Multilevel analysis of determinants in postnatal care utilisation among mother-newborn pairs in India, 2019-21.

Background: Postnatal care (PNC) utilisation within 24 hours of delivery is a critical component of health care services for mothers and newborns. While substantial geographic variations in various health outcomes have been documented in India, there remains a lack of understanding regarding PNC utilisation and underlying factors accounting for these geographic variations. In this study, we aimed to partition and explain the variation in PNC utilisation across multiple geographic levels in India. Methods: Using India's 5th National Family Health Survey (2019-21), we conducted four-level logistic regression analyses to partition the total geographic variation in PNC utilisation by state, district, and cluster levels, and to quantify how much of theses variations are explained by a set of 12 demographic, socioeconomic, and pregnancy-related factors. We also conducted analyses stratified by selected states/union territories. Results: Among 149 622 mother-newborn pairs, 82.29% of mothers and 84.92% of newborns were reported to have received PNC within 24 hours of delivery. In the null model, more than half (56.64%) of the total geographic variation in mother's PNC utilisation was attributed to clusters, followed by 26.06% to states/union territories, and 17.30% to districts. Almost 30% of the between-state variation in mother's PNC utilisation was explained by the demographic, socioeconomic, and pregnancy-related factors (i.e. state level variance reduced from 0.486 (95% confidence interval (CI) = 0.238, 0.735) to 0.320 (95% CI = 0.152, 0.488)). We observed consistent results for newborn's PNC utilisation. State-specific analyses showed substantial geographic variation attributed to clusters across all selected states/union territories. Conclusions: Our findings highlight the consistently large cluster variation in PNC utilisation that remains unexplained by compositional effects. Future studies should explore contextual drivers of cluster variation in PNC utilisation to inform and design interventions aimed to improve maternal and child health.