**5. Determinants of maternal and newborn healthcare utilization in sub-Saharan Africa**

Several studies have documented various facilitators and barriers to women's access to healthcare during pregnancy, childbirth and the postnatal period in SSA [23]. These determinants occur at the individual, health system and contextual levels.

#### **5.1 Individual factors**

At the individual level, maternal age, educational attainment, occupation, income, religion, family structure, information accessibility, location of residence, health awareness, and decision-making authority are all factors that affect maternal and newborn healthcare access and utilization [24]. For instance, exposure to local media and information sources has a positive impact on maternal and neonatal care utilization [25], and frequent broadcast of the benefits of birthing at a healthcare facility encourage mothers to adopt health facility deliveries [25].

#### **5.2 Health system factors**

At the health system level, maternal healthcare utilization in sub-Saharan Africa is influenced by factors that include accessibility to healthcare facilities, perceived quality of care, financial cost, timeliness of care, availability of drugs and equipment, and emergency care [26, 27]. Healthcare quality considerations include human resource availability, the population-to-healthcare-professionals ratio, and service accessibility [28, 29]. Women are more likely to use maternal healthcare services if they reside in areas with high-performing and high-quality health systems. However, some studies have also reported either a negative association between distance and maternal healthcare utilization or no significant association [29, 30]. In these instances, increased rates of facility delivery were attributed to contextual factors such as access to health facilities within communities, which appeared to have an impact on immediate postnatal care [29].

#### **5.3 Contextual factors**

Individual and health system-level variables reflect "upstream" contextual variables that are ingrained in larger social systems. For instance, discussions of the *Perspective Chapter: Challenges to Postnatal Care in Sub-Saharan Africa – A Review DOI: http://dx.doi.org/10.5772/intechopen.113846*

impact of women's autonomy and decision-making power on maternal healthcare frequently take place within the context of prevalent masculine beliefs or local cultural norms [31]. Pregnancy and childbirth have typically offered women in sub-Saharan Africa an opportunity to establish their worth and stake an assertion on social status through childbirth [32]. In cases where a woman gives birth without external support, she is held in high esteem. Such perspectives may influence the decision of childbirth at home without the support of any health professional. Also, in some communities, local beliefs prevent health facility deliveries as they are considered unacceptable [33]. Expectant mothers, out of fear, choose to appease their families by having home births in order not to endanger their lives and that of their babies [33]. These beliefs make it difficult for mothers to freely access maternal health care. In some traditional settings, the consent of the woman's spouse is often required to access care at a healthcare facility [34]. Some men insist on home birth in order to prevent their wives from being attended to by male health personnel [34]. For women who live in vulnerable environments such as in conflict and war situations, the risk of being kidnapped, raped or killed makes it impractical to travel to a health facility for childbirth and PNC services [35]. Similarly, the dysfunction of the political and governance institutions that control health systems may have a direct or indirect impact on health systems. Contextual-level factors strongly explain variability in individual access to healthcare and health outcomes [36].
