Health system responsiveness for maternal healthcare services in East Africa: a mixed-methods systematic review

Abstract

Background

Health system responsiveness (HSR) is the ability to respond to universal legitimate expectations of service consumers. This contributes to achieving short and long-term health sector goals, such as universal health coverage. However, no comprehensive summary of evidence exists on how HSR can achieve universal maternal health services. Therefore, we aim to examine the successes, challenges, and strategies of HSR toward universal maternity care in East Africa using a mixed-methods systematic review.

Methods

We conducted a mixed-methods systematic review of studies published from 1 January 2020 to 8 June 2024. Articles were searched using six databases: Medline, Web of Science, Scopus, CINAHL, PsycINFO, and ProQuest. We used three main search terms: HSR, maternal health, and East Africa. A mixed-methods appraisal tool (MMAT) was used to assess the quality and methodological validity of the studies. We then analysed and synthesised the data using the World Health Organization (WHO) HSR framework components.

Results

A total of 72 articles (23 quantitative, 15 mixed-method, and 34 qualitative articles) were included. This review revealed that the responsiveness of obstetric services ranged from 45.8 to 75.6%. Challenges contributing to poor HSR, include limited decision-making autonomy, breaches of confidentiality, non-dignified care, poor communication, delay in care, and unhygienic maternity care. However, maintaining confidentiality, providing abuse-free care, permitting companions, and ensuring informed consent improved responsiveness of maternity care.

Conclusion

The included studies reported wide ranges of the overall HSR and its specific domains for maternity care. Unresponsive health system remains a significant challenge for achieving universal access to maternal healthcare services. As such, HSR continues to hinder quality of maternal healthcare and its utilisation. Ensuring responsive maternity services requires continuous attention from policymakers, managers, and healthcare providers. Strengthening HSR will promote inclusive, effective, and respectful care that safeguards women’s rights and ensures equitable care regardless of their circumstances.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-025-07995-1.

Background

In 2020, approximately 800 women died each day due to pregnancy and/or childbirth-related complications, which is equivalent to one woman dying every two minutes [1]. About 95% of obstetric deaths worldwide also occurred in Low-and Lower-Middle Income Countries (LLMICs) in 2020 [1, 2]. Specifically, Sub-Saharan Africa (SSA) alone covers 70% of the global maternal deaths [1, 2]. East Africa also had Maternal Mortality Ratio (MMR) of 351 maternal deaths per 100,000 live births [2]. Despite this, MMR globally dropped by 34% from 2000 to 2020 [2]. In 2015, it was estimated that achieving an MMR of fewer than 70 deaths per 100,000 live births by 2030 would require an average global annual reduction rate (ARR) of 5.5% [3]. However, the actual ARR of 2.1% from 2000 to 2020 falls far short to meet the Sustainable Development Goal (SDG) an 11.6% annual reduction is now needed from 2021 to 2030 [2].

Effective health systems are essential to improving health outcomes [4] and achieving Universal Health Coverage (UHC). Universal health coverage is an approach to providing quality essential health services to all without any financial hardship [4]. The United Nations (UN) Member States have agreed to achieve UHC (SDG target 3.8) by 2030 [5]. Progress toward the health system goals depends on how well the health systems carry out their vital functions, including service provision, resource mobilization, health financing, and stewardship [6]. Health system responsiveness (HSR) entails examining an individual’s actual interactions with their health system to meet their universally legitimate expectations of the non-medical aspects of the healthcare system [7, 8]. The HSR framework includes autonomy, confidentiality, dignity, choice of provider, basic amenities, communication, prompt attention, and social support [7, 9, 10] aspects of the healthcare system and consumer interaction.

A responsive health system anticipates and adapts to the existing and future health needs of the population for better health outcomes [11]. Responsiveness is the means for attracting consumers to the healthcare system and protects the rights of patients to access adequate and timely healthcare [7]. Responsiveness addresses the ethical needs of consumers and consumer satisfaction between the health system and clients [12]. Health system responsiveness varies across health facilities, service types, and nations, with research from Germany and Iran demonstrating these variabilities in HSR. In Germany, the proportion of inpatient and outpatient mental healthcare service users receiving responsive services were 22% and 15%, respectively [13]. A study in Iran suggests a significant proportion of inpatients (58.4%) received responsive health services [14]. Also, only 41.8% of obstetrics and gynecology patients in Iranian teaching hospitals received responsive healthcare services [15]. Studies from Tehran among inpatients suggested dignity and confidentiality were the best-performing HSR domains, with a score of 78%, and the worst-performing domain of autonomy, with a score of 62% [16]. Research in Ethiopia also showed just over half (53.0%) of maternity care consumers in the Hadya zone received responsive skilled facility birthing services [17].

Appropriate maternal healthcare services before, during, and following childbirth can save the lives of women and newborns [1]. Health systems play a key role in improving the population’s health status. Health systems, particularly in LLMICs, face serious challenges regarding financial sustainability, equity, universal access, quality, and responsiveness. However, there is no comprehensive evidence of whether the health system responds to service users’ legitimate expectations for universal maternal healthcare services in East Africa. Our review specifically focused on East Africa because East African countries share common characteristics across several dimensions, including cultural and linguistic diversity, political instability and/or conflicts [18] and uneven educational access [19]. Therefore, we explored the challenges, successes, and strategies for HSR toward universal maternal healthcare services in East Africa using a mixed methods systematic review. In this review, universal maternal healthcare service refers to the provision of quality and equitable maternity care for all women without any financial risk. This systematic review was designed to answer the following research questions: (1) What is the magnitude of HSR and its domains for maternal healthcare services in East Africa; (2) What is the existing evidence on the impact of HSR on universal maternal health services in East Africa as per the WHO framework components; and (3) What strategic directions exist to demonstrate how to build a responsive health system for universal maternal health coverage in East Africa?

Methods and materials

Protocol registration and reports

We followed the Joanna Briggs Institute (JBI) methodology for systematic reviews of mixed methods studies. This review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [20]. The review protocol was registered with the International Prospective Register of Systematic Reviews [CRD42024554426].

Eligibility criteria

We included articles published from 1 January 2020 to 8 June 2024. We used January 2020 as the starting period when Coronavirus Disease of 2019 (COVID-19) was declared a Public Health Emergency [21], because the healthcare system was significantly impacted by the COVID-19 pandemic. COVID-19 served as a real-time stress test that exposed both the strengths and weaknesses of HSR, especially in meeting people’s needs and expectations. Evaluating HSR after COVID-19 pandemic provide the opportunity to explore the sustainability or the challenges of health care in building more inclusive and resilient health systems which in turn affect access to universal health care. Despite we acknowledged the impact of COVID-19 on HSR, we only used the COVID-19 pandemic as a reference point for our review. As such, we did not use COVID-19 as inclusion or exclusion eligibility criteria since our study included any studies that examined the challenges, successes, and strategies for HSR in achieving universal maternal healthcare. As a result, articles published since January 2020 and fulfill the eligibility criteria were included in the review, even if articles contained information and data collected before COVID-19 pandemic. In this study, we only included articles published in English language. A detailed explanation of the eligibility criteria is shown in Table 1.

Table 1.

