pág. 6730
SOCIAL INEQUALITIES AND GESTATIONAL
RISK IN RURAL AND URBAN WOMEN: A
SYSTEMATIC REVIEW OF LITERATURE
DESIGUALDADES SOCIALES Y RIESGOS GESTACIONALES
EN MUJERES DE ZONAS RURALES Y URBANAS: UNA
REVISIÓN SISTEMÁTICA DE LA LITERATURA
Salomón Torres Ferro
Faculty of medicine and basic sciences
Sergio Alejandro Conde Avilés
Fundacion Universitaria Navarra
Carlos Fernando Sánchez Caicedo
Programa de Medicina, Fundación Universitaria Navarra - UNINAVARRA
Michell Dayana Fonseca Santander
Faculty of medicine and basic sciences, Fundacion Universitaria Navarra
Andrés Felipe Rivera
Faculty of medicine and basic sciences, Fundacion Universitaria Navarra
Jose Daniel Charry Cuellar
Center for Research and Innovation Uninavarra - CIINA
pág. 6731
DOI: https://doi.org/10.37811/cl_rcm.v10i3.24736
Social Inequalities and Gestational Risk in Rural and Urban Women: A
Systematic Review of Literature
Salomón Torres Ferro1
salomon.torres@uninavarra.edu.co
https://orcid.org/0009-0002-0543-0301
Faculty of medicine and basic sciences
Fundacion Universitaria Navarra
UNINAVARRA, Neiva, Colombia.
Sergio Alejandro Conde Avilés
sergio.conde@uninavarra.edu.co
https://orcid.org/0009-0001-8922-9236
Faculty of medicine and basic sciences
Fundacion Universitaria Navarra
UNINAVARRA, Neiva, Colombia.
Carlos Fernando Sánchez Caicedo
carlos.sanchez75@uninavarra.edu.co
https://orcid.org/0009-0004-2776-3304
Programa de Medicina, Fundación
Universitaria Navarra - UNINAVARRA,
Colombia.
Michell Dayana Fonseca Santander
Michell.fonseca@uninavarra.edu.co
https://orcid.org/0009-0008-0049-6882
Faculty of medicine and basic sciences,
Fundacion Universitaria Navarra
UNINAVARRA, Neiva, Colombia.
Andrés Felipe Rivera
andres.rivera56@uninavarra.edu.co
https://orcid.org/0000-0001-5893-439X
Faculty of medicine and basic sciences,
Fundacion Universitaria Navarra
UNINAVARRA, Neiva, Colombia.
Jose Daniel Charry Cuellar
jd.charry@uninavarra.edu.co
https://orcid.org/0000-0002-8789-7281
Center for Research and Innovation Uninavarra
- CIINA, Fundacion Universitaria Navarra
UNINAVARRA Neiva, Colombia.
ABSTRACT
Maternal health reflects social equity and remains strongly influenced by the Social Determinants of
Health (SDH), particularly in rural and low-resource settings. The objective was to describe social
inequalities and their effect on pregnancy risk. This systematic review, conducted under PRISMA 2020
guidelines. The databases were PubMed, Scopus, and ScienceDirect. The synthesis of evidence reveals
a direct correlation between the poverty index and the severity of complications. In various Latin
American and middle-income country contexts, the maternal mortality ratio reached 75.19 per 1,000
live births, exceeding the national average, with critical vulnerability among women over 40 years of
age (Ratio: 165.75). Although urban areas report a higher number of cases (251 vs. 165), rural areas
face greater barriers related to the "third delay" (transportation and referral). The cost of care for severe
preeclampsia (USD 827) acts as an impoverishment factor for low-income families, exacerbating the
cycle of inequality. Social inequalities are not only geographical, but also structural and economic. A
differentiated public policy is needed to mitigate the access gap in sparsely populated rural areas in order
to effectively reduce maternal morbidity and mortality in the department.
Keywords: Maternal mortality, social inequalities, rural health, social determinants of health, obstetric
risk.
1 Autor principal
Correspondencia: salomon.torres@uninavarra.edu.co
DOI: https://doi.org/10.37811/cl_rcm.v10i3.24736
Social Inequalities and Gestational Risk in Rural and Urban Women: A
Systematic Review of Literature
Salomón Torres Ferro1
salomon.torres@uninavarra.edu.co
https://orcid.org/0009-0002-0543-0301
Faculty of medicine and basic sciences
Fundacion Universitaria Navarra
UNINAVARRA, Neiva, Colombia.
