Disability Inclusion in Maternal Health Services in Mozambique: A Mixed- Methods Analysis of Barriers Experienced by Women with Disabilities

Disability Inclusion in Maternal Health Services in Mozambique: A Mixed- Methods Analysis of Barriers Experienced by Women with Disabilities | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Disability Inclusion in Maternal Health Services in Mozambique: A Mixed- Methods Analysis of Barriers Experienced by Women with Disabilities Dulce Osório, Miguel Osório, Edy Nacarapa, Zuana Cossa, Percina Machava, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8797817/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background In Sub-Saharan Africa, maternal health remains a significant public health challenge, and women with disabilities (WWD) experience profound inequities in access to essential healthcare services. In Mozambique, although national strategies promote disability inclusion, systemic and structural barriers continue to undermine equitable access to maternal health services. This study explores the intersection of maternal health and disability inclusion in Mozambique, identifying barriers faced by WWD and opportunities to improve service accessibility and quality. Methods A mixed-methods design was employed, integrating a desk review with stakeholder consultations and interactive workshops. The desk review examined national policies and relevant literature on maternal health and disability inclusion. Stakeholder consultations were conducted via surveys across multiple regions, engaging women WWD, healthcare providers, policymakers, and disability advocates. Key findings were validated and refined through participatory workshops involving diverse stakeholders. Quantitative data were analysed descriptively, while qualitative responses were thematically analysed. Results The study found that WWD face multifaceted barriers to maternal health, including inaccessible infrastructure, lack of adapted medical equipment, financial constraints, inadequate provider training, communication gaps and stigmatizing attitudes. Among 81 surveyed participants, over 80% reported physical and communication barriers as major obstacles, while 65% reported inadequate medical equipment. Although some participants noted the existence of policies such as the National Action Plan for Disability and the Strategy for People with Disabilities in Public Services, their implementation was widely perceived as ineffective or insufficient in improving maternal health service accessibility for WWD. Conclusion Disability inclusion within Mozambique’s maternal health system remains limited, with policy commitments insufficiently translated into practice. Achieving equitable and inclusive maternal healthcare for WWD in Mozambique requires sustained investment in accessible infrastructure, provider training, community engagement, and effective accountability mechanisms. Addressing these systemic barriers is critical to improving maternal health outcomes and advancing health equity for all women in Mozambique. maternal health women with disabilities Mozambique health equity inclusion Figures Figure 1 Figure 2 INTRODUCTION Maternal health, defined by the World Health Organization (WHO) as the well-being of women during pregnancy, childbirth, and the postpartum period, is fundamental to the development of healthy and productive societies. [ 1 ] Key indicators for assessing maternal health include reductions in maternal mortality, access to sexual and reproductive health services, and progress toward universal health coverage. [ 1 ] Despite substantial progress in reducing maternal mortality ratios was achieved over the past decades, globally, about 800 women die every day from preventable maternal causes, most occurring in low-income countries (LIC). [ 2 ] While maternal health challenges affect women generally in many developing countries, particularly in Sub-Saharan Africa (SSA), these challenges are more pronounced among women with disabilities (WWD), who often receive less attention in health policy and service delivery. [ 3 , 4 ] Disability is an important public health problem globally. According to WHO, Disability is a broad term encompassing impairments, activity limitations, and participation restrictions that arise from the interaction between an individual with a health condition and their surrounding environmental factors. [ 5 ] Globally, around 1.3 billion people (16% of the global population), live with disabilities, with approximately 80% of them living in LMIC. [ 5 ] People with disabilities face higher mortality rates, poorer health outcomes, and greater functional limitations due to health inequities driven by factors such as stigma, discrimination, poverty, exclusion from education and employment, and systemic barriers within healthcare. [ 5 – 7 ] In Mozambique, around 727,620 individuals (2.7% of the population) live with disability, nearly half of whom are women. [ 8 ] Despite overall health gains over time, specific groups, including women and people with disability, continue to experience significant health disparities and poorer health outcomes. Structural factors, such as the socioeconomic and political environment, along with socioeconomic status, and living conditions, are key social