Effect of pregnancy intention on completion of maternity continuum of care in Sub-Saharan Africa: systematic review and meta-analysis

Abstract

Background

The maternity continuum of care is a strategy to provide timely and quality maternal and child healthcare through preconception, pregnancy, childbirth, postnatal, and the early childhood periods. The maternity continuum of care effectively reduces global maternal and neonatal deaths. However, several factors are reported to cause low completion of the maternity continuum of care in sub–Saharan Africa. There has been substantial debate in the literature as to whether pregnancy intention influences the completion of the maternity continuum of care. Although several studies have been conducted to determine the influence of pregnancy intention on the completion of the maternity continuum of care, findings are inconsistent and have not been systematically reviewed. Therefore, this review aims to determine the effect of pregnancy intention on the completion of the maternity continuum of care in sub–Saharan African countries.

Methods

A systematic search of articles was performed from MEDLINE Complete, CINAHL Complete, PsycINFO, EMBASE, Maternity & Infant Care, Global Health, Scopus, and Web of Science. The identified articles were imported into Covidence and independently screened by two researchers for abstract and title, and then full-text. The quality of the studies was evaluated using the Newcastle-Ottawa Scale. The Cochran’s Q test and I² were used for assessing the potential heterogeneity of the studies. Publication bias was assessed using Egger’s regression test and inspection of a funnel plot. A fixed-effects meta-analysis model was used to compute the effect of pregnancy intention on the completion of the maternity continuum of care.

Results

Ten studies involving 343,932 participants were included in the final analysis. The pooled estimate of the meta-analysis found that women with intended pregnancy had 2.12 times higher odds of completing the maternity continuum of care (pooled odds ratio: 2.12, 95% CI: 1.33, 3.36) as compared to women with unintended pregnancy.

Conclusion

Intended pregnancy has a statistically significant positive effect on completing the maternity continuum of care. Policymakers and healthcare providers need to implement strategies to encourage women to plan their pregnancies through the strengthening of pre-conception care and contraceptive counselling to prevent unintended pregnancies.

Systematic review registration

PROSPERO CRD42023409134.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-024-06998-8.

Background

Maternal mortality remains high, with a global Maternal Mortality Ratio (MMR) in 2020 of 223 per 100,000 live births [1]. In 2020, approximately 287,000 women died because of complications related to pregnancy, childbirth, or postpartum [2, 3]. Almost all (95%) of these maternal deaths occurred in low- and middle-income countries (LMICs), with Sub-Saharan African (SSA) countries contributing approximately 70% of these deaths [3]. In SSA, the lifetime risk of maternal death is 1 in 59, much higher than in all low-income countries, which is 1 in 160 [4]. One of the Sustainable Development Goals (SDGs) targets is to decrease the global MMR to 70 per 100,000 live births by 2030 [5]. The World Health Organization (WHO) advocate for global strategies such as the completion of the maternity continuum of care to reduce the rates of maternal, neonatal, and child mortality with the aim to achieve the SDG target [6, 7].

The continuum of care is a holistic approach that addresses integrated service delivery throughout preconception, pregnancy, childbirth, postnatal, and childhood periods at family, community, and facility levels [8, 9]. The maternity continuum of care is a common strategy in LMICs to provide timely and quality maternal, and newborn healthcare [10, 11]. Evidence has shown that maternal and neonatal deaths can be averted through completing the maternity continuum of care, which is safe, effective, accessible, and equitable [12, 13]. Although the importance of an effective maternity continuum of care is well recognised, it is not well practised in SSA [14]. Recent studies have shown that completing the maternity continuum of care in SSA countries ranges from 25% [15] to 35.81% [16]. Many pregnant women start their contact late or do not visit a health facility at all, giving birth at home [17, 18].

Several factors that cause the low completion of the maternity continuum of care are reported across studies. Poor quality of care, disrespect during service delivery, low satisfaction with healthcare services, and lack of transportation have been reported [19, 20]. Conversely, higher educational status, having a history of pregnancy termination, timely initiation of antenatal care, planned pregnancy, women’s autonomy, shared decision-making with husband/partners, and distance to the closest health facility were identified as positive determinants for the completion of the maternity continuum of care [15, 16, 21–25].

