Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa: a systematic review of literature

Existing evidence indicated that 15% of pregnant women develop some form of obstetric complications during pregnancy and childbirth which is likely to result in maternal death if they fail to receive rapid obstetric interventions [1]. The majority of maternal mortalities are caused by direct obstetric events such as haemorrhage, hypertension, obstructed labour, sepsis, and complications of abortion [2]. The World Health Organization’s (WHO) report indicated that globally in 2015, an estimated 303,000 women died due to obstetric complications [3]. While almost all of the global maternal deaths occurred in developing countries, about two thirds of these deaths took place in sub-Saharan Africa [4].

Though the occurrence of obstetric complications is often unpredictable [5], there is evidence that maternal mortality can be prevented [6]. Prevention of maternal mortality can be realized through making pregnancy and childbirth safer by ensuring that women who face obstetric complications have access to timely obstetric care [7]. Emergency obstetric care (EmOC) is an evidence-based service required to manage potentially life-threatening complications that affect many women during pregnancy, childbirth, and the immediate postpartum period [8, 9].

There are two complementary types of EmOC facilities: basic emergency obstetric care (BEmOC) and comprehensive emergency obstetric care (CEmOC) facilities [9]. A BEmOC facility can provide six crucial obstetric services, known as “signal functions”, which include administration of parenteral antibiotics, parenteral anticonvulsants, and parenteral uterotonics; removal of retained products; manual removal of the placenta; and assisted vaginal delivery (AVD). A CEmOC facility provides caesarean sections and blood transfusions, in addition to the six signal functions of BEmOC [8].

It has been suggested that the execution of EmOC has resulted in a noticeable global reduction of the maternal mortality ratio (MMR) since 1990 [10]. However, there was a significant regional variation in MMR across the globe, where sub-Saharan Africa still sustains a large MMR [3]. Recognizing this problem, the United Nations (UN) has set a new global strategy, the Sustainable Development Goals (SDGs), which are aimed at reducing the global MMR to fewer than 70 per 100,000 live births by 2030 [11]. This target will not be achieved unless the provision of quality EmOC is strengthened, especially in sub-Saharan Africa where the MMR is currently 546 per 100,000 live births [3].

Nevertheless, findings of research in developing countries have indicated poor utilization of EmOC among women who have experienced obstetric complications. In a study conducted in nine sub-Saharan African countries, researchers showed that only 28% of women who experienced obstetric complications obtained EmOC [12]. In a recent study in Tanzania, it was indicated that the met need for emergency obstetric care was 22% [13] while the met need of EmOC for Malawian and Zambian women was reported to be 20.7% [14] and 27% [15] respectively. In Ethiopia, the findings of Admasu et al. (2011) showed that only 6% of women who experienced obstetric complications were treated at health institutes [16].

In sub-Saharan Africa, access to and utilization of EmOC services among women are affected by several factors. Unavailability of the services is the most important factor that influenced utilization of services among women [15‐17]. Other barriers to access and utilization of EmOC services included a woman’s lack of knowledge about pregnancy complications [18, 19] and women’s poor awareness of the availability of EmOC services [20, 21]. Poor quality of EmOC services, as defined by a lack of essential medical supplies [22] and lack of training among healthcare providers resulting in a lack of competency [23], was frequently reported to affect utilization of EmOC services. In the majority of studies conducted in sub-Saharan Africa, researchers concluded that the quality of EmOC services is usually poor, as indicated by higher direct obstetric case fatality rates than the UN standard of not more than 1% [23‐25].

The three delays model is an ideal framework for conceptualizing the various barriers to access and utilization of EmOC services (Fig. 1). This model can capture factors that cause delays in seeking obstetric care and has been employed in several studies [26, 27]. In this model, three types of delays are proposed: the delays that could occur either at home, on the way to the health facility, or in the health facility [28]. Socio-cultural factors, accessibility and affordability of the service, and quality of care may independently affect the lengths of each delay.

Limited previous reviews exist on obstetric health services in sub-Saharan Africa, and no reviews to date have specifically focused on barriers to access and utilization of EmOC services. While some reviews have focused on accessing barriers to obstetric care [29], these have not specifically been in relation to EmOC services. Rather, researchers have focused on facilitators and barriers of facility delivery [30] and the application of international guidelines for EmOC [31]. Therefore, this systematic review was aimed at identifying and presenting factors affecting access to and utilization of EmOC services at health facilities in sub-Saharan Africa.

The study protocol of this review was registered in PROSPERO 2017 and is available at http://​www.​crd.​york.​ac.​uk/​PROSPERO/​display_​record.​asp?​ID=​CRD42017074102, ID = CRD42017074102. The review protocol was also published on BMC systematic review and can be found at https://​systematicreview​sjournal.​biomedcentral.​com/​track/​pdf/​10.​1186/​s13643-018-0720-y. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [32] was employed to present the findings of studies on barriers to utilization of EmOC in sub-Saharan Africa.