Sergio Alejandro Conde Avilés
sergio.conde@uninavarra.edu.co
https://orcid.org/0009-0001-8922-9236
Faculty of medicine and basic sciences
Fundacion Universitaria Navarra
UNINAVARRA, Neiva, Colombia.
Carlos Fernando Sánchez Caicedo
carlos.sanchez75@uninavarra.edu.co
https://orcid.org/0009-0004-2776-3304
Programa de Medicina, Fundación
Universitaria Navarra - UNINAVARRA,
Colombia.
Michell Dayana Fonseca Santander
Michell.fonseca@uninavarra.edu.co
https://orcid.org/0009-0008-0049-6882
Faculty of medicine and basic sciences,
Fundacion Universitaria Navarra
UNINAVARRA, Neiva, Colombia.
Andrés Felipe Rivera
andres.rivera56@uninavarra.edu.co
https://orcid.org/0000-0001-5893-439X
Faculty of medicine and basic sciences,
Fundacion Universitaria Navarra
UNINAVARRA, Neiva, Colombia.
Jose Daniel Charry Cuellar
jd.charry@uninavarra.edu.co
https://orcid.org/0000-0002-8789-7281
Center for Research and Innovation Uninavarra
- CIINA, Fundacion Universitaria Navarra
UNINAVARRA Neiva, Colombia.
ABSTRACT
Maternal health reflects social equity and remains strongly influenced by the Social Determinants of
Health (SDH), particularly in rural and low-resource settings. The objective was to describe social
inequalities and their effect on pregnancy risk. This systematic review, conducted under PRISMA 2020
guidelines. The databases were PubMed, Scopus, and ScienceDirect. The synthesis of evidence reveals
a direct correlation between the poverty index and the severity of complications. In various Latin
American and middle-income country contexts, the maternal mortality ratio reached 75.19 per 1,000
live births, exceeding the national average, with critical vulnerability among women over 40 years of
age (Ratio: 165.75). Although urban areas report a higher number of cases (251 vs. 165), rural areas
face greater barriers related to the "third delay" (transportation and referral). The cost of care for severe
preeclampsia (USD 827) acts as an impoverishment factor for low-income families, exacerbating the
cycle of inequality. Social inequalities are not only geographical, but also structural and economic. A
differentiated public policy is needed to mitigate the access gap in sparsely populated rural areas in order
to effectively reduce maternal morbidity and mortality in the department.
Keywords: Maternal mortality, social inequalities, rural health, social determinants of health, obstetric
risk.
1 Autor principal
Correspondencia: salomon.torres@uninavarra.edu.co
pág. 6732
Desigualdades sociales y riesgos gestacionales en mujeres de zonas rurales y
urbanas: una revisión sistemática de la literatura
RESUMEN
La salud materna es un reflejo de la equidad social y sigue estando fuertemente influenciada por los
determinantes sociales de la salud (DSS), especialmente en entornos rurales y de escasos recursos. El
objetivo fue describir las desigualdades sociales y su efecto sobre el riesgo durante el embarazo. Esta
revisión sistemática se llevó a cabo siguiendo las directrices PRISMA 2020. Las bases de datos
utilizadas fueron PubMed, Scopus y ScienceDirect. La síntesis de la evidencia revela una correlación
directa entre el índice de pobreza y la gravedad de las complicaciones. En diversos contextos de países
latinoamericanos y de renta media, la tasa de mortalidad materna alcanzó los 75,19 por cada 1.000
nacidos vivos, superando la media nacional, con una vulnerabilidad crítica entre las mujeres mayores
de 40 años (tasa: 165,75). Aunque las zonas urbanas registran un mayor número de casos (251 frente a
165), las zonas rurales se enfrentan a mayores barreras relacionadas con el «tercer retraso» (transporte
y derivación). El coste de la atención de la preeclampsia grave (827 dólares estadounidenses) actúa
como factor de empobrecimiento para las familias con bajos ingresos, lo que agrava el ciclo de
desigualdad. Las desigualdades sociales no son solo geográficas, sino también estructurales y
económicas. Se necesita una política pública diferenciada para mitigar la brecha de acceso en las zonas
rurales escasamente pobladas, con el fin de reducir de manera efectiva la morbilidad y la mortalidad
maternas en el departamento.
Palabras clave: Mortalidad materna, desigualdades sociales, salud rural, determinantes sociales de la
salud, riesgo obstétrico.
