Exploring barriers to hospital delivery in Sub-Saharan Africa: a review of the literature

Background: The maternal mortality ratio (MMR) in sub-Saharan Africa is more than 60 times that in the UK. Both the Millennium Development Goals and the Sustainable Development Goals set out by the United Nations include a focus on reducing worldwide MMR. One way in which to achieve this is to encourage mothers in the developing world to deliver their babies in healthcare facilities. This review aims to identify the barriers to hospital delivery in sub-Saharan Africa. Methods: Two databases were searched for relevant studies published within the last fi ve years. All articles included in the review were critically appraised using CASP checklists and the STROBE statement to assess for bias. Barriers to hospital delivery were identi fi ed in each study and organised into categories according to the three delays model. Results: Thirteen barriers to facility delivery were identi fi ed. Fear of maltreatment by healthcare sta ff , perceived low quality of care, distance and lack of transport to facilities, and cost of delivery were identi fi ed as the barriers for which there was the highest level of evidence. Discussion: Successful interventions to tackle lack of transport and cost of delivery have been identi fi ed. It appears more di ffi cult to fi nd a solution to the barriers created by societal norms, however, as it would be culturally insensitive to impose Western beliefs on those with di ff erent traditional and religious views. This review provides suggestions for future research and potential interventions to reduce maternal mortality in sub-Saharan Africa.

Exploring barriers to hospital delivery in Sub-Saharan Africa: a review of the literature BACKGROUND Every day there are approximately 830 preventable deaths of women relating to pregnancy worldwide, with more than half of these occurring in sub-Saharan Africa.(1) The most common causes of death include haemorrhage, sepsis, hypertensive disorders, pulmonary embolism, unsafe abortion and delivery complications.
(2) Maternal death has huge societal impact in low-and middleincome countries due to the economic roles of women.(3,4) Children of mothers who die have increased rates of mortality, (4-6) poverty, (3,4,7) psychological problems, (8) early pregnancy, ( 9) malnutrition (7,9) and poor educational attainment.(4,(7)(8)(9) The United Nations Millennium Development Goals (MDGs) are eight goals that were set in 2000 to be achieved by 2015.(10) MDG5 aimed to improve maternal health by reducing the worldwide maternal mortality ratio (MMR) by 75%.(10) MMR is measured in maternal deaths per 100,000 live births.Significant progress has been made, with worldwide MMR decreasing by 37% between 2000 and 2015.(11) However, geographical inequalities still exist: in 2015, the MMR in sub-Saharan Africa was estimated at 546, compared to just nine in the UK.(11) In 2015, the United Nations (UN) adopted the Development Agenda "Transforming our World", containing 17 Sustainable Development Goals (SDGs) for review in 2030.(12) SDG3 aims to improve health at all ages, again focusing on reducing worldwide MMR.(12) Skilled attendance at delivery was recognised as a key factor in the reduction of maternal mortality by the Safe Motherhood Initiative in 1987.(13) As part of progress towards achieving MDG5 and SDG3, interventions have been introduced to encourage mothers in the developing world to deliver in healthcare facilities.(10,12) However, rates of facility delivery in this setting remain low.(14) This review will explore the barriers towards facility delivery in sub-Saharan Africa.
Maternal mortality is an important global health issue that UK medical students should be aware of.An appreciation of the barriers towards facility delivery in developing countries is essential in understanding why maternal healthcare inequalities exist globally and to identify successful interventions to improve maternal mortality in these countries in the future.This review is of particular interest to students with an interest in global health, international obstetrics or those undertaking a medical elective in sub-Saharan Africa.

METHODS
A comprehensive literature search was conducted using two databases: MEDLINE and Web of Science.MEDLINE was chosen for its wide range of medical literature whilst Web of Science was chosen to reflect a multi-disciplinary approach.Three key themes of the research question were identified: hospital delivery, barrier, and sub-Saharan Africa.Variations of these themes were used to conduct the searches.Search filters included English language and 'published since 2012'.The literature search was limited to papers published between 1st January 2012 and 17th February 2017 (the date on which the searches were conducted) in order to ensure that all of the identified barriers were relevant to the present day.104 papers were identified in total, ten of which were duplicates.The titles and abstracts of the remaining 94 papers were read and papers were excluded from the review if they did not specifically focus on barriers to hospital birth in sub-Saharan Africa.15 papers remained at the end of this process, all of which were included in the review.Articles were reviewed by one researcher (R Best).Exploring barriers to hospital delivery in Sub-Saharan Africa: a review of the literature Rebecca Robyn Best bsdj.org.uk The proposed barriers to hospital delivery were identified in each paper and collated into a spreadsheet.These barriers were then organised into three categories according to the three delays model proposed by Thaddeus and Maine in 1994.This model identifies three points at which delays prevent mothers from delivering at hospital: 1) delays in decisions to seek care; 2) delays to arrival at a healthcare facility; and 3) delays in care provision.(18) Considering the barriers to facility delivery using this framework allows interventions to be targeted to these three stages in seeking and receiving care.
The barriers are discussed below with consideration of the scientific rigour of the papers in which they were identified.Ethical approval was not required for this literature review.

