Social capital and maternal and child health services uptake in low- and middle-income countries: mixed methods systematic review

Background Social capital has become an important concept in the field of public health, and is associated with improved health services uptake. This study aimed to systematically review the available literature on the role of social capital on the utilization of maternal and child health services in low- and middle-income countries (LMICs). Methods Mixed-methods research review and synthesis using three databases PubMed, Scopus, and Science Direct for peer-reviewed literature and Google Scholar and Google search engines for gray literature were performed. Both quantitative and qualitative studies conducted in LMICs, published in English and in grey literature were considered. Prior to inclusion in the review methodological quality was assessed using a standardized critical appraisal instrument. Results A total of 1,545 studies were identified, of which 13 records were included after exclusions of studies due to duplicates, reading titles, abstracts, and full-text reviews. Of these eligible studies, six studies were included for quantitative synthesis, and seven were included for qualitative synthesis. Of the six quantitative studies, five of them addressed the association between social capital and health facility delivery. Women who lived in communities with higher membership in groups that helps to form intergroup bridging ties had higher odds of using antenatal care services. Synthesized qualitative findings revealed that women received some form of emotional, informational, and instrumental support from their network members. Receiving health information from trusted people and socio-cultural factors influenced the use of maternal and child health services. Conclusions Social capital has a great contribution to improve maternal and child health services. Countries aiming at improving maternal and child health services can be benefited from adapting existing context-specific social networks in the community. This review identified limited available evidence examining the role of social capital on maternal and child health services uptake and future studies may be required for an in-depth understanding of how social capital could improve maternal and child health services. Systematic review registration PROSPERO CRD42021226923. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07129-1.


Keywords: Maternal and child health services, Social capital, Social network, LMICs
Background Maternal and child mortality is declining in the last two decades but remains relatively high in the low-and middle-income countries (LMICs). About 86 % of the global maternal deaths occurred in two regions, sub-Saharan Africa (SSA) (accounted for 66 %), and southern Asia (accounted nearly 20 %) [1][2][3]. Although global neonatal mortality rate has declined by half between 1990 and 2017, over 2.5 million children are still dying in the first month of life [4]. Sustainable Developmental Goals (SDGs) have target of less than 70 maternal deaths per 100,000 live births and a reduction in under-5 mortality to 25 per 1000 live births by 2030. The ambition of these SDGs targets can be achieved by improving maternal and child health (MCH) services uptake, especially in the high-burden regions of south Asia and SSA [4].
Provisions of MCH services are essential for the early detection of mothers and infants at high risk of morbidity and mortality [5,6]. Maternal and child health services are series of interlinked healthcare services provided during pregnancy, childbirth, and postpartum periods. These services has been advocated for improving MCH as each stage builds on the success of the previous stage [7]. For example, a systematic review conducted in east African countries showed that women who received antenatal care (ANC) services are more likely to attend postnatal care (PNC) services than those who did not received ANC [8]. Although there have been improvements in MCH services coverage globally, overall MCH indicators remained low with significant disparities between the lowest and highest wealth quintiles [9,10]. Studies in LMICs showed that high maternal and child mortality was highly related to low level of ANC visits, health facility delivery, immunization, decision making capacity and social capital scores [8,[11][12][13][14][15][16][17]. Social capital can play a role in improving MCH services uptake and it has been positively related to physical and mental health of members in the social networks [18,19].
Social capital has multiple definitions and concepts in the field of economics, sociology, political science, and other disciplines [20]. Recently, it has become an important concept in field of public health [21] and is defined as social relations that may provide individuals and groups with access to resources and supports in their community networks. It may include different forms such as exchange of favors, maintenance of group norms, trust towards individuals or groups, and supports offered to members of social groups [22]. A number of social capital theories were grounded so far and growing from individual and family property to features of communities and nations [23][24][25]. The theory of social capital can be explained in structural and cognitive forms. In the structural form, it focuses on the externally observable aspects of social organizations and refers to the intensity of an individual's participation in community networks measured in objective terms [26]. The cognitive form involves subjective aspects such as norms, values, attitudes and perceptions of an individual's social relationship and can be measured subjectively. Structural and cognitive forms of social capital are not mutually exclusive and characterized in terms of social relations as what people 'do' and what people 'feel', respectively [18,27,28].
Evidence on the role of social capital and MCH has grown in recent years; however, most of these studies were conducted in high-income countries, such as the Netherlands [29,30], USA [31,32], UK [33] and Spain [34]. However, there are some studies from LMICs, where socio-economic inequality is higher, reported that social capital has a stronger relationship and a greater effect on health [35,36]. Our preliminary cursory searches identified additional studies conducted in India [27,37], Tanzania [38] and Cameroon [39]. In other African countries such as Ethiopia, there is high levels of group membership, high participation in citizenship activities and high levels of cognitive social capital [40]. However, its benefit to improve women and families access to healthcare is not well studied. For example, women and family members who are involved in social networks including 'Debo' and 'Iqqub' in Ethiopia could offer great opportunities for them to receive important health information. These networks also usually established for economic and social supports to the members and families. 'Debo' is working together informal grouping in the community to help each other for farming, house building and construction in Ethiopia community. 'Iqqub' is a common financial assistance association where families, friends or other groups contribute some money together and share the money in rounds for each of the contributors in a specified time period [41].
To date, there was no systematic or narrative review that systematically synthesizes the available literature focusing on the role of social capital on MCH services use in LMICs. Therefore, this review aimed to synthesize the available quantitative and qualitative literature on the role of social capital on MCH services uptake in LMICs.
The findings of the study will inform policy and decision makers to improve MCH services uptake in LMICs.

