World Health Organization antenatal care recommendations include an ultrasound scan as a part of routine antenatal care. The impact of routine ultrasound imaging in terms of significantly improving the overall pregnancy outcome has been disputed by recent Cochrane review based on trials conducted mostly in developed countries. When ultrasound is used in high-risk pregnancies, its use becomes clearly beneficial. However, the fatal pregnancy outcomes (stillbirth, maternal, and early neonatal death) as end points are considerably rare in developed countries, while it must be highlighted that developing countries account for 99% of maternal and neonatal mortality. Also, considering the fact that there are no sufficient studies conducted in developing countries, particularly in rural settings and high-risk pregnancies, it is still unclear whether some positive impact as described in developed countries will produce similar results in low-income countries with specific problems and needs. This review not only provides further evidence of the promising potential of the use of ultrasound in resource-limited settings but also addresses some critical issues of maternity care in developing countries. Also, certain proposals and ideas about how to implement ultrasound in clinical practice to reduce maternal and neonatal mortality will be discussed.