Equity in prenatal healthcare services globally: an umbrella review

Timely, quality healthcare should be available and accessible to all individuals, and the policies that guide healthcare decision making should foster equitable care. However, globally, achieving this has proved to be challenging [1‐3]. Broadly, equity is conceptualized as the absence of differences in healthcare access and use among population groups, and that all population groups can achieve the health outcomes of the most socially advantaged [4, 5]. Prominently, evidence suggests that healthcare inequities disproportionately affect women’s, maternal, birthing individuals’ health, infant development, and family wellbeing [3, 6].

Globally, major health organizations have categorized prenatal health as encompassing overall maternal health during pregnancy [3, 7]. The prenatal period is defined as the time from conception of pregnancy up to delivery. Evidence suggests that suboptimal health outcomes during this life-stage stem from inequitable access to and subsequent engagement in prenatal care services [8, 9]. Studies have identified that inadequate prenatal care can result in a higher risk of complications during and after pregnancy for the birthing individual and infant [10‐16]. Our review focuses on the prenatal period as adequacy of care during this time can influence subsequent physiological and psychological experiences during birth and the postpartum period [10‐17]. Inequities are rooted in systemic factors such as institutional racism, and social and economic inequities that influence one’s social determinants of health [18]. Common patient reported challenges include geographical proximity (e.g., rural and remote settings), communication barriers, financial barriers, lack of cultural safety, and a lack of known services. These challenges have been exacerbated during the COVID-19 pandemic [1, 3, 6].

Despite the merit of contemporary policies that strive to foster the conditions for health equity for all, inequities in maternal healthcare persist. For example, inequities can be observed in access to services such as consultation with a healthcare professional (i.e., general practitioner, obstetrician, gynecologist, midwife), timely prenatal screening, and prevention and early intervention for maternal mental health needs [1, 3]. Complicating matters further, evidence suggests that individual practitioners’ interpretations of policies may contribute to variability in application of these guidelines resulting in inconsistent implementation of everyday practices with diverse populations [19, 20]. As such, research aimed at addressing birthing individuals’ access to and use of prenatal healthcare is necessary at practice and policy levels, to ensure that care is both equitable and effective in improving the health of prenatal patients [1, 3, 21]. Prenatal healthcare services include care provided to a birthing individual, to prevent complications of pregnancy and to ensure the wellbeing of the birthing individual and infant following birth [17, 22, 23]. Examples of these services include, but are not limited to, visiting a healthcare professional or community health worker in person or through virtual care for a physical exam, a fetal ultrasound, prenatal genetic testing or screening, gestational diabetes screening, birth planning, nutrition, substance use and mental health consults [22, 23].

The aim of this umbrella review was to identify and summarize practices within prenatal healthcare services as they relate to equity/inequity and explore barriers and facilitators of how equities/inequities influence the patient experience or health outcomes when accessing/using services, and to review how equity is reported. We intended to identify both qualitative and quantitative systematic reviews that investigated primary studies for practices in prenatal healthcare. This review provides an overarching scan of existing evidence of prenatal healthcare practices globally and a platform to critically discuss their contribution to reduce inequity present in prenatal healthcare, and plausible solutions to improve equity.

The systematic search captured 8065 articles (Fig. 1). Of the 236 articles reviewed during secondary, full-text screening, 68 systematic reviews were included in this umbrella review (Fig. 1). A condensed summary of study characteristics and outcomes for each included review can be viewed in Supplementary file 4 and all excluded studies with reason for exclusion can be viewed in Supplementary file 5. To address the aims of this review, we present findings in six categories: Study Characteristics; Study Foci, to identify and summarize practices within prenatal healthcare services; Impact of Equity/Inequity on Prenatal Care and Other Factors Impacting Access/Use of Prenatal Care, to explore barriers and facilitators of how equities/inequities influence the patient experience or health outcomes when accessing/using services; Equity Reporting Characteristics to review how equity is reported; and Quality Assessment.

This umbrella review identified and summarized practices within prenatal healthcare services as they related to equity/inequity, consolidated barriers and facilitators of equity/inequity factors and summarized how these factors influence the prenatal patient experience or health outcomes when accessing/using health services, globally. The included studies represent 20 different countries. In addition to reporting on types and reasons for inequities as described in the included studies, this review consolidates practices that are suggested to facilitate the conditions necessary for health equity in prenatal care (e.g., CHWs, home visitation programs, CCT programs, virtual care options, and cross-cultural training). Additionally, this review explored how equity is presented in each of the systematic reviews, and if the authors of each review provided a working definition or conceptualization of the term.

