Objective: To explain the factors related to the implementation of antenatal care in developing countries.
Methods: The systematic review was conducted in June 2020 and comprised literature search on Scopus, Cumulated Index to Nursing and Allied Health Literature, PubMed and Garba Rujukan Digital databases for cross-sectional, survey-based, prospective, mixed-method, correlational, experimental, longitudinal, cohort and case-control studies published after 2015 in either English or Indonesian. The studies included involved pregnant women and discussed the factors of implementing antenatal care in developing countries, and explained the factors related to the implementation of antenatal care in accordance with the World Health Organisation recommendation. The Population, Intervention, Comparison, Outcomes and Study framework was used, and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. Data was analysed using descriptive statistics with a narrative approach.
Results: Of the 9,733 studies initially found, 50(0.005%) were shortlisted for full-text review, and, of them, 15(30%) were reviewed and analysed. There were 3(20%) each from Pakistan and Ghana, 2(13.3%) each from Nepal and India, and 1(6.66%) each from Jordan, Egypt, Yemen, South Africa and Vietnam. Overall, 10(66.6%) were cross-sectional studies. There were five factors identified regarding antenatal care; behaviour intention, social support, accessibility of information, personal autonomy, and action situations, including economic status, availability of facility and transportation.
Conclusion: Antenatal care in pregnant women in developing countries is influenced by several factors, and economic status and the availability of facilities and infrastructure optimise the use of such services.
Keywords: Pregnancy, Prenatal care, Maternal mortality, Autonomy. (JPMA 73: S-162 [Suppl. 2]; 2023)
Pregnancy is a natural process and the changes that occur in women during normal pregnancy1 may cause complications. Antenatal care (ANC) helps mothers prepare for labour and understand the warning signs during pregnancy and delivery.2 The use of ANC in developing countries has increased, but there are still disparities due to geographical, demographic, socioeconomic and cultural factors.3,4 Inhibiting factors in the use of ANC are poverty, distance to facilities, lack of information, inadequate and poor-quality services, and cultural beliefs.5
The implementation of ANC is motivated by various factors6 and it is necessary to carry out research to review the relevant factors. A review on factors related to the behaviour of pregnant women towards ANC in developing countries did not cover the intention factor.7 Snehandu B. Karr’s Theory of Health Behaviour8 identified 5 determinants of health behaviour, namely the existence of a person’s intention to act in relation to a stimulus outside himself (behaviour intention), social support, accessibility of information, The 2017 maternal mortality rate (MMR) in low-income countries (LICs) was 462 per 100,000 live births.5 The MMR in Indonesia in 2015 was 305 per 100,000 live births and the World Bank reported 2017 MMR to be 177 per 100,000 live births.9 The target for reducing MMR globally by 2030 is <70 deaths per 100,000 live births as stated in the Sustainable Development Goals (SDGs).10
Acute kidney injury (AKI) is one of the consequences of low ANC coverage, and becomes an important indicator in determining the degree of public health. Globally, 86% of pregnant women have had ANC visits at least once, and 65% at least 4 times. Ethiopia (43%), Bangladesh (36.9%) and Afghanistan (20.9%) were the countries with the lowest ANC utilisation in the 2016-19 period5. One of the efforts to reduce maternal mortality is by improving maternal and neonatal health (MNH) services through service programmes.11
ANC non-compliance results in not knowing whether the pregnancy is going well, experiencing high-risk conditions and obstetric complications that can endanger the life of the mother and the foetus, causing high morbidity and mortality.12 Obstetric complications include bleeding, infection, pre-eclampsia and eclampsia, complications of childbirth, and unsafe abortion. Most of these complications develop during pregnancy and can be prevented and managed.
ANC provided by skilled health workers can reduce maternal and infant mortality during pregnancy and birth. The World Health Organisation (WHO) has recommended a minimum of 4 ANC visits for pregnant women.2 ANC must be carried out routinely, according to standards, and in an integrated manner in order to prepare for a clean, safe and healthy delivery.
The current systematic review was planned to explain the factors related to ANV implementation in developing countries.
Materials and Methods
The systematic review was conducted in June 2020 and comprised literature search on Scopus, Cumulated Index to Nursing and Allied Health Literature (CINAHIL), PubMed and Garba Rujukan Digital (GARUDA) databases.