Pregnancy intention determines the completion of the continuum of maternity care [26]. Women who have planned their pregnancies tend to be more cautious about their pregnancy, are psychologically prepared, and have higher health-seeking behaviour for maternal and neonatal healthcare services than women with unplanned pregnancies [27, 28]. Reducing the rates of unintended pregnancies and increasing completion of the maternity continuum of care would reduce maternal and neonatal deaths [29, 30]. Unintended pregnancy correlates with late initiation of antenatal care [18, 31], low rate of antenatal care visit [27, 31, 32], low rate of institutional childbirth [27, 32], and low rate of postnatal care [27], compared to planned pregnancies. Unintended pregnancy resulted in a 25 – 39% reduction in maternity care use [33] and an increased risk of pregnancy complications [34–36]. Despite its impact on maternal and newborn health, global rates of unintended pregnancy vary widely, ranging from 11 per 1,000 in Montenegro to 145 per 1,000 in Uganda [37]. Evidence has shown that the pooled prevalence of unintended pregnancy in SSA was 34% [38].

Given the high prevalence of unintended pregnancies in SSA and its potential impact on maternal, newborn, and child health, assessing the effect of pregnancy intention on the completion of the maternity continuum of care is important for informing maternal health policy and practice. Although studies have identified pregnancy intention as a determinant of the completion of maternity continuum of care, findings are inconsistent and there has been no systematic review and meta-analysis conducted to estimate the effect of pregnancy intention on completion of the maternity continuum of care in SSA countries. Therefore, the aim of this systematic review and meta-analysis was to determine the effect of pregnancy intention on the completion of the maternity continuum of care in SSA countries.

Methods

Registration and reporting

The review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) after checking for other similar review protocols (registration Identifier: CRD42023409134). We prepared and reported this review following the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [39].

Information sources and search strategy

Key search terms were developed for the following three concepts: pregnancy intention, maternity continuum of care, and Sub-Saharan Africa. The search terms included both Medical Subject Headings (MeSH) to increase the specificity of search terms, and free text keywords to capture records without subject headings, such as recently added records to a database. A variety of truncation, proximity, Boolean operators, and phrases were used for the various databases. A systematic literature search was conducted on April 05, 2023, in databases that contain maternity care evidence. These included MEDLINE Complete (EBSCOhost platform), CINAHL Complete (EBSCOhost platform), PsycINFO (EBSCOhost platform), EMBASE, Maternity & Infant Care, Global Health (EBSCOhost platform), Scopus, and Web of Science. Furthermore, the reference lists of the identified studies and reviews were checked in Google Scholar for potentially relevant articles. The search strategy was initially developed in EBSCOhost MEDLINE and then modified for other databases (Supplementary File 1). A senior librarian reviewed the search strategies and provided advice to optimise the search.

Eligibility criteria

Inclusion criteria

We included observational studies that reported pregnancy intention as an exposure variable and the completion of the maternity continuum of care as an outcome variable. Quantitative or mixed-method studies published since 2000 reporting on SSA countries that were peer-reviewed, and published in English language were included. Furthermore, only articles that reported the adjusted odds ratios with a 95% confidence interval (CI) were included.

Exclusion criteria

We excluded studies that were conducted on maternity continuum of care dropout, or only reported on either antenatal care, institutional childbirth, or postnatal care but did not report the completion of the maternity continuum of care as an outcome variable. Additionally, qualitative studies, case reports, case series, commentaries, case studies, review articles, conference abstracts, and opinion pieces were excluded.

Study selection

Studies were screened using Covidence (Veritas Health Innovation, Melbourne, VIC, Australia) systematic review software. Following the removal of duplicates, the titles and abstracts of all identified records were screened against the eligibility criteria. Three reviewers (BDM, VV, AGB) were responsible for abstract and full-text screening. Two authors independently screened the studies initially by title and abstract, with conflicts resolved by a third reviewer (LS). The full texts of potentially eligible articles were retrieved and then systematically screened using the same process. The result of the search, screening, and selection process is shown in a PRISMA 2020 flow diagram.

