Factors impacting antenatal care utilization: a systematic review of 37 fragile and conflict-affected situations

Abstract

Background It is estimated that over 930 million people live in fragile and conflict-affected situations (FCAS) worldwide. These regions, characterized by violence, civil unrest, and war, are often governed by corrupt administrations who are unwilling to provide their citizens with basic human rights. Individuals living in FCAS face health inequities; however, women are disproportionally affected and face additional barriers to accessing sexual and reproductive services, including antenatal care (ANC). This systematic review aims to identify the factors that impact ANC usage in the 37 countries or regions classified as FCAS in 2020 by The World Bank. Methods Using the PRISMA guidelines, a systematic search of five databases (SCOPUS, Web of Science, PubMed, EMBASE, and CINAHL) was conducted. Results were limited to human studies, written in English, and published between January 2002 and January 2022. Studies that identified factors affecting utilization of ANC or maternal health services were included for review and critically appraised using the National Institute of Health’s Quality Assessment Tools. Findings were summarized using a narrative synthesis approach. Results The database search yielded 26,527 studies. After title, abstract and full-text review, and exclusion of duplicate articles, 121 studies remained. Twenty-eight of the 37 FCAS were represented in the included studies. The studies highlighted that women in FCAS’ are still not meeting the World Health Organization’s 2002 recommendation of four ANC visits during pregnancy, a recommendation which has since been increased to eight visits. The most cited factors impacting ANC were socioeconomic status, education, and poor quality of ANC. Despite all studies being conducted in conflict-affected regions, only nine studies explicitly identified conflict as a direct barrier to accessing ANC. Conclusion This review demonstrated that there is a paucity in the literature examining the direct and indirect impacts of conflict on ANC utilization. Specifically, research should be conducted in the nine FCAS that are not currently represented in the literature. To mitigate the barriers that prevent utilization of maternal health services identified in this review, policy makers, women utilizing ANC, and global organizations should attempt to collaborate to enact policy change at the local level.

Decision-making process in seeking antenatal care: A cohort study in a poor urban and a typical rural area in Bangladesh

“…Similar findings were observed in studies conducted in Iran and Malawi, indicating that maternity hospitals were advantageous for availability of specialist doctors, facilities for normal delivery, caesarean section, and good management, despite the crowdedness and lack of sufficient resources, which led to women seeking care there [ 35 – 37 ]. These factors not only drew women to facilities with one-stop services, but also helped them decide to return to there for pregnancy care [ 38 ].…”

Understanding Challenges Women Face in Flood-Affected Areas to Access Sexual and Reproductive Health Services: A Rapid Assessment from a Disaster-Torn Pakistan

“…The literature identifies that infrastructure or lack of resources was a factor reported to impact access to ANC. Studies found that women who perceived operational and infrastructure problems in their community were deterred from accessing ANC and faced poorer health outcomes as a result [ 23 , 24 ]. A study in Pakistan in 2011 highlighted that women who gave birth in relief camps during the flood had no skilled birth attendants present, used unhygienic birth stations, and had poor postnatal services which increased the risk of mortality [ 25 ].…”

Effectiveness of the Gratuité user fee exemption policy on utilization and outcomes of maternal, newborn and child health services in conflict-affected districts of Burkina Faso from 2013 to 2018: a pre-post analysis

“…For ANC, there was no statistically significant positive upward trend as was expected for ANC1 rates, ANC5+ rates, rates of women seen in the first trimester of pregnancy, and rates of malaria cases in pregnancy seen in the health facility during ANC. As with health facility delivery, the conflict may explain this finding, especially as there is strong evidence that conflict affects ANC utilization in fragile and conflict-affected settings [ 27 ]. With employment opportunities limited in such settings, pregnant women may be challenged to secure the funds needed to pay for the service and transportation fees associated with ANC.…”