Background
Sub-Saharan Africa has the world’s highest adverse maternal health outcomes. The designation sub-Saharan Africa as employed in this paper refers to its usage as given in the United Nations (MDGs) regions’ groupings, where it is used to indicate all of Africa except northern Africa (that is, Algeria, Egypt, Libyan Arab Jamahiriya, Morocco, Tunisia, and Western Sahara) [
1]. The lifetime risk of maternal death in sub-Saharan Africa is 1 in 38 compared to 1 in 160 for developing regions in general and 1 in 3,800 in developed regions [
2]. Between 1990 and 2013, there has been a 45% decline in global maternal mortality ratio (MMR), that is, from 380 to 210 deaths per 100,000 live births. Despite this decline, sub-Saharan Africa had a high MMR of 510 per 100,000 live births, compared to Northern Africa which generally had an average MMR of 69 per 100,000 live births in 2013. As a consequence, sub-Saharan Africa accounted for 62% of global maternal deaths in 2013 [
2].
Several sub-Saharan African countries have made significant progress in reducing MMR, but maternal death trends are variable. An estimated 15% (and possibly more) of all pregnant women in the world develop serious obstetric complications [
3,
4], most of which are treatable [
4]. The majority of these complications occur during, before, or shortly after birth [
5]. This knowledge about when most of these deaths occur provides an excellent window for interventions that could improve outcomes. In order to minimize related threats to life and improve outcomes for mother and child, skilled care in a supportive environment is essential [
6,
7]. This is supported by the World Health Organization’s recommendations on basic and comprehensive emergency obstetric care (EmOC), which outlines essential services, level of healthcare delivery, and related skilled attendants required for safe care [
3].
However, most sub-Saharan African nations are faced with a diverse range of individual/household problems as well as health system challenges. Challenges may include sociocultural barriers [
8], poor maternity referral systems [
9-
11], shortage of skilled health personnel [
12], and poor transport infrastructure coupled with long distances to health facilities [
13-
15]. Ultimately, these problems impact on access to skilled care at birth, which is integral to improved obstetric outcomes.
Basic and comprehensive EmOC is often not equitably distributed in many sub-Saharan African countries, in terms of its availability, accessibility, and acceptability [
5,
16,
17]. Additionally, countries with the worst maternal healthcare outcomes also have the least number of health workforce per population [
7]. As reported in the 2014
State of the World’
s Midwifery Report, 73 countries have 78% of births worldwide, 96% of global maternal deaths, and less than 42% of the world’s midwives, nurses, and doctors [
7]. Not surprisingly, the rate of skilled care at birth in Africa is low, at about 51%, with considerable rural/urban and socio-economic disparities [
18]. Even among those who receive skilled care at birth, adverse obstetric outcomes remain higher than expected. Given substantial efforts invested in encouraging women to use formal birthing services, end users may find obstetric care services more appealing if outcomes are significantly improved. In fact, institutional (health facility-based) maternal deaths and other adverse outcomes are significantly higher in developing regions, such as sub-Saharan Africa and South East Asia [
5].
This situation points partly to challenges regarding access to timely and appropriate obstetric care within health facilities. Of equal significance is safeguarding the trust of healthcare service users in facility-based care, without which maternal health outcomes are only likely to worsen. This is important because skilled care in sub-Saharan Africa is generally available in health facilities. Nonetheless, a larger than average number of deaths occur in healthcare facilities. Institutional maternal deaths may occur before or after receiving obstetric care. The former may be accounted for by delays in seeking care by women/families or a poor referral system; and the latter raises concerns about the nature of care provided and possible challenges [
5].
Significance
In light of these maternal health challenges, this systematic review will focus on gathering evidence from peer-reviewed literature on barriers to timely and appropriate obstetric care in sub-Saharan Africa. Apart from potentially improving obstetric care received by women in health facilities, identifying and removing barriers in healthcare settings could ultimately help boost skilled care attendance. This is because observable improvement in maternity outcomes may be a strong motivation for other women to choose healthcare facilities for birthing services. In other words, given the pivotal role of basic and comprehensive EmOC, synthesis of related literature will provide evidence to help strengthen policies aimed at improving obstetric care practice and also facilitate efforts in promoting the use of birthing services. Considering the strategic role of skilled care in reducing maternal deaths and on-going efforts to encourage healthcare facility-based births, it is crucial to ensure that scarce resources allocated to these efforts yield intended outcomes. This review will help assess the extent, strength, and implications of evidence across countries in sub-Saharan Africa.
Scope of the systematic review
This review aims to examine literature on barriers to obstetric care at health institutions in sub-Saharan Africa. It will focus on barriers or challenges that emerge after pregnant women have decided to seek obstetric care. It will also consider such barriers from the perspectives of maternity care workers (supply-side barriers) and service users (demand-side barriers) accessing formal maternity care services. Demand-side barriers are independent of service delivery or price and occur at the household and community level, such as transport costs to health facilities and lack of health awareness. Supply-side barriers, on the other hand, are constraints at the service delivery level and are beyond the control of health service users, such as long waiting times and high service costs [
19]. Articles of interest will be quantitative studies targeting maternity care workers and pregnant women accessing care and addressing any of the following:
-
barriers to accessing obstetric care and referral services,
-
barriers/challenges to receiving timely and appropriate care while utilizing maternity services, and
-
barriers encountered by maternity care workers in providing obstetric care and referral services.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
All authors (MKN, MCO, and TVM) made substantial contributions to the conception of this paper. MKN wrote the first draft of the manuscript. MCO and TVM provided substantive feedback, critically reviewed, and contributed to the intellectual content of this paper. All authors read and approved the final manuscript.