Enhancing Reproductive Healthcare Accessibility for Women of Reproductive Age in Africa

Abstract

Reproductive healthcare accessibility enhancement is integral in reducing maternal mortality among women of childbearing age in Africa. This chapter highlights the current status of reproductive healthcare access in Africa for women of childbearing age, using maternal mortality metrics (maternal mortality rate and maternal mortality ratio) of five countries representing the five African regions. Egypt represented Northern Africa, Nigeria represented Western Africa, the Democratic Republic of the Congo represented Central Africa, Ethiopia represented Eastern Africa, and South Africa represented Southern Africa. This chapter discusses the importance of reproductive healthcare access in achieving the third goal of the Sustainable Development Goals (SDG) and Universal Health Coverage (UHC). It also shows a positive relationship between reproductive health access and health-seeking behaviours using evidence from published studies. It also offers evidence-based recommendations to help enhance reproductive healthcare access among women of reproductive age in Africa.

1. Introduction

Addressing the problem of high maternal mortality ratio (MMR) in Africa can be achieved through enhancing reproductive healthcare access for women of reproductive age [1]. Studies have shown that many African nations have poor access to reproductive healthcare services, which has significantly contributed to 69% of the global maternal deaths occurring in Africa [2, 3]. Also, inadequate reproductive healthcare access has been shown to affect the healthcare-seeking behaviours of women of childbearing age [4]. Enhancing reproductive healthcare access may contribute significantly towards the global effort of achieving the 2030 SDG MMR goal of 70 per 100,000 live births in developing countries [1]. This chapter highlights the current status of reproductive healthcare access in Africa for women of childbearing age, the significance of improving reproductive healthcare access and the relationship of reproductive healthcare access to healthcare-seeking behaviours and offers evidence-based recommendations to improve reproductive healthcare access in Africa.

2. The current status of reproductive healthcare access in Africa for women of childbearing age

Access to reproductive healthcare for women of childbearing age in Africa is a pressing issue that significantly impacts maternal mortality rates. The continent struggles with considerable disparities in healthcare provision, resulting in notable differences between low-income and high-income regions [5]. Understanding the metrics used in measuring maternal mortality ratio (MMR) and the Maternal mortality rate (MMRate) and contributory factors that have affected reproductive healthcare access is instrumental to understanding the current status of reproductive healthcare access among women of childbearing age.

The ‘Maternal Mortality Ratio’ (MMR) measures the number of maternal deaths per 100,000 live births in a population at a given point in time that might occur as complications that may arise from pregnancy or childbirth, puerperium or related conditions only [6]. It provides a clear indication to understand the risk of maternal death per 100,000 live births in a particular population [5]. On the other hand, the ‘Maternal Mortality Rate’ (MMRate) helps in quantifying the number of maternal deaths per 1000 women of reproductive age (usually 15–49 years) [6].

According to a published article by the World Health Organisation, in 2020, the maternal mortality ratio in low-income countries fluctuated around 430 per 100,000 live births [5]. However, in high-income nations, the maternal mortality ratio was as low as around 13 per 100,000 live births [5]. The above comparison indicates a significant difference among the above category of nations, which highlights increased inequalities in accessing quality reproductive healthcare services in lower-income countries. For instance, countries in Sub-Saharan Africa in 2020 contributed to about 70% of the global burden of maternal mortality ratio [7]. Another example of high mortality ratios in low-income nations can be found in Southern Asia, which also contributed to about 16% (47,000 deaths) of the global burden of maternal mortality [5]. In addition, the lifetime risk of maternal deaths in low-income nations is 1 in 49, while in high-income nations, it is about 1 in 5300 [5].

Despite these notable challenges, African nations have witnessed gradual but significant improvements in their maternal health outcomes in the past 20 years (especially between 2000 and 2020). A 33% reduction in MMR was reported in African nations over the period, which indicates that some progress has been achieved in addressing issues affecting maternal health outcomes [7]. Although the above offers evidence of progress in the African region, such progress cannot be compared to the significant improvement in the reduction in maternal mortality ratio in European and some Asian nations, which is about 70 and 67% decrease in maternal mortality ratio, respectively [5]. These improvements illustrate that with sustained efforts and effective interventions, the maternal mortality ratio can be addressed effectively. The above figures indicate that while some achievements have been recorded, more efforts are still required to enhance reproductive healthcare access for women of childbearing age in Africa.

