Direct and indirect costs as barriers to maternal healthcare utilization among adolescent mothers in low- and middle-income countries: a systematic review

Poverty significantly affects the utilization of maternal services in low- and middle-income countries (LMICs), with adolescent mothers being particularly vulnerable due to their reliance on family and partners for financial support. Despite free-maternity initiatives implemented in most LMICs, financial barriers remain widespread. This systematic review aims to synthesize existing evidence on the effect of costs on maternal healthcare service utilization among adolescent mothers in LMICs. Electronic databases such as PubMed, Scopus, Embase, CINAHL, Web of Science, and African Journal Online were utilized to search for articles published between 2000 and 2024. The quality of the studies and risk of bias were assessed using 10 and 8 items for qualitative and quantitative studies, respectively, and the effect of costs on maternal healthcare service utilization were thematically summarized. Direct medical cost, direct non-medical cost and indirect costs were considered as financial barriers to maternal healthcare service utilization. Of 2,345 records, 18 studies across 11 countries met inclusion criteria. Among the 18 studies, 14 explored the effect of direct medical costs on maternal healthcare utilization, 11 explored direct non-medical costs, and 7 assessed the influence of indirect costs on service utilization. Overall, the evidence shows that maternal healthcare service utilization among adolescent mothers was affected by a wide range of costs, including medication expenses, service or consultation fees, antenatal care (ANC) registration costs, transportation costs, food and drink expenses, costs related to birth preparation, and indirect costs such as prolonged waiting times and long travel distances. The study found that both direct medical and indirect costs affect adolescent mothers to maternal healthcare service utilization. Therefore, we recommend that policymakers review the implementation of free-maternity policies to ensure they cover both non-medical and indirect expenses and expand mobile health clinics to reduce travel time for underserved adolescent mothers. Addressing these financial and physical barriers is essential to improving equity in maternal healthcare and achieving better birth outcomes among adolescents.