determinants of health that contribute to these health disparities in Mozambique. [ 9 , 10 ] Women with disabilities face some of the most significant health and social inequalities, particularly in sexual and reproductive health; a domain often neglected in both policy and practice. These inequities persist across the continuum of care, from family planning and antenatal care to childbirth and postpartum services. [ 3 , 11 ] As a result, WWD experience disproportionately higher maternal mortality and morbidity rates, limited access to critical health information and services, and a greater incidence of pregnancy complications, preterm births, and low birth weight infants. [ 3 , 4 , 11 ] The pervasive misconception that WWD are not sexually active further exacerbates their exclusion, reinforcing systemic neglect and lack of tailored maternal health services. [ 3 , 12 – 14 ] Together, these inequities underscore an urgent need to address disability inclusion as a central priority in maternal health. This study, therefore, explores the intersection of maternal health and disability in Mozambique, identifying barriers to inclusive care and proposing actionable strategies to strengthen equity in service delivery. MATERIALS AND METHODS Study Design This study employed a mixed-methods design encompassing desk review, stakeholders’ consultation and interactive workshops to comprehensively assess the intersection of maternal health and disability in Mozambique. By integrating quantitative and qualitative approaches, the study aimed to capture both policy-level insights and lived experiences of WWD and key stakeholders. Data Collection Three complementary data collection methods were used to collect both secondary and primary data and to validate findings across stakeholder groups: Desk Review : A comprehensive review of policy documents, national guidelines, and relevant literature on maternal health and disability in Mozambique was conducted to identify existing frameworks, gaps, and best practices. Searches were performed across Google, Google Scholar, and PubMed. Eligible documents were those published in English or Portuguese, with no time restrictions applied, and relevant to maternal health, disability inclusion, or health policy in Mozambique. Documents were screened for relevance, and duplicates or those lacking reference to maternal health or disability inclusion were excluded. Information was extracted and synthesized narratively according to predefined themes, including policy frameworks, service accessibility, and disability inclusion gaps. Stakeholder Consultations : Surveys were administered to stakeholders both online and in-person to ensure participation of individuals with disabilities and those with limited access to technology. Participants were selected using purposive sampling to ensure representation from different provinces, disability types, and institutional sectors. Eligible participants included WWD, healthcare providers, policymakers, and disability advocates. A structured questionnaire was specifically developed for this study in English and Portuguese. The instrument included both closed- and open-ended questions addressing access to maternal health services, experienced barriers, and proposed solutions for improving disability inclusion. The questionnaire was piloted with a small group of stakeholders to assess clarity, relevance, and comprehensibility, and minor revisions were made accordingly. The English version of the questionnaire is provided as Supplementary File 1. Interactive Workshop : One interactive workshop, lasting approximately two hours, was conducted in Maputo, with participants joining both in person and online via zoom (hybrid section). The workshop included policymakers, health workers, WWD, and disability advocates to ensure a multi-sectoral perspective. Sessions were facilitated using participatory methods; discussions were audio-recorded and summarized into key themes by note-takers. These sessions served to validate survey findings, explore emerging themes, and collaboratively discuss solutions to improve disability inclusion in maternal health services. Data Analysis Narrative synthesis was used to integrate and summarize the findings of the desk review, grouping evidence by policy domains and thematic relevance. Quantitative survey data were entered into Microsoft Excel (Office 365, Version 2408) and analysed using descriptive statistics, including frequencies and percentages. Qualitative data from open-ended survey responses and workshop discussions were coded manually using an inductive approach to identify recurrent themes and barriers. Findings from all three components were triangulated to identify consistent patterns and to validate emerging recommendations. Ethical Considerations This study did not involve clinical interventions. The desk review relied on publicly available documents. Participation in surveys and workshops was voluntary, with informed consent obtained from participants prior to data collection. Responses were anonymized to ensure confidentiality. Ethical approval was obtained from the Institutional Bioethics Committee for Health of Gaza (Reference No. 197/CIBS-Gaza/2024). Participant responses were anonymized, and all data were stored securely