Artículo recibido 20 mayo 2026
Aceptado para publicación: 20 junio 2026
Desigualdades sociales y riesgos gestacionales en mujeres de zonas rurales y
urbanas: una revisión sistemática de la literatura
RESUMEN
La salud materna es un reflejo de la equidad social y sigue estando fuertemente influenciada por los
determinantes sociales de la salud (DSS), especialmente en entornos rurales y de escasos recursos. El
objetivo fue describir las desigualdades sociales y su efecto sobre el riesgo durante el embarazo. Esta
revisión sistemática se llevó a cabo siguiendo las directrices PRISMA 2020. Las bases de datos
utilizadas fueron PubMed, Scopus y ScienceDirect. La síntesis de la evidencia revela una correlación
directa entre el índice de pobreza y la gravedad de las complicaciones. En diversos contextos de países
latinoamericanos y de renta media, la tasa de mortalidad materna alcanzó los 75,19 por cada 1.000
nacidos vivos, superando la media nacional, con una vulnerabilidad crítica entre las mujeres mayores
de 40 años (tasa: 165,75). Aunque las zonas urbanas registran un mayor número de casos (251 frente a
165), las zonas rurales se enfrentan a mayores barreras relacionadas con el «tercer retraso» (transporte
y derivación). El coste de la atención de la preeclampsia grave (827 dólares estadounidenses) actúa
como factor de empobrecimiento para las familias con bajos ingresos, lo que agrava el ciclo de
desigualdad. Las desigualdades sociales no son solo geográficas, sino también estructurales y
económicas. Se necesita una política pública diferenciada para mitigar la brecha de acceso en las zonas
rurales escasamente pobladas, con el fin de reducir de manera efectiva la morbilidad y la mortalidad
maternas en el departamento.
Palabras clave: Mortalidad materna, desigualdades sociales, salud rural, determinantes sociales de la
salud, riesgo obstétrico.
Artículo recibido 20 mayo 2026
Aceptado para publicación: 20 junio 2026
pág. 6733
INTRODUCTION
Maternal health is one of the most sensitive indicators of socioeconomic development, territorial equity,
and the operational capacity of health systems (1,2). Beyond its clinical dimension, it reflects the
structural conditions in which women live, including access to education, income, healthcare, and social
support networks. In Latin America, despite regulatory efforts aimed at reducing maternal morbidity
and mortality (such as expanding insurance coverage and establishing comprehensive maternal and
perinatal care pathways), significant gaps persist between territories and population groups (2, 3). These
disparities are not random but rather reflect structural inequities associated with the Social Determinants
of Health (SDH).
Pregnancy risk is not distributed homogeneously across the population. On the contrary, it is organized
along a social gradient determined by factors such as poverty, rurality, low educational attainment, and
limited reproductive autonomy, all of which increase maternal vulnerability. In this context, obstetric
complications (including hypertensive disorders of pregnancy, postpartum hemorrhage, and infections)
cannot be addressed solely from a biomedical perspective, since their timely detection and appropriate
management are conditioned by social and territorial factors that determine effective access to health
services (2). This becomes particularly relevant in middle-income countries, where medium- and high-
complexity institutions prevail, specialized human resources are available in this field, and diagnostic
technologies are accessible within the system. In contrast, in rural areas, structural barriers related to
road accessibility, ambulance transport, continuity of prenatal care, and the availability of
comprehensive obstetric services still exist (4). In this case, rural women bear what we call a "triple
burden": geographical distance leading to a delay in seeking medical care; economic insecurity that
encourages delayed care seeking; and cultural and institutional barriers that inhibit successful interaction
with the health system (4, 5).
This is a central issue of interest to the public health community in general: are current models of
maternal care sensitive to the pluralistic aspects supported by territorial and social diversity, or do they
reflect the same models that fail to address the particularities of rural areas? Exploring gestational risk
among rural and urban women provides a path not only to making entrenched inequalities visible, but
also evidence that supports the design of differentiated, territorial, and intersectional strategies to meet
INTRODUCTION
Maternal health is one of the most sensitive indicators of socioeconomic development, territorial equity,
and the operational capacity of health systems (1,2). Beyond its clinical dimension, it reflects the
structural conditions in which women live, including access to education, income, healthcare, and social
support networks. In Latin America, despite regulatory efforts aimed at reducing maternal morbidity
and mortality (such as expanding insurance coverage and establishing comprehensive maternal and
perinatal care pathways), significant gaps persist between territories and population groups (2, 3). These
disparities are not random but rather reflect structural inequities associated with the Social Determinants
of Health (SDH).