Africa is the second-most populous continent in the world after Asia [8]. However, it comprises nations that are categorised as middle-level developing to least developed nations in terms of economy, which has also affected other sectors, including the healthcare sector. Africa is divided into five (5) regions, and they are Northern Africa, Western Africa, Central Africa, Eastern Africa and Southern Africa [9]. To further understand the current status of reproductive healthcare access in Africa for women of childbearing age, it is essential to consider all the regions in Africa separately. Therefore, a representative nation from each region will be analysed to understand the status of reproductive healthcare access, as this will help offer a comprehensive overview of the subject matter in Africa. Egypt was selected to represent Northern Africa, Nigeria was selected to represent Western Africa, the Democratic Republic of the Congo was chosen to represent Central Africa, Ethiopia was selected to represent Eastern Africa, and South Africa was selected to represent Southern Africa.

2.1 North Africa (Egypt)

The current status of reproductive healthcare access for women of reproductive age in Egypt includes both achievements over the years as well as several challenges. Overall, the current status of maternal mortality rate in Egypt is 239 deaths per 100,000 live births, and maternal mortality ratio is 83 deaths per 100,000 live births [10]. Considering research investigations in Egypt, the following studies will offer insights into some of the contributory factors associated with maternal deaths in the country.

In 2015, a qualitative study on family planning in Egypt involving service providers and married women who are young, which focused on family planning services, offered relevant information to the context of this sub-section [11]. The study identified significant barriers to information access, service quality and reproductive decision-making ability regarding family planning services [11]. The study recommended the consideration of a right-based approach to enhance the empowerment of young married women to promote their reproductive rights, ensure structural changes to enhance service delivery and address the issues resulting in the barriers affecting access to reproductive healthcare access with regards to family planning [11].

In 2019, a community-based intervention was conducted on antenatal, delivery and postnatal care services in the two poorest regions in Egypt [12]. The study involved 22,644 women who participated in three stages of the intervention study [12]. The study identified that educating women about their healthcare rights and utilisation of maternal healthcare services enhanced their knowledge of their reproductive healthcare services [12]. The indicators of such improvements were enhanced knowledge of the women regarding their pregnancy rights, possession of pregnancy cards and their knowledge regarding safe delivery practices. Therefore, the study highlighted the importance of improving access to reproductive health education and high-quality care provided by government health facilities to improve reproductive healthcare access among women of childbearing age in the nation.

In the same year (2019), another study conducted in Egypt showed that pursuing higher education enhanced women’s decision-making power and resulted in a controlled fertility rate [13]. Higher education was also associated with achieving sustainable fertility in the nation [13].

Furthermore, in 2021, the association between education and women’s empowerment with access to reproductive healthcare services was investigated [14]. The study showed that women’s education and empowerment showed significant associations with receiving reproductive healthcare, especially among women who were poor and lived in rural settings [14]. It was also noted that the level of the husband’s education showed a significant impact on their wives’ access to reproductive healthcare services [14].

A more recent study provided new perspectives on how intersectionality impacts women’s ability to access sexual and reproductive health services in Egypt [15]. The research indicated that married women frequently had insufficient understanding of their sexual and reproductive well-being, which was impacted by various factors such as power imbalances, economic conditions, cultural standards, and misconceptions based on religion. These elements hindered these women’s ability to obtain equitable and appropriate sexual and reproductive healthcare services [15]. The research demonstrated that implementing health promotion methods, such as educational initiatives and awareness programmes, can improve women’s ability to access reproductive healthcare services, regardless of marital status.

In summary, the present maternal mortality rate in Egypt, as recorded in the latest DHS survey, is influenced by a range of factors. Decreasing maternal deaths requires implementing various measures to improve women’s access to reproductive healthcare services. Tackling these issues necessitates a comprehensive strategy involving educational changes, community-based actions and empowerment initiatives to guarantee that all women, regardless of their economic status or location, can avail the reproductive healthcare services they require and are entitled to.

2.2 Western Africa (Nigeria)

The current situation regarding access to reproductive healthcare in Western Africa, especially in Nigeria, is characterised by a multifaceted environment influenced by socioeconomic, cultural and systemic hurdles. In the last published demographic health survey in Nigeria, the maternal mortality rate in Nigeria was recorded as 576 deaths per 100,000 live births, and the maternal mortality ratio was noted as 512 deaths per 100,000 live births [16].

Several research studies have highlighted the various challenges that limit women’s ability to obtain necessary reproductive health services, such as family planning and maternal healthcare. One of the Nigerian studies offers a human rights perspective, stressing the need to recognise reproductive health as a fundamental right in the nation [17]. Despite global frameworks supporting reproductive rights, Nigeria faces legislative and cultural challenges that hinder realising these rights [17]. The article recommends legislative reforms and a shift in culture to enhance women’s access to safe motherhood, contraception and protection against harmful practices like female genital mutilation [17].

