Access to the maternal and newborn CoC has a positive impact on both mother and newborn health. However, the use of these services is fragmented across the care pathways in many LMICs. Our findings present the pattern of maternal health service utilization along the maternal CoC in nine LMICs, comparing WwD with WwoD. About one in seven (14.0%) women in our sample have a disability which involves at least some difficulty in one of the domains of function. This is comparable with the global report of people living with at least some difficulty (15%) [3].
In this study, 90.3% of women had at least one ANC visit during pregnancy, yet only 35.8% fully completed the CoC, with a slightly lower percentage among WwD (32.7%) compared to WwoD (36.4%). The odds of completing CoC was 11% lower among WwD compared to WwoD after controlling for other covariates. There might be several reasons for the shortfall of WwD from CoC. Physically, WwD may encounter difficulties in accessing healthcare facilities due to inadequate infrastructure, lack of transportation options, or inaccessible medical equipment [44]. Additionally, they may face discrimination or stigma from healthcare providers, leading to substandard care or denial of services. Systemically, healthcare systems may not be equipped to accommodate the specific needs of WwD, such as providing sign language interpreters, offering accessible information, or ensuring that medical personnel are trained in disability-inclusive care [45]. These factors contribute to a higher likelihood of WwD experiencing complications during pregnancy and childbirth, as well as higher rates of maternal and infant mortality [14, 15].
Only 55.6% of women had the minimum of 4 ANC contacts, with a slightly lower percentage among WwD (54.8%) compared to WwoD (55.8%). The gap in the continuity of care from first ANC contact to ANC4 + is probably due to delays in their first visit and inadequate quality of care provided during early visits [46]. Nearly half of WwD (47.3%) and 43.4% of WwoD experienced delayed initiation of ANC visit. This is lower than previous studies in LMICs, that report the proportion of women with delayed ANC initiation from 63.0% [47] to 68.9% [22]. This difference might be due to the countries included in the studies. For instance, three Asian countries with improved maternal health services are part of this study, in which 71.4% of them had timely ANC initiation compared to 49.6% in SSA. Given, antenatal contact is a window of opportunity to sign up women into the maternal CoC, this finding highlights the urgent need for a roadmap of strategic actions to end preventable maternal and neonatal death by ensuring access to the maternal CoC, which should prioritize WwD.
The highest dropout along the CoC is detected between childbirth and postnatal follow-up with the largest dropout observed among WwD. Given the sizable number of maternal deaths that occur during childbirth and shortly after delivery, the postnatal period would be a potential time to curb the death rate of the maternal-baby dyad. It is also a potential period to provide counselling for nutrition and family planning methods. Our finding of a large gap between entering the maternal care pathway and completing the CoC is inline with similar study from sub-Saharan Africa [22].
Our inequality analysis highlighted that WwD from a lower socioeconomic background experienced a lower completion of maternal CoC. For instance, the rate of CoC completion is higher among the richest quintile by more than one-quarter in countries such as Mali (47.8%), Senegal (31.6%), and Pakistan (56.0%) as compared to WwD from lower wealth quintile. The inequalities between the countries could be attributed to difference in countries’ performance to ensure compliance of their laws and policies with the UNCRPD. For instance, UNCRPD identified serious concerns about unequal access to education, employment, and healthcare services, including services related to HIV/AIDS, for women and girls with disabilities in Senegal [48]. Similarly, in Rwanda, the UNCRPD has identified insufficient access to public health education, healthcare facilities and services, including emergency care and sexual and reproductive health services, particularly in remote rural regions. Additionally, UNCRPD identified that there was insufficient training for health professionals on the human rights of persons with disabilities, including issues related to free and informed consent [49].
Likewise, in Pakistan, where our findings indicated one of the highest levels of inequality, UNCRPD committee identified a lack of proper mechanisms at the national and local level to implement policies developed for the wellbeing of disadvantaged people [50]. In contrast, in countries like South Africa, where there has been an improvement in socioeconomic status [51], and Cambodia, where maternal service coverage is high [52], less wealth related disparity was observed in the completion of CoC among WwD.
Overall, WwD in sub-Saharan African countries such as Mali, Senegal, Mauritius, Rwanda, Uganda, and South-Africa recorded a lower percentage completing CoC as compared to south Asian countries such as Cambodia, Pakistan, and Timor-Leste (29.2% versus 43.4%). Even though both WHO regions are the highest shareholders of maternal mortality, the lower coverage of key maternal health services has been witnessed in sub-Saharan Africa [53]. The gap could be attributed to the lower universal health care service coverage index and the smaller proportion of the population spending over 10% of their household budget on healthcare in sub-Saharan Africa. Additionally, in sub-Saharan Africa more than two-thirds of the rural population is affected by lack of access, which needs a holistic approach to achieve the SDG agenda of leaving no one behind by 2030 [54].