Methods
This study followed mixed methods systematic review (MMSR) approach developed by the Joanna Briggs Institute (JBI) for mixed evidence synthesis. The MMSR is an emerging systematic review approach that can bring together the findings of quantitative and qualitative evidence to provide comprehensive evidence to enhance the findings applicability for decision-makers [42]. The protocol of this review was registered with the PROSPERO database (registration number: CRD42021226923). The review also followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Supplementary file 1) [43].

Inclusion criteria
In this systematic review, the inclusion criteria were: Types of studies: both quantitative and qualitative studies. Publication status: both published and unpublished/ grey literature. Language: articles and reports written in English. Population: studies reporting on women and children were considered. Intervention: social capital was the intervention for our study. Context: studies that were conducted in one or more of the LMICs based on the World Bank criteria. Outcome reported: studies that reported on the association of social capital and MCH services were considered. In this review, MCH services comprised ANC, health facility delivery and PNC use. The phenomenon of interest for the qualitative component included experiences/views/perceptions of women on the role of social capital on MCH services uptake.

Search and search strategy
We used PubMed, Scopus and Science Direct databases to search peer-reviewed articles. In addition, Google and Google Scholar search engines were used to identify grey literature and government reports. A comprehensive search strategy was initially developed by EWM and reviewed by GAT and YA. Medical subject headings (MeSH), text words and key words in the title or abstract were considered when developing search strategy. Our search strategy combined terms related to the three domains: In the first category, the term related to 'social capital' such as 'social support', 'social trust', 'social network', 'community network', OR 'social cohesion'; in the second category, 'maternal and child health services' terms that comprised 'antenatal care', 'health facility delivery' OR 'postnatal care'; in the third category, country terms such as 'LMICs' regions were included. Lists of LMICs were found from recent World Bank classification [44]. All synonym keywords and subject headings were combined with the "OR" Boolean operator. Finally, we combined all the three categories using the Boolean operator "AND" to run in the databases (Supplementary file 2). When we search in Google Scholar and Google search engines, the first 100 hits were included. Moreover, we also reviewed websites of international organizations such as the World Health Organization and the World Bank for unpublished reports.

