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Heliyon 10 (2024) e35629
Available online 3 August 2024
2405-8440/© 2024 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
Research article
Adolescent maternal health services utilization and associated
barriers in Sub-Saharan Africa: A comprehensive systematic
review and meta-analysis before and during the sustainable
development goals
Tadesse Tolossa
a
,
b
,
*
, Lisa Gold
b
, Merga Dheresa
c
, Ebisa Turi
a
,
b
, Yordanos
Gizachew Yeshitila
b
,
d
,
e
, Julie Abimanyi-Ochom
b
a
Department of Public Health, Institutes of Health Sciences, Wollega University, Nekemte, Ethiopia
b
Deakin University, Deakin Health Economics, School of Health and Social Development, Institute for Health Transformation, Faculty of Health,
Geelong, 3220, Australia
c
Haramaya University, College of Health and Medical Sciences, Department of Nursing and Midwifery, Harar, Ethiopia
d
School of Nursing, College of Medicine and Health Science, Arba Minch University, Arba Minch, Ethiopia
e
Intergenerational Health, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
ARTICLE INFO
Keywords:
Adolescent
Adolescent girls
Teenagers
Maternal health
Antenatal care
Prenatal care
Skilled birth attendant
Skilled delivery
Postnatal care
Pregnancy
Meta-analysis
Systematic review
SSA
ABSTRACT
Introduction: Effective and adequate maternal health service utilization is critical for improving
maternal and newborn health, reducing maternal and perinatal mortality, and important to
achieve global sustainable development goals (SDGs). The purpose of this systematic review was
to assess adolescent maternal health service utilization and its barriers before and during SDG era
in Sub-Saharan Africa (SSA).
Methods: Systematic review of published articles, sourced from multiple electronic databases such
as Medline, PubMed, Scopus, Embase, CINAHL, PsycINFO, Web of Science, African Journal On-
line (AJOL) and Google Scholar were conducted up to January 2024. Assessment of risk of bias in
the individual studies were undertaken using the Johanna Briggs Institute (JBI) quality assess-
ment tool. The maternal health service utilization of adolescent women was compared before and
after adoption of SDGs. Barriers of maternal health service utilization was synthesized using
Andersen’s health-seeking model. Meta-analysis was carried out using the STATA version 17
software.
Results: Thirty-eight studies from 15 SSA countries were included in the review. Before adoption
of SDGs, 38.2 % (95 % CI: 28.5 %, 47.9 %) adolescents utilized full antenatal care (ANC) and
44.9 % (95%CI: 26.2, 63.6 %) were attended by skilled birth attendants (SBA). During SDGs, 42.6
% (95 % CI: 32.4 %, 52.8 %) of adolescents utilized full ANC and 53.0 % (95 % CI: 40.6 %, 65.5
%) were attended by SBAs. Furthermore, this review found that adolescent women’s utilization of
maternal health services is inuenced by various barriers, including predisposing, enabling, need,
and contextual factors.
* Corresponding author. Department of Public Health, Institutes of Health Sciences, Wollega University, Nekemte, Ethiopia, P.O.BOX: 395,
Nekemte, Ethiopia.
E-mail addresses: yadanotolasa@gmail.com (T. Tolossa), lisa.gold@deakin.edu.au (L. Gold), mderesa@yahoo.com (M. Dheresa), ebakoturi@
gmail.com (E. Turi), y.yeshitila@deakin.edu.au (Y.G. Yeshitila), j.abimanyiochom@deakin.edu.au (J. Abimanyi-Ochom).
Contents lists available at ScienceDirect
Heliyon
journal homepage: www.cell.com/heliyon
https://doi.org/10.1016/j.heliyon.2024.e35629
Received 6 January 2024; Received in revised form 31 July 2024; Accepted 1 August 2024
Heliyon 10 (2024) e35629
2
Conclusions: There was a modest rise in the utilization of ANC services and SBA from the pre-SDG
era to the SDG era. However, the level of maternal health service utilization by adolescent women
remains low, with signicant disparities across SSA regions and multiple barriers to access ser-
vices. These ndings indicate the importance of developing context-specic interventions that
target adolescent women to achieve SDG3 by the year 2030.
1. Introduction
Adolescent pregnancy, occurring in women aged 10 to 19, remains a global concern [1]. While the global adolescent birth rate has
shown a decline from 64.5 births per 1000 women in 2000 to 41.3 births per 1000 women in 2023, it remains high in Sub-Saharan
Africa (SSA) region, with 97.9 births per 1000 women in 2023 [2]. Adolescent pregnancy often has negative physiological and so-
cial consequences [3,4]. The maternal mortality rate among adolescent women was 260 per 100,000 live births, surpassing that of
women aged over 19 years, reported as 190 per 100,000 live births in 2014 [5]. SSA has the world’s highest maternal mortality rates,
disproportionately affecting adolescent women [6].
In SSA, limited access to education, healthcare, reproductive health information, economic opportunities, and cultural norms make
adolescent women vulnerable to early, unplanned pregnancies [3,7]. These pregnancies pose health risks, including maternal mor-
tality and adverse fetal outcomes like premature birth, low birth weight, and neonatal death [3,8].
In 2015, the United Nations set Sustainable Development Goals (SDGs), including SDG3, aiming to reduce maternal mortality to 70
deaths per 100,000 live births by 2030 [9]. Despite the ambitious targets set by SDG3.1, the maternal mortality rate has remained
stagnant following the implementation of the SDGs [10]. As of 2023, the global maternal mortality rate stands at 223 deaths per 100,
000 live births, which is considerably far from the target set by SDGs [11]. This stagnation could be due to resources limitations [12],
lack of priorities due to conicts and the COVID-19 pandemic [13], regional health system weaknesses [14], and policy gaps [12].
Access to essential maternal health services, such as antenatal care (ANC), skilled delivery assistance, and postnatal care (PNC) is
critical for preventing maternal and child deaths, especially among adolescents [9]. Although adolescent pregnancy and maternal
mortality rates are highest in SSA globally [6], adolescent maternal health service utilization remains low in this region [15]. A review
conducted in SSA revealed that many adolescent women lack access to maternal healthcare due to various factors, including indi-
vidual, interpersonal, community, and contextual barriers [16]. Utilization rates vary widely across SSA countries, ranging from 12.6
% in Ethiopia [17] to 61.7 % in Kenya [18].