Pregnancy risk is not distributed homogeneously across the population. On the contrary, it is organized
along a social gradient determined by factors such as poverty, rurality, low educational attainment, and
limited reproductive autonomy, all of which increase maternal vulnerability. In this context, obstetric
complications (including hypertensive disorders of pregnancy, postpartum hemorrhage, and infections)
cannot be addressed solely from a biomedical perspective, since their timely detection and appropriate
management are conditioned by social and territorial factors that determine effective access to health
services (2). This becomes particularly relevant in middle-income countries, where medium- and high-
complexity institutions prevail, specialized human resources are available in this field, and diagnostic
technologies are accessible within the system. In contrast, in rural areas, structural barriers related to
road accessibility, ambulance transport, continuity of prenatal care, and the availability of
comprehensive obstetric services still exist (4). In this case, rural women bear what we call a "triple
burden": geographical distance leading to a delay in seeking medical care; economic insecurity that
encourages delayed care seeking; and cultural and institutional barriers that inhibit successful interaction
with the health system (4, 5).
This is a central issue of interest to the public health community in general: are current models of
maternal care sensitive to the pluralistic aspects supported by territorial and social diversity, or do they
reflect the same models that fail to address the particularities of rural areas? Exploring gestational risk
among rural and urban women provides a path not only to making entrenched inequalities visible, but
also evidence that supports the design of differentiated, territorial, and intersectional strategies to meet
pág. 6734
the needs for inequitable and timely maternal care (6, 7). Current models of maternal care still face
structural limitations in adequately addressing the diverse territorial and social needs of contemporary
Latin America.
METHODS
Protocol and registration:
This systematic review was not registered in an international database of protocols such as PROSPERO
prior to its execution. However, an internal methodological protocol was developed before the start of
the search and selection process, defining the objectives, eligibility criteria, search strategies, and
synthesis methods. The lack of public registration constitutes a methodological limitation that is
explicitly acknowledged in this study.
Studio design:
A systematic review with a comparative-analytical approach was conducted with the objective of
identifying, evaluating and integrating the available scientific evidence on the impact of Social
Determinants of Health (SDH) on gestational risk in women of reproductive age and on maternal
morbidity and mortality, in particular contrasting rural and urban environments in Latin America.
Eligibility criteria (PICO): The inclusion and exclusion criteria for article selection included:
Table 1. PICO.
Table 2. Inclusion and exclusion criteria.
Search strategy and information sources:
The identification of scientific evidence was based on a systematic search of PubMed, Scopus , and
ScienceDirect , covering the period 2018–2024. MeSH and DeCS descriptors were interconnected using
Boolean operators to maximize the retrieval of studies focused on maternal mortality and social
determinants. This phase allowed for the identification of critical research such as Rodríguez
Hernández's (2023) analysis of inequality in Chocó, Ocampo-Mendoza's (2024) study of the economic
impact of preeclampsia, and Vargas Martínez's (2024) study of vulnerability in Meta.
The search strategy combined controlled terms ( MeSH and DeCS ) and free terms related to maternal
mortality, maternal morbidity, social determinants of health, and rural/urban residence. The search
equation used in PubMed was: ("Maternal Mortality "[ MeSH ] OR "Maternal Morbidity "[ MeSH ] OR
the needs for inequitable and timely maternal care (6, 7). Current models of maternal care still face
structural limitations in adequately addressing the diverse territorial and social needs of contemporary
Latin America.
METHODS
Protocol and registration:
This systematic review was not registered in an international database of protocols such as PROSPERO
prior to its execution. However, an internal methodological protocol was developed before the start of
the search and selection process, defining the objectives, eligibility criteria, search strategies, and
synthesis methods. The lack of public registration constitutes a methodological limitation that is
explicitly acknowledged in this study.
Studio design:
A systematic review with a comparative-analytical approach was conducted with the objective of
identifying, evaluating and integrating the available scientific evidence on the impact of Social
Determinants of Health (SDH) on gestational risk in women of reproductive age and on maternal
morbidity and mortality, in particular contrasting rural and urban environments in Latin America.
Eligibility criteria (PICO): The inclusion and exclusion criteria for article selection included:
Table 1. PICO.
Table 2. Inclusion and exclusion criteria.
Search strategy and information sources:
The identification of scientific evidence was based on a systematic search of PubMed, Scopus , and
ScienceDirect , covering the period 2018–2024. MeSH and DeCS descriptors were interconnected using
Boolean operators to maximize the retrieval of studies focused on maternal mortality and social
determinants. This phase allowed for the identification of critical research such as Rodríguez
Hernández's (2023) analysis of inequality in Chocó, Ocampo-Mendoza's (2024) study of the economic
impact of preeclampsia, and Vargas Martínez's (2024) study of vulnerability in Meta.
