A systematic search was conducted with six electronic databases, including MEDLINE, PubMed, Web of Science, Scopus, ProQuest Sociological Abstract, and ProQuest Dissertation and Theses, to identify studies for inclusion in the review. For the MEDLINE database search, the Ovid interface was used, and for the PubMed database search, as PubMed includes all MEDLINE records, only resources apart from MEDLINE (e.g., PubMed Central articles) were used. All databases encompass published manuscripts in health and biomedical sciences, social sciences, public health, and nursing, offering relevant insights into the specific topic of interest [5]. The search with electronic databases was first undertaken in November 2019 and then updated in June 2024. To identify additional literature, first conducted in 2019 and then repeated in June 2024, Google Scholar, Google, and Leeds University Library were accessed using keywords (Table 1). The search included medical subject headings (MeSH) and text words for barriers and facilitators, maternal healthcare access, and maternal healthcare utilization. The Population, Intervention, Comparison, and Outcome (PICO) model (see an example in Table 1) was used to develop the search terms from the research question: What are the barriers and facilitators to accessing and using MHC services by rural Bangladeshi women? An example of search terms in MEDLINE (Ovid) has been included in Supplementary Material S1. Study titles and abstracts were screened first, and then full-text versions of potential citations were retrieved for detailed examination based on the eligibility criteria below.

Studies were included in the review if they: (i) incorporated access to and use of MHC services by women aged 16–49; (ii) were full-type peer-reviewed studies published in the English language; (iii) were conducted in Bangladesh; and (iv) were published after 2000. This review examined changes in MHC services in Bangladesh over the past two decades as the nation’s healthcare system has undergone changes during that time [5]. For example, in 1998, community clinics were built to provide MHC services to women residing in rural Bangladesh [22]. As a result, studies pertaining to these services were not published before 2000.

Studies were excluded when they included texts not available in full and primary data, such as conference abstracts, commentaries, editorials, and opinion papers.

A total of 3,619 publications were identified from electronic databases and manual searches. 1903 publications from the electronic databases were removed because of duplication, and the remaining 1706 abstracts were screened. Duplicate detection of studies was executed using EndNote software and a manual process where each individual study was checked. Of these, 1,045 publications were excluded based on the exclusion criteria. The full texts of the remaining 565 studies were examined in detail, and 538 studies were further excluded. Therefore, 27 studies were included from the database search. Additionally, 10 studies were identified from a manual search of the reference lists of the studies included, and they were all included after assessment. Finally, 37 studies were considered eligible and included in this review. A PRISMA flowchart was used to enhance the transparency and reporting of the literature search and selection process, as summarized in Figure 2.

The selected studies were assessed to determine their level of quality. As the review encompassed multiple study designs, three different appraisal checklists were used to assess qualitative, quantitative, and mixed methods (MM) studies (Supplementary Material S2), as recommended in the literature [23] and found in practice [24]. For this assessment process, cohort and randomized control trial (RCT) studies were assessed using the Critical Appraisal Skills Programme (CASP) checklists [25, 26], and cross-sectional quantitative studies using the critical appraisal checklist for cross-sectional studies that was adapted from Combie [27]. Additionally, the CASP checklist [28] was used to appraise qualitative studies, and the mixed methods appraisal tool (MMAT) version 2018 [29] for MM studies. Appraisals included a minimum of 10 and a maximum of 17 questions with possible answers of “Yes,” “No,” or “Can’t tell.” Each question contains one score.

To classify the quality of studies included in this review, a scoring procedure used in another review [24] was adopted for all the appraisals: (i) the individual score for each study was calculated based on the appraisal questions in each row of the Table (Supplementary Material S2); (ii) the score achieved was divided by the total score, and then converted into a percentage; and (iii) finally, three categories based on the percentage and range were made to classify the quality of the studies: 80%–100% = high, 60%–79% = medium, and <60% = low. Descriptive responses were not counted for scoring, and explanations were provided for each question.