To achieve the United Nations’ SDG3 target, it is crucial to focus on adolescent maternal health, as their health outcomes will have a
signicant impact on progress toward the SDGs [19]. Investing in the maternal health of adolescent women can have long-term
benets, breaking poverty cycles, enhancing education, and ensuring healthier generations [20]. Revisiting maternal service utili-
zation is essential to understand evolving challenges, assess progress, and identify gaps, prioritize adolescent rights and needs, and
develop targeted intervention, especially during the pre-to-post-SDG transition. Barriers of maternal service utilization identied by
Andersen’s health-seeking behavioral model which include predisposing, enabling, need, and contextual factors [21]. Predisposing
factors, such as demographics and pre-existing knowledge, play a signicant role in adolescents’ healthcare preferences. Enabling
factors, related to resources and economies, are particularly relevant in SSA due to its poor economic status and healthcare infra-
structure. Need factors including immediate health outcomes, affects adolescents’ decisions to seek and access care. Contextual factors
consisting of environmental, policy, and health system factors, affecting adolescents’ service availability, acceptability, accessibility
and affordability [21,22].
To date, there has been no synthesis of available data on adolescent maternal service utilization in SSA during the SDG era.
Therefore, this study aims to conduct a comprehensive systematic review of adolescent maternal health service utilization before and
after the adoption of SDGs in SSA. This study is crucial as it informs policy makers in prioritizing adolescent unique challenges in
accessing maternal health services, guides targeted interventions, and helps in improving health outcomes of adolescent women.
2. Methods and materials
2.1. Registration
The study protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO), with the
registration ID CRD42022370207 [23].
2.2. Search strategy
Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, the systematic review and meta-
analysis were reported [24]. A preliminary search was undertaken to check for the presence of similar systematic reviews and
meta-analyses that have been published on the same topic to avoid repetition and to ensure that we had enough articles to conduct a
current systematic review. All published studies were searched thoroughly using nine electronic databases: Scopus, Medline, Embase,
PubMed, Web of Science, CINAHL, Psycinfo, AJOL and Google Scholar (S1 le). Unpublished studies were sought from the library
catalogues of different Universities in SSA. Key concept terms such as adolescent, adolescent girls, teenagers, maternal health,
T. Tolossa et al.
Heliyon 10 (2024) e35629
3
antenatal care, prenatal care, skilled birth attendant, skilled delivery, postnatal care, pregnancy, meta-analysis, systematic review, SSA
were developed and modied for each database. In searching different databases, search terms were combined based on different
search tools (truncation, wildcards, search phrases and Boolean operators). Articles accessed from both published and unpublished
data sources were compiled in Endnote version 20 reference management software [25]. After duplicate articles were removed, the
articles were exported to Covidence software for further screening [26]. References of included studies were accessed and reviewed for
further inclusion. The search was conducted from September 5, 2022, to January 1, 2024.
2.3. Selection of articles and eligibility criteria
The overall search strategy and eligibility criteria were developed according to the Co–Co-Pop framework for observational studies
[27].
•Condition- All articles conducted on antenatal care (ANC), skilled birth attendants (SBA) and postnatal care (PNC) utilization and
their barriers were reviewed.
•Context- Studies conducted in SSA countries were considered for the review (S1 le).
•Population- Studies conducted among adolescent women.
•Study design: All observational study designs including cross-sectional (both qualitative and quantitative), case‒control and cohort
study designs were included in the review.
•Language: Articles published in English were eligible for the review.
•Publication: Published and unpublished studies were considered.
•Time: All studies published on adolescent maternal service utilization between 2000 and January 2024 were considered for review.
•Sample size: No restrictions were placed on sample size for eligibility criteria.
Gray literature (e.g., conference papers, government reports, newsletters and proceedings), preprints, abstracts, editorials, com-
mentary reports, and nonhuman studies were excluded. The primary author attempted contact for articles with incomplete data; those
inaccessible after contacting the principal investigator were excluded.
2.4. Outcome measurement
This study has two main outcomes. The rst outcome was to assess the utilization of maternal health services by adolescent women
in SSA. Maternal health service utilization includes ANC, SBA, and PNC. ANC utilization is categorized as "utilized full ANC follow-up"
(four or more visits) or "low utilization" (at least one but <4 visits). SBA refers to skilled health professionals assisting during childbirth.
PNC utilization measures care received within six weeks post-delivery [28,29]. The second outcome of this study was the determinants
and barriers associated with maternal health service utilization among adolescent women in SSA.
2.5. Methodological quality and data extraction
Assessment of risk of bias in the individual studies were undertaken using the Johanna Briggs Institute (JBI) quality assessment tool
for observational studies [30]. The tool has 10 items for qualitative studies and 8 items for quantitative studies. The response of the tool
is “yes”, “no” or “unclear” where “yes” shows that the quality is met. Studies that scored ≥4 “yes” response were included in the review
[31]. Two reviewers (TTD, ET) assessed article inclusion through a four-step process: selection, title/abstract screening, full-text re-
view, and quality assessment. Any disagreements that arose between the two reviewers were resolved by involving a third reviewer
(JAO). Data were extracted by two data extractors (TTD and YY) using a standardized data extraction checklist on Microsoft Excel [32].
For the rst outcome (maternal health service utilization), data included author, year, country, study design, sample size, outcome
measurement, data collection method, sampling technique, and number of women utilized service. The second outcome (de-
terminants) involved creating 2 ×2 tables to compute log odds ratios for studies examining maternal health service utilization de-
terminants. Studies addressing maternal health service utilization barriers were thematically synthesized using Andersen’s
health-seeking model, categorized as predisposing, enabling, need, and contextual barriers [21].
2.6. Statistical analysis
Data for quantitative studies were retrieved in Microsoft Excel spreadsheet format and imported into STATA version 17 statistical
software for analysis [33]. The prevalence, logarithm, and standard error of the odds ratio (OR) for each included study were generated
using the “generate” command in STATA. The reported service use from each included study and the pooled result across studies were
presented in the form of a forest plot. The presence of heterogeneity among the included studies was assessed by Cochran’s Q test
(reported as the P-value) and inverse variance index (I
2
) [34]. A random-effects model was computed to estimate the pooled maternal
health service utilization. Subgroup analysis was conducted to compare maternal health service utilization in two time periods:
“pre-SDGs” (2000–2015), also known as the period of the Millennium Development Goals (MDGs) and “SDGs” (2016 onwards), the
period after the adoption of the SDGs. Subgroup analysis was also conducted to identify the source of heterogeneity, specically to
explore differences between studies conducted in Western, Eastern and Southern regions of SSA [35] and between different study types
(primary versus secondary data analyses and quantitative versus mixed method studies). We considered maternal health service
T. Tolossa et al.
Heliyon 10 (2024) e35629
4
utilization before and after the adoption of the SDGs using the study period rather than the year of publication to account for potential
time difference between data collection and publication. Funnel plot and sensitivity analysis was performed to see the publication bias
and the effect of single study on overall studies respectively.
