Interventions That Improve the Uptake of Antenatal Care Services in 	Sub-saharan Africa: a Systematic Review and Meta-analysis

doi:10.21203/rs.3.rs-4707245/v1

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Interventions That Improve the Uptake of Antenatal Care Services in Sub-saharan Africa: a Systematic Review and Meta-analysis

https://doi.org/10.21203/rs.3.rs-4707245/v1

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Introduction: Despite 70% of global maternal deaths occurring in sub-Saharan Africa (SSA), antenatal care (ANC) still remains underutilized with diverse, inconsistent impact from interventions. This systematic review identifies the most effective interventions to improve ANC uptake in the region, aiming to inform policy decisions and ultimately reduce maternal and perinatal mortality.

Methods: A systematic review of studies published between 2000 and 2022 was conducted to identify effective interventions that improve ANC uptake in SSA. Studies were screened using Rayyan software^â, and data was extracted by two reviewers. Interventions included ICT interventions, financial incentives, mobile clinics, and pharmacological interventions. Studies were included if they were conducted in SSA, and if they reported on maternal-fetal outcomes. Data was synthesized using a narrative and graphic approach and meta-analysis was conducted using the empirical Bayes method. Publication bias was assessed using Egger's and Begg's tests and addressed using the Trim and Fill method.

Results: In an analysis of 17 studies, which all either had the cluster-randomized controlled trial or randomized controlled trial study design, we investigated the effectiveness of diverse interventions in increasing ANC attendance. Our findings revealed an overall increase in ANC utilization across all interventions (OR=3.94, RR=1.16). Sub-group analysis further identified studies jointly reported from Kenya and Nigeria as demonstrating the highest impact. However, a crucial caveat emerged with the detection of publication bias, prompting cautious interpretation, and emphasizing the need for further research.

Conclusion: Our analysis offers valuable insights for policymakers aiming to optimize interventions and maximize ANC uptake, potentially paving the way for improved maternal and perinatal outcomes in SSA.

In 2020, approximately 287,000 maternal deaths occurred globally, with 70% of these fatalities happening in sub-Saharan Africa (SSA)(1). It is thus not surprising that in 2020, SSA had the relatively highest maternal mortality ratio (MMR) of 545 deaths per 100,000 live births, with a lifetime risk of maternal death of 1 in 40 (2). This was in sharp contrast to the MMR in developed regions, such as the MMR of 4 and 13 deaths per 100,000 live births in 2020 for Australia and New Zealand and Europe and Northern America, respectively(2). Also, both of these regions had the relatively lowest lifetime risk of maternal death of 1 in 16,000 and 1 in 5,100, respectively, in 2020(2). This is worrisome because there is less than a decade left to achieve the United Nations(UN) Sustainable Development Goals(SDG), which has the 1st target of the 3rd goal (that is, SDG target 3.1) as reduction of global MMR to less than 70 deaths per 100,000 live births by 2030 (2).

Despite efforts made, challenges such as low maternal health coverage, poor quality of care, and inequalities persist with maternal health services access and utilisation in SSA(3–5). Antenatal care (ANC), that is a crucial component of maternal health care, is provided to pregnant women to ensure healthy pregnancies and positive outcomes for both mothers and their babies(6). It has evolved from traditional models to the 2002 World Health Organization (WHO) focused antenatal care, and then more recently to the 2016 WHO individual-based ANC model, with its impact often persisting even after delivery(7). The ANC services offered to pregnant women was designed to be conducted in a midwife-led unit, a nurse-led unit, or a doctor/consultant-led unit, or a combination of all three, depending on the perceived risk of the current pregnancy (7).

The prompt initiation and adequate utilization of quality ANC services have been proven to reduce maternal, perinatal, and neonatal morbidity and mortality(2, 7). This is because, amongst others, ANC allows for preventive treatment to be administered, such as prophylactic malaria treatment or regular screening for sexually transmitted diseases such as HIV, so as to generally augment healthcare, and hence improve health outcomes, for both mother and child during and after pregnancy (8). In addition, using evidence-based practices, with ANC, there is the opportunity for the early detection and prompt treatment/management of diseases/medical conditions by the skilled healthcare personnels(9, 10). These diseases/medical conditions are either directly caused by the complications of pregnancy or indirectly by the already existing underlying diseases which can possibly be aggravated by pregnancy, with risk of additional complications/diseases occurring (11, 12). All of these are important, according to a recent systematic review, the leading causes of maternal mortality in SSA are obstetric hemorrhage, hypertensive disorders, non-obstetric complications, and pregnancy-related infections, in that order (11).

