Maternal health care is defined as the medical care provided to women in regard to all aspects of their pregnancy. According to the Institute of Health Metrics and Evaluation, maternal health care refers to “the health of women and childbearing people during pregnancy, childbirth, and the postnatal months” (IHME, 2019). Leading up to the birth of their child, women can engage in a variety of medical services that constitute prenatal care, also referred to as antenatal care. Maternal health care is essential in reducing maternal mortality rates in countries across the globe. Within the past 100 years, progress and reduction in maternal mortality rates are visible, however, maternal deaths are still a leading cause of death across the globe, affecting women disproportionately and more significantly in certain countries than others. Countries in sub-Saharan Africa are among the countries with the highest maternal mortality rates. Ghana, located in the Western part of this region in Africa, has a maternal mortality rate of 310 deaths for every 100,000 live births. When compared to a country like the U.S., this is a high maternal mortality rate. Although still relatively high for a high-income country, the U.S. has a much lower maternal mortality rate than Ghana, with 17.4 deaths for every 100,000 live births (Commonwealth Fund, 2021). What are the fundamental causes of disparities in prenatal and maternal health care observed in Ghana and in the United States and what effect do these have on maternal survival and birth outcomes? Additionally, how do these contributing factors differ based on the healthcare systems in place in Ghana versus the United States?

Although maternal mortality is a leading cause of death across the globe, there are various measures that individuals and healthcare professionals can take to screen and prevent complications in advance. Because various complications can occur throughout pregnancy, maternal mortalities can be caused by various conditions both directly and indirectly including

“postpartum hemorrhage, preeclampsia and hypertensive disorders, pregnancy-related infections, and complications of unsafe abortion, as well as pre-existing medical conditions aggravated by the pregnancy”(UNICEF, 2023). Prenatal care includes screenings, counseling, and treatments in the early stages of pregnancy and is an indicator of the quality and access to care that a woman will receive throughout the rest of her pregnancy and beyond. Women who utilize prenatal care observe visible differences in birth outcomes, as prenatal care comes with many health benefits. Prenatal care is directly correlated with, “reductions in maternal smoking, lower rates of preventable pregnancy complications like high blood pressure, better management of the mother’s weight after giving birth...[and] mothers who initiate care earlier are more likely to take their infants to well-baby visits after their babies are born” (Green, T. (n.d.)., 2019). As a result of this, maternal health care including routine prenatal checkups is foundational to healthy birth outcomes, however, receiving this care is not always straightforward.

Many factors influence and impact a woman’s choice to receive prenatal care. First and foremost, if this care is available or accessible to individuals to begin with is of vast importance. In both Ghana and the United States, women who utilize prenatal care more frequently have more successful birth outcomes, contributing to the better infant and maternal mortality trends observed in both countries. The leading factors contributing to the accessibility and quality of prenatal care in both Ghana and the United States are socioeconomic status, proximity to medical facilities, racial disparities, and socio-cultural beliefs. The differences in these factors result from an array of differences between the two countries including differences in the healthcare system in place, the GDP of the two countries, and the amount of medical resources, technology, and facilities available. These differences create the large, visible disparities in maternal mortality rates that are observed.

In Ghana, the health care system is categorized by government intervention, with a national health insurance system in place, known as the National Health Insurance Scheme (NHIS). In 2003, the Ghana Ministry of Health implemented the NHIS, which “pays for hospitalizations and outpatient doctor visits, as well as basic laboratory testing and certain medications.” This system improved prenatal health services and maternal health care in general within the country, however, NHIS does not cover all medical procedures or medications that individuals may face. Then in 2008, Ghana implemented the Free Maternal Health Care Policy (FMHCP) through the NHIS, which “targeted every pregnant woman in Ghana with a full benefits package covering comprehensive maternal healthcare” (D;, A. J. P. G. (n.d.), 2020).

In contrast, the U.S. is dominated by private insurance along with the government programs of Medicaid and Medicare. In 2010, the Patient Protection and Affordable Care Act (ACA), expanded the qualifications of those who were eligible for Medicaid, particularly to a wider range of adults. As a result of this, “studies have shown that the ACA Medicaid expansions led to increases in Medicaid enrollment among women of reproductive ages, and if the new access to care results in the identification and management of chronic health conditions, women may enter pregnancy in better health”(Chatterji, P., Glenn, H., Markowitz, S., & Montez, J. K, 2023).