3. Results
3.1. Search results
A total of 4643 studies were identied from the search strategy. After removal of duplicates, the remaining 3923 articles were
screened and 3864 excluded after reading titles and abstracts. Full texts of the remaining 59 articles were assessed, and 38 studies
included in the nal systematic review and meta-analysis (Fig. 1).
3.2. Characteristics of the included studies
Of the 38 studies included in the review, 27 studies were published after 2015 [36–60]. However, when considering the timing of
data collection in included studies, 20 studies were conducted during the pre-SDG era [17,37,40,41,44,46,57,59,61–72], and 18
studies were conducted during the era of SDG [38,39,42,43,45,47–56,58,60]. The 38 studies included a total of 58097 adolescent
women. Of the 38 included studies, more than half (17) were conducted using a quantitative cross-sectional study design [17,36–38,
40,41,43,47,49,56,57,62,63,68–70,72], 14 studies were conducted using a qualitative study design [39,42,44,45,48,54,55,58,60,61,
65–67,71], and the remaining seven [46,50–53,59,64] were conducted with a mixed method. Studies from 15 SSA countries and 4
multicounty studies [43,48,49,57] were included in the review. The largest number of studies (eight) were conducted in Nigeria
[36–38,50–52,56,69], followed by Uganda [39,55,61,62,71] and South Africa [45,46,58,65,66]. Three studies were from Kenya [40,
53,73], two each from Malawi [44,70] and two Zimbabwe [63,64] and one each from Ethiopia [17], Zambia [42], Namibia [60],
Tanzania [54], Niger [70], Mali [72], Guinea [47], Lesotho [67], and Ghana [59]. Two-thirds (65 %) of the studies were conducted at
the community level [17,36–39,41,43,47–52,54,56,57,59,62,68–70], and the remaining eleven studies (35 %) were facility-based
studies [42,44–46,53,55,58,60,61,63–67,71] (Table 1).
3.3. Level of maternal health service utilization
Twenty studies assessed the level of ANC utilization among adolescents [17,36–38,40,41,43,46,47,49–51,53,57,59,62,68–70,72],
Fig. 1. PRISMA ow diagram of systematic review and meta-analysis.
T. Tolossa et al.
Heliyon 10 (2024) e35629
5
Table 1
Summary of studies included in the systematic review and meta-analysis.
S.
N
Author Year of
publ.
Country Study design Data
collection
period
Setting Source of
data
Sampling technique Types of maternal service utilization and
outcome measurement
Risk of bias
assessment
1 Alemayehu T et al.
[17]
2010 Ethiopia Cross-
sectional
Pre-SDG Community
based
Secondary
data
Multistage sampling
and snowball
ANC-Attending ANC at least 4 visits 7
SBA- Delivery conducted by HPs in HF
2 Apolot R et al. [39] 2020 Uganda Qualitative
study
SDG Community
based
Primary
data
Purposive Sampling ANC, SBA and PNC- Challenges faced by
adolescents during pregnancy, delivery,
and the post-natal period
8
3 Atuyambe L et al. [61] 2009 Uganda Qualitative
study
Pre-SDG Facility based Primary
data
Purposive Sampling ANC- Explore adolescent health seeking
behaviour during pregnancy
6
4 Hackett K et al. [48] 2019 Tanzania and
Ghana
Qualitative
study
SDG Community
based
Primary
data
Purposive Sampling ANC- Adolescent girls experience of ANC
utilization
7
5 Rukundo G et al. [71] 2015 Uganda Qualitative
study
Pre-SDG Facility based primary
data
Purposive Sampling ANC- Availability, accessibility, and
utilization of teenager friendly antenatal
services
9
6 Rai RK et al. [69] 2012 Nigeria Cross-
sectional
Pre-SDG Community
based
Secondary
data
Equal probability
systematic
ANC- Attending ANC at least 4 visits. 6
SBA- Delivery conducted by HPs in HF.
PNC- Postnatal follow-up within 2 months
of delivery
7 Shatilwe et al. [60] 2022 Namibia Qualitative
study
SDG Facility based Primary
data
– ANC- Explore accessibility and utilization
of service during pregnancy
7
8 Olakunde et al. [56] 2019 Nigeria Cross-
sectional
SDG Community
based
Secondary
data
Cluster sampling SBA- Delivery conducted by HPs in HF 6
9 Samuel N et al. [55] 2022 Uganda Qualitative
study
SDG Facility based Primary
data
Convenience
sampling
ANC- Explores barriers of maternal health
services during pregnancy
9
10 Duggan R et al. [65] 2012 South Africa Qualitative
study
Pre-SDG Facility based Primary
data
Purposive Sampling ANC and PNC- Adolescents perceptions
and expectations of maternity services
7
11 Owolabi O et al. [57] 2017 Multi-
country
Cross-
sectional
Pre-SDG Community
based
Secondary
data
Multistage stratied
sampling
ANC- Attending ANC at least 4 visits. 7
12 Shamaternal service
utilization D et al. [59]
2018 Ghana Mixed study Pre-SDG Community
based
Primary
data
Purposive Sampling ANC- Attending ANC at least 4 visits. 5
SBA- Delivery conducted by HPs in HF
13 Mweteni W et al. [54] 2021 Tanzania Qualitative
study
SDG Community
based
Primary
data
Purposive Sampling ANC- Pregnant adolescents’ barriers and
facilitators to accessing ANC
10
14 Singh PK et al. [72] 2013 Mali Cross-
sectional
Pre-SDG Community
based
Secondary
data
Stratied, two stage
cluster sampling
ANC- Attending ANC at least 4 visits. 6
SBA-Delivery assisted by a doctor, nurse,
or midwife.
PNC- Postnatal follow-up within 2 months
of delivery
15 Mekwunyei L et al.
[50]
2022 Nigeria Mixed study SDG Community
based
Primary
data
Multistage sampling
and snowball
ANC- ANC visit appropriate with their
gestational age
6
16 Akinyemi A et al. [36] 2021 Nigeria Cross-
sectional
SDG Community
based
Primary
data
Random sampling ANC- Attending ANC at least 4 visits. 7
17 Rai RK et al. [70] 2014 Niger Cross-
sectional
Pre-SDG Community
based
Secondary
data
Stratied two-stage
cluster
ANC- Attending ANC at least 4 visits. 8
SBA- Delivery conducted by HPs at health
facility
18 Thomas A et al. [40] 2017 Kenya Cross-
sectional
Pre-SDG Community
based
Secondary
data
Two stage cluster
sampling
ANC- Attending ANC at least 4 visits. 8
SBA- Delivery assisted by HPs.
PNC- Care given six-week period following
delivery
(continued on next page)
T. Tolossa et al.
Heliyon 10 (2024) e35629
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Table 1 (continued )
S.
