Determinants of antenatal care utilisation in sub-Saharan Africa: A systematic review

  • BMJ Open, Volume 9, No. 10, Year 2019

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Study Justification:
This systematic review aims to identify the determinants of antenatal care (ANC) utilization in sub-Saharan Africa. Understanding the factors that influence ANC utilization is crucial for improving maternal and child health outcomes in the region. By synthesizing the existing literature, this study provides valuable insights into the barriers and facilitators of ANC utilization, which can inform the development of effective interventions and policies.
Highlights:
– 74 studies were included in the review, which met the inclusion criteria.
– Socioeconomic status, urban residence, older age, low parity, education, employment, marriage, and Christian religion were identified as predictors of ANC attendance and timeliness.
– Factors such as awareness of danger signs, timing and number of ANC visits, exposure to mass media, and positive attitude towards ANC utilization were associated with increased likelihood of ANC initiation in the first trimester.
– On the other hand, factors such as unplanned pregnancy, previous pregnancy complications, lack of autonomy, lack of husband’s support, increased distance to health facility, lack of health insurance, and high cost of services negatively impacted ANC utilization.
– The review highlights the importance of intersectoral collaboration to promote female education and empowerment, improve geographical access to ANC services, and strengthen the implementation of ANC policies with active community participation.
Recommendations:
– Promote female education and empowerment: Efforts should be made to improve access to education for women, as education has been identified as a key determinant of ANC utilization.
– Improve geographical access: Strategies should be implemented to address the challenges of distance and transportation that hinder women from accessing ANC services.
– Strengthen ANC policies: Policies related to ANC should be effectively implemented, with a focus on community participation and engagement.
– Raise awareness and address cultural beliefs: Efforts should be made to increase awareness of the importance of ANC and address cultural beliefs that may hinder its utilization.
– Provide financial support: Measures should be taken to reduce the financial burden associated with ANC, such as providing health insurance coverage or subsidies for ANC services.
Key Role Players:
– Ministry of Health: Responsible for developing and implementing policies related to maternal and child health, including ANC.
– Non-governmental organizations (NGOs): NGOs can play a crucial role in implementing interventions and programs aimed at improving ANC utilization.
– Community leaders and traditional birth attendants: Engaging community leaders and traditional birth attendants can help in raising awareness and addressing cultural beliefs.
– Education sector: Collaboration with the education sector is important for promoting female education and empowerment.
Cost Items:
– Education programs: Budget for initiatives aimed at improving female education and empowerment.
– Infrastructure development: Funds for improving healthcare infrastructure, including the establishment of ANC facilities in remote areas.
– Transportation services: Budget for providing transportation services to ensure women can access ANC services.
– Awareness campaigns: Funds for raising awareness about ANC and its importance.
– Subsidies or health insurance coverage: Budget for providing financial support to reduce the cost burden of ANC services for women.
Please note that the cost items provided are general categories and not actual cost estimates. The actual budget will depend on the specific context and implementation strategies.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is based on a systematic review that includes a large number of studies conducted in sub-Saharan Africa. The review followed a rigorous methodology, including a comprehensive search strategy and quality assessment of the included studies. The findings provide a detailed overview of the determinants of antenatal care (ANC) utilization in the region. However, the abstract does not provide specific details about the individual studies included in the review, such as their sample sizes or the statistical methods used. To improve the evidence, it would be helpful to include more specific information about the individual studies, as well as any limitations or potential biases in the review process.

