Intervention Strategies to Reduce Maternal Mortality in the Context of the Sustainable Development Goals: A Scoping Review

Abstract

According to the United Nations Population Fund, approximately every two minutes, a woman dies, totalling approximately 800 deaths per day for reasons related to a maternal causes. Therefore, within the Sustainable Development Goals of the 2030 Agenda, the goal is to reduce the global maternal mortality rate to less than 70 deaths per 100,000 live births by 2030. We aim to analyse strategies to reduce maternal mortality in the context of the Sustainable Development Goals, identify barriers that hinder their implementation, and analyse the impact of the COVID-19 pandemic on their achievement. We performed a scoping review of the following databases and distributors of specialised information in the health area: PubMed, Medes, Lilacs, Cuiden, Cinahl, Scopus, SciELO, and websites of the United Nations (UN), United Nations Population Fund (UNFPA), and Cooperanda. A total of 24 articles were reviewed. The results obtainded determined that reviewed studies agree that despite efforts to reduce maternal mortality, significant social and structural barriers still exist in developing countries that slow the implementation of strategies to protect maternal health, especially in the most at-risk populations, and the improvement of the health system. The main strategy consists of increasing the number of deliveries attended by qualified personnel, which is the greatest indicator of progress in reducing maternal mortality. To conclude, Economic, social, and political barriers remain in developing countries in the context of the Sustainable Development Goals. The intervention that has shown the most success is the attendance of deliveries by qualified personnel. It is essential to prioritise maternal care, triangular cooperation, and effective connection between the different Sustainable Development Goals.

1. Introduction

Maternal mortality (MM) remains a major global issue. Beyond its impact on health, it also influences and is influenced by social, psychological, and economic factors that affect both individuals and society [1]. As part of the Sustainable Development Goals (SDGs) of the 2030 Agenda, one of the objectives is to reduce the global maternal mortality rate (MMR) to less than 70 deaths per 100,000 live births by 2030 [1].

The MMR is defined as the proportion of mothers who do not survive childbirth compared to those who do per 100,000 live births [1]. The Millennium Development Goals (MDGs) achieved a 37% reduction in global MMR from 385 to 216 deaths per 100,000 live births between 1990 and 2015 [2]. However, according to the United Nations Population Fund (UNFPA) and the WHO, in 2020, an estimated 287,000 women globally died from a maternal causes, equivalent to almost 800 maternal deaths every day and approximately one every two minutes. This is more than a third lower than in 2000, when there were an estimated 446,000 maternal deaths [3]. The global MMR in 2020 was estimated at 223 maternal deaths per 100,000 live births (UI 202 to 255), down from 227 in 2015 (uncertainty interval 211 to 246) and from 339 in 2000 (UI 319 to 360)—a reduction of one third (34.3%) over the full 20-year period.

On current trends, more than one million additional maternal deaths will occur by 2030. The average annual rate of reduction (ARR) in the global MMR from 2000 to 2020 was 2.1% (UI 1.3% to 2.6%), meaning that, on average, the global MMR declined by 2.1% every year between 2000 and 2020, although progress was uneven throughout this period. In 2020, sub-Saharan Africa was the only region with a very high MMR—estimated at 545 maternal deaths per 100,000 live births (UI 477 to 654). This is 136 times higher than the MMR in Australia and New Zealand (4; UI 3 to 4), where the MMR was lowest.

From lowest to highest, the regions of Europe and Northern America (13), Eastern and South-Eastern Asia (74), Northern Africa and Western Asia (84), and Latin America and the Caribbean (88) all had low MMRs (below 100) in 2020. Sub-Saharan Africa alone accounted for approximately 70% of global maternal deaths in 2020, followed by Central and Southern Asia, which accounted for almost 17%. These regional differences in the MMR corresponded to substantial differences in the lifetime risk of dying from a maternal cause [4].

These statistics help us to understand that MM is not only a significant health problem but also a key indicator of a country’s development, heavily impacting its society and economy and highlighting disparities between rich and poor countries [4].

The most significant underlying causes of MM include obstetric bleeding (the most frequent and severe), spontaneous and induced abortions, complications during childbirth, hypertensive disorders (eclampsia), infections and sepsis, unpredictable complications during pregnancy, and non-obstetric complications (such as embolism- or HIV/AIDS-related issues [5].