with access limited to the research team. RESULTS The findings of this study are presented in two sections. Section A reports insights from the desk review, and Section B summarizes the results from stakeholder consultations and interactive workshop. Section A: Desk review Findings The desk review examined both peer-reviewed and Gray literature including national and international reports, policy documents and peer reviewed articles. Disability Policies in Mozambique Mozambique ratified the Convention on the Rights of Persons with Disabilities (CRPD) and its Optional Protocol in 2012, signalling a formal commitment to promoting and protecting the rights of persons with disabilities in line with global standards for disability rights. [ 15 ] Despite this progress, the national legal and policy framework continues to present significant gaps that prevent it from adequately promoting and protecting the rights of the diverse population of people with disabilities. People with disabilities face persistent barriers, including inaccessibility, limited access to information, and discriminatory practices. [ 15 ] However, none of the reviewed policies explicitly address maternal health needs of WWD, reflecting a gap between general disability rights and health sector implementation. For instance, disability policies lack clear indicators or funding mechanisms for inclusive reproductive health services. Maternal Health in Mozambique Maternal health remains a major public health challenge in Mozambique, despite gradual improvements in recent decades. The Sustainable Development Goals emphasize expanding equitable access to quality healthcare and providing integrated services as key strategies for reducing maternal mortality. [ 11 ] Mozambique continues to report one of the highest maternal mortality rates in Sub-Saharan Africa, estimated at 223 deaths per 100,000 live births in 2023. [ 16 ]. No disaggregated data on maternal mortality among women with disabilities are currently available in Mozambique, making it difficult to monitor equity in maternal outcomes. A significant portion of the population, approximately 32.6%, lacks access to healthcare services, highlighting the overall difficulty in accessing maternal healthcare. [ 15 ] Evidence shows that the access and utilisation of maternal health services is significantly lower among women who are poor, live in rural areas or less empowered. [ 17 ] For WWD, challenges in accessing maternal health services are even greater compared to the general population. Public maternal healthcare services are generally under-resourced and poorly equipped to address the specific needs of WWD. [ 13 ] Barriers to Healthcare Access for Women with Disabilities Women with disability often encounter multiple and intersecting barriers that hinder their access to essential maternal health services, including structural, financial, and attitudinal barriers. Structural Barriers : The healthcare infrastructure in Mozambique is not adequately equipped to serve the needs of WWD. A 2023 analysis revealed that health facilities are physically inaccessible, lacking necessary features such as ramps, adequately sized bathrooms, and specialized equipment designed to meet the needs of physically disabled individuals. [ 18 ] This issue is pronounced in maternal health services, where antenatal and perinatal care are often out of reach for WWD due to shortage of appropriate resources including delivery beds that can accommodate women with physical disabilities or shorter stature. [ 19 ] Additionally, crucial information regarding sexual and reproductive health, family planning, and rights remain inaccessible to women with visual, hearing, intellectual, or other disabilities, who require alternative communication methods to fully understand and utilize these services. [ 15 , 19 ] Financial Barriers : Financial constraints represent a substantial obstacle for people with disabilities. [ 18 ] The economic burden associated with disability often includes additional costs for medical care, assistive devices, transportation, and other necessities, which can strain limited financial resources. In Mozambique, where poverty is widespread, these financial challenges are exacerbated for people with disabilities, who already face reduced earning potential due to systemic discrimination in employment and education. [ 15 ] Furthermore, health facilities are often located at long distances from communities, leading to additional transportation costs, which further limit access for WWD. Women with disabilities face even fewer employment opportunities compared to women without disabilities, intensifying their financial vulnerability and reducing their ability to afford necessary healthcare services. [ 19 ] Attitudinal and Communication Barriers : Stigmatization and discriminatory behaviour from some healthcare professionals are common experiences for WWD in Mozambique. [ 15 ] Additionally, women with visual and hearing impairments encounter communication barriers due to the lack of sign language interpreters and alternative communication methods such as materials in Braille or easy-to-read formats of. [ 18 ] These barriers compound across the continuum of maternal care, from antenatal visits to delivery and postnatal follow-up. Section