Inclusion and exclusion criteria

Inclusion

Exclusion

Published in English from 1 January 2020 to 8 June 2024 All full-text qualitative, quantitative, and mixed study articles that assessed the level of health system responsiveness and its domains for maternity care and exploring the challenges, successes, and strategies of health system responsiveness toward universal maternal healthcare services, including antenatal care, institutional delivery, postnatal care, and continuity of maternity care Articles in 14 East African countries, including Burundi, Comoros, Djibouti, Ethiopia, Eritrea, Kenya, Madagascar, Rwanda, Seychelles, Somalia, South Sudan, Sudan, Tanzania, and Uganda [105, 106]

Quantitative studies that did not explicitly report the overall proportion of health system responsiveness or at least one of its specific domains related to maternity care Articles, including perspectives, commentary, expert opinions, conference abstracts, debates, conference reports, letters to the editor, editorials, reviews, gray literature, preprints, and interventional studies Articles published in predatory journals Articles published before January 2020

Databases and searches

We searched articles from Medline/Ovid, Scopus, Web of Science, CINHAL, PsycINFO, and ProQuest databases. The main search terms were health system responsiveness, maternal health, and East Africa. We constructed the search strategies using Medical Subject Headings (MeSH) for each broad domain and other associated search terms by combining “AND” and “OR” Boolean operators as appropriate (Supplementary Table 1).

Selection of studies

All retrieved articles were exported into Covidence software to remove duplicates and for title and abstract screening. Two authors (AD, MDM) independently reviewed articles’ title and abstracts to identify those meeting the inclusion criteria. These two authors also independently read the full texts and decided whether articles were to be included for data extraction. Any differing opinions during article screening and full-text review were resolved either through discussion or, when resolution was not achieved, via input from the senior authors (JHS, MMW).

Quality appraisal and data extraction

We retrieved qualitative, quantitative, and mixed-methods studies and assessed their methodological validity using the mixed-methods appraisal tool (MMAT) [22] (Supplementary Table 2). An independent quality appraisal (AD) was conducted of the included articles, with extracted data verified by a senior author (JHS). The data extraction template included: first author’s surname, year of publication, country/s, setting, aim, area of interest, study participants, sample sizes, data collection methods, analysis, and key findings.

Data analysis

We conducted meta-synthesis of the challenges, successes, and strategies of HSR toward universal maternal health services. Meta-synthesis is a data synthesis method used to combine and interpret findings from multiple qualitative studies, aiming to provide a deeper nuanced understanding of the phenomenon under investigation. We also employed convergent segregated mixed-methods data synthesis approach [23], analysing quantitative and qualitative data separately, and then integrating the findings in the discussion to generate a comprehensive evidence. Due to a lack of uniformity in measuring HSR across the studies, we could not perform a meta-analysis. Descriptive characteristics and key findings of individual studies were reported in tables. NVivo software was used to categorise and code the extracted data using eight WHO health system responsiveness framework components. Explanations of the HSR framework components [7, 9] are provided in Table 2.

Table 2.

Explanations of health system responsiveness domains

Domains	Explanations of the terms
Dignity	The right of a care seeker to be treated as a person rather than simply as a patient.
Autonomy	Self-directing freedom and informed choice.
Confidentiality	The information relating to the patient and their illness should not be divulged (disclosed) during care, except in specific contexts, without the prior permission of the patient.
Prompt attention	Provision of care within reasonable periods, even in the case of non-emergency health care problems.
Basic Amenities	Healthcare aspects related to physical infrastructure and a conducive care environment.
Social support	Regular visits by relatives and friends and religious practices that do not hinder health facility activities.
Choice of care provider	Service users’ ability to choose between care providers and/or institutions.
Communication	Clarity and interaction between service users and providers.

Results

Study characteristics

The searches identified 6,198 articles from databases. After screening and full-text review (Fig. 1), 72 articles met our inclusion criteria. These included 23 quantitative, 15 mixed-methods, and 34 qualitative articles. Three studies (two quantitative, one mixed-methods evaluation) reported on the overall HSR and each of its specific framework components. Additionally, one qualitative study conducted in the pastoral community of Ethiopia used the HSR framework domains to report its findings. Most included articles were from Ethiopia (n = 51, 70.8%), with seven from Tanzania, nine from Kenya, and the remaining five from other East African countries. The study populations in the included studies were diverse, including women, men, religious leaders, Traditional Birth Attendants (TBAs), Health Development Armies (HDAs), religious leaders, local leaders, healthcare providers (nurses, midwives, doctors, etc.), Health Extension Workers (HEWs), maternal health coordinators, healthcare managers, and policy experts (Supplementary Table 3).

Fig. 1.

PRISMA flowchart, 2024

Overall health system responsiveness

The challenges, successes, and strategies of HSR and each of its domains toward universal maternity healthcare services were reported in Supplementary Table 4. The overall responsiveness of health systems to obstetric care ranged from 45.8 to 75.6% [17, 24, 25]. Several factors have been linked to responsive maternity care, including maternal age, residence in urban areas, obstetric complications, birthing by caesarean section, referral during labour, the duration of labour, and maternal satisfaction during maternity care [17, 24] (Supplementary Table 4). The articles included in the overall HSR and across its domains were indicated in Table 3.

Table 3.

Contributing articles included in the overall HSR and across its domains

Health system responsiveness and its domains	Contributing studies
Autonomy	[10, 17, 24–38 ]
Confidentiality	[17, 24, 25, 27, 36, 39–59]
Dignity	[10, 17, 24–28, 31–33, 35–37, 39, 44, 46–50, 52, 53, 57, 59–76]
Basic amenities	[10, 17, 24, 25, 28, 29, 32, 37, 39, 54, 58, 62, 63, 67, 68, 71, 75, 77, 78]
Choice of care providers	[10, 17, 24, 25, 28, 31, 36, 38, 56, 62–66, 68, 69, 71, 72, 75, 78, 79]
Communication	[10, 17, 24–27, 29, 31, 32, 34, 35, 37, 38, 43, 52, 53, 56, 58, 61–63, 65, 67, 71, 73, 74, 78, 80–85]
Prompt Attention	[10, 17, 24, 25, 29, 36, 37, 39, 42, 43, 45, 56, 62–64, 66, 68, 69, 71, 73, 75–77, 83, 86–91]
Social support	[10, 17, 24–26, 28, 33–35, 37, 53, 55, 64, 66, 72, 76, 81, 83, 86, 92, 93]
Overall health system responsiveness	[17, 24, 25]

This review illustrated that respectful, non-discriminatory, and rights-based care, along with welcoming behaviours by staff, enhanced responsiveness and support the achievement of universal maternity care. Conversely, where there is a loss of women’s autonomy, exclusion from decision-making, and lack of informed consent, this weakened health system responsiveness and hindered access to universal maternity care. Disrespectful practices by healthcare providers during maternity care, including abuse, discrimination, and denial of companion support, reduced service quality and discouraged women from utilizing maternity care. High client load, poor hygiene, workforce shortages, and lack of provider choice at health facilities further compromised responsiveness and access to universal maternity care. Communication challenges, including language barriers and use of medical jargon words, weaken provider-client relationships. Delays in care and long waiting times also resulted in poor responsiveness of maternity care services. We also described the magnitudes, strengths, and areas of improvement across each domain of HSR for maternal healthcare services in Table 4.

Table 4.