The search strategy combined controlled terms ( MeSH and DeCS ) and free terms related to maternal
mortality, maternal morbidity, social determinants of health, and rural/urban residence. The search
equation used in PubMed was: ("Maternal Mortality "[ MeSH ] OR "Maternal Morbidity "[ MeSH ] OR
pág. 6735
" Pregnancy Complications "[ MeSH ]) AND ("Social Determinants of Health "[ MeSH ] OR poverty
OR " socioeconomic factors " OR inequality OR rural population OR urban population ) AND (" Latin
America " OR Colombia OR Brazil OR Mexico OR Peru OR Ecuador) Filters : Humans ; Publication
date from 2018/01/01 to 2024/12/31; English OR Spanish.
For Scopus and ScienceDirect , the strategy was adapted using TITLE-ABS-KEY fields and equivalent
Boolean operators: TITLE-ABS-KEY ("maternal mortality " OR "maternal morbidity " OR "
pregnancy" complications ") AND TITLE-ABS-KEY ("social determinants " OR poverty OR inequality
OR "rural population " OR " urban population ") AND TITLE-ABS-KEY (" Latin America " OR
Colombia OR Brazil OR Mexico OR Peru OR Ecuador).
Table 3. Search strategies.
Selection of studies:
The selection of studies was carried out in two phases. In the first phase, two reviewers independent
evaluated titles and summaries of the records identified to determine his eligibility Preliminary. In the
second phase, the articles potentially relevant were evaluated to text complete according to the inclusion
and exclusion criteria previously defined.
Data selection and extraction was carried out by two reviewers in an independent. The discrepancies
between the reviewers were resolved through Discussion and consensus. In case of disagreement If the
issue persisted, a third evaluator was brought in for the final decision. The selection process was
documented through the flowchart in accordance with the PRISMA 2020 statement.
Data summary:
Table 3 presented the characteristics, intervention, outcome measures, and conclusions of each, in order
to demonstrate the articles used for the research.
RESULTS
Selection of studies:
Our search began in PubMed, Scopus, and ScienceDirect, yielding a total of 57 studies. Two duplicate
articles were initially removed. Then, 17 records were excluded based on title and abstract criteria for
not meeting the inclusion criteria. Finally, the remaining 38 articles were read in full, resulting in the
" Pregnancy Complications "[ MeSH ]) AND ("Social Determinants of Health "[ MeSH ] OR poverty
OR " socioeconomic factors " OR inequality OR rural population OR urban population ) AND (" Latin
America " OR Colombia OR Brazil OR Mexico OR Peru OR Ecuador) Filters : Humans ; Publication
date from 2018/01/01 to 2024/12/31; English OR Spanish.
For Scopus and ScienceDirect , the strategy was adapted using TITLE-ABS-KEY fields and equivalent
Boolean operators: TITLE-ABS-KEY ("maternal mortality " OR "maternal morbidity " OR "
pregnancy" complications ") AND TITLE-ABS-KEY ("social determinants " OR poverty OR inequality
OR "rural population " OR " urban population ") AND TITLE-ABS-KEY (" Latin America " OR
Colombia OR Brazil OR Mexico OR Peru OR Ecuador).
Table 3. Search strategies.
Selection of studies:
The selection of studies was carried out in two phases. In the first phase, two reviewers independent
evaluated titles and summaries of the records identified to determine his eligibility Preliminary. In the
second phase, the articles potentially relevant were evaluated to text complete according to the inclusion
and exclusion criteria previously defined.
Data selection and extraction was carried out by two reviewers in an independent. The discrepancies
between the reviewers were resolved through Discussion and consensus. In case of disagreement If the
issue persisted, a third evaluator was brought in for the final decision. The selection process was
documented through the flowchart in accordance with the PRISMA 2020 statement.
Data summary:
Table 3 presented the characteristics, intervention, outcome measures, and conclusions of each, in order
to demonstrate the articles used for the research.
RESULTS
Selection of studies:
Our search began in PubMed, Scopus, and ScienceDirect, yielding a total of 57 studies. Two duplicate
articles were initially removed. Then, 17 records were excluded based on title and abstract criteria for
not meeting the inclusion criteria. Finally, the remaining 38 articles were read in full, resulting in the
pág. 6736
exclusion of 9 articles for various methodological reasons. Ultimately, 29 articles met the inclusion
criteria and were incorporated into the final review. (Figure 1.)