Critical appraisal
Six of the studies were deemed to be of high quality, with low risk of bias and high confidence in the findings.(21,24,26,28,30,33) Five studies were assessed as being of moderate quality, (19,22,23,25,32) whilst the remaining four were deemed to have low confidence in the study findings.(20,27,29,31) Full details of the critical appraisal findings for each study are given in Table 2.

Barriers identified
Thirteen barriers to facility delivery were identified: community influence, cost of treatment, cultural beliefs, fear of HIV testing, lack of autonomy and confidentiality, lack of knowledge, lack of a support person, lack of transport, perceived low quality of care, fear of maltreatment, medicalisation of childbirth, precipitous labour, and poor facility equipment.These barriers are further discussed in terms of the three delays model below.(18)

Community influence
Five papers identified family or community influence as a barrier to facility delivery due to the pregnant woman's lack of autonomy within her community.(21,(30)(31)(32)(33) In the settings described, the decision to receive hospital care is made either by the woman's husband or community elders, (21,(30)(31)(32)(33) particularly when there are costs associated with delivery.(31)

Cultural beliefs
Four papers identified women's cultural beliefs as a barrier.(21,28,31,33) Bohren et al. highlight the belief that complications of childbirth, particularly eclamptic seizures, are spiritual in nature rather than physical and therefore could not be treated by healthcare professionals.(33) Similarly, Brighton et al. describe the belief that complications during pregnancy are caused by women's bad behaviour and the only curative treatment is the confession of sins.(31) In Tigray, Ethiopia, women value traditional practices during childbirth such as rituals to summon the support of Saint Mary, which are infeasible to replicate in a healthcare setting.( 21)

Fear of HIV testing
Two studies found fear of HIV testing to be a barrier to facility delivery in pregnant women.(

Lack of autonomy and confidentiality
O'Donnell et al. identified lack of autonomy as a major barrier to facility delivery in Malawi, with women reporting that they often did not understand why a treatment had been given in hospital and had not been asked for consent for procedures.(29) Also in Malawi, Kumbani et al. found lack of confidentiality to be a reason to avoid delivering at a facility.( 25)

Lack of knowledge
Echoka et al. describe women's lack of knowledge about pregnancy as a barrier to seeking a facility delivery in the Malindi district of Kenya.Many women stated that they thought the pregnancy complications they were experiencing were part of a normal labour and delivery and therefore did not know to seek help.(20) This The British Student Doctor Volume 3, No. 1 (2019)

Poor facility equipment
Poor-quality facility equipment was identified as a barrier by Gebrehiwot et al. in Ethiopia.(21) In this study, healthcare workers describe an absence of infection prevention equipment such as masks and goggles as well as shortage of clean water and electricity, which acts as a barrier to women seeking healthcare at the facilities.( 21)

Precipitous labour
Three studies described precipitous labour as a barrier to facility delivery, whereby women had intended on attending the hospital to give birth but were unable to make it to the hospital in time.(19,25,28)

Cost of delivery
Cost of facility delivery was identified as a barrier in eight studies.(19, 22, 26-28, 30, 32, 33) In many settings, patients are denied medical treatment unless they pay for the service beforehand, (33)(34)(35) limiting the number of hospital deliveries even when mothers are able to reach the facility in time.Even in countries where there is no fee for delivery, studies describe the 'hidden costs' of childbirth, which include transportation, (27,33) registration, (26) laboratory tests (26) and items such as sheets and antiseptics that women are expected to bring with them to hospital.( 19)

DISCUSSION
Thirteen barriers to facility delivery were identified by this review.An important link that can be made between several of these barriers is societal norms.Cultural beliefs, community influence, maltreatment in hospital facilities and childbirth as a natural process are barriers that result from what is perceived as normal in sub-Saharan African communities.It can therefore be difficult to implement effective interventions to tackle these barriers, as it would be culturally insensitive to try to impose Western beliefs on barrier was also identified by women in Coast Province, Kenya (27) and healthcare workers in Rwanda.( 22)

Lack of support person
Crissman et al. identified lack of a support person as a barrier to hospital delivery in rural Ghana, (19) as the presence of a birth partner is a prerequisite for healthcare worker delivery in this area.