N
Author Year of
publ.
Country Study design Data
collection
period
Setting Source of
data
Sampling technique Types of maternal service utilization and
outcome measurement
Risk of bias
assessment
19 Mulinge N et al. [53] 2017 kenya Mixed study SDG Facility based Primary
data
Multistage random
sampling
ANC- Attending ANC at least 4 visits 7
20 CN Chaibva et al. [63] 2009 Zimbabwe Cross-
sectional
Pre-SDG Facility based Primary
data
Purposive,
nonprobability
sampling
ANC- Assessing regular care and
monitoring given to a woman during
pregnancy
9
21 GrovoguiI F et al. [47] 2022 Guinea Cross-
sectional
SDG Community
based
Secondary
data
Multilevel cluster
sampling
ANC- Attending ANC at least 4 visits. 7
SBA- Care given by HPs at government
health facility
22 Chikalipo et al. [44] 2018 Malawi Qualitative
study
Pre-SDG Facility based Primary
data
Purposive sampling ANC- Attending ANC at least 4 visits. 8
PNC-Postnatal care within 42 days of
delivery
23 Erasmus M et al. [45] 2020 South Africa Qualitative
study
SDG Facility based Primary
data
Purposive sampling ANC- Barriers to accessing maternal health
care of adolescent women
8
24 Rai RK et al. [70] 2014 Malawi Cross-
sectional
Pre-SDG Community
based
Secondary
data
Stratied two-stage
cluster design
ANC- At least four antenatal care visits,
PNC- Care within 42 days of delivery
8
25 Atuyambe Let al. [62] 2008 Uganda Cross-
sectional
Pre-SDG Community
based
Primary
data
Multistage and cluster
sampling
ANC- Attending ANC at least 4 visits. 8
SBA- Delivery attended at health facility by
HPs
26 Alex-Ojei et al. [37] 2020 Nigeria Cross-
sectional
Pre-SDG Community
based
Secondary
data
Multistage cluster
sampling
SBA-Delivery assisted by a doctor, nurse,
or midwife
8
27 Iacoella [49] 2019 Multi-
country
Cross-
sectional
SDG Community
based
Secondary
data
Multistage cluster
sampling
ANC- Attending ANC at least 4 visits. 8
PNC- Postnatal care within 2 months of
delivery
28 C.A. Alex et al. [38] 2021 Nigeria Cross-
sectional
SDG Community
based
Secondary
data
Multistage cluster
sampling
ANC- Attending ANC at least 4 visits. 7
SBA- Delivery attended at health facility by
HPs
29 Bwalya et al. [42] 2018 Zambia Qualitative
study
SDG Facility based Primary
data
Purposive Sampling ANC- Experience of adolescent women
service utilization
8
30 Carvajal et al. [43] 2020 Multi-
country
Cross-
sectional
SDG Community
based
Secondary
data
Multistage cluster
sampling
ANC- Attending ANC at least 4 visits. 6
SBA- Delivery attended at health facility by
HPs
31 Banke-T et al. [41] 2018 Kenya Cross-
sectional
Pre-SDG Community
based
Secondary
data
Multistage cluster
sampling
ANC- Attending ANC at least 4 visits. 8
SBA- Delivery by skilled HPs in health
facility
PNC- Postnatal care within 2 months of
delivery
32 Govendera T et al. [46] 2018 South Africa Mixed study Pre-SDG Setting Primary
data
Convenience
sampling
ANC- Attending ANC at least 4 visits 8
33 James S et al. [66] 2012 South Africa Qualitative
study
Pre-SDG Community
based
Primary
data
Purposive sampling ANC- Experience of attendance of the ANC
clinic by adolescent women
7
34 Phafoli Sh et al. [67] 2014 Lesotho Qualitative
study
Pre-SDG Community
based
Primary
data
Purposive sampling ANC- Explore the reason for delayed ANC
initiation
8
35 Sewpaul R et al. [58] 2021 South Africa Qualitative
study
SDG Facility based Primary
data
Purposive sampling ANC- Explored experiences of pregnant
adolescents’ treatment by HCWs
6
36 Michael T et al. [51] 2023 Nigeria Mixed study SDG Community
based
Primary
data
Multistage sampling
and purposive
ANC- Attending ANC at least 4 visits 7
37 Michael T et al. [52] 2021 Nigeria Mixed study SDG Facility based Primary
data
– SBA- Delivery by skilled HPs in health
facility
7
(continued on next page)
T. Tolossa et al.
Heliyon 10 (2024) e35629
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Table 1 (continued )
S.
N
Author Year of
publ.
Country Study design Data
collection
period
Setting Source of
data
Sampling technique Types of maternal service utilization and
outcome measurement
Risk of bias
assessment
38 Chaibva C et al. [64] 2010 Zimbabwe Mixed study Pre-SDG Community
based
Primary
data
– ANC- Midwives’ perceptions reason for
delay and non-utilization of prenatal
services
7
ANC- antenatal care, HF- health facility, HPs-health professionals, MDG- Millennium Development Goal, SDG- Sustainable Development Goal, IDI- In-depth interview, FDG-focus group.
T. Tolossa et al.
Heliyon 10 (2024) e35629
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14 studies assessed the level of SBA [17,38,40,41,43,47,49,52,56,59,62,69,70,72], and six studies reported the level of PNC utilization
[40,41,49,68,69,72]. From the meta-analysis, the pooled level of utilising ≥4 ANC visits by adolescent women was 40.2 % (95 % CI:
33.7 %, 46.6 %). In SSA, the pooled level of SBA and PNC service utilization among adolescent women were 48.4 % (95 % CI: 35.3 %,
61.5 %) and 33.1 % (95 % CI: 26.3 %, 39.9 %) respectively (Fig. 2).
3.4. ANC and SBA utilization before and during SDG
The pooled level of ANC and SBA were compared before and after the adoption of SDGs. Accordingly, the level of ANC utilization
before SDG adoption was 38.2 % (95 % CI: 28.5 %, 47.9 %) and 42.6 % (95 % CI: 32.4 %, 52.8 %) during the era of SDG. The level of
SBA utilization before SDG adoption and during SDG were 44.9 % (95%CI:26.2, 63.6 %) and 53.0 % (95 % CI: 40.6 %, 65.5 %)
respectively. The comparison of PNC service utilization before SDG adoption and during SDG was not conducted due to a lack of
studies that reported PNC utilization during the SDG era (Fig. 3).
3.5. ANC and SBA utilization across SSA regions
ANC utilization varied across SSA regions, with the highest in Southern Africa at 44.5 % (95 % CI: 39.1, 50.1) and the lowest in
Fig. 2. Adolescent maternal service utilization (ANC, SBA, PNC) in SSA.
