Factors and Determinants Influencing Maternal Mortality in Rural Uganda and Prospects for Sustainability: A Literature Review

Uganda faces one of the highest maternal mortality rates worldwide as a result of multiple factors and determinants.  This review consolidated some of the factors and determinants driving these high mortality rates to contribute towards alleviating the situation. The review found that maternal mortality rates are particularly elevated in rural areas due to insufficient government policies that control the socio-economic variables on which expectant mothers depend to access healthcare. Based on the review, the paper proposes interventions to help reduce rural maternal mortality rates, underscoring the importance of governmental policy reforms and behavioral change among pregnant women as part of this process. Implementing the interventions will likely lower mortality rates in rural Uganda. However, this would only be possible through the collaborative effort of multiple stakeholders to enhance maternal healthcare outcomes.

Keywords: Maternal, determinants, factors, Healthcare, Mortality

Research question: What are the factors and individual determinants influencing access to maternal healthcare services in Rural Uganda? How can these factors and determinants be improved to reduce access and reduce maternal mortality rates in rural Uganda?

Author: Robinah Namulindwa
Co-Author: Chris Byaruhhanga

1. Introduction:

Countries worldwide are working towards providing safe antenatal care to pregnant mothers to achieve Sustainable Development Goal (SDG) 3.1, aiming to reduce the maternal mortality ratio to 70 deaths per 100,000 live births (Khalil et al., 2023). Ensuring equitable access to antenatal care, especially in Sub-Saharan Africa, where government healthcare capacities vary due to socio-economic and governance factors, presents significant challenges (Aboagye et al., 2022; Addo et al., 2023).

In Uganda, the high maternal mortality rate of 435 deaths per 100,000 live births, mainly due to deliveries outside health facilities, is a significant concern impeding SDG progress and overall healthcare outcomes (Morut et al., 2022). Understanding and addressing the factors behind maternal mortality in rural Uganda, where healthcare services are inadequate, is crucial for improving health equity and reducing maternal and infant mortality rates (Atuoye et al., 2020).

This focus on rural areas aims to enhance access to essential maternal healthcare services for all women, contributing to improved health outcomes and well-being.

This paper aims to synthesize existing literature on the factors contributing to maternal mortality in rural Uganda and to suggest actionable measures for enhancing access and utilization of healthcare facilities by pregnant women in rural areas.

1. Factors and determinants contributing to maternal mortality in rural Uganda.

1.1. Policy challenges

High maternal mortality rates persist in rural Uganda, where accessing maternal health services is challenging. This issue is exacerbated by weak maternal health policies influenced by the personal interests of elites rather than a focus on universal healthcare access, hindering efforts to reduce maternal mortality. To address this, it is essential to review and amend health policies to prioritize providing maternal healthcare for all, ultimately reducing maternal deaths (Raru et al., 2022; Mukuru et al. et al., 2021).

Rural areas still face high maternal death rates due to economic barriers preventing pregnant women from accessing essential health services. Public health facilities in rural areas are often underequipped compared to urban counterparts, underscoring the need to establish and enforce interventions and policies to enhance maternal healthcare access in rural Uganda (Atukunda et al., 2023; Chowdhury & Chakraborty, 2017; Magunda et al., 2023). Uganda requires a comprehensive plan and policy overhaul to strengthen rural health facilities, thereby improving maternal healthcare access for the target population (Kim et al., 2022).

​1.2. The Economic Situation of Uganda

The high mortality rates in Uganda are influenced by the country’s economic status, impacting healthcare infrastructure and service provision. Being one of Africa’s poorest nations, Uganda faces challenges such as weak economic growth, heavy reliance on agriculture, and high poverty rates (Dektar et al., 2023). With limited government spending on health and inadequate health worker density, access to maternal healthcare is hindered, particularly in rural areas (Kakumba, 2022).

The poor economic situation has led to inadequate infrastructural facilities, often cramped and lacking space for maternal care services like operating theatres. Bugiri faces challenges with insufficient maternity rooms and sanitary facilities, compromising privacy during maternal care (Poppens et al., 2023).