Study selection
Once literature searching was completed, studies were screened for eligibility by EWM and DA independently by considering the inclusion criteria after retrieved records were exported into EndNote. Any disagreements on article exclusion or inclusion were resolved by consensus. A total of 1,545 studies were identified by searching databases and other search engines to synthesize evidence about the role of social capital on uptake of MCH services in LMICs, of which, 328 records were removed due to duplication. Then 13 records were selected after reading titles, abstracts, and full texts. The reasons for exclusions after full text review included low methodological quality, and did not assess uptake of MCH services. (Fig. 1)

Data extraction and management
Data were extracted from articles or reports using an excel sheet. The main information collected from each study contain last name of author(s), year of publication, study methods (study setting, study participants, study design, the year of data collection, sample size and data analysis), key findings and limitation acknowledged by the author(s) of the study.

Data synthesis
For the quantitative studies, we performed textual narrative synthesis after tabulating individual studies. Due to lack of uniformity on the definitions and measurement of social capital, we were not able to conduct metaanalysis. Descriptive characteristics, key findings, and limitations of individual studies were presented in tables. For the qualitative evidence, findings were synthesized using meta-aggregation approach. Initially, views/experiences of mothers on social capital were synthesized. Then pooled findings were grouped into categories defined by their similarity of meaning and then combined into one or more synthesized finding(s) that captured their meaning.

Methodological quality assessment
Both quantitative and qualitative studies selected for retrieval were assessed by two independent reviewers (EWM and DA) for methodological validity prior to inclusion in the review using standardized critical appraisal instrument. The criteria were adapted from the JBI Critical Appraisal Checklist and classified as high quality: meets ≥ 7 criteria, moderate quality: meets ≥ 4 criteria, and low quality: meets < 4 criteria [45].
Any disagreements that arise between the reviewers were resolved through discussion. The results of critical appraisal were reported in narrative form and in a table. Assessment of methodological quality, or critical appraisal, was conducted to establish the internal validity and risk of bias of studies that meet the review inclusion criteria. We checked the appropriateness of study methodology for addressing the research question and interpretation of findings in a way that is appropriate to the methodology. (Supplementary file 3)

Characteristics of the studies
A total of 13 studies were included for this systematic review. Of these eligible studies, six studies [27, 37-39, 46, 47] were included for quantitative synthesis and seven [48][49][50][51][52] of them for qualitative synthesis. Based on the income distribution of the studies, eleven studies came from lower middle-income countries, and the rest two belongs to low income countries. In relation to geographical distribution, seven countries came from south Asian countries, and six studies appeared from SSA countries. Most of the included quantitative studies (n = 5) investigated the association between social capital and health facility delivery. Three studies reported the relationship between social capital and ANC service. (Tables 1 and 2)

Quality assessment of included studies
Of the six quantitative studies, five [27,37,39,46,47] were rated as moderate quality and one [38] was rated high quality. Four out of six studies undertook systematic random sampling in selecting their study participants. The samples taken for the study were representative and outcomes were measured using reliable methods. All of the six studies assessed their outcome using objective measures through proxy questions; controlled confounding factors using multivariate and multivariable regression analysis and did not describe those participants who withdraw or refused to participant in the study.
Regarding the qualitative synthesis, six out of the seven primary qualitative studies were assessed as high quality [48,[50][51][52][53][54]. The studies lacked description of the congruency between the philosophical perspectives and research methodology used. Moreover, the failure to describe the researchers' perspectives may influence the analysis and interpretation of findings.