Despite these significant benefits of ANC, their adoption has encountered numerous challenges/barriers in SSA (13). These difficulties include a lack of understanding about the importance of such services and failure to comply with standard uptake guidelines(14). These challenges may arise from prevalent social issues in the region, such as poverty, illiteracy, and a lack of women's empowerment (13, 15, 16). Additionally, obstacles to accessing and affording the service, as well as its unavailability, may also contribute to these challenges(17).

Various interventions have been implemented by different countries in SSA to enhance the uptake of ANC, including financial incentives, gift packs, telecommunication services, nutritional and psychological support(18, 19). However, despite these efforts, there has been little or no improvement in the prevalence of ANC utilization in SSA across the years (12). For example, from the statistics made available in 2022, 88% and 69% of the pregnant women of reproductive age (15 to 49 years) globally utilized ANC services at least once and at least four times (ANC + 1 and ANC + 4), respectively (12, 20) Dickson established a pooled prevalence of 76.0% for ANC + 1 utilisation using data from several recent Demographic and Health Survey (DHS) for 32 countries in SSA(20).

Furthermore, in the sub-regions of the world with the relatively highest MMR such as in Western and the Central part of Africa, the ANC service coverage are relatively lower, especially as the number of ANC contacts increases (12). For example, in 2022, 81% and 56% of the pregnant women of reproductive age utilized ANC + 1 and ANC + 4 services, respectively, in West and Central Africa, which are sub-regions within SSA (12). On the other hand, in 2022, 86% and 55% of the pregnant women of reproductive age utilized ANC + 1 and ANC + 4 services, respectively, in Eastern and Southern Africa, which are also sub-regions within SSA (12).

This is in sharp contrast to the developed regions of the world which have the relatively lowest MMR, such as in Northern America where 99% of pregnant women of reproductive age utilized ANC + 4 services in 2022(12). Note that in 2012, 51% of pregnant women of reproductive age in West and Central Africa, as opposed to 97% in Northern America, utilized ANC + 4 services (12). Also, in 2012, 47% of pregnant women of reproductive age in Eastern and Southern Africa utilized ANC + 4 services (12). This thus represents an abysmal increase of only five and eight percentage points across 10 years; that is, from 2012 to 2022, in relation to pregnant women of reproductive age utilizing ANC + 4 services in West and Central Africa and in Eastern and Southern Africa, respectively (12).

Also, within the various countries in SSA, variations exist in terms of the utilisation of ANC + 4 services (12). This could be as low as 24% in Somalia using data from Her 2020 DHS, and 29% in Senegal using data from Her 2020 to 2021 Malaria Indicator Survey (MIS) (12). It could also be as high as 85% in Ghana using data from her 2017 to 2018 Multiple Indicator Cluster Survey (MICS), and 87% in Liberia using data from her 2019 to 2020 DHS (12).

Therefore, all of the above underscores the importance of increasing adequate access to and utilisation of quality ANC services in SSA, with the end goal of reducing the MMR within this region and hence in the world, using different interventions. However, numerous studies evaluating the effectiveness of these interventions aimed at improving ANC uptake in SSA have yielded inconsistent findings, with some interventions proving effective, while others were not or had neutral effects (18, 19, 21–23).

To address these inconsistencies and inform policy decisions on which interventions to adopt to improve ANC uptake and utilization in this region, we conducted a systematic review and meta-analysis of these studies. Our primary objective was to identify the most effective interventions targeting women of reproductive age, including pregnant and non-pregnant women, that enhance the utilization of ANC services in sub-Saharan African countries. Also, to quantitatively synthesize the evidence using meta-analysis. We hypothesized that specific interventions could be identified that if adopted would improve access to and utilisation of quality ANC services and ultimately lead to better maternal and perinatal outcomes, in alignment with the achievement of SDG 3.

