Selection of articles
A total of 3,037 studies were initially searched through four different databases using different keywords. Then a total of 2001 studies were removed based on title screening and duplication. After the articles screened by abstract, 872 did not meet the inclusion criteria, and 164 full-text articles were further assessed for eligibility. Of these, 108 studies were excluded based on multiple reasons, such as primary outcomes other than OCS barriers (n=52), insufficient data/information (n=18), and not fitting in the quality assessment (n=9). Finally, 56 studies were included in the review. The study selection flow diagram is presented in (Figure 2).
Methodological quality of studies
Notably, all studies included in the review were rated under the good to moderate category. However, out of 18 qualitative studies, 7 studies were assessed as a low category (score between 6.0 – 7.0). In quantitative studies, all included studies under the good to moderate category. Out of five mixed-method studies, four were under the good category (score 4–5 out of 5 questions). Overall all included studies lack bias and are satisfactory in quality assessment. The full explanation of the quality assessment of all three types of studies is mentioned in Additional file 3.
Characteristics of the included studies
The descriptive statistics of the study sample show that a total of 56 studies were included for systematic review. The included studies consist of quantitative (n =33, 58.9%), qualitative (n=18, 32.1%) and (n=5, 8.9%) were mixed-method studies. Moreover, (n=16, 28.6%) of studies focused on antenatal care, (n=12, 21.4%) of studies focused on breastfeeding, and (n=9, 16.1%) of studies examined all three components of OCS (antenatal care, delivery care, postnatal care). The majority of studies were published between 2019-2021 year, (n=25, 44.7%). Also, the majority of studies were based on primary data (n=46, 82.1%). As per the data collection method, (n=18, 32.1%) of studies are based on a community-based cross-sectional study. The full explanation of the characteristics of included studies is well illustrated in table number 1.
Table 1. Characteristics of included studies (n=56)
General characteristics of studies
|
N (%)
|
Study Reference
|
Study methods
|
|
|
Quantitative
|
33(58.9)
|
[2–5,8,9,11–22,24,28–30,32,33,36,40–47]
|
Qualitative
|
18 (32.1)
|
[1,23,26,27,34,35,48–59]
|
Mix-Method (qualitative + quantitative)
|
5 (8.9)
|
[10,25,60–62]
|
Study focused
|
|
|
Antenatal care
|
16 (28.6)
|
[2,3,5,8,9,11–16,42,53,55,57,58]
|
Breastfeeding
|
12 (21.4)
|
[18,20–26,43,50,52,60]
|
Delivery (institutional/home)
|
5 (8.9)
|
[17,19,49,54,59]
|
Postnatal care
|
8 (14.3)
|
[1,27–30,47,48,51]
|
Antenatal care and delivery care
|
2 (3.6)
|
[4,34]
|
Antenatal care and postnatal care
|
3 (5.4)
|
[32,40,56]
|
Postnatal care and delivery care
|
1 (1.8)
|
[10]
|
OCS (ANC, child deliver, breastfeeding, PNC)
|
9 (16.1)
|
[35,36,41,44–46,48,61,62]
|
Study Year
|
|
|
2010
|
1 (1.8)
|
[17]
|
2011
|
3 (5.4)
|
[4,32,45]
|
2012
|
N.A
|
N.A
|
2013
|
2 (3.6)
|
[33,44]
|
2014
|
5 (8.9)
|
[18,29,30,36,61]
|
2015
|
2 (3.6)
|
[9,49]
|
2016
|
5 (8.9)
|
[11,12,25,52,56]
|
2017
|
4 (7.1)
|
[40,57,59,62]
|
2018
|
6 (10.7)
|
[1,27,34,47,48,54]
|
2019
|
8 (14.3)
|
[2,5,19–21,28,46,53]
|
2020
|
11 (9.6)
|
[13,14,22,23,26,42,43,50,51,55,58]
|
2021
|
7 (12.5)
|
[8,10,15,16,24,41,60]
|
2022
|
2 (3.6)
|
[3,35]
|
Data source
|
|
|
Primary data
|
46 (82.1)
|
[1,4,9–11,13–16,18–27,29,30,33–35,40,42–62]
|
Secondary data
|
10 (17.9)
|
[2,3,5,8,12,17,28,32,36,41]
|
Sample size
|
|
|
< 50
|
10 (17.9)
|
[1,26,33,35,49,50,52,53,57,58]
|
50 -100
|
7 (12.5)
|
[10,22,23,27,34,55,61]
|
101 – 200
|
8 (14.3)
|
[15,16,43,44,47,51,54,59]
|
201 -500
|
13 (23.2)
|
[4,9,11,13,19–21,24,25,30,40,56,60]
|
501 - 1000
|
5 (8.9)
|
[14,18,29,33,45]
|
More than 1000
|
13 (23.2)
|
[2,3,5,8,12,17,28,32,36,41,42,46,62]
|
Method of data collection
|
|
|
NFHS/DLHS/CNSG
|
9 (16.1)
|
[2,3,8,12,17,28,32,36,41]
|
Community-based cross-sectional Study
|
18 (32.1)
|
[4,4,5,9,11,13–15,20,21,24,29,30,33,40,42,44–46]
|
Cohort study
|
1 (1.8)
|
[60]
|
Hospital/clinic based cross sectional study
|
6 (10.7)
|
[16,18,19,22,43,47]
|
Key informants/IDI
|
7 (12.5)
|
[1,26,34,35,55,57,59]
|
FGD/Case study
|
7 (12.5)
|
[23,27,49,51–53,56]
|
FGD and IDI
|
4 (7.1)
|
[48,50,54,58]
|
Community-based cross-sectional study and FGD/IDI
|
4 (7.1)
|
[10,25,61,62]
|
Note: N.A: Not available; NFHS: National Family Health Survey; DLHS: District Level Health Survey; CNSG: Comprehensive Nutrition Survey in Gujarat; FGD: Focus group discussion; IDI: In-depth interview
Individual and interpersonal barriers