Outcome measurement

The outcome of interest in this review was the effect of pregnancy intention on the completion of the maternity continuum of care. For this review, a complete maternity continuum of care was defined as a woman who had received antenatal care, use of skilled birth attendants during childbirth, and use of postnatal care within six weeks following childbirth [11]. In the primary studies, women were asked to state if their pregnancy was planned or unplanned. Accordingly, pregnancy intention was classified into intended and unintended. Intended pregnancy was considered when the woman reported that she planned or wanted her last pregnancy at the time of conception. Unintended pregnancy was characterised as unwanted pregnancy (no children are desired at all) or mistimed pregnancy (wanted at some time but occurred sooner than desired). Both were considered a pregnancy that the woman had not desired at the time of conception [40, 41].

Data extraction

Data were independently extracted in a standardised data abstraction format prepared using Microsoft Excel by two reviewers (BDM and VV), with any variance or unclear information resolved by discussion with the third and fourth reviewers (AGB, LS). All relevant information from each included study, such as author(s), study setting and design, publication year, sample size, study population, response rate, odds ratio with 95% CI for the association of pregnancy intention with maternity continuum of care, and the definition of maternity continuum of care was documented. The total number of participants was also extracted with the completion of the maternity continuum of care and pregnancy intention (intendeded or unintended).

Quality assessment

The Newcastle-Ottawa Scale (NOS) adapted for cross-sectional studies was used to evaluate the methodological quality of each study [42]. The NOS tool is used to assess three domains and enables studies to be rated with a maximum score of ten. The first domain focuses on the selection of study groups (sample size, representativeness of the sample, non-response rate, ascertainment of the exposure) and is rated with a maximum score of five. The second domain focuses on the comparability of groups and if the study controlled for the important factors that potentially influence the outcome of interest with a possibility of gaining a maximum score of two. The third domain is concerned with the assessment of ascertainment of the outcomes of interest (assessment of outcome, appropriateness of statistical test) with a maximum score of three. Finally, the scores for each study are tallied. The quality of the studies is rated based on the overall score. Studies with a score of 9 or 10 were deemed very-good quality, and those with a score of 7 or 8 were deemed to be good quality. Studies with a score of 5 or 6 were deemed satisfactory, with studies having a score of four or less being deemed unsatisfactory quality. Papers with a score of four or less were to be removed from the review due to poor quality. Two reviewers (BDM, AGB) evaluated the quality of each original study, with conflicts resolved through the third and fourth reviewers (LS, VV). While we could not identify the original source adapted specifically for cross sectional studies, similar previous studies have been used this tool [33, 43, 44].

Data analysis

The adjusted odds ratios as the measure of effect were extracted from each primary study. The log ORs and corresponding sampling variances were calculated for each study. Stata statistical software version 17 was used to execute all statistical analyses. The summary effect sizes with 95% CI were calculated and displayed graphically with forest plots and tables. The inverse of the variance was performed to calculate the weight of each study in the pooled estimate. A fixed-effect meta-analysis model was applied to compute the pooled effect of pregnancy intention on completion of the maternity continuum of care because no significant heterogeneity was detected. In this analysis, mistimed and unwanted pregnancy were used interchangeably if primary studies had reported one of the two instead of unintended pregnancy compared to planned or intended pregnancy.

The Cochran’s Q test was used to statistically estimate the variation among the primary studies and heterogeneity was quantified by I². Substantial heterogeneity was considered at p-value < 0.1 or I² > 50% [45]. Publication bias was estimated using Egger’s regression test for small-study effects at a p-value < 0.05 and checked with a visual inspection of the funnel plot symmetry [46]. We did a subgroup analysis based on the number of antenatal care visits that women had received during pregnancy as defined by the studies (i.e.,1 or more antenatal visits versus 4 or more antenatal visits). Furthermore, a sensitivity analysis was performed to evaluate the stability of results and the effects of outliers on the meta-analysis.

