It is widely understood that maternal health care relies on the entire health system. However, little empirical, country-specific, research has been done to trace out the ways in which health system elements can shape maternal health outcomes. This study seeks to redress this situation, by providing an example of how a health systems approach can benefit the understanding of maternal health services. A comparative analysis was conducted based on extensive case studies of maternal health and health systems in Bangladesh, Russia, South Africa, and Uganda. A number of cross-cutting health system characteristics affecting maternal health were identified by comparing these diverse settings. The most important common systems issues underlying maternal health care were found to be the human resource structures, the public-private mix of service provision, and the changes involved with health sector reforms. Specific country contexts can further determine many factors influencing maternal health outcomes and service performance. Systems issues were found to influence the access to and utilization of services, quality of care provided, and ultimately maternal health outcomes. This paper provides a first step in tracing out how such broad systems issues actually work to influence maternal health.