gaps regarding antenatal care (ANC), maternal nutrition, and institutional deliveries among women residing in rural areas of Himachal Pradesh. Despite the substantial efforts made at national and state levels to promote safe motherhood practices, our findings highlight that while a significant proportion of women demonstrate good understanding, there remains a considerable segment with fair to poor awareness, thereby posing a persistent challenge to achieving universal maternal health goals.

The socio-demographic profile of the study participants revealed that the majority were in the reproductive age group of 26–35 years, with a high prevalence of marriage (90%). Educational attainment was encouraging, with over 70% of participants having completed at least secondary education. However, a notable 19.5% were involved in agricultural labor, reflecting the rural economy's heavy reliance on agrarian livelihoods, which may limit women's ability to access and prioritize health services due to occupational demands and financial constraints. Nearly half of the respondents belonged to low socio-economic backgrounds, underlining the intersection between poverty and health inequities that continue to affect maternal healthcare utilization.

In terms of awareness of antenatal care, it is promising that 80% of women correctly knew the WHO recommendation for at least four ANC visits, and an impressive 83.8% recognized the importance of blood pressure monitoring during pregnancy. This suggests that essential ANC components are increasingly being understood, possibly due to strengthened frontline health worker activities (such as ASHA-led initiatives) in rural Himachal Pradesh. Nonetheless, awareness about financial support programs like Janani Suraksha Yojana (63.8%) and Pradhan Mantri Matru Vandana Yojana (60.7%) remained modest, implying that despite policy efforts, dissemination of information about maternal benefits is not reaching the entire rural populace effectively. Strengthened awareness campaigns and clearer communication by health workers regarding these schemes could bridge this gap.

Maternal nutrition knowledge showed encouraging trends, with over 70% of participants correctly linking poor nutrition to adverse pregnancy outcomes such as low birth weight and maternal mortality. Awareness of iron-folic acid supplementation (76.0%) and the role of a protein-rich diet (70.0%) were fairly high, although calcium supplementation awareness (66.4%) was relatively lower. This highlights the need for intensified nutrition counseling during ANC visits, especially focusing on micronutrient importance beyond anemia prevention, to ensure comprehensive maternal and fetal well-being.

One of the most promising findings was the high recognition of the importance of institutional deliveries (85.7%) and the role of skilled birth attendants (84.0%). This indicates a positive shift away from traditional home deliveries, which historically posed significant risks to maternal and neonatal survival. However, lingering cultural preferences, transportation challenges, and perceived quality of care issues may still act as barriers that prevent some women from opting for institutional births despite this awareness. Therefore, future interventions must not only focus on knowledge dissemination but also on addressing structural and perceptual barriers to healthcare facility utilization.

Knowledge score analysis revealed that while nearly three-fourths (75.5%) of participants demonstrated either "Good" or "Very Good" awareness, about 24.5% fell into "Fair" or "Poor" categories. This segment represents a vulnerable group at greater risk of experiencing preventable maternal and neonatal complications. Targeted educational interventions, peer support groups, and personalized ANC counseling can be instrumental in uplifting these women from informational disadvantage, thereby promoting equity in maternal health outcomes.

It is important to acknowledge the limitations of the study. The sample was limited to women residing in rural areas of selected districts in Himachal Pradesh and thus may not be fully generalizable to all rural populations or tribal communities with unique challenges. Additionally, the reliance on self-reported knowledge could introduce social desirability bias, with participants possibly providing what they perceived as expected responses rather than true reflections of their understanding.

In conclusion, while this study demonstrates that awareness regarding antenatal care, maternal nutrition, and institutional deliveries is progressively improving among rural women in Himachal Pradesh, significant gaps remain, particularly regarding government benefit schemes and nuanced aspects of maternal nutrition. Strengthening health education through community engagement, improving the reach and impact of financial incentive programs, and addressing systemic healthcare access barriers are essential steps toward achieving the vision of safe motherhood for every woman, regardless of geographic or socio-economic status. Focused, culturally sensitive, and community-driven initiatives must continue to be prioritized to ensure that no mother is left behind in the journey toward maternal health equity.

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