Protocol and Registration

This systematic review was carried out in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and also the guidelines for systematic reviews of health promotion and public health interventions(24, 25). The review protocol was registered with the international Prospective Register of Systematic Reviews (PROSPERO) on… with registration number…

Search Strategy

The study search strategy was based on the guidelines for systematic reviews of health promotion and public health interventions(26). We conducted a search across various databases, including Pubmed, CINAHL Plus, Cochrane, AJOL, BIOLINE Web of Science/Core Collection, Embase via Ovid, and Scopus via Elsevier, to identify studies published between January 1, 2000 and December 31st, 2022 on interventions that can improve the uptake of ANC in sub-Saharan African countries. Note that we chose the year 2000 as the starting point to reflect the increased global attention placed on maternal health due to the formation and adoption of the UN Millennium Development Goals (MDG)(27). These MDG spanned for 15 years and were replaced in 2016 by the SDG(28)

Our research question was centered around identifying appropriate interventions targeting women of reproductive age that aimed to increase the utilization of ANC services. To ensure consistency in our search, we grouped our search terms into four major categories of interest following an adaptation of the PICO (Patient/population/problem; Intervention/exposure; Context/setting; and Outcome) search framework, as used by Ifeagwu et al (29).

We used Medical Subject Headings (MeSH) whenever possible, and our search terms included terms like "pregnancy" [MeSH] OR pregnant women OR pregnant mothers* OR gestational mothers* OR women OR maternal age women OR matern*) and "antenatal care" [tw] OR prenatal care [MeSH Terms] or "antenatal care services" [tw] OR pre-delivery care" AND ("intervention s"[All Fields] OR "interventions"[All Fields] OR "interventive"[All Fields] OR "methods"[MeSH Terms] OR "methods"[All Fields] OR "intervention"[All Fields] OR "interventional"[All Fields]. Each iteration was restricted to SSA. The search was also made with individual SSA country names. For more information on our search strategy, please refer to Supplementary Table 1.

Study Inclusion and Exclusion Criteria

Two reviewers (Z F and O L) /authors used pre-established standards to evaluate the studies, with a third reviewer (B MM)/author resolving by consensus any disagreements. At first, the title and abstract were used to exclude certain studies. Then, the entire text was evaluated to determine if it was appropriate for the review. Finally, final the full text of the selected artcles were re-examined. Rayyan software^®(30), which is a web and mobile app for systematic reviews, was used for the initial screening of the title and abstract. We included studies that provided information and data for interventions targeting women for increased uptake of ANC services.

The interventions were considered eligible if they were information and communication technology (ICT) interventions, antiretroviral therapy (ART) compliance reminders, conditional financial incentives, managerial and financial level interventions, mobile clinics and teleconsultation, and pharmacological. Also, gift packs, mosquito nets, group antenatal, nutritional intervention, cost-effectiveness of intervention, emergency ANC. Studies that directly or indirectly aimed at increasing the utilization of ANC services using different interventions, with the prevention of maternal deaths and the improvement of maternal and child health as the outcomes of interest, were eligible. Furthermore, studies are considered eligible if implemented in SSA. The included studies must have a design such as: randomized controlled trials (RCTs); systematic reviews and meta-analyses; clinical control trials; quasi-experimental studies; before and after (pre-post studies); qualitative formative studies. There were no language restrictions. Note that additionally, the reference lists of selected articles were searched so as to assess if more eligible studies could be possibly identified, and then included in this review.

Exclusion Criteria

We omitted studies that did not involve human populations or not focused on pregnant women. Additionally, we excluded studies conducted outside of the SSA and those that did not report on maternal-perinatal or neonatal outcomes. Non-intervention studies such as opinions or proposed strategies were also excluded.

Quality Assessment of Included Studies

The following parameters were used to assess the quality of the included publications: Random sequence generation, Allocation concealment, Blinding of participants and personnel, Blinding of outcome assessment, Recruitment bias (for cluster RCTs), Incomplete outcome data, Selective reporting, Analysis bias, Other sources of bias. The details as in supplementary table 1.

