Effectiveness of culturally appropriate antenatal education packages to improve birth preparedness and complication readiness in low- and middle-income countries: a systematic review

Abstract

BACKGROUND: Birth preparedness and complication readiness (BPCR) remain essential components of maternal survival strategies in low- and middle-income countries (LMICs). Suboptimal antenatal education contributes significantly to delayed recognition of obstetric danger signs and late care-seeking. Delays in recognising obstetric danger signs and seeking care contribute to high maternal mortality in LMICs. Culturally tailored antenatal education packages have been increasingly used to improve BPCR; however, evidence across LMICs has not been systematically synthesised. OBJECTIVE: To synthesise evidence on the effectiveness of culturally appropriate antenatal education interventions on BPCR outcomes among pregnant women in LMICs. METHODS: This systematic review adhered to PRISMA 2020 and JBI guidelines. We searched PubMed, Scopus, Web of Science, CINAHL, AJOL, and Google Scholar (January 2015-July 2025) for English-language studies on antenatal education interventions reporting BPCR outcomes in LMICs. Two reviewers screened titles/abstracts, assessed full texts, appraised quality (JBI checklists), and extracted data for narrative synthesis due to heterogeneity. RESULTS: Eleven studies (n = 5,802; quasi-experimental n = 4, cross-sectional n = 4, cohort n = 2, community-based n = 1) from Ethiopia (3), Nigeria (3), Tanzania (2), Cameroon (1), Kenya (1), Bangladesh (1) showed consistent improvements: danger sign knowledge up to 85% (mobile SMS, Tanzania), BPCR practices 25-95% (e.g., goal-oriented education, Nigeria: 65.5% to 95.3%), institutional delivery 53.5% to 93.5%. Predictors include early ANC, partner involvement and local languages. Quality: low-moderate risk of bias. CONCLUSIONS: Culturally matched antenatal classes help pregnant women in low-income countries better prepare for childbirth and emergencies, improving knowledge by up to 85% and care-seeking behaviour by 25-95%. This review of 11 studies supports the use of local languages, family involvement, and phone messages in routine prenatal care to save lives. More high-quality trials are needed.