Maternal Healthcare Access and Childbirth Outcomes in Rural, Resource-Limited Settings: Evidence from the Eastern Cape, South Africa

Background: Maternal healthcare access is a critical determinant of women’s and neonatal health, especially in rural areas of low- and middle-income countries. Despite high reported utilization in South Africa, rural communities continue to experience adverse childbirth outcomes. Objective: To evaluate the association between maternal healthcare access and childbirth outcomes in Ingquza Hill Local Municipality, Eastern Cape Province of South Africa. Methods: A cross-sectional study was conducted among 213 pregnant and postpartum women receiving maternal healthcare services at St Elizabeth Hospital, a regional referral hospital serving multiple primary healthcare clinics across the municipality. Data were collected using structured questionnaires and maternity access indicators (including ANC attendance, timing of first ANC visit, number of visits, physical accessibility, and place of delivery), and childbirth outcomes. Logic regression analyses were performed to identify associations between access indicators and unfavorable childbirth outcomes. Results: Utilization of maternal healthcare services was high, with 96% of participants reporting ANC attendance, 92% receiving skilled care during pregnancy, and 91% delivering in a health facility. Unfavorable childbirth outcomes were observed in 12% of participants. Conventional indicators of maternal healthcare access, including ANC attendance, number of visits, physical accessibility, and place of delivery, were not statistically associated with childbirth outcomes in regression analyses. However, initiation of antenatal care was notably delayed, with a mean gestational age at first ANC visit of 21.7 weeks. The limited number of adverse outcomes constrained statistical power to detect modest associations. Conclusions: High maternal healthcare utilization alone did not ensure improved childbirth outcomes in this rural setting. Delayed initiation of antenatal care emerged as a critical gap that may limit the effectiveness of subsequent care, highlighting the limitations of coverage-based access indicators. Strategies to improve maternal and neonatal outcomes should prioritize early antenatal engagement, quality and continuity of care, and move beyond utilization metrics toward measures of effective coverage in rural and resource-limited contexts.