A study in Benue State, Nigeria, emphasised the significant impact of inadequate infrastructure and economic constraints on reproductive health in Nigeria [18]. The study showed that a substantial proportion of women faced barriers due to economic limitations, with 94.5% of respondents identifying economic status as a major obstacle to accessing healthcare [18]. The study’s findings implied that there is a significant need for comprehensive efforts to enhance infrastructure and economic conditions, which will help promote women’s access to reproductive healthcare services.

Age disparities between young mothers and older mothers have been reported among Nigerian women, with younger mothers experiencing significant barriers in utilising healthcare facilities for delivery purposes [19]. The study findings inferred that age-sensitive interventions that promote early engagement with healthcare services to improve maternal and reproductive health outcomes are necessary and required [19].

A 2023 report by Public Services International discussed Nigeria’s maternal and reproductive health programs, acknowledging their potential as well as critiquing their limitations in addressing underlying structural barriers [20]. The report showed that gender biases and restrictive cultural norms persisted, which affected the right and autonomy of such women to make their reproductive healthcare decisions and access quality reproductive healthcare services. The report highlighted the need for transformative approaches that challenge traditional gender roles and empower women to access healthcare independently [20].

Another study showed that reproductive health concerns are affected by access to information and reproductive health services [21]. Their survey highlighted significant public interest in sexual health, contraceptio, and fertility issues, as well as a strong demand for improved access to services through various channels, including social media and community health workers [21]. This reflects individual opinions on the barriers in current service provisions and the need for inclusive strategies to reach diverse demographic groups.

Disparities exist in the urban and rural access to skilled healthcare providers during antenatal and delivery care in a particular area in Nigeria, using a comparative study in Abia State as an example [22]. While urban areas showed higher utilisation rates, rural areas showed limited utilisation due to logistical challenges and inadequate healthcare facilities [22]. It is essential to implement specific measures to enhance healthcare facilities and services in rural areas. Maternal mortality in Nigeria is primarily due to conditions such as hypertensive disease during pregnancy, septicemia, haemorrhage, obstructed labour and unsafe abortion. Skilled birth attendants are crucial in addressing these emergencies.

In summary, to effectively tackle the existing obstacles in reproductive healthcare access in Nigeria, a comprehensive strategy that encompasses economic progress, gender equality, legal changes and involvement of local communities is needed. The emphasis should be on enhancing infrastructure and expertise, enabling women to make knowledgeable choices and addressing cultural and systemic obstacles to ensure fair access to reproductive health services for all segments of the population.

2.3 Central Africa (Democratic Republic of the Congo)

The existing state of reproductive healthcare access in the Democratic Republic of the Congo (DRC) in Central Africa showcases a complex situation marked by advancements as well as enduring obstacles. As per the Democratic Republic of Congo (2013–2014 DHS) data, the maternal mortality rate stands at 846 deaths per 100,000 live births, with a maternal mortality ratio of 554 maternal deaths per 100,000 live births [23]. Despite concerted efforts and increasing international support, the utilisation of modern contraception (MC) remained low among Congolese women aged 15–49. This demographic group faces substantial barriers, including limited access to comprehensive family planning services and entrenched cultural norms in favour of larger families [24].

The study emphasises the important role of women’s ability to make independent healthcare decisions, particularly in choosing modern contraceptives [25]. The research revealed that women who made decisions about their healthcare on their own were much more inclined to use modern contraceptives [25]. This underscores the significant importance of empowering women to autonomously manage their reproductive decisions, ultimately leading to increased use of modern contraceptives in the DRC.

In addition, the availability of safe abortion services continues to be a debated topic in the DRC because of unclear historical laws. The implementation of the 2018 Public Health Law and the accompanying Ministry of Health directives represent a significant move in clarifying legal structures and improving reproductive rights [26]. These legal developments are essential for protecting women’s health and rights, reducing the dangers of unsafe abortions and advocating for comprehensive reproductive health services throughout the nation.

Enhanced focus on family planning in the DRC has led to gradual progress, particularly in urban areas such as Kinshasa, where there has been an improvement in the use of modern contraceptives [24]. However, obstacles remain at a national level, including difficulties in managing the supply chain for contraceptives and insufficient healthcare facilities in remote regions [24].

The United States Agency for International Development (USAID) Integrated Health Program (IHP) has significantly contributed to increasing the availability of family planning services by implementing creative outreach methods in different regions of the DRC [27]. The programs they have put in place have raised consciousness and given women the ability to participate in making decisions about family planning. This has encouraged positive changes in behaviour and community-level support for reproductive health rights.