The three-delay model described by Thaddeus and Maine suggests that pregnancy-related mortality is overwhelmingly due to the following: (1) delay in deciding to seek appropriate medical help when an obstetric emergent appears, (2) delay in reaching an appropriate obstetric facility, and (3) delay in receiving adequate care once the facility is reached [6]. There are also significant differences in morbidity and MM related to social determinants affecting women (such as their socioeconomic status, ethnicity, or beliefs), their communities (economic development, available policies, and institutions), and healthcare providers (such as the presence or absence of multidisciplinary teams or quality training) [4,5,6].

Research shows that socioeconomic status significantly influences MM, and the economic resources available to mothers cause three significant delays in receiving care during pregnancy: delay in deciding to seek healthcare, delay in reaching healthcare facilities, and delay in receiving quality care [7,8]. Regarding the health policies of public health systems, we should highlight those implemented by the English NHS and the Brazilian SUS. Although they have been effective and aligned with sustainable development objectives, there is still a long way to go as there are still differences in maternal mortality between women from black ethnic backgrounds compared to white women and women living in the most deprived areas [9,10].

These causes, along with the medical problems that they represent, are exacerbated in many parts of the world by the lack of quality healthcare, often resulting in maternal death [5]. Mothers who survive can suffer significant physical (prolapse, anemia, incontinence, infertility), psychological, social, and economic repercussions; this, in turn, creates a “domino effect” that increases the vulnerability of their children (significantly increasing the risk of mortality in children under two), families, communities, and countries [3,8].

Another important aspect is the significant disparity between developed countries and those that are developing [9]. Developed countries have lower MMRs due to better health coverage; however, even among them, there are disparities due to ethnic or racial reasons. For example, in the United States, the United Kingdom, or the Netherlands, despite them being multicultural and diverse nations, the MMR is more than twice as high among black women compared to white women [9]. In developing countries, the MMR is 14 times higher than in developed countries, with only half of women receiving the medical care that they need [1]. Thus, 85% of current MM cases are concentrated in sub-Saharan Africa and South Asia [3], where unequal access to healthcare and a lack of training to detect and treat pregnancy complications continue to hinder women’s survival [3,10].

The most crucial measure related to maternal health is the availability of qualified personnel for childbirth and emergency obstetric care. It was estimated that in 2012, only 68% of births worldwide were attended by trained personnel, and although in developed countries this figure increased to 86% by 2023, in developing countries, the percentage barely changed [11,12,13,14]. Therefore, developing countries are encouraged to build facilities equipped for delivery and to train healthcare workers to help with deliveries. Professional qualification is essential to detect complications, treat basic problems, refer severe cases to emergency obstetric care services, care for newborns, and prevent perinatal deaths, which occur primarily during childbirth or within 48 h thereafter. Access to postnatal care for both the mother and the newborn is also vital. Therefore, the implementation of follow-up visits by healthcare personnel is sought as a measure to improve maternal and infant health worldwide [3,15].

The main objective of our scoping review is to analyse intervention strategies to reduce MM in the context of the SDGs. In addition, it aims to identify the barriers that hinder the implementation of these interventions in developing countries.

2. Material and Methods

2.1. Methodology

The chosen approach for this work was a Scoping Review using the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” for Scoping reviews (PRISMA-ScR) guidelines [16], carried out from December 2023 to February 2024, for the period from January 2015 to February 2024. The search focused on the main databases and distributors of specialised information in the health field: PubMed, Medes, Lilacs, Cuiden, Cinahl, WOS, and SciELO. Relevant information was also found on the websites of the UN, the UNFPA, and Cooperanda. These pages, as information sources, compile relevant information related to data from developing countries. The PICO format (Population/Intervention/Comparison/Outcome) was used to prepare the following research question: what interventions are being carried out to reduce MM within the SDGs?

Population: Countries where strategies are used to reduce MM have been evaluated. Intervention: Strategies aimed at reducing MM. Comparison: Usual activity without the application of these strategies. Outcome: The strategies developed allowed for the reduction in MM and, secondarily, the identification of strategies to reduce it and the barriers that prevent this reduction.

2.1.1. Search Strategy

After defining the study theme and establishing our objectives, keywords or descriptors for the search were established. At the same time, these keywords were translated into documentary language using the Health Sciences Descriptors (DeCSs) through the Virtual Health Library, consulting its permuted index, and obtaining the following correspondence to thesauri or Medical Subject Headings (MeSHs) such as “Maternal mortality”, “Sustainable development”, and “Treatment outcome”, as described in

Table 1. MeSH types used for the bibliographic research.

