**7. Challenges to postnatal care in sub-Sahara Africa**

Several challenges to PNC in sub-Saharan Africa have been documented [23]. One of the key challenges associated with postnatal care in SSA is a lack of access to basic healthcare services [23]. Many women in the region live in remote, rural areas that lack adequate healthcare facilities [35, 38]. Healthcare facilities in the region are often understaffed, and the staff available may not be adequately trained to provide the care that is needed [18]. The facilities also lack basic medical supplies such as drugs and equipment, which can make it difficult for healthcare workers to provide the care that is needed, and for women to receive appropriate care during the postnatal period [18, 38].

Even when postnatal care services are available, a variety of sociocultural barriers prevent mothers and their newborns from accessing these services. These include household barriers related to the educational level and health literacy of mothers and other family members, the influence of sociocultural beliefs and practices, and

women's autonomy and decision-making power [39]. Specific examples of sociocultural barriers to postnatal care utilization include cultural beliefs about the 40 days following childbirth, during which mothers and babies should stay indoors [40], misconceptions about the importance of postnatal care, and a lack of knowledge about postnatal care and its benefits [35].

At the individual level, a woman's education and literacy level, occupation, income and access to information influence her access and utilization of PNC. At the health system level, the cost of health services, transportation, accessibility, travel time and distance to healthcare facilities all influence utilization of PNC. The functionality and standard of health systems at the community level, the standard of care provided at the facility and concerns about the quality of care, including the attitudes of health workers, their skills, resources, workload and effect on the quality of care, and the cultural acceptability of services all influence women's decision to seek PNC [28, 35].

Socioeconomic characteristics such as place of residence, cultural attitudes, gender norms, women's autonomy and empowerment, wealth or poverty levels in the community, levels of education at the community level, population density, and the government's contribution to healthcare spending, and gross national income per capita are contextual variables that affect the utilization of postnatal care [25, 29]. The extent of poverty, socioeconomic development and infrastructure, including poor roads and transportation, can also make it difficult for women to reach healthcare facilities, even if they are available [18, 35, 38].

Utilization of postnatal care is correlated with several of these factors predictably and consistently. For instance, it is well known that women are more likely to use maternal healthcare if they reside in regions or countries with higher socioeconomic or educational standards. it is also well known that women who reside in rural regions are less likely to use postnatal care and other maternal healthcare services. Many women in the region live in poverty and do not have the resources, information, autonomy and decision-making power to access care during the postnatal period. Discrimination and other social factors also make it difficult for women to access and receive the care they need [18, 35, 38].

Contextual factors such as cultural beliefs and practices, also hinder the delivery of quality postnatal care in SSA [18, 35]. Many women in the region follow traditional birthing practices, which can make it difficult for healthcare workers to provide the care that is needed [35]. Additionally, there may be cultural taboos surrounding certain aspects of postnatal care, such as institutional childbirth, which can make it difficult for women to access PNC [33].

One of the strongest predictors of postnatal care use is women's empowerment and autonomy [41]. The evidence suggests, that living in communities where the majority of women are empowered, that is, educated and financially independent, is advantageous for access and utilization of postnatal care in sub-Saharan Africa [29]. Furthermore, women who reside in places where their freedom is curtailed, due to certain cultural beliefs or social restrictions on women and/or insecure places such as conflict situations are less likely to seek postnatal care after childbirth. Relational factors have also been shown to be significant contextual determinants of postnatal care use. These elements mostly stem from regular contacts or relationships that women have with males. These relationships may have an impact on whether or not women choose to receive maternity care. Furthermore, household size, the number of children per household, and small family norms also influence the decision to access postnatal care [41].
