Health Literacy and Attitudinal Dynamics in Maternal Health Service Utilisation: A Study of Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) in Urban Slums of Kolkata Municipal Corporation

Maternal health behaviours are dependent on a mother’s level of health literacy, which can either enable or hinder care-seeking, particularly in low-socioeconomic-status urban slum settings where access to comprehensive and timely antenatal care (ANC) services is often inadequate. Although the Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) offers free and inclusive ANC services across India, utilisation among pregnant women residing in the Kolkata Municipal Corporation (KMC) slums remains limited. A community-based mixed methods cross-sectional study was conducted among mothers who had delivered within the previous year to assess their understanding of ANC benefits, awareness of danger signs during pregnancy, and knowledge of PMSMA, supplemented by qualitative interviews exploring perceptions, barriers, and facilitators of care-seeking. Findings indicated that PMSMA awareness was generally high, especially among women aged 20–35 years (94.44%), those with higher educational levels (97.4%), and those living in joint families (100%), while household income showed no significant association. ANC utilisation, however, varied considerably by education: primary-educated women demonstrated better adherence (42.9% attending more than four visits), whereas women with higher secondary education or above were more likely to participate in fewer visits (83.3% attending only one to two visits). Attitudinal measures showed improvement with increasing PMSMA exposure. However, all women with no PMSMA visits were unaware of its purpose (100%), those with more than four visits recognised benefits such as early detection of complications (44.2%) and safeguarding fetal health (53.3%). Perceived helpfulness and satisfaction also rose with utilisation, with 31.3% of high-utilisation women rating services as “very helpful” and 33.3% as “very satisfied,” compared to universal dissatisfaction among non-users. Preference for private facilities increased with greater ANC engagement. Women in joint families demonstrated the highest awareness, supported by intergenerational guidance, stronger information-sharing networks, and collective decision-making. Overall, inadequate maternal health literacy emerged as a key barrier to optimal PMSMA utilisation. Strengthening culturally sensitive community-based awareness initiatives and enhancing provider communication are critical to improving ANC uptake in urban slum environments.