MeSH
Maternal mortality
Sustainable development
Treatment outcome

. This led to us defining the search profile, combining the descriptors with the most suitable Boolean operators, and using them in English or Spanish depending on the database consulted at the time. Thus, the association was with the Boolean “AND” used to obtain, in the search, those documents that directly related MM and sustainable development.

Table 2. The search strategy used in the databases.

Database Name	Search Dates	Strategy	Filter	Number of Records
PubMed	December 2023	“Maternal mortality” AND “Sustainable development” AND “treatment outcome”	January 2015-February 2024 humans, language English, Spanish, and Portuguese	345
Medes	December 2023			98
Lilacs	January 2024			105
Cuiden	January 2024			58
WOS	December 2023			324
SciELO	January 2024			46
				976

shows the different search equations applied in each database, with the filters used and the results obtained. The search dates for all databases are included in Table 2.

2.1.2. Inclusion/Exclusion Criteria

The inclusion criteria were articles focused on MM in the context of the SDGs. Original articles on controlled and randomised clinical trials, controlled non-random trials, experimental and quasi-experimental studies, and observational studies were selected during the period from January 2015 to February 2024 if written in English, Spanish, or Portuguese. The exclusion criteria were articles that did not relate MM to the SDGs and therefore did not help us to answer the study question, as well as those from which the full document could not be obtained (because the relevance was low due to the low impact factor) and those of low quality (not included in the Journal Citation Ranking and grey literature). Articles published before 2015 and written in a language other than Spanish, English, or Portuguese were also excluded.

2.1.3. Data Collection

Two authors (I.C-G and L.M.O-R) carried out the search. Studies that met the eligibility criteria obtained from the 7 databases were imported into Mendeley^® reference manager software (London, UK), removing duplicates. The eligibility of the articles was based on the titles and abstracts, analysing their relevance. After this process, the two authors checked the methodological quality of the studies and potential biases. The quality of the included systematic reviews was assessed using the AMSTAR 2 checklist [17] to identify high-quality systematic reviews, including those based on non-randomised studies of healthcare interventions. The methodological quality of consensus documents was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument [18]. They were identified as “High quality” articles when they met more than 75% of the standard criteria proposal, as “Medium-Low quality” if the percentage was between 50% and 75% of the criteria, and as “Low quality” if the percentage was below 50%. The degree of agreement between the two researchers in the eligibility assessment was determined using the Kappa statistic (calculated with the IBM SPSS v. 28 for Windows), obtaining a high concordance result (Kappa statistic: 0.79). Due to the heterogeneity of the interventions, as well as of the participants, a meta-analysis could not be carried out. Any discrepancies between the authors were resolved through discussion until consensus was reached.

2.1.4. Variables Analysed

The variables included in this scoping review were the following: maternal mortality, whose definition based on WHO is the annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of the termination of pregnancy, irrespective of the duration and site of the pregnancy; principal barriers to the implementation of interventions to reduce maternal mortality in developing countries and interventions to reduce maternal mortality currently in place [4].

3. Results

3.1. Results of the Literature Review

The search was carried out in 7 databases, yielding a total of 976 results. Of these, 651 were discarded after being added to Mendeley^® reference manager due to duplicity, not being related to the purpose of the revision abstracts for which we were unable to find the complete reports, or being studies with low-quality evaluations. The application of various filters refined the selection to 325 articles. Further exclusion of articles for not meeting the review objectives, based on their title or abstract, resulted in a total of 24. The flow chart according to the PRISMA methodology is included in Figure 1.

3.1.1. Characteristics of the Sample

Twenty-four scientific literature documents were examined, including six systematic reviews, two meta-analyses, two ecological studies, two narrative reviews, nine original articles, two consensus documents, and one institutional webpage. The number of countries analysed was 174. After reading and analysing,

Table 3. Synthesis of results.