A total of 30 studies, including seventeen quantitative [2,4,5,9,11,18,21,22,24,28–30,40,43–46], ten qualitative [1,8,23,26,35,50,52,53,57,58] and three mix-method studies [25,60,61], reported that lack of knowledge and awareness was a prominent barrier for incomplete or non-utilization of obstetric care services (OCS). Dalal et al. [2022] explained that due to a lack of awareness, women were unable to understand the process and system in the health facility and felt uncomfortable while visiting it, which directly influenced the OCS utilization [35]. This situation is well understood by the following statement given by a woman from a rural community in Udaipur, India:
"I have never been to a hospital, so I do not know what happens there. There is a bus stop near my house, but I do not know how to reach the hospital by taking a bus, so I did not go. Next month my husband will come back from his labor work in Udaipur. I am waiting for him to take me to the hospital. I will not go alone" [35].
Regarding ignorance towards utilization of OCS, Sarkar et al., [2021] explained that women who had a previous gestational period and birth experience, feel more confident and ignore the OCS services [8]. A 20-year-old tribal woman's statement well illustrates the ignorance towards utilization of OCS:
"I don't like to go to the hospital. Although they took me to the hospital last time, it was not needed. I don't go to the hospital for any disease. Sister gave me tablets, but I did not take any of them. I don't want a tablet" [61].
Furthermore, lack of counselling on proper breastfeeding practice and its benefits were major barriers towards delay in breastfeeding initiation or exclusive breastfeeding [20,21,43,52]. Additionally, due to increased domestic workload, mothers did not have proper time to adhere to early breastfeeding [24]. Previous study also revealed a link between inadequate support from family members with poor pregnancy outcomes in terms of low birth weight, preterm labour, low maternal weight gain, etc. [53]. It also emerged from the review that husbands oppose institutional delivery if their wives’ had experienced any complications during previous institutional delivery [28,33]. Moreover, poor communication between health care providers and women availing the OCS was another interpersonal barrier that led to poor quality of OCS [5,55,62]. This type of barrier was predominantly found in the tribal community of India [34,58].
Social and cultural barriers
Belief in the efficacy of traditional herbs and healers [1,4,8,33,34,47,51,56–60] were frequently reported barriers and were more prevalent in rural Indian settings. Consequently, home delivery or using a traditional birth attendant (TBA) who was receptive to herbs became a preferred choice [1,57]. Many studies revealed that the culture of discarding first milk (colostrum) was a major barrier to exclusive breastfeeding and newborn health [24,27,47,50,51,62]. In the tribal community in Kalahandi district, Odisha, India, one traditional midwife explained that:
"Colostrum is the milk that had been in the breast for nine months and is impure through storage. It is therefore unhealthy for the baby and should be offered to mother earth for her blessing on the child" [62].
Many previous studies also revealed that pre-lacteal feeding rituals were major barriers to exclusive breastfeeding. For example, pre-lacteal feeding rituals (like jaggery, honey, sugar water, cow milk, and ghee) were observed in many previous studies [27,47,50–52,60]. A 25-year-old woman expressed the cultural belief for feeding honey to a newborn child as:
"This is my second child and is a son. My husband was so happy that he only fed him honey after we came back home. This is a ritual, which we have to follow. Even if I disagree then also my family members will give it. Better not to disagree. We do not do all these in the hospital, Sister didi (Nurse) told us not to give honey. However, family members wanted to feed him honey, so they fed". [60].
Another common barrier such as food restriction during pregnancy and lactation were major concerns for mother and child health [27,34]. Most mothers believed that more food intake would cause digestive disorders in the baby. In an in-depth interview, one mother said:
"In my post-natal period, up to 12 days after delivery, I ate less amount of food than the usual amount I eat. Because I believe that if I eat more, the baby will have a bloated abdomen" [27].
In addition to the above beliefs and cultural practices, a wide range of taboos and superstitions were reported that were major obstacles to the utilization of OCS [16,18,20,26,34,56,62]. For example, a study conducted in Bihar, India, revealed women delayed the initiation of breastfeeding for several days for the pandit (Hindu priest) or maulana (Islam priest) to bless the infant [51]. Purification ceremony [27,47,51,52,54], restriction of women's mobility [27,51,54], and oil massages [27,47,52] was reported as other barriers in previous studies.