Addressing these infrastructure deficiencies is vital to ensure quality maternal healthcare services and improve access to essential antenatal, postnatal, skilled birth assistance, and post-abortion care services.

The country’s economic situation has led to the inadequacy of essential medical supplies like drugs, gloves, and screening equipment in rural health facilities, which is a significant barrier to accessing maternal healthcare in Uganda. Shortages of these supplies impact the completion of ANC services, with rural mothers facing challenges in obtaining necessary care due to these deficiencies. The unavailability of obstetric care further increases the risks for maternal health and contributes to poor outcomes.

Addressing these gaps in medical supplies is crucial to improving maternal health outcomes and reducing the risks faced by pregnant women in rural areas.

Understaffing and absenteeism of midwives and nurses in rural maternity wards have severely affected access to maternal healthcare in Uganda. The scarcity of midwives in these areas leads to increased workloads for pregnant women and delays in receiving necessary maternal health services, elevating the risk of maternal mortality (Adatara et al., 2021)

Pregnant women in rural areas face inadequate management of their health issues due to the limited obstetric skills of medical staff, leading to increased risks of mortality. Midwives and nurses are often interns or recent graduates who lack the necessary training and confidence to handle maternal complications effectively. This results in poor treatment of conditions like stillbirths and hemorrhage (Nakijoba, 2023; Namutebi et al., 2023)

1.3. Socio-economic Determinants and Access to Maternal Healthcare Services

In rural Uganda, pregnant mothers benefit from spousal care, yet adolescent pregnant women are often neglected by their partners and relatives. This lack of support leads to emotional and financial instability, hindering access to maternal health services. Spousal support in Mbale is linked to improved maternal healthcare for rural mothers (Apolot et al., 2020; Daniele, 2021; Kayemba et al., 2023; Mwije&Holvoet, 2021; Olubodun et al., 2023). Male partner involvement in maternal health programs motivates pregnant women to seek care, particularly in rural areas with limited information. Pregnant women rely on their husbands for antenatal care, but financial support is crucial for accessing maternal services (Roed et al., 2021).

Women with involved husbands during pregnancy and postnatal care are more likely to access maternal healthcare. However, the slow progress in engaging male partners since 2014 poses challenges (Auma et al., 2023; Bagenda et al., 2021; Gopal et al., 2020; Kabagenyi et al., 2014; Muheirwe& Nuhu, 2019; Mwije&Holvoet, 2021; Omona&Mahoro, 2023).

Reasons for low involvement include work commitments, social activities, and financial constraints. This lack of support from husbands in rural maternal health raises concerns over the well-being and development of maternal mothers in rural  Uganda (MoH-UG, 2019; Bagenda et al., 2021; Daniele, 2021;). However, little research has been conducted on male involvement in maternal health in the rural areas of Uganda.

Stigma and discrimination are other factors significantly impacting pregnant rural mothers, particularly adolescents, affecting their access to maternal health services in rural Uganda (Edna et al., 2022). Adolescent pregnant women in rural areas face community and parental abuse, along with HIV-related stigma, leading to delays in seeking maternal care (Apolot et al., 2020; Jolle et al., 2022; Rustad et al., 2021).

Unmarried pregnant adolescents often experience abandonment by family and friends due to societal views on pregnancies outside marriage, leading to social support withdrawal and psychosocial challenges. They also encounter family conflicts, violence, and disrespect from healthcare providers (Sserwanja., et al., 2022). In Bugiri District, pregnant mothers, especially adolescents, fear community and healthcare facility stigma, although limited research on stigma’s impact on maternal healthcare access exists in the area. Current studies in the Bugiri District focus on assessing stigma and mother-to-child HIV prevention (Owumugisha, 2022; UNICEF, 2018).