The Population, Intervention, Comparison, Outcomes and Study (PICOS)13 framework was used, and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines11 were followed. The search was carried out using key words “antenatal care,” “prenatal care,” “factors,” “visit,” “attendance,” “determinant,” “enabler,” “influencing,” “affecting,” “supporting,” “pregnant women,” and “pregnancy”. The key words were combined with Boolean operators AND, OR, and NOT. Those included were cross-sectional, survey-based, prospective, mixed-method, correlational, experimental, longitudinal, cohort and case-control studies published after 2015 in either English or Bhasha. The studies included involved pregnant women and discussed the factors of ANC implementation in developing countries, and explained the factors related to such implementation in accordance with the relevant WHO recommendation.4 Duplicates and articles for which full text was not available were excluded. The articles were screened for quality based on relevance, accuracy and purpose.
Of the 9,733 studies initially found, 50(0.005%) were shortlisted for full-text review, and, of them, 15(30%)12-26 were reviewed and analysed (Figure).
There were 3(20%) each from Pakistan and Ghana, 2(13.3%) each from Nepal and India, and 1(6.66%) each from Jordan, Egypt, Yemen, South Africa and Vietnam. Overall, 10(66.6%) were cross-sectional studies (Table 1).
There were five factors identified regarding antenatal care; behaviour intention,12,13 social support,14-17 accessibility of information,14,16,17,21 personal autonomy14,16 and action situations,12,14-17,20-26 including economic status, availability of facility and transportation.
The desire of women for pregnancy is an important factor in determining approach towards ANC. Mothers who have the intention to become pregnant are 1.82 times more likely to have enough ANC visits compared to mothers who have no desire to become pregnant.16,14 ANC is an important factor in determining the timing of ANC initiation.15 The Health Behaviour Theory of Snehandu B. Karr8 explains that behaviour is influenced by a person’s behaviour intention to act in relation to an object or stimulus outside oneself. Person behaves because of a desire, intentional or because it was planned. This is in line with the Theory of Planned Behaviour8 which conveys that the behaviour displayed by the individual arises because of the intention to behave. Ajzen and Fishbein say that intention is the best indicator to predict behaviour, especially when someone acts under the control of their will. Intentions are formed by three factors, namely attitudes, subjective norms, and behavioural control beliefs.16
Intention is a predictor of health behaviour for pregnant women in developing countries.
The association of mothers with a group being fairly treated by Female Community Health Volunteers (FCHVs) during pregnancy were associated with 4 or more ANC visits. This is because positive past experiences encourage the use of ANC in the future, and negative experiences make pregnant women reluctant to make ANC visits. Pregnant women exposed to FCHV were about twice as likely to use ANC as their counterparts, because exposure to FCHV increased the likelihood of sharing information about health services.17 The involvement of Lady Health Workers (LHWs), parents-in-law, friends/relatives, and nurses/midwives in providing information related to MNH shows that there is social support for pregnant women from the surrounding environment. The support provided is in the form of information support. The more education and information are given to mothers, the more likely they are to make at least 4 ANC visits.18 Financial support from the husband is considered an important factor in increasing the use of ANC services.19 Social and economic support through Public Distribution System (PDS) and Integrated Child Development Services (ICDS) can strengthen the ANC programme. More women who attend Village Health Sanitation and Nutrition Day (VHSND) meetings have access to ICDS services and can take advantage of services and counselling.20
Karr8 states that a person’s behaviour is influenced by support from the surrounding community (social support). One’s behaviour tends to require legitimacy from the surrounding community. If a person’s behaviour contradicts or does not get support from the community, then that person will feel uncomfortable. The forms of support can be in the form of emotional support, appreciation, instrumental and through information.21 The life of traditional communities in some developing countries is still largely controlled and influenced by customs and traditions.22 People in rural areas generally have very close relationships with one another. Social support for pregnant women can come from the environment, friends, family, parents, husbands and health workers. Social support is needed by a woman during pregnancy, especially from those closest to her.23 Pregnant women feel comfortable when there is support from the people around them. In addition, pregnant women who get support will have a high motivation to undertake ANC.
