A systematic review of implementation strategies to improve timely initiation of antenatal care among pregnant women in sub-Saharan Africa

Background: Despite the availability of antenatal care (ANC) services, fewer than 40% of pregnant women in sub-Saharan Africa initiate ANC within the first trimester, indicating suboptimal early utilisation of maternal health services in the region. Aim: This review aimed to identify and synthesise evidence on interventions that improve the timely initiation of ANC among pregnant adolescents and women in sub-Saharan Africa. Setting: All studies included in the review were conducted in sub-Saharan Africa. Method: A systematic search guided by Preferred Reporting Items for Systematic Review and Meta-Analyses across seven databases (PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature [CINAHL], Scopus, and the Cochrane Database of Systematic Reviews - and grey literature sources including ProQuest Dissertations & Theses Global and African Journals Online [AJOL]) identified eligible English-language studies (1990–2022), including randomised and non-randomised trials, controlled before-and-after studies, and interrupted time-series. The review was conducted between September 2022 and October 2022, and the protocol was registered with PROSPERO (CRD42022380283). Results: Eleven studies met the inclusion criteria. Three types of intervention approaches were identified: community-based, facility-based, and a combination of both. Facility-based interventions, such as mobile phone reminders, for instance, the wired mothers innovation and quality improvement initiatives, showed improvements in early ANC attendance ranging from a 5% increase to more than triple the uptake. Community-based interventions also proved effective, with gains of up to 200%, as in Malawi, where early ANC increased from 10% to 29%. These mechanisms included home visits, education, male involvement, and engagement with traditional leaders. Conclusion: Integrated community and facility-based interventions offer promising strategies to improve timely ANC. Future efforts should consider cost-effectiveness and implementation research to enhance decision-making. Contribution: This study demonstrates the potential of underutilised interventions to enhance first-trimester ANC attendance and maternal health outcomes across sub-Saharan Africa.