Magnitude, strengths, and areas of improvement across each domain of HSR for universal maternal healthcare services in East Africa

Domains	Magnitude	Strengths	Areas of improvement
Autonomy	Women’s autonomy for maternity care: 57.9–66.8% [17, 24, 25].	Obtaining consent of women before doing any procedures and examinations [33–35]. Respecting women’s right to choice of care provider and refusal to care [36]. Involving women in decision-making and sharing information [34, 37, 38].	Conduct physical assessments and procedures without explaining the procedure in non-emergency situations [26–29]. Undermined women’s decision-making power and right to refuse unfavourable conditions [28]. Low involvement of woman in decision-making during caesarean delivery [29, 30]. Unable to involve women in the decision of delivery position, having companions during labour, and procedures [10, 31, 32].
Confidentiality	Confidentiality of maternity care: 15–89.3% [17, 24, 25, 39–45]. Other studies reported non-confidential maternity care: 35–66.2% [46–51].	Midwives never share women’s information with non-concerned individuals [52].	Violating the privacy of information during maternity care [27, 36, 43, 53–59]. Sharing a single room by two or more women [36, 53, 56, 58, 59]. Absence of screens or partitions between delivery couches [54, 55].
Dignity	Dignified maternity care: 70.8–80% [17, 24, 25, 39, 44, 53]. Other studies reported non-dignified maternity care: 25.5–60.4% [46–50, 60].	Initiation of non-discriminatory care [35]. Respecting the right to equality and equitable care, the right to liberty and freedom from coercion [36]. Practicing abuse-free care [33, 69]. Covering the maternal perineum and maintaining privacy during care [37, 61].	Physical abuse, including beating, slapping, pinching, physical assault, and forceful opening of women’s legs [27, 28, 36, 61–65]. Lack of privacy during childbirth and physical assessments caused humiliating and disappointing, causing anxiety, additional pain, and discomfort to women [10, 28, 32, 57, 59, 63, 66–69]. Verbal abuse, including shouting, insulting, yelling, verbal harassment, unpleasant language, lack of compassion, and blaming [10, 26–28, 31, 32, 36, 39, 52, 59, 61–66, 69–72]. Providers perception on slapping or pinching, holding a woman forcefully on a delivery bed, and verbally threatening were acceptable to avoid adverse birth outcomes [33, 59, 70]. Declined women’s health services [25, 72]. Unfriendly maternity care [31, 68, 73]. Unfair healthcare service provision and stereotyping practices [10, 27, 59, 71]. Lack of sympathy, lack of hospitality, poor receptiveness, neglected care, and negative attitudes of healthcare providers [10, 28, 64, 74, 75].
Basic amenities	Quality of basic amenities: 45.8–65.8% [17, 24, 25].	Use of sterile equipment and clean bed linen [29, 37, 67]. Healthcare facilities keep their compound clean and gave sufficient food to women [29, 62].	Poor hygiene of delivery beds or rooms, dirty washrooms, unhygienic health facilities, and unhygienic practices of healthcare workers and support staff [10, 28, 62, 63, 67, 71, 77]. Poor infection prevention protocols, poor room arrangements, and non-favourable working environments [29, 68, 75]. Lack of water, inadequate feminine hygiene products, cotton wool, sanitary pads, sheets, detergents, and unstable electric sources with no backup [10, 25, 28, 54, 62, 77, 78]. Inadequate and poor food quality [63, 77]. • Lack of enough bed and bed sheets, blankets, shower rooms, personal protective equipment, delivery coaches, bedpan, and waiting rooms [32, 39, 75, 78]. Lack of a maternity-specific operating theatre for caesarean Sect. [58].
Choice of care providers	Choice of healthcare provider: 41.6–68% [17, 24, 25].		Women’s provider preferences were not maintained [10, 25, 38, 56, 66, 78, 79]. Concern of women by male healthcare provider [10, 56, 66, 79]. Lack of experience, expertise, and attitudes of providers [72]. Frequent changes in service providers, particularly during ANC visits [75]. Disruptions in service operations, loss of trained staff, increased staff fatigue and workloads, and negligence in care [31, 62, 64, 68, 75, 78]. Poor health workers’ discipline and readiness [68, 71]. Weak provider and women relationships [65]. Unable to employ specialists and other healthcare workers [63]. Absence of supervision by senior healthcare professionals [68]. Undergoing frequent examinations [69]. Lack of supervision [28].
Communication	Effective communication: 46–76.3% [17, 24, 25, 43, 53, 73, 80].	Friendly welcome with polite language, introducing themselves, calling clients by name, positive non-verbal body gestures, and establishing an interpersonal connection [32, 34, 35, 37, 61, 62, 67]. Care providers provided their phone numbers for continuous communication [52, 71]. Trust between care providers and women [65, 84, 85]. Making women feel well before care, receiving care from the same care provider, and calling women by name [32, 34, 38, 65].	Communication gaps or inadequate information [25–27, 29, 31, 52, 53, 63, 67, 81]. Poor care provider-client relationships and the use of medical jargon words or other non-local languages during discussion [10, 26, 31, 65]. Allowed only a one-way hierarchical communication [62]. Unnecessary referrals, poor referral linkages or communication between different levels, and lack of midwives’ decision-making power on referrals [78, 82]. Misinformation, poor interaction, fearful news about COVID-19, and providers’ rude and abusive speech [56, 58, 65, 74, 83].
Prompt Attention	Prompt attention (timely) maternity care: 62.1–96.3% [17, 24, 25, 42, 45, 76, 86–89].	Timely care provision, availability and readiness of healthcare workers [37, 62, 69].	Far geographical distance from healthcare facilities [66, 71, 77, 90]. Long wait times for care and delays in receiving care [10, 29, 36, 39, 43, 56, 62, 63, 66, 68, 71, 73, 75, 90, 91]. Lack of staff and high workload [29, 36, 39, 90]. Closure of healthcare facilities during the night, unreasonable delays, providers’ absenteeism or late entrance from work, and lack of equipment and supplies [56, 66, 75]. Non-accessible roads, challenging topography, lack of transportation options, and inadequate number of ambulances [56, 64, 66, 71, 73, 83, 90]. Transportation bans or lockdowns, especially during emergencies like pandemics [83].
Social support	Women allowed social support or companionship during maternity care: 13.8–69% [17, 24, 25, 55, 76, 86, 92]	Respect the right to have a birthing companion [33]. Involving companions enhancing confidence in difficult situations, providing emotional support, facilitating referrals and continuity of care, persuading uncooperative women, and linking the midwife’s instructions with the woman’s adherence [28, 34, 35, 55, 93]. Birth companions identify complications, inform medical staff, and bring essential supplies [28].	Women did not have companions, which made their stay at health facilities unfavourable [10, 26, 28, 37, 53, 55, 81, 83]. Providers not allowed companions because of fear of witnesses during incidents and unsupportive administration [55]. Worsening of the coronavirus during the pandemic periods [81]. Cultural preferences incompatible with health facility practices [66]. Absence of celebration after childbirth at health facilities [64].

Autonomy

Seventeen articles described self-directing freedom and women’s informed choice about their maternity care. The proportion of women exercising autonomy in child birthing service ranged from 57.9 to 66.8% [17, 24, 25], indicating a moderate level of participation in decision-making. Qualitative findings suggested although healthcare providers were expected to adhere the standards, healthcare providers conducted procedures without obtaining informed consent and providing adequate explanation of the procedure [26–29]. The loss of women’s autonomy in maternity care, which undermined their decision-making power and right to refuse unfavourable conditions [28], reflected poor health system responsiveness. Evidence from Ethiopia and Kenya shows limited decision-making power and lack of informed consent from women for their caesarean sections, contributing to mistrust in public healthcare services [29, 30]. A woman who delivered at a private facility mentioned that:

“…Like for me, when I had my first pregnancy, there was a lady who told me since it was my first pregnancy, I should not go to [Major Maternity A] because if I go there they will just take me to the theatre and operate on me and so I was very afraid…” (FGD, Mother of two who delivered at a private facility B, performing a procedure without obtaining consent affected service utilisation, Oluoch-Aridi et al.) [29].

