Utilization of healthcare services is associated with the link between three factors, i.e., provision of services, physical and social access to services, and cultural and behavioral factors (1, 2). Physical and social access determines whether the public has access to healthcare services. It should be noted that quality of care can affect an individual's decision regarding the use of services (3). According to reports by World Health Organization, lack of access to adequate resources and facilities providing local healthcare services majorly contributes to the relatively slow progress in meeting the Millennium Development Goals (MDGs) (4, 5).
Although the relationship between inadequate prenatal care and high maternal mortality is complex and controversial, identification of this relationship can help determine, control, and overcome the risks of pregnancy (6-8). In fact, there is substantial evidence indicating the impact of prenatal care on pregnancy outcomes (8); this influence is more highlighted in developing countries and underserved populations.
Despite improvements in prenatal care, which can help obtain better prenatal outcomes, we still face various pregnancy, childbirth, and neonatal complications. Various studies have shown that problems related to prenatal care, including delayed care and treatment, inadequate care and medical advice, and poor adherence to medical suggestions, could lead to the persistence of such adverse outcomes (9).
In order to improve maternal and neonatal health, the available interventions regarding maternal and neonatal care need to be enhanced. According to previous studies, prenatal and neonatal care can influence the contributing factors and patterns of neonatal mortality. In addition, prenatal care may play an indirect role in reducing maternal mortality by promoting safe deliveries (10).
The role of timely and adequate prenatal care visits in ensuring maternal and neonatal health cannot be underestimated. Early prenatal care provides an opportunity for primary screening of complications, patient referral, and treatment. Moreover, adequate prenatal care visits facilitate the follow-up and monitoring of fetal growth and maternal health by physicians. In addition, prenatal care provision can create a friendly atmosphere for care providers and mothers, which is a prerequisite for safe delivery (11).
During prenatal care visits, mothers can be informed about the warning signs and symptoms during pregnancy, preventive care and treatment strategies, proper nutrition, breastfeeding, and use of contraceptive methods for family planning (11). Overall, the mentioned issues show the critical need for early initiation of antenatal care (ANC) and adequate prenatal care visits. Accordingly, many countries have made targeted efforts to ensure the provision and utilization of timely and adequate ANC (11). In fact, delayed care provision can result in missed opportunities for the diagnosis of gestational hypertension, gestational diabetes, or sexually transmitted diseases (12-15).
According to several studies, inadequate prenatal care visits can result in a significantly higher risk of severe complications associated with pregnancy (16, 17). ANC is a key strategy for achieving public health goals, primary healthcare objectives, and MDGs (8). The aim of this study was to investigate the factors influencing the use of prenatal care services in order to design proper interventions and promote the use of such services.
Materials and Methods
In this study, we reviewed the available literature by exploring two international electronic databases including Scopus and PubMed, using the following keywords: "Socioeconomic factors", "risk factors", "socioeconomic determinants", "prenatal care", "postnatal care", "maternal health services", "delivery", "obstetric", "rural health services", "urban health services", "prenatal care, organization, and administration", "maternal health services, organization, and administration", "postnatal care, organization, and administration", "pregnancy", "prenatal care/standards", "preconception care", and "postnatal care".
English-language publications were searched, using relevant keywords, and the reference lists of the articles were hand-searched. In this literature review, a systematic search was performed on studies published in years 2010-2014. Relevant articles were fully examined, using a data extraction sheet. We reviewed all cross-sectional and prospective studies, which focused on factors associated with the use of prenatal care services within the specified period of time.
Study selection was completed in three phases. In the first phase, the reviewer examined the study titles, according to the selection criteria. In the next phase, abstracts of the selected articles were reviewed to assess their eligibility. After reviewing the abstracts, in case an article met one or more of the exclusion criteria (based on the reviewer's opinion), it was removed from the analysis. The last phase was performed independently by two reviewers to determine if the full manuscripts should be included in data extraction. Disagreements regarding the inclusion of full-text articles were resolved by discussion, consensus, or third-party adjudication.