Figure 1. Selection of studies.
The study selection process was conducted according to the PRISMA 2020 statement. Initially, 57
records were identified from the PubMed, Scopus, and ScienceDirect databases. After removing two
duplicate records, 55 titles and abstracts were assessed. Subsequently, 38 articles were reviewed in full
text, of which 9 were excluded for not meeting the methodological eligibility criteria. Finally, 29 studies
were included in the qualitative synthesis (Figure 1).
Study characteristics:
Detailed data extracted from each article are presented in Table 4, where characteristics were categorized
according to the PICOS criteria: study design, participants, intervention, outcomes, and main findings.
Each included study provided and reported key data for comparing maternal health in rural and urban
women.
Table 4. Characteristics of the studies.
Quality assessment methodological and risk of bias
To ensure that the risk of bias in the included studies was adequately assessed, the methodological
quality of the included studies was evaluated using tools specific to each study design. One instrument
for evaluating observational studies (cohort, cross-sectional, and ecological) was the Newcastle-
Ottawa Scale (NOS), which identifies three dimensions, including sample selection, comparability of
groups, and outcome assessment.
Qualitative and mixed-methods studies were measured by the Joanna Briggs Institute (JBI) checklists,
which focused specifically on evidence of methodological congruence, research purposes and
consistency (or lack thereof), theoretical perspective and methodology employed, and the validity of
the analysis and clarity of the meaning of the results.
Systematic reviews were assessed as an adequate comparison of reviews in the AMSTAR 2 tool,
which allows systematic reviews that include observational studies with respect to methodological
quality under certain critical domains (e.g., search strategy, study selection, assessment of risk of bias,
synthesis of evidence).
exclusion of 9 articles for various methodological reasons. Ultimately, 29 articles met the inclusion
criteria and were incorporated into the final review. (Figure 1.)
Figure 1. Selection of studies.
The study selection process was conducted according to the PRISMA 2020 statement. Initially, 57
records were identified from the PubMed, Scopus, and ScienceDirect databases. After removing two
duplicate records, 55 titles and abstracts were assessed. Subsequently, 38 articles were reviewed in full
text, of which 9 were excluded for not meeting the methodological eligibility criteria. Finally, 29 studies
were included in the qualitative synthesis (Figure 1).
Study characteristics:
Detailed data extracted from each article are presented in Table 4, where characteristics were categorized
according to the PICOS criteria: study design, participants, intervention, outcomes, and main findings.
Each included study provided and reported key data for comparing maternal health in rural and urban
women.
Table 4. Characteristics of the studies.
Quality assessment methodological and risk of bias
To ensure that the risk of bias in the included studies was adequately assessed, the methodological
quality of the included studies was evaluated using tools specific to each study design. One instrument
for evaluating observational studies (cohort, cross-sectional, and ecological) was the Newcastle-
Ottawa Scale (NOS), which identifies three dimensions, including sample selection, comparability of
groups, and outcome assessment.
Qualitative and mixed-methods studies were measured by the Joanna Briggs Institute (JBI) checklists,
which focused specifically on evidence of methodological congruence, research purposes and
consistency (or lack thereof), theoretical perspective and methodology employed, and the validity of
the analysis and clarity of the meaning of the results.
Systematic reviews were assessed as an adequate comparison of reviews in the AMSTAR 2 tool,
which allows systematic reviews that include observational studies with respect to methodological
quality under certain critical domains (e.g., search strategy, study selection, assessment of risk of bias,
synthesis of evidence).
pág. 6737
Each study was scored according to how well it met the criteria of the relevant tool for classifying
articles as high, moderate, or low quality. Overall, most included studies demonstrated good
methodological quality in terms of participant selection and outcome specification. However, we
found limitations in the control of confounding variables and heterogeneity of contexts in some
observational studies. Despite these limitations, the evidence was generally consistent and provided a
robust narrative synthesis of the available evidence.
Table 5. Quality Assessment methodological according to tool applied (NOS, JBI and AMSTAR 2).
Most studies demonstrated high methodological quality according to the tools applied (NOS, JBI, and
AMSTAR 2). However, heterogeneity in designs and outcomes limited the possibility of establishing a
formal hierarchy of evidence or issuing direct clinical recommendations.
Limitations of the study
This study presents some limitations that must be considered when interpreting their findings. First, the
review systematic was not registered previously in an international database of protocols as
PROSPERO, which can limit design traceability methodological Initial. Second, the heterogeneity of
the studies included in design terms, populations, and outcomes obstetrics prevented the performance
of a meta-analysis quantitative. Likewise, the predominance of observational studies limits the
possibility of establishing relations causes direct. However, the consistency of the results across different
contexts strengthens the validity of the synthesis presented.