Title	Author and Publication Date	Type of Study	Sample Size (n)/Number of Studies Reviewed	Main Results	CATEGO- RISATION
Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes.	Lassi ZS, Bhutta ZA. 2020 [19]	Systematic Review	26 randomised/quasi-randomised trials	- Possible reduction in maternal mortality and significant reductions in maternal and neonatal morbidity with community interventions, especially in developing countries, including interventions such as skilled delivery, facility-based services for maternal and newborn care, and community-based care through packages that can be delivered by a variety of community workers.	B High
Death audits and reviews for reducing maternal, perinatal and child mortality.	Willcox ML, Price J, Scott S, Nicholson BD, Stuart B, Roberts NW et al. 2020 [20]	Systematic Review	2 randomised trials	- Maternal and perinatal death audits demonstrate that they are effective as a feedback element within interventions to reduce maternal and perinatal mortality, together with training activities for obstetric teams and support from external facilitators in countries with high rates of maternal and perinatal mortality, although they are not sufficiently effective on their own.	B Moderate
Global initiatives in maternal and newborn health.	Brizuela V, Tunçalp Ö. 2017 [21]	Original Paper	Not applicable	- Difficulties in reducing maternal mortality due to inequalities experienced by mothers. - Various strategies implemented to improve maternal and child health and reduce maternal mortality are described, such as the “Every Woman, Every Child” initiative.	A-B High
Governance commitment to reduce maternal mortality. A political determinant beyond the wealth of the countries.	Ruiz-Cantero MT, Guijarro-Garvi M, Bean DR, Martínez-Riera JR, Fernández-Sáez J. 2019 [22]	Cross-sectional ecological study	174 countries	- There is a significant association between maternal mortality and the quality of governments. - Many developing countries are undergoing an “obstetric transition,” as explained by the “Three Delays Model.” - Maternal mortality would be reduced if governments increased the quality of public healthcare, promoting sexual and reproductive health policies from a gender perspective.	A-B High
The Midwifery services framework: What is it, and why is it needed?	Nove A, Hoope-Bender PT, Moyo NT, Bokosi M. 2018 [23]	Original Paper	Not applicable	- “The Midwifery Services Framework” (MSF) of the International Confederation of Midwives has proven to be a useful tool to guide developing countries in creating, training, strengthening, and evaluating obstetric teams, adapted to the needs and conditions of each country.	B Moderate
Strategies to reduce the global burden of direct maternal deaths.	von Dadelszen P, Magee LA. 2017 [24]	Original Paper	Not applicable	- Interventions carried out through other Sustainable Development Goals (SDGs) facilitate the achievement of reducing direct-cause maternal mortality. - The development and strengthening of obstetric medicine are fundamental pillars involved in reducing the direct causes of maternal death and in managing the main complications that arise from pregnancy.	B Moderate
Beyond the Safe Motherhood Initiative: Accelerated Action Urgently Needed to End Preventable Maternal Mortality.	Stanton ME, Kwast BE, Shaver T, McCallon B, Koblinsky M. 2018 [25]	Original Paper	Not applicable	- The Safe Motherhood Initiative aims to prevent and address the main direct causes of maternal death, reduce barriers, train professionals for childbirth care, and improve the facilities where women give birth, among other actions.	A-B High
Cross-country analysis of strategies for achieving progress towards global goals for women’s and children’s health.	Ahmed SM, Rawal LB, Chowdhury SA, Murray J, Arscott-Mills S, Jack S et al. 2016 [26]	Ecological study	10 countries	- “Success Factors Studies”: A total of 10 developing countries are making faster progress towards achieving the SDG of reducing maternal and neonatal mortality thanks to the development of programmes in areas associated with factors identified as successful in improving the health of women and children. - Four common areas of intervention: leadership and partnership; health sector; non-health sectors; recording and communication of resources and results.	A-B High
Reducing maternal mortality: the case for availability and safety of blood supply.	Abdella Y, Haijeh R, Sibinga CTS. 2018 [27]	Original Paper	Not applicable	- Blood transfusion services should be included in maternal health programmes to allow quick access to safe blood transfusions, which can help to reduce the number of maternal deaths due to haemorrhage.	A-B Moderate
Health facility delivery in sub-Saharan Africa: successes, challenges, and implications for the 2030 development agenda.	Doctor HV, Nkhana-Salimu S, Abdulsalam-Anibilowo M. 2018 [28]	Meta-analysis	29 countries (58 demographic and health surveys)	- There has been an increase in the number of childbirths attended by healthcare personnel in Sub-Saharan Africa; however, significant disparities exist compared to developed countries. - Interventions aimed at reducing inequality in access to healthcare are essential to reduce maternal mortality in sub-Saharan Africa.	A-B High
Maternal mortality: What are women dying from?	Antsaklis A, Papamichail M, Antsaklis P. 2020 [9]	Original Paper	Not applicable	- The “Three Delays Model” as an explanation for why women do not receive the assistance that they need during pregnancy and childbirth and recommendations to reduce these delays. - The main indicator of progress in reducing maternal mortality is the proportion of women who give birth attended by trained healthcare personnel.	A-B High
Barriers to accessing maternal care in low income countries in Africa: A systematic review.	Dahab R, Sakellariou D. 2020 [26]	Systematic Review	13 observational studies (8 countries)	- The existing barriers to accessing maternal assistance are interconnected. - Further studies are necessary to better understand the issues and assess the barriers to accessing maternal care.	A High