Data Extraction Strategy

The articles were evaluated by two reviewers/authors separately, with a third reviewer/author acting as a mediator to resolve any discrepancies through mutual agreement. The extracted data from the articles included the author's names, year of publication, country of study, study area, implementing agency, type of intervention, year of data collection, study design, assessed outcome(s), effect estimate, number of ANC visits, and quality score.

Statistics

In order to analyze and present our findings, we employed a narrative and graphic synthesis approach. To summarize dichotomous data, we utilized composite odds ratios with 95% confidence intervals (CI), while for continuous data measured in similar units, we used the mean difference effect measure. To combine the findings from various studies and determine the overall odds ratio and relative risk, we used the empirical Bayes method of random effects meta-analysis. We assessed heterogeneity using Cochran's Q test and graphical presentations and classified it as low, medium, or high based on a predefined Cochrane Q of 25%, 50%, and 75%, respectively. We evaluated publication bias using Egger's and Begg's adjusted rank correlation tests and visually represented the results with a funnel plot. We also addressed any potential publication bias using the Trim and Fill method, which is a rank-based data augmentation technique. This method estimates the number and outcomes of missing studies and adjusts the meta-analysis to incorporate the theoretically missing studies. The level of significance was set at P < 0.05.

We adhered to the PRISMA guidelines(25), as shown in Figure 1, to select relevant studies. Initially, we identified a total of 124 studies from the different databases searched, and then an additional 12 studies from other sources. Upon further evaluation, 17 studies met the criteria for inclusion in this review, and the details of these studies are summarized in Table 1.9 We excluded certain studies for reasons such as not reporting treatment effects on ANC, including different or mixed populations, or lacking the necessary indices to compute odds ratios or relative risks. All included studies were carried out in rural settings, with nine in health facilities and eight in local communities.

Among the 17 studies included in the review(18, 19, 21-23, 31-43), four specifically focused on HIV-positive pregnant women attending ANC. Out of these 17 studies, two employed text messaging interventions, four utilized enhanced health education, and two used conditional cash transfers as interventions. The remaining studies employed various other interventions, which are specified in Table 1. All the included studies either had RCTs or cluster randomized controlled trial design methods. The studies were carried out in the Democratic Republic of Congo (DRC)(21, 38), Ethiopia (19, 34), Zimbabwe(33), Uganda (22, 39, 41), Ghana (41), Tanzania (18, 42), Nigeria(35), and Kenya (23, 31, 43).

Overall, the summary effect measure for the 17 studies demonstrated statistically significant effectiveness of interventions aimed at increasing ANC utilization: 2.31; 95% C.I (1.34 – 3.28), as seen in figure 2. However, considering the limitation imposed by combining summary odds ratio and summary relative risk we assessed for separate effect measures for the two. The summary effect measure for odds ratio was statistically significant at 3.94; 95% C.I. (2.00 -5.89); while that of relative risk was not statistically significant, although it also showed a positive effect, at 1.16; 95% C.I. (0.92 – 1.41). Thus, the studies with odds ratio as the effect measure had an overall higher impact (figure 2).

From our findings, some of interventions used had a positive effect size, meaning that they were associated with an increase in the number of ANC visits women attended. Although, all of the effects had variable statistical significance, the most effective intervention was the impact of group antenatal care (G-ANC) with OR 13.30(figure 2).This was followed by combination of ANC plus HIV care, which had an effect size of 3.94 (figure 2). This means that women who received this intervention were nearly four times more likely to attend ANC than women who did not receive the intervention. Other effective interventions included group ANC, health education, and cash transfers. These interventions had effect sizes ranging from 1.02 to 1.50, meaning that they were associated with a roughly 2% to 50% increase in ANC attendance (figure 2)

