A Social Equity Lens on Maternal Health Outcomes: Developing a Conceptual Framework

A Social Equity Lens on Maternal Health Outcomes: Developing a Conceptual Framework

Mamerito Nturanabo, Arinaitwe Winfred

Department of Political and Administrative Studies, Kampala International University

DOI: https://dx.doi.org/10.47772/IJRISS.2025.905000284

Received: 04 May 2025; Accepted: 11 May 2025; Published: 11 June 2025

ABSTRACT

This article proposes a comprehensive conceptual framework for analyzing the impact of social equity interventions specifically health provision, civic education, and legislative action on maternal health outcomes in Bugiri District, Eastern Uganda. Anchored in the Social Determinants of Health Theory (Marmot & Allen, 2010), the Health Belief Model (Rosenstock, 1974), and Health Equity Theory (Braveman & Gruskin, 2003), the framework systematically explicates the multi-level mechanisms through which socioeconomic, educational, infrastructural, and policy-driven interventions shape maternal health indicators, including maternal mortality and morbidity, neonatal and infant mortality, preterm birth, low birth weight, and delivery-related complications. Integrating intervening variables such as community engagement and institutional capacity, the model reflects the nuanced, context-specific dynamics illuminated by the researcher’s empirical investigations. By synthesizing theoretical and empirical insights, the framework provides an advanced analytical tool for scholars and policymakers seeking to design, implement, and evaluate equity-oriented strategies aimed at improving maternal health outcomes in low-resource settings.

Keywords: Conceptual framework; social equity interventions; maternal health outcomes; Bugiri District; health equity; Uganda.

INTRODUCTION

Drawing on Marmot’s (2018) seminal articulation of the social determinants of health and refined in 2024 to address the particular exigencies of maternal care in Uganda, the conceptual framework foregrounds social equity interventions as the primary levers through which structural disparities are attenuated and maternal outcomes improved. At this high‐order of analysis, equity interventions—ranging from targeted financial subsidies and legal protections to community governance reforms and culturally attuned outreach—are understood not merely as inputs but as catalysts that reconfigure both the “causes of the causes” and the proximal determinants of maternal well‐being. By delineating upstream domains (e.g., gender‐norm transformation, resource redistribution) and downstream endpoints (e.g., maternal mortality ratio, skilled birth attendance, experiential measures of agency), the framework constructs a coherent narrative that links policy innovations to measurable health metrics, while situating women’s lived experiences at the center of its theorization. This integrative stance permits a nuanced interrogation of how structural equity drives both access to and quality of care—thus rendering the study’s hypotheses both conceptually rigorous and empirically testable.

Crucially, the framework elaborates four interdependent pathways—Access and Utilization, Empowerment and Agency, Health System Responsiveness, and Broader Social Determinants—each mediating the effect of equity interventions on maternal health. Within these pathways, feedback loops and contextual moderators (e.g., entrenched gender norms, governance capacity) are explicitly modeled, acknowledging that the efficacy of any single intervention is contingent upon synergistic reforms and community‐level norm change. By mapping these complex mechanisms, the framework transcends correlative description to explicate causative processes, thereby guiding variable selection, methodological design, and analytical strategy. In doing so, it advances the researcher’s overarching objective: to generate actionable, context‐sensitive insights into how social equity strategies can be most effectively harnessed to reduce maternal mortality and enhance the holistic well‐being of women in Ugandan settings.

Theoretical Foundations

Social Determinants of Health Theory

Marmot and Allen (2010) argue that socio-economic and environmental conditions—such as income, education, and housing—influence health outcomes beyond individual behaviors. In the context of maternal health, interventions that enhance economic equity and educational attainment are theorized to mitigate underlying drivers of morbidity and mortality

Health Belief Model

Originally formulated by Rosenstock (1974), the Health Belief Model posits that individuals’ perceptions of susceptibility, severity, benefits, and barriers determine health-seeking actions. Civic education programs that heighten awareness of pregnancy risks and the advantages of skilled care can thus foster timely antenatal and delivery attendance.

Health Equity Theory

Braveman and Gruskin (2003) define health equity as the absence of unfair, remediable differences across social groups. Legislative and policy interventions—such as gender-sensitive laws and resource allocation mandates—are essential to dismantle structural barriers and promote equitable access to maternal health services.

Conceptual Framework

Building on Marmot (2010) diagrammatic approach and modified for this study, (2025)

Figure 1 depicts

Framework Components and Pathways

Social Equity Interventions (Independent Variables)

These are disaggregated into three interrelated pillars:

a) Health Provision

This component represents supply-side enhancements that improve the structural readiness and functionality of the health system. It encompasses:

• Expansion and equitable distribution of maternal health infrastructure.
• Deployment of skilled health professionals.
• Implementation of financial risk protection mechanisms (e.g., health insurance, free maternal services).

These inputs directly affect availability, accessibility, and quality of care, aligning with WHO’s Health System Building Blocks framework.

b) Civic Education

This is the demand-side driver focused on shaping health-seeking behavior and enhancing individual and community agency. Key strategies include:

• Rights-based education on maternal health entitlements.
• Community sensitization and empowerment to reshape harmful gender norms.
• Promotion of male involvement and participatory governance in maternal health.

