Table 2 Barriers and facilitators of equity in prenatal healthcare practices that impact access or use of health services

Place of Residence

Barriers

Despite availability of innovations (i.e., CCT, home visitation, CHWs), remote/rural patients face difficulties in accessing or having knowledge of resources because of geographical remoteness and poor transportation options, especially during obstetrical emergencies [41, 42, 45,46,47,48,49,50,51,52].

Facilitators

Availability of multipurpose healthcare professionals facilitates provision of prenatal care in remote areas [53].

Community referrals, CHWs, CCTs, and transport innovations reduce referral times, improve access to care for rural/remote patients, and reduce adverse outcomes [54,55,56,57].

CCTs that distribute resources directly to communities avoid transportation barriers [58].

Telemedicine innovations increase access and use of care, and improves patient satisfaction [56, 59, 60].

Home visiting programs reduce transport/mobility/communication barriers, improve access to care, and improve pregnancy outcomes [46, 61,62,63,64].

Race, Ethnicity, Culture, Language, Religion

Barriers

Non-White/European patients are less likely to initiate, book late or fewer prenatal appointments [65,66,67,68] and show lower uptake of prenatal testing and screening because they are less likely to be offered the service or provided with information or consent compared to White/European individuals [49, 65, 66, 68]. Non-White/European patients experience greater unfair, discriminatory treatment compared to White individuals which leads to a greater risk of adverse birth outcomes [69, 70].

Cultural (i.e., smoking as a spiritual practice) or religious (i.e., not have other people examine one’s body) norms and perceptions of distrust and patriarchy in the western healthcare system and lack of healthcare professionals with similar ethnic or cultural background leads to delayed initiation of prenatal care by patients and feelings of being unwelcome, patronized, and an unsafe pregnancy [43, 44, 49,50,51, 53, 58, 68, 70,71,72,73,74,75,76].

Cultural norms of family members making decisions on behalf of the patient leads to uninformed decisions [50, 68, 77].

Patients that spoke the language or who were born in the country have a greater knowledge of healthcare practices and access to care [68, 70, 74, 78] compared to those with communication difficulties, especially without adequate interpretation services [70, 73, 75,76,77].

Language barriers, lack of cultural appreciation, poor attitudes, and reluctance among healthcare professionals limits opportunities of religious and ethnic minority patients and leads to these patients feeling unsupported, devalued, and fearful [43, 49, 50, 52, 68, 74,75,76, 79].

Patients who are immigrants and ethnic minorities experience a lack of communication and receive inadequate access to services. Some even avoid maternal healthcare because they perceive or actually receive a different quality of care and health education or they want to prevent being discriminated against by healthcare professionals [44, 49, 50, 52, 53, 58, 70, 71, 73, 74, 76, 80].

Programs targeted at lower socioeconomic groups do not effectively reach ethnic minority patients, as such these populations receive incomplete benefits [79].

Facilitators

CHWs (including Aboriginal Health Workers) improve health education, increase prenatal care attendance, reduces stress, and increase healthy habits (i.e., smoking abstinence) for non-White and Aboriginal patients, and those of non-Western culture [46, 55].

Maternity care services (e.g., midwifery) adapted to patient′s expectations enhance the patient experience by reducing anxiety, creating a sense of cultural safety, and allowing patients to feel valued and to take control of their pregnancy. Examples of adaptations include interpretation services, social support, cultural knowledge, cross-cultural training of healthcare professionals, and relevant and easy to understand information [42,43,44, 49, 51, 71, 74, 75].

Virtual health innovations that incorporate local language use improve access to care and ease of use [81].

Occupation

Barriers

Unemployed patients and their partners book late or fewer prenatal appointments and employed face barriers in taking time off work due to financial constraints or for family obligations [50, 65, 75, 77, 79].

Gender/Sex

Barriers

Gender norms (i.e., women cannot travel alone, make decisions, or they must stay home to take care of their children) lead to delayed care and underuse of health services proportionate to needs and feelings of powerlessness and loss of autonomy [49, 58, 62, 70, 71, 74, 77, 79, 82].

Lack of available female staff leads to patients delayed seeking of care or feelings of embarrassment [44, 49, 77, 79, 82].

Lack of a female support system leads to patients feeling less confident to discuss their concerns with healthcare professionals [71].

Experiences for LGBTQ2S+ identifying patients are distressing because of the frequency of use of sex-specific words, assumptions that patients are women, lack of healthcare professionals’ knowledge or acknowledgement [42].

Facilitators

Targeted gender innovations that encourage men to support women, promote women’s autonomy, and provide health education, increase care use, improve nutrition, improve mental health, and reduce adverse pregnancy outcomes [49, 52, 77, 83].

