Duke Medical Ethics Journal
Healthy Moms, Healthy Nations
by Eugene Cho
“Ensuring a broad set of options for maternal health in various regions for the various circumstances that women may be facing will increase accessibility of maternal health”
There has been an increased interest in maternal health in recent decades, specifically in higher-income countries with increasing allocation of resources toward the field. However, the quality of maternal health as well as its availability varies from region to region. Maternal health refers to the care given to women during pregnancy, delivery, and the time immediately following childbirth . Unfortunately, 830 women die every day globally due to improper maternal care . More specifically, 99% of mortality cases occur in low-income countries (LICs) where there is much less focus on maternal care . This lack of focus results in extreme maternal mortality rates, further affecting infants, households, and the economy of LICs as a whole. One of the new Sustainable Development Goals for 2030 includes the reduction of the global maternal mortality ratio to less than 70 per 100,000 live births . Although there are many barriers to accessible, high-quality maternal health services, particularly in LICs, there have also been many developments to decrease maternal mortality, specifically in LICs. By exploring existing barriers to receiving maternal care in LICs, as well as assessing existing interventions, there can be an increased understanding of what further actions are needed to improve maternal care and reach sustainable goals.
There are many barriers to maternal health in LICs including transportation and cultural beliefs; however, two of the biggest barriers to maternal health are economic barriers and quality of care . There are many direct and indirect costs related to maternal health. Many women cannot afford institutional delivery because the costs often exceed the monthly income of family members. Studies have shown that in Benin, cases of dystocia (or difficult births often due to awkward fetal position) have accounted for up to 34% of annual household expenditure . Furthermore, studies have shown that families in Mali were responsible for paying for emergency obstetrics care that accounted for up to a quarter of their annual income, putting a major strain on families’ finances . Out-of-pocket payments are a major form of payment in LICs due to the lack of insurance and insurance coverage over procedures related to maternal health. The quality of maternal care and insufficiencies in infrastructure in LICs is also a barrier to maternal health. In places like Togo and South Sudan, research shows insufficient bed capacity and private birth space in maternity wards . Countries like Ethiopia lack clean water and food, preventing women from receiving quality care . The lack of maternal resources like medications and medical supplies also prevents women from receiving adequate care . Beyond inefficiencies in infrastructure, healthcare workers may also act as barriers to receiving quality maternal care. Patients may often feel as though vaginal examinations are an invasion of privacy, especially if healthcare workers do not adequately explain to patients what the deliverance of maternal health entails . In multilingual countries like Ethiopia and Malawi, miscommunications may often occur between healthcare workers and women, resulting in poorer care .
Despite the many barriers women face in LICs, there has also been increased attention toward improving maternal care in these countries. Many interventions, spearheaded by both internal and external organizations, work to increase the accessibility of maternal health in low-income countries. The use of mobile devices or the mHealth platform for the deliverance of health-related interventions is an example of an intervention that has been investigated. In Rwanda, researchers have explored the effect of mobile devices on communication between community health workers and the formal health system . The increase in communication in alignment with this referral system has allowed for the communication of danger signs and maternal deaths, resulting in a 27% increase in facility-based deliveries . In Nigeria, mothers received reminders to attend hospital visits after giving birth to their babies, resulting in 8% more women attending postpartum visits which are often neglected by new mothers . Additionally, some of these efforts made through text messages and reminders encouraged pregnant women to shift their behaviors towards prenatal care and postpartum visits. Beyond appointment attendance, the use of mobile devices has shown to have also increased health education for these women. A study done in Tanzania showed that 71% of women felt that the educational messages sent through the platform were useful in informing them about possible signs of pregnancy complications . Although there has been much promising research suggesting that mobile phones and mHealth platforms may be useful in decreasing maternal mortality rates, it comes with the caveat of the ability for LICs to support the infrastructure necessary to make mobile phones a long term reality in LICs.
Research has shown that the improvement of policies, which has led to updates in guidelines and interventions for maternal health, is another strategy to increase efforts to address barriers to maternal health . Places like Cambodia attribute improvements in maternal health to the alignment of strategies across multiple sectors. Engaging non-health sectors to help improve maternal health outcomes has been shown to improve health outcomes overall . Additionally, Syed et al (2022) found that low GDP levels correlate with higher mortality rates . Out-of-pocket spending remains high for mothers and their families, with fluctuating reliability of the availability of actual available maternal services. By aligning policies and updating guidelines, there can be a shift towards allocation of more money toward maternal care services, to address the deficiency in quality maternal services. Shifts in social policies that value female autonomy and empowering women have also seen reductions in maternal mortality . Countries that have made steps to improve women’s education and social status have experienced a rapid decline in maternal mortality rates (like Cambodia and Georgia), further emphasizing the role of the social status of women in shifting attitudes towards maternal health and care . By increasing advocacy for the recognition of the social status of women and amending policy in alignment to that recognition, it can contribute to increased resources and funding towards maternal health, as shown in past literature.