Civic education influences health literacy, cultural attitudes, and decision-making autonomy, which are preconditions for timely and appropriate service utilization.

c) Legislation

This captures the enabling policy and legal environment that institutionalizes maternal health as a public good. It includes:

• Development and enforcement of maternal health laws and standards.
• Budgetary allocations and reproductive health policy reforms.
• Protection of reproductive rights and elimination of discriminatory practices.

Effective legislative frameworks act as macro-level determinants that reinforce both health system accountability and citizen entitlements.

Intermediate Outcomes

These represent the proximal effects of interventions, functioning as mediating variables:

• Improved Accessibility of Services: Both geographic and financial access to antenatal care, skilled birth attendance, and emergency obstetric care.
• Increased Awareness and Utilization: Enhanced knowledge leads to higher uptake of services such as ANC visits, institutional deliveries, and postpartum follow-up.
• Behavioral and Cultural Shifts: Reduction in socio-cultural barriers like gender-based norms, stigma, and fatalism around maternal complications.

These changes are necessary conditions for achieving downstream improvements in maternal outcomes.

Maternal Health Outcomes (Dependent Variables)

The framework culminates in the ultimate goal of improving maternal health, operationalized through:

• Reduction in Maternal Mortality Ratio (MMR)
• Decrease in Severe Maternal Morbidity (e.g., eclampsia, sepsis)
• Improved Equity in Maternal Health Metrics (e.g., between rural and urban populations, or across socio-economic quintiles)

Outcomes are not only assessed in terms of aggregate gains but also through an equity lens, emphasizing distributional justice and the closing of disparity gaps.

Feedback Loops and Systemic Interdependence

The arrows and linkages in the framework also suggest bidirectional and feedback mechanisms:

• Success in health provision enhances trust and increases community engagement (reinforcing civic education).
• Civic education fuels advocacy, driving legal reforms and better enforcement.
• Effective legislation mandates investments in health infrastructure and staffing.

These dynamic interactions emphasize the need for policy coherence and multi-sectoral coordination in public health planning.

DISCUSSION

The conceptual framework provides a rigorous, theory-driven foundation for researchers to systematically examine the relationship between social equity interventions and maternal health outcomes. It operationalizes abstract constructs into measurable indicators, such as health facility density and literacy scores, ensuring validity and comparability through established data sources. By facilitating hypothesis formulation grounded in behavioural models (Rosenstock, 1974) and structural determinants (Braveman & Gruskin, 2003), the framework supports empirical testing through advanced multilevel and structural equation methodologies. Furthermore, it promotes the integration of mixed-methods approaches, linking quantitative associations with qualitative contextual mechanisms to yield a comprehensive understanding of health behaviors within broader socio-political structures (Marmot & Allen, 2010).

In recognizing the embeddedness of individual behaviors within systemic contexts, the framework fosters holistic intervention design that targets both immediate behavioral drivers and upstream structural factors. It also advances cross-sectoral collaboration by identifying mechanisms—such as community oversight and enhanced health literacy—that necessitate joint action across education, finance, health, and civil society sectors. Ultimately, the framework equips researchers to bridge micro-level and macro-level analyses, enabling the design of empirically grounded, contextually nuanced, and equity-oriented interventions aimed at achieving sustainable improvements in maternal health outcomes.

CONCLUSION AND IMPLICATIONS

The proposed conceptual framework offers a robust, theory-grounded platform for interrogating how social equity interventions can mitigate maternal health disparities, particularly within Bugiri District. It sets a clear agenda for future research, calling for its application in both longitudinal and cross-sectional designs, refinement of measurement instruments, and critical exploration of the moderating effects exerted by cultural and institutional contexts. By anchoring inquiries in this integrated model, researchers can generate nuanced, context-sensitive insights that transcend simplistic causal attributions, thus enriching the empirical literature on maternal health equity.

Beyond academic inquiry, the framework bears significant practical implications for policymakers and practitioners. It provides a strategic blueprint for aligning initiatives across the health, education, and governance sectors, thereby fostering synergistic interventions capable of advancing Uganda’s Vision 2040 and Sustainable Development Goal 3 objectives. By illuminating the structural and behavioral pathways through which equity-focused policies exert influence, the model empowers stakeholders to design targeted, sustainable, and systemically integrated strategies to reduce maternal health disparities and promote broader social justice outcomes.

REFERENCES

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3. Marmot, M., & Allen, J. (2010). Closing the gap in a generation: health equity through action on the social determinants of health. The Lancet, 372(9650), 1661–1669.
4. Rosenstock, I. M. (1974). Historical origins of the health belief model. Health Education Monographs, 2(4), 328–335.
5. United Nations Children’s Fund (UNICEF). (2022). Uganda demographic and health survey 2022.
6. World Health Organization (WHO). (2019). Trends in maternal mortality 2000 to 2017.