Thematic synthesis [30] was used for data synthesis as this review included heterogeneous study designs, and is recommended by the literature [30, 31]. There are trends in the use of thematic synthesis for narrative review in healthcare research where there is heterogeneity in studies [32, 33]. Thematic synthesis is considered an adaptation of thematic analysis to synthesize the research studies and offers a range of established methods and techniques for the identification and development of analytic themes in first-hand data [30]. Thematic synthesis [30] based on the SEM [17] was undertaken. Based on the SEM levels of influence, the extracted data were inductively coded, and themes and subthemes were then identified (Supplementary Material S3).

The characteristics and key findings were extracted and tabulated according to the Ma et al. [18] guidelines. The main characteristics include: (i) author(s) and year of publication, (ii) region where the study was conducted, (iii) aims of the study, (iv) study design, (v) sampling method and participants, (vi) types of healthcare services, and (vii) main findings, including barriers and facilitators. Initially, the studies were grouped and summarized separately on the basis of quantitative or qualitative design. Likewise, data obtained from the quantitative and qualitative components of the MM studies were included in the relevant group. The characteristics and key findings of these studies are summarized and categorized in Table 2.

Table 2 presents a summary of the characteristics of the studies included in this review. Studies were published between 2001 and 2023. The majority of studies were published between 2011 and 2018 (n = 23; 62%). Most of the included studies (n = 29; 78%) in this review were considered of high quality, and the remaining eight were of medium quality (Table 2). The review included 37 studies, of which 24 were quantitative, 10 were qualitative, and three were MM studies. Fourteen studies were carried out in rural locations, and the remaining 23 studies focused on both rural and urban locations.

Four key themes related to accessing and using MHC services by rural Bangladeshi women emerged from the thematic analysis of the studies, using the SEM as the guiding framework: (i) individual-level barriers and facilitators; (ii) family-level barriers and facilitators; (iii) community and social-level barriers and facilitators; and (iv) organizational-level barriers and facilitators.

This theme included two sub-themes, including demographic barriers and facilitators and lack of self-confidence in treatment.

Fifteen quantitative [34–48], two MM studies [49, 50], and one qualitative [51] out of the 37 studies focused on demographic barriers to women accessing MHC services. Women and their husbands with lower levels of education [34, 35, 37–41, 43–49, 51, 52] reported having less access to MHC services. Educated mothers were approximately 16 times more likely to receive ANC compared to illiterate mothers, and 14 times more likely to obtain the components of ANC content visits, such as counselling regarding danger signs [35].

Another barrier is related to the early age of being married and being a mother of women. Women living in rural Bangladesh reported that early age of marriage [35, 36, 38, 43, 49] and early age of being a mother [36, 38–41, 43, 45, 46] impeded them from accessing and using MHC services. Women aged 30–49 in rural Bangladesh reported that they had twice as many facility-based deliveries compared to the younger group [36]. In addition, higher parity (the number of children a woman has had) [34, 36–41, 44, 46], mothers’ involvement with no income-generating activities [34, 36, 38, 43, 46], unintended pregnancy [38, 45], and lack of ANC checkup [48] were also identified as barriers to accessing and using MHC services for women living in rural Bangladesh.

Positive associations between demographic facilitators and access to and use of MHC services were identified in 16 quantitative studies [34, 36–41, 43–48, 52–54] and one MM [50]. Four facilitators were found to be associated with access to and use of MHC services by women: higher literacy level enabled women to be aware of the MHC services [38, 40, 41, 43–48, 52–54]; low parity [35–37, 40, 44]; having income made women capable of affording the cost associated with services [46, 50, 53]; and the mother being older showed greater experience of seeking services [36, 38]. For example, ANC visits were found to be three times higher among mothers with a higher level of education compared to mothers with no education [35].

Ten studies, five qualitative [55–59] and five quantitative [34, 38, 52, 54, 60], reported on the lack of self-confidence in MHC treatment among women living in rural Bangladesh. This lack of self-confidence was based on a number of factors. Misconceptions or limited knowledge of MHC services [54–57, 59, 60] were reported as the reason for women’s self-confidence in treatment. In most cases, women living in rural areas of Bangladesh were not informed about the reasons for their physical examinations [55, 59], taking medicines [57], and menstrual regulation (MR) services [56, 59], which led to misconceptions among them. Additionally, fear in using MHC services [55–60] was identified as being linked with women’s lack of self-confidence. Fear was mostly reported to be associated with pain, increased blood pressure after childbirth, etc. [55, 59, 60]. Finally, low decision-making ability [34, 38, 52] was identified as a barrier to women residing in rural Bangladesh in seeking treatment.