Excluding women from decisions regarding childbirth options, companionship during labour, and medical procedures [10, 31, 32] posed a significant challenge to maternity healthcare services. However, obtaining the consent of women before doing any procedures and examination [33–35] maintains women’s autonomy. Explaining the procedure and obtaining consent creates an interpersonal connection, establishes rapport, and avoids blame or legal actions [34]. Respecting women’s right to information, informed consent, choices, and refusal [36] helps to maintain women’s autonomy during maternity care. Involving women or their families in decision-making and sharing information regarding their health services empowers them to improve continuity of care, adherence, and referrals [34, 37, 38]. An urban in-depth interview (IDI) participant reported that:

“No women must undergo any procedure without her informed consent. Women have the right to know and willingly consent to or refuse a procedure. The procedure might be important, but her consent is necessary.” (Urban IDI, performing a procedure without obtaining consent is not acceptable, Adinew et al.) [33].

Obtaining informed consent from women prior to examinations and procedures were essential for upholding their autonomy throughout maternity care [30, 32, 34, 37]. Ensuring the provision of clear and comprehensive information, including the use of consent forms translated into the local languages of service consumers, further facilitated women’s active participation in decision-making regarding their care [30, 37].

Confidentiality

Twenty-six articles described the ability to maintain confidentiality of a woman’s health information during maternity care. Confidentiality in maternity care ranged widely, with maintained confidentiality reported between15% and 89.3% [17, 24, 25, 39–45] and other studies reported confidentiality breaching in maternity care between 35% and 66.2% [46–51]. Midwives assured they never share women’s information with non-concerned individuals [52]; for example, a 32 years old experienced midwife mentioned that:

“(…) the information they provide is kept confidential, the information women provide to us remains with us and women will not hear them on the street or elsewhere (…).” (IDI, a 32 years old midwife with 7 years of experience, breaching of confidentiality could be the concern of women, Heri et al.) [52].

Qualitative studies also suggested ensuring the privacy of information was a challenge during maternal healthcare service [27, 36, 43, 53–59] due to the nature of the care. Sharing a single room by two or more women due to a shortage of spaces within maternity wards was an obstacle to care providers’ ability to provide confidential information to the women [36, 53, 56, 58, 59]. Lack of screens and absence of partitions between delivery couches were also a barrier to maintaining the confidentiality of a woman because of the open and narrow nature of the labour wards or child birthing rooms [54, 55]. An IDI study participant reported that:

“There are many challenges. Let us talk about infrastructure and hospital capacity. When we receive many clients two women share the same bed which interferes with the privacy of the client, at that time the only thing to do as healthcare provider is to maximize the benefit from each one.” (IDI, Participant 18, poor privacy due to lack of adequate space in maternity wards breaches confidentiality, Uwamahoro et al.) [36].

Continuing to uphold women’s privacy during their maternity care was important to maintain the confidentiality of women’s healthcare information [43, 52, 53]. Building or renovating additional rooms for maternity care allowed one woman admitted per room to improve privacy and confidentiality [53]. Modifying service rooms in a way that can maintain client’s confidentiality and privacy were identified as an effective measure [43].

Dignity

Forty-one articles described dignified care during maternity care. The proportion of women receiving dignified care ranged from 70.8–80% [17, 24, 25, 39, 44, 53], while other papers reported non-dignified maternity care was reported from 25.5–60.4% [46–50, 60]. The qualitative findings also implied beating, slapping, pinching, physical assault, and forcefully opening women’s legs were common physical abuses practised during childbirth [27, 28, 36, 61–64]. A participant proudly explained that:

“Myself and a few of my colleagues at our workplace are nicknamed commandos because when we are on shift, we never end up with birth asphyxia. We are very tough with women during labour. If women fail to collaborate, they could be slapped, pressure applied to rescue her life and that of a child” (IDI, physical abuse affected dignity, Mwasha et al.) [27].

Physical abuse during maternity care hurt and compromised the ability of care providers’ to act in a moral way [65]. Lack of privacy during child birth and physical assessments caused humiliation, anxiety, pain, and discomfort [10, 28, 32, 57, 59, 63, 66–69]; for example, a 39-year-old woman accompanied her neighbour to health facility stated that:

“.when my neighbour gave birth in the facility, the midwife invaded her privacy and conducted too many vaginal examinations, which was dehumanizing and shameful. So, how am I able to use the treatment room knowing that my friend had a tough experience there? I preferred to give birth at home with the assistance of a TBA, as she can give me more privacy and control over the situation than the midwife at the health facility” (IDI, Para 6, 39-year-old woman, frequent invasion of women’s body affected privacy and dignity, Zepro et al.) [10].

In addition, a 32-years-old mother described her experience, as follows:

“. there were no curtains to cover my body, the window was broken so that everyone can see you from outside or inside of the delivery room.generally, I wasn’t that much satisfied with their care” (IDI, a 32-year-old mother, absence of infrastructure like curtains affected privacy and dignity of woman, Dagnaw et al.) [32].

Verbal abuse, including shouting, insults, yells, verbal harassment, use of unpleasant language, and lack of compassion undermined responsive maternity care by degrading women and violating their dignity [10, 26–28, 31, 32, 36, 39, 52, 59, 61–66, 69–72]. Healthcare providers often belittled and verbally abused women during labour, criticizing their performance and making derogatory remarks about their pregnancy choices, disabilities, and future childbirth capabilities [10, 59]. Some articles, however, reported slapping, pinching, or holding a woman forcefully on a delivery bed [33, 59, 70] and verbal threats [33] were believed to be acceptable to avoid adverse birth outcomes.

Healthcare providers occasionally denied providing maternal healthcare services and might not uphold the rights to be treated ethically and healthcare access of childbearing mothers [25, 72]. Experiencing unfriendly maternity care during childbirth was also a detriment to service utilisation [31, 68, 73]. Unfair healthcare service provision and stereotyping practices were other challenges that discouraged women from maternity care [10, 27, 59, 71]. Lack of sympathy, lack of hospitality, poor receptiveness, neglect, and negative attitudes of healthcare providers contributed to the unpleasant experiences of the women [10, 28, 64, 74, 75].

“While I delivered my second baby at a health centre I was in pain and shouting for help to the midwife who was chatting with her friends. She didn’t show any concern to me and one physician also came and yelled at me. I suggest that these people have to in the first place respect their clients and also know their professional duties and responsibilities” (IDI, Participant 06, verbal abuse and negligence affected dignity, Sendo et al.) [64].

In contrast, the initiation of non-discriminatory care [35, 76] and respecting the right to equality and equitable care, the right to liberty, and freedom from coercion [36] improved dignified maternity care. Some healthcare providers believed and practised abuse-free care during maternity care [33, 69]. Additionally, healthcare providers emphasised maintaining privacy and dignity by using screens and curtains, while also acknowledging that shouting at women during maternity care is unacceptable [37, 61, 70]. A woman in a rural IDI described that:

“It is never acceptable to forcefully open a woman’s legs even if it is to save her baby. The only thing the provider can do is to tell her the importance of opening her leg. If she does not comply, it is better to involve her family to convince her than forcefully opening her leg. It is against her rights.” (Rural IDI, physical abuse affected dignity, Adinew et al.) [33].

Providing training to healthcare workers, along with conducting supportive supervision and mentorship, was critical for addressing the challenges associated with ensuring dignified care during maternity services [53, 70]. Fostering a care environment that is free from abuse, discrimination, and hostility were essential for enhancing health facility childbirth rates [76]. Furthermore, the recruitment of additional healthcare workers was a key strategy to mitigate the impact of excessive workloads, which can contribute to the provision of non-dignified care [47].