Pro-equity legislation, health policy and utilisation of sexual and reproductive health services by vulnerable populations in sub-Saharan Africa: A systematic review.	Mac-Seing M, Zinszer K, Oga Omenka C, de Beaudrap P, Mehrabi F, Zarowsky C. 2020 [27]	Systematic Review	32 studies (14 countries)	- Social determinants of health, such as being a woman, living in rural areas, and low economic status, are documented barriers to accessing healthcare services. - Policies aimed at reducing or eliminating healthcare costs and promoting national health services increase access to healthcare for vulnerable population groups.	A-B High
Maternal healthcare coverage for first pregnancies in adolescent girls: a systematic comparison with adult mothers in household surveys across 105 countries, 2000–2019.	Li Z, Patton G, Sabet F, Subramanian SV, Lu C. 2020 [28]	Systematic Review	283 surveys (928.736 adolescents y 2.412.973 adult women) 105 conuntries	- There are significant disparities between the care provided to adult mothers and adolescent mothers, especially in countries of the western Pacific. - Adolescents continue to face barriers to accessing obstetric care, which makes interventions aimed at increasing healthcare coverage for adolescent pregnancies important.	A-B High
Women’s education and coverage of skilled birth attendance: An assessment of Sustainable Development Goal 3.1 in the South and Southeast Asian Region.	Bhowmik J, Biswas RK, Ananna N. 2020 [29]	Meta-analysis	38 surveys (1.171.731 women) 10 conutries	- The deep-rooted patriarchal culture and traditions in the countries of South and Southeast Asia limit women’s autonomy and promote mothers’ care through unqualified traditional methods, making it difficult to reduce maternal deaths in this region. - Increasing the educational level of women is a significant strategy to improve their access to qualified maternal care.	A-B High
Women’s health and well-being in the United Nations Sustainable Development Goals: A narrative review of achievements and gaps in the Gulf States.	Daher-Nashif S, Bawadi H. 2020 [30]	Narrative Review	6 countries	- The Gulf States share common sociocultural factors and use similar strategies for the prevention, treatment and restructuring of healthcare to reduce maternal mortality; therefore, it would be advisable for them to establish cooperation programmes among themselves to achieve the Sustainable Development Goals (SDGs).	A-B Low
Maternal mortality among refugees and in zones of conflict.	Adra A, Saad M. 2020 [10]	Original Paper	Not applicable	- Countries experiencing humanitarian crises are currently making the least progress towards reducing maternal mortality due to significant deficiencies in emergency obstetric care in conflict zones. - Minimum initial service package (MISP) is an effective strategy to prevent excessive increases in maternal and neonatal mortality and morbidity among refugees.	A-B Moderate
Sustainable Development Goals and the ongoing process of reducing maternal mortality.	Callister LC, Edwards JE. 2017 [31]	Original Paper	Not applicable	- The implementation of community health strategies such as quality improvement programmes, educational campaigns, and improved access to care reduces barriers and is associated with a reduction in maternal mortality rates.	A-B Moderate
Effectiveness of continuum of care-Linking pre-pregnancy care and pregnancy care to improve neonatal and perinatal mortality: A systematic review and meta-analysis.	Kikuchi K, Okawa S, Zamawe COF, Shibanuma A, Nanishi K, Iwamoto A et al. 2016 [32]	Systematic Review and Metanalysis	5 estudies	- Continued maternal health care from the preconception period through to the postpartum period has proven to be an effective strategy for reducing neonatal and perinatal mortality and can help to decrease maternal mortality, but more studies are needed to understand its impact.	B High
Costing the Three Transformative Results.	United Nations Population Fund. 2019 [33]	Consensus document	Not applicable	- In support of maternal health and its work around the SDGs, the UNFPA organises its work in three phases: from 2018–2021 to define the issues and start taking action; from 2022–2025 to consolidate progress; and from 2026–2030 to accelerate achievements.	B Moderate
The maternal and newborn health thematic fund. Annual Report 2019.	UNFPA. 2019 [34]	Consensus document	Not applicable	- The “Maternal and Newborn Health Thematic Fund” (MHTF) operates in 39 countries with high maternal mortality rates with the goal of ensuring that all women can give birth safely, reducing barriers to maternal health, and it bases its activities around four pillars: midwives, emergency obstetric and neonatal care (EmONC), surveillance and response to maternal and perinatal deaths (MPDSR), and obstetric fistula and other causes of maternal morbidity.	A-B Moderate
Cooperanda.	AACID, Universidad de Granada. [35]	Institucional website	Not applicable	- A project on citizen participation and international cooperation for development managed by the Andalusian Agency for International Development Cooperation (AACID), part of the Ministry of Equality, Social Policies, and Conciliation of the Andalusian Government, in collaboration with the University of Granada. Conceived as a fundamental part of the Andalusian Plan for Development Cooperation 2020–2023, it is closely related to the SDGs and the 2030 Agenda.	B Low
Maternal Health in the Perinatal Period and Beyond 1.	Souza J.P., Day L.T., Rezende-Gomes A.C. et al. 2024 [36]	Narrative review	Not applicable	- The preventable deaths of millions of women each decade are not only due to biomedical complications of pregnancy, childbirth, and the postnatal period but are also tangible manifestations of the prevailing determinants of maternal health and persistent inequities in global health and socioeconomic development.	A Low
Why maternal mortality in the world remains tragedy in low-income countries and shame for high-income ones: will sustainable development goals (SDG) help?	Kurjak A., et al. 2024 [37]	Orignal paper	Not applicable	- To reduce MMR, inequalities in access to and the quality of reproductive, maternal, and newborn health care services should be addressed together with strengthening health systems to respond to the needs and priorities of women and girls, ensuring accountability to improve quality of care and equity.	B Moderate