Results

Study selection

A total of 1,216 articles were identified from the database searches, with a further 11 studies sourced from manual searches of reference lists of relevant studies. After the comprehensive screening process, ten studies fulfilled the inclusion criteria and were retained for the meta-analysis. The reasons for articles exclusion were wrong outcomes, wrong intervention, insufficient data, and inconsistent exposure category (categorisation of the exposure variable as intended, mistimed, and unwanted; and then made intended pregnancy as a reference variable which made it difficult to get the adjusted odds ratio). Article screening process and the reasons for exclusion are provided in supplementary file 2. Article screening and the selection processes are illustrated in the PRISMA flow diagram (Fig. 1).

Fig. 1.

PRISMA flow diagram illustrating the studies screening process

Studies characteristics

All the studies included in the review were cross-sectional designs. The sample sizes of the selected articles ranged from 310 to 337,297, with an overall sample of 343,932 women. The studies were conducted from January 2013 to October 2021 and published between 2018 and 2022. Most of the studies (n = 7, 70%) were conducted in Ethiopia [24, 25, 47–51]. All the studies assessed pregnancy intention and maternity continuum of care retrospectively. Studies included in the review used different types of data collection tools, such as demographic and health survey questionnaires [52], structured questionnaires developed through literature reviews [24, 25, 47–51], or a questionnaire developed by the researchers [53]. The studies employed different random sampling techniques, such as a multi-stage random sampling [47, 51, 54], multi-stage cluster sampling [48], simple random sampling [24, 25, 50], multistage stratified sampling [52], and stratified random sampling [49, 53]. Summaries of the ten papers are shown in Table 1.

Table 1.

Characteristics of studies included in the systematic review and meta-analysis of the effect of pregnancy intention on the completion of maternity continuum of care in SSA, 2023

