Invisible Barriers: Informal Costs, Staffing, and Quality in Maternal Care
Maternal health numbers tell an incomplete story. Mortality ratios, coverage indicators, and SDG dashboards capture what is measurable, but they often miss what truly shapes the care experience for mothers in low- and middle-income countries. In hospitals the realities behind those numbers—staffing constraints, hidden costs, and daily improvisations—influence outcomes as much as any policy or protocol.
Photo Credit: Eduardo Barrios
I have observed midwives working long shifts without breaks because there is no one to relieve them. I have seen families purchase gloves, gauze, or essential medications from local pharmacies when hospital supplies run short. These are not isolated events. They are part of a complex, often unspoken system that enables care to continue despite resource limitations.
The Hidden Cost of “Free” Care
On paper, maternity services in many hospitals are free. Yet women often discover that “free” care comes with small, unofficial expenses: payments for gloves, contributions toward generator fuel during emergencies, or small tokens to ensure timely attention from overstretched staff. For families with limited means, these costs can delay care or create barriers to accessing services.
These informal practices are not the result of negligence or greed; they emerge from necessity. When staff compensation is modest and supply chains are inconsistent, informal adaptations arise to keep services functioning. While these measures sustain care, they can unintentionally erode trust, create inequities, and make formal quality improvement efforts difficult to implement.
“Quality in maternal care extends beyond survival—it includes dignity, consistency, and the ability of staff to provide care without undue moral or operational stress.”
Staffing Challenges and Quality Gaps
Staff shortages remain a key barrier. In some facilities, a single midwife may attend to multiple laboring women simultaneously. Emergencies do not wait for shift changes, and documentation, counseling, and emotional support are often sacrificed to meet immediate clinical demands. Global health indicators such as “skilled birth attendance” rarely reflect whether these professionals are adequately supported, rested, or equipped. Counting a midwife as present does not capture the quality or sustainability of care provided under challenging conditions.
When Quality Cannot Be Captured in Numbers
In the push for data-driven performance, we risk overlooking the human dimensions of care. A woman may survive childbirth but experience neglect or distress. A newborn may be successfully resuscitated, yet the nurse providing care may be coping with delayed or insufficient remuneration.
Performance metrics that focus solely on outcomes can mask these realities. Quality in maternal care extends beyond survival—it includes dignity, consistency, and the ability of staff to provide care without undue moral or operational stress.
Bridging Policy and Practice
Improving maternal health in resource-limited settings requires more than new protocols. It requires recognition of the informal systems that sustain care where resources are constrained. Policymakers, administrators, and partners must view these workarounds as signals of structural gaps, not failures of individuals.
Investing in fair compensation, reliable supply chains, and transparent accountability strengthens both quality of care and staff morale. When staff can focus on care rather than improvisation, outcomes improve naturally, and trust in the health system is reinforced.
Seeing the Invisible
Global health discussions often happen far from the wards where care is delivered. Yet the most important stories are those that rarely appear in reports: the mother who sells personal items to cover essential care, the midwife who stays overnight to ensure continuous attention, or the manager who carefully stretches limited supplies to avoid service disruption.
These situations reflect systemic challenges rather than individual failings. Recognizing and addressing these “invisible barriers” is crucial to ensuring that maternal health strategies translate into real, equitable improvements.
Real progress in maternal health will not come from data alone. It comes from seeing what numbers cannot capture—the daily efforts, sacrifices, and resilience that keep fragile health systems alive.