A total of 28,565 articles, published during 2010 and 2014, were investigated. In total, 7,364 duplicate studies were removed. Moreover, 21,127 papers were excluded due to lack of consistency with the study objectives. Therefore, studies which evaluated the determinants of prenatal care utilization by specific groups (e.g., teenage pregnancies or high-risk women), without making comparisons with the general population, as well as studies which provided no new empirical data (i.e., reviews, letters to the editor, and brief reports), were excluded from the analysis.
Also, after the assessment of titles and abstracts, articles which only provided qualitative data, failed to report the sampling method, used a non-representative sampling method, or selected participants through non-probability sampling were excluded from our analysis. Moreover, 57 papers were removed due to lack of access to the original article (owing to language differences, etc). Finally, 17 papers and their reference lists were included in the final analysis (Figure 1). These studies were reviewed and the required information was extracted and documented in the data extraction sheet. Finally, the data extraction sheet was used to summarize the data.
The extracted data for the analysis were as follows: general information (i.e., study title, place of study, publication year, study year, journal, and population characteristics), methodological information (i.e., study design, sample size, and sampling method), and study results (details of relevant findings). The quality of the studies was assessed by two reviewers according to the Crowe Critical Appraisal Tool. The extracted data, along with a narrative synthesis, are presented in Table 1.
Table 1 presents the general characteristics of the included studies. All 17 studies were either cross-sectional or prospective. The literature review showed that delayed or inadequate utilization of prenatal care may be attributed to personal characteristics, cultural, ethnic, religious, and socioeconomic factors, personal health behaviors, and factors associated with the characteristics of prenatal care providers. In this section, each of these factors will be discussed in detail:
Demographic and background factors included age, educational level of parturient women and their partners, parity, birth order, birth interval, and ethnicity (18).
Several studies have assessed the relationship between age and prenatal care. A number of these studies have introduced maternal age as one of the barriers against timely and adequate prenatal care visits. In fact, a significant relationship has been reported between maternal age (< 20 years) and infrequent use of prenatal care services (19, 20). According to a previous study, time and frequency of prenatal care visits are significantly associated with maternal age (11). Also, the results of a previous review study revealed that maternal age is a factor associated with the use of prenatal care services (21).
Several researchers have studied the relationship between education and prenatal care. A number of these studies have shown that low educational level (< 9 years) is associated with the reduced use of prenatal care services, late initiation of care, and inattention to such services (19). Also, based on a previous research, time and frequency of prenatal care are significantly associated with the educational level of mothers and their partners (11). According to the findings, literate women are exposed to social media and are more likely to use both prenatal and neonatal care services (10).
Several studies have shown that low maternal education is one of the barriers against receiving timely and frequent prenatal care (19, 22, 23). In fact, inadequate use of prenatal care services has been reported
among women with lower levels of education (20), whereas women with higher educational levels benefit from timely prenatal care services (9).
Moreover, many studies conducted in developing countries have shown that maternal education is one of the main factors influencing the use of maternal care services (while controlling other intervening factors) (7, 24-27). In fact, the documented social and demographic information shows that women with lower educational levels (despite their access to services) are less likely to use prenatal care services (21, 28, 29).
The literature review showed that multiparous women are less likely to use prenatal care services (30). As our investigation revealed, primiparous women start receiving prenatal care earlier than other women (9, 19); also, low-parity women are more likely to use both prenatal and neonatal care services (10). The results of a review study revealed that parity is among factors associated with the use of prenatal care services (21).
1.4. Household dimension, birth order, and birth interval
Household dimension is an important factor in the use of prenatal care. In fact, women from nuclear families are substantially less likely to receive prenatal care, compared to other women (31). Also, according to several studies, birth order and birth interval are associated with prenatal care (32). In fact, in a previous study, women who had received inadequate care in their previous pregnancies were more likely to have a short subsequent birth interval (32, 33). Therefore, high parity is associated with late initiation or inadequate use of prenatal care services. As documented in a previous study, mothers with a birth interval of three years have more frequent prenatal care visits, compared to those with two-year birth intervals (33).
Ethnicity plays an important role in receiving prenatal care. In fact, initiation of prenatal care varies among different ethnicities (33). For instance, based on a previous study, Kurdish women in Turkey are less likely to use prenatal care services (34).
