Barriers in accessing early antenatal booking in Africa: A Scoping Review.

Globally, maternal and neonatal health remain key indicators of health system effectiveness and equity. The World Health Organization defines early antenatal care (ANC) as a pregnant woman’s initial interaction with a healthcare provider within the first 12 weeks of gestation. This early engagement is a vital component of the maternal healthcare continuum, offering an essential opportunity for timely screening, risk identification, and preventive interventions that substantially reduce both maternal and neonatal morbidity and mortality (Thierbach et al., 2015).Through early ANC, expectant mothers receive vital health education, undergo timely screenings for conditions such as anemia, HIV, and gestational diabetes, and benefit from preventive interventions like tetanus vaccination and nutritional supplementation. Despite global consensus on the importance of early ANC, timely booking remains a challenge in many low- and middle-income countries, particularly in Sub-Saharan Africa. (Belete et al., 2024), assert that early engagement with antenatal care ideally within the first trimester greatly enhances maternal and neonatal health by allowing prompt risk identification, targeted health education, and timely access to necessary interventions. Recent research emphasizes that early first-trimester visits markedly reduce maternal and newborn morbidity and mortality. Study by (Phiri et al., 2025) shows that , as many as 85.5% of pregnant women in Mozambique initiate their first ANC visit after the first trimester. Despite World Health Organization recommendations, only about 24–27% of pregnant women in regions like southern Benin and Cameroon initiate antenatal care within the first trimester, highlighting significant delays in early engagement with maternal health services (Aboagye et al., 2024). These patterns reflect a broader public health concern that disconnect between global best practices and local realities, driven by a web of interrelated barriers ranging from systemic limitations to cultural norms. In Sub-Saharan Africa, delays in ANC initiation are seldom the result of a single factor. Instead, they often emerge from the intersection of accessibility challenges, socio-economic hardships, cultural perceptions, gender dynamics, and shortcomings within health systems(Mgata & Maluka, 2019). For many women living in rural or low-resource settings, the journey to a health facility is long and physically demanding. In Malawi, some pregnant women walk as far as 20 kilometers to access care, while others describe the burden of travel and poverty in stark terms(Nyando et al., 2023). In countries such as Togo, Zimbabwe, and Mozambique, seasonal flooding frequently severs access to health clinics, while in Ethiopia, ambulance services are often unreliable or entirely unavailable, thereby severely limiting emergency maternal and early child healthcare access (Wuneh et al., 2022). Economic barriers only compound these geographic constraints. Even in countries where maternal care is officially free, hidden costs such as laboratory tests, medications, or registration fees can deter early engagement. In one community, the out-of-pocket cost associated with registering for antenatal care was approximately USD 26, posing a substantial financial barrier to accessing maternal health services (Banke-Thomas et al., 2021).Cultural beliefs also heavily influence ANC timing. In some communities in South Sudan and Ethiopia, pregnancy is seen as a normal and healthy condition rather than a medical issue requiring early attention. Consequently, individuals often delay seeking medical care until symptoms emerge, leading to missed opportunities for early intervention and preventive treatment ((Obsa et al., 2021). In addition, social stigma, secrecy, and fear of judgment often lead women to conceal their pregnancies in early stages. In The Gambia, many women deliberately delay antenatal care bookings in order to avoid social disapproval or perceived shame, often choosing to conceal early pregnancy and thereby missing out on recommended first‐trimester care (Parrish et al., 2023). In Ghana, entrenched sociocultural norms emphasizing modesty and discretion around pregnancy lead many women to delay booking antenatal care until their pregnancy is visibly apparent often into the second trimester thereby delaying essential early care ((Ziblim et al., 2022).In Ghana specifically, the interplay of economic hardship, cultural expectations, and strained health systems presents a unique barrier to early ANC. Women frequently face long queues at overcrowded clinics, unprofessional staff behavior, and a lack of privacy. (Wongnaah et al., 2025) Disrespectful treatment and poor communication between healthcare workers and pregnant women are commonly reported and contribute significantly to avoidance or delay of ANC booking (Dzomeku et al., 2020). In many parts of Africa, women have limited autonomy over health decisions, especially when they rely on their partners for transportation or financial support. South Sudanese women cited domestic chores and unsupportive spouses as key reasons for delay (Trecki & Smith, 2017). In Tanzania, the requirement for male accompaniment has led some women to avoid ANC altogether due to fear of being turned away or embarrassed: “lack of spouse’s escort and health providers’ disrespect” were among the major deterrents (Mgata & Maluka, 2019). Even when women understand the importance of early care, these complex and often overlapping barriers can turn awareness into inaction. A study from Eritrea found that although 72% of women knew the recommended time for booking, only 41% actually registered early. Many simply relied on what they perceived as “the right time” or delayed without reason (Estifanos et al., 2025). Understanding these diverse and deeply rooted challenges is essential not only for developing targeted public health interventions but also for equipping emerging Health professionals with the cultural competence, empathy, and advocacy skills needed to address maternal health inequalities. The persistent delay in ANC booking across Africa is not just a health service issue, it is a complex reflection of social structures, healthcare systems, and gender power relations. Given the multifactorial nature of these challenges, a scoping review is appropriate to explore the breadth and depth of barriers affecting early ANC booking across African contexts. This review aims to systematically map existing literature to identify demand-side (individual, household, community) and supply-side (health system, policy) barriers from 2000 to 2025. The purpose of this scoping review is to summarize studies published on barriers in assessing early antenatal booking in Africa. The insights gained from this scoping review will inform future studies and systematic reviews. Furthermore, the findings will guide policymakers, educators, and healthcare professionals in developing evidence-based interventions that support the achievement of Sustainable Development Goal (SDG) 3, which seeks to achieve good health and well-being for all at all ages(Nation, 2015). Additionaly, stakeholders can unlock opportunities for collaborative action, promote healthier, more resilient Africa women and accelerate progress towards sustainable development by addressing the complex interplay of factors underpinning early antenatal booking.