In summary, the Democratic Republic of the Congo has made progress in improving access to reproductive healthcare, but significant challenges persist. This is evident in the high rate of maternal mortality, which is much higher compared to Nigeria in West Africa and Egypt in North Africa. It is crucial to continue investing in healthcare infrastructure, enacting legal reforms and implementing community-based empowerment programmes to further reproductive rights, decrease maternal mortality and ensure fair access to comprehensive healthcare services throughout Central Africa.

2.4 Eastern Africa (Ethiopia)

In Ethiopia, women of childbearing age encounter considerable obstacles in accessing reproductive healthcare services, as recent studies have pointed out. The Ethiopian Demographic Health Survey (2016 DHS) revealed a maternal mortality rate of 412 deaths per 100,000 live births and a maternal mortality ratio of 353 maternal deaths per 100,000 live births in the region. [28].

Analysis of the 2016 Ethiopia Demographic and Health Survey showed that 71.0% of women of reproductive age face challenges when trying to access healthcare services [29]. Unmarried women have significant issues as some of their demographic characteristics have worsened their access to those services, such as lower educational attainment (including primary education), coming from rural residents and women from poorer and middle-wealth status households [29]. Other factors, such as being unemployed or engaged in agriculture, have also contributed significantly to these access challenges [29].

A study recently conducted in the southern region of Ethiopia highlights inadequate service utilisation of sexual and reproductive health services [30]. The research findings indicated that in 2023, only 54.4% of women of reproductive age made use of sexual and reproductive health (SRH) services, and many of these women experienced workplace harassment. The study highlighted the necessity for specific outreach initiatives aimed at improving the accessibility of SRH services for marginalised groups such as construction workers [30].

Insufficient participation in health insurance has led to a decline in the use of reproductive health services by women of childbearing age, ultimately impacting their ability to access reproductive healthcare services [31]. The research findings indicate that just 43.2% of women of reproductive age in the study group have registered for insurance programs. The associated factors include residing in a rural setting, coming from a large family, coming from a particular region and having religious beliefs [31]. The study advocated for improved awareness and support to enhance health insurance coverage among women, thereby promoting universal health coverage (UHC) [31].

Barriers to healthcare access from the perspective of women of reproductive age in Ethiopia have been reported [32]. About 69.9% of the study participants reported challenges in accessing healthcare services with the following significant associated factors: rural residency, older age groups, marital status, educational level, and economic status [32]. The study highlighted the importance of addressing these factors through policy interventions to improve healthcare access [32].

Other factors, such as individual and community-level factors, were also identified to significantly influence the challenges hindering healthcare access among married women in Ethiopia [33]. The study findings highlighted the following factors, such as education, socioeconomic status and community literacy, as significant factors that can be worked on to reduce the barriers to healthcare access [33]. The study recommended multidimensional strategies to enhance healthcare access by addressing individual and community-level factors [33].

Therefore, reproductive healthcare access for women of childbearing age persists as a critical issue in Ethiopia and is associated with several factors, such as socioeconomic, educational and geographical. Addressing these challenges requires targeted policy interventions to improve educational opportunities, socioeconomic status and healthcare infrastructure to achieve equitable healthcare access for women of childbearing age in Eastern Africa.

2.5 Southern Africa (South Africa)

In Southern Africa, particularly in South Africa, access to reproductive healthcare for women of childbearing age remains an issue of significant concern, even though they had lower maternal mortality compared to other representative regions in Africa that have been reviewed. According to the 2016 DHS Country, the maternal mortality rate was 219 deaths per 100,000 live births, and the maternal mortality ratio was 141 maternal deaths per 100,000 live births [34]. Socioeconomic, cultural and healthcare system factors characterise such indicators. Several studies highlight the multifaceted challenges and varying access points that influence women’s reproductive health outcomes.

According to a study conducted in 2015, young women of the 18–24 age group faced significant challenges in accessing and utilising SRH services in Soweto [35]. Although the level of awareness was reported to be good, barriers such as healthcare provider attitudes, poor relations and poor communication with healthcare providers have worsened the problem significantly. Hence, the study recommends youth-friendly services that provide age-appropriate information and support healthy sexual practices to enhance access to SRH services in the area [35].

Regarding improving reproductive outcomes, the prevalence and factors affecting reproductive health outcomes have been reported among South African women [36]. The prevalence rates measured include teenage pregnancy rate (44.4%), HIV prevalence rate (17.1%), sexually transmitted infections rate (40.5%) and female genital schistosomiasis rate (19.7%). The factors contributing to such prevalence levels include early sexual debut, inconsistent contraceptive use and socioeconomic differences. Therefore, the study recommends that addressing the complex relationship between individual behaviours and systemic challenges is relevant to enhancing reproductive healthcare access among such women.