Basic amenities

Nineteen studies explained the physical infrastructure and conducive care environment aspects of healthcare during maternal healthcare services. Overall, the quality of basic amenities during childbirth service ranged from 45.8 to 65.8% [17, 24, 25]. Qualitative findings identified the lack of basic amenities, including poor hygiene of delivery beds and rooms, dirty washrooms, unhygienic health facilities, and improper practices by healthcare workers and support staff were the critical barriers for maternity care [10, 28, 62, 63, 67, 71, 77]. A 25-years-old parity 1 woman replied that:

“When I was admitted to the hospital, the beds were not cleaned well. A health care provider said to me, “Lie down on that bed”. I could not refuse because I thought the provider might get upset with my suggestion, and my subsequent care might be affected” (IDI, 25 years old woman, parity 1, lack of cleanness affected amenities, Werdofa et al.) [28].

A parity 3 woman who participated in a focus group discussion (FGD) also reported that:

“At the time of labour, there were blood drops on the delivery bed, the surface and bed linen smelled bad. There was no water in the facility. For example, I was bleeding; my mother took me to the bathroom, but could not wash me. This year I did not see this. I think there are changes, maybe” (FGD 2, Parity 3, lack of water in the bathroom affected amenities, Zepro et al.) [10].

Another study participant mentioned that:

“The toilet and shower rooms were filthy and smelled terrible. There was no running water or electricity in the delivery ward. Since the facilities are far from my home, it was a problem to have proper food and drink. My family was challenged with taking care of my food” (IDI, parity 3, absence of running water or electricity in labour ward affected amenities, Zepro et al.) [10].

Poor physical amenities, including inadequate infection prevention protocols, poor room arrangements, and unfavourable working environments, were critical challenges during maternity care [29, 68, 75]. The lack of essential hygiene supplies, such as, water, feminine hygiene products, cotton wool, sanitary pads, sheets, detergents, and reliable electricity with backup generators, hindered the establishment of a clean and comfortable working environment in the maternity wards [10, 25, 28, 54, 62, 77, 78]. In addition, shortages of health facility supplies and equipment, such as lack of enough beds and bed sheets, blankets, shower rooms, personal protective equipment, delivery couches, bedpan, and waiting rooms, were the identified detriments for maternity care [32, 39, 71, 75, 78]. Additionally, the absence of a maternity-specific operating theatre for caesarean sections affected the provision of reliable maternity care [58]. Inadequacy of food and poor food quality were also among the barriers that affect the quality of basic amenities in a healthcare facility [63, 77].

Care providers and service consumers acknowledged using sterile equipment and clean bed linen in the facilities to keep the quality of basic amenities [29, 37, 67]. Healthcare facilities should keep their compound clean and give sufficient food for women [29, 62] to enhance the quality of basic amenities. Fulfilling essential equipment and supplies helped to provide comfortable and hygienic care [24, 28, 39] regarding the quality of amenities.

Choice of care provider

Twenty-one papers described women’s ability to choose their care providers during maternity care. The proportion of women who chose their care provider during obstetric care ranged from 41.6 to 68% [17, 24, 25]. The qualitative studies also indicated women might not have the opportunity to choose healthcare providers during their maternity care [10, 25, 38, 56, 66, 78, 79]. Concerns about male healthcare workers, along with provider incompetence, inexperience, and poor attitudes, led some women to avoid childbirth at health facilities [10, 56, 66, 72, 79]. A parity 3 IDI participant replied that:

“.Women in my locality frequently explain that anger, sadness, and shame accompany a loss of culture and being distant from Allah’s (God) laws about being seen naked by strangers (male midwife) in the health facility. Male birth attendants are also involved in assisting women in labour. That is quite against our faith and culture. God prohibits us from doing so. I fear this will cause punishment from God; Almighty Lord” (IDI, parity 3, male care provider was not the choice of woman for their maternity care, Zepro et al.) [10].

Women’s limited access to diverse providers hinders quality of care by restricting access to varied expertise and skills [38]. Frequent provider changes during ANC visits caused dissatisfaction and interruptions, as some women preferred consistent care and disliked repeating their health history [75]. For example, a participant of an IDI said that:

“Having different service providers to attend a single pregnant woman at her ANC visits is one of the potential reasons for dissatisfaction and interruption as pregnant women are not comfortable to tell their entire health history to different people and this is evident as many of them ask for the person who provided the service initially and will leave if s/he is not around” (IDI, frequent change of care provider was not favourable for the women during their ANC visits, Tsegaye et al.) [75].

Insufficient health care providers and workforce turnover posed various challenges, such as disruptions in service operations, loss of experienced and trained staff, increased staff fatigue and workloads, negligent care, resulting in low quality and discontinuation of services [28, 31, 62, 64, 68, 75, 78]. Poor health workers’ discipline and readiness were the other barriers to maternal healthcare delivery [68, 71]. Weak relationships between providers and women might also fuel legal disputes between MCH clients, care providers, and healthcare facilities [65]. A client at a health center stated:

“Bad relationship negatively impacts maternal and child health services…There is a particular nurse; if I go to the regional hospital and find her, I avoid receiving care from her altogether. I [am] better [to] go back home without treatment or to a traditional healer…” (FGD, Client at Health center, care providers who had poor acceptance by service consumer affected maternity care and responsiveness, Isangula et al.) [65].

Challenges in recruiting specialists and healthcare workers, along with limited supervision by senior professionals, negatively affected the quality of maternity care [28, 63, 68]. Frequent unsupervised examinations by students also contributed to women’s experiences of disrespectful and abusive care [69].

Respecting women’s preferences for healthcare providers, coupled with increased investment and recruitment of adequate number and variety of care providers, including the hiring of female healthcare professionals, has the potential to enhance responsiveness for maternity care [24, 36, 56, 75].

Communication

Thirty-three studies revealed the exchange of information and instructions between healthcare workers and women during their maternity healthcare services. The proportion of women who had effective communication with care providers during their care ranged from 46 to 76.3% [17, 24, 25, 43, 53, 73, 80]. Qualitative studies identified the impact of communication gaps or inadequate information on maternity care service utilisation [25–27, 29, 31, 52, 53, 63, 67, 81]. Poor care provider-client relationships, use of medical jargon or non-local languages, and hierarchical one-way communication practices hindered maternity care provision and discouraged women from engaging with health services [10, 26, 31, 62, 65]. For example, a 35-years-old key informant interview (KII) mother reported that:

“Sometimes, there is a communication gap before, during and after giving services. Most of the time, [staff] try to give service or do procedures without communicating the mother well and left the room.” (KII, a 35 years old mother, communication gaps were among the common challenges during maternity care, Girma et al.) [25].

Another participant reported that:

“I didn’t go to school; I don’t know English, but if they (providers) speak, I notice the actions and understand…. they did not talk to me directly, and I didn’t understand their conversations except their actions, which showed me that these guys must be talking about me on something…” (IDI, Facility 2, language is one of the communication barrier during maternity care, Metta et al.) [26].

Inadequate referral linkages, poor inter-level communication, limited decision-making power among midwives regarding referrals, were critical barriers to maternity care service utilisation [78, 82]. Additionally, misinformation, poor provider-woman interaction, fear of disclosing bad news related to COVID-19, and providers’ rude or abusive language contributed to the negative perception of healthcare providers and a decline in trust towards healthcare facilities [56, 58, 65, 74, 83]. The flow of information during pandemics like COVID-19 frustrated maternity care consumers and impacted their use of services [83]. A woman who gave birth at home mentioned that:

“I gave birth when the issue of Corona was hot in our country. My family and I felt sad as we heard the frightening news on the radio. Then my husband and I decided not to go anywhere… death is inevitable…” (FGD, home childbirth, poor communication means during pandemics affected responsiveness of maternity care, Abdi et al.) [83].

