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Duke Medical Ethics Journal

The Ethics of Maternal Health Disparities in Developing Nations

by Devin Mulcrone

In modern western societies, we take for granted our access to and quality of maternal healthcare. Our healthcare system and financial means allow mothers to give safe births at hospitals surrounded by doctors, nurses, administration, and other healthcare services. We consider giving birth to be a relatively safe procedure, and our expected outcome, almost always, is a safe, successful childbirth. Approximately 1.4% of women giving birth experience complications during childbirth in the US [1]. Contrastingly, 99% of maternal deaths across the world occur in developing countries [6]. While this represents a staggering statistic, it is necessary to confront the fact that maternal health disparities in developing nations exist and are in desperate need of action. In this piece, I intend to describe the barriers and inequalities that exist in maternal health across the world, explore potential solutions to these disparities, and finally derive an ethical argument advocating for widespread action against these disparities.

Barriers in maternal systems are divided into the healthcare system and the patient. Barriers across the healthcare system include transportation, communication, quality of care, referral documentation, standard and monitoring, and network infrastructure [2]. These healthcare system barriers are worsened by socioeconomic status, as well as healthcare infrastructure of developing countries. Without networks and proper training of physicians and other staff, healthcare systems in developing countries fail to provide their citizens with the proper resources for treatment in clinical settings. These healthcare system barriers are far more important in determining maternal health outcomes because patient barriers are often the result of a lack of knowledge or lack of wealth. Barriers to patients include environments, knowledge about the referral, poverty, health status of the mother, and culture. While these factors do play an important role in maternal health, they do not directly contribute to how mothers are actually given care. The healthcare system is what most commonly fails maternal healthcare in developing nations. Thus, the system should be targeted rather than patients themselves. Recently, developing countries have used this research to implement various technologies to reduce disparities in their countries. The most successful of these technologies have been healthcare call centers, where patients can call for accurate information on how to navigate the healthcare system of their countries [2]. These centers work to address mistrust and have worked in resolving patient barriers. However, the root cause of maternal health disparities rests on healthcare system barriers themselves, which should be targeted in greater quantities.


To better healthcare systems in developing nations, a shift from quantity to quality must be made. Currently, efforts to better healthcare in developing nations has focused on building as many hospitals as possible and attempting to employ mass amounts of healthcare employees. However, when quantity becomes the focus of healthcare, quality is worsened at a high degree. There is no point in having an extensive healthcare network if that network cannot treat its patients nor provide reliable, adequate healthcare. These deficiencies in quality result from gaps in knowledge, inappropriate applications of available technology [4], and the inability of organizations to change [3]. Healthcare systems must be responsible and adaptive in order to properly treat their patients. Additionally, real investment into healthcare in developing countries must be made that results in competent healthcare workers with the ability to properly treat their patients. These investments must train doctors in adequate medical schools, hospital staff in developing networks throughout their country, and any other healthcare workers in creating an expansive healthcare network. If an emphasis on quality can be implemented, it will begin to spread across these nations to create a strong, large healthcare network. But, healthcare systems cannot exist in developing nations when they are mistrusted, corrupt, and not properly trained in delivering healthcare to patients.


Now that information has been provided and explained on disparities of maternal health in developing nations, it is not sufficient to simply say that developing countries should fix their healthcare systems through investment. The reality of our world is that complex forces prevent the development of these healthcare systems. For these maternal health disparities to actually be resolved, they require global initiative and support. To advocate for necessary action to be taken, it is important to explain the concept of utilitarianism in regards to moral ethics. In Famine, Affluence, and Morality, Peter Singer explains how “if it is in our power to prevent something bad from happening, without thereby sacrificing anything of comparable moral importance, we ought, morally, to do it” (Singer, 231). Singer emphasizes the drowning child example, where a person walks by a drowning child on their way to work and has the opportunity to save the child. Singer argues that most would jump in to save the child, but the addition of external circumstances alter people’s situations to the point where some may not jump in. Singer extends this argument to our current world with the amount of suffering occurring. In wealthy countries, many citizens have the financial means to save lives around the world, but we choose not to in order to purchase material goods and accumulate wealth. Singer argues that in utilitarianism, “the traditional distinction between duty and charity cannot be drawn” (Singer, 235). People in our world focus too much on modernity and have forgotten how much good we can truly do with our actions and means.

