Bypassing primary healthcare facilities for maternal and child health services in low- and middle-income countries: a scoping review.

backgroundsBypassing primary healthcare (PHC) facilities for maternal and child health (MCH) services is an increasingly common phenomenon in low- and middle-income countries (LMICs). This behaviour can undermine health system efficiency by overburdening referral hospitals and leaving PHC centres underutilised in LMICs. However, no comprehensive review has examined this behaviour. This scoping review synthesises evidence on how bypassing is defined, its prevalence, determinants, and how the concept has been framed in LMIC settings.

methodsFollowing PRISMA-ScR guidelines, we systematically searched PubMed, Embase, and Web of Science for peer-reviewed studies published between January 2010 and September 2024. Eligible studies reported empirical qualitative, quantitative, or mixed-methods findings on bypassing behaviour in PHC settings for MCH services in LMICs. We used a thematic synthesis approach to map definitions, estimate prevalence, and identify determinants and conceptualisations of bypassing behaviour.

results20 studies from 11 LMICs met the inclusion criteria. Definitions of bypassing varied considerably, particularly regarding service type, treatment of referral or complication cases, and facility level. Because of this heterogeneity, reported prevalence of bypassing ranged widely from 1.8% to 88%, and these values were not directly comparable across studies. Determinants of bypassing behaviour fell into three broad categories: (1) individual factors such as higher socioeconomic status and previous obstetric complications; (2) perceptions of service quality, including inadequate equipment and negative prior experiences; and (3) sociocultural influences shaped by community perceptions. Conceptually, bypassing was interpreted both as a reactive response to perceived weaknesses in PHC and as a proactive strategy to seek safer and higher-quality care. Several studies also framed bypassing as a systemic issue, highlighting the limited obstetric capacity and readiness of PHC facilities and the need to reconsider the role of PHC in maternal care delivery.

conclusionEvidence from this review shows that bypassing PHC facilities for MCH services is common in LMICs, especially for childbirth care. The behaviour reflects concerns about PHC quality rather than physical proximity to facilities. The substantial variability in how bypassing is defined highlights the need for conceptual clarity, including a clear distinction between voluntary bypassing and clinically indicated referrals. Strengthening both the technical and experiential quality of PHC, and clarifying its role within maternal care pathways, is essential. Clearer integration with higher-level facilities would also support more coordinated referral systems and help reposition PHC within maternal health service delivery.