In contrast, effective communication marked by respectful greetings, provider introductions, honest dialogue, use of clients’ names, attentive listening, and positive non-verbal body gestures enhanced provider–client rapport and significantly facilitated maternity care utilisation [32, 34, 35, 37, 61, 62, 67]. Positive experiences, including security guards or care providers welcoming women at facility entrances, highlighted the responsiveness of the health facility [62]. In addition, women appreciated when healthcare providers gave women their phone numbers to ensure continuous communication, allowing women to ask questions and interact freely, which is crucial for understanding and addressing their needs [52, 71]. Trust between care providers and women improves care-seeking behaviours, emotional well-being, treatment adherence, and facility reputation while encouraging openness and increasing the likelihood of return visits for maternity care [65, 84, 85]. Making women feel well before care, ensuring continuity with the same provider, and addressing them by name helped build trust between care providers and women [32, 34, 38, 65]. For example, maternity care service consumers expressed their satisfaction when health care providers called by name and explained the procedures they perform; however, they noted that not all providers consistently demonstrated this practice [32]. This is illustrated by the following statement from a 29-years-old mother, who said:

“.I was very satisfied if the health care providers called me by my name and if he [health care provider] explained what he is going to give me but. umm some of them didn’t do that.” (IDI, a 29 years old mother, effective communication increased women’s satisfaction and decreased their anxiety, Dagnaw et al.) [32].

Training and mentoring healthcare workers, along with conducting supportive supervision, are essential to improving communication and emotional support during childbirth, while fostering intersectoral collaboration to address misconceptions during health crises [53, 83]. Ensuring that procedures and medication purposes are clearly explained to women and encouraging them to ask questions promotes informed participation in their care [32]. Self-introduction of healthcare workers, applying two-way communication, employing technology for information sharing, and using polite language are vital for enhancing effective communication during maternity care [24, 29, 34, 52].

Prompt attention

Thirty studies examined maternity care provision within reasonable periods, even during non-emergency healthcare services, with reasonable waiting time and traveling time to healthcare. Between 62.1% and 96.3% of women received timely care during maternity services [17, 24, 25, 42, 45, 76, 86–89]. Qualitative studies indicated far geographical distance from healthcare facilities affected women’s timely maternity care [66, 71, 77, 90]. Long wait times and delays in receiving care upon arrival discouraged women from attending health facilities for maternity services [10, 29, 36, 39, 43, 56, 62, 63, 66, 68, 71, 73, 75, 90, 91]. Lack of staff and high workloads contributed to unequal and delayed provision of maternity care [29, 36, 39, 90]. A 34-year-old mother reported that:

“.The MNHC providers didn’t assess and evaluate me on time. But after my birth companion called his friend Dr. X. who was working in this hospital, they immediately started to assess and evaluate me properly as indicated. I think in this hospital, no one can get appropriate and timely care unless you have friends/relatives from MNHC providers. Generally, the service was biased.” (FGD, 34 years old mother, delay in care affected maternity care responsiveness, Amsalu et al.) [39].

Closure of healthcare facilities during the night, unreasonable delays, providers’ absenteeism or late entrance from work, and lack of equipment and supplies were other barriers to timely care of maternal health services [56, 66, 75]. A woman stated that:

“Health facilities in this district don’t work 24 hours. They do not have light in the night even. They close during the evening time and open morning when the people wake up.” (FGD-07, breastfeeding mother, Deynile, working hours of health facilities affected timely access to maternity care, Mohamed et al.) [56].

Timely maternity care in rural areas was hindered by poor road access, difficult topography, limited transport options, ambulance shortages, and transportation restrictions during pandemics [56, 64, 66, 71, 73, 83, 90],, all impacting responsiveness and access to universal maternity care. A woman at term pregnancy during the first phase of COVID-19 stated that:

“… during the first phase of COVID-19, I was a term [pregnancy], and my labor started very soon. I stayed about 4 hours at the bus station because there was no bus to go to a hospital, which is located 45 km away. My husband and I decided to go back home and seek help from a traditional birth attendant… ’’ (FGD, home childbirth, lack of transportation affected timely maternity care, Abdi et al.) [83].

The following quote from a 37-year-old Health Extension Worker (HEW) further illustrated these difficulties:

“. Also, there is a topographical difficulty and distance from a health facility. It is very difficult even for us [normal people or non-pregnant women], not only for a pregnant woman. It is difficult even to use traditional ambulance because of its [slope] and hill.” (FGD, a 37 years old HEW, topographical difficulty affected timely maternity care, Higi et al.) [71].

Instead, timely assessments and the consistent availability and preparedness of healthcare workers reduced delays, manage obstetric emergencies and improve efficiency and outcomes of maternity care for both mothers and babies [37, 62, 69]. Enhancing ambulance access, constructing maternity waiting rooms, improving road infrastructure, ensuring 24-hour availability of health facilities, providing timely and free maternity care, and fostering intersectoral collaboration contributed to facilitating timely maternity care [29, 43, 56, 62, 73, 76, 83]. Strengthening the collaboration with transport sectors was particularly crucial for addressing transport-related challenges during epidemics or pandemics, such as the COVID-19 transport restrictions, to ensure uninterrupted maternity care services [83].

Social support

Twenty-one articles reported on women’s social support or companion visits during maternity care. This includes regular visits by relatives and friends, practicing their cultures (e.g., religious practices) that do not impede healthcare activities, and receiving food and other consumables from relatives and friends. The proportion of women receiving social support or companionship during childbirth ranged from 13.8 to 69% [17, 24, 25, 55, 76, 86, 92]. The qualitative findings also indicated that, when women frequently were not allowed to have a companion during their maternity care, this made their experience at health facilities unfavourable [10, 26, 28, 37, 53, 55, 81, 83]. Healthcare providers often restricted companion access due to fear of witnesses during incidents and unsupportive administration, with the COVID-19 pandemic further limiting family support during facility-based childbirth [55, 81]. A 24-years-old primigravida woman stated:

“…. In some cases, hospitals restrict access to support people, which worry me a lot about who will be my helper during the childbirth process. I’m not sure what will happen; maybe I’ll get COVID-19 and won’t be able to nurse my child.…Who is going to stick by me?” (IDI, P-7, a 24 years old primigravida woman, restriction of companionship worried maternity care consumers, Cherinet et al.) [81].

Cultural preferences incompatible with health facility practices also deterred accessing maternity care [64, 66]. Specifically, the absence of celebration after childbirth at health facilities, in contrast to home births where family and community celebrate with traditional songs and provide care to the mother, such as feeding the mother porridge [64], highlighted a lack of cultural and emotional support in facility-based maternity care. The following quote illustrates the importance of these cultural celebrations:

“Following childbirth, neighbouring women will make some porridge and will serve the woman. They (women) will celebrate this special occasion by singing traditional songs and eating porridge. If childbirth takes place in the facility, you miss this wonderful event and the warmness of your home. I think this ceremony is unique to Ethiopian women” (IDI, Participant 01, absence of birth celebration at health facility affected maternal satisfaction during maternity care, Sendo et al.) [64].