Objectives: To identify the determinants of antenatal care (ANC) utilisation in sub-Saharan Africa. Design: Systematic review. Data sources: Databases searched were PubMed, OVID, EMBASE, CINAHL and Web of Science. Eligibility criteria: Primary studies reporting on determinants of ANC utilisation following multivariate analysis, conducted in sub-Saharan Africa and published in English language between 2008 and 2018. Data extraction and synthesis: A data extraction form was used to extract the following information: name of first author, year of publication, study location, study design, study subjects, sample size and determinants. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for reporting a systematic review or meta-analysis protocol was used to guide the screening and eligibility of the studies. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess the quality of the studies while the Andersen framework was used to report findings. Results: 74 studies that met the inclusion criteria were fully assessed. Most studies identified socioeconomic status, urban residence, older/increasing age, low parity, being educated and having an educated partner, being employed, being married and Christian religion as predictors of ANC attendance and timeliness. Awareness of danger signs, timing and adequate number of antenatal visits, exposure to mass media and good attitude towards ANC utilisation made attendance and initiation of ANC in first trimester more likely. Having an unplanned pregnancy, previous pregnancy complications, poor autonomy, lack of husband’s support, increased distance to health facility, not having health insurance and high cost of services negatively impacted the overall uptake, timing and frequency of antenatal visits. Conclusion: A variety of predisposing, enabling and need factors affect ANC utilisation in sub-Saharan Africa. Intersectoral collaboration to promote female education and empowerment, improve geographical access and strengthened implementation of ANC policies with active community participation are recommended.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for reporting a systematic review or meta-analysis protocol37 was used in screening studies for eligibility (see online supplementary file 1). bmjopen-2019-031890supp001.pdf A systematic review of published quantitative literature was conducted between October 2018 and April 2019 to capture studies published in the last 10 years (2008–2018). The databases searched were PubMed, OVID, EMBASE, CINAHL and Web of Science. Other databases searched were Google Scholar and African Journal Online. The search terms used include: antenatal, prenatal, maternal health, maternal care, maternal health services, utilisation, factors, determinants, predictors, Africa. The search strategy and results are provided in online supplementary file 2. bmjopen-2019-031890supp002.pdf Studies were eligible for inclusion if they were quantitative (primary or secondary data used) reporting on factors associated with ANC utilisation following multivariate analysis, conducted in SSA and published between 2008 and 2018. ANC utilisation in this review refers to attendance of at least one and at least four ANC visits and booking visit within the first trimester of pregnancy. Various study designs (longitudinal, cohort, case–control, cross-sectional and experimental) were eligible for inclusion if they assessed the predictors of ANC utilisation. This review excluded articles and studies published before 2008 and written in any language other than English. Studies that used measures other than the WHO recommendation for ANC were excluded. Review articles, case reports, case studies and simple descriptive studies without regression analyses were excluded. At the level of titles, titles that did not address ANC and maternal health/health services utilisation were excluded. At the abstracts stage, studies that did not report factors associated with ANC and qualitative studies were excluded. Full-text quantitative studies that did not report on the determinants of ANC utilisation after multivariable regression analysis such as studies that assessed the predictors of utilisation skilled birth attendance and postnatal care were excluded. Full-text publications that did not employ the WHO definitions for ANC and qualitative were also excluded A data extraction form was developed and reviewed by all reviewers. Screening of titles and abstracts and the full texts was carried out independently by two of the review authors (INOA and ICA). Any disagreements were resolved through discussion and consensus between the two review authors or with the help of the third author (OBE). Mendeley reference manager was used to keep track of references. Data were extracted for each paper using standardised forms with the following domains: the name of first author and year of publication, study location and setting, study design, study subjects and sample size and factors/determinants. Figure 1 shows the article selection and inclusion process. Selection and inclusion process for articles included in the review. ANC, antenatal care. Quality assessment of the studies included in this review was carried out by the main reviewer in consultation with the other authors. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess the quality of the studies. This quality assessment tool has been used in other systematic reviews38 39 (see online supplementary file 3). The tool consists of 14 questions assessing different aspects of a study including but not limited to definition of objectives, study population, sampling strategy, sample size and statistical analyses. To appraise a study, each question is scored as Yes (1) or No (0), and others (CD, cannot determine; NA, not applicable and NR, not reported). All the studies included in this review were assessed for quality using the appropriate criteria based on study design. Elements of the criteria which did not apply to a particular study were marked as not applicable. bmjopen-2019-031890supp003.pdf All the studies fulfilled the quality criteria except for six studies9 40–44 that did not report on sample size. It was not appropriate or possible to involve patients or the public in this work

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile health (mHealth) interventions: Develop mobile applications or text messaging services to provide pregnant women with information about antenatal care, including appointment reminders, educational resources, and guidance on danger signs during pregnancy.

2. Telemedicine: Implement telemedicine programs that allow pregnant women in remote or underserved areas to consult with healthcare providers through video calls or phone consultations. This can help overcome geographical barriers and provide timely advice and support.

3. Community health workers: Train and deploy community health workers who can provide basic antenatal care services, educate pregnant women about the importance of ANC, and facilitate referrals to healthcare facilities when necessary. This can help reach women who have limited access to formal healthcare services.

4. Financial incentives: Introduce financial incentives, such as cash transfers or vouchers, to encourage pregnant women to attend ANC visits and deliver in healthcare facilities. This can help address financial barriers and increase utilization of maternal health services.

5. Public-private partnerships: Foster collaborations between public and private sectors to improve access to maternal health services. This can involve leveraging private sector resources and expertise to expand healthcare infrastructure, improve service quality, and increase availability of ANC services.