was compiled, which synthesises the main information and results of each reviewed study, categorises them by quality, and groups them into categories A and B according to the following specific objectives:

• Studies showing the main barriers that hinder the implementation of interventions to reduce MM in developing countries (A);
• Studies describing current interventions aimed at reducing MM (B).

3.1.2. Main Results

Main Barriers to Implementation

Socioeconomic inequalities in developing countries [26,31] and low educational level impede access to quality health centres in terms of connections [21]. This situation is compounded by poor government quality (corruption control, political stability, legislative quality) that reduces compliance with required quality indicators [19]. Furthermore, a precarious health system [24,29], a lack of adequately trained personnel [25], delays in receiving medical care from mothers [10], and their ignorance of risk situations [8,26,30] deprive mothers of the right to choose where and with whom to deliver. Lastly, the lack of records (such as medical records, police records, surveillance systems, national registries, death certificates, censuses, medical autopsies, and administrative reviews to estimate the true number of maternal deaths in a specified geographic area) prevents appropriate understanding of this significant issue [14,32].

Interventions Aimed at Reducing MM

Interventions designed to reduce inequalities in access to healthcare are crucial to reducing high rates of maternal mortality in developing countries [25,30,31]. In recent years, various initiatives and strategies supported by organisations such as the United Nations or the WHO, in collaboration with various organisations, have emerged to promote maternal health and reduce MM worldwide [22,23] with proper healthcare [21,25,31,32,34], facilitate access [31], train healthcare professionals [20,24], register health and MM data [8,17,31], and address other SDGs [21,30]. Multisectoral action is needed to target the distal determinants of maternal mortality, including health system failures, social determinants that put some subpopulations at greater risk, harmful gender norms and biases, and both humanitarian and climate crises that lead to health system fragility [4]. Locally, the Andalusian (in the South of Spain) Plan for Development Cooperation 2020-2030 currently has 42 projects focused on SDG 3 (Health and Well-Being), including the goal of reducing MM [38].

4. Discussion

After analysing the bibliography included in this review, we can observe that most studies show that in most countries with higher maternal mortality rates (MMRs), which also correspond to developing countries with fewer resources, efforts are directed towards developing and implementing fairly similar strategies. However, despite this, strategies or cooperation programmes between countries (known as South–South cooperation) are scarce, a synergy that we believe could be beneficial for sharing action plans and advances that could help other countries reduce their MMRs [38].