The search of the selected databases initially returned 3534 articles. After 1036 duplicates were removed, 2498 articles remained for further screening and 13 additional studies were located through checking the reference lists of the identified papers. Finally, 317 articles were retrieved for full-text review, of which 280 studies were excluded for not meeting the eligibility criteria. Thirty-seven studies [38‐73] were retained for the final qualitative analysis as shown in the PRISMA flow chart (Fig. 2).

The main themes and sub-themes presented in the current review showed that barriers occurred at different levels. Some of these barriers were within women’s control; others were slightly outside of their control and barriers at the facility level, which were completely out of women’s control. This review utilized the three delays model to illustrate how different societal and institutional factors resulted in delays to seek obstetric care when needed. Factors related to the first delays were thematically grouped into five sub-themes, and specific factors affecting women’s decision-making ability were detailed under each sub-theme. Similarly, three sub-themes emerged from the second and third delays, and specific barriers experienced by clients and the service providers’ perspectives were presented under each sub-theme.

In the majority of the articles, decision-making to seek obstetric care during obstetric emergencies was found to be impeded by different factors. As Thaddeus and Maine (1994) have pointed out, the actual decision-making process is determined by the reluctance of the patients to seek healthcare and perceived and actual barriers experienced by the clients [28]. Likewise, in our systematic review, socio-economic factors were found to play a crucial role in delaying decision-making to seek EmOC when needed. Most of the identified socio-economic barriers in the current review were consistent with other study findings in developing countries that delayed decision-making in seeking obstetric care was more likely to be observed among younger women [74‐76] and uneducated mothers [20, 74, 76‐78]. Delays in accessing obstetric care were frequently reported among women from a low household income [20, 29, 74, 75, 78‐81] who lacked financial resources. Similarly, we identified that delays among unemployed women [20, 74, 80] who lived in rural areas [80, 82] with lower access to media [29, 74, 80, 81] were commonly reported.

Perceptions of women and the general community have been identified as an important influence on women’s decision to seek appropriate healthcare, especially during the perinatal period [50, 56]. Findings from a number of studies identified that women prioritize their privacy [41, 44, 65]; hence, they prefer to visit a traditional healer where privacy is relatively maximized. Women with obstetric complications may fear unwelcome procedures, such as intrusive vaginal exams and painful surgical interventions [38, 72], at a health facility. The findings of our review are in agreement with other findings of systematic reviews in developing countries [80, 82‐84]. Similar study findings were reported from developing countries including Indonesia [85] and Bangladesh [75, 81] that the perception of the community has impacted the decision-making time for women to seek timely obstetric care when needed.

In the current review, a lack of decision-making autonomy among women and the influence of male partners were reported in several articles to affect the length of time to seek obstetric care. This is the main barrier for many women in developing countries, which affected women’s access to EmOC, as they have to wait for permission from their spouse and other family members [29, 78, 79, 82‐84]. Researchers in other developing countries also supported the current finding that women who utilized ANC were less likely to delay in deciding to seek obstetric care when they experienced obstetric emergencies [74, 76, 84, 86]. This might be attributed to the counselling services women receive during ANC visits [87]. A delay in decision-making was also less likely among women who did not experience previous birth complications [74].

In the findings of several studies in our review, it was indicated that most women were unable to recognize the symptoms of pregnancy complications due to the lack of knowledge about obstetric danger signs. Delays in seeking care for obstetric complications were found to be more likely among women with a lower level of knowledge about obstetric danger signs. Several study findings from developing countries supported the current review in that women with a lower level of knowledge about obstetric danger signs were relatively more delayed in seeking obstetric care [75, 76, 80‐82, 85]. In other studies, similar findings to ours have been reported; a lower level of women’s knowledge about obstetric danger signs was more likely among uneducated women [75, 81, 82].

This review revealed that the unavailability of transportation options played a central role in whether or not a facility could be reached in a timely manner. The majority of the second delays occurred due to a shortage of vehicles, poor road infrastructure, and shortage of ambulances. In the absence of a reliable transportation, women used difficult modes of transportation including bicycles, which take longer to reach a facility [84]. In some rural areas, local public transportation, which is the only means available, was often erratic, and the transportation fee was prohibitively expensive [29, 88]. Furthermore, it is usually difficult for women from a lower household income to afford transportation fees [29, 75, 77, 79, 81, 82]. Shortage of ambulances [29, 77, 79‐84, 89, 90] for patients and distance from health facility [20, 29, 74, 77, 79‐86, 89] were also found to be major barriers delaying women on the way to a health facility. Poor topographical access to a health facility was consistently reported to be an essential cause of the second delays [77, 79, 85].