Measurement of social capital
Studies included in this review reflected multiple dimensions of social capital. While some studies assessed both structural and cognitive social capital [37,46,47], other studies also examined bonding and bridging dimensions    [27,38]. Related to measurement tools for social capital, studies used different types of measurement tools ranging from using individual questions for selected dimensions of social capital to composite tools that measured each dimension of social capital using several questions. The variations among tools in its content may indicate that instruments for measuring social capital are at the developmental stage. Exploratory factor analysis (EFA) was used to develop and validate a tool for measuring social capital and investigate the influence of sociocontextual variables [27,[55][56][57][58][59]. In addition, confirmative factor analysis (CFA) indicated the reliability and validity of social capital scales [56,60]. Furthermore, regression analyses including multiple hierarchical linear regression [61], multilevel models [27,37,62], multivariate regression [63,64], multiple linear regression and logistic regressions [46,65,66] were used to examine the relationship between social capital and the outcome variables. For qualitative studies, data were analyzed using narrative summaries and thematic analysis approach [48,[50][51][52].
Role of social capital on uptake of maternal and child health services Of six reviewed quantitative studies, five of them addressed the relationship between social capital and health facility delivery. However, the six study included in our study examined the association between social networks and maternal health services during pregnancy.
A study from rural India [46] showed that women from villages with a social capital in term of a self-help group were more likely to give birth in a health facility. In contrast, other study from India [67] reported that although the presence of self-help groups in the community, there was no evidence suggesting social networks would improve health facility delivery. These discrepancies could be women used self-help group for financial purpose only and they did not access health care messages during their meetings. (Table 1) Three of the six studies [27,37,47] focused on the association between social capital and ANC uptake. Women who lived in communities with higher membership in groups that help form intergroup bridging ties had higher odds of ANC use than women who lived in communities with higher intragroup bonding ties and collective efficacy [27]. Furthermore, male partners' involvement in maternal health care during pregnancy has improved maternal health care services access and uptake. The odds of having at least one ANC was higher in women whose male partners' involvement scores were higher than those women whose partner's involvement scores were lower [47].

Experience of women on social capital
A total of seven qualitative studies were included in this systematic review. These studies followed phenomenology [51,52], case study [48,49], ethnography [50] and exploratory [53,54] qualitative study designs. The synthesized qualitative findings of this study revealed that social support groups, receiving health information from trusted people and sociocultural factors played a significant role on the uptake of MCH services. Across network support groups, most women indicated that network members provided emotional, informational, and instrumental supports. Health extension workers (HEWs), women development army (WDA), Male development army (MDA) and religious leaders were also participated on community mobilization activities, provision of continuous support and promotion of MCH services [48][49][50][51][52][53][54]. For example, a study in Ethiopia reflected that religious leaders were crucial in providing emotional and spiritual support to their followers by committing themselves in prayer activities. This was illustrated when a female FGD participant said : "In the Orthodox Church, while the religious leaders pray, they also pray for pregnant women and for women in postpartum period…to live in agreements as our governments ordered us, the church also ordered us too and made pray for us, we also pray at home" (Female FGD participant) [48]. It was also shown that religious leaders were found to be influential in many aspects of community wellbeing including by the promotion of safe motherhood. "…Now we are advising pregnant women to give birth in health facility. We also advise them to attend health checkup during pregnancy and go directly to health facility when labor starts. We are advising people to stop harmful practice like massaging the belly of pregnant women" (Muslim religious leader) [52].  Other evidence showed that some women had numerous sources of support that include their own mothers, female relatives and friends. Female friendships were particularly important in those who lived in nuclear households or those who were far away from their own families [50]. Husbands had helped to boost their wife's confidence and reduce anxieties during the childbirth. Regarding the community social networks, the benefit may be direct, through the young person's own networks, or indirect, through the networks of their parent(s). Network support for women's pregnancy-related care affects their place of childbirth. Women who had positive experiences of having health facility delivery previously and who lived in close proximity with the pregnant women tend to encourage women to consider birth at health facility. Those husbands lived in the same house further confirmed the emotional supportive roles of these network members [51]. Studies conducted in Ethiopia [48], India [49,50], Ghana [51] and Kenya [52] demonstrated that women received some form of emotional, informational and instrumental support from their network members during pregnancy and to use health facility delivery [51].
Receiving health information from trusted people and socio-cultural factors influenced use of MCH services. A study conducted in Ethiopia [48] and Kenya [52] showed that religious and socio-cultural norms as well as gender stereotypes influenced uptake of MCH services. In Nepal, mothers-in-law played ambivalent role in the uptake of ANC. They have a positive influence when encouraging women to seek ANC, but more often a negative role in discouraging women from accessing ANC. Mothers-in-law appeared to have less influence on ANC uptake if they did not live in the same household as their daughters-in-law [53] (Tables 2 and 3).

