PRISMA 2020 Checklist

Digital health reforms are increasingly embedded within public health systems to improve maternal healthcare delivery in low- and middle-income countries, yet evidence from health systems remains limited on whether basic digital access functions as enabling infrastructure or reinforces existing inequities. In India, where large-scale digital health platforms are expanding, this study examines whether women’s digital access—measured through mobile phone ownership and engagement with maternal health registries—acts as a health system enabler of maternal healthcare utilization. A mixed-methods design combined a PRISMA-guided systematic literature review with quasi-experimental analysis of three rounds of the National Family Health Survey (NFHS-3, NFHS-4, NFHS-5; 2005–2021). State-level panel data were analyzed using Difference-in-Differences and Propensity Score Matching, supported by placebo tests and parallel trends diagnostics, with uptake of four or more antenatal care visits (ANC4) as the primary outcome. ANC4 coverage increased nationally between NFHS-4 and NFHS-5, with larger gains in states with lower baseline digital access. Quasi-experimental estimates indicate a significant increase in ANC4 utilization associated with mobile expansion, particularly in underserved regions. The findings suggest that women’s mobile phone access functions as part of the health system infrastructure rather than a stand-alone technology. However, its effectiveness depends on institutional embedding, trusted governance arrangements, frontline health worker mediation, and equity-oriented system design. Treating digital connectivity as essential public health infrastructure is critical for strengthening maternal health systems and advancing equity.