In our multilevel analysis, beside disability status, other covariates such as educational status, female headed household, wealth status, working status, caesarean delivery, ever had terminated pregnancy, WHO region, and exposure to media were found to be associated with maternal CoC completion.
We found that residence (urban) and region (South and Eastern Asia) were positively associated with maternal CoC completion. The fact that rural women are less likely to complete CoC could be attributed to the interplay of factors such as low acceptability of service, low socioeconomic status, barriers in terms of geography, and finance. This can be addressed by increasing healthcare workers coverage in rural and remote areas aligning with the SDGs of leaving no one behind, universal health coverage, the reaffirmation of a global dedication to primary health care, and an improved evidence base to support cost-effective interventions to improve WwD’s access to maternal health care services [55].
Women who attained secondary or higher education were more likely completing CoC. This observation aligns with earlier research conducted in LMICs [56, 57] that demonstrates a positive association between education attainment and CoC completion. Maternal education and media exposure may enhance access to maternal healthcare through the synergistic effect of education on health literacy fostering positive attitudes and improving health-seeking behavior [58].
Our finding indicates that women from lower socioeconomic status and those who are not working are less likely to complete CoC. Women from lower socioeconomic status are affected through multifaceted ways: limited financial resources, limited health insurance coverage, transportation and geographic barriers, and psychosocial stressors [59]. Hence, strategies such as community-based health workers, conditional cash transfers and removing persistent barriers to WwD should be considered by all countries to address inequality in access to care.
We also found that women who are unmarried, i.e., divorced, widowed or separated were more likely to receive no or few of maternal health services. In contrast female headed household, delivery by caesarean section, and having terminated pregnancy are positively related with maternal CoC completion. The positive association to caesarean delivery is likely to reflect the longer hospital length of stay, ensuring access to postnatal care within the birth hospitalisation as found in other LMICs studies [60, 61].
Pregnancy intention was negatively associated with completing maternal CoC. Women with unintended pregnancy were less likely to complete maternal continuum of care. This finding is in line with studies conducted in LMICs [31, 62]. Several factors contribute to this negative association. Unintended pregnancy is common among women with lower income and education status. In this study, unintended pregnancy was higher among WwD which creates the compounded disadvantage for WwD to navigate through maternal healthcare services.
As a strength, our study is the first to evaluate socioeconomic inequality along maternal continuum of care for women with disability in nine LMICs using DHS. DHS surveys cover a wide range of health and demographic indicators using standardized data collection methods and questionnaires across different countries, ensuring comparability of data over time and between countries. Our study is based on a large sample size which enhances the reliability and precision of the estimates. Additionally, this study used concentration curves and indexes to offer more comprehensive evidence to evaluate inequalities in completing the continuum of care relative to socioeconomic indicators such as wealth and educational status. It also examines other significant determinants of these inequalities through a multilevel analysis.
Our study has some limitations. Given that our study relies on self-reported information, there may be recall bias, especially for events that occurred in the distant past, ranging from weeks to five years. Despite large sample sizes, sampling errors can still affect the precision of estimates, particularly for small sub-populations.
Policy implications
This study comprehensively investigated the socioeconomic related inequalities in completion of continuum of care by including women living with disabilities. Leaving no one behind is a core principle of the SDGs to identify and lift up those who are left furthest behind. Hence, to reduce preventable maternal and child mortality, which is unequivocally higher among the socioeconomically disadvantaged women and women with disability, equitable and comprehensive access to the maternity continuum of care plays a paramount role.
Achieving equity in access to maternal CoC must involve more than just targeting those with the lowest income levels but also necessitates combating discrimination and rising inequalities within and amongst WwD, and their root causes. A comprehensive approach that considers both the physical and financial barriers is crucial to ensure WwD receive equal access to maternal CoC. Removing physical barriers should involve a continuity of care strategy between various caregiving locations, including households, communities, outpatient and outreach services, clinical-care settings, and residential places [17].
Additionally, reducing financial barriers through creating effective community support networks and implementing policies that provide financial assistance or subsidies specifically targeted at poor and WwD is paramount. These policies might include conditional cash transfers, which serve as a targeted approach to improve the well-being and empower WwD through a combination of financial support and incentivized actions [63].