T. Tolossa et al.
Heliyon 10 (2024) e35629
9
Easten Africa at 33.5 % (95 % CI: 28.2, 38.9). SBA utilization was lowest in Eastern Africa (27.5 %, 95 % CI: 26.3, 28.9) compared to
Western Africa (38.6 %, 95 % CI: 37.6, 39.5). Variability was observed in study designs, data types, and study settings (Table 2).
3.6. Methodological quality, publication bias and sensitivity analysis
All studies included in the review scored 4 and above using JBI risk of bias assessment tool. Publication bias was assessed both
graphically, showing asymmetry in the funnel plot, and statistically using Egger’s weighted test, which did not reveal a signicant
presence of publication bias (P =0.200 for ANC and 0.359 for SBA) (S2 le). Sensitivity analysis showed no strong evidence of in-
dividual studies signicantly inuencing the overall results of the remaining studies.
3.7. Determinants and barriers of maternal health service utilization
The determinants and barriers of maternal health service utilization was assessed using Andersen’s health-seeking model, cate-
gorizing them into predisposing, enabling, need, and contextual barriers, further segmented by thematic areas (Table 4). The result of
Fig. 3. Comparison of ANC and SBA utilization by adolescent women before and during SDG in SSA.
T. Tolossa et al.
Heliyon 10 (2024) e35629
10
quantitative meta-analysis was summarized using Table 3.
3.8. Predisposing barriers
3.8.1. Socio-demographic barriers
The educational levels of mothers, husbands, and families play a signicant role in maternal health service utilization of adolescent
women in SSA. A meta-analysis of nine studies revealed that educated women were more likely to use maternal health care compared
to those with no formal education [36–38,40,41,49,50,53,72] (OR =2.02, 95 % CI: 1.08, 3.78). Similarly, women with educated
partners were 1.94 times more likely to utilize maternal health care compared to those with uneducated partners (OR =1.94, 95 % CI:
1.80, 2.10), as indicated by ndings from ve studies [36–38,40,72]. The inuence of education extends to the family level, where
adolescent women from uneducated families were less likely to use maternal health care [17,36].
The effect of age on maternal health service utilization was assessed by using six studies [37,38,41,53,59,72] the pooled ndings
showed that maternal health service utilization was 1.36 times higher among women aged over 18 years than younger adolescent
women (OR =1.36, 95 % CI: 1.07, 1.71). Findings from three qualitative studies supported this nding by indicating that younger
women were less likely to utilize maternal health care [56,59,70].
Five quantitative studies [37,38,41,53,59] found insignicant association between marital status and maternal health service
utilization. However, the result of three qualitative studies found that women who were single, divorced and separated were less likely
Table 2
Summary of subgroup analysis for ANC and SBA service utilization.
Subgroup ANC utilization SBA utilization
No of
studies
Level of ANC (95%
CI)
Study heterogeneity (I
2
and P value)
No of
studies
Level of SBA (95%
CI)
Study heterogeneity (I
2
and P value)
Study
design
Cross-
sectional
15 38.3 % (95 %
CI:31.4, 45.2)
(99.6 %, P <0.001) 12 47.9 % (95 %
CI:33.8, 62.1)
(99.9 %, P <0.001)
Mixed 5 45.9 % (95 % CI:
17.5, 74.3)
(99.5 %, P <0.001) 2 51.3 % (95 % CI:
4.7, 107.3)
(99.5 %, P <0.001)
Source of
data
Secondary 11 37.6 % (95 % CI:
30.2, 45.1)
(99.6 %, P <0.001) 10 43.8 % (95%CI:
28.3, 59.3)
(99.9 %, P <0.001)
Primary 9 43.4 % (95 % CI:
27.4 %, 59.4 %)
(99.6 %, P <0.001) 4 59.9 % (95 % CI:
27.9, 92.0)
(99.6 %, P <0.001)
Region Western
Africa
11 43.3 % (95 %
CI:34.3, 52.2)
(99.5 %, P <0.001) 8 38.6 % (95 % CI:
37.6, 39.5)
(99.6 %, P <0.001)
Eastern
Africa
6 34.1 % (95 %
CI:17.8, 50.2)
(99.5 %, P <0.001) 4 27.5 % (95 % CI:
26.3, 28.6)
(99.6 %, P <0.001)
Southern
Africa
1 44.5 % (95 % CI:
39.1, 50.0)
–
Table 3
Determinants of maternal service utilization among adolescent women in SSA.
Variables Categories OR with 95%CI I
2
and P value Number studies Sample size
Age <18 years ref (75.0 %, P =0.001) 6 9323
18–19 years 1.36 (1.07, 1.71)
Residence Rural ref (98.6 %, P <0.001) 6 9836
Urban 1.44 (0.52, 3.99)
Marital status Single ref (97.6 %, P <0.001) 5 7677
Married 1.41 (0.43, 4.60)
Religion Christian 1.68 (0.87, 3.27) (87.8 %, P <0.001) 4 1482
Others ref
Women’s educational status No formal education ref (98.5 %, P <0.001) 9 17,713
Formal education 2.02 (1.08, 3.79)
Partner’s educational status No formal education ref (98.5 %, P <0.001) 5 11,930
Formal education 1.94 (1.80, 2.10)
Employment Unemployed ref (0.00 %, P =0.662) 2 2031
Employed 1.24 (1.02, 1.51)
Wealth status Poor ref (98.3 %, P <0.001) 5 12,828
Rich 1.67 (0.92, 3.05)
Media exposure No exposure ref (0.00 %, P =0.544) 2 1947
Exposure 3.93 (2.87, 5.38)
Household head Male ref (74.8 %, P =0.046) 2 3742
Female 1.66 (1.12, 2.47)
Parity One ref (0.00 %, P =0.602) 2 1199
Multiple 0.78 (0.47, 1.28)
Pregnancy intention Unplanned ref (72.8 %, P =0.005) 5 10219
Planned 0.97 (0.72, 1.29)
T. Tolossa et al.
Heliyon 10 (2024) e35629
11
to utilize maternal health care than married adolescent women [36,49,50]. Religious beliefs were associated with low maternal health
service utilization in four studies: in Nigeria [69] and Guinea [47] women belonging to the Muslim religion had lower uptake of the
maternal health service than women belonging to catholic religion while in Malawi women of catholic faith were less likely utilize
maternal health care than other religions [68]. In Zimbabwe, approximately 12.5 % of adolescent women did not attend ANC
follow-up due to religious inuences [63].