The amount of information obtained by pregnant women is related to higher education level, because higher education also increases knowledge and awareness about health.17 Pregnant women exposed to mass media at least once a week were more likely to use ANC services than those who were not exposed at all. Exposure to electronic media enables mothers to increase their understanding of the benefits and uses of ANC.24 The exchange of information between pregnant women and healthcare providers during consultations also affects the frequency of ANC visits.14 MNH information plays an important role in determining the use of ANC. Women who receive information from the nurse/agency tend to make the recommended ANC visits.18 However, not all pregnant women in developing countries can have easy access to information because of the poor economic conditions and inadequate infrastructure.
The power to take one’s own decisions, or autonomy, is related to the use of ANC services. Higher autonomy is reflected in mothers’ ability to decide whether or not to attend ANC, and makes mothers more likely to take advantage of such services.20 The higher a woman’s education level is, the more chances she has of involvement in household decision-making, better communication with partners, negotiation skills, and the ability to demand adequate services. The wife’s involvement in household decision-making is inseparable from the husband’s education level. Educated husbands may be more aware of the benefits of ANC.17
The existence of autonomy or personal freedom to make decisions is one of the determinants of health behaviour.25 The concept of women’s autonomy includes all dimensions.26
Among the studies reviewed, the highest ANC visits in the first semester of pregnancy were carried out by pregnant women with high economic status.20 Mothers with the highest wealth index were approximately 6 times more likely to have the recommended ANC visits than mothers with lower wealth index. Women belonging to the upper economy class have more capacity to pay for healthcare, ANC visits, and costs related to services, such as transportation, than women in the lower segments of economy.18 The poorest women have difficulty accessing ANC22, particularly in households with low economic levels, and cannot optimise the use of ANC services because of the direct and indirect costs associated with it, such as transportation, purchase of medicines, and other supplies.27,28. Pregnant women who work and have an income also have control over the things that affect their lives as far as their healthcare needs are concerned. Household wealth significantly affects the type of facility to access ANC at.22
Economic status is the position of a person or family in society based on monthly income.31 The highest priority for families with low incomes is basic needs. A person’s economic status will determine the availability of the necessary facilities for certain activities. In addition, developing countries rely more on the primary sector as their main income.
Distance and availability of transportation facilities are related to the use of ANC services. Distance from place of residence and healthcare facilities as well as ease of transportation are important factors in increasing ANC compliance because accessibility affects patient satisfaction. The main reasons reported by the mothers included lack of ANC information and the distance between their homes and health facilities.17,28,30 Empirical studies have shown that there is a relationship between the location of residence and the use of ANC.32 In most developing countries, urban residents; use of ANC is more than those living in rural areas, which, among other things, may well be because of poor roads in rural communities.27
Conditions and situations falling under the ‘action situations’ category are one of the determinants of health behaviour according to Karr8. Increased access to ANC facilities is influenced by reduced distance, travel time or travel costs, resulting in an increase in service usage.33,34
The low level of the economy in developing countries causes a lack of equitable development. Infrastructure problems in developing countries that are not evenly distributed prevent people from utilising health services.
ANC helps mothers prepare for labour and understand the warning signs during pregnancy. ANC in pregnant women in developing countries is influenced by several factors, such as intention, social support, availability of information, personal autonomy, and situational action. Economic status, and the availability of facilities and infrastructure optimise the use of ANC services. The availability of information from various sources increases mothers’ understanding of the benefits and uses of ANC for their health and good pregnancy outcomes. Nurses and midwives have an important role in providing information related to MNH.
Limitation: The current systematic review was not registered with the International Prospective Register of Systematic Reviews (PROSPERO).
Conflict of Interest: None.
Source of Funding: None.
1. Hatini EE. Pregnancy Midwifery Care. Malang, Indonesia: Wineka Media; 2018.
2. The United Nations Children’s Fund (UNICEF). Monitoring the situation of children and women. New York, USA: The United Nations Children’s Fund (UNICEF); 2006.
3. Haque MA, Dash SK, Chowdhury MA. Maternal health care seeking behavior: the case of Haor (wetland) in Bangladesh. BMC Public Health 2016;16:592. doi: 10.1186/s12889-016-3296-2.
4. Chi PC, Bulage P, Urdal H, Sundby J. A qualitative study exploring the determinants of maternal health service uptake in post-conflict Burundi and Northern Uganda. BMC Pregnancy Childbirth 2015;15:18. doi: 10.1186/s12884-015-0449-8.