Availability of EmOC services and necessary medical supplies eases the access to and utilization of the service for women when they face obstetric emergencies [41, 47, 67]. In the current review, a lack of EmOC service and a shortage of medical supplies were found to be the major causes of the third delays. Shortage of utilities including insufficient beds, shortage of rooms, and irregular supply of electricity and water supply were also reported to delay service provision. Likewise, the current findings were in line with studies in developing countries where barriers due to unavailability of service [20, 82, 90, 91] and a lack of essential drugs and medical supplies [82, 83, 90‐92] resulted in delays in the health facility. In developing countries, a lack of an operation theatre [83, 90] and a shortage of maternity service rooms [80, 84, 92] consistently affected the provision of EmOC services in health facilities. Similar to the findings of the current review, in different developing countries, lack of blood supply [84, 90] and insufficient utilities [20, 82, 84, 90] was found to affect the length of time to provide EmOC services.

In this review, delayed EmOC service provision due to factors related to lack of human resources was reported in several articles. This impediment of service provision resulted from a shortage of human resources was reported in different perspectives including lack of skill, shortage of staff, and poor attitude among providers. The findings of the current systematic review could be justified with other study findings conducted in developing countries where a shortage of competent human resource [82, 83, 90, 92, 93] and lack of training [29, 80, 82, 90‐92, 94] resulted in delays to provide quality obstetric care. Similarly, unwelcoming providers’ attitude [82‐84, 91] and staff absenteeism [80, 82] were reported to be the primary cause of delays that occurred in health facilities.

Problems related to the management of EmOC services were reported in many articles to pose a challenge to the provision of effective EmOC services. Similar to the findings of the current review, in developing countries, an absence of supportive supervision [83, 94] and poor staff motivation mechanism [82, 90, 92, 93] impeded the provision of quality EmOC services. Poor liaison among health facilities affected patient referral [29, 80, 82, 89, 92, 94] and resulted in unnecessary delays. Evidence supporting the current review was reported in different studies. Poor communication among providers [77, 82, 90, 94], poor coordination of service provision [29, 82, 90], reluctance to implement guidelines [84, 91, 92, 94], and unaccountability among facility managers [29, 82, 94] were reported to affect EmOC service provision.

The current review has the following strengths. Current evidence on the barriers to access and utilization of emergency obstetric care was systematically synthesized from both sides: the service providers’ and users’ perspectives. Methodologically, we included articles conducted with quantitative, qualitative, and mixed-methods study designs, rather than a homogeneous source; hence, wider findings were represented. Barriers reported in the quantitative studies were supported with descriptive factors obtained from the qualitative studies, which strengthened the review. Likewise, studies with a mixed-method design provided more wide-ranging barriers to access and utilization of emergency obstetric care. Generally, barriers to access and utilization of EmOC were identified from papers with a diversity of study designs and are presented using the standardized analytical framework. Screening for articles, data extraction, and evidence synthesis were conducted by two reviewers in order to strengthen the reliability of the study outcomes and minimize the subjectivity of the data extraction, evidence synthesis, and interpretation. Similarly, we strictly adhered to the inclusion and exclusion criteria, and the quality of articles was appraised using a validated quality appraisal method.

Beside these strengths, the limitations of the review should be noted. In a relatively fewer number of studies, researchers reported barriers from the service providers’ perspective so that few health system-related barriers were reported. We included only articles published in English and indexed in MEDLINE, CINAHL, Embase, Psych Info, and Maternity and Infant Care databases. Gray literature, including government reports, was not included in the review; hence, there is a possibility that some potentially relevant studies indexed elsewhere or published in a language other than English may have been missed. Nevertheless, a comprehensive search for articles offered identification of major barriers to access and utilization of EmOC care in sub-Saharan Africa.

Different factors were found to hamper access and utilization of EmOC among women in sub-Saharan Africa. Very complex and multi-faceted barriers delayed women’s access to and utilization of EmOC when they are in need. These barriers are inter-dependent and occur at multiple levels. These multiple barriers require multi-dimensional interventions that can take into consideration the challenges of the service providers’ and users’ perspectives. Though the factors are nearly similar across sub-Saharan African, country-specific interventions that are able to overcome the identified barriers are needed to tackle these challenges. Intersectoral collaboration should be strengthened, and all stakeholders should cooperate and work together to alleviate barriers that are observed at multiple levels. Health insurance should be made available for women to improve the effect of economic liability on health service utilization.

Investments in healthcare infrastructure, including roads facilities, obstetric care facilities, toilet facilities, water supply, interpersonal communication, equipment, human resources for health, and community-based health information dissemination, may lead to improved access to emergency obstetric services. Future research should focus on the exploitation of new opportunities that are helpful to eliminate these barriers and improve women’s access to and utilization of EmOC. Further research should focus on the third delays, as little is known about facility readiness to render quality EmOC.