As New Challenges Emerge, Africa is Still Faced with Sociocultural and Health System Challenges Leading to Maternal Mortality

Abstract

Globally, the most crucial element of development strategies is a decrease in maternal mortality. Every 2 minutes, a pregnant woman dies from complications related to pregnancy or childbirth. According to studies, the majority of pregnancy and delivery difficulties are mostly influenced by sociocultural and health system factors. PUBMED, Google Scholar, National EDT, EBSCOHost, and Science Direct databases were used to find relevant articles. The process for choosing relevant and qualified articles was based on a PRISMA flowchart. The standard of the accepted articles was evaluated using the Critical Appraisal Skill Program (CASP) checklists. This study employed a thematic analysis, and in the articles on sociocultural and healthcare system factors influencing maternal mortality, six themes and 23 subthemes were found. It was determined that most women choose to consult traditional experts during pregnancy or childbirth rather than health facilities, and that there is little interaction between societal expectations and the healthcare system, which further contributes to problems and maternal mortality. This study found that social, cultural, and health system factors may directly and indirectly contribute to maternal mortality. It is also recommended that cultural norms and health system norms collaborate together to reduce maternal mortality.

1. Introduction

A worldwide crisis has been identified: maternal mortality. Despite all the efforts put in place, maternal mortality has been reported by the World Health Organization (WHO) [1] to be high in African countries. Despite various methods and estimates, it is a fact that Nigeria has the highest maternal mortality rate in Africa. The rate is considerably higher than the global average of 290 maternal deaths per 100,000 live births [2, 3, 4]. Sub-Saharan Africa continues to have the highest rates of maternal mortality in the entire world. Up to half of all maternal deaths worldwide caused by pregnancy-related complications occur in sub-Saharan Africa [5, 6, 7]. According to the literature, sub-Saharan Africa has the highest maternal death rate in the world [8]. Moreover, Mozambique is one of the sub-Saharan African nations with a high death rate of 500 per 100,000 live births [8, 9, 10, 11]. Maternal mortality is more prevalent in poor households than in rich households in sub-Saharan countries, according to studies comparing maternal mortality between rich and poor households [12, 13, 14, 15]. This is mainly because poor households lack the resources to pay for quality prenatal and postpartum care. Although maternal mortality in South Africa has decreased compared to other African nations, it is still above the objective. The WHO [1] underlined this objective, noting that it aimed to “reduce the global maternal mortality rate (MMR) to fewer than 70 per 100,000 births, with no nation having a maternal mortality rate that is more than twice the global average.” Maternal mortality has decreased in South Africa, according to Moodley et al. [16]. The number of deaths resulting from specific conditions that increase maternal mortality is still stubbornly high. Much research has been carried out to determine the causes of maternal mortality in several African nations, including South Africa [2, 16, 17, 18]. However, maternal mortality is still increasing [1, 19]. Cardiovascular problems, obstetric hemorrhage, eclampsia, and ectopic pregnancy are factors in maternal mortality that have been extensively studied [20, 21]. According to a study conducted in Africa, traditional practices and health system factors may cause pregnant women to wait longer before seeking medical attention, which increases the risk of maternal mortality [22, 23, 24]. This indicates that there are some cultural beliefs and health system factors that may increase the risk of maternal mortality.

This systematic review seeks to present a clear or comprehensive picture of sociocultural practices/contributors and aspects of the health system that have been identified as factors influencing maternal mortality, specifically in scholarly papers of studies conducted in Africa. It appears that no systematic review of the expanding body of knowledge on this subject, specifically in Africa, has been published. Consequently, the researcher conducted a methodical examination of the available data on sociocultural practices and healthcare system factors that play a role in maternal mortality in Africa, and pinpointed the elements that were referenced in the studies mentioned earlier. The review question was, “What are the sociocultural and health systems factors contributing to maternal mortality in Africa?”

