Challenges
Across regions, experts emphasized that many barriers and norms, largely associated with community cultural beliefs, and influenced by the traditional household set-up, limit expectant mothers’ autonomy to seek care. In fact, in many instances, women are expected to prioritise the health of their family over their own, and to continue to work both outside and inside the home [
11]. Furthermore, socially constructed gender norms continue to hinder men’s participation in pregnancy and childbirth. Men control decision-making at home, which influences the timing of ANC attendance [
12]. Similarly, men control the economic resources of the household, which in turn influences women’s choice and ability to use maternal and child health services. Men and the community still view pregnancy as a typically feminine domain and do not feel involved. Pregnancy is still a stressful event that disrupts the link between families and communities. Women are often burdened by physical, psychological, and financial hardships, coupled with inadequate care of ANC, skilled birth attendance coverage and transport facilities. These results are consistent with previous studies [
13].
Consistent with the literature, many experts have emphasised that women’s beliefs and attitudes play a role in deciding whether to initiate or continue ANC. There are numerous shared cultural experiences when the patient seeks care; their cultural background, the culture of their provider, and the medical culture. Patient have different beliefs, attitudes, values and behaviours to healthcare providers. The culture of the medical community is often at odds with the patient’s culture; i.e., education, means of transport, occupation and socio-demographic factors, and when they fail to recognize these differences, they may deliver low-quality care. Such differences can also influence women’s decision making, acceptance of care and can make it difficult for patients to follow advice from the medical community [
14]. Thus, especially in pregnancy care, a doctor should have a basic understanding of patients’ needs and communicate with them effectively in a way that makes them feel comfortable. Doctor’s interventions must consider broader economic, geographical and social factors that might affect an individual’s access to services. Finally, it is essential to have cohesiveness between culturally-appropriate services and other health care providers that women and their families encounter along the continuum of care through pregnancy [
15].
Additionally, another significant aspect highlighted by the experts in respect to the challenges of ANC delivery, was the reported limited understanding that women have on the purpose of early ANC. This lack of understanding was suggested to associate with women’s educational level and literacy rate. In fact, it has been shown that the increase in women’s educational level is a major motivator for increasing the likelihood of her ANC attendance [
16,
17]. This suggests that educated women are more likely to have adequate knowledge of prenatal care services and understand the importance of early booking for ANC as well as attending the recommended eight visits [
18]. Thus, they tend to value ANC and will use pregnancy care services more, compared to less educated women. Longer time in school can also develop women’s ability to reach out to health workers to ask questions and discuss possible health issues [
19].
Programs to promote health education among expectant mothers with low levels of education are necessary to raise awareness among rural women about the benefits of optimal ANC. In order to do this, it is important to strengthen the existing role of CHWs, who are able to provide appropriate health education and create connections between vulnerable populations and healthcare providers [
20]. Thus, it is imperative that significant efforts be made to improve the quality of ANC by providing pregnant women with appropriate counselling, including supportive listening, advice, and relevant information. Involving mothers as active participants in the decision-making about their care would also help make changes in health care, from one based on provider-dominated dialogue to one that involves clients in the decision-making process. This requires a transition in the role of health workers from one of authority to one that is based on collaboration and partnership between patients and providers. Pregnancy information should also be provided in a form that is easy to understand and accessible to users of ANC services. Healthcare providers’ statements on reproductive health issues need to be adapted to different social contexts, including those with low levels of education and income. Furthermore, there is a need to continue to focus on community education and awareness campaigns on the importance of early participation in ANC. Educational interventions targeting both men and women have been reported to improve the health-oriented behaviour of pregnant women and improve birth preparedness and complication readiness. In addition to home visits, education could be offered at various political and social gatherings in the community. In Tanzania, community health workers are reported to play an important role in promoting men’s participation in maternal and child health issues [
21]. A key question for practitioners and policy makers is how to improve women’s perception of the importance of pregnancy care. Any intervention should be culturally relevant. Training programs in cultural literacy and sensitivity should be developed to improve healthcare utilization among women. Stakeholders may want to include cultural skills and sensitivity training in its health education curriculum when training new health professionals [
22].
Finally, a recurrent theme in the expert consultation was namely that geographical inaccessibility contributes to the late onset of ANC attendance. This finding has also been reported in other studies. In fact, Nsibu and colleagues showed statistically significant associations between the place of residence and attendance to the first prenatal visit in the first trimester [
23]. Additionally, a great discrimination in the allocation of resources and in the availability of rural and urban health facilities was described. Poor reediness to provide antenatal/natal health services and supplies is hindering the ANC landscape. In fact, differences have been documented in availability of equipment and supplies needed for antenatal and natal services between urban facilities and rural ones [
24].
