Abstract
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 five 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 identified in each study and organised into categories according to the three delays model. Results: Thirteen barriers to facility delivery were identified. Fear of maltreatment by healthcare staff; perceived low quality of care; distance and lack of transport to facilities; and cost of delivery were identified 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 identified, though it appears more difficult to find a solution to the barriers created by societal norms, as it would be culturally insensitive to impose Western beliefs on those with different traditional and religious views. This review provides suggestions for future research and potential interventions to reduce maternal mortality in sub-Saharan Africa.
Highlights
The maternal mortality ratio (MMR) in sub-Saharan Africa is more than 60 times that in the UK
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] when there are costs associated with delivery. [31]
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] a free emergency transport service implemented in central India, which is a developing country with a high maternal mortality ratio, has been found to increase the number of hospital deliveries. [39]
Summary
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. [10] MDG5 aimed to improve maternal health by reducing the worldwide maternal mortality ratio (MMR) by 75%. [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. 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
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