The Influence of Contextual Factors on Maternal Healthcare Utilization in sub-Saharan Africa: A Scoping Review of Multilevel Models

Abstract Introduction Sub-Saharan Africa still bears the heaviest burden of maternal mortality among the regions of the world, with an estimated 201,000 (66%) women dying annually due to pregnancy and childbirth related complications. Utilisation of maternal healthcare services including antenatal care, skilled delivery and postnatal care contribute to a reduction of maternal and child mortality and morbidity. Factors influencing use of maternal healthcare occur at both the individual and contextual levels. The objective of this study was to systematically examine the evidence regarding the influence of contextual factors on uptake of maternal health care in sub-Saharan Africa. Materials and Methods The process of scoping review involved searching several electronic databases, identifying articles corresponding to the inclusion criteria and selecting them for extraction and analysis. Peer reviewed multilevel studies on maternal healthcare utilisation in sub-Saharan Africa published between 2007 and 2019 were selected. Two reviewers independently evaluated each study for inclusion and conflicts were resolved by consensus. Results We synthesised 34 studies that met the criteria of inclusion out of a total of 1,654 initial records. Most of the studies were single-country, cross-sectional in nature and involved two-level multilevel logistic regression models. The findings confirm the important role played by contextual factors in determining use of available maternal health care services in sub-Saharan Africa. The level of educational status, poverty, media exposure, autonomy, empowerment and access to health facilities within communities are some of the major drivers of use of maternal health services. Conclusions This review highlights the potential of addressing high-level factors in bolstering maternal health care utilisation in sub-Saharan Africa. Societies that prioritise the betterment of social conditions in communities and deal with the problematic gender norms will have a good chance of improving maternal health care utilisation and reducing maternal and child mortality. Better multilevel explanatory mechanisms that incorporates social theories are recommended in understanding use of maternal health care services in sub-Saharan Africa.