2. Socioeconomic factors
Socioeconomic factors include the socioeconomic status (or household income) and occupational status of parturient women and their partners. Overall, several studies have shown that infrastructure and socioeconomic parameters are among the most important factors affecting prenatal care (35).
2.1. Household income
Time and frequency of prenatal care visits are significantly associated with the level of household income (11). The results of a review study revealed that family income is among factors related to the use of prenatal care services (21). In fact, women in middle-income families use prenatal care services less frequently than other women (36). Overall, economic status of the family has a positive and significant influence on the use of prenatal care services.
Women of higher socioeconomic status are more likely to receive early and adequate prenatal care, compared to those of a lower socioeconomic status (31, 33, 37). In fact, continuity of care during pregnancy is influenced by financial resources and social support (38). Sociodemographic evidence shows that rural women or those residing in relatively poor areas (despite access to services) use prenatal care services less frequently than others (21, 28, 29).
2.2. Occupational status of women and their partners
A number of studies have shown that unemployment is one of the barriers against optimal, timely, and frequent utilization of prenatal care services (39, 40). Overall, timing and frequency of prenatal care visits are significantly associated with the occupational status of parturient women and their partners (11). Based on a previous study, women whose partners were unemployed or workers did not receive full prenatal care, unlike those whose partners were gainfully employed (41).
Occupational status of women is among the most common factors affecting the utilization of prenatal care services. Employed women more frequently receive prenatal care, compared to housewives (21, 42, 43); in fact, these women are more likely to receive timely prenatal care services (32, 33). In contrast, a study in India showed that prenatal care is more common among housewives, compared to employed women (44).
3. Predisposing cultural and religious factors
Several studies have revealed the relationship between prenatal care and women's culture, values, norms, religious beliefs, and language barriers (18, 45, 46). According to a previous study, time and frequency of prenatal care are significantly associated with religious differences (11). For instance, in a previous study, some Muslim women refused to attend prenatal classes since they were not exclusively designed for women (11).
Additionally, women from higher social classes receive more prenatal care services, compared to others (32). Also, according to the literature, language affects the use of maternal health services by local women in rural areas (47). In fact, language barriers are among the main obstacles against prenatal and postpartum care among immigrants, and use of postpartum care by this group is limited to emergency care (48).
4. Social support
Social support by family members can significantly affect the use of prenatal care services. Based on a previous study, older women in Bangladesh do not refer to healthcare centers for receiving prenatal care and advise their daughters accordingly (49). Also, as revealed by the literature review, women who are not supported by friends and family members are less likely to receive prenatal care services (50).
Extent of contact with social networks and receiving information and support from these sources are also related to the use of prenatal care (18). Health and social services can indeed help improve pregnancy outcomes. Therefore, it is important to promote access to social services for women with socioeconomic problems (51).
5. Factors associated with healthcare providers
Factors associated with healthcare providers affecting prenatal care include access to care services and methods of communication (18, 47).
Accessibility-related factors influencing prenatal care include long distance from facilities providing services, mode of transport, working hours, booking appointments, and direct or indirect discrimination by prenatal care providers (18, 45). The results of a review study showed that availability of prenatal care services is related to the use of these services (21).
Few studies have been conducted in developing countries in this regard. The reported findings have indicated a significant association between the use of prenatal care services and distance from facilities providing these services, mode of transport (52, 53), and the waiting time to receive services (52, 54). Lack of access to services due to long distance and transport-associated problems are among the main reasons for not receiving prenatal care (35, 43, 55-57).
5.2. Communication methods
Methods of initiating communication between prenatal care providers and women, together with access to information and training materials, are among important factors affecting the use of prenatal care services (45). In fact, poor quality of care and negative attitudes of healthcare providers can hinder the use of healthcare services. Moreover, poor communication between patients and healthcare providers, unfriendly behaviors, and negative attitudes of healthcare providers are among major factors, which inhibit women from receiving healthcare services (34, 41, 58).
Continuity of prenatal care is influenced by the quality of services, which is dependent on women's confidence in healthcare providers and their mutual respect (38). Moreover, patient satisfaction, as an important factor in health care, can influence the use of prenatal care services (59, 60). In fact, a positive relationship has been reported between service quality and service continuity, which is associated with patient satisfaction (61, 62).
