Antenatal health, healthcare utilisation, and barriers to care among homeless women in Kolkata, India: a mixed-methods cross-sectional study

Abstract

Homeless women experience disproportionate maternal health risks, yet evidence on antenatal health and healthcare utilisation among this population remains limited in low- and middle-income countries, including India. Antenatal health is central to maternal and neonatal outcomes, but existing Indian studies have largely focused on service utilisation rather than health status and access barriers. We conducted an exploratory convergent mixed-methods cross-sectional study among homeless pregnant women in Kolkata during 2022–2023, India, integrating quantitative survey data with qualitative in-depth interviews. Quantitative data were collected from 400 homeless women aged 15–49 years using time–location sampling. Poor antenatal self-rated health (SRH) was assessed alongside self-reported morbidities and healthcare-seeking behaviour. Multivariable penalized logistic regression was used to identify independent predictors of poor SRH. Additionally, 32 in-depth interviews were conducted to explore barriers to antenatal care utilisation, analysed using inductive thematic analysis. Over half of participants reported poor antenatal SRH (53.0%). Depression or anxiety, anaemia, swelling of extremities, sexually transmitted infections, and gestational diabetes were prevalent. Poor SRH was independently associated with adolescent pregnancy, early childbearing, chronic homelessness, living alone, rough sleeping, exposure to violence, and higher antenatal care visits, reflecting need-driven utilisation. Qualitative findings revealed intersecting sociocultural beliefs, stigma within health facilities, economic precarity, competing livelihood priorities, and limited perceived relevance of antenatal care as key barriers to service use. The integration of quantitative and qualitative evidence demonstrated that antenatal health inequalities among homeless women are driven by both measurable socioeconomic disadvantages and complex structural, behavioural, and health-system barriers. Strengthening outreach-oriented, trauma-informed, and shelter-linked antenatal services is essential to improve maternal health equity and advance progress toward Sustainable Development Goal 3.