5. World Health Organization (WHO). Maternal Mortality. News release. The WHO Media Centre. [Online] 2019 [Cited 2023 January 22]. Available from URL: https://www.who.int/news-room/fact-sheets/ detail/maternal-mortality
6. Goemawati E, Kristy TW. The Equity Of Antenatal Care Standard in Different Ages. J Adm Kesehat Indones 2019;7:60–5. doi: 10.20473/jaki.v7i1.2019.60-65
7. Nurlaili H. Determinantd of ANC Utilization in Developing Country: Traditional Literature Review. PLACENTUM J Ilm Kesehat dan Apl 2019;7:1-7. doi: 10.20961/placentum.v7i2.29718
8. Bosnjak M, Ajzen I, Schmidt P. The Theory of Planned Behavior: Selected Recent Advances and Applications. Eur J Psychol 2020;16:352-6. doi: 10.5964/ejop.v16i3.3107.
9. Firmansyah F. Socialization of Family Health Program Support for Stunting City District Locus. [Online] 2019 [Cited 2023 January 22]. Available from URL: https://kesmas.kemkes.go.id/konten/133/0/ 051510-sosialisasi-dukungan-program-kesehatan-keluarga-bagi-lokus-kab-kota-stunting
10. Ministry of Women’s Empowerment and Child Protection of the Republic of Indonesia. Build synergy and collaboration to reduce the maternal mortality rate. [Online] 2022 [Cited 2023 January 22]. Available from URL: https://www.kemenpppa.go.id/index.php/ page/read/29/3864/bangun-sinergi-dan-kolaborasi-untuk-turunkan-angka-kematian-ibu-aki
11. Efendi F, Chen CM, Kurniati A, Berliana SM. Determinants of utilization of antenatal care services among adolescent girls and young women in Indonesia. Women Health 2017;57:614-29. doi: 10.1080/03630242.2016.1181136.
12. Lamiday SP, Machmud PB. The association between women’s empowerment and antenatal care coverage in Indonesia in 2017. J Berk Epidemiol 2019;7:172–9. doi: 10.20473/jbe.V7I32019.172-179
13. Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res 2014;14:579. doi: 10.1186/s12913-014-0579-0.
14. Hijazi HH, Alyahya MS, Sindiani AM, Saqan RS, Okour AM. Determinants of antenatal care attendance among women residing in highly disadvantaged communities in northern Jordan: a cross-sectional study. Reprod Health 2018;15:106. doi: 10.1186/s12978-018-0542-3.
15. Muhwava LS, Morojele N, London L. Psychosocial factors associated with early initiation and frequency of antenatal care (ANC) visits in a rural and urban setting in South Africa: a cross-sectional survey. BMC Pregnancy Childbirth 2016;16:18. doi: 10.1186/s12884-016-0807-1.
16. Ajzen I. Attitudes, Personality and Behaviour, 2nd ed. New York, USA: Mc Graw Hill Open University Press; 2005.
17. Chaurasiya SP, Pravana NK, Khanal V, Giri D. Factors Affecting Antenatal Care Utilization Among the Disadvantaged Dalit Population of Nepal: A Cross-sectional Study. Open Public Health J 2019;12:155–63. DOI: 10.2174/1874944501912010155
18. Noh JW, Kim YM, Lee LJ, Akram N, Shahid F, Kwon YD, et al. Factors associated with the use of antenatal care in Sindh province, Pakistan: A population-based study. PLoS One 2019;14:e0213987. doi: 10.1371/journal.pone.0213987.
19. Ha BT, Tac PV, Duc DM, Duong DT, Thi le M. Factors associated with four or more antenatal care services among pregnant women: a cross-sectional survey in eight South Central Coast provinces of Vietnam. Int J Womens Health 2015;7:699-706. doi: 10.2147/IJWH. S87276.
20. Fulpagare PH, Saraswat A, Dinachandra K, Surani N, Parhi RN, Bhattacharjee S, et al. Antenatal Care Service Utilization Among Adolescent Pregnant Women-Evidence From Swabhimaan Programme in India. Front Public Health 2019;7:e369. doi: 10.3389/fpubh.2019.00369.