6. Women’s awareness and attitude
Several studies have exhibited a relationship between women’s awareness and attitude and use of prenatal care services during pregnancy. Early detection of pregnancy (before the sixth week of gestation) results in increased chance of receiving prenatal care services (19). In a previous study, some pregnant women did not consider prenatal care to be necessary, unless a complication had occurred in their previous experiences or there was a risk of complication in the current pregnancy (49). Overall, women’s understanding and awareness of warning signs during pregnancy are significantly associated with receiving prenatal care services (41, 63). In fact, continuity of prenatal care is influenced by the advantages one attributes to these services (38).
7. Unintended pregnancy
Unintended pregnancy is also associated with prenatal care. Women with unintended pregnancies start prenatal care later and receive fewer prenatal care visits, compared to others (30). Accordingly, a systematic review on the relationship between unintended pregnancy and utilization of prenatal care services showed that in both developing and developed countries, women with unintended pregnancies postpone prenatal care; also, the frequency of prenatal care visits is inadequate for these women (64).
8. High-risk medical or obstetric history
Several studies have shown an association between high-risk obstetric or medical history and use of prenatal care services. Time and frequency of prenatal care are significantly associated with prior delivery experiences (11). Results of previous studies have revealed that women experiencing complications in their previous pregnancies have more frequent prenatal care visits (52). Also, women with a history of premature birth start using prenatal care before the 12th week of pregnancy (19). Similarly, women with a history of fetal loss in previous pregnancies are more likely to use prenatal care services (41, 63).
9. Health behaviors
According to various studies, insufficient utilization of prenatal care is more common among women who smoke during pregnancy (36). In fact, smokers are at a higher risk of delayed prenatal care (after 10 weeks of pregnancy) (65). Moreover, several studies have shown that behavioral risk factors are still significantly associated with improper use of prenatal care services in developing countries (21, 66, 67)..
The results of this study showed that late initiation and inadequate use of prenatal care services are independently associated with several variables such as demographic characteristics, socioeconomic factors, predisposing cultural and religious factors, social support, factors associated with healthcare providers, women’s awareness and attitude, unintended pregnancy, high-risk medical or obstetric history, and health behaviors.
Proper use of prenatal care services cannot be achieved merely by establishing healthcare centers. In fact, further qualitative research is required to explore the effects of women's satisfaction and autonomy, as well as the role of gender in the decision-making process; also, socioeconomic status of women should be taken into account.
Socioeconomic status of the family and maternal education are among the most important factors associated with the use of prenatal care services. Therefore, empowering women and promoting maternal education are effective in increasing the use of maternal health services. The results of this study showed that healthcare providers should consider family power structure, family beliefs, and public opinion concerning the pursuit of medical care.
Midwives as the main providers of prenatal care services should be aware of the potential barriers against receiving prenatal care. These care providers should be familiar with the socioeconomic status of women and traditional/cultural beliefs; they should also have an understanding of their own personal skills to improve communication with women. It seems that care providers’ attention to personal characteristics may play a significant role in improving the quality of care for pregnant women; however, further quantitative and qualitative research is highly required.
The findings of this study showed that utilization of maternal health services may be achieved and improved via developing socioeconomic factors and addressing the basic needs of patients including education and financial independence. According to a report by the World Health Organization in 2013, MDG on maternal health has been neglected, and effective measures are required to achieve this goal by 2015.
To achieve the Sustainable Development Goals, it is crucial to make significant investments in the development of proper maternal health services and promote programs aimed at poverty eradication (MDG-1), universal primary education (MDG-2), and empowerment of women (MDG-3).
The strength of the present study was the use of a comprehensive search strategy with broad search terms. However, we restricted our search to English-language articles, published in two international electronic databases (i.e., Scopus and PubMed); consequently, we may have missed some relevant studies. This review specifically focused on factors affecting prenatal care utilization by women, as discussed in articles published in 2010-2014 (regardless of the study groups). Also, in order to improve the generalizability of the findings, this review study was not restricted to countries with similar levels of accessibility to healthcare facilities.
The authors would like to thank the Research Deputy of Shahid Beheshti University of Medical Sciences, Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, and Shahid Beheshti University of Medical Sciences.
Conflicts of interest
The authors declare no conflicts of interest.