B: Stakeholders’ consultation and Workshop Participant Characteristics A total of 81 stakeholders participated in the survey, representing diverse regions across the country, with the highest proportion (44%, n = 36) from Maputo City. Participants included public healthcare workers (40%, n = 32), policymakers (6%, n = 5), non-governmental organization representatives (37%, n = 30), and people with disabilities (17%, n = 14). The majority (90%) reported five or more years of experience working with women or in maternal health. Perceptions of Maternal Health Services Of 81 respondents, 57% rated maternal health services as unsatisfactory or very unsatisfactory. With regard to equity accessing maternal healthcare for WWD, 63% of participants described it as rarely equitable or not equitable (Fig. 1 ). Additionally, two in five respondents (40%) reported that maternal health services fail to meet the specific needs of WWD at all, while 33% indicated that they only partially meet these needs. Furthermore, approximately 80% of participants reported that healthcare providers are not adequately trained to address the needs of WWD. Barriers and Challenges to Maternal Health Services Table 1 summarizes the key barriers identified by participants, grouped into four main categories (structural, financial, attitudinal and communication barriers) along with their relative frequency based on survey responses. Structural barriers, including inaccessible buildings, lack of adapted delivery beds, and absence of ramps or accessible bathrooms, were the most frequently cited, reported by 84% of respondents. Financial barriers, such as transportation costs and inability to pay for assistive devices or consultations, were reported by approximately 33% participants. Attitudinal and communication barriers, including discriminatory behaviours and lack of sign-language or Braille materials, were mentioned by 62% and 82% of participants respectively. Together, these findings reveal that barriers to maternal healthcare for WWD in Mozambique are multidimensional and mutually reinforcing. Table 1 Barriers to maternal health services for women with disabilities, grouped by category and frequency of reporting Category Specific Barriers Identified % of Participants Reporting (N = 81) Illustrative Quotes Structural/physical Barriers Lack of ramps and accessible toilets; narrow doorways; non-adjustable delivery beds; absence of adapted equipment. 84% (n = 68) “The main challenges are distance, the lack of ramps in some health facilities, and beds that are not appropriate for women with physical disabilities.” “…lack of accessibility for people with disabilities—for example, as a person with short stature, I cannot get onto the beds and there is no assistance to help me. There is a lack of ramps, inappropriate showers...” Financial Barriers Cost of transport to health facilities; absence of disability-friendly transport; out-of-pocket payments for services or assistive devices 41% (n = 31) “The lack of transportation, such as ambulances, and in some cases the long distances to the health facility.” “Extreme poverty.” Attitudinal Discriminatory behaviours and stigmatizing assumptions about WWD. Many participants described negative experiences, including health workers questioning the legitimacy of WWD’s pregnancies, lack of privacy, judgmental treatment, and in some cases, obstetric violence. 62% (n = 50) “There is judgment because of our disability and discrimination. People need to get it out of their heads that a woman with a disability cannot have sex and have children.” “The maternity ward has no privacy. I always have to bring a companion to the health facility, which is uncomfortable because I do not speak freely and sometimes have personal concerns.” Communication Barriers Absence of sign-language interpreters; lack of materials in Braille or easy-to-read formats 83% (n = 67) “Lack of communication (absence of professionals who can communicate in sign language, lack of communication in Hebraic).” More than 80% of participants cited physical and communication barriers as critical obstacles (Fig. 2 ). Policy Awareness and Gaps When asked about existing policies or programs addressing WWD, only 35% of participants were aware of such initiatives, most often citing the National Action Plan for Disability and the Strategy for People with Disabilities in Public Services. Among those aware of existing frameworks, 42% considered them ineffective or insufficient in improving maternal health service accessibility for WWD. DISCUSSION Women with disability face significant challenges accessing maternal health services, particularly in settings where health systems are already under strain. This study examined the intersection of maternal health and disability in Mozambique, a country where maternal mortality remains among the highest in SSA and where WWD are particularly underserved. Despite Mozambique’s formal commitments to disability rights through ratification of the CRPD in 2012, findings from the desk review, stakeholder consultations and workshop reveal a profound gap between policy intent and implementation. WWD continue to experience inequitable access to maternal health services due to inaccessible infrastructure, financial constraints, communication