Low quality of care
Six papers identified a perception of poor-quality care at facilities as a barrier to hospital delivery.(24-26, 28, 32, 33) In the study by Bohren et al., women reported healthcare workers to be undertrained, incompetent and inexperienced.(33) Other perceptions of low quality care included lack of pain relief and unavailability of delivery attendants; (24) long waiting times for antenatal care appointments; (25,26) and unprofessional attitudes from staff.( 26)

Medicalisation of childbirth
One theme identified by five papers was the perception of childbirth as a natural process that should not require medical treatment.(20-22, 30, 32) Echoka et al. discuss the fact that despite high levels of birth preparedness, mothers in Kenya choose to deliver at home because they do not associate pregnancy with illhealth.(20) Similarly, Gebrehiwot et al. found that women living in rural Ethiopia are reluctant to visit hospital for delivery unless they perceive themselves to be sick.(21) This finding is reflected in studies in Rwanda (22) and Nigeria (30) as well as in Tey and Lai's quantitative study in sub-Saharan African and South Asia.(32) Exploring barriers to hospital delivery in Sub-Saharan Africa: a review of the literature Rebecca Robyn Best bsdj.org.ukthose with different traditional and religious views.
Barriers that may be tackled more readily are cost of delivery and lack of transport to facilities.Free and heavily subsidised obstetric care programmes have already been introduced in many countries in sub-Saharan Africa, which have been shown to increase the number of facility deliveries and reduce maternal mortality.(34,(36)(37)(38) Similarly, a free emergency transport service implemented in central India, which is also a developing country with a high maternal mortality ratio, has been found to increase the number of hospital deliveries.(39) Interestingly, Mason et al. identified HIV testing as both a barrier and facilitator to hospital delivery, as some women recognised the value of being tested and appreciated the free service whilst others feared the stigma of a positive result.(26) A suggested intervention here might be to highlight the importance of a woman's right to choose whether or not she receives the test, though this does raise potential ethical issues surrounding unknown vertical transmission of HIV.
The three most commonly identified barriers to facility delivery were fear of maltreatment by healthcare staff; (19, 23-29, 31, 33) distance and lack of transport to facilities; (19-21, 25, 27, 28, 30, 32, 33) and cost of delivery.(19, 22, 26-28, 30, 32, 33) Each of these barriers were identified by four papers that were assessed to be of high quality as well as a number of papers that were assessed to be of moderate or low quality.Perceived poor quality of care was another barrier identified by four high quality studies, (24-26, 28, 32, 33) though it was identified as a barrier in fewer total papers than the other three common barriers.
On the other hand, three barriers to hospital delivery were only identified by papers that were assessed to be of moderate or low quality: lack of a support person; (19) lack of knowledge; (20,22,27) and lack of autonomy and confidentiality.(25,29) The evidence for these barriers is therefore weaker than the evidence for the other barriers identified.
Strengths of this review include the recent nature of all of the articles included.This suggests that all of the barriers identified are current issues, as it is recognised that barriers to hospital delivery may change over time.The included studies also represent the views of healthcare workers and communities as well as pregnant women themselves.Finally, validated scoring systems have been used to critically appraise the literature.
Limitations of the review include the relatively small sample size and the fact that several of the included studies were assessed as having low confidence in the quality of evidence.The qualitative study by Mwangome et al (27) in particular was found to be poorly conducted with reference to the CASP criteria.Another limitation is that different scoring systems were used to critically appraise the papers, due to differences in study design, and each paper was only appraised by one researcher (R Best).This review has identified the main barriers to hospital delivery in sub-Saharan Africa, which enables organisations such as the World Health Organisation and the United Nations to target their interventions towards the relevant barriers in order to improve maternal mortality.

CONCLUSION
The barriers identified by the most papers with the highest quality evidence in this review were fear of maltreatment by healthcare staff; perceived low quality of care at facilities; distance and lack of transport; and cost of delivery.Successful interventions to tackle lack of transport and cost of delivery have been identified, though it appears more difficult to find a solution to the barriers created by societal norms.
Future research should focus on the implementation of effective interventions to target transport and cost as well as investigating the reasons behind maltreatment of pregnant women by hospital staff.Investment should also be made in hospitals where there is lack of equipment and utilities such as running water and electricity in order to improve standards and encourage women to deliver in hospital.Exploring barriers to hospital delivery in Sub-Saharan Africa: a review of the literature Rebecca Robyn Best

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Figure 1 -
Figure 1 -PRISMA flow diagram 26,33) Bohren et al. highlight how women in low-and middle-income countries fear the discrimination associated with a positive HIV test result.(33) Mason et al. noted a similar fear in Kenyan women, with many participants not wishing to know their own result as well as being fearful of others discovering that they tested positive.(26) abuse.Bohren et al. describe pregnant women being slapped, hit and forcefully restrained by medical staff.(33) Brighton et al. highlight how women are not allowed to express pain or make noise during labour.(31)

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