3.8.2. Health knowledge and beliefs
Maternal healthcare utilization is inuenced by women’s awareness of available services and cultural beliefs. In twelve studies,
women with good awareness and knowledge about available services were more likely to use maternal healthcare [45,53,54,58,59,61,
63–65,67,69]. Cultural beliefs such as unwritten community laws, and using herbs inhibit the maternal health service utilization of
adolescent women [39,54,59,61]. In Tanzania, local laws require pregnant women to attend ANC with their spouse, prohibiting
unmarried or unaccompanied women due to denial of paternity by their partner or spouse [54]. In Uganda, retaining the placenta at
home is seen as a sign of giving birth to an intelligent child. Consequently, adolescent women tend to choose home deliveries over
healthcare facilities to retain access to the placenta due to this cultural belief [61]. In Ghana, it is culturally forbidden to disclose a
woman’s pregnancy publicly until a specic ritual is performed, potentially delaying early ANC initiation [59].
3.9. Enabling factors
3.9.1. Individual related factors
Fourteen studies assessed the association between cost and maternal health service utilization of adolescent women [37,39,46,48,
50,54,55,59–64,67]. Of the total 14 studies, ten studies indicated the effect of direct medical cost on maternal health service utilization
Table 4
Summary of the barriers and determinants of maternal service utilization among adolescent women in SSA.
Framework Categories Barriers
Predisposing
barriers
Socio-demographic
barriers
•Age <18 years [37,51,56,59,70], lack of education [17,36,38,40,41,47,49,51,59,69,70,72], low
educational status of the family [17,36], low educational status of husband [37,38,40,41,49,59,69,72],
rural residence [17,40,41,47,49,54,59,69,70,72], low birth order and interval [49,69,70,72], religious
factors [47,63,68,69], unmarried marital status [36,49,50,53,59], male household head [37], ethnicity
[41], lack of parents [51].
Health knowledge and
beliefs
•Lack of knowledge about ANC [45,53,54,58,59,63,64,67], lack of awareness [61,65,69], cultural
mal-practices or unwritten community laws [39,54,59,61], using herbs [61]
Enabling barriers Individual level barriers •Lack of money for transportation [39,46,48,50,55,60,61], lack of income [46,51,52,54,59,60,62,63,67],
lack of money for maternity wear [39], lack of autonomy [17,38,49,53,54,60,70], fear of health
professionals [48], shyness and embarrassment [46,48], fear of adult women [71], fear of disclosing
pregnancy [45,60,63], lack of privacy and condentiality [55]
Family related barriers •Poor wealth status of family [17,36–38,40,41,47,49,51,56,62,69,70], rejection by partner and not
accepting paternity [39,61,62,67,71], not accepting her pregnancy by family [39,45,67], harsh treatment
by family and use of abusive language (due to pregnancy before marriage and unknown husband) [39,50,
54,60,62], family denied food, money, and bed [39], lack of family support [39,59,64,65,71], absence of
male involvement [51]
Community level barriers •Stigma from community [17,42,45,48,49,60,61], fear of peers and community [39], lack of social support
[48,71], society does not promote the use of PNC [69], presence of TBA in community [50–52,63,64], lack
of transport and poor infrastructure [52,60], lack of media exposure [40,41,49,54,60,69,72]
Need factors •Lack of birth preparedness [39], place of delivery affect PNC [61,69,72], unplanned pregnancy [36,37,41,
53,70–72], lack of ANC [37,47,56,69,70,72], fear of caesarean section [50], coercion and violence from
friends and family, negative emotional response to pregnancy (sadness, fear, and guilt) when they are
pregnant [45], fear of HIV status (since they had sex without condom) [46,64], only visiting ANC when they
develop medical problem otherwise utilising TBAs (assuming ANC is only for sick) [51]
Contextual factors Availability (HP and
infrastructure)
•Lack of adolescent friendly services [39], lack of comprehensive services such as family planning and
post-abortion care [39,60], frequent lack of drugs and stock-outs from health facility [39,48], only
conducting ANC service on specic days [48], staff shortages [48,50,66], lack of obstetric equipment [48],
illegal fees and high prenatal fee [48], lack of referrals and transfers system [48], lack of adolescent waiting
place and delivery place [42], lack of separate ANC clinic (giving ANC service with under-ve clinic) [42,46,
66], health facility does not work at night [52], long waiting times [39,42,48,59,60,65], long distance [38,
46,52], indirect medical cost not covered by health facilities [39], difculty in reaching health facility [55]
Acceptability •HWs give priority to women who were escorted by their partners [39], lack of compassionate care [46,58,
61,67], health system policy (pregnancy is not allowed in school in Tanzania) [48], negative attitude from
health workers such as insulting, using inappropriate words [39,42,45,48,51,55,59,60,65,71], lack of
friendly communication between health workers and adolescents [51,64,65], dismissal of pregnant women
from school [67], lack of privacy and condentiality in health facility [42,48,65,66,71]
Abbreviation.
ANC- Antenatal care.
SBA- Skilled Birth attendant.
TBAs- Traditional Birth attendants.
PNC- Postnatal care.
T. Tolossa et al.
Heliyon 10 (2024) e35629
12
[37,39,46,48,50,59–61,63,64,67]. The studies revealed that adolescent women often dropout from maternal healthcare services for
various nancial reasons. These include a lack of money to acquire essential medications [39,48,55], insufcient nancial resources in
emergency situations [61], and lack of money to initiate and attend ANC service [37,46,59,63,67]. In instances where health facilities
impose high prenatal fees, women choose to not utilize maternal health care [48,64].
Nine studies assessed the effect of direct non-medical cost on maternal health service utilization [37,39,46,48,50,54,55,60,61].
Eight studies revealed that adolescent women faced challenges in utilising ANC services due to the nancial burden of transportation
costs [37,46,48,50,54,55,60,61]. A study conducted in Uganda found that lack of money for transportation is the main reasons behind
adolescent women’s preference for traditional birth attendants (TBAs) over trained health professionals [61]. Other studies reported
the effect of cost on maternal service utilization due to lack of money for clothes and birth preparedness [39,54,61,62] and lack of
money for referral to higher health facilities during complications [61].
Eight studies explored the association between decision making autonomy of the women and maternal health service utilization.
Adolescent women who participated in decision making jointly with their husband/partner were more likely to utilize maternal health
care than women whose husband/partner made decisions without involving the women [17,38,49,53,54,60,70]. Individual-related
enabling barriers such as fear of health professionals [48], shyness and embarrassment [46,48], fear of adult women [71], and fear
of disclosing pregnancy [45,60,63] were identied as the barriers of accessing maternal health care. A meta-analysis of two studies
found no signicant association between maternal health service utilization and number of pregnancies (OR =0.78, 95 % CI: 0.47,
1.28) [40,41].