Thirteen studies, six qualitative [55, 57–59, 61, 62], five quantitative [43, 47, 63–65], and two MM [49, 66], reported on family issues that were reported to hinder women in accessing and using MHC services. As reported in several studies, delays in decision-making when seeking MHC services were identified as a family-level barrier, as women from rural Bangladeshi families relied on family members, including husbands and mothers-in-law, for seeking advice to travel outside that is often delayed [43, 49, 55, 57, 59, 61, 65]. Moreover, absence of husbands’ participation in maternity care due to their shyness and family culture [62], intimate partner violence (IPV) [63], family financial constraints to afford the expense related to using MHC services [47, 58, 64], and a culture of home childbirth [64, 66] were commonly reported as family-level barriers to women accessing and using MHC services.

However, 15 studies, 13 quantitative [34–40, 43, 44, 52, 54, 64, 65], one qualitative [58] and one MM [50], highlighted how the family supported women’s access to MHC services. Husbands in a patriarchal society like Bangladesh generally have a key household decision-making role. Husbands who had a higher level of education [34, 35, 37, 40, 52], occupational involvement [36, 37, 43, 50], wealth status [35–39, 44, 52, 64, 65], positive attitudes toward care [58, 59], and shared their mobile phones with women to access mHealth services [54] were found to be positively related to women’s access to and use of MHC services.

Three subthemes were identified under this theme: sociocultural barriers, geographical barriers, and Non-Governmental Organization (NGO) and microcredit support and mass media exposure.

Several sociocultural barriers were highlighted in six studies, which include four qualitative [55, 57, 58, 62], one quantitative [54], and one MM [66]. Traditional attitudes and beliefs about pregnancy and childbirth [55, 57, 58, 62, 66] were identified as a sociocultural barrier for women living in rural Bangladesh to access and use MHC services. For example, there was a belief that pregnancy disclosure could lead to unwanted spiritual complications and that pregnant women going outdoors during certain times of the day and week was considered to be harmful to the fetus [57]. Additionally, gender inequality in mobile phone ownership affected women, as they were unable to make a call to a doctor if needed [54]. Finally, religious rituals such as setting up a separate room outside of the household for childbirth and seclusion [58, 66] were reported to adversely affect women residing in rural Bangladesh in accessing and using facility-based delivery care.

Geographical barriers were reported in 14 studies, which included 10 quantitative [35, 36, 39, 40, 44, 45, 47, 52, 53, 67], three MM [49, 50, 66], and one qualitative [61]. Geographical barriers included residing in rural areas, which reduced women’s access to MHC due to limited and remote healthcare facilities [35, 36, 39, 40, 44, 45, 47]. For example, urban women, as a result of having available healthcare facilities, were 1.4 times more likely to receive ANC services compared with their rural sisters (OR = 1.351; 95% CI: 1.104–1.496) [35]. Another geographical barrier included long travel distances to healthcare points, which prevented women from seeking care, as it involved physical risks to pregnant women [50, 52, 66]. Moreover, having inadequate transportation [49, 50, 61] and living in a flood-prone area [53, 67] were all found to be associated with a delay in seeking MHC services among women living in rural Bangladesh.

Seven studies, five quantitative [35–37, 42, 44] and two MM [49, 50], reported on NGO and microcredit support and/or mass media exposure. Three studies [35, 42, 50] reported that NGO and microcredit involvement among Bangladeshi women empowered them to access and use MHC services. For example, utilization of MHC services was found to be twice as high among mothers who visited NGO health facilities as compared to those who did not use the facilities [35]. Additionally, six studies reported that exposure to mass media (television and radio) messages [35–37, 42, 44, 49] was helpful for women in accessing healthcare services. For example, awareness-raising messages, such as timely using ANC services at the nearest community clinic and risks of early conception, through television or radio programs have been found to be effective by expectant mothers who reside in rural Bangladesh [36, 37].