Implementing interventions for safe motherhood is not as expensive as one would expect. Reports have shown that the cost of significantly reducing maternal mortality through various health interventions is about $1 per capita . The World Health Organization (WHO) also developed a Mother Baby Package that includes programs and care for important maternal health problems and interventions. Features of the Mother Baby Package include basic antenatal care, prevention and treatment of malaria, and clean and safe delivery . The total costs of the package was approximated to be about $3 per capita to provide low-income countries. While this cost is much more than low-income countries are willing to put in, it is a cost-effective option in the long term, not only aiding household incomes but also families overall. For example, evidence has shown that in Bangladesh, children under the age of 10 years without mothers are 3 to 10 times more likely to die in two years, than those whose mothers have not . Maternal mortality and illness also contribute negatively to household incomes, whether it be due to the extra hospital expenses or the lack of income mothers bring while they are sick. There has been an increase in research on various services related to maternal care during and post-pregnancy; however, it is essential for countries to acknowledge research findings and to develop interventions that align with those findings.
While many interventions have been implemented to improve maternal health, there are still many areas of improvement within maternal health. First, with sustainable goals of completely reducing the maternal mortality rate to zero, it is essential to constantly evaluate the state of maternal health in various health systems. Ensuring a broad set of options for maternal health in various regions for the various circumstances that women may be facing will increase accessibility of maternal health . Additionally, communities can promote community-driven initiatives to make maternal health opportunities more accessible to particularly marginalized and remote communities . Lastly, while many countries have developed and included interventions in their national plans, budgets still need to be adequately allocated to implement the plans . By aligning policy efforts across various sectors and collaborating with various organizations, LICs can prioritize maternal health and work to make services more accessible and affordable to all.
Women residing in LICs are more vulnerable to inaccessible, unaffordable, and low-quality maternal healthcare. Due to barriers like transportation, financial, and quality of care, women may be less likely to seek maternal health or receive proper maternal health after seeking it. Despite these barriers, there has been research that shows that improvements in maternal care accessibility can be made through interventions involving mHealth, updating national guidelines, as well as adopting cost efficient strategies. These interventions show promising results for mothers globally, although there must be more research done to explore these options in more LICs, as different countries have different contexts that must be taken into account. It is crucial for LICs to recognize the need for increased maternal health services for the benefit of women, mothers, families, and the country as a whole. By doing it, it not only guarantees the wellbeing of individuals, but for the country as a whole.
Review Editor: Caroline Palmer
Design Editor: Eugene Cho
 Dahab, R., & Sakellariou, D. (2020). Barriers to accessing maternal care in low income countries in Africa: A systematic review. International Journal of Environmental Research and Public Health, 17(12), 4292. https://doi.org/10.3390/ijerph17124292
Banke-Thomas, A., Ayomoh, F. I., Abejirinde, I.-O. O., Banke-Thomas, O., Eboreime, E. A., & Ameh, C. A. (2020). Cost of utilising maternal health services in low- and middle-income countries: A systematic review. International Journal of Health Policy and Management. https://doi.org/10.34172/ijhpm.2020.104
 Puchalski Ritchie, L. M., Khan, S., Moore, J. E., Timmings, C., van Lettow, M., Vogel, J. P., Khan, D. N., Mbaruku, G., Mrisho, M., Mugerwa, K., Uka, S., Gülmezoglu, A. M., & Straus, S. E. (2016). Low- and middle-income countries face many common barriers to implementation of maternal health evidence products. Journal of Clinical Epidemiology, 76, 229–237. https://doi.org/10.1016/j.jclinepi.2016.02.017
 Colaci, D., Chaudhri, S., & Vasan, A. (2017). MHealth interventions in low-income countries to address Maternal Health: A Systematic Review. Annals of Global Health, 82(5), 922. https://doi.org/10.1016/j.aogh.2016.09.001
 Syed, U., Kinney, M. V., Pestvenidze, E., Vandy, A. O., Slowing, K., Kayita, J., Lewis, A. F., Kenneh, S., Moses, F. L., Aabroo, A., Thom, E., Uzma, Q., Zaka, N., Rattana, K., Cheang, K., Kanke, R. M., Kini, B., Epondo, J.-B. E., & Moran, A. C. (2022). Advancing maternal and perinatal health in low- and middle-income countries: A multi-country review of policies and programmes. Frontiers in Global Women's Health, 3. https://doi.org/10.3389/fgwh.2022.909991
 Jowett, M. (2000). Safe motherhood interventions in low-income countries: An economic justification and evidence of cost effectiveness. Health Policy, 53(3), 201–228. https://doi.org/10.1016/s0168-8510(00)00089-0
 Office of the Surgeon General Washington. (2020). The Surgeon General’s Call to Action to Improve Maternal Health [Internet]. US Department of Health and Human Services (pp. 24-29).