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Table 1 Analytical framework for demand- and supply-side barriers to obstetric care

From: Access barriers to obstetric care at health facilities in sub-Saharan Africa—a systematic review

Demand-side barriers (service users) Countries of study
 Geographic accessibility
  -Indirect costs to households (transport)1
  -Means of transport available2
Ethiopia1, 2; Zimbabwe; Nigeria2; Tanzania1, 2; Sierra Leone2; Malawi2; Zambia1; Kenya1, 2; South Africa1, 2; Uganda2; Mali1; Ghana1, 2; Gambia2; Burkina Faso1, 2; Senegal2
 Availability of services
  -Information on health care services/providers3
  -Health education4
Ethiopia3; Nigeria3; Zimbabwe3; Malawi; Kenya3, 4; Ghana3, 4; Uganda3, 4; South Africa3; Gambia3
 Affordability of services
  -Household resources and willingness to pay5
  -Opportunity costs (often expressed as being too busy to attend/access services)6
 Cash flow within society7
Nigeria5, 6; Ethiopia5, 6; Tanzania5; Sierra Leone5, 6; Burkina Faso5; Kenya5; Ghana5; South Africa5; Uganda5; Zambia5; Mali5, Malawi5; Democratic Republic of Congo5; Angola5; Zimbabwe5; Cameroon5; Gambia6
 Acceptability of services
  -Households’ expectations8
  -Low self-esteem and assertiveness (women’s low status in society and a lack of decision-making autonomy)9
  -Community and cultural preferences10
  -Stigma11
  -Lack of health awareness12
Nigeria9, 10, 12; Ethiopia8, 9, 10, 11, 12; Zimbabwe10, 11, 12; Burkina Faso9, 10; Tanzania9, 10, 11, 12; Malawi9, 10, 11 12; Kenya8, 9, 10, 11, 12; Zambia8, 9, 10, 12; South Africa9, 11; Ghana9, 10, 12; Uganda9, 10, 11, 12; Gambia9, 12; Zanbia9; Mozambique10; Senegal10; Angola9, 10; Cameroon10; Mali9; Liberia9
 Other barriers
  -Religious affiliation/beliefs13
  -Lower maternal age (teenage/adolescence)14
  -Low level of formal education (woman, couple or household head)15
  -Higher parity16
  -Fear of surgery, episiotomy, HIV testing or other procedures17
  -Higher maternal age18
  -Marital status (married, divorced, separated, single, widowed, polygamous marriage)19
  -Unintended pregnancy20
  -Rural residence21
  -Non-attendance/low attendance of antenatal clinic (as barrier to institutional delivery or postnatal services)22
  -Agricultural occupations (of women or their partners)23
  -Household access to telephones or mobile phones40
  -Lack of birth preparation41
  -Delayed decision-making within family42
  -Low media exposure44
  -Higher levels of household wealth45
Nigeria13, 14, 15, 16, 17, 21; Ethiopia13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 41 42, 44; Burkina Faso13, 15, 45; Sierra Leone15; Tanzania14, 15, 16, 18, 22, 41; Malawi15, 16, 19, 21, 41, 42; Ghana13, 15,16, 17, 20, 22, 41, 44; Kenya15, 16, 17, 19, 22, 23, 41, 42; South Africa14, 15, 18, 19, 21; Uganda15, 16, 21, 22, 41, 42; Rwanda15, 16; Democratic Republic of Congo 15, 16, 20; Gambia41; Senegal16, 19; Zambia15, 41, 42; Liberia17
Supply-side barriers (maternity care workers/health system factors) Country
 Geographic accessibility
  -Service location24
Nigeria24; Ethiopia24; Tanzania24; Burkina Faso24; Malawi24; Kenya24; Ghana24; South Africa24; Zambia24; Rwanda24; Uganda24; Burkina Faso24; Senegal24
 Availability of services
  -Unqualified health workers, staff absenteeism, inadequate staff, opening hours25
  -Waiting time26
  -Motivation of staff27
  -Equipment, drugs and other consumables28
  -Non-integration of health services29
  -Lack of opportunity (exclusion from services)30
  -Late or no referral (Poor referral practices/systems)31
Nigeria25, 26, 27, 28, 31; Tanzania25, 26, 27, 28, 31; Ethiopia25, 26, 30; Sierra Leone30; Malawi25, 26, 28, 30; Kenya25, 26, 27, 28; Uganda25, 28, 30, 31, Ghana25, 26, 28, 31; Gambia26; (Burundi and northern Uganda)25, 27, 28, 31; Cameroon22, 28; South Africa25, 26; Zambia28
 Affordability of services
  -Costs of services, including informal payments32
  -Private–public dual practices33
Zambia32; Ethiopia 32; South Africa32; Kenya32, Malawi32; Nigeria32; Ghana32; Tanzania32; Angola32; Burkina Faso32
 Acceptability of services
  -Complexity of billing system and inability to know prices beforehand34
  -Staff interpersonal skills, including trust35
Ethiopia35; Malawi 35; Zambia35; Ghana35; South Africa35; Kenya34, 35; Democratic Republic of Congo35; Uganda35; Benin35; Nigeria35; Tanzania34, 35; Liberia35
 Other barriers
  -Poor clinical skills/non-adherence to clinical protocol (perceived or experienced)36
  -Poor staff knowledge about emergency obstetric care and the contents of antenatal care counselling services37
  -Poor/inadequate facilities/services38
  -Inadequate/lack of professional development/support (in-service training and supervision); non-availability of guidelines and clinical protocols39
  -Unsatisfactory quality of care50
  -Lack of empowerment of health workers to enforce change/decisions51
Ethiopia36, 37, 38, 39, 50; Zimbabwe; Tanzania36, 38, 39, 50; Nigeria36, 37, 38, 39, 50; Uganda36, 38, 39, 50; Malawi37, 38, 50, 51; Kenya36, 38, 50; Ghana36, 37 38, 50; Cameroon36, 37, 39; Senegal50; Benin50; Gambia50; Zambia38, 39, 50; Angola36, 50; Burkina Faso50; South Africa50
  1. Adapted from Jacobs et al. (2012) [11]
  2. The numbered superscripts represent pre-identified barriers in the analytical framework and additional ones derived from the review. In the second column, the numbers have been matched against the countries where such barriers were reported