2. Methods and materials

The aim of this systematic review was to identify the sociocultural and health system factors influencing maternal mortality in Africa. The review utilized specific search strategies, inclusion criteria, study selection, data abstraction, and article evaluation methods. The search was conducted using various databases including PUBMED, Google Scholar, National EDT, EBSCOHost, and Science Direct, and the search terms used were “sociocultural factors,” “health system factors,” “traditional practices,” “contribut*,” “maternal mortality,” and “Africa.” The inclusion criteria involved articles published in English, between 2012 and 2022, conducted on humans, using both qualitative and quantitative methods, and focusing on sociocultural and health system factors contributing to maternal mortality in Africa. Participants included pregnant women or those who had given birth within 42 days. The PRISMA flow diagram [25] was used to select relevant studies and eliminate duplicates. All articles were initially screened using their titles and abstracts; they included PubMed (n = 24), EBSCOHOST (n = 227), National EDT (n = 129), ScienceDirect (n = 1922), and Google Scholar (n = 18,401), for a total of 20,703. Additionally, 2666 duplicates were eliminated from the list, leaving a total of 180,367. Following a review of the themes and abstracts of the studies, 7633 studies were eliminated. Of the 10,404 studies that met the inclusion criteria—which included being published in English and being located on the African continent and having a publication year between 2012 and 2022—2110,383 studies were excluded (see PRISMA Flowchart in Figure 1). After screening and eliminating articles that did not meet the inclusion criteria, eight articles matched the criteria. Permission was not required since all articles were publicly available.

Figure 1.

Study selection procedure (PRISMA flowchart).

The researcher conducted a comparison of collected data and extracted information. They gathered information on all research articles and literature reviews that met the inclusion criteria, including the study’s author, publication year, location, aims, population, outcomes, and limitations. More details on the study’s characteristics that were examined during the review are available in Table 1. (Refer to Table 1 for further information.)