Our study aligns with recent literature highlighting how inequities lead to suboptimal healthcare for prenatal patients [110‐121]. For example, studies investigating access and uptake of prenatal screening services in Canada and New Zealand have identified similar challenges for patients in navigating services. This includes cost of services, remote living, low maternal age, being an ethnic minority, or having a recent immigrant status [110, 121]. In both countries, coverage of basic prenatal screening services is publicly insured for residents [110, 121]. Comparable to our findings, patients lacked knowledge and awareness of available services which was an inherent barrier of accessing care [110, 121]. Disparities in prenatal healthcare have been reported in urban areas in Southern Brazil and rural areas in China, such as the inadequate use and uptake of prenatal supplements (e.g., folic acid or iron) to support the health and development of birthing individuals and their fetus [112, 113, 118]. Indeed, the study in China by Liu et al. reported that despite government recommendations, there was a barrier to uptake of prenatal supplements by pregnant women that had lower levels of education, were an ethnic minority, or were unemployed [112]. A study by Yaya et al. conducted in rural areas of Nigeria uncovered the challenge of gender inequality in accessing healthcare services. Similar to our review, they identified the cultural norm of women having less decision-making power in a relationship and therefore were restricted in accessing quality care by their partner, usually identified as a man [116]. Our review identified that patient-centred care influenced patients’ satisfaction with the care they received. Complementing this finding, a recent study by King et al. found that education and a non-white ethnicity were inversely related to the perceived quality of patient-centred care in a cohort of prenatal patients at a provincial health centre in Canada [122].

This umbrella review also identified facilitators to health equity that led to a greater perceived quality of prenatal healthcare. Although these findings are not as common, recent literature has identified strategies towards achieving health equity in prenatal care [123, 124]. An established prenatal care program in Mexico, a low-middle income country, which targets populations from rural areas with low SES used shared-care between general practitioners, obstetricians, and other specialized health professionals, to ensure a multidisciplinary approach to care, similar to the team-based findings from our review [123]. In the United States of America, a high income country, a study evaluated the effect of trauma-informed care for adolescents receiving prenatal care services at an established adolescent maternity program and found that this strategy led to equitable pregnancy outcomes across racial and ethnic groups, which is comparable to our findings of cross-cultural training for professionals as a strategy to reduce patient anxiety [124].

A gap in our findings was the association between equity/inequity and the implementation climate of practices, which is important to consider for longevity and sustainability of equitable practices [125]. Implementation climate is defined by the surrounding context of where an intervention is to be incorporated; this can include the people, the physical environment, or social or cultural norms [126, 127]. Cultural norms of the implementation climate should be a priori of consideration when establishing how to implement a practice and how inequities may play a role. For example, research from China, Nigeria, and South Africa have investigated the SES of different regions and how this affected the adoption of prenatal healthcare services. The studies depicted that generalizability, spread and scale, are not always possible [111, 112, 128]. Interestingly, Linhares et al. found an inverse inequality distribution where supplements had a greater uptake in urban Southern Brazilian prenatal populations of low income or education level, which depicts how context matters [113]. A recent United States ethnography study of the clinical environment in prenatal care discussed the difference in site specific factors for care that led to differing perspectives of service by patients and healthcare professionals. For example, waiting time was a great disruption in the patient journey. Those who were of low SES, non-white, often of immigrant status or non-English speaking were expected to accommodate their own schedules to the demands of health service centres [115]. A timely example of an implementation climate which influences equitable access to prenatal care is the COVID-19 pandemic. During the pandemic, healthcare services related to obstetrics and gynecology were overlooked, leading to an increase in prenatal morbidity, mortality, and an overall decline in wellbeing [6, 129, 130]. There is limited data in the literature to explain the effects of inequity on access and use of care for this population during and since the COVID-19 pandemic [131]. This umbrella review provides a global perspective of how equity/inequity may influence prenatal care; it is important to consider how the context and implementation climate of different countries plays a role in this influence.

As part of the review, we also examined how equity was reported. Surprisingly, the majority of studies did not define equity and none defined inequity, which adds to the confusion of the use of the terms and how they may be perceived by different researchers and decision-makers [29, 30]. The studies that did define equity [46, 47, 79, 89, 94] were quite consistent; they each mentioned terminology surrounding the inclusion of every person or population including those that are vulnerable or disadvantaged, and the necessity of healthcare to be fair. The inconsistency of definitions became apparent when discussing what constructs were recognized as factors of equity and the spectrum from inequity to equity. Most of the included studies did not use an equity related framework to guide their methods which contributes to the variability in reporting. A relevant study by Hartwell and colleagues from 2022 explored equity reporting characteristics of systematic reviews and meta-analyses that focused on the COVID-19 pandemic, and maternal and childbirth outcomes [131]. This study also used PROGRESS-Plus as a guiding framework and only identified factual relations between outcomes and equity factors. Our umbrella review presents data prior to and during the pandemic, and narrows its focus to the prenatal population to enhance the specificity of how equity influences care in this population.

In this umbrella review, we explored reported barriers and facilitators to health equity/inequity across the globe and their impact on prenatal care and subsequently infant health and development. The review highlights how equity/inequity influences prenatal patients’ access and use of care within prenatal healthcare practices and collates potential solutions to gaps in health equity for this population. The findings highly overlapped across PROGRESS-Plus equity factors and the barriers and facilitators that we identified are likely much more complex and intertwined [133]. This study adds value to the literature as it shows how current innovations, some of which are common across the globe, are utilized to overcome barriers to achieving equity. The data also speaks to how barriers and potential facilitators or solutions are common across countries. Decision-makers and knowledge-users from across the globe, including healthcare professionals, healthcare administrators, and policy-makers, can apply these findings in their own contexts to improve equity in the access and use of prenatal healthcare services.