Authors	Study country	Study population	Definition of maternity continuum of care	Sample size	Response rate (%)	Pregnancy intention	Completion of maternity continuum of care		Adjusted odds ratio (95% CI)	Controlled confounding factors
							Yes	No
Ahmed et al. 2022 [51]	Ethiopia	Women who give birth within 12 months before the study period	Mothers who received ANC 4+, SBA, and PNC within 48 h after birth	823	99	Intended (n = 603)	92	724	1.3 (0.6, 2.6)	Women’s age, women’s educational status, women’s occupation, husband’s occupation, residence, decision on maternal and child health, wealth quintile, parity, the timing of first ANC, complications encountered during the last pregnancy, knowledge of danger signs of postpartum, birth preparedness and complication readiness plan, distance from health facilities
						Unintended (n = 213)
Asratie et al. 2022 [52]	Multi-country in SSA	Women who give birth and had children aged 0–36 months	Women who received ANC 1+, SBA, and PNC within 6 weeks postpartum	337,297	100	Intended (n = 306,423)	120,786	216,511	2.51 (1.82, 3.12)	Women’s age, women’s educational status, marital status, wealth status, exposure to media, residence, region, distance to the nearby health facility, health insurance, number of under 5 age children alive, parity, history of terminated pregnancy, the content of ANC, decision maker to attend maternal healthcare, use of medication during pregnancy, time to start ANC, site of ANC visit, informed about pregnancy complications, health care provider support,
						Unintended (n = 30,874)
Buli et al. 2022 [49]	Ethiopia	Women who gave birth within 6 months before the study	Mothers who received ANC 4+, SBA, and PNC within the first week after childbirth	630	99.5	Intended	84	252	3.29 (1.02,10.57)	Residence, women’s educational status, husband’s educational status, women’s employment status, monthly income, traveling time to reach health facility on foot, mode of transportation, maternal age at first pregnancy, number of children, knowledge of appropriate time for first ANC booking, early ANC booking within the first trimester, receiving adequate ANC services, attendance of pregnant women’s conference, place of ANC visits, informed about pregnancy-related complications, had birth preparedness and complication readiness plan, accompanied by partners, informed about postpartum danger signs, informed when to return for PNC before discharge
						Unintended	8	84
Cherie et al. 2021 [47]	Ethiopia	Mothers who gave birth and found between the first week to 6 months after childbirth	Women who had received ANC 4+, SBA, and had at least 3 PNC visits	732	100	Intended	57	253	2.45 (1.36, 4.4)	Residence, pre-pregnancy family planning use, counselling about family planning, exposure to media, women’s autonomy in making health care decisions, heard about PNC
						Unintended	25	397
Emiru et al. 2020 [48]	Ethiopia	Women who gave birth within 12 months before the survey date	Women who had received ANC 4+, SBA, and PNC within 48 h after birth	1337	95.8	Intended (n = 1062)	155	1126	2.09 (0.66, 6.69)	Women’s age, women’s educational status, women’s occupation, husband’s occupation, residence, religion, household wealth index, health facility readiness level, birth interval, history of poor foetal outcome, complications encountered during the last pregnancy, knowledge of danger signs of pregnancy, timing of first ANC, content of ANC, mode of delivery
						Unintended (n = 219)
Enos et al. 2021 [53]	Ghana	Women who give birth within 24 months before the study	Women who had received ANC 1+, SBA, and PNC along the continuum of care	310	100	Intended	203	107	2.1 (0.6, 7.73)	Women’s age, women’s educational status, residence, income status, health insurance, distance to the health facility, parity, exposure to media, had ANC4 + visits, delivery at a health facility
						Unintended
Haile et al. 2020 [25]	Ethiopia	Women who started ANC and had PNC within six or more weeks after childbirth	Women who had received ANC 4+, SBA, and at least one PNC within 6 weeks after childbirth	438	98.6	Intended	38	295	3.5 (1.1, 11.4)	Women’s education status, women’s employment status, perceived time to reach health facilities, pre-pregnancy contraceptive use, knowledge of key pregnancy danger signs, birth order, time for first ANC booking, birth preparedness and complications readiness plan
						Unintended	4	95
Sertsewold et al. 2021 [50]	Ethiopia	Reproductive-age women who gave birth within 12 months before the data collection period	Women who had ANC 4+, SBA, and at least one PNC within 6 weeks after childbirth	620	99	Intended	83	211	1.98 (0.42, 9.3)	Women’s age, women’s educational status, residence, monthly income, perceived time to reach health facilities, distance from health facility, mode of transport, perceived quality of care, women’s autonomy, knowledge of maternal healthcare, attitude towards maternal healthcare, birth order, history of contraceptive use
						Unintended	16	204
Shibanuma et al. 2018 [54]	Ghana	Reproductive-age women who experienced their latest pregnancy as a live birth or stillbirth	Women who had received ANC 4+, SBA, and PNC within 48 h, 2, and 6 weeks of childbirth	1500	93.4	Intended (n = 816)	111	1290	1.38 (0.46, 4.14)	Women’s age, women’s educational status, religion, partner’s age, partner’s education, number of children aged under 5 years, money prepared for delivery, held health insurance card, number of pregnancies, received support from a household member during and after delivery, any complications for women during pregnancy, or delivery or postpartum, any complications for the child
						Unintended (n = 585)
Shitie et al. 2020 [24]	Ethiopia	Mothers who gave birth within 12 months before the study	Women who had received ANC 1+, SBA, and PNC within 48 h after childbirth	651	95.4	Intended	250	243	3.33 (1.87, 5.9)	Women’s age, women’s educational status, marital status, residence, women’s occupation, exposure to media, husband’s education, husband’s occupation, women’s autonomy in health care decision-making, parity
						Unintended	29	99

ANC = antenatal care, SBA = skilled birth attendant, PNC = postnatal care

Quality assessment results

All studies used random sampling. Except for one, all studies had adequate sample size, and nine studies had adequate response rates. However, only two studies used validated tools for the ascertainment of the exposure. All studies clearly described and used an appropriate statistical test to analyse the data. Only one study assessed the outcome of interest with record linkage. It was noted that all studies controlled the most important factors and demographic characteristics that potentially influence the maternity continuum of care. Three studies were ranked as a very good quality, and the remaining seven studies were rated as good quality, so all were retained in the analysis (Table 2).