Eight studies, five qualitative [55, 56, 58, 59, 61], two quantitative [48, 68] and one MM [66], focused on organizational barriers to access and utilization of MHC services by women living in rural Bangladesh. A wide range of organizational-related barriers were identified. An important organizational barrier included lack of quality healthcare services [55, 66], which affected women using satisfactory services. Patients in rural Bangladesh reportedly received poorer quality of MHC services for the following reasons: shortages of qualified personnel, lack of training of health staff, and limitations of diagnosis [55, 66]. Experiencing mistreatment, including use of vulgar words, from healthcare providers [48, 55, 58, 59] was also reported to be another important organizational barrier to assessing and using MHC services for women living in rural Bangladesh. Moreover, the gender of the healthcare personnel [59, 66] was reported to be an issue when women felt discomfort seeking care from male doctors. Another barrier included service costs related to medication and investigation fees [56, 58, 61, 66], discriminatory service provision [66], and uncleanliness and lack of privacy [68].

Organizational facilitators were the factors that helped women to access and use of MHC services in public and private facilities, identified in four qualitative [51, 57, 59, 69] and three quantitative [54, 60, 70] studies. Key facilitators to increasing access and use of MHC services by women in public facilities included: (i) health center-based support, including free services to users [57, 60, 69, 70]; (ii) incentives to healthcare providers [70]; and (iii) technology support, including mHealth such as calling doctors from the home or online services such as emergency blood management [51, 54, 69] to reduce the cultural gap between the patient and doctor to the use of services. Additionally, one quantitative [68] and two qualitative [56, 59] studies reported on some private health center-based facilitators, that included convenient opening hours, privacy, cleanliness, caregiving, and normal childbirth management skills. Women were reported to be more satisfied with private facilities compared to public facilities.

Although one review on access to healthcare services by women in rural Bangladesh [14] has been published, it was conducted more than a decade ago. This is the first known narrative literature review with a systematic search and updated study to identify access to and use of MHC services by women in rural Bangladesh. This review’s strength lies in its application of the SEM model to synthesize findings spanning more than 20 years of literature on the barriers and facilitators to accessing and utilizing MHC services by women in rural Bangladesh.

However, there are some limitations to this narrative literature review. There are not many studies on health-related topics published in Bengali, and most of them lack peer review, so their potential impact is likely to be minimal. Therefore, the review only included peer-reviewed studies and those published in English due to limited resources, which may have narrowed the scope of this review. It is likely that studies in other languages, particularly Bengali, may have provided further contributions. In addition, the wide variety of study methods precluded the possibility of conducting a meta-analysis, which can be used to identify the common effect [5].

Accessing and using MHC services for women residing in rural Bangladesh is a complex issue involving a wide range of barriers and facilitators at the individual, family, community and social, and organizational levels. By using the SEM framework to guide this review, the influence of multiple, interrelated factors in shaping behavior to access and use MHC services by women living in rural Bangladesh has been highlighted. More studies focusing on the barriers than the facilitators were identified in this review. Significant barriers to accessing and using MHC services encompass low levels of women’s literacy, insufficient self-confidence regarding treatment, delays in decision-making processes, absence of male support, a preference for home childbirth, restrictions on disclosing pregnancy, distance to healthcare facilities, and inadequate quality of care. Conversely, key facilitators, such as high literacy rates of women and their spouses, support from NGOs and microcredit programs, media exposure, and the availability of free services, enhance women’s access to and use of MHC services in rural areas. To attain SDG3, policymakers and healthcare professionals need to focus on these barriers and facilitators and develop interventions that can increase access and use of MHC services by women residing in rural Bangladesh. Researchers can use these findings to help make plans for how to enable more women in low- and middle-income countries like Bangladesh to access and use MHC services. Further studies, including meta-analyses are needed to understand the causal relationship and actual magnitude of the barriers and facilitators to MHC services.