Discussion:
The findings confirm that social and territorial inequalities play a decisive role in shaping gestational
risk in different global contexts.(4) Maternal risk is closely linked to structural factors such as poverty,
rurality, gaps in insurance coverage and limited availability of accessible and timely services (21). In
rural areas, these conditions are exacerbated by geographical dispersion, precarious transportation and
greater distance to centers of high-level care, elements that increase the vulnerability of pregnant women
and explain a significant part of the variability observed in maternal morbidity and mortality (6 ,21).
Although urban areas register a higher absolute number of obstetric events, the review shows that rural
women face a proportionally greater risk, especially due to delays associated with transportation and
medical referral. This “third delay,” widely documented in Latin American literature, represents a
Each study was scored according to how well it met the criteria of the relevant tool for classifying
articles as high, moderate, or low quality. Overall, most included studies demonstrated good
methodological quality in terms of participant selection and outcome specification. However, we
found limitations in the control of confounding variables and heterogeneity of contexts in some
observational studies. Despite these limitations, the evidence was generally consistent and provided a
robust narrative synthesis of the available evidence.
Table 5. Quality Assessment methodological according to tool applied (NOS, JBI and AMSTAR 2).
Most studies demonstrated high methodological quality according to the tools applied (NOS, JBI, and
AMSTAR 2). However, heterogeneity in designs and outcomes limited the possibility of establishing a
formal hierarchy of evidence or issuing direct clinical recommendations.
Limitations of the study
This study presents some limitations that must be considered when interpreting their findings. First, the
review systematic was not registered previously in an international database of protocols as
PROSPERO, which can limit design traceability methodological Initial. Second, the heterogeneity of
the studies included in design terms, populations, and outcomes obstetrics prevented the performance
of a meta-analysis quantitative. Likewise, the predominance of observational studies limits the
possibility of establishing relations causes direct. However, the consistency of the results across different
contexts strengthens the validity of the synthesis presented.
Discussion:
The findings confirm that social and territorial inequalities play a decisive role in shaping gestational
risk in different global contexts.(4) Maternal risk is closely linked to structural factors such as poverty,
rurality, gaps in insurance coverage and limited availability of accessible and timely services (21). In
rural areas, these conditions are exacerbated by geographical dispersion, precarious transportation and
greater distance to centers of high-level care, elements that increase the vulnerability of pregnant women
and explain a significant part of the variability observed in maternal morbidity and mortality (6 ,21).
Although urban areas register a higher absolute number of obstetric events, the review shows that rural
women face a proportionally greater risk, especially due to delays associated with transportation and
medical referral. This “third delay,” widely documented in Latin American literature, represents a
pág. 6738
critical factor that conditions late access to specialized services and increases the probability of adverse
outcomes (6).
In this regard, the relationship between poverty and obstetric complications is one of the most consistent
elements identified. Adverse socioeconomic conditions not only increase exposure to risk factors but
also limit early initiation and continuity of prenatal care. The high cost of managing serious
complications, such as severe preeclampsia, is also a factor of impoverishment that perpetuates cycles
of inequality, especially in households with lower economic capacity. This analysis shows that
gestational risk cannot be interpreted solely as an individual health problem, but as a phenomenon deeply
associated with self-reinforcing structural inequities (22).
Similarly, this review identifies that rural women bear a “triple burden” characterized by geographical,
economic, and cultural barriers that affect their interaction with the health system across the board. The
lack of effective insurance coverage, limitations in medical transport, and the discontinuity of obstetric
services create a cycle of vulnerability that is difficult to break (1, 6). Beyond the rural-urban
comparison, these findings demonstrate that pregnancy risk responds to structural dynamics that require
multisectoral interventions and not just isolated clinical strategies (16).
Finally, although the review was conducted using rigorous methodological criteria, it is acknowledged
that the heterogeneity of the included studies and the predominance of observational designs may
influence the consistency and generalizability of the results. One limitation of the study is the lack of
prior registration of protocols on international platforms, which could limit the traceability of the initial
methodological design. Nevertheless, the convergence of evidence regarding the influence of social
determinants of health and territorial inequalities strengthens the validity of the conclusions. The
findings highlight the need to implement public policies with a differential and territorial approach,
addressing not only the provision of services but also the structural conditions that influence pregnancy
risk in rural and urban populations. Closing gaps in access, insurance coverage, and quality of care is
essential to improving maternal outcomes in territories with persistent inequities (2,6).