Furthermore, with sub-group analysis among regions, as seen in Table 2, the study reporting jointly, on intervention in Kenya and Nigeria had the highest impact with an effect size measure of 9.42; 95% CI (0.57 - 15.28). Also, with the sub-group analysis, as seen in Table 2, the difference in study design; that is, whether cluster randomized controlled trial or RCT, did not have a significant impact on the outcome of intervention; with an effect measure of 1.24;95%CI(1.0 to 1.38) and 1.23;95%CI(0.59 to 1.87), respectively. Furthermore, assessing based on the setting of study, as seen in Table 2, studies done in health facilities had a higher effect size of 2.02; 95% CI (1.31- 2.74), in comparison to those carried out in the community, with an effect size of 1.14; 95%CI (1.00 to 1.27). The difference in setting of the studies thus had a significant impact on the increase of ANC utilization. The difference in target population did not have a significant impact on the effect size of intervention between 1.34(0.67 to 2.02) and 1.21(1.07 to 1.35) for HIV-positive pregnant women and those with undeclared HIV status, respectively.

Table 2: Sub group analysis to assess for impact for confounders on determinants of size of Effect size affecting interventions that increase ANC uptake

Effect measure

Confidence Interval

I²

p-value

Sub-grouping

Country

DRC^{(21, 38)}

Ethiopia^{(19, 34)}

Ghana⁽⁴¹⁾

Kenya ^{(23, 31, 32, 38, 43)}

Kenya & Nigeria⁽³⁵⁾

Sub-Saharan Africa⁽³⁶⁾

Tanzania ^{(15, 37, 42)}

Uganda ^{(22, 39, 41)}

Zimbabwe ⁽³³⁾

1.237

1.278

1.020

1.965

9.424

5.860

1.412

1.041

1.500

0.45 - 2.021

1.030 - 1.527

0.96 - 1.09

1.34 - 2.59

0.57 - 15.28

0.66 - 11.06

0.69 - 2.14

0.73 - 1.35

0.94 - 2.06

17.94

93.18

94.7

96.8

46.59

54.1

78.84

69.05

78.8

0.01

0.03

0.02

0.01

0.03

0.01

0.03

Study design

Cluster Randomized Control Trial

Randomized Control Trial

1.235

1.231

1.08 - 1.38

0.59 - 1.87

85.36

7.43

0.001

0.01

Effect measure

Odds Ratio

Relative Risk

3.94

1.16

1.99 -5.88

0.92 - 1.41

91.71

0.01

Setting

Community

Facility

1.14

2.024

1.00 - 1.27

1.31- 2.74

87.25

70.90

0.001

Target population

HIV+ pregnant women

Pregnant women with undeclared HIV status

1.341

1.211

0.666 2.017

1.070 1.352

11.01

84.62

0.338

0.001

We performed meta-regression to delineate the impact of time of publication on study effect size. We found a rising trend with a regression coefficient of 0.13 (p-value 0.285) (figure 3)

We assessed for publication bias in included studies. It shows both graphical (figure 4) and computational evidence of publication bias, with eggers test p value of 0.001.

In an attempt to find ways to reduce the high maternal and perinatal morbidity and mortality in SSA, we conducted a systematic review and meta-analysis on interventions that enhance the utilization of ANC services, and subsequently lead to improved maternal and perinatal outcomes. To the best of our knowledge, this review stands as the first one to comprehensively focus on all interventions; both pharmacological and non-pharmacological which have the potential to augment the utilization of ANC services in SSA.

Overall, all the interventions analyzed in this review; including health education (19, 34, 39, 42), conditional cash transfer (21, 23), group ANC, home visit (35)(37), ANC integrated with HIV care (18, 43), telecommunication augmented ANC (18, 31), and increased frequency of ANC, led to increased ANC attendance. Amongst these interventions, group ANC, health education, and ANC with incentives were most effective in enhancing ANC uptake in SSA. The positive impact of this intervention may not be unrelated to the expected roles that incentives, reminders, information provision and companionship used as forms of interventions in these studies could have had in a region where poverty, ignorance, and illiteracy predominate (44, 45).

These aforementioned factors often negatively affect people’s ability to make rational decisions. Linking ANC attendance with incentives not only encourages expectant mothers to seek care early and regularly but also alleviates financial barriers that often deter women from accessing essential healthcare services. Health education also empowers expectant mothers with comprehensive knowledge about the importance of ANC, prenatal nutrition, danger signs during pregnancy, and the benefits of skilled birth attendance. Furthermore, group ANC fosters a supportive environment where women can share experiences, address concerns, and collectively commit to prioritizing their maternal health.