Author and year	Country	Objectives of the article	Study design	Population	Documented outcomes	Limitations
Kea et al. [26]	Ethiopia	The aim of this study was to identify the factors that influence the frequency of maternal health service utilization at the primary healthcare unit (PHCU) level among rural populations in the Sidama zone, south Ethiopia. Additionally, the study aimed to develop strategies for improving the quality of maternal health services.	Explorative qualitative study	The population for this study included community members such as women, men, traditional birth attendants (TBAs), and local kebele administrators, as well as health professionals and health extension workers.	This study’s findings revealed that various factors affect access to high-quality treatment, including traditional and cultural beliefs, distance to medical facilities, previous successful deliveries, and trust in TBAs.	Due to the recent prohibition of TBAs from conducting delivery services, they were often hesitant to provide detailed information.
Bucher et al. [27]	Kenya	The aim of the study was to understand the practices and protocols adopted by traditional birth attendants within our catchment area and to provide valuable insights into the discussion surrounding their roles.	Descriptive study	Traditional birth attendants (TBAs)	The results of the study showed a positive association between traditional birth attendants (TBAs) and healthcare facilities. In addition, harmful practices that can lead to maternal mortality were identified.	The conclusions of this study were drawn from self-reported data. This descriptive study focused on a limited sample of traditional birth attendants from Western Kenya, so the findings may not be entirely representative of TBAs in other regions of Kenya or in other countries.
Berhan & Berhan [28]	Ethiopia	To make a rough estimate of the impact of various socioeconomic and cultural factors on maternal mortality.	Literature review	The study population consisted of electronic databases from Ethiopian Central Statistics Agency, MEASURE DHS, World Health Organization, and PUBMED.	The study identified low contraceptive utilization, risky traditional practices, low economic status, and poor adult literacy rates as key factors that contribute to Ethiopia’s persistently high rates of maternal and perinatal mortality.
Abubakar; Yohanna & Zubairu [29]	Nigeria	The study aimed to explore the impact of cultural beliefs and values on obstetric complications experienced by women who delivered their babies at Yusuf Dantsoho Memorial Hospital in Tudun Wada, Kaduna.	Cross-sectional quantitative study	The study population was comprised of women who delivered babies at Yusuf Dantsoho Memorial Hospital in Tudun Wada, Kaduna during April 2014.	The results of the research align with the universal report on common obstetric issues. Nevertheless, other cultural factors were making the situation more complex by preventing women from seeking medical care.
Sibiya et al. [30]	South Africa	The aim was to explore the factors that impacted the access of pregnant women from the rural community of KwaMkhizwana to antenatal care (ANC) services.; This research sought to investigate the variables that affected the utilization of antenatal care (ANC) services by pregnant women living in the rural community of KwaMkhizwana.	The qualitative study employed an exploratory descriptive, and contextual research design	The study population consisted of pregnant women residing in the remote area and all nursing specialties employed at the three healthcare facilities.	Most of the pregnant women who participated in the study reported experiencing restricted availability to healthcare services.	The study involved pregnant women who were 18 years old and above. However, some pregnant women were unable to participate because they did not use the accessible healthcare facilities in the region.
Muhwava, Morojele & London [31]	South Africa	The objective was to explore the correlation between psychosocial factors and the prompt initiation of antenatal care (ANC) and appropriate attendance frequency of ANC visits among women in South Africa.	Cross-sectional quantitative research design	The research focused solely on women who had experienced pregnancy and were therefore eligible to participate in the study.	The study found no noteworthy correlations between psychosocial factors and appropriate ANC attendance frequency in the urban location.	The utilization of an existing dataset restricted the research to utilizing the survey questionnaire design for data gathering purposes.
Marchie [32]	Nigeria	The aim was to investigate the sociocultural factors that impact maternal mortality in the Edo South Senatorial District.	The research employed a descriptive survey methodology.	The study population comprised of all married females of reproductive age, healthcare workers, and relatives of women who passed away during pregnancy, childbirth, or the postpartum period.	According to the study findings, cultural and traditional factors were found to potentially heighten the chances of maternal mortality. Additionally, harmful traditional practices like female genital mutilation were identified as sociocultural factors that contribute to maternal mortality.
Ansong et al. [33]	Southern Ghana	The purpose of this study was to examine the impact of beliefs and practices on maternal and child healthcare services.	The research utilized both narrative and phenomenology study methodologies.	The study involved individuals from the community, including pregnant women and women with children under the age of five.	The study results indicated that sociocultural beliefs and practices were present during the prenatal, delivery, and postnatal stages. These behaviors were found to be both positive and negative. The tradition of seclusion and the delayed initiation of antenatal care was seen as a means of protecting the pregnancy from evil forces. The study also noted that women who take herbal medications to hasten labor tended to prefer home deliveries with the aid of traditional birth attendants.

Table 1.

Characteristics of the selected studies.

Quality assessment only applied to the entire texts of the papers that were selected and met the criteria for inclusion (see Table 2). Utilizing Critical Appraisal Skill Program (CASP), all the researches included in the review were methodically and meticulously assessed to determine their value, applicability, and credibility. The included studies’ overall quality ranged from 60 to 90%, with an average of 75% exhibiting moderate to high quality.

Authors and year	Study design	Assessment of Studies
Marchie [32]	Descriptive survey method	80%
Muhwava et al. [31]	Cross-sectional quantitative method	70%
Sibiya et al. [30]	Qualitative, exploratory, descriptive design	69%
Berhan & Berhan [28]	Literature review	60%
Bucher et al. [27]	Descriptive study	85%
Kea et al. [26]	Explorative qualitative study	90%
Abubakar et al. [29]	Cross-sectional quantitative study	70%
Ansong et al. [33]	Qualitative, both narrative and phenomenology study designs	80%

Table 2.

Appraisal of studies using CASP.