Structural barriers
A poor economic status was a major hindrance in accessing OCS [1,8,9,33,40,42,45,55,56]. High costs for availing the OCS services, such as cost of institutional delivery [15,17,25,33,35,40,46,55,62] and transportation cost [2,14,29,62] were other important barriers to service utilization. It was predominantly found in women's stand on the intersection of caste and poverty [25,33,35,40]. Additionally, the cost of referral services, including travel and subsistence cost, was major barrier to delay or unable to reach a referred health facility [1,9,33,35]. In this regard, qualitative studies revealed that the cost of services was a key determining factor for the majority of women when deciding between home birth and institutional delivery [17,35,40]. The following quote illustrates how the high cost of delivery affects the institutional delivery of a woman, age 35, explained that:
If delivery is done somewhere else like a hospital, it costs a lot of money. It can be done at home for less money. I am afraid that's why I didn't visit the hospital. It's good to bear pain and expenses at home; at least I'll be happy at home. [25].
The study consistently shows that due to financial constraints, women are not able to take local transport to visit the health facilities and avail the OCS [14,62]. We found from the mixed method study that despite free access to most maternal health care services and cash incentive schemes for pregnant women in India, pregnant women still opted for home delivery. The net value of the cash incentive was less than the total expense of facility-based childbirth in terms of both monetary and actual costs (healthcare expenditure, food, and transport expenses for the mother and her caregivers) [59]. Therefore, there was less motivation to opt for institutional delivery.
Logistical barriers
Long distance to health facilities [3-4,6,8,9,11,13,24,25,30,32, 38-39,42,46,58] and lack of transport facilities [7,10,12,22,24,29,30,38,40,42,48,55,60] were major barrier in accessing the OCS. Specifically, this type of barriers occurs frequently for people who live in rural areas and in geographically isolated regions [13,32,38]. Similarly, poor road conditions [4,10, 53] and lack or delay of ambulance service [4,32,56,58] were other major barriers to access the OCS. It was reported that due to the long distance to health facilities, women were forced to deliver at home and dependent on local herbs and practitioners [56, 62]. A 29-year-old woman from Odisha, India, pointed out:
“I don’t go to the hospital. The hospital is very far away from here; it costs me around 100 rupees for going there on way. Moreover, there is no facility in the hospital.” [62].
Similarly, barriers related to poor road condition and lack or delay of ambulance service was understood by following a qualitative study conducted in Meghalaya and Bihar State of India:
“It is difficult to travel for pregnant women in such poor road conditions. Most of the time, pregnant women have to deliver their baby on the way to hospital” [10].
Organization barriers
Previous studies documented that poor quality of treatment [4,17,25,26,28,33,34,35,40,41,44,49,53,59] and the non-cooperative attitude of health professionals were responsible for women and their families in hesitating to seek OCS [14,20,25,44, 53,54]. Previous studies also reveal that disrespectful behaviors of health professionals toward pregnant women are major barriers to institutional deliveries [20,44,53].
One pregnant woman from a previous study explained that: “My first delivery was conducted in a government hospital. They admit you, allot you a bed, and then they treat you badly. The nurses scream so loudly as if they are Gods themselves. Rather than helping the women in labor, they abuse them. I was shouted at and even slapped in the labor room. I was so scared that I planned my second delivery at home. I received more care at home than at the hospital. I would advise others not to go there ever” [53].
On the other hand, women are deterred from completing their ANC services due to health system-related barriers such as the unavailability of trained health personnel [10,36,41,49,52,53], long waiting time in hospitals [15,26,36,41,44,55], inadequate equipment and shortage of drugs [9,12,26,36,40,49,59], and poor health infrastructure [9,10,15,36,49,54]. In this context, a previous study explained that non-availability of adequate beds, labour/examination tables, and bed screens significantly reduced the volume of antenatal registrations and postnatal services [9,12]. Similarly, not having an electricity connection in a health facility was associated with an approximately 32% decrease in the volume of institutional deliveries and almost 10% decrease in ANC registrations [12]. Moreover, the shortage of female doctors is also an important barrier that affects maternity care [26,54]. An in-depth interview of the medical officer-in-charge from Uttar Pradesh stated that:
Doctor’s unavailability is a problem. Male doctors can’t do deliveries – women are shy and don’t let them do so. But the female staff is not enough in number, and hence we are forced to get contractual staff [48].
Other studies also reported that the unavailability of labor rooms, long waiting time in the health facility, and lack of medical equipment and infrastructure are driving barriers to home delivery in India [12,15,26,36,41,49].
“In hospitals, good doctors are not there. Electricity and water is not always available ([The] vehicle [ambulance] was unable to reach [the house in time], so [my child was] born at home; [a] phone call was made to ‘sister-ji’ [ASHA], [the] vehicle did not come, and [my] child was delivered at home” [59].