3.9.2. Family/partner related factors
Meta-analysis of ve studies found no signicant association between household wealth index and adolescent maternal health
service use (OR =1.67, 95 % CI: 0.92, 3.05) [36–38,41,72]. However, eight qualitative studies indicated that lower wealth status in
families/partners reduced maternal health care utilization compared to higher wealth families [39,50,54–56,59,63,69].
In SSA, many adolescent women were not accessing maternal health care due partner’s refusal to accept paternity [39,61,62,67,71]
and stigma associated with premarital pregnancy [39,45,67]. This rejection is often accompanied by denial of basic necessities like
food and money [39], and even harsh treatment by family members [50,54,60,62]. Additionally, the absence of family support [39,59,
64,65,71], and limited male involvement in maternal care further deter maternal health service utilization [51].
3.9.3. Community related factors
Six studies assessed the association between residence and maternal health service utilization. Four studies Four studies reported
higher service utilization among women from areas [37,40,41,72], while two studies indicated lower service utilization [38,59]. The
pooled result showed a non-signicant association between residence and maternal health service utilization (OR =1.44, 95 % CI:
0.52, 3.99). Meta-analysis on media exposure and maternal health service utilization [40,41,49,54,60,69,72] found that women
exposed to media were more signicantly more likely to utilize maternal health care compared to those not exposed to media (OR =
3.93, 95 % CI: 2.87, 5.38).
Eight studies addressed the relationship between TBAs and maternal health service utilization with varying ndings. In Ethiopia,
over 80 % of women receiving ANC at health facilities opted for home births without skilled attendants [17]. In Kenya and Zimbabwe,
only 7 % [40] and 8.8 % [63] of pregnant women sought care from TBAs during pregnancy and childbirth, while in Nigeria, 32.3 % of
adolescent women used TBAs [38]. Reasons for TBA preference over modern health care facilities included nancial constraints for
transportation, birth preparations, and medication [61], fear of stigma and discrimination from the community and friends [54,61],
and unfavourable attitudes of health professionals [39,61]. Cultural practices, family history, and limited decision-making power in
families also inuenced TBA use [48,50,59,61].
3.10. Need factors
A meta-analysis of ve studies found no signicant association between pregnancy intention and maternal health service utilization
[36,37,41,53,72] (AOR =0.97, 95 % CI: 0.72, 1.29). However, two qualitative studies [70,71] suggest that planned pregnancies lead
to higher maternal health care utilization. In eight studies examining ANC and SBA utilization, full ANC attendance increased the
likelihood of facility based deliveries [37,47,51,56,68–70,72]. SBA users were also more likely to access PNC in two studies [61,69].
Factors like negative emotional responses during pregnancy [45], fear of HIV due to condomless sex [46,64], and using ANC only for
medical issues [51] prevented women from using ANC service.
3.11. Contextual factors
3.11.1. Availability of health professional and infrastructure
Service availability signicantly affects maternal health care utilization. In Uganda, the absence of adolescent-friendly services
hinders utilization among adolescent women [39]. Studies in Uganda and Namibia, also reported reduced utilization due to the lack of
comprehensive maternal care, including post-abortion care and family planning [39,60]. Additionally, conducting ANC service only on
specic days [48], staff shortages [48,50,66], lack of referral system [48], absence of maternity waiting rooms [42], and the absence of
separate ANC clinics for adolescent women [42,46,66] were further barriers to seeking health care. Long waiting times were found to
decrease maternal health service utilization in six studies [39,42,48,59,60,65] and long distances hindered or delayed service use in
three studies [38,46,52]. Poor transportation and infrastructure further reduced maternal health care utilization [55].
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Heliyon 10 (2024) e35629
13
3.11.2. Acceptability of the service
The maternal health service utilization of adolescent women in SSA was inuenced by poor health system and country policies.
Two studies assessed the impact of health-related policies on maternal health service utilization. A study conducted in Tanzania
showed that prohibition of pregnancies during and the fear of health care services after becoming pregnant hinder utilization [48].
According to a study in Lesotho, unmarried pregnant women face expulsion from school and fear discrimination and stigma, pre-
venting them from seeking maternal health care utilization [67]. Moreover, unfavourable attitudes of health professionals including
lack of compassionate care [46,58,61,67], insults and using inappropriate language [39,42,45,48,51,55,59,60,65,71], and unfriendly
communication [51,64,65] discourage women from accessing services in SSA.
4. Discussion
This systematic review examined the level of maternal health service utilization and associated barriers among adolescent women
in SSA. The ndings of the study provide strong evidence of low maternal health service utilization among adolescent women and
identied predisposing, enabling, need and contextual factors that inuence their maternal service utilization.
The study indicates that adolescent women’s ANC service utilization in SSA increased from 38.2 % pre-SDG to 42.6 % post-SDG,
showing a slight positive change. This level of ANC service utilization during the SDG era aligns with ndings in India [74,75] and
Nepal [76], but is lower compared to studies in Indonesia [77,78], Nepal [79] and Bangladesh [80]. Difference may be due to age
variations across studies with some including women aged 20–24 which can affect utilization patterns if these older women have
different utilization patterns than women under 20 years. Conversely, utilization in this review was higher than previous estimates for
India [81] but this may be due to different ANC denitions, potentially underestimating utilization in the India study. Additionally,
SBA utilization during childbirth rose from 44.8 % pre-SDG to 53.0 % during SDG, consistent with studies conducted in Nepal [76] and
India [74]. However, it was lower than the joint WHO and UNICEF report in SSA [82], and a SSA study using a recent DHS dataset [83].
Differences may arise from the broader SSA data in previous reports, while this study focused on specic SSA regions.
The increase in ANC and SBA utilization could be attributed to increased health awareness, better healthcare infrastructure,
resource allocation for maternity services, the availability of facilities and trained professionals, and SDG-driven policies aimed at
enhancing maternal and child health [84]. These policies include raising the target ANC visits to eight [85], implementation national
health insurance schemes [86], and free maternity policy in the region [87,88]. Community health workers have also played a pivotal
role in improved service access across SSA regions [89–91]. The greater increase in SBA compared to ANC in SSA may be linked to
persistent challenges in accessing and utilising ANC services. These challenges often require early initiation and multiple visits, posing
difculties in regions with transportation and infrastructure limitations [52,60]. Despite progress, there remains a substantial gap in
improving coverage for ANC, SBA and PNC service utilization. Addressing these gaps is crucial for ensuring the comprehensive
well-being of both mothers and newborns, particularly within the context of adolescent women.
Regarding the regional comparison, disparities persist in utilization of the service across various SSA regions. The observed dis-
parities might be due to a combination of social, economic, cultural, infrastructural and policy differences in the region [92,93]. The
variation in service use observed across SSA regions and individual countries suggests that closing these gaps is achievable, though
additional efforts may be needed especially, in regions with the lowest current service utilization, such as Eastern Africa.