Table 2.

Quality assessment of studies using the Newcastle-Ottawa Scale adapted for cross-sectional studies, 2023

Authors, year	Selection (Maximum score of 5)				Comparability (Maximum score of 2)	Outcome (Maximum score of 3)		NOS score
	Representativeness of the sample (max. 1 score)	Sample size (max. 1 score)	Non-response rate (max. 1 score)	Ascertainment of the exposure (max. 2 scores)	The subjects in different outcome groups are comparable, based on the study design or analysis (Confounding factors are controlled)	Assessment of outcome (max. 2 scores)	Statistical test is appropriate (max. 1 score)
Ahmed et al. 2022	1	1	1	1	2	1	1	8
Asratie et al. 2022	1	1	1	2	2	1	1	9
Buli et al. 2023	1	1	1	1	2	1	1	8
Cherie et al. 2021	1	1	1	1	2	1	1	8
Emiru et al. 2020	1	1	1	1	2	2	1	9
Enos et al. 2021	1		1	1	2	1	1	7
Haile et al. 2020	1	1	1	2	2	1	1	9
Sertsewold et al. 2021	1	1	1	1	2	1	1	8
Shibanuma et al. 2018	1	1		1	2	1	1	7
Shitie et al. 2020	1	1	1	1	2	1	1	8

Effect of pregnancy intention on the maternity continuum of care

Ten studies incorporating 343,932 participants contributed to the meta-analysis on the effect of pregnancy intention on completing the maternity continuum of care. Meta-analysis of these studies revealed that the odds of completing the maternity continuum of care were two times higher (pooled OR: 2.12, 95% CI: 1.33, 3.36) in women who had intended pregnancy as compared to those with unintended pregnancy. In this analysis, no significant heterogeneity (I² = 0.00%, p = 1.00) was identified across the studies (Fig. 2).

Fig. 2.

Forest plot of the pooled effect of pregnancy intention on the maternity continuum of care in SSA

Subgroup analysis was conducted based on the number of antenatal care visits used by primary studies to define the completion of the maternity continuum of care (at least one antenatal care visit vs. four or more visits). The results of the three studies that defined the maternity continuum of care using at least one antenatal care visit showed that women with intended pregnancies had higher odds of completing the maternity continuum of care (pooled OR: 2.56, 95% CI: 1.39, 4.71) compared to those with unintended pregnancies. However, the results of the seven studies that defined completion of the maternity continuum of care using four or more antenatal care visits showed no difference in completion of the maternity continuum of care (pooled OR: 1.63, 95% CI: 0.80, 3.32) between women with intended and unintended pregnancies (Fig. 3).

Fig. 3.

Subgroup analysis of the effect of pregnancy intention on the completion of the maternity continuum of care by the number of antenatal care visits. ANC = antenatal care episodes, SBA = skilled birth attendant during childbirth, PNC = postnatal care episode before 6 weeks after childbirth

Publication bias

The results of both Egger’s linear regression test and Begg’s rank correlation test indicated that there was no statistically significant publication bias. The scatter of the studies in the funnel plot demonstrated that publication bias was not observed (Fig. 4).

Fig. 4.

Funnel plot of the included studies

Sensitivity analysis

Sensitivity analysis of the included studies was performed using a fixed effect model to assess the stability of results and the effect of outliers on the meta-analysis. The result shows that there was no strong evidence of individual study influence on the pooled results (Table 3).

Table 3.