Home visitation programs are valuable to provide health education and care to women who were disadvantaged by gender norms [46].

Strategies focused on using gender-neutral pronouns, inclusive tools, and trauma-informed training for healthcare professionals improve experience and enhance comfort for LGBTQ2S+ identifying patients [42].

Education

Barriers

Lower levels of patient and partner education are associated with lack of health education [79] and leads to a delayed initiation of or infrequent use of prenatal care by patients and increased risk of adverse pregnancy outcomes [53, 62, 70, 77, 79, 82, 84].

Patients with a higher level of education tend to have greater authority during their pregnancy [82].

Despite available innovations, patients are unaware of their eligibility, lack knowledge of services or lack general health education and therefore do not seek services which can lead to greater pregnancy complications or maternal near miss situations [58, 64, 85]. When services are utilized, some patients are still provided with misinformation [43, 44, 64].

Facilitators

CHWs (including Aboriginal Health Workers), birth preparedness, and home visitation programs improve patient’s health education (including smoking cessation), confidence and preparedness, and care-seeking habits which leads to less maternal stress and prevention of obstetrical complications and improves nutritional status [46, 47, 55, 59, 63, 86,87,88,89].

Home-based records target and improve patient and family knowledge and lead to improved confidence and sense of empowerment, increases prenatal care attendance, and improved recognition of pregnancy complications [90, 91].

Media campaigns and health education programs increase patient knowledge, awareness and readiness during pregnancy and lead to improved health outcomes [88, 92, 93].

Socioeconomic Status

Barriers

Patients of lower SES show lower receipt and uptake of prenatal care [50, 74, 94,95,96], testing, and screening [41, 66] because of barriers accessing care and stigmatizing behaviour they receive [70]. Many patients also worry about loss of income and care seeking costs and therefore work right up to delivery [79].

Nutrition supplementation (e.g., iron, folic acid) coverage favours the wealthiest over poorest patient households and leads to a greater proportion of anemic patients of poor households [94].

Increased fees for care limits access for patients [53, 72], fees external to innovation/service costs (i.e., nicotine therapy), and narrow eligibility of innovations (i.e., CCT) also prohibit patients from using services [42, 45, 46, 50, 52, 58, 64, 75, 96,97,98].

Patients of low SES households have limited access to phones, cellular or internet networks or electricity and therefore cannot engage in virtual health innovations [78].

Facilitators

Free/universal healthcare, reducing user fees, public assistance and insurance programs, or CCT innovations leads to increased household income/spending. This increases access to and use of services for socioeconomically disadvantaged patients and improves health education [45, 53, 54, 56, 57, 59, 62, 67, 92, 99,100,101,102,103,104,105], nutritional status [99], and pregnancy outcomes [45, 59, 61, 62, 101, 102], reduces pregnancy complications, and develops a sense of empowerment for patients [45].

CCTs that include cost coverage that may be indirectly associated with care services (i.e., travel) improves access to care [58].

Targeted nutrition programs improve knowledge and practices of dietary habits and supplements during pregnancy among the poorest households [94].

Innovations such as CHWs that actively connect prenatal patients of low/middle-income with care during pregnancy including home visits, increases service utilization and timeliness, improves preparedness, and reduces adverse outcomes [54].

CHWs improve health education and reduce smoking, for low-income patients [55].

Social Capital

Barriers

Personal/family priorities including childcare may conflict with available innovations, especially with lack of family support, and those who are socially excluded face barriers including lack of knowledge [45, 50, 51, 75].

Nepotism and personal connections influence availability of services [46].

Facilitators

Faith-based and community organizations provide higher-quality care, increased referrals, greater access to services, improve health education, pregnancy outcomes, and prenatal attendance [56, 59, 103, 106]. Additionally, family involvement has an even greater impact on these outcomes [107].

Innovations that encourage significant relationships, family and partner support, peer support, and community support, positively influence the patient’s well-being and health habits (e.g., smoking abstinence) and their relationship with their baby [49, 51, 59, 64, 71, 83, 89, 93, 108]. Tailored psychosocial support innovations co-developed or led by patients improve pregnancy and birth outcomes, improve cultural appropriateness, and are valued by patients [51, 59, 63, 64, 75, 88, 108].

Virtual health innovations that incorporate an interactive online community improves interaction between patients and with healthcare professionals [60, 78, 81].

Plus—Age

Barriers

Patients of older age or that have previous experience with pregnancy have greater authority during their pregnancy [82], however, young and older women are still treated biased in terms of care quality [70].

Facilitators

Mobile and electronic health innovations improve retention of patients under 18 years [59].