It is important to ensure greater use of ANC services, by establishing health care facilities in catchment areas in rural communities, employing more qualified health workers to provide medical care to women in their communities, and ensuring adequate transportation infrastructures and services. Stakeholders need to ensure that maternity care services are closer to home, which could be achieved, especially in rural and hard-to-reach areas, through mobile clinics that would help many women with financial difficulties access prenatal care.
Solutions
Reshaping the health system requires political leadership and policy change, hospitals that can provide high quality, respectful maternal and childcare, health systems that can break down barriers to access, and empowered populations that can demand high quality care [
25,
26]. Improving nurses’ and midwifes’ knowledge of comprehensive care and its contribution to the quality of care is an important issue that needs to be addressed in many countries where existing nursing practices are unsatisfactory and the doctor-led care is commonly applied in clinical environments. The central role of nurses and midwives in delivering respectful, caring, friendly and helpful ANC can be seen in many studies throughout the literature. For example, many studies have showed that the presence of providers who were caring and sympathetic, and familiar with patient’s cultural practices and communities, were essential factors in encouraging ANC demand and usage [
27,
28]. Through the identification of the needs of patients who are neglected by sole use of the doctor-led care recovery can accelerate, hospital stays can shorten and the costs reduced [
29].
As discussed earlier, barriers to access maternal health services using telehealth relate to common challenges, as limited access to broadband in rural areas, cost of the equipment, scheduling time with providers [
30]. Due to the scarcity of health resources, particularly in developing countries where those are often very limited, only appropriate (effective, safe and feasible) technologies should be implemented and used. There are different opportunities to use telemedicine to expand access to maternal health care for women living in rural areas; however, its acceptance remains limited. Based on the current literature, technological anxiety and perceived risk act as significant barriers to telemedicine usage. Kamal and colleagues [
31] have demonstrated that technological anxiety had a significant negative relationship with telemedicine usage intention. In fact, because people living in developing countries don’t frequently access medical care, they prefer face-to-face meeting with doctors, instead of remote mode of communication. Additionally, they have noted that, due to already inadequate and poor resource, people associate a perceived sense of risk with the adoption of telemedicine [
31].
Nonetheless, digital health technologies overall hold promises for addressing major public health backlogs and for strengthening health systems in LMICs. New technologies have the potential to harness clinical and public health, and more research is needed around emerging ones, including artificial intelligence, big data, cloud, cybersecurity, telemedicine and wearable devices to demonstrate their potential use in remote settings. For example, a recent case reported by Runckle et al. [
32], have showed that the use of wearable sensor technology in prenatal care, was well received by both patients and providers, which responded favourably to the implementation of such technology, especially in rural underserved populations.
From the need of new technologies, to address the healthcare staff shortages occurring in resource-limited areas, addressing financial barriers that many countries encounter is fundamental. Thus, it is important to ensure value for money through an integrated people-centred health service approach. This approach should consciously incorporate the perspectives of individuals, families and communities and should see them as participants and beneficiaries of a trustworthy health systems that address their needs and preferences in more holistic way [
33]. Different examples of people-centred and integrated health services can be found in literature. In Mali, primary care networks have been developed, which are made up of community-owned, community-operated primary care centres with the support of government-run district health teams. In rural South Africa, nurse-led chronic disease management programmes focusing on people with high blood pressure, diabetes, asthma have supported patient education, self-management support and improved surveillance leading to improved control of disease. In South Sudan, Uganda and Zambia there have been cases of integrated community case for the management for malaria, pneumonia and diarrhoea to reduce child mortality, involving community health workers who assess and treat children with serious illnesses [
34].
Ensuring equal access to quality health services that meet the broad needs of individuals and communities requires a fundamental change in the way health services are planned, funded and delivered. Thus, it is essential to engage and empower individuals, families and communities so that they have the opportunity, skills and resources to develop into articulate and empowered users of health services. Hence, policy interventions should actively promote health literacy, shared decision-making and patient self-management contribute to the health services that people value most. For instance, a study investigating the association between access to health care and women’s empowerment in Myanmar, have found that, especially in rural areas, women’s empowerment was an important factor of one’s ability to access care [
35].