Facilitators and barriers to the implementation of the WHO ANC-8 contact model among pregnant women: a systematic review in low- and middle-income countries

Abstract Background: By 2016, the World Health organization (WHO) recommended increasing antenatal care (ANC) contacts from four to a minimum of eight contacts to improve maternal and newborn health outcomes. While barriers to the previously focused ANC model were well documented, facilitators and barriers to this new recommendation are limited. This systematic review synthesized available evidence from low- and middle-income countries (LMICs). Methods: We searched PubMed and Google scholar for studies published between 2016 and 2025 through predefined search terms and Boolean operators. Eligible studies examined facilitators or barriers to the new ANC eight contact model among pregnant women. Quality appraisal was conducted using the JBI-2024 critical appraisal tool individually. Given the heterogeneity, findings were narratively synthesized. Result: seventeen studies met the inclusion criteria, (eight quantitative, nine qualitative). ANC 8+ coverage remained low across LMICs, typically between 8-20% with higher uptake in urban over rural. ( e.g , Benin 8%, Nigeria urban 35%, Gahana 44%). Barriers included low awareness, financial constraints, limited autonomy in decision making cultural and religious beliefs, Lack of integration of traditional and religious practices into healthcare, poor health system responsiveness and inadequate health insurance coverage. Reported facilitators were higher maternal and partner education, early ANC initiation, male involvement, supportive family, community outreach and media exposures. Conclusion: Uptake of the ANC eight and more contact model remained suboptimal with variations across socio-economic, cultural and health system barriers. Disparities by residence, educational, health insurance highlight the need for equity focused interventions. Strengthening health system, promoting women empowerment and implementing culturally sensitive strategies are critical. Country specific research and fidelity studies are needed to guide effective adaptation of the model in diverse contexts.