Discussion
This study aimed to synthesize the available literature about the role of social capital on the uptake of MCH services in LMICs. The results of this study indicated that social capital has dual roles with the favorable impact to improve MCH services uptake but also some negative consequences. Network members who have sufficient health information provide advice to the pregnant women to access ANC, avail a transport vehicle for travelling to health facility during childbirth. In contrast, some network members who lived in close proximity  Finding: Network members lived in close proximity provide advice to the pregnant women Reflection: "Hamdia (brother-in-law's wife). . .and my husband. They told me to not work as hard as I used to because now that I am pregnant I need to be cautious of the kind of work that I do. .Bintu (Friend) was also involved. .if I was not feeling well, I would call her and tell her. She would then tell me to go to the hospital because that is where we will find out what is actually wrong with me. . ."( woman in the facility birth group) Cofie et al., page 8 Finding: Close network members were ready to avail a transport vehicle for travelling to health facility during child birth. Instrumental support Finding: Network members able to help her access and utilize facility delivery Reflection: "The women health development army exists in the form of AFOSHA (cultural self-help system). They help one another not only when someone dies, but also when someone gives birth and during festivals. They even help one another financially. They contribute money and buy basic household materials." (Male FGD participant from Gomma district) Mamo et al., page 6 Finding: Some women had numerous sources of support, their own mothers, female relatives and friends. Reflection: "There are enough people around me to talk to and support, (but) mainly I would tell my mother about everything. She has been very supportive throughout." (29 years, educated) Raman et al., page 132 Reflection: "When I was vomiting for the first few months, three different friends used to cook different dishes for me every day; they looked after me so well." (27 year old, nuclear family) Raman et al., page 133 Finding: MDA and WDA leaders are good in passing different knowledge to mothers and members of the community during community meetings, women's association meetings, antenatal outreach sessions, and coffee ceremony Reflection: "We are doing many activities like advising women to prepare before delivery. There could be different problems during delivery and they may need money, so I inform them to save certain money and keep it with them." (MDA from Gomma district) Mamo et al., page 6