In contrast, some healthcare providers did believe every childbearing woman has the right to have a birthing companion during maternity care service utilisation [33]. In addition, some facilities involving companions had various positive contributions, such as enhancing confidence in difficult situations, providing emotional support, facilitating referrals and continuity of care, persuading uncooperative women for necessary procedures like episiotomy, and linking the midwife’s instructions with the woman’s adherence during maternity care [28, 34, 35, 55, 93]. Birth companions might also identify complications, inform medical staff, and brought essential supplies [28]. As an example, a 25-years-old woman said:

“After I gave birth, one of my relatives hid from the health care provider and entered my partition. She yelled and notified the health care provider of the blood that had accumulated between my two legs. As medical personnel arrived at my partition, they checked my bleeding and provided the necessary treatment to stop it. So, if my relative had not come to my aid, no one would have noticed my bleeding, and I might have died because of it. For a mother, having a companion after childbirth is crucial” (IDI, a 25 years old, para 1, birth companion could have the ability to identify complications and informed to care providers, Werdofa et al.) [28].

Providing social support through continuous companionship during labour improved the quality of care [24, 92]. Improving infrastructure with better space and privacy at healthcare facilities reduced overcrowding and allow women to get support from their companions [37, 72, 81].

Discussion

This mixed-method systematic review examines the challenges, successes, and strategies for HSR in accessing universal maternal healthcare services in East Africa. This review illustrated the interaction between healthcare system actors, such as providers, managers, and policymakers, and maternal healthcare service consumers (e.g., women, their families, and communities), in relation to achieving maternal health goals. This is depicted in Fig. 2, which shows the interaction between health system and service consumers which is partially adapted from HSR framework by Mirzoev et al. [11] and its effect on maternal health service and long-term goals. As shown in Fig. 2, a responsive health system that meets consumers’ expectations can strengthen key maternal health service performance attributes: quality, utilisation, equity, and satisfaction. These attributes are essential for building trust in the health system and are critical to achieving universal maternity care. Over time, a responsive and high-quality health service can lead to improvements in maternal health outcomes. Ultimately, this will contribute to the reduction of maternal morbidity and mortality. In contrast, we found that inadequate responsiveness of the health system for maternity care was still challenging for service consumer women. This indicates that the healthcare system is not adequately addressing maternity care consumers’ need, preference, and expectation. Such an unresponsive health system for maternity care ultimately erodes trust in the system, leading to poor health outcomes and increased healthcare disparities. This review also highlighted that the availability of skilled healthcare providers, essential supplies and infrastructure, capacity building, and accountability were key enablers across HSR domains and countries. On the contrary, lack of autonomy in decision-making, violation of confidentiality, verbal abuse, lack of choice in care providers, unhygienic practices, delayed care, and denial of companionship during maternity care were the critical challenges to providing responsive maternity care.

Fig. 2.

Health system responsiveness framework (partly adapted from Mirzoev et al., 2017 framework) and its effect on maternal health services and long-term goals

The overall HSR for maternity care ranged from 45.8 to 75.6% [17, 24, 25]. However, overall HSR was only reported in Ethiopia, with the overall HSR of 53% in Southern Ethiopia [17], 45.8% at public health facilities in Northeast Ethiopia [24], and 75.6% in Southwest Ethiopia [25]. This overall range of HSR, as reported in this review, was higher than that reported in a study conducted among obstetrics and gynecology patients in Iranian teaching hospitals (41.8%) [15] and consistent with studies conducted on HSR for HIV/AIDS treatment and care in the North Shewa zone (55.3%) and Wolaita zone (68.3%) of Ethiopia [94, 95], and on Iranian inpatients (58.4%) [14]. The magnitude of the reported overall proportion of HSR for maternity care in the individual studies in Northeast (45.8%) and Southern (53%) Ethiopia [17, 24] was lower, while a report from Southwest Ethiopia [25] had a higher proportion of the overall HSR than in the North Shewa and Wolaita zones of Ethiopia [94, 95] and inpatients in Iran [14]. These variations might be due to the differences in service types, participant characteristics, and healthcare systems. Socio-cultural disparities among service consumers, such as varying perceptions of care, can also contribute to these differences. Furthermore, factors like the availability of skilled health workers, access to healthcare, and transportation discrepancies play a significant role [94].

Inadequate women’s involvement in their maternity care decisions [26–29] was a critical challenge to maternal healthcare service utilisation. Loss of autonomy during maternity care might result in feelings of disempowerment, dependency, and mistreatment among women [96]. This finding was supported by a mixed-methods systematic review of the mistreatment of women [96] and a meta-synthesis of qualitative studies on the inadequate use of ANC services in LMICs [97]. Involving women in decisions about their care and obtaining their consent can reduce anxiety and align with WHO’s recommendations to make healthcare more responsive to their needs and interests [98]. Active participation of women in their maternity care choices also advances a collaborative relationship with healthcare providers and reduces potential power imbalances [99]. Explaining procedures and obtaining consent, along with providing clear, translated consent forms, ensures women’s autonomy and enables informed participation in their own care decisions [30, 32, 34, 37].

Lack of trust in maintaining the confidentiality of private information during their maternity care [27, 36, 43, 53–59] was another challenge in providing responsive maternity care. This challenge was associated with sharing a single room by two or more women [36, 53, 56, 58, 59] and the lack of screens and the absence of partitions between delivery couches [54, 55]. This finding was supported by studies in Kenya [100], Tanzania [101], and mixed-methods review globally [96]. The possible justification might be due to women being concerned about stigma and discrimination associated with the disclosure of their health status to other community members or healthcare providers [100]. Discrimination weakens trust and discourages future maternity care-seeking [58]. Ensuring women’s privacy during maternity care, through strategies like building or renovating additional rooms to reduce overcrowding and restructuring service spaces to safeguard confidentiality [43, 52, 53].

Non-dignified maternity care [47, 48] was another challenge in providing responsive maternity care. Non-dignified care in maternity settings, including physical abuse, is often linked to poor provider practices Non-dignified care in maternity settings, including physical abuse, results from poor provider practices [27, 28, 36, 61–64] further exacerbating inequities in access to respectful and quality maternal care. In addition, emotional and verbal abuse along with unfair and stereotypical treatments [10, 27, 59, 71], severely hinder women’s universal access to maternity care by fostering an environment of fear, discrimination, and mistrust in healthcare services. This kind of treatment was prevalent in many health facilities and reinforces findings of a WHO report [102]. These unacceptable practices might violate the human rights of women and discourage them from seeking care during childbirth [102]. Capacity building, including the provision of ongoing training to healthcare workers and conducting supportive supervision, is essential to address the challenges of non-dignified care during maternity care [53, 70]. Health systems also adopt a model of care that empowers women to achieve optimal physical, emotional, and psychological outcomes [102]. Recruiting the health workforce [47] and providing friendly, abuse-free, and discrimination-free maternity care [76] are necessary to improve institutional child birthing.

Insufficient quality of basic amenities at healthcare facilities [10, 28, 62, 63, 67, 71, 77] were among the critical challenges affecting provision of maternity care. This was linked to a lack of essential hygiene supplies and unstable electricity sources [10, 25, 28, 54, 62, 77, 78]. This might be associated with healthcare facilities without basic water, sanitation, and hygiene (WASH) services endangering patient and staff safety, increasing the risk of healthcare-associated infections, especially for women and newborns [103]. Additionally, the WHO WASH working document shows simple measures like enhancing toilet cleanliness, installing affordable handwashing stations, and water treatment in healthcare facilities improve care quality, boost service use, and inspire better WASH practices in communities [104]. Therefore, fulfilling essential infrastructure, equipment and supplies is crucial for maintaining comfort and hygienic care [24, 28, 39], and contribution to the quality of amenities.

