Structural ethnic inequities in maternal mortality between Indigenous and non-Indigenous women in Paraguay, 2014-2023: a national analysis of territorial, institutional, and preventable factors.

Background: Indigenous women in Paraguay continue to experience disproportionately high maternal mortality despite national efforts to improve maternal health. Evidence on the structural factors underlying these disparities remains limited. Objectives: To analyze structural ethnic inequities in maternal mortality between Indigenous and non-Indigenous women in Paraguay, focusing on territorial patterns, institutional access, and potentially preventable causes of death. Design: National population-based study using maternal mortality records registered in Paraguay between 2014 and 2023. Maternal mortality ratios (MMRs), incidence rate ratios (IRRs), and absolute differences were estimated according to Indigenous status. Logistic regression models were used to assess associations with deaths occurring outside healthcare institutions and specific preventable causes of death. Results: A total of 907 maternal deaths were identified, including 112 among Indigenous women (12.3%). Indigenous women were overrepresented by a factor of 4.8 relative to their population share. Maternal mortality remained consistently higher among Indigenous women throughout the study period, with mortality ratios ranging from 317.7 to 773.6 per 100,000 live births, compared with 58.7 to 145.1 among non-Indigenous women. Absolute inequalities remained persistently high over time. Overall, 24.3% of maternal deaths occurred outside healthcare institutions, with a substantially higher proportion among Indigenous women (44.6% versus 21.5%). After adjustment for age and educational level, Indigenous women had more than three times greater odds of dying outside healthcare institutions (aOR = 3.41; 95% CI: 2.20-5.29). Potentially preventable causes accounted for 42.4% of maternal deaths. Obstetric hemorrhage was strongly associated with Indigenous status (aOR = 3.83; 95% CI: 2.31-6.37). Conclusion: Indigenous women in Paraguay experience a disproportionate burden of maternal mortality characterized by persistent ethnic disparities, higher occurrence of deaths outside healthcare institutions, and a substantial burden of preventable causes of death. These findings suggest the presence of enduring territorial, institutional, and healthcare access barriers that contribute to structural ethnic inequities in maternal health.