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Factors impacting antenatal care utilization: a systematic review of 37 fragile and conflict-affected situations

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Alibhai, Kameela Miriam, Ziegler, Bianca R., Meddings, Louise, Batung, Evans, Luginaah, Isaac·2022·Conflict and Health
DOI 10.1186/s13031-022-00459-9PMC PMC9188725
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Abstract

Background: It is estimated that over 930 million people live in fragile and conflict-affected situations (FCAS) worldwide. These regions, characterized by violence, civil unrest, and war, are often governed by corrupt administrations who are unwilling to provide their citizens with basic human rights. Individuals living in FCAS face health inequities; however, women are disproportionally affected and face additional barriers to accessing sexual and reproductive services, including antenatal care (ANC). This systematic review aims to identify the factors that impact ANC usage in the 37 countries or regions classified as FCAS in 2020 by The World Bank. Methods: Using the PRISMA guidelines, a systematic search of five databases (SCOPUS, Web of Science, PubMed, EMBASE, and CINAHL) was conducted. Results were limited to human studies, written in English, and published between January 2002 and January 2022. Studies that identified factors affecting utilization of ANC or maternal health services were included for review and critically appraised using the National Institute of Health’s Quality Assessment Tools. Findings were summarized using a narrative synthesis approach. Results: The database search yielded 26,527 studies. After title, abstract and full-text review, and exclusion of duplicate articles, 121 studies remained. Twenty-eight of the 37 FCAS were represented in the included studies. The studies highlighted that women in FCAS’ are still not meeting the World Health Organization’s 2002 recommendation of four ANC visits during pregnancy, a recommendation which has since been increased to eight visits. The most cited factors impacting ANC were socioeconomic status, education, and poor quality of ANC. Despite all studies being conducted in conflict-affected regions, only nine studies explicitly identified conflict as a direct barrier to accessing ANC. Conclusion: This review demonstrated that there is a paucity in the literature examining the direct and indirect impacts of conflict on ANC utilization. Specifically, research should be conducted in the nine FCAS that are not currently represented in the literature. To mitigate the barriers that prevent utilization of maternal health services identified in this review, policy makers, women utilizing ANC, and global organizations should attempt to collaborate to enact policy change at the local level.

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  • The past decade has seen a push toward understanding ANC utilization behavior and the effects of targeted community-based programs in crisis settings.

    “The past decade has seen a push toward understanding ANC utilization behavior and the effects of targeted community-based programs, including the training of community health workers, home visits, and peer-led educational campaigns on ANC utilization and facility-based deliveries in crisis settings [18, 28–30].”

    From Predictors of antenatal care utilization among the Rohingya population in the refugee camps of Cox's Bazar, Bangladesh (2025) · cites this paper as [18]

    The Results report that most included studies were published in 2014 or later and examine factors affecting ANC use in fragile and conflict-affected settings. They also list home visits and health education among interventions studied. The cited passages do not establish effects of community-health-worker training or peer-led campaigns on ANC use and facility-based deliveries. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

  • Some studies have shown that younger pregnant women have less adequate ANC utilization.

    “while some studies have shown that the younger a pregnant woman is, the less adequate [18] or later into her pregnancy her ANC utilization is [16]”

    From Predictors of antenatal care utilization among the Rohingya population in the refugee camps of Cox's Bazar, Bangladesh (2025) · cites this paper as [18]

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Cited by

Sorted by citations

Authors
Alibhai, K. M., Ziegler, B. R., Meddings, L., Batung, E., & Luginaah, I.
Affiliations
  • University of Ottawa (CA)
  • McMaster University (CA)
  • Western University (CA)
Corresponding author
Alibhai, Kameela Miriam
ORCID
Venue
Conflict and Health
Publisher
Springer Science and Business Media LLC
Published
2022-06-11
Volume
16
Issue
1
Pages
33-33
ISSN
1752-1505 (ISSN-L)
DOI
10.1186/s13031-022-00459-9
PMC
PMC9188725
OpenAlex
W4282922070
Cited by
94
References
9
Citations by year
2026: 32 · 2025: 24 · 2024: 25 · 2023: 13
FWCI
3.99
Type
journal article
Language
en
Open access
Licence
Locations
  • Conflict and Health (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • uO Research (University of Ottawa) (submittedVersion, public-domain)
Funders
  • Government of Ontario
  • Social Science and Humanities Research Council
Topics
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
  • Health Sciences › Health Professions › General Health Professions › Maternal and Neonatal Healthcare
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Reproductive Health and Contraception
Keywords
antenatal care utilization, fragile and conflict-affected situations, obstetric care, barriers to health care access, conflict zones, socioeconomic status, maternal education, prenatal care quality, health disparities, women's health

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