While the most important factors associated with facility-based delivery (FBD) have been explored within individual countries in Africa, no systematic review has explored the factors associated with FBD across sub-Saharan Africa. A systematic search of the peer-reviewed literature was conducted to identify articles published in English from 1/1995-12/2011 that reported on original research conducted entirely or in part in sub-Saharan Africa and included a primary outcome variable of FBD, delivery location, or skilled birth attendance (SBA). Out of 1,168 citations identified, 65 met inclusion criteria. 62 of 65 were cross-sectional, and 58 of 65 relied upon household survey data. Fewer than two-thirds (43) included multivariate analyses. The factors associated with facility delivery were categorized as maternal, social, antenatal-related, facility-related, and macro-level factors. Maternal factors were the most commonly studied. This may be a result of the overwhelming reliance on household survey data – where maternal sociodemographic factors are likely to be well-represented and non-maternal factors may be less consistently and accurately represented. Multivariate analysis suggests that maternal education, parity / birth order, rural / urban residence, household wealth / socioeconomic status, distance to the nearest facility, and number of antenatal care visits were the factors most consistently associated with FBD. In conclusion, FBD is a complex issue that is influenced by characteristics of the pregnant woman herself, her immediate social circle, the community in which she lives, the facility that is closest to her, and context of the country in which she lives. Research to date has been dominated by analysis of cross-sectional household survey data. More research is needed that explores regional variability, examines longitudinal trends, and studies the impact of interventions to boost rates of facility delivery in sub-Saharan Africa.

The aim of this study is to explore the impact of the COVID-19 pandemic on pregnant women’s anxiety and identify factors most strongly associated with greater changes in anxiety. An anonymous, online, survey of pregnant women (distributed April 3–24, 2020) included a modified pregnancy-related anxiety scale (PRAS) reflecting respondents’ perception of pregnancy anxiety before COVID-19 and a current assessment of pregnancy-related anxiety. The difference between these scores was used as the outcome variable. Data were analyzed using bivariate and multivariate linear regression analyses. Two thousand seven hundred forty pregnant women from 47 states completed the survey. 25.8% (N = 706) stopped in-person visits, 15.2% used video visits (N = 415), and 31.8% (N = 817) used phone visits for prenatal care as a result of COVID-19. Those planning a hospital birth dropped from 2641 (96.4%) to 2400 (87.7%) following COVID-19. More than half of women reported increased stress about food running out (59.2%, N = 1622), losing a job or household income (63.7%, N = 1745), or loss of childcare (56.3%, N = 1543). More than a third reported increasing stress about conflict between household members (37.5%, N = 1028), and 93% (N = 2556) reported increased stress about getting infected with COVID-19. Slightly less than half of respondents (either selves or family members) were healthcare workers (41.4%, N = 1133) or worked in essential services (45.5%, N = 1246). In multivariate analysis, those reporting higher agreement with COVID-19-related stressors had greater changes in pre- to post-COVID-19 pregnancy-related anxiety. The COVID-19 pandemic is profoundly affecting pregnant women’s mental health, and factors independent of pregnancy appear to be driving changes in pregnancy-specific anxiety.