By applying Singer’s argument on utilitarianism to disparities in maternal health in developing countries, we can deduce that the ethical person should devote their time and excess money to reducing these disparities. The ethical person would be employed by a non-profit organization working to reduce these disparities and would live as cheaply as possible. They would use their excess income to donate to organizations combating these disparities. However, this radical approach to Singer’s version of an ethical life will likely not be taken on by anyone. It is too much for any single person to dedicate their entire life to one cause. I, myself, can even say that I could never see myself living a life guided completely by utilitarianism. However, what is important to draw from Singer’s argument is that we need to take a step back from the materialism that clouds our judgment. We forget that people die from maternal health barriers and other disparities because we are in very far proximity from them. However, just because we cannot see someone suffer does not mean they are not suffering. People may not follow utilitarianism, but its strict ethical code should induce people to analyze how they can reduce suffering in the world. 


There are a variety of ways for anyone to reduce suffering in the world whether it relates to disparities in maternal health or not. You can start by simply educating yourself on an important topic of suffering, research how you can donate to resolve this issue, or educate others on important sources of suffering that require attention. If we all can realize that suffering in our modern world can be eliminated through simple actions and steps, we can strive towards a better world. Maternal health in developing countries is a widespread example of suffering that can be resolved. If you feel compelled to act and make a difference in our world, I encourage you to start small and employ doses of utilitarianism into your life. Without all of our help, suffering cannot end.

Through an interview in 1982 with Laurie Mercier for Oral History conducted by the Montana Historical Society, we learn that in the Spanish Flu Pandemic of 1918, Jarussi’s father was experiencing symptoms but unable to be diagnosed. “He was going to go to Thermopolis to the springs. He thought going there would help him. And just before he was leaving, he went to the doctor. Dr. Gardner was the doctor at that time, his doctor.” Jarussi recounts, “And he said, ‘Dr. Gardner, I’m going to try and go to the springs and see if that helps me.’ And he said, ‘Well, Louie, it might help you’” [14]. By 1930, the United States had over 2,000 hot and cold-spring resorts for wellness, featuring a vast array of procedures for an equally vast range of health needs under the umbrella term of “hydropathy”. In City Water, City Life, Carl Smith explains hydropathy as the cure for the well-off urbanite, the illness of the “overly refined life characteristic of cities”. In 1946, 649,000 baths were taken in Hot Springs, Arkansas on Bathhouse Row [7]. 

With an increased colloquial understanding of how to prevent acute infectious diseases—and the increase of occupational and chronic illness with the Epidemiological Transition in the 20th Century—we began to see psychological illnesses such as broadly defined “depletion of nervous energy” in workers. Examples such as “neurasthenia” demand treatment with “camp cures” and more outdoor time for men, with more bedrest and domesticity for women [20]. In addition, the presence of Black Lung, lead exposure, poor factory conditions, and illness as a product of working conditions also saw a call to gain access to the fresh air. Yet, alongside political and economic ideology and policy changes to emerge after the 1940’s, much of the systemic and environmental public health was replaced with a pathology-based, clinical, and individual-centric healthcare that allocated the corresponding social systems to non-health divisions such as those specific to labor or housing [11]. This transformation led to the closing of facilities for health retreats and a focus on moving a narrow view of health inwards to hospitals rather than outwards to nature in the latter half of the 20th century.

In a re-emerged uptick in this practice, as a result of the commercialization and commodification of “Wellness” in addition to healthcare in the 21st century, according to Global Wellness Institute, the Wellness Tourism Industry was worth $639 billion. Holistic approaches to feeling healthy around the year 2017 demonstrated the return of an apparent rural health benefit in healthcare. Now, the Global Wellness Institute projects that post pandemic wellness tourism will increase by over 20% annually [23].

Review Editor: Shaily Pal
Design Editor: Alejandra Gonzalez-Acosta

[1] Declercq, E., & Zephyrin, L. (2021). A greater health system and policy focus on maternal health before, during, and after childbirth is needed to prevent deaths related to pregnancy and address inequities.

[2] Harahap, N. C., Handayani, P. W., & Hidayanto, A. N. (2019). Barriers and technologies of maternal and neonatal referral systems in developing countries: A narrative review. Informatics in Medicine Unlocked, 15, 100184.

[3] Jamison, D. T., Breman, J. G., Measham, A. R., Alleyne, G., Claeson, M., Evans, D. B., Jha, P., Mills, A., & Musgrove, P. (Eds.). (2006). Chapter 70. Improving the Quality of Care in Developing Countries. In Disease Control Priorities in Developing Countries (2nd Edition) (pp. 1293–1308). World Bank Publications.

[4] Murray, C. J., & Frenk, J. (2000). A framework for assessing the performance of health systems. Bulletin of the World Health Organization, 78(6), 717–731.

[5] Singer, P. (2016). Famine, affluence and morality. Oxford University Press. 

[6] United Nations (2008). Nearly all maternal deaths occur in developing countries, UNICEF report finds.,Nations%20Children%27s%20Fund%20(UNICEF)

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