Migration status was another identified factor affecting SRH services among South African women, especially in contraceptive use [37]. Migration status, educational level and knowledge about SRH are critical determinants of contraceptive accessibility and usage [37]. The findings suggest the need for targeted SRH programmes that address the specific needs of migrant populations and promote comprehensive knowledge dissemination [37].

The policy and advocacy landscape surrounding women’s reproductive rights in South Africa can influence their access to quality reproductive services [38]. The study showed that the legalisation of abortion contributed to a better way to enhance reproductive utilisation by women of childbearing age in South Africa [38]. However, many oppositions, such as stigma, poor dissemination of information, and an increase in the number of conscientious objectors, to this policy, the Termination of Pregnancy Act, have also impaired the use of safe abortion services, thus leading to an increase in patronage of unsafe abortion services [39]. Therefore, a change in policy can help address the factors that have impeded the progress of improving reproductive healthcare access among women in the nation. Thus, addressing these factors will help improve reproductive healthcare services among women of childbearing age in the country.

Also, community and healthcare providers’ opinions on access to reproductive healthcare services have been investigated [40]. The study findings highlight that increasing access to free contraceptive services is hampered by service availability, long waiting times and limited provider training, which are termed structural barriers affecting the access to contraceptive services among women of childbearing age in South Africa [40].

In summary, the current status of reproductive healthcare access in Southern Africa particularly shows a complex interplay of socioeconomic, cultural and systemic factors. Addressing these challenges requires multidimensional approaches, including youth-friendly services, comprehensive SRH education, targeted interventions for migrant populations and policy reforms that safeguard women’s reproductive rights and health outcomes. These efforts are crucial for achieving equitable access to reproductive healthcare services and promoting women’s overall health and well-being in the region.

3. The significance of improving reproductive healthcare access

Reproductive healthcare is a crucial component of public health, impacting maternal, newborn and child health outcomes globally. Achieving the third Sustainable Development Goal (which aims to ensure the achievement of healthy lives and well-being for all) and universal healthcare coverage (UHC) is intricately linked with improving reproductive healthcare access.

3.1 The need for achieving SDG 3 (ensure the achievement of healthy lives and well-being for all)

3.1.1 Maternal and child health targets

The 3.1 section of SDG 3 sets a goal to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 [41]. Achieving this global status by many nations of the world, including African countries, lies in enhancing and addressing the barriers affecting women of reproductive age from accessing quality reproductive healthcare services. The World Health Organisation emphasises the need for urgent action, noting that many countries are likely to meet their national targets with significant interventions [41]. Factors contributing to maternal mortality include postpartum haemorrhage, eclampsia, sepsis and unsafe abortion, underscoring the critical need for improved healthcare infrastructure and emergency obstetric care services [42]. Hence, these factors must be addressed to increase access for women of reproductive age to enjoy high-quality healthcare services.

3.1.2 Child health and mortality

Section 3.2 aims to end preventable deaths of newborns and children under 5 years of age, striving for neonatal mortality rates as low as 12 per 1000 live births and under-5 mortality rates as low as 25 per 1000 live births globally by 2030 [41]. This target necessitates comprehensive healthcare strategies to enhance maternal healthcare access, including nutrition services, immunisations, and access to quality maternal and child health services [41]. Therefore, enhancing such access to maternal healthcare services will improve child health and reduce child mortality.

3.1.3 Maternal, newborn, child and adolescent health

Ensuring universal access to sexual and reproductive health services is pivotal in achieving Sustainable Development Goal (SDG) 3.7, which aims to support maternal, newborn, child and adolescent health by promoting comprehensive reproductive healthcare rights and services [41]. This goal recognises that access to such services improves health outcomes and empowers individuals to make informed decisions about their reproductive health, thereby contributing to broader societal well-being [41].

Access to reproductive healthcare services encompasses a spectrum of interventions, including family planning, maternal healthcare and safe abortion services where legal. Family planning, in particular, plays a crucial role in reducing unintended pregnancies, maternal mortality and unsafe abortions [43]. It enables individuals and couples to decide their children’s number, timing and spacing, which has long-term implications for maternal and child health outcomes [6].

Despite global commitments, significant disparities in access persist, disproportionately affecting marginalised populations, including women in rural areas, adolescents and those in least developed areas. These disparities are exacerbated by socioeconomic factors, cultural norms and legislative restrictions that limit access to comprehensive reproductive healthcare services [42]. For instance, restrictive laws and policies on abortion hinder access to safe procedures, leading to higher rates of maternal mortality and morbidity in regions with limited healthcare infrastructure [40, 43].