A thematic analysis was performed to identify similar patterns among the articles reviewed. The similar patterns were grouped together, forming themes, and the following were the themes that emerged from the review: community members’ opinions about the state of maternal health (n = 8), culture-related factors (n = 7), ppregnant-women-related factors (n = 4), healthcare system factors (n = 4), choice of care (n = 5), and Traditional birth attendant (TBA)-related factors (n = 2).

3. Results

According to the studies examined in this review, the majority of women prefer TBAs over medical visits, despite the fact that doing so carries a significant risk of complications that could result in maternal mortality. This showed that women’s decisions about their healthcare are influenced by a variety of other factors. Six themes and 23 subthemes emerged regarding sociocultural and health system factors/practices contributing to maternal mortality from the included articles (see Table 3). The themes that emerged included culture-related factors, pregnant-women-related factors, health system factors, choice of care, and traditional-birth-attendant-related factors.

Themes	Subthemes
Community members’ opinions about the state of maternal health	Lack of knowledge,
	Traditional birth attendance experience,
	Previous childbirth experience,
	Perceptions of risk
	And facility-based experiences
Culture-related factors	Early marriage
	Genital mutilation
	Limited women’s power in decision-making
	Cultural beliefs
	Harmful traditional practices
Pregnant-women-related factors	Late ANC booking,
	Frequency of ANC attendance
	Unwanted pregnancy
	Lack of knowledge
Healthcare system factors	The distance where the healthcare facilities are situated
	Shortage of resources which also includes human resources,
	Provision of services only within the allocated hours
	Lack of privacy in the healthcare facilities
Choice of care	The attitude of healthcare practitioners in the healthcare facilities
	Past birth experiences
Traditional-birth-attendant-related factors	Poor referral practices for obstetric complications
	Poor relationships with the local healthcare team

Table 3.

Themes and subthemes.

3.1 Community members’ opinions about the state of maternal health

The reviewed studies have shown that a variety of factors, including ignorance (n = 7, 100%), traditional birth attendance experience (n = 3, 43%), prior childbirth experience (n = 3, 43%), perceptions of risk (n = 1, 14%), and facility-based experiences (n = 2, 29%), affect people’s perceptions of maternal health [26, 27, 28, 29, 30, 31, 32]. Lack of knowledge was revealed to be the main factor influencing how community members perceive maternal mortality. According to Meh et al. [4], Batist [5], Yemane & Tiruneh [6], Ahinkorah et al. [7], Central Intelligence Agency [8], Buor & Bream [9], and Adde et al. [10], the lack of awareness about risk factors and problems may contribute to maternal mortality, which may result in most women delaying booking for antenatal care (ANC) and opting to deliver their babies in hospitals rather than at home. Lack of information has been identified as the primary barrier to receiving maternal health services in a study by Kea et al. [26], and the majority of women who have delivered at home say they would not do so if they were aware of the advantages of receiving maternal health services in health facilities.

Through the reviewed studies, most women’s perceptions regarding maternal health have been reported to be affected by their previous experiences during pregnancy, their perceptions regarding the risks associated with maternal mortality, and their earlier experiences with the healthcare facilities’ services during childbirth [26, 27, 31]. According to Kea et al. [26], some women who experienced issues during delivery at the healthcare facilities and were passionately assisted may not think twice about going to the facilities during their pregnancy, childbirth, and recovery time. However, other women had unpleasant experiences with prior deliveries in medical facilities due to issues in the healthcare system, such as the unfavorable attitudes of medical staff, the facilities’ remote locations, and a lack of privacy, which led them to choose home birth to medical facilities. Culture-influenced lack of decision-making on the part of women regarding their past pregnancies is another element influencing how people view maternal health. According to research by Kea et al. [26] and Marchie [32], women are never given the opportunity to make decisions throughout pregnancy, childbirth, or following delivery. Yet, the family’s elders, who are the custodians of culture, decide based on their customs and culture. Several behaviors have been shown to prevent women from accessing prenatal care in a way that reduces their risk of maternal death [26].