Many pregnant mothers in rural Uganda grapple with high poverty levels, worsened by the impact of Covid-19. Economic opportunities are scarce, leading most mothers to focus on household agriculture. However, financial constraints, limited access to quality seeds, and land ownership challenges result in low agricultural returns. This economic hardship is particularly severe for pregnant mothers, especially those without financial support from spouses. Pregnant women in higher-income households have better access to maternal health services, as they can afford healthcare costs and transportation more efficiently.

Wealthier women are more likely to access comprehensive maternal healthcare services compared to those in poverty (Bwirire et al., 2023; Chowdhury & Chakraborty, 2017; Gayatri et al., 2023; Magunda et al., 2023; Towongo et al., 2023).

Despite the introduction of a universal health program in Uganda, pregnant women in rural areas often have to pay for certain maternal health services at public facilities or are referred to private clinics for medications and supplies (Magunda et al., 2023; Mollel et al., 2024). Due to these economic constraints, many rural pregnant women turn to Traditional Birth Attendants. Introducing income-generating activities in health programs is crucial to help pregnant women cover basic health service fees.

Pregnant women who are employed are more inclined to utilize antenatal care services in rural Uganda. Job-holding women tend to access and attend antenatal care services more regularly, with their daily income influencing the level of care received. Maternal employment and economic assistance, mainly through income-generating activities, are vital in facilitating access to maternal health services for teenage expectant mothers in rural areas(Kayemba et al., 2023; Towongo et al., 2023).

The age of pregnant and adolescent mothers impacts their access to maternal health services in rural Uganda. Factors influencing this access vary. Teenage girls in the rural Busoga sub-region face a high risk of early pregnancy due to sexual abuse and early entry into forced marriages. Generally, pregnant mothers aged 15-24 are more likely to use ANC services in rural areas compared to older mothers (Apolot et al., 2020; Budu et al., 2021; Rutindangyezi and Nakasolo, 2022; Tsegaw et al., 2023).

Education level significantly influences maternal healthcare access in rural areas. Higher female education positively correlates with better service utilization, with secondary and tertiary education notably improving access in Uganda. Limited primary education among rural women hinders ANC, postnatal care, and skilled birth attendant access. Implementing adult education centers can enhance maternal health literacy and reduce maternal mortality. In Buwunga Sub-County, Bugiri District, pregnant women with primary education or higher are more likely to use insecticide-treated nets (ITNs) for mosquito protection during pregnancy. Educating pregnant women on ITN usage could be vital in rural Uganda.

Married mothers have higher access to maternal health services compared to single or never-married mothers. They receive more financial support from spouses, enabling better access to services, although cohabitation has been linked to delayed ANC attendance in Uganda (Nuamah et al., 2019; Towongo et al., 2023). Surprisingly, unmarried adolescents in Uganda were found to attend at least four ANCs, although rural implications were uncertain (Agaba et al., 2022).

In rural Uganda, cultural traditions drive families to desire large households for reasons like inheritance and agricultural labor. This inclination towards many children correlates with delayed attendance at Antenatal Care services. Additionally, studies in the Bugiri district show a link between beliefs and the use of insecticide-treated bed nets for malaria prevention (Samuel, 2023; Tumwizere and Mbonye, 2023)

Inadequate road conditions and the absence of ambulances have led to some pregnant women experiencing tragic outcomes while attempting to reach health facilities for childbirth. Poor road infrastructure contributes to delays and obstacles in accessing obstetric care, with some mothers not surviving the journey. Research links late Antenatal Care (ANC) attendance with long distances to health facilities, resulting in increased out-of-hours births at Traditional Birth Attendant (TBA) clinics. The impact of distance on healthcare access underscores the challenges pregnant women face in rural areas and emphasizes the importance of improving transportation and maternal health services (Atuhaire et al., 2023; Kayemba et al., 2023). The prevalence of infectious diseases such as malaria and HIV/AIDS in rural Uganda further exacerbates maternal health challenges and increases the risk of maternal mortality (Muhumuza et al., 2016).