Predisposing sociodemographic barriers, such as younger age group, lack of education, and having uneducated partner/husband,
decrease the likelihood of maternal health service utilization among adolescent women. These aligns with previous studies conducted
in different settings [94–98]. Enhancing adolescent literacy and education is a key strategy to improve adolescents’ use of maternal
health care. Younger women often nancially dependent on their family and partners, with limited-service utilization, experience, and
lower educational status, face additional challenge compared to older women. Women with higher educational attainment are more
likely to be more aware healthcare services’ value, initiate service use early, and proactively planning delivery. Furthermore, educated
partners contribute positively by understanding the importance of attending health facilities for ANC or delivery services, providing
nancially and psychological support, and mitigating discrimination and stigma within the family. These factors collectively enhance
decision-making autonomy.
This review also found that lack of media exposure, insufcient knowledge, and adherence to cultural beliefs and norms decrease
the likelihood of maternal health service utilization. Exposure to media and possessing adequate knowledge empower women to
understand the importance of service utilization, the signicance of consulting qualied health professionals, the risks associated with
not receiving essential services from health facilities and facilitate active involvement in decision making with their family and
partner. These ndings align with studies conducted in in India [75,97], and South-east Asia [99]. Social norms and cultural beliefs
further inuence maternal health service utilization particularly in SSA countries, where communities often value TBAs and prefer
home births under TBAs care due to cultural norms, trust in traditional practices, accessibility, lower costs, and assumed better
counselling compared to trained health workers [61]. Fear of stigma and discrimination from health professionals further encourage
women to choose TBAs over seeking health services from trained health professionals [50,54]. Given the signicant inuence of social
norms and cultural beliefs on maternal health service utilization in SSA region, it is crucial to consider community perspectives and
incorporate TBAs into policy design. Developing context-specic recommendations is essential to improve maternal healthcare
outcomes.
High out-of-pocket expenses including consultation fees, medications, and transportation costs discourage women from seeking
maternal health care. This aligns with studies in LMICs [100], India [101,102], and Myanmar [103]. While several SSA countries
introduced free maternity policies to alleviate nancial barriers, challenges such as insufcient funding, staff shortages, and low
motivation hinder their effectiveness [104]. Particularly, these policies often overlook non-medical costs, posing a signicant concern
T. Tolossa et al.
Heliyon 10 (2024) e35629
14
for adolescent women in LMICs [55,105]. Recommendations for improvement include enhancing drugs and laboratory services
availability, increasing staff numbers, and improving funding for maternal healthcare programs. Furthermore, policies should address
non-medical expenses, as solely focusing on medical costs may not effectively enhance maternal health service utilization in
resource-constrained settings.
The access of adolescent women to maternal healthcare is inuenced by service availability and acceptability. Factors such as
proximity to facilities, long waiting times, and staff shortages affects access to these services. This is consistent with ndings from
previous studies done in South-East Asia and SSA [106,107]. Distant healthcare facilities pose challenges for adolescent women in
accessing essential maternal health services. The shortage of healthcare professionals contributes to longer waiting times, reduced
quality of care, and overall dissatisfaction with services [108]. Improving adolescent maternal healthcare in resource-limited settings,
like SSA, requires enhancing the availability and accessibility of services. This involves expanding healthcare infrastructure, increasing
the number of trained healthcare professionals, and ensuring comprehensive maternal healthcare for adolescent women.
4.1. Strength and limitation of the study
The strength of this review includes a comprehensive assessment of maternal health service utilization components and its barriers,
thorough search strategies by including more than eight databases, and protocol registration on PROSPERO. In addition, we used
Andersen’s health-seeking model to comprehensively address the barriers of maternal health service utilization. The study has certain
limitations. Firstly, the review focused on studies published only in English, potentially overlooking evidence, especially from Fran-
cophone Africa. The reliance on cross-sectional study designs in all quantitative studies limits causal inference. Moreover, the included
studies represent only fteen countries, potentially not capturing the full diversity of SSA countries. Lastly, the scarcity of relevant
studies during the SDG era prevented comparison of pre- and post-SDG postnatal care utilization.
5. Conclusion and recommendations
In SSA, maternal health service utilization among adolescents remains at a low level. While there was a modest increase in ANC
service utilization, the rise in SBA was more substantial from pre-SDG to the SDG era. Disparities across SSA regions and various
barriers including predisposing, enabling, need and contextual barriers inuence adolescent women maternal service utilization.
These highlight the need to develop context-specic strategies and interventions targeting adolescent women. Addressing these
challenges is crucial to achieving SDG3 by 2030.
Ethical approval and consent to participate
Not applicable.
Funding
This research did not receive any specic grant from funding agencies in the public, commercial, or not-for-prot sectors.
Data availability
No data was used for this specic research article.
CRediT authorship contribution statement
Tadesse Tolossa: Writing – review & editing, Writing – original draft, Visualization, Supervision, Software, Methodology, Funding
acquisition, Formal analysis, Data curation, Conceptualization. Lisa Gold: Writing – review & editing, Writing – original draft,
Visualization, Validation, Supervision, Resources, Project administration, Investigation, Formal analysis, Data curation, Conceptual-
ization. Merga Dheresa: Writing – review & editing, Visualization, Validation, Supervision, Resources, Funding acquisition, Formal
analysis. Ebisa Turi: Writing – review & editing, Visualization, Validation, Resources, Methodology, Formal analysis. Yordanos
Gizachew Yeshitila: Writing – review & editing, Validation, Software, Resources, Investigation, Data curation. Julie Abimanyi-
Ochom: Writing – review & editing, Writing – original draft, Validation, Software, Project administration, Investigation, Formal
analysis, Data curation, Conceptualization.
Declaration of competing interest
The authors declare that they have no known competing nancial interests or personal relationships that could have appeared to
inuence the work reported in this paper.
Acknowledgement
Special thanks are extended to the dedicated librarians at Deakin University for their invaluable support and assistance in
T. Tolossa et al.
Heliyon 10 (2024) e35629
15
conducting database searches and developing search terms. Lastly, the authors would like to extend their appreciation to all the
authors of the studies included in this systematic review and meta-analysis for their contributions to the eld of research.
Supporting Information
S1 le-Database search results.
S2 le- JBI Quality assessment results.
Abbreviation
ANC Antenatal care
CI Condence Interval
OR Odd Ratio
LMIC Low- and Middle-Income Countries
MDG Millennium Development Goal
PNC Postnatal care
SBA Skilled birth attendants
SSA Sab-Saharan Africa
SDGs Sustainable Development Goal
TBAs Traditional birth attendants
WHO World Health Organization
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.heliyon.2024.e35629.
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