However, regardless of the healthcare systems in place, in Ghana or the U.S., many individuals face challenges in accessing care due to the high costs of healthcare insurance. Socioeconomic status is a major factor that contributes to whether women can or are willing to afford and utilize prenatal care services in both countries. Socioeconomic status is evident in regard to medical coverage or insurance, household family income, level of education, and marital status.

The WHO found that in Ghana women ages 15-49 with national health insurance were more likely to utilize the three major components of maternal healthcare under analysis including skilled antenatal care, skilled birth attendance, and postnatal care within the first 24 hours after delivery, compared to those without national health insurance (Ameyaw, E. K., Dickson, K. S., & Adde, K. S., 2021). In Ghana, “only 21.2% [of women] utilised all three components of maternal healthcare,” which portrays how the majority of women and families are burdened by the financial realities of maternal health costs and health care in general (Ameyaw, E. K., Dickson, K. S., & Adde, K. S., 2021). With a lower socioeconomic status, women are limited to fewer resources and therefore the WHO additionally found that in Ghana “poor women, the uneducated or least educated women, and rural residents least utilise these recommended life-saving services.”

Additionally, this study revealed that women who had less than four prenatal care visits were less likely to utilize all three maternal healthcare services compared to those who made four or more. This shows the correlation between prenatal healthcare and birth outcomes, as the women who make routine visits before they give birth are more likely to continue engaging in maternal healthcare services through the end of their pregnancy and after they give birth. Women with a higher socioeconomic status and more resources can more easily access these routine prenatal services without burden. In Ghana, poorer women are limited to what the NHIS can provide for maternal healthcare, if they even utilize this to begin with. On the contrary, wealthier women can place their money towards additional care or services outside of what the NHIS provides. For example, this money could go towards additional examinations, screenings, medical supplies, or transportation to get to medical facilities.

In the U.S. a similar trend is observed, where those with public insurance often rely solely on the services that the government can cover for them financially. Whereas, those who are wealthier or who have private insurance can use their additional money to expand the services and medications they purchase beyond what Medicare or Medicaid can provide them. When comparing disparities in maternal mortality rates and the quality and accessibility of prenatal care by income group it is observed that “the lifetime risk of maternal death ranges from 1 in 5,300 in high income countries [like the U.S.], to 1 in 49 in low income countries [like Ghana]” (UNICEF, 2023). This proves that income and socioeconomic status play a large role on a local level between different families but also on the larger scale of a whole country in terms of income level and GDP.

Whether individuals have the economic means to own a vehicle that can transport them to the nearest hospital, or a partner or spouse who can drive them additionally contribute to women’s access to care along with their location and proximity to medical facilities. The location of facilities, whether in an urban, or rural setting factors into the accessibility and quality of care provided to women. Through various studies, it was found that in Ghana women in urban areas had higher levels of education and in turn were more knowledgeable regarding hypertensive disorders during pregnancy. With greater knowledge of a topic such as this one, women are more likely to seek prenatal care or medical advice during and after their pregnancy as they know the risks and potential harms of a hypertensive condition.

Additionally, differences in the quality of care provided based on location is a trend seen in both Ghana and the U.S. A study conducted in the Ashanti region of Ghana revealed that there were differences in the quality of antenatal care services within urban health facilities versus “peri urban” health facilities of the same region. As a result of this, there were therefore differences in birth outcomes as “mothers attending urban health facilities were likely to be hypertensive, receive quality ANC services, and have excellent knowledge on HDPs compared to women receiving care in peri-urban health facilities”(Boachie-Ansah, P., Anto, B. P., Marfo, A. F. A., Dassah, E. T., Mozu, I. E., & Attakora, J., 2023). This was seen on the individual level from woman to woman, as surveys displayed that 94.8% of women in urban areas of the Ashanti region described their antenatal care as satisfactory, whereas only 73% of women in periurban areas said the same regarding the care they received.

