# Unmet Need for Completing the Antenatal Care Continuum Among Pregnant Women in Rural India: A Mixed-Methods Study

## TL;DR

This study in rural India finds that many pregnant women miss critical thyroid tests during antenatal care, risking high-risk pregnancies due to undiagnosed conditions.

## Contribution

The study combines mixed methods to quantify missed thyroid diagnoses and associated costs in rural India's antenatal care system.

## Key findings

- 59% of pregnant women had not undergone prior thyroid testing, with 5% found to have undiagnosed hypothyroidism.
- Most diagnostic investigations were performed at private facilities, with thyroid-stimulating hormone testing costing a median of ₹500.
- Undiagnosed thyroid disorders were more common in first-trimester pregnancies classified as high-risk.

## Abstract

Introduction

India’s National Health Programs aim to provide quality antenatal care (ANC). However, gaps remain, particularly in the availability of essential diagnostics such as thyroid function tests, which are critical for identifying high-risk pregnancies (HRPs). This study explores the proportion of missed at-risk pregnancies due to undiagnosed thyroid disorders and the associated out-of-pocket expenditure (OOPE) in rural Andhra Pradesh.

Methodology

A convergent parallel mixed-methods design was adopted, combining a cross-sectional study with focus group discussions and in-depth interviews. Quantitative data were collected from 96 pregnant women attending primary health centers (PHCs). Qualitative insights were gathered from healthcare providers and pregnant women with missed thyroid disorder diagnoses. The study was conducted over a one-year period (2024-2025) across four PHCs in Mangalagiri Mandal, Andhra Pradesh, India. Blood samples for thyroid function testing were collected at the PHCs and transported to a central laboratory at a tertiary care facility using drone technology.

Results

The study included women with a mean age of 24.0 years, most of whom were housewives with at least a high school education. Among them, 59% had not undergone prior thyroid testing, and 5% were found to have undiagnosed hypothyroidism. Women without prior testing were more likely to be in their first trimester and classified as HRPs. Most diagnostic investigations were performed at private facilities, with thyroid-stimulating hormone testing costing a median of ₹500.

Conclusions

While the National Health Program has strengthened ANC, critical gaps remain, particularly in the early diagnosis of thyroid disorders at the primary care level. Strengthening diagnostic capabilities, reducing OOPE, and ensuring timely follow-up for HRPs are essential to lowering maternal and neonatal mortality in rural settings.