Access to maternal health services for Indigenous women in low- and middle-income countries: an updated integrative review of the literature from 2018 to 2023

Introduction: Ninety-seven per cent of Indigenous peoples live in low-and middle-income countries (LMICs). A previous systematic integrative review, of papers published between 2000 and 2017, identified numerous barriers for Indigenous women in LMICs in accessing maternal healthcare services. It is timely given the aim of achieving Universal Health Coverage (UHC), in six years’ time, by 2030, to undertake another review. This paper updates the previous review exploring the recent available literature on Indigenous women’s access to maternal health services in LMICs identifying barriers to services.
Methods: An integrative review of literature published between 2018-2023 was undertaken. This review followed a systematic process using Whittemore and Knafl’s five step framework for integrative reviews and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Nine hundred and forty-four (944) articles were identified from six data-bases: Academic Search Premier, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycInfo, CINAHL Plus with Full Text, APA PsycArticles (through EBSOhost). The search was undertaken on the 16th of January 2023. After screening of the title/abstract and the full text using inclusion and exclusion criteria twenty-six articles were identified. Critical appraisal resulted in twenty-four (24) articles being included in the review. Data were extracted using a matrix informed by Penchansky and Thomas’s taxonomy, extended by Saurman, which focused on six dimensions of access to healthcare: affordability, accessibility, availability, accommodation, acceptability, awareness. Ten studies took place in Asia, ten studies were from the Americas and four studies took place in the African region. Seventeen articles were qualitative. two were quantitative, and five mixed methods. The methods for the integrative review were pre-specified in a protocol, registered at Open Science Framework.
Results: Barriers identified included affordability; community awareness of services including poor communication between providers and women; the availability of services with staff often missing from the facilities; poor quality services which did not take on board the cultural and spiritual needs of Indigenous peoples; an over-reliance on the bio-medical model; a lack of facilities to enable appropriate maternal care; services which did not accommodate the everyday needs of women including work and family responsibilities; lack of understanding of Indigenous cultures from health professionals; and evidence of obstetric violence and mistreatment of Indigenous women.
Discussion: Barriers to Indigenous women’s access to maternal health services are underpinned by the social exclusion and marginalisation of Indigenous peoples. Empowerment of Indigenous women and communities in LMICs are required as well as initiatives to challenge the stigmatisation and marginalisation that they face. The importance of community involvement in design and interventions that support the political and human rights of Indigenous peoples are required. Limitations of this review include the possibility of missing articles as it was sometimes unclear from the articles whether a particular group was from an Indigenous community. More research on access to services in the postnatal period is still needed, as well as quality quantitative research. There is also a lack of research on Indigenous groups in North Africa, and sub-Saharan Africa especially hunter-gatherer groups as well as the impact of COVID 19 on access to services.
Keywords: Indigenous women, maternal health services, antenatal care, postnatal care, childbirth, access to services, low- and middle-income countries