2. Prospects for improving access to healthcare in rural Uganda 

  2.1. Policy reform and access to healthcare for maternal mothers

Maternal mortality rates in rural Uganda are a pressing concern due to their surpassing national averages, prompting urgent policy actions (Dantas et al., 2020; Dektar et al., 2023; Kyeyune, 2020b). The country’s economic constraints highlight the necessity to bridge the gap between the current US$9 per capita health infrastructure spending and the WHO’s recommended US$34 per capita (Al-Zubayer et al 2024).

Enhancing investment in healthcare facilities will make it possible to strengthen and upgrade healthcare facilities in rural areas, equipping them with necessary medical supplies, equipment, and skilled healthcare professionals, which can improve access to quality maternal healthcare services. Furthermore, investing in better roads, ambulances, and transportation networks would ensure pregnant women have access to healthcare facilities during emergencies or regular check-ups.

Although Traditional Birth Attendants (TBAs) are formally banned in Uganda’s health policy, they continue to operate clandestinely and play a pivotal role in supporting maternal healthcare in rural areas (Namulindwa & Byaruhanga, 2024). TBAs offer advantages in improving maternal healthcare accessibility and addressing socio-economic barriers, despite concerns about their capabilities in managing complications like hemorrhage (Kyeyune, 2020b; Munabi-Babigumira et al., 2019).

To enhance maternal healthcare in rural areas, the Government of Uganda should consider integrating and supporting TBAs within the formal health system through training and financial aid, recognizing their potential to expand maternal healthcare access and improve outcomes, especially in underserved rural regions (Rutindangyezi&Nakasolo, 2022). By embracing this approach, Uganda can significantly reduce maternal mortality rates and address healthcare disparities in rural communities.

2.2. Strengthening Traditional Birth Attendants

The reliance on Traditional Birth Attendants (TBAs) in rural Sub-Saharan Africa, including Uganda, stems from inadequate maternal healthcare services, skilled staff shortages, limited medical resources, and distant healthcare facilities (Kassie et al., 2022). Despite TBAs lacking formal education, the World Health Organisation (WHO) recognizes them as skilled midwives who acquire expertise through apprenticeship. They play crucial roles in childbirth assistance and community engagement, particularly in mobilizing men for maternal health programs.

Integration of TBAs into healthcare systems in various African countries has shown promise in reducing maternal mortality rates, addressing human resource deficits in remote areas, and enhancing healthcare accessibility (Graham & Davis-Floyd, 2021; Ntoimo et al., 2022). Given the lack of maternal health knowledge among adolescent mothers, training and employing TBAs to provide skilled maternal healthcare services could significantly improve maternal health outcomes (Chi et al., 2018; Musyimi et al., 2019).

Despite the government’s ban on TBAs due to concerns about their ability to manage complications like hemorrhage, TBAs operate clandestinely in Uganda, delivering vital maternal health services and supporting rural communities in childbirth and referrals (Dektar et al., 2023; Urendi, 2023). While TBAs primarily handle straightforward cases, enhancing their support and training could strengthen the quality of maternal healthcare they provide, potentially contributing to improved maternal health outcomes (Kassie et al., 2022).

Recognizing TBAs’ continued relevance in rural Uganda, exploring approaches to strengthen their capacities and foster partnerships with formal healthcare institutions is essential to enhance maternal healthcare access in underserved regions and improve overall maternal health outcomes. This research initiative aims to identify avenues for empowering TBAs and facilitating effective collaborations to promote better maternal health in rural communities.

2.3. Mobile Antenatal Clinics

Limited access to healthcare facilities, exacerbated by long distances in rural Uganda, contributes significantly to high maternal mortality rates (Apolot et al., 2020; Jolle et al., 2022; Rustad et al., 2021). Mobile antenatal clinics (MHCs) have emerged as a viable solution to provide quality antenatal care for pregnant women in underserved rural areas (Agaba et al., 2022; MobileMed, 2024). The effectiveness of mobile clinics in delivering antenatal care has been well-tested and found suitable for rural contexts due to their cost-effectiveness and mobility (Obioha et al., 2023; Phillips et al., 2017).