3.2 Culture-related factors

Early marriage, genital mutilation, limited women’s power in decision-making, cultural beliefs, and harmful traditional practices were identified to be the factors influencing maternal mortality under cultural factors [26, 30, 31]. The problems that cause maternal mortality have been shown to be influenced by customs or culturally relevant elements. In this context, women who participated in the research that are included stated that it is extremely difficult for them to decide to visit the healthcare facilities owing to culture because they are not permitted to make decisions [26, 28, 32]. The main factor in this theme was limited women’s power in decision-making (n = 3, 43%), which means that elders are responsible for making decisions for pregnant women according to culture [26, 29]. Therefore, older women hold power over the outcomes of ANC attendance.

3.3 Pregnant-women-related factors

In this theme, the subthemes that were identified were: late ANC booking, frequency of ANC attendance, unwanted pregnancy, and lack of knowledge [26, 30, 31]. The studies revealed that married women attended ANC earlier than unmarried women. Moreover, employed women attended ANC most frequently compared to unemployed women. Moreover, it was found that most women visiting ANC had planned pregnancies rather than unintended pregnancies [30].

The review found that several pregnant women in the studies did not show up for ANC on time. Hence, insufficient ANC attendance or late reservations may prevent women from receiving a diagnosis for diseases that could arise early in pregnancy and result in complications that could result in maternal mortality [26, 30, 31]. Lack of awareness of the significance of attending antenatal clinics, unintended pregnancy, and unprofessional behavior of healthcare professionals all contributed to late booking.

3.4 Healthcare system factors

The healthcare system factors, such as distance from the healthcare facilities, a lack of resources, including human resources, the provision of services only during the designated hours, and a lack of privacy in the healthcare facilities, were also found to be contributing factors to maternal mortality [26, 30, 32, 33]. Lack of privacy discouraged pregnant women from going to the hospital; they claimed it was preferable to give birth in front of their husbands and family members than in front of medical personnel. Due to poor mobility, pregnant women who live in those areas are not frequently visited or attended by healthcare facilities [30, 32]. According to the literature, women are prevented from visiting medical facilities because; when they go for an ANC appointment, there is occasionally no medical personnel available to help them or, more frequently, there is no medical equipment available to offer them the necessary care [26, 30].

3.5 Choice of care

Pregnant women in this situation typically rely on TBAs for assistance rather than contact medical institutions [26, 29, 30, 31, 32, 33]. The included studies indicated that past delivery experiences and the attitudes of healthcare professionals in healthcare facilities are two factors that influence the choice of women. Past birth experiences in medical facilities accounted for most of the theme’s variance (n = 6, 71%) [26, 29, 30, 31, 32, 33]. The ladies in the included studies stated that they were persuaded to avoid using healthcare facilities while pregnant by their unpleasant experiences there.

3.6 Traditional-birth-attendant-related factors

Poor referral procedures for maternal problems and strained relationships with the local medical staff were factors that were identified under this theme [27]. Because there is a dearth of referrals when there is an obstetric difficulty, there are no partnerships between healthcare facilities and traditional birth attendants, which exacerbates the issues that could cause maternal mortality. Traditional birth attendants have stated that traditional substances can be utilized to handle difficulties such as protracted labor, obstructed labor, retained placenta, and maternal bleeding instead of sending the women to a medical center [27]. The absence of referrals when issues develop has also been linked to a bad interaction between the TBAs and the neighborhood healthcare institutions [27].

The themes were conceptualized hereunder into a framework that provides the interrelationship triad between pregnant women, healthcare facilities, and traditional birth attendants. The review provided that both directions of the relationship triad have contributory factors at different levels (see Figure 2).

Figure 2.

Conceptual map of the systematic review results.