The highest rate of uptake of ANC amongst HIV positive women when ANC was integrated with HIV care in SSA might be because integration allows for streamlined access to comprehensive healthcare thereby reducing stigma and discrimination associated with seeking separate services for HIV care. Moreover, the combined services facilitate the delivery of preventive interventions, such as ART and prevention of mother-to-child transmission interventions, within the ANC framework, thereby ensuring a holistic approach to maternal and child health.

This finding is however, in contrast to the review done by Esopo et al(36) which observed that only studies that employed non-biological factors like incentives, reminders, and planning improved the uptake of ANC. Similarly, a Cochrane review by Mbuagbaw et al(46) also revealed that only a few interventions improved ANC coverage and suggested that a combination of more than one intervention is more likely to increase ANC uptake. The findings of Esopo et al(36) may have been affected by their methodology which limited their reviews to only non-biological interventions and home visits, unlike the index study which considered biological and other interventions.

Although, all the interventions evaluated, as seen from the overall estimate effect, were statistically significant in improving ANC uptake, however, when the effect measures were separated, only the summary estimate pooling together the studies that used odd ratio as the effect measure were statistically significant. This may not be unconnected to the differences in sample sizes as some of the studies evaluated had small sample sizes. Also, some of the studies which used relative risk for measuring effect changes only focused on retroviral disease-positive pregnant women which is a subset of the study population and not the entire pregnant women considered in the present study.

Furthermore, a combined study conducted in Kenya and Nigeria(35) showed the highest effect size. This might not be unconnected to their large sample size and the intervention they employed, which is four or more ANC visits which is a common practice in SSA. In addition, we also observed a rising trend of the effect size over the year of study publication. Although this was not statistically significant, this might suggest an improvement in the methodology over the years. Our study, also revealed significant evidence of publication bias.

Like other qualitative reviews on intervention studies, this systematic review has its limitations. The goal of this review was to identify all studies that met the eligibility criteria, but it is possible that we might have missed some relevant articles included in other databases than those chosen to be reviewed. Also, the intervention measures were too heterogeneous to be categorized into any meaningful classification and this may have affected our meta-analysis. The heterogenicity of these interventions has also made us depend on simple summary data for each intervention group, such as the different effect size measures and there accompanying 95%CI used for each study, for our analysis and discussions.

The present study has demonstrated that health education, group ANC, conditional cash transfer, and ANC integrated with HIV care in HIV positive individuals were the most effective interventions, and hence directly increased the uptake of antenatal care in SSA. However, it seems that increased uptake of ANC alone is sub-optimal in reducing maternal and perinatal mortality, and so more emphasis should be placed on both the quality and quantity of ANC and not just to increase the uptake of ANC. Furthermore, a bundled combination of more than one intervention should be explored to increase ANC uptake. Future research should investigate the factors that contribute to the effectiveness of different interventions, as well as the cost-effectiveness of different interventions. This information can be used to develop and implement more effective ANC interventions in SSA.

FUNDING

The authors declared that they have not obtained any grant for this research from any funding agency in the public or commercial sectors

ETHICS DECLARATION

Ethics approval and consent to participate were not applicable as secondary data was used

COMPETING INTRESTS

None declared

Author Contribution

HG and FO designed the study, BMM, ZF and AM did the analysis,IJO and LFO did the write up of the work, AS, ON,DO, VO and EO substantively revised it, AMY, BMM and IJO interpreted the data

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Table 1 is available in the Supplementary Files section.

No competing interests reported.

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Interventions That Improve the Uptake of Antenatal Care Services in Sub-saharan Africa: a Systematic Review and Meta-analysis

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Abstract

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INTRODUCTION

METHODOLOGY

Protocol and Registration

Search Strategy

Study Inclusion and Exclusion Criteria

Exclusion Criteria

Quality Assessment of Included Studies

Data Extraction Strategy

Statistics

RESULT

DISCUSSION

CONCLUSION

Declarations

Author Contribution

References

Table

Additional Declarations

Supplementary Files

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