Protecting Maternal Health in an Era of Aid Contraction: A Systematic Review of Resilient National Financing, Commodity Security, Governance, Workforce, and Social Protection Linkages
Wiku Andonotopo, Muhammad Adrianes Bachnas, Wisnu Prabowo, Eric Edwin Yuliantara, Mochammad Besari Adi Pramono, Julian Dewantiningrum, Efendi Lukas, I Nyoman Hariyasa Sanjaya, Anak Agung Gede Putra Wiradnyana, Anak Agung Ngurah Jaya Kusuma, Ryan Saktika Mulyana, Khanisyah Erza Gumilar, Ernawati Darmawan, Muhammad Ilham Aldika Akbar, Dudy Aldiansyah, Dovy Djanas, Aloysius Suryawan, Ridwan Abdullah Putra, Anita Deborah Anwar, Cut Meurah Yeni, Nuswil Bernolian, Harry Kurniawan Gondo, Laksmana Adi Krista Nugraha, Waskita Ekamaheswara Kasumba Andanaputra, Wibisana Andika Krista Dharma, Milan StanojevicAbstract
As external development assistance for health plateaus or declines, many low- and middle-income countries face renewed pressure to sustain maternal health gains through domestic systems. This systematic review examines how national health systems adapt to aid contraction and identifies system-level capacities associated with continuity of maternal health services. Guided by PRISMA 2020 reporting standards, a comprehensive search of four electronic databases identified 1276 records published between 2012 and 2025, from which 25 studies met the inclusion criteria following screening and quality appraisal. The evidence base comprised a diverse mix of systematic reviews, modeling studies, cross-sectional analyses, and implementation-focused evaluations spanning multiple regions. Rather than focusing on individual clinical interventions, the synthesis explored how financing arrangements, access to essential maternal medicines, workforce stability, governance structures, and social protection mechanisms interact under conditions of fiscal constraint. Across settings, studies consistently described greater service continuity where maternal health was embedded within predictable domestic financing frameworks, supported by reliable procurement systems for medicines used in the prevention and management of postpartum hemorrhage and hypertensive disorders of pregnancy. Workforce stability and utilization patterns appeared closely tied to these structural conditions, whereas governance capacity shaped how resources were translated into operational performance. Social protection mechanisms influenced equity in access, particularly during periods of economic stress. Taken together, the findings suggest that maternal health resilience reflects the coherence of national systems rather than the presence of isolated programs. While pathways differed by context, systems that aligned fiscal protection, institutional accountability, and service delivery were better positioned to sustain maternal health outcomes as external funding declined. This review offers an integrated perspective to inform policy dialog on protecting maternal health during fiscal transition, without presuming uniform solutions across diverse health system contexts.