International cooperation and advocacy play crucial roles in advancing reproductive health rights and dismantling barriers to access [41]. By promoting evidence-based policies, supporting health system strengthening and empowering communities to demand and utilise services, stakeholders can accelerate progress towards achieving SDG targets related to maternal, newborn and child health through enhancing access to reproductive healthcare access [41].

The global commitment to SDGs necessitates collaborative efforts across sectors and regions. It has been shown that progress and challenges have been encountered within Gulf Cooperation Council (GCC) states, where initiatives have reduced maternal mortality. However, gaps remain in comprehensive reproductive healthcare access, particularly concerning cultural barriers and disparities in service delivery, especially in the least developed nations in Africa [42].

While substantial effort has been put in place to meet the SDG 3 goal, concerted efforts are needed to bridge gaps in healthcare infrastructure, address socio-cultural barriers and advocate for policy reforms that support comprehensive reproductive healthcare rights and enhance access to reproductive healthcare services for women of reproductive age. By prioritising these efforts, countries, including African nations, can accelerate progress towards achieving SDG 3 and ensuring healthy lives for all.

In summary, expanding access to reproductive healthcare services is a public health imperative and a human rights issue critical for achieving SDG 3 and promoting equitable and sustainable development worldwide. African nations can accomplish these goals by addressing barriers and investing in comprehensive reproductive healthcare to ensure adequate healthcare access is provided for women of childbearing age in their countries.

3.2 The need for achieving universal healthcare coverage (UHC)

Ensuring that every woman has access to reproductive healthcare services is also helpful for accomplishing Universal Healthcare Coverage. The journey towards achieving universal health coverage (UHC) includes improving the availability of essential healthcare services and addressing obstacles that hinder progress in providing reproductive healthcare for women of childbearing age.

3.2.1 Primary healthcare systems

WHO emphasises that sexual and reproductive health (SRH) is integral to health and well-being across the life course and must be embedded within PHC systems for universal access to be achieved [41]. These services not only contribute to reducing maternal mortality and morbidity but also empower individuals to make informed choices about their reproductive health [44].

However, despite global commitments, substantial gaps in SRH service access persist, affecting billions worldwide, particularly women, adolescents and marginalised populations, such as in Africa. Integrating SRH into PHC for UHC requires political commitment, coherent strategies and sufficient resources [41]. Evidence suggests comprehensive SRH services integrated into PHC can improve health outcomes, enhance service delivery efficiency and promote health equity across diverse socioeconomic and cultural contexts [44].

The WHO has developed practical tools and resources to support countries in integrating SRH into broader UHC reforms. The Handbook on Integrating SRH within PHC Strategies guides planning, implementing and monitoring of integrated SRH services. It emphasises the importance of aligning national health benefit packages with SRH needs, ensuring service availability and enhancing healthcare provider competencies [41]. This approach enhances service delivery and promotes accountability and inclusivity in healthcare systems.

The Learning by Sharing Portal (LSP) also offers qualitative case studies and best practices from countries worldwide, showcasing innovative approaches to SRH-UHC integration. These examples highlight the role of policy reforms, community engagement and multi-sectoral partnerships in expanding SRH service coverage and improving health outcomes [41].

3.2.2 Challenges and opportunities

Despite progress, several challenges hinder universal access to SRH services. These include policy and legal barriers, inadequate financing, gender inequalities and socio-cultural norms that restrict access to essential SRH interventions like safe abortion services and reproductive cancer care [44]. Addressing these barriers requires sustained advocacy, increased public financing for SRH and strategies to overcome gender-based disparities in service provision.

Evidence indicates that countries with robust PHC systems and inclusive SRH policies achieved better health outcomes and reduced health inequities. For instance, Ireland’s approach to strengthening abortion services and Thailand’s adoption of health technology assessments for vaccine inclusion demonstrate effective strategies within local contexts [41].

Moving forward, enhancing the priority of SRH within national EPHS and health budgets is crucial for achieving UHC goals. Finding secure and long-lasting funding methods can decrease the need for direct payments, making sexual and reproductive health services more affordable and financially accessible to marginalised communities [44]. Additionally, building alliances among governmental entities, non-governmental organisations and private businesses can utilise resources and knowledge to broaden sexual and reproductive health service availability and enhance service standards.

Additionally, it is crucial to achieve universal health coverage in order to address these disparities and guarantee fair and equal access to vital reproductive health services. This involves enhancing healthcare systems to provide inclusive, affordable and culturally suitable quality services for various populations [41]. Investments in healthcare infrastructure, workforce training and community-based outreach programmes are essential to expanding service delivery and addressing barriers such as geographic isolation and lack of information [6].

