The global effort to ensure safe motherhood faces its greatest challenge in low-resource settings, where the risk of death during pregnancy or childbirth remains unacceptably high. The disparity in outcomes is stark; in 2023, the maternal mortality ratio (MMR) in low-income countries was 346 deaths per 100,000 live births, compared to just 10 per 100,000 live births in high-income countries. The vast majority of these deaths, which are overwhelmingly preventable, occur in low- and lower-middle-income nations, demanding targeted and multi-faceted interventions.
Prioritizing Access to Preventative and Routine Care
Reducing maternal deaths begins long before labor with consistent, quality preventative and routine care. Universal access to antenatal care (ANC) allows health providers to screen for high-risk conditions that can lead to fatal complications later in pregnancy. Early screening and management are necessary for conditions like severe anemia and hypertensive disorders such as pre-eclampsia, which are significant causes of maternal death.
Targeted interventions during ANC visits can provide substantial protection for the mother and baby. The World Health Organization recommends low-dose aspirin for women at high risk of pre-eclampsia, which has been associated with a 25% risk reduction when initiated before 20 weeks of gestation. Additionally, promoting family planning and contraception access is a highly effective, low-cost intervention that allows for birth spacing and limits high-risk pregnancies occurring too frequently or too early in life.
Health education and literacy provided through community health workers or during ANC visits enable women and their families to recognize danger signs. When women understand symptoms requiring immediate attention, such as persistent headaches, blurred vision, or severe abdominal pain, they can seek help before a complication becomes life-threatening. This proactive approach helps to address the first delay in the “Three Delays Model.”
Strengthening Emergency Obstetric and Newborn Care
While preventative care addresses upstream risks, immediate clinical intervention is necessary when complications arise during delivery. The majority of maternal deaths are caused by severe bleeding, infections, high blood pressure (eclampsia), and obstructed labor, all requiring timely, skilled intervention. Ensuring every birth is attended by a skilled health professional is a foundational step, as these attendants are trained to manage normal delivery, recognize complications, and initiate immediate referral.
The availability of Comprehensive Emergency Obstetric and Newborn Care (CEmONC) services is necessary for managing the direct causes of maternal death. CEmONC facilities must be equipped to provide the full suite of “signal functions,” which include:
- Administering parenteral antibiotics and anticonvulsants.
- Performing manual removal of the placenta.
- Removing retained products.
- Performing emergency Caesarean sections and blood transfusions, which are often the last line of defense against death from hemorrhage or obstructed labor.
Postpartum Hemorrhage (PPH) remains the leading cause of maternal mortality, and its prevention and treatment rely on specific medical protocols. Access to uterotonic drugs, such as oxytocin, is paramount, as prophylactic use during the third stage of labor can halve the risk of severe PPH. The delay in receiving adequate treatment at the health facility, known as the third delay, is often linked to a lack of trained staff or a shortage of essential supplies.
Building Sustainable Health Infrastructure
Clinical interventions cannot save lives without the underlying logistical framework to support them, particularly in remote or underserved areas. A reliable supply chain must ensure that essential, life-saving drugs like oxytocin and magnesium sulfate are consistently available at all levels of the health system, not just the central hospitals. This logistical stability prevents stock-outs that can render facility-based care useless during an emergency.
Effective referral and transport systems are necessary to bridge the geographic distance between a woman’s home, local clinic, and the nearest CEmONC facility. This addresses the second delay, which is the delay in reaching proper medical services. Establishing functional communication networks and dedicated emergency transport, such as community-based ambulance schemes or motorbike ambulances, is necessary to ensure timely transfer when complications arise.
Health systems need robust mechanisms for continuous quality improvement. Maternal Death Surveillance and Response (MDSR) systems collect and analyze data on every maternal death to identify contributing factors and systemic gaps. This process, which requires a blame-free culture, translates data into actionable recommendations to prevent future deaths and strengthens health system accountability.
Addressing Socioeconomic and Cultural Determinants
Medical solutions must be paired with efforts to dismantle the socioeconomic and cultural barriers that prevent women from accessing care. Financial barriers are a significant deterrent, as user fees for maternal care can be prohibitive for poor families, causing them to delay seeking help or opting for home births. Eliminating or subsidizing fees for ANC, facility delivery, and emergency care is a necessary step to ensure financial protection and encourage utilization of services.
Cultural norms and gender inequity often limit a woman’s autonomy to make timely decisions about her health. Women may require permission from a spouse or mother-in-law to seek care, contributing to the first delay in seeking help. Interventions must focus on empowering women and engaging male partners and community leaders to support facility-based care and emergency preparedness.
Community engagement, utilizing local figures like traditional birth attendants (TBAs) in supportive roles, helps bridge the gap between medical facilities and the community. Community health workers (CHWs) provide home visits, promote birth preparedness, and educate families on the benefits of facility delivery. This inclusive approach integrates formal healthcare into the local cultural context, ensuring interventions are accessible and culturally acceptable.