Sensitivity analysis for the study effect of pregnancy intention on the completion of maternity continuum of care in SSA

Study ID/ Author, year	Estimate	[95%Confidence Interval]
Ahmed R et al. 2022	2.4162951	1.4329036	4.0745807
Asratie M H et al. 2022	1.7735143	0.91662556	3.4314477
Buli T D et al. 2023	2.1066282	1.3228363	3.3548236
Cherie N et al. 2021	2.0839372	1.2814891	3.3888652
Emiru AA et al. 2020	2.1161008	1.3243159	3.3812795
Enos J Y et al. 2021	2.1157479	1.326221	3.3752966
Haile D et al. 2020	2.1068153	1.3233635	3.3540826
Sertsewold S G et al. 2021	2.1170218	1.3289025	3.3725436
Shibanuma A et al. 2018	2.1774986	1.3493922	3.5138042
Shitie A et al. 2020	2.0626242	1.2816175	3.3195696
Combined	2.1154812	1.3313128	3.3615396

Discussion

This systematic review and meta-analysis summarises the available data on the effect of pregnancy intention on the completion of the maternity continuum of care in SSA women. A total of ten studies with adjusted effect estimates were included. Among the studies included in the review, three studies with a total sample of 338,228 defined the completion of the maternity continuum of care as having at least one antenatal care visit, skilled birth attendant, and postnatal care, while the other seven studies with a total sample of 5,704 used four or more antenatal care visit, skilled birth attendant, and postnatal care. The subgroup analysis of studies defining maternity continuum of care completion with at least one antenatal visit showed a significant positive effect of pregnancy intention on completion of the maternity continuum of care. In contrast, studies using four or more antenatal visits to define continuum of care completion found no difference between women with intended and unintended pregnancies. The variation in sample size likely influenced the subgroup analysis. Smaller sample sizes produce wider confidence intervals, indicating greater uncertainty and lower precision in effect estimates, which may reduce the ability to detect significant differences [55, 56].

Notably, the overall meta-analysis showed a significant positive effect of pregnancy intention on the completion of the maternity continuum of care. This highlights the importance of planning a pregnancy and in maternity care engagement. Importantly, the WHO recommendation suggests a shift from a minimum of four ANC visits to a minimum of eight ANC contacts for reducing maternal and perinatal deaths, with the first contact taking place within 12 weeks of gestation [57]. However, none of the studies included in this review used eight or more ANC contacts for defining the completion of the maternity continuum of care. Countries hesitancy to adopt the new guidelines or late implementation of the recommendations is likely to result in a delay in obtaining data that specifies eight or more ANC contacts [58, 59]. There needs to be strong advocacy and support for LMICs to follow current guidelines for reducing maternal mortality rates and achieving SDGs. To encourage this, further analysis of the impact of pregnancy intention and other factors on the completion of the maternity continuum of care incorporating the minimum of eight ANC contacts is needed.

The review showed that women with intended pregnancy were more likely to complete the maternity continuum of care. Research has shown that unintended pregnancy was a major factor in the reduced use of essential maternal healthcare services during pregnancy, childbirth, and postpartum [26, 33, 60, 61]. This is further supported by previous systematic reviews and meta-analyses assessing the completion of the maternity continuum of care and its determinants in Ethiopia [21, 22]. The observed effect of pregnancy intention on completing the maternity continuum of care could be linked to women with unintended pregnancies being unaware of their pregnancy, or giving it less priority, which can reduce their engagement with essential maternal healthcare services. Evidence has shown that mothers who planned their pregnancy were more likely to realise their pregnancy status early and engage with recommended maternal healthcare services in a timely manner [27, 28, 61, 62]. In contrast, women with unintended pregnancies may delay or avoid accessing maternity care to keep their pregnancies secret due to community norms or fear of social stigma [63]. Furthermore, women with unintended pregnancies are more likely to have low social support and self-efficacy [64], making it difficult to identify healthcare needs, seek, access, and use maternity care services.