In summary, achieving universal access to SRH services through integrated PHC is essential for advancing UHC and fulfilling global health commitments. The WHO’s tools and initiatives provide practical frameworks for policymakers, implementers and stakeholders to strengthen SRH service integration, promote health equity and improve health outcomes globally. African countries can adopt the WHO strategies and guidelines to address barriers and invest in comprehensive SRH interventions to facilitate access to reproductive healthcare services among women of childbearing age.

4. Relationship of reproductive healthcare access with healthcare-seeking behaviour

Numerous studies in various geographical areas have highlighted the intricate relationship between the availability of reproductive healthcare and individuals’ healthcare-seeking habits. These factors influence a range of socio-cultural, economic and educational factors.

A study carried out among women residing in rural communities in the Haramaya region of East Ethiopia examined the patterns of seeking maternal healthcare [4]. The research results indicated that improving healthcare availability and increasing the utilisation of maternal healthcare services played a crucial role in decreasing maternal illness and death. There is a notable disparity in the utilisation of antenatal care services, hospital deliveries and postnatal care among women. The study reported that educational status, awareness of pregnancy complications and religious beliefs were significant determinants of healthcare-seeking behaviour [4]. Hence, it was suggested that healthcare providers’ targeted health education and supportive counselling could enhance maternal healthcare-seeking behaviours [4].

Another study conducted among rural women in Telangana investigated healthcare-seeking behaviour [45]. The study showed poor healthcare-seeking behaviour despite the high awareness among individuals regarding healthcare centres in the study area. Most participants reported that they often visited unqualified healthcare professionals or used home remedies [45]. Therefore, distance to the health facility and improved health behaviour are related to healthcare accessibility. Thus, increasing access to available health centres and access to qualified medical practitioners is essential to enhance positive health-seeking behaviours in rural settings.

Maternal health outcomes in northwest Nigeria, known for having the highest maternal illness and death rates in Africa and globally, have been the subject of research [46]. The research results indicated that various socio-cultural and economic aspects, such as restricted ability to make decisions, deep-seated cultural beliefs, lack of education and limited healthcare access, serve as significant obstacles to using healthcare services [46]. The research suggested taking action to engage husbands, who are often in charge of healthcare decisions within households, and to improve women’s access to education in the area.

Envuladu et al. conducted a study on the utilisation of sexual and reproductive health (SRH) services among adolescents in Plateau State, Nigeria [47]. The research discovered that nearly all of the teenagers had not sought out healthcare facilities for sexual and reproductive health (SRH) concerns. Additionally, over half of them expressed unwillingness to seek such help in the future [47]. The main factors contributing to this hesitancy included concerns about privacy and confidentiality, as well as receiving negative attitudes from healthcare providers [47]. The research suggested that enhancing these factors and raising awareness about sexual and reproductive health before initiating sexual activity could potentially boost adolescents’ access to sexual and reproductive health services in the area studied [47].

The research emphasises that the utilisation of reproductive healthcare services is closely tied to healthcare-seeking habits, which are greatly affected by educational, socio-cultural and economic aspects. In Ethiopia, a woman’s education and understanding of pregnancy complications played a vital role in her decision to seek maternal healthcare services [4]. In Telangana, knowing about the healthcare facilities was crucial but not enough on its own, as it did not address the prevailing dependence on unqualified healthcare providers [45]. The healthcare-seeking behaviours of women in northwest Nigeria are significantly influenced by traditional cultural practices and the dynamics of household decision-making, particularly the influence of husbands [46]. The above studies show that improving women’s access to education and including key decision-makers in the household in health initiatives can lead to better utilisation of healthcare services. Adolescents in Plateau State encounter barriers when trying to access sexual and reproductive health services, including challenges related to privacy, confidentiality and healthcare provider attitudes [47]. This emphasises the need for healthcare systems to give more attention to these issues in order to effectively assist adolescents in utilising the services that are available to them.

Therefore, improving access to reproductive healthcare can positively impact women’s healthcare-seeking habits when using such services. However, a comprehensive strategy that includes teaching, cultural sensitivity and fundamental modifications in healthcare provision is required. Tailored health education, guidance, involvement of pertinent parties and protecting privacy and confidentiality are crucial methods for improving the accessibility of reproductive healthcare services.

5. Evidence-based recommendations to improve reproductive healthcare access in Africa

Enhancing reproductive healthcare access in Africa necessitates a comprehensive approach, as underscored by various studies. These studies identify effective interventions, challenges and strategies for scaling up access to reproductive healthcare services.