To enhance the impact of MHCs in rural settings, future programs should consider integrating additional outreach activities such as mobile text messaging, awareness campaigns through posters, and the establishment of community education centers. In Uganda and other Sub-Saharan African countries, piloting MHCs in collaboration with Traditional Birth Attendants (TBAs) could strengthen maternal healthcare capacity and facilitate their integration into mainstream hospital systems, ultimately improving maternal health outcomes and access in rural areas.

2.4. Access to income-generating activities

Limited access to maternal healthcare services in rural Uganda is exacerbated by low income levels among pregnant women, particularly impacting economically disadvantaged and adolescent mothers (Adeyanju et al., 2017; Kangbai et al., 2022; Sui et al., 2021). Increasing maternal income is essential to improve access to and utilization of maternal health services, with income-generating activities such as farming, fishing, and cooperative initiatives showing promise in boosting economic empowerment for pregnant women globally (Akter et al., 2020; Gizaw et al., 2022). Family size, financial experience, and funding availability significantly determine rural women’s income levels (Akter et al., 2022). Empowering pregnant women through income-generating activities can help address financial barriers and enhance maternal healthcare access, improving maternal health outcomes in rural Uganda.

2.5. Education and outreach to raise awareness and facilitate access to information 

Insufficient access to healthcare facilities in rural Uganda is influenced by a lack of information and local beliefs impacting maternal health utilization. Education and awareness campaigns have proven effective in enhancing maternal health outcomes globally. Educating expectant mothers on nutrition, immunization, exercise, and seeking help promotes healthy pregnancy practices and reduces risks during childbirth (Amwonya et al., 2022). In rural areas, where cultural beliefs may discourage healthcare facility visits, sensitization efforts and direct support for pregnant women can increase maternal healthcare utilization, addressing barriers posed by traditional beliefs (Muhumuza et al., 2016; Samuel, 2023).

2.6. Improve access to information and technology

Improving access to information and technology is crucial for enhancing maternal healthcare in rural Uganda. Utilizing social media and innovative tools like the MatHealth app have proven effective in providing maternal health information and empowering pregnant women with knowledge and skills to access healthcare services (Abandu et al., 2019; Atukunda et al., 2023; Musiimenta et al., 2021). Studies have shown that phone access, news reading, and technology correlates with higher maternal health service utilization rates (Aboagye et al., 2022; Chowdhury and Chakraborty, 2017).

The scarcity of healthcare resources in Uganda, highlighted by low government health expenditures and inadequate healthcare worker density, underscores the importance of exploring alternative strategies like integrating Traditional Birth Attendants (TBAs) into the healthcare system (Dektar et al., 2023; Kwesiga et al., 2020). Initiatives promoting radio and television usage and effective communication strategies are vital for reaching rural pregnant women and improving maternal health outcomes (Kassie et al., 2022; Khorshed et al., 2022). Given the challenges faced by rural pregnant women in accessing maternal healthcare, prioritizing access to radios and televisions is crucial to disseminating maternal health information efficiently and enhancing service utilization in underserved areas.

3. Conclusions

The literature review underscores multiple challenges hindering pregnant women’s access to healthcare facilities in rural Uganda, influenced by factors like government policies and the country’s economic landscape (Ssetaala et al., 2022; Dantas et al., 2023). These barriers parallel issues found in other Sub-Saharan African countries, emphasizing socio-economic disparities, environmental conditions, cultural beliefs, and limited healthcare information as critical impediments to maternal healthcare access in rural areas. Overcoming these obstacles necessitates political commitment, evidence-based policy formulation, and collaborative engagement involving stakeholders, women in need, and developmental organizations.

Enhancing maternal healthcare access in rural Uganda demands innovative, collective efforts involving healthcare actors, governmental bodies, and creative strategies to address challenges related to accessibility, finances, technology, energy, and cultural norms.

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