4.1. Strategies for Reducing Maternal Mortality

4.1.1. Increasing the Presence of Skilled Birth Attendants

Above all, we see that almost all the reviewed articles that analyse the strategies necessary to reduce MMR agree that the main strategy followed by countries in recent years is to increase the number of childbirths attended by qualified personnel, as this is the most significant indicator of progress in reducing MMR. To achieve this, a larger number of obstetric professionals and community agents are being trained to provide basic care to mothers from the preconception period to the postpartum period. In addition to training, through triangular cooperation, involving both developed and developing countries, multidisciplinary teams are being created to strengthen obstetric services, with the support of external evaluators who act as guides and advisors in these developing countries to help their professionals provide higher-quality care to mothers [35,39].

4.1.2. Enhancing Maternal Health Data Systems

Another crucial aspect in reducing MMR is improving the collection and use of maternal health records. These records are vital for providing feedback and assessing the quality of care provided. Unfortunately, the scarcity and poor quality of these records in many developing countries limit their usefulness. Efforts should be directed towards training healthcare professionals to better manage these databases, ensuring more reliable information for future interventions [40].

4.1.3. Investing in Maternal Health as a National Priority

Many of the articles included [19,22,23] also agree that all this must be accompanied by prioritisation by maternal care governments, as well as increases in economic and political investments that contribute to the SDGs to help to reduce MMR. This is because, as we have seen during our review, a large proportion of current maternal deaths is due to preventable causes, which could be avoided if investments in training, equipment, and health infrastructure were increased. Unfortunately, there is still a need to advance further so that maternal care is truly prioritised in developing countries.

4.2. Empowering Women for Better Maternal Health Outcomes

4.2.1. Respecting Women’s Autonomy and Rights

Apart from improvements in the healthcare sector, with the review conducted during this work, we can also assert that for MMR to decrease in developing countries, it is essential to respect women’s rights and allow them to gain autonomy. Many women continue to suffer the consequences of patriarchal cultures and traditions and even some laws imposed on them. This situation causes their husbands, fathers, or in-laws to make decisions for them, lacking the independence necessary to be active participants in making decisions about their care during pregnancy and childbirth [27].

This circumstance continues to cause too many maternal deaths due to a lack of foresight and the need for emergency care for potential complications during pregnancy, as well as due to the belief that it is better to give birth alongside traditional caregivers without quality obstetric training and the large number of unsafe induced abortions. To address this, the review conducted highlights the need to encourage societal advancement through proposals or laws that grant greater autonomy to women, allow women access to higher levels of education, conduct training campaigns that enable them to identify warning signs and symptoms to seek help early in case of potential complications, and increase women’s access to family planning services to avoid the risks associated with unwanted pregnancies [18].

4.2.2. Addressing Rural and Adolescent Maternal Health Disparities

In terms of women’s treatment, due to the articles analysed, we have been able to highlight how, within a disadvantaged group in terms of healthcare, such as women in many developing countries, pregnant women living in rural areas and pregnant adolescent women are even more unprotected [4]. Regarding pregnant women in rural areas, while some articles agree that this disadvantageous situation is due to the greater influence of religion and traditions, others argue that it is mainly due to poor communication, infrastructure, and services in these areas [4,24]. Therefore, to improve this situation considering both perspectives, interventions should be directed both at supporting education and reversing myths, as previously described, and strengthening investments to provide better roads, public transport, and health centres and equipment in these rural areas.

On the other hand, the disadvantages faced by pregnant women or adolescents are also related to their lower educational level and autonomy. A notable theme in the reviewed literature is stigmatisation by society, and even by healthcare professionals, which causes pregnant women adolescents to not seek the quality of healthcare that they need [21]. From our perspective, it is therefore necessary, in addition to providing adolescents with knowledge tools, to train the professionals who care for them from a gender perspective and fundamentally train them in care and communication models adapted to the life stage of pregnant adolescent women, which in turn would promote their adherence to obstetric follow-up programmes and relevant treatments as needed.