Evidence has highlighted that identifying the challenges and opportunities for maternal healthcare service use is vital for achieving universal access to maternal healthcare services and the SDGs, particularly in countries where coverage of maternity care remains low [65–68]. This review found that intended pregnancy could be an important factor in enhancing the completion of the maternity continuum of care. Therefore, preventing unintended pregnancies by improving access to sexual and reproductive health education and services, and promoting contraceptive use in SSA countries is essential [69–71]. Furthermore, examining the barriers and enablers for accessing and using contraception services to reduce unmet needs and enhance engagement is also necessary [72–76]. On the other hand, increasing women’s knowledge about the importance of pregnancy planning and early pregnancy detection through effective pre-conception care would support the timely initiation of engaging with the maternity continuum of care [73, 77]. Preconception care provides women the opportunity to receive counselling about pregnancy planning and interventions that improve outcomes for mothers and newborns, regardless of pregnancy status or intention [78–80].

The findings of this study underscore the need to discuss with women about their pregnancy intentions and provide health education emphasising the benefit of completing the maternity continuum of care. Furthermore, a robust pathway that explicitly reaches out to women with unintended pregnancies could be established to improve engagement with the maternity continuum of care. Evidence suggests that community health workers can track women to initiate and continue care along the maternity continuum of care [81–83]. While this analysis was restricted to the effect of pregnancy intention on the maternity continuum of care completion, it is important to recognise that pregnancy intention is not the only factor influencing care engagement. There are also several individual, relationship, community, and societal level factors that influence the maternity continuum of care [15, 84–86].

Strengths and limitations

This review involved a systematic search of several databases to retrieve all relevant articles and engaged multiple reviewers to ensure the methodological rigor of the review. In addition, this review provided the first pooled quantitative estimate of the effect of pregnancy intention on the completion of the maternity continuum of care in SSA. However, it is necessary to interpret the findings with caution regarding the following limitations. Firstly, as all the included studies employed a cross-sectional study design, certainty in the causal effect of pregnancy intention on the completion of the maternity continuum of care could not be established. Secondly, some studies defined the maternity continuum of care with at least one ANC visit instead of four or more visits. To address this variation, a subgroup analysis was performed based on the number of ANC visits. Thirdly, we defined the completion of the maternity continuum of care as including at least one PNC visit, due to variations in the timing and frequency of PNC visits used in the included studies. Finally, we included only peer-reviewed articles published in English; hence, there is a possibility that some potentially relevant studies published in a language other than English may have been missed.

Conclusions

The results of this review revealed that intended pregnancy has a significant positive effect on the completion of the maternity continuum of care. Hence, policymakers and healthcare providers should encourage reproductive health services that focus on improving women’s health in the preconception period when pregnancy is desired or strengthening contraceptive use and counselling to help prevent unintended pregnancies. Furthermore, interventions designed to prevent unintended pregnancies and promote planning for future pregnancies can further encourage the completion of the maternity continuum of care. Addressing community and cultural barriers is crucial for enhancing engagement with the maternity continuum of care, as these factors can discourage women with unintended pregnancies from seeking necessary services. Furthermore, community norms and perceptions around contraception significantly influence women’s ability to make informed pregnancy decisions, impacting their reproductive choices and contraceptive use. Moreover, prospective primary research which adheres to the new recommendations of minimum eight ANC contacts is needed to produce better evidence of factors that impact on the completion of the maternity continuum of care.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

ANC

Antenatal care

LMCs

Low- and middle-income countries

MMR

Maternal Mortality Ratio

NOS

Newcastle-Ottawa scale

PNC

Postnatal care

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

SBA

Skilled birth attendant

SSA

Sub-Saharan African countries

SDG

Sustainable Development Goal

WHO

World Health Organization

Author contributions

All authors developed the conception of the review and study design. BDM conducted the literature review, study screening, data extraction, quality assessment, data analysis, interpretation of results, and drafting of the manuscript. VV, AGB and LS contributed to study screening, quality assessment, data extraction, assist data analysis, and critically reviewed the manuscript. All authors read and approved the final manuscript.

Funding

The first author is supported by Deakin University with a PhD research scholarship.

Data availability

All relevant data is included either in the manuscript or as supplementary files.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.