challenges, and stigmatizing provider attitudes. These barriers occur within an already strained health system, reflecting the structural and systemic nature of exclusion. The barriers identified in this study align with evidence from other SSA contexts, where WWD consistently report profound difficulties accessing and utilising maternity services including antenatal care, facility delivery and post-natal care. [ 20 ] Previous studies have consistently reported that visually impaired women struggle with inaccessible information and facility design, while women with hearing impairments face major communication challenges due to the absence of sign-language interpreters or adapted materials. Physically disabled women encounter facilities without ramps, small consultation rooms, and non-adjustable beds. [ 13 , 21 ] These obstacles mirror those identified in Mozambique, suggesting that such barriers are systemic across the region rather than context specific. Negative and discriminatory attitudes from healthcare providers emerged as one of the most pervasive barriers in this study. Participants described being judged or questioned about their right to motherhood. These findings are consistent with global evidence and studies from SSA showing that stigma and negative provider attitudes are major deterrents to equitable maternal health for WWD. [ 20 , 22 ] Further supporting discriminatory attitudes from health workers, a study in Ghana found that some health professionals had negative perceptions questioning the need of WWD getting pregnant and maintaining it. [ 23 ] Stigma and implicit bias in provider–patient interactions undermine not only access but also the quality of care and trust in the health system. Nearly four in five stakeholders in our consultations stated that healthcare workers were not adequately trained to address the specific needs of WWD, a pattern consistent with findings across SSA. [ 20 ] These attitudes, rooted in social stigma and lack of professional training, highlight the urgent need for institutional reforms to embed disability inclusion within all levels of health-worker education. These barriers are not only inconveniences; they represent a fundamental weakness of the healthcare system to recognize and address the diverse needs of WWD. Evidence consistently shows that WWD face elevated risks of adverse maternal outcomes, underscoring the need for care that is not only accessible but also inclusive and responsive to their specific needs. [ 24 – 26 ] The pervasive nature of these challenges across the region suggests a broader systemic problem, in which healthcare infrastructure, policies, and practices have not evolved sufficiently to accommodate all individuals. This lack of inclusivity perpetuates health disparities and social inequalities, highlighting the urgent need for comprehensive reforms that prioritize accessibility, equity, and quality of care for vulnerable populations. Although Mozambique has adopted policies such as the National Action Plan for Disability and the Strategy for People with Disabilities in Public Services, their impact remains limited. Participants in this study perceived these frameworks as largely symbolic, with insufficient enforcement, monitoring, and funding. Weak coordination between disability and maternal-health programs, poor dissemination of guidelines, and the absence of accountability mechanisms contribute to implementation failure, a problem similarly reported by policymakers in earlier analyses of women’s health programs in Mozambique. [ 27 ] These challenges mirror broader structural issues in SSA, where ambitious health policies often falter during implementation due to resource constraints, limited local ownership, and workforce shortages [ 28 , 29 ]. Collectively, these findings suggest that without stronger accountability mechanisms, sustained investments, and disability-sensitive training for healthcare workers, policy commitments will remain largely symbolic, with limited impact on equitable access to maternal health services for WWD. Applying the WHO Health Systems Building Blocks lens [ 30 , 31 ], the barriers identified span multiple domains. Service delivery remains constrained by the absence of ramps, adapted delivery beds, and disability-friendly toilets. Health workforce gaps include inadequate pre-service and in-service training on disability inclusion, lack of sign-language skills, and minimal sensitivity to gender and disability rights. Health information systems do not disaggregate data by disability, preventing effective monitoring of outcomes and policy progress. Governance and leadership remain weak, with limited accountability and coordination across sectors. Addressing these deficiencies requires cross-cutting reforms that combine infrastructure investment, training, inclusive policy enforcement, and strong community partnerships. Engaging disability associations and community health workers could help to strengthen outreach, reduce stigma, and facilitate patient feedback mechanisms. Community-based initiatives, including participatory audits of facility accessibility, have proven effective in other settings and could be adapted for Mozambique. [ 32 , 33 ] Moreover, integrating disability indicators into national health-information