4.3. Impact of Armed Conflicts and Humanitarian Crises on Maternal Health

With the completion of this review, we have also been able to delve deeper into a problems of great magnitude in general and specifically of great impact for MMRs, such as armed conflicts and humanitarian crises currently occurring in various parts of the world. Our analysis of the articles shows that the countries experiencing these conflicts are those that maintain the highest MMRs and where the least progress has been made [10]. This situation is due, as we know, to the lack of access to quality healthcare and the lack of gestational health controls caused by the forced displacement of women and the population in general, as well as the blockade of communications and infrastructure from which these territories suffer.

However, despite limited progress in reducing MMR rates, there are hopeful signs, such as the implementation of emergency obstetric care programmes by various organisations like the Women’s Refugee Commission, which help to prevent many maternal deaths among refugee women. Given this, we believe that greater cooperation is needed from other countries to prevent women suffering the consequences of humanitarian crises from dying from preventable causes by providing them with the necessary equipment, medications, and personnel to care for them [13].

Member states must intensify efforts to address health system failures that erode the provision of safe, affordable, and high-quality sexual and reproductive health care [4]. Efforts must be made to reduce health inequities by addressing the needs of populations in vulnerable and marginalised situations. These inequities can lead to mistreatment within the health system, erode trust, and impede service utilisation [41,42].

4.4. Integration of the SGDs and Synergy Among Strategies

Regarding the SDGs, our review shows how, in addition to knowing that they were conceived with many interconnected and influencing parts, it is necessary to effectively interconnect them to achieve synergies in each of their objectives. However, we believe that there are certain limitations related to moving from theory to practice, as while, globally, it is stated that objectives should be unified, we see how in many countries, instead of seeking strategies that connect the various SDGs, isolated interventions are carried out for each SDG and different goals even hinder each other. An example of this is the existing inconsistency between knowing based on evidence that family planning programmes and access to contraceptives significantly reduce MMR and the fact that in many of these countries, incorrect information is still provided and access to services is impeded as a remnant of centuries-old culture and traditions [17].

4.5. Strengths and Limitations of This Review

The completion of this review highlights the social relevance of the MMR in the world today and the dramatic situation experienced by pregnant women in developing countries. In addition to the negative consequences caused by the already-known barriers to the health of pregnant women, we have been able to verify how the MMR is an important indicator of the advancement of societies, as maternal deaths affect the entire environment around them, leaving not only orphans but also increased vulnerability in the rest of their family and community [6]. The greater involvement of developed countries in this issue is essential. As we have emphasised throughout this work, in addition to the strategies implemented through various organisations in the context of the SDGs, if governments of countries with more resources were to promote initiatives that materialise as effective economic investments to help these countries improve the quality of care that they can offer pregnant women worldwide, thousands of lives could be saved.

As the main limitation of the review, several studies highlight the lack of high-quality data records related to MM in most developing countries, which, as we have already seen, are fundamental to reducing MM, as well as being essential from the researcher’s point of view to show representative results; therefore, it would be necessary to improve them in order to do so. Likewise, it would be necessary to conduct a greater number of studies with a sample size representative of the population to be studied and sufficient follow-up over time. Future research could focus on assessing whether, in the coming years, the described barriers have been overcome.

5. Conclusions

Significant barriers remain to the establishment of strategies to reduce maternal mortality in developing countries in the context of the Sustainable Development Goals. Economically, the main issues are infrastructure and transport deficiencies, a lack of services, and a lack of obstetric professionals with high-quality training, as well as problems with financial funding. Socially, barriers include low educational levels and a lack of autonomy among pregnant women, along with the influence of cultural beliefs and traditions. Politically, notable issues include the presence of armed conflicts and humanitarian crises, as well as government deficiencies.

The intervention that has proven to be the most successful in reducing MM is the assistance of qualified personnel during delivery. There has been an increase in the quality of training, both in care and in data recording, among healthcare professionals in developing countries. Additionally, prioritizing maternal care and triangular cooperation among governments of developed and developing countries, thus encouraging policies and investments aimed at reducing MM, is crucial. Effective connections among the various SDGs are necessary to accelerate the achievement of reducing MM. Substantial shifts in focus and investment are needed now if the SDG target of achieving a global MMR below 70 is to be met. If the 2016–2020 pace of progress continues, by 2030, the global MMR would still be 222 maternal deaths per 100,000 live births—the same as the figure estimated for 2020—due to the stagnation in the ARRs observed during the first years of the SDG era.

With half of the SDG period remaining, now is the time to intensity efforts and renew the commitment to end preventable maternal mortality, as well as to ensure that women not only simply survive a pregnancy but are healthy and thrive.