6. Task-shifting: Train and empower non-physician healthcare providers, such as nurses and midwives, to provide comprehensive ANC services. This can help alleviate the shortage of skilled healthcare professionals and increase access to quality care.

7. Health education campaigns: Launch targeted health education campaigns to raise awareness about the importance of ANC and address cultural and social barriers that may prevent women from seeking care. This can involve community engagement, media campaigns, and partnerships with local organizations.

It is important to note that the effectiveness of these innovations may vary depending on the specific context and resources available. Further research and evaluation are needed to determine the most appropriate and impactful strategies for improving access to maternal health in sub-Saharan Africa.
AI Innovations Description
Based on the systematic review titled “Determinants of antenatal care utilization in sub-Saharan Africa,” several recommendations can be made to develop innovations that improve access to maternal health. These recommendations include:

1. Intersectoral collaboration: Promote female education and empowerment through collaboration between the education and health sectors. This can include initiatives that provide educational opportunities for women and girls, as well as programs that empower women to make informed decisions about their reproductive health.

2. Improve geographical access: Strengthen efforts to improve access to maternal health services by addressing geographical barriers. This can involve increasing the number of health facilities in rural areas, improving transportation infrastructure, and implementing mobile health clinics to reach remote communities.

3. Strengthen implementation of ANC policies: Ensure the effective implementation of antenatal care (ANC) policies by providing training and support to healthcare providers. This can include regular updates on best practices, guidelines, and protocols for ANC, as well as monitoring and evaluation systems to track progress and identify areas for improvement.

4. Active community participation: Engage communities in the planning, implementation, and evaluation of maternal health programs. This can involve community awareness campaigns, community health workers, and community-based support groups to promote ANC utilization and address barriers at the community level.

By implementing these recommendations, innovative solutions can be developed to improve access to maternal health in sub-Saharan Africa. These solutions should focus on addressing the determinants identified in the systematic review, such as socioeconomic status, urban residence, age, education, employment, marital status, religion, awareness of danger signs, and cost of services.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations for improving access to maternal health:

1. Strengthen intersectoral collaboration: Promote female education and empowerment by working with the education sector to ensure girls have access to quality education. This can help improve knowledge and awareness about maternal health, leading to increased utilization of antenatal care services.

2. Improve geographical access: Enhance transportation infrastructure and services to reduce the distance between communities and health facilities. This can be achieved by building more health facilities in remote areas or providing mobile health clinics to reach underserved populations.

3. Strengthen implementation of ANC policies: Ensure that policies related to antenatal care are effectively implemented at all levels, from national to community. This can be done by providing training and resources to healthcare providers, monitoring and evaluation of services, and engaging the community in decision-making processes.

4. Active community participation: Involve the community in planning, implementing, and monitoring maternal health programs. This can be achieved through community health workers, community-based organizations, and community engagement activities such as health education campaigns and support groups.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that will be used to measure the impact of the recommendations. For example, indicators could include the percentage of pregnant women receiving at least one ANC visit, the percentage of women receiving ANC visits in the first trimester, or the percentage of women receiving the recommended number of ANC visits.

2. Collect baseline data: Gather data on the current status of maternal health access and utilization in the target population. This can be done through surveys, interviews, or existing data sources.

3. Develop a simulation model: Create a mathematical or statistical model that incorporates the identified determinants of ANC utilization and the potential impact of the recommendations. The model should consider factors such as population size, geographical distribution, socioeconomic status, and healthcare infrastructure.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to estimate the potential impact of the recommendations. This can be done by adjusting the values of the determinants and observing the resulting changes in the indicators.

5. Analyze and interpret results: Analyze the simulation results to understand the potential impact of the recommendations on improving access to maternal health. This can include comparing the baseline data with the simulated data and identifying trends or patterns.

6. Validate and refine the model: Validate the simulation model by comparing the simulated results with real-world data, if available. Refine the model based on feedback and further analysis.

7. Communicate findings: Present the findings of the simulation study in a clear and concise manner, highlighting the potential benefits of implementing the recommendations. This can be done through reports, presentations, or visualizations.

It is important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data.


Statistics:
Citations: 120
Identifiers:
DOI: 10.1136/bmjopen-2019-031890
Research Areas:
Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Design:
Case-Control Study, Cohort Study, Cross Sectional Study
Study Approach:
Mixed-methods, Qualitative, Quantitative, Systematic Review
Participants Gender:
Female
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