This is observed in the U.S. as well, where location and area impact the accessibility and quality of healthcare available. Oftentimes, women living in more rural areas are required to travel much longer distances to facilities to receive care. Making extensive trips back and forth requires more time, energy, and money spent on gas than if facilities were located closer. Additionally, because prenatal care often requires seeing specialists, which are often limited and hard to make an appointment with, especially in the U.S., women in rural areas often experience a lack of necessary medical personnel in their area or medical facilities shutting down all together where they live. In rural Alabama, maternal units are closing one after another, in one example forcing a woman to drive 100 miles to the nearest hospital when she was actively going into labor (Healy, 2018). This highlights the Bierman model which outlines the three levels of factors affecting access to health care including 1) primary access - which is access to the health system and services, 2) secondary access - which is barriers within the health system, and 3) tertiary access - which is provider ability to address patient needs. Specifically, this example highlights challenges to primary access and the detrimental outcomes this can have on both the woman going into labor and her child. Issues arise when women have trouble gaining care throughout their pregnancy or when they are forced to wait late into their pregnancy before receiving care.

This leads to the next factor impacting disparities in maternal healthcare which are racial disparities. In the U.S., racial disparities in accessing health care specifically prenatal and postnatal care are apparent and widespread, observable in how early into their pregnancy women seek medical care. For example, “approximately 89 percent of white mothers initiate care during the first trimester, [whereas] only 75 percent of black mothers and 79 percent of Hispanic mothers do so”(Green, T. (n.d.), 2019). This in turn affects whether women will seek care after giving birth which is essential as this can include different forms of counseling, postpartum depression services, and treatment for hypertensive disorders, all of which can be lethal if not addressed or treated. The prevalence of hypertensive disorders relating to delivery increased specifically from 2017-2019 in the U.S. from 13.3% to 15.9% (CDC, 2022). Amongst these disorders “the highest prevalence was among women who were Black (20.9%) or American Indian and Alaska Native (16.4%)” (CDC, 2022). Many women of color or women who identify as a part of a minority group report that they often feel overlooked and unheard by medical professionals. For example, it is common for women to face hypertension related issues following childbirth, and many women of color recount that they were not taken seriously when they voiced their concerns regarding fluctuations in their blood pressure. This is detrimental and can be deadly, as maternal mortality often results from issues with blood pressure or bleeding out. In the U.S., African American women face maternal mortality rates three to four times higher than non-Hispanic white women do (Chalhoub, T., & Rimar, K., 2024).

While racial disparities contribute largely to maternal health care in the U.S., sociocultural beliefs and attitudes contribute similarly in Ghana. For example, in various cultures and religions individuals view giving birth in a medical facility as “weak” and instead prefer natural births in the home, impacting the number of women who voluntarily go to medical facilities for prenatal care and to give birth. Additionally, in a patriarchal system in Ghana, women can face difficulty gaining permission from members of their home to go to medical facilities and seek prenatal care. In Ghana along with other countries in West and Central Africa, the “lifetime risk of maternal death is 1 in 27 whereas in Western Europe it is 1 in 11,000” (UNICEF, 2023). This may be additionally due to the fact that it is more common for individuals to engage in unsafe practices, including at home abortions, out of fear of the negative connotations of going to medical facilities or seeking assistance for this type of care (Drislane, F. W., Akpalu, A., & Wegdam, H. H. J., 2014).

Overall, there are many areas of focus that need considerable attention before maternal mortality can be considered less harmful and less of a global crisis than it is today. Maternal health care and mortality rates are important public health issues, as they affect women disproportionately across the globe. To make necessary improvements, patient oriented care must be employed where medical professionals listen and actively work with women to ensure healthy birth outcomes. Health professionals in countries across the world, regardless of the healthcare system in place or the amount of resources or medical facilities available, must commit to acknowledging women’s circumstances and personal experiences without diminishing their concerns when it comes to prenatal care, giving birth, and postnatal care. Furthermore, increasing and improving education regarding what maternal health care is and its importance on birth outcomes is an achievable goal that all countries can work towards in improving the current situation. Additionally, prompting government officials and stakeholders to write legislation, enact health communication campaigns, improve resource distribution, and enhance contraceptive services and support services for women can all contribute to public health goals of improving women’s health and care across the globe. Implementing these strategies, Ghana has a chance to reach its goal of a maternal mortality ratio of 70 per 100,000 live births by 2030, which would place it much closer to where the U.S. is ranked in terms of maternal mortality rates today(WHO).

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