5.1 Youth-friendly health services/adolescent health services in Nigeria

Youth-Friendly Health Services (YFHS) represents a cost-effective approach/intervention to addressing the sexual and reproductive health needs of young individuals in sub-Saharan Africa (SSA) [48]. Their review identifies significant implementation strategies: stakeholder training, infrastructure modification and consumer engagement. The study showed that YFHS interventions were effective; however, optimisation and sustainability of these interventions in resource-limited settings, such as Africa [48], are required. The implementation of YFHS can be achieved by channelling the strategies to specific contexts and regularly evaluating their effectiveness and sustainability. In addition, another study has investigated four Nigerian states integrating adolescent and youth-friendly health services (AYFHS) within a systems-based approach [49]. The study showed that implementing a streamlined quality assurance (QA) tool and follow-up quality improvement (QI) activities achieved significant improvements in contraceptive services for adolescents and youth. Training providers and using quality assurance/quality improvement tools within supportive supervision systems can effectively enhance the quality and uptake of AYFHS [49].

5.2 Maternal health interventions

A systematic review study that offers a realist synthesis of maternal health interventions in low- and middle-income countries shows helpful interventions that can help enhance maternal health outcomes [50]. The study underscores the significance of healthcare system infrastructure in the success of these interventions. Effective interventions often involve increasing knowledge and awareness among individuals and healthcare providers regarding maternal health [50]. The study also emphasises the importance of engaging communities and families to address social and cultural norms that influence healthcare-seeking behaviours [50].

5.3 Reforming primary health care

A review of interventions aimed at improving primary healthcare (PHC) for maternal, newborn and child health (MNCH) in SSA has been conducted [51]. Effective strategies include financial incentives, task-shifting, community-directed engagements and mobile health. The review suggests that to improve access to and quality of PHC services, these interventions must be scaled up and sustained through appropriate policies and programmes [51]. The findings provide valuable insights into reforming PHC systems to enhance regional MNCH outcomes. Also, adopting the practical tool offered by the WHO can be beneficial. The Handbook on Integrating SRH within PHC Strategies guides planning, implementing, and monitoring of integrated SRH services. It emphasises the importance of aligning national health benefit packages with SRH needs, ensuring service availability and enhancing healthcare provider competencies [41].

5.4 Institutionalising health technology assessment

The role of health technology assessment (HTA) in designing health benefit packages for sexual and reproductive health and rights (SRHR) has been identified as an effective intervention to improving reproductive healthcare access [52]. The study highlights the need for stakeholder participation and standardised assessment processes to ensure fair and effective SRHR interventions. Institutionalising HTA and establishing clear decision-making criteria can help integrate diverse social values and improve SRHR outcomes [52].

5.5 Promoting task sharing for family planning

Implementing task sharing for family planning in five sub-Saharan African countries was reviewed by Ouedraogo et al. [53]. The study found that involving community health workers, midwives and nurses in delivering contraceptive services significantly increased the contraceptive uptake rate. Despite the success, poor provider retention and inadequate documentation persist [53]. Task-sharing is a promising strategy to enhance family planning services, but it requires robust policy frameworks and effective data systems for sustainability.

Therefore, to enhance reproductive healthcare access in Africa, evidence-based strategies must address the unique needs and challenges of the region. Thus, considering the identified evidence-based interventions (Youth-Friendly Health Services/Adolescent Health Services in Nigeria, maternal health interventions, reforming primary healthcare, institutionalising health technology assessment, promoting task-sharing for family planning) will help in enhancing reproductive healthcare access, reducing maternal mortality and improving the achievement of SDG 3 and UHC global goals in African nations.

6. Conclusion

This chapter has discussed comprehensively the theme of enhancing reproductive healthcare access for women of childbearing age in Africa. It highlighted the current status of reproductive healthcare access in Africa by using maternal mortality metrics and evidence from existing studies that have highlighted the factors influencing reproductive healthcare access among women of childbearing age. It discussed the importance of reproductive healthcare access in achieving SDG 3 and UHC. In addition, it showed that a positive relationship exists between reproductive health access and health-seeking behaviours using evidence from published studies. It finally identified five recommendations that will help enhance access to reproductive healthcare access among women of reproductive age, which African nations can adopt based on the unique challenges of the region.

Acknowledgments

I want to extend my sincere appreciation to my former master’s supervisor and current co-author, Professor Charles Tobin-West, for his guidance, support, corrections, feedback, and constructive criticism throughout the development of this chapter despite his tight schedule. I would also like to express my heartfelt gratitude to my parents (Mr. and Mrs. David Ngweeh), Siblings (Jonathan, Bethel, & Kingsley) and friends (Samson, Rejoice, Salvation, Oyiza, and Frank) for their unwavering support and encouragement throughout this journey.

Conflict of interest

The authors declare no conflict of interest.

Thanks

Thank you, IntechOpen, for deeming us worthy of contributing to this global project. I look forward to future opportunities for collaboration.