Barriers and facilitators to maternal healthcare in East Africa: a systematic review and qualitative synthesis of perspectives from women, their families, healthcare providers, and key stakeholders.

Background: In East Africa, women face significant challenges accessing maternal healthcare during pregnancy, childbirth, and the postnatal period. While several studies have examined barriers and facilitators to maternal care, there is no comprehensive review reflecting the various perspectives of women, their families, healthcare providers, and key stakeholders. We systematically reviewed qualitative literature on maternal healthcare in East Africa, synthesizing insights from multiple perspectives and exploring barriers and facilitators across socioecological levels.

Methods: A qualitative evidence synthesis focused on studies from East Africa published between January 2015 and June 2024. We searched electronic databases, including PubMed, Embase, Scopus, Cochrane, Web of Science, and ProQuest, and used citation tracking to find additional references. Eligible studies were critically appraised using the Critical Appraisal Skills Program, and a thematic synthesis was performed to identify barriers and facilitators.

Results: Of the 3181 records identified, 81 studies (63 qualitative and 18 mixed method) met the inclusion criteria, representing 4816 individuals from six East African countries. This review identified barriers at various levels: individual barriers included a lack of awareness and knowledge, fear of being treated poorly, and financial constraints; interpersonal barriers comprised limited family support, communication challenges, and a lack of decision-making autonomy; health facility barriers included poor quality of healthcare, poor infrastructure, limited medical supplies, provider shortages, abusive behaviors from healthcare providers, lack of transportation, and high service costs; community-level barriers involved socio-cultural norms, societal stigma, and gender-based disparities; and policy-level barriers included poor focus on maternal health, a lack of male accompaniment policies, and conflicts. Key facilitators identified included improved healthcare understanding and women's self-efficacy at the individual level, family support and positive social influences at the interpersonal level, high-quality services, reliable transportation, compassionate care, and health education at the health facility level, community initiatives, gender equality, and maternity waiting homes at the community level, as well as free maternity services and health extension programs at the policy level.

Conclusion: The synthesis identified key barriers and facilitators to the maternal healthcare in East African countries, ranging from individual to policy levels. We recommend that future initiatives focus on addressing these barriers while enhancing facilitators across individual, interpersonal, health facility, community, and policy levels through woman-centered, evidence-based strategies. Moreover, fostering collaboration among governments, healthcare providers, and communities is essential for improving access to the maternal continuum of care.