Limited opportunities of women for choosing their own care providers [10, 25, 38, 56, 66, 78, 79] also affected maternity care utilisation. This could be associated with women feeling concerned about being assisted by a male health worker [10, 56, 66, 79], high provider workload [28], shortage of the required number and type of providers [75], and providers’ incompetencies [72]. Controversial study findings were also reported regarding the choice of women for their maternity care. For instance, some women prefer to receive care from different healthcare providers to get the variations in expertise, skills, and levels of care that prevent women from receiving adequate and quality healthcare services [38]. In contrast, some women were dissatisfied with the frequent changes in service providers and wanted to receive services from the same provider [75]. Therefore, increasing investment and employing an adequate number and type of care providers to address women’s preferences led to better maternity care service utilisation [24, 36, 56, 75].

Poor communication between healthcare providers and women [25–27, 29, 31, 52, 53, 63, 67, 81] was a key barrier to responsive maternity care. This was mainly related to poor care provider-client relationships and the use of medical jargon words [10, 26, 31, 65]. The latter allows only one-way hierarchical communication, and discourages questions [62]. Moreover, poor referral linkages or communication between different levels and a lack of midwives’ decision-making power on referrals [78, 82] were also critical barriers to maternity care service utilisation. Therefore, maternity services need to provide training to health workers, conduct mentorship, supportive supervision, and drill exercises to enhance communication and emotional support during childbirth. It is important to strengthen intersectoral collaboration between health and communication ministries to address misconceptions during health crises [53, 83]. In addition, explaining the procedures and the purpose of medications to women and creating an environment that encourages women to ask questions about their care [32] is helpful to improve the interaction between them. Healthcare workers are also required to introduce themselves and call women by name to show respect and care, apply two-way communication during referrals and feedback, use technology like mobile apps for information sharing, and use polite language to enhance overall communication [24, 29, 34, 52].

Delays in care provision to women during their maternity care [29, 36, 39, 66, 71, 77, 90] hindered access to maternity care. As such, timely maternity care was challenged by insufficient staffing, high workloads, healthcare facility closures during night shifts, delays in service provision, provider absenteeism, and shortages of equipment and supplies [29, 36, 39, 56, 66, 75, 90]. Improving access to ambulance services, building maternity waiting rooms, ensuring 24-hour operation of health facilities, and providing timely free maternity care can address many challenges in maternity care. Strengthening collaboration between the Ministries of Health and Transport, including road construction and resolving transport restrictions during pandemics [29, 43, 56, 62, 73, 76, 83], will improve responsiveness and facilitate timely access to maternity care.

Limited social support during maternity care [10, 26, 28, 37, 53, 55, 81, 83] was another barrier that could affect health facility child birthing. These low social support practices challenges during maternity care were related to fear of witnesses during incidents, restricted access to child birthing rooms for companions due to unsupportive administration [55], fear of coronavirus transmission [81], cultural preferences incompatibility with health facility practices [66], and absence of celebration after childbirth at health facilities [64]. Remarkably, this can be alleviated through continuous companionship during labour [24, 92]. Improving infrastructure by creating more spacious and private areas within healthcare facilities that can help to reduce overcrowding, can ensure that women have the opportunity to receive support from their chosen companions [37, 72, 81]. Such emotional and physical support contributes to a more positive childbirth experience and can promote better outcomes for both women and newborns.

Strengths and limitations

This mixed-methods review is the first study which was performed a framework analysis using the HSR domains and provides comprehensive evidence on HSR for universal maternity care in the East African context. However, the limitation of this review is the inability to report pooled estimations of HSR and its domains due to the variations in measuring and categorising the level of responsiveness and its domains. Publication bias might be introduced due to the exclusion of non-English language studies. The high representation of studies from Ethiopia may also limit the ability to fully understand how their health systems respond to maternity care within some countries with low representation of studies.

Policy implications

This review highlights the successes, challenges, and strategies of HSR and examines its impact on achieving universal maternal health service coverage in East Africa. This review will help to enhance awareness among maternal health program personnel of the role of HSR and initiate future discussions and debates on the topic. Additionally, the findings will assist policymakers and government officials to revise and update strategic plans and policy frameworks to improve access to universal maternity care. The review emphasises the need for accountability in healthcare institutions to ensure the provision of inclusive and equitable health services to achieve universal health coverage. Furthermore, it proposes the development of a core set of regional and national indicators to monitor and enhance maternal health performance. This health system responsiveness framework will be valuable for national, regional, and global health communities for its context-specific application to improve their health system performance for any health program. This review also serves as a valuable baseline resource for future public health researchers.

Conclusion

The included studies reported wide ranges of the overall HSR and its specific domains for maternity care. In this review, we concluded that HSR remains a major barrier for maternal healthcare service utilisation and quality of care. Specifically, limited decision-making autonomy, non-confidential care, non-dignified care, poor communication, long waiting times to access services, and unhygienic practices were the critical challenges to providing maternity healthcare services. Such lack of HSR limits the quality of care and hinders efforts to provide essential support for women throughout pregnancy, childbirth, and postpartum care. Employing diverse and context-specific strategies beyond the one-size-fits-all approach is crucial to resolving the complex challenges of HSR and ensuring universal maternal health coverage. Therefore, provision of responsive maternity health service demands the policymakers, managers, and providers’ ongoing and sustainable attention to realise universal access to maternity care. It is essential to monitor key responsiveness indicators and invest in capacity building at all levels through ongoing training, supportive supervision, mentorship, and strong monitoring and evaluation to improve the responsiveness of the health system for maternity care. Implementing rewards and recognition systems, such as fair remuneration, can also help motivate and retain healthcare workers. Similarly, ensuring accountability at all levels and empowering women to express their needs and preferences are essential to providing women-centered maternity care. Federal and Provincial level health officials can advocate for improved roads through coordination with their corresponding transport authorities, while healthcare providers and support staff play a key role in providing respectful maternity care to enhance responsiveness and access to universal maternity care. In addition, it is important that skills in communication and respectful maternity care are integrated into the education curricula of maternity care providers to enhance HSR in maternal healthcare services. Researchers should also conduct primary studies in underrepresented countries identified in this review to better understand HSR to maternity care across diverse settings. In addition, we advised researchers could focus on reviewing the impact of COVID-19 on HSR for maternity care through setting a specific time frame before, during, and after COVID-19 pandemic. Furthermore, future researchers should identify context-specific strategies for building a responsive health system for universal maternity care by actively engaging key stakeholders.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ANC

Ante-natal care

COVID-19

Coronavirus disease of 2019

FGD

Focus group discussion

HEW

Health extension workers

HSR

Health system responsiveness

IDI

In-depth interview

JBI

Joanna briggs institute

LLMICs

Low and lower-middle-income countries

MMR

Maternal mortality ratio

MeSH

Medical subject headings

MoH

Ministry of health

MMAT

Mixed methods appraisal tool

PNC

Post-natal care

PRISMA

Preferred reporting items for systematic reviews and meta-analyses

SSA

Sub-Saharan Africa

SDGs

Sustainable development goals

TBAs

Traditional birth attendants

UHC

Universal health coverage

WHO

World Health Organization

Author contributions

All authors made substantial contributions to the study’s conception and design. AD initially conceived the study and wrote the main manuscript. Initially, AD and MDM screened the articles by title and abstract and then by full-text review. JHS and MMW resolved the differences between AD and MDM. AD extracted the data and conducted a quality appraisal. JHS reviewed and verified the extracted information. AD prepared the first draft of the review manuscript. AD, MMW, CTR, AW, and JHS were involved in the data synthesis and review of the article. All authors also agreed to be personally accountable for the author’s contributions and to ensure that questions related to the accuracy or integrity of any part of the work. Finally, all authors read and approved the final version of the manuscript.

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Ethical approval was not required since the study was a systematic review of published articles.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.