CONCLUSION
The results of this review demonstrate that pregnancy risk is profoundly influenced by social, economic,
and territorial inequalities that transcend biomedical factors. Women living in rural areas face a “triple
critical factor that conditions late access to specialized services and increases the probability of adverse
outcomes (6).
In this regard, the relationship between poverty and obstetric complications is one of the most consistent
elements identified. Adverse socioeconomic conditions not only increase exposure to risk factors but
also limit early initiation and continuity of prenatal care. The high cost of managing serious
complications, such as severe preeclampsia, is also a factor of impoverishment that perpetuates cycles
of inequality, especially in households with lower economic capacity. This analysis shows that
gestational risk cannot be interpreted solely as an individual health problem, but as a phenomenon deeply
associated with self-reinforcing structural inequities (22).
Similarly, this review identifies that rural women bear a “triple burden” characterized by geographical,
economic, and cultural barriers that affect their interaction with the health system across the board. The
lack of effective insurance coverage, limitations in medical transport, and the discontinuity of obstetric
services create a cycle of vulnerability that is difficult to break (1, 6). Beyond the rural-urban
comparison, these findings demonstrate that pregnancy risk responds to structural dynamics that require
multisectoral interventions and not just isolated clinical strategies (16).
Finally, although the review was conducted using rigorous methodological criteria, it is acknowledged
that the heterogeneity of the included studies and the predominance of observational designs may
influence the consistency and generalizability of the results. One limitation of the study is the lack of
prior registration of protocols on international platforms, which could limit the traceability of the initial
methodological design. Nevertheless, the convergence of evidence regarding the influence of social
determinants of health and territorial inequalities strengthens the validity of the conclusions. The
findings highlight the need to implement public policies with a differential and territorial approach,
addressing not only the provision of services but also the structural conditions that influence pregnancy
risk in rural and urban populations. Closing gaps in access, insurance coverage, and quality of care is
essential to improving maternal outcomes in territories with persistent inequities (2,6).
CONCLUSION
The results of this review demonstrate that pregnancy risk is profoundly influenced by social, economic,
and territorial inequalities that transcend biomedical factors. Women living in rural areas face a “triple
pág. 6739
burden” of geographical barriers, economic limitations, and cultural and institutional obstacles, resulting
in delayed or fragmented access to maternal services and greater vulnerability to serious obstetric
complications.
The evidence analyzed confirms that poverty, precarious insurance coverage, and high obstetric care
costs not only increase gestational risk but also perpetuate cycles of inequality that disproportionately
impact women in more vulnerable conditions, particularly older women and those residing in territories
with less capacity to resolve these issues.
In this context, it is essential to move towards public policies with a territorial, differential, and
intersectional approach that address the identified structural gaps. Strengthening health insurance
coverage, improving ambulance services, integrating cultural and community-based approaches, and
reinforcing epidemiological surveillance systems are priority areas for intervention to reduce critical
delays and improve maternal outcomes. Only through coordinated, multisectoral strategies will it be
possible to move towards more equitable maternal care that is sensitive to persistent territorial
inequalities.
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in delayed or fragmented access to maternal services and greater vulnerability to serious obstetric
complications.
The evidence analyzed confirms that poverty, precarious insurance coverage, and high obstetric care
costs not only increase gestational risk but also perpetuate cycles of inequality that disproportionately
impact women in more vulnerable conditions, particularly older women and those residing in territories
with less capacity to resolve these issues.
In this context, it is essential to move towards public policies with a territorial, differential, and
intersectional approach that address the identified structural gaps. Strengthening health insurance
coverage, improving ambulance services, integrating cultural and community-based approaches, and
reinforcing epidemiological surveillance systems are priority areas for intervention to reduce critical
delays and improve maternal outcomes. Only through coordinated, multisectoral strategies will it be
possible to move towards more equitable maternal care that is sensitive to persistent territorial
inequalities.
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migrants in Brazil: a study using the 100 Million Brazilian Cohort. Lancet Reg Health Am
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Balaj M, Sripada K, Besnier E, et al. Parental education and inequalities in child mortality: a global
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infant mortality: an analysis of 4·1 million births from 60 low-income and middle-income
countries between 2000 and 2019. Lancet Glob Health [Internet]. 2023;11(4):e526-e536.
Available from: https://doi.org/10.1016/S2214-109X(24)00040-8
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improving maternal and child health in Bangladesh: pilot study. JMIR Mhealth Uhealth
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