21. Sarafino EP, Smith TW. Health Psychology: Biopsychosocial Interactions, 7th ed. New York, USA: John Wiley & Sons, Inc; 2010.
22. Armini NKA, Hidayati N, Kusumaningrum T. Determinants of Nutritional Status Among Pregnant Women: a Transcultural Nursing Approach. J Ners 2020;15:214-21. doi: 10.20473/jn.v15i2.21388
23. Sebayang SK, Astutik E, Dewi DMSK, Mandagi AM, Puspikawati SI. Health care-seeking behaviour of coastal communities in Banyuwangi, Indonesia: Results of a cross-sectional survey. J Ners 2017;12:66-73.
24. Basharat J, Kamal A, Manzoor I, Nauman U. Socio-Demographic Differentials for Utilization of Antenatal Health Care among Pakistani Women: A Negative Binomial-Logit Hurdle (HNBLOGIT) Regression Model Approach (1990-2013). Pak Paed J 2016;40:242–53.
25. Notoatmodjo S. Health Promotion Theory and Applications. Jakarta, Indonesia: PT Rineka Cipta; 2005.
26. Woldemicael G. Women’s autonomy and reproductive preferences in Eritrea. J Biosoc Sci 2009;41:161-81. doi: 10.1017/ S0021932008003040.
27. Abubakari A, Agbozo F, Abiiro GA. Factors associated with optimal antenatal care use in Northern region, Ghana. Women Health 2018;58:942-54. doi: 10.1080/03630242.2017.1372842.
28. Farrag NS, Abdelwahab F, Ismail GR. Patterns and factors affecting antenatal care utilization in Damietta Governorate, Egypt: a retrospective cross-sectional study. Fam Pract 2019;36:479-85. doi: 10.1093/fampra/cmy105.
29. Sharma A, Meshram P, Pandey D, Kasar PK, Tiwari R. Utilization of antenatal services and concerning factors: A community based study. Indian J Community Heal 2018;30:56–62.
30. Akowuah JA, Agyei-Baffour P, Awunyo-Vitor D. Determinants of Antenatal Healthcare Utilisation by Pregnant Women in Third Trimester in Peri-Urban Ghana.J Trop Med. 2018;2018:e1673517. doi: 10.1155/2018/1673517.
31. Purwoastuti E, Walyani E. Public Health Sciences in Midwifery. Yogyakarta, Indonesia: Pustaka Baru Press; 2015.
32. Patriajati S, Sriatmi A. Determinants of mothers’ participation in antenatal classes. J Adm Kesehat Indones 2019;7:139–46. Doi: 10.20473/jaki.v7i2.2019.139-146
33. Murhan A. Factors Associated with Pregnant Women’s Visit to Antenatal Care (K4) Examination in the Work Area of the Sukoharjo Health Center, Pringsewu Regency. J Kesehat Metro Sai Wawai 2014;7:33-40. DOI: 10.26630/jkm.v7i1.285
34. Green LW, Kreuter M. Health Program Planning. An Educational Ecological Approach, 4th ed. New York, USA: The MeGraw-Hill Companies. Inc; 2004.
35. Aziz Ali S, Aziz Ali S, Feroz A, Saleem S, Fatmai Z, Kadir MM. Factors affecting the utilization of antenatal care among married women of reproductive age in the rural Thatta, Pakistan: findings from a community-based case-control study. BMC Pregnancy Childbirth 2020;20:355. doi: 10.1186/s12884-020-03009-4.
36. Sakeah E, Okawa S, Rexford Oduro A, Shibanuma A, Ansah E, Kikuchi K, et al. Determinants of attending antenatal care at least four times in rural Ghana: analysis of a cross-sectional survey. Glob Health Action 2017;10:e1291879. doi: 10.1080/16549716.2017.1291879.
37. Othman S, Almahbashi T, Alabed AAA, Abdulwahed A. Factors affecting utilization of antenatal care services in Sana’a city, Yemen. Malaysian J Public Heal Med 2017;17:1–14.
38. Acharya D, Khanal V, Singh JK, Adhikari M, Gautam S. Impact of mass media on the utilization of antenatal care services among women of rural community in Nepal. BMC Res Notes 2015;8:345. doi: 10.1186/s13104-015-1312-8.