systems would enable systematic monitoring of service access and maternal outcomes for WWD, closing the current data gap. Strengths and Limitations This study provides novel insights by integrating policy analysis with first-hand perspectives from WWD, healthcare providers, and policymakers, offering a comprehensive assessment of disability inclusion gaps in maternal health. A key strength of the study is its mixed-methods design, which triangulates evidence from policy review, quantitative survey’s findings, and qualitative insights from key stakeholders across multiple regions of the country. This methodological triangulation enhanced the depth and validity of the findings by capturing both documentary evidence and lived experiences. Importantly, the inclusion of WWD as active participants added essential lived perspectives that are often overlooked in maternal-health research. Despite these strengths, several limitations must be acknowledged. First, there is lack data on maternal health and disability in Mozambique, with the existing literature primarily focusing on general maternal health indicators or disability rights but rarely examining the specific challenges faced by WWD in accessing maternal healthcare. Second, the small and non-random sample of the survey limits generalizability, and reliance on self-reported perceptions may introduce recall or social-desirability bias. Additionally, data collection was conducted during a period of socio-political unrest, which may have constrained participation from some regions. Despite these challenges, triangulation across data sources enhanced the validity of findings and ensured that key themes were consistently observed across stakeholder groups providing valuable evidence in an underexplored topic and offering important insights to inform future research, policy development, and programmatic efforts to strengthen inclusive maternal health services for WWD in Mozambique. Implications for Policy and Practice The findings of this study highlight critical opportunities to strengthen disability inclusion within Mozambique’s maternal health system. Addressing barriers to accessibility, provider training, and policy implementation is essential to align national commitments with service delivery. Progress in these areas would contribute to national maternal health goals and advance the Sustainable Development Goals, particularly Goal 3 (health and well-being) and Goal 10 (reduced inequalities). [ 34 , 35 ] Several key areas of actions are recommended based on the findings of this study in order to enhance accessibility and inclusiveness of maternal health services for WWD: Infrastructure and Equipment : Adapt health facilities by constructing ramps, accessible bathrooms, and appropriately designed consultation rooms; ensure the availability of adjustable examination tables, assistive devices, and clear signage to improve physical accessibility. Training for Healthcare Professionals : Integrate disability content into pre- and in-service curricula; provide continuous training in sign language, inclusive communication, respectful care, and the rights of WWD to address stigma and attitudinal barriers. Inclusive Policies and Programs : Develop or revise maternal health policies to explicitly address disability inclusion; establish robust monitoring and evaluation frameworks; and create mechanisms for WWD to participate meaningfully in policy development and feedback processes. Community Engagement and Awareness : Strengthen community outreach and public campaigns to reduce stigma, raise awareness of the rights of WWD, and involve community and religious leaders in promoting inclusive maternal health practices. Financial Support and Resource Allocation : Allocate dedicated budgets for infrastructure adaptation and capacity building; provide financial incentives or support mechanisms to reduce economic barriers; and foster partnerships with NGOs and disability associations to scale up implementation efforts. Data monitoring : integrating disability indicators into national health-information systems would enable systematic monitoring of service access and maternal outcomes for WWD, closing the current data gap. Collectively, these measures would help ensure that maternal health services become more inclusive, equitable, and responsive to the needs of WWD, aligning practice with policy commitments and leaving no woman behind in accessing essential sexual and reproductive health services. Future research should prioritize generating disaggregated data on maternal health outcomes among WWD, as current national health statistics do not capture these disparities. Additionally, intervention-based studies are needed to evaluate the effectiveness of specific strategies such as provider training, infrastructural adaptations, and financial support mechanisms, in improving equitable access and outcomes for WWD. CONCLUSION Collectively, the findings demonstrate that disability inclusion within Mozambique’s maternal-health system remains weak and uneven. The persistence of physical, attitudinal, communication and systemic barriers reveals that policy commitments have not yet translated into equitable service delivery. To advance inclusive maternal health, Mozambique must prioritize