4. Discussion

In this systematic review, five major factors that influence maternal mortality in Africa emerged. These were identified as past birth delivery, late booking, lack of transportation to the facility, attitude of healthcare professionals, and traditional practices. According to the included studies, traditional practices are the major factor leading to complications causing maternal mortality. It has been revealed that TBAs do not refer pregnant women to healthcare facilities for further management. However, they report to the traditional authorities about the complications [27]. Poor referral systems between TBA and healthcare professionals are a serious concern as the two sectors should approach maternal care collaboratively, involving a positive combined effort to eradicate avoidable maternal mortality.

Although maternal mortality declines in developed countries, it remains unexpectedly high in rural communities. Various factors have been found to contribute to maternal mortality. The elements mentioned above had a significant role in this systematic study regarding problems resulting in maternal death. However, all the factors that affect maternal mortality are grouped under cultural norms and practices. The included research showed that culture has a big impact on expecting mothers. To avoid witchcraft and keep the baby from dying, some women, for example, choose not to enroll in ANC since the culture forbids them from being seen while pregnant. Many customs prevent women from seeking out healthcare facilities at this time. It has been noted that multifaceted factors heavily impact the goal of reducing maternal mortality. Thus, sociocultural factors have been reported to take the lead and warrant the collaborative approach from the health system and traditional or community-based stakeholders. Similar issues have been raised in Pakistan, and the most challenging struggle to reduce maternal mortality is firmly rooted in tackling sociocultural practices that build hindrances to maternal care-seeking [34, 35].

It is indeed difficult for African women to find themselves cornered between sociocultural practices that they have been taught from their initiation through rites of passage and the teachings from the healthcare professional in primary healthcare facilities. A need for a socioculturally congruent approach to creating awareness of the sociocultural maternal health practices’ impact on their health has the potential to reduce maternal mortality. Community outreach programs are critical through community gatherings, door-to-door family-based visits, social media, and the use of community health workers can be implemented and maintained sustainably to help reduce maternal mortality. Some sociocultural factors are imposed based on the family history, knowledge, and beliefs, which becomes an internalized body of knowledge that requires combined effort to correct. There is also a need to eradicate the one-size-fits-all approach from TBAs, elderly family members, and traditional healthcare practitioners. This is important given that most women will still go through the cultural practice regardless of the previous encounter that may not have ended well.

Besides the sociocultural factors, the attitudes of healthcare professionals, mainly midwives, are reported to be a considerable challenge that also, in a way, influences women rather to follow cultural practices and continue to use TBA. There is a need for healthcare professionals to be capacitated in terms of positive values grounded by the Ubuntu philosophy. Thus, the ability to attend to pregnant women with respect, courtesy and all positive morals and within the positive boundaries of ethics. The latter is imperative and crucial as women need to rely on both systems for the greater good of the maternal care outcome.

5. Identified gaps

The reviewed research studies showed that culture is important, particularly for pregnant women, and that older persons are mostly in charge of maintaining it. Early booking is one of the strategies to reduce problems that can result in maternal death, according to the WHO [1]. But according to the research included, some women are forbidden from leaving the house when they are expecting to avoid witchcraft. Hence, sociocultural traditions and the health system’s needs must be in harmony.

6. Conclusion

Globally, maternal mortality is a crucial issue. The millennium development goal (MDG) of 38 deaths per 10,000 live births was not achieved in 2015 due to several issues. This comprehensive review identifies the causes of maternal mortality in Africa. The interventions being developed are intended to lessen this issue and are also based on patient-reported barriers to attending ANC or maternity check-ups at healthcare facilities to avoid problems that could result in maternal mortality. Due to many traditional circumstances, there still appears to be a gap in the required compliance in other regions, particularly in rural areas. It is anticipated that relevant interventions that are collaborative can be created using the data from this review, which will assist in preventing the problems that cause maternal death and achieving SDG 3 target 1.

Acknowledgments

The authors acknowledge the University of Venda librarian for assistance in the literature search.

The authors also acknowledge SAMRC for funding this study.

Conflict of interest

The authors declare no conflict of interest.