The multi-mechanism pathway: quantifying the mediating role of perceived barriers of healthcare access in the relationship between intimate partner violence and antenatal care adherence across 31 sub-Saharan African countries

Background Intimate partner violence (IPV) is highly prevalent in sub-Saharan Africa (SSA) and is consistently associated with reduced maternal health service utilisation, including inadequate antenatal care (ANC). However, the pathways linking IPV to poor ANC uptake—through structural and psychosocial barriers—remain insufficiently quantified.Objective To examine the mediating role of perceived healthcare access barriers in the relationship between IPV and adequate ANC utilisation across 31 SSA countries.Methods We used nationally representative Demographic and Health Survey data (2011–2023) from 31 SSA countries. The analytic sample included 82 153 women aged 15–49 years with a live birth in the past 5 years. Adequate ANC was defined as ≥4 visits. Parallel mediation analysis was conducted using weighted generalised structural equation modelling to estimate indirect associations through four perceived barriers: financial, distance, permission and companionship. Sensitivity analyses included restricting IPV exposure to the past 12 months and applying inverse probability weighting (IPW) to address selection bias.Results 32.9% of women reported lifetime IPV and 59.7% achieved adequate ANC. All four barriers were associated with lower ANC utilisation, with permission barriers showing the strongest effect (adjusted OR 0.80). Physical and sexual violence were associated with all barriers, whereas emotional violence was primarily linked to financial constraints. Mediation analysis showed that financial barriers accounted for the largest share of indirect associations for lifetime physical and emotional violence, while permission barriers were dominated for sexual violence and recent IPV. Sensitivity analyses confirmed that permission barriers were the primary mediator for past-year IPV and IPW-adjusted models showed autonomy-related barriers remained robust while financial and distance barriers were attenuated.Conclusion IPV is associated with lower ANC utilisation in SSA through distinct pathways. Sexual and recent IPV primarily operate through restrictions on women’s autonomy, while lifetime physical and emotional violence act through economic deprivation. Interventions should address gendered power dynamics alongside traditional access barriers.