Convergence without connectivity: a difference-in-differences analysis of women’s mobile phone ownership and antenatal care coverage across 35 Indian states, 2015–2021

In the modern world, the mobile phone has become a universal tool for connection, a device that bridges distances and delivers information to the fingertips of billions. In the realm of public health, this technology is often seen as a lifeline, a way to remind mothers of medical appointments, track pregnancies, and ensure that women receive the care they need. India, with its vast population and ambitious digital health initiatives, has built one of the largest national systems of its kind in the developing world. The logic is straightforward: if more women own phones, more women should be able to access healthcare services. It is a compelling narrative of progress, where the spread of technology is expected to drive the spread of well-being.

However, the relationship between owning a device and receiving care is not always as direct as it appears. While the number of phones in women's hands has grown rapidly, the question remains whether this growth is actually the cause of better health outcomes, or if both trends are simply rising together because of other, deeper changes in society. To answer this, researchers needed to look beyond the national averages and examine how different regions moved over time. They asked a specific, difficult question: did the states where women gained the most phones also see the biggest improvements in their healthcare coverage, or was the improvement happening for entirely different reasons?

A team of researchers set out to investigate this by analyzing data from thirty-five states and territories across India, covering the period from 2015 to 2021. They focused on two specific measures: the percentage of women aged fifteen to forty-nine who owned a mobile phone they could use themselves, and the percentage of mothers who received four or more antenatal care visits during their most recent pregnancy. These four visits are a standard benchmark for quality prenatal care, ensuring that a mother and baby are monitored throughout the pregnancy. The researchers gathered this information from two major national surveys conducted at the beginning and end of this six-year window.

The data revealed a story of simultaneous growth. Nationally, the share of women owning a mobile phone rose from about fifty-five percent to nearly sixty-five percent. At the same time, the share of mothers receiving the recommended four prenatal visits increased from sixty-one percent to sixty-five percent. On the surface, these two lines climbing together might suggest that the phones were doing the work. But when the researchers looked closer at the differences between the states, the connection began to unravel. They found that the states that started with the lowest levels of prenatal care coverage were the ones that improved the most, regardless of how many phones their women owned. This pattern, known as convergence, means that the poorer-performing regions were catching up to the better ones, driven by factors other than digital access.

The researchers tested whether the growth in phone ownership explained these improvements by using a statistical method that compares changes over time between groups. They divided the states into two groups based on how many women owned phones in 2015: those with higher ownership and those with lower ownership. If phones were the key driver, the states with more phones should have seen faster improvements in healthcare coverage. The results showed no such link. The states with the most phones did not gain more healthcare coverage than the states with fewer phones. In fact, the statistical analysis suggested that the growth in phone ownership had no measurable effect on the growth of prenatal care coverage. The improvements in healthcare were happening in parallel with the rise in phone ownership, but one was not causing the other.

The study also uncovered a surprising and troubling detail that national averages often hide. While the country as a whole saw an improvement in prenatal care, twelve of the thirty-five states actually saw their coverage rates decline. Some of these were states with historically strong healthcare systems, such as Kerala and Punjab. In these places, the number of women receiving four prenatal visits dropped significantly, even as the number of women with mobile phones continued to rise. For example, in the state of Sikkim, coverage fell by more than sixteen percentage points, while mobile ownership increased. In Jammu and Kashmir, mobile ownership jumped by twenty-one percentage points, yet prenatal care coverage fell. These declines suggest that the expansion of digital access is not a guarantee of better health outcomes and that other forces, perhaps related to service delivery or the challenges of the pandemic era, were at play.

The researchers were careful to note that their findings do not mean a mobile phone is useless for an individual woman. A phone can still be a vital tool for a specific mother to receive a reminder or access information. However, at the level of entire states, simply having more phones did not translate into more women getting medical care. The study suggests that the improvements seen in India's healthcare system were likely driven by other factors, such as better education, the recruitment of health workers, or the expansion of government facilities, rather than by the spread of mobile technology alone. The data indicates that when a region starts with low healthcare coverage, it has more room to improve, and it is these regions that have seen the most progress, independent of their digital connectivity.

This research serves as a reminder that the correlation between two rising trends does not prove that one causes the other. Just because mobile phone ownership and prenatal care coverage both increased across India does not mean the phones caused the care. The study concludes that the national success in maternal health is a story of catch-up and broader development, not a direct result of digital expansion. The fact that some states with high phone ownership saw their healthcare coverage drop further underscores that technology is not a magic solution; it is only as effective as the health system it is meant to support. Without a functioning system of clinics, doctors, and records, the mere presence of a device cannot ensure that a mother receives the care she needs.