Promotion of MCH services
Receiving health information from trusted people enhanced uptake of MCH services.
Finding: HEWs, WDA and religious leaders are also participating on community mobilization activities including use of full ANC services, health facility delivery and PNC Reflection: "What I should do for pregnant women during pregnancy is taking them to health facility for regular check-up and helping them to go and deliver in health facility and taking the children to health facility for vaccination." (Muslim Religious leader from Kersa district) Mamo et al., page 6 Finding: Assistance with community, husbands and WDA support women during and after pregnancy period. Reflection: "…when she is ready to deliver, I will take her to the health center and then come back home with her… after delivery I am responsible for preparing food and giving her advice about not working beyond her capacity and for washing the baby clothes. Provision of continuous support Finding: Integrating activities between community leaders to be enhance strong relationship and communication between HEWs, primary health care units and community members Reflection: "What makes women health development army leader support special is that, they involve starting by enrolling the pregnant women and reporting to health extension worker at the termination of first menstrual cycle"(HEWs from Kersa district) Mamo et al., page 8 A link between communities and health system Findings: Some members of the community cannot go to the hospital for health care services for whatever problem without first going to herbalists. Ill health is as a result of evil spirits and traditional systems of health care were best-placed to deal with them Reflection: "…in the olden days of our grandfathers and grandmothers, we just used to stay like that when a woman got pregnant; she would just use some roots (herbs) and she would deliver without any problem.  tended to first seek the involvement of a traditional birth attendant during women's labor and did not make timely arrangements to transport women to a facility. These findings are in line with other studies that have found a significant effect of social capital on other health outcomes [69,70]. Women's social capital had great contribution on the uptake of MCH services. Women from villages with a self-help group were more likely to give birth in a health facility [46]. Likewise, the qualitative component of this review complemented that family members, particularly husbands, mother in laws, mothers and grandmothers advice women provided suggestions on how to experience safe pregnancy and health facility delivery [51].
Women who lived in communities with higher social capital had higher odds of ANC uptake [27]. Most women received support from group members to use facility-based pregnancy and delivery care [50]. Besides male partners' involvement in MCH care has benefits on better uptake MCH services [47]. This might be that husbands who attend ANC with their partners acquire useful knowledge on how to support their wives during pregnancy. In line with this finding, a systematic review in developing countries revealed that good male involvement improved the uptake of MCH services [71].
Social capital influences uptake of MCH services through social networks between communities or community members and representatives of formal institutions such as health care providers, teachers and government officers [72]. Moreover, involvement of religious leaders, health extension workers, women developmental army leaders, and selected community members could enhance use of MCH services. Women who received health information from people they trust are more likely to access and use health services [48]. Neighborhoods with higher levels of social trust experience lower rates of health and health related problems, and have fewer signs of physical disorder, making residents of these neighborhoods feel safer [73][74][75][76].
Socio-cultural factors might hinder uptake of MCH services [52]. In some communities, women who gave birth have to stay indoors for a month up to 40 days; some members of the community cannot seek health care services at health facilities for whatever problems without first going to herbalists; only opting for a facility delivery if complications arise during the birthing process and traditional birth attendants play a critical role in the decision-making pathway for choice of place of delivery [48,52,53]. In line with these findings, a previous systematic review reported that influence of traditional beliefs and sociocultural norms was high during childbirth. Women interpreted their expectations through the lens of family birth stories and social norms [77].
There is no single universally accepted measurement tool for social capital that may partly attributed to the fact that the nature of social networks as social interactions and functions could be context specific. Most of the tools used to measure social capital in LMICs were originally developed in higher income countries. Cultural adaptation of the tool is an important procedure especially when the original tool is from a different cultural setting [78,79]. However, the review identified that social capital was measured at both at individual and at community levels. Assessment of social capital at individual or community level may depend upon researchers' interest. Community level measures are required if the researcher is aimed to examine contextual outcomes. When interpreting aggregated social capital at group level, aggregation of individual social capital measures would not resemble the social capital of the whole community [56-59, 61-66, 80-85]. Most studies included in this review assessed both structural and cognitive social capital in which it was consistent with other systematic reviews conducted in least developed countries and LMICs [78,79,86,87].

Strengths and limitations of the review
The current review has its own strength and limitations. Its strength includes its ability to integrate the results of quantitative and qualitative studies. Regarding the limitations, there is no accepted definition and uniform measurement tool for social capital across the studies and thus was not possible to conduct meta-analysis. Also, some studies have no information about the validity and reliability of social capital measurement tool. Although our searching was comprehensive, it is possible that some articles were missed. Moreover, studies with

Implication for public policy makers and researchers
The evidence in this review showed that social capital may contribute for improving women's uptake of MCH services for themselves and their children. Therefore, it will be worthwhile for policy makers to design strategies on strengthening community's social capital to enhance uptake of MCH services. It may also be necessary for available social networks and groups to be targeted for health education and promotion activities.

Conclusions
Social capital has great contribution on uptake of MCH services even though socio-cultural factors may influence its functionality. Countries aiming at improving MCH services can be benefited from adapting existing contextspecific social networks in the community. This review identified limited available evidence examining the role of social capital on MCH services uptake. Measurement tools for social capital have no uniformity across studies and most of them were conducted using a crosssectional design. Hence, future studies may be required for in-depth understanding of how social capital could improve MCH services.