sustained investment in accessible infrastructure, disability-sensitive provider training, and integration of disability considerations into all health-sector planning and monitoring frameworks. Strengthening community engagement and accountability will be essential for transforming inclusion from policy rhetoric into lived reality. Achieving these reforms would contribute directly to the realization of the CRPD and the Sustainable Development Goals, ensuring that no woman is left behind in the pursuit of maternal health equity. Declarations Ethics approval and consent to participate: This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Institutional Bioethics Committee for Health of Gaza (Reference No. 197/CIBS-Gaza/2024). Informed consent was obtained from all participants prior to their participation in the study. Consent for publication: Not applicable. Competing interests: The authors declare that they have no conflicts of interest. Funding: This study was supported by a small grant from the Australia Awards Africa program attributed to the first author, linked to her Master of Global Health and Infectious Diseases Intelligence at the University of New South Wales, Sydney. The small grant aimed to support student’s academic projects to enhance the On-Award experience. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Author Contribution Conceptualisation: D.O; Funding Acquisition: D.O; Investigation: D.O, M.O and I.M; Data collection and stakeholder engagement D.O, M.O, E.N, E.M and I.M; Formal analysis: D.O; Visualisation: D.O; Writing – original draft preparation: D.O., M.O, E.N and I.M; Writing – review and editing: D.O, M.O, I.M, EN, Z.C, P.M, M.N, L.S, H.J, A.N, E.M. All authors provided intellectual input during data interpretation and approved the final version of the manuscript. Acknowledgement The authors would like to thank the women with disabilities who generously shared their experiences and perspectives for this study. We also acknowledge the contributions of healthcare providers and policymakers who participated in the consultation surveys, and the stakeholder workshop. We are grateful to the Mozambican Association of Women with Disabilities for their support with community engagement and recruitment. We also acknowledge the Ministry of Health of Mozambique for their institutional support and collaboration. We thank colleagues at the University of New South Wales for academic guidance and technical support throughout the study. Data Availability De-identified data underlying the findings are available from the corresponding author upon reasonable request. Relevant policy documents analysed in this study are publicly available and can be accessed through the references provided. References World Health Organization (WHO). Maternal Health 2024 [Available from: https://www.who.int/health-topics/maternal-health#tab=tab_1 World Health Organization (WHO). 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World Health Organization (WHO). Everybody's business - strengthening health systems to improve health outcomes: WHO's framework for action 2007 [Available from: https://www.who.int/publications/i/item/everybody-s-business----strengthening-health-systems-to-improve-health-outcomes Manyazewal T. Using the World Health Organization health system building blocks through survey of healthcare professionals to determine the performance of public healthcare facilities. Archives Public Health. 2017;75(1):50. World Health Organization (WHO). Good practices on disability-inclusive health: The WHO European framework to achieve the highest attainable standard of health for people with disabilities. 2025. Kuper H, Gatta DR, Rotenberg S, Banks LM, Smythe T, Heydt P. Building disability-inclusive health systems. Lancet Public Health. 2024;9(5):e316–25. Indicators S. Global indicator framework for the Sustainable Development Goals and targets of the 2030 Agenda for Sustainable Development. URL: https://unstats un org/sdgs/indicators/indicators-list/(дата обращения : 2002 2023). 2020. Institute for Health Metrics and Evaluation (IHME). Health-related SDGs 2023 [Available from: https://www.healthdata.org/data-tools-practices/interactive-visuals/health-related-sdgs Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1.Questionnaireforstakeholdersconsultation.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Apr, 2026 Reviews received at journal 31 Mar, 2026 Reviews received at journal 20 Mar, 2026 Reviews received at journal 06 Mar, 2026 Reviewers agreed at journal 23 Feb, 2026 Reviewers agreed at journal 21 Feb, 2026 Reviewers agreed at journal 21 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviewers invited by journal 13 Feb, 2026 Editor assigned by journal 13 Feb, 2026 Editor invited by journal 12 Feb, 2026 Submission checks completed at journal 12 Feb, 2026 First submitted to journal 12 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Osório","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYDCCA8wNEAYzA+ODDxUgBkwEpxZGuBZmwxlnQAyYCEEtDAxs0rxtIJqAFr4biY0fPlTUyZm3Mx+T4J1XG83fDtTyo2IbTi2SNxKbJWecOWwsc5gt2UJy2/HcGYcZGxh7ztzGqcXgRmIbM2/bgcQZzDyGNwy3HcttAGphZmwjoOVvWx1Ii4FE4pxjufOJ0sLYxgzSYiRxsKEmdwMhLZJnHjZL9gD9IsHMlmzYcOxA7kagloP4/MJ3PPnghx/AEJPgP3zw8Z+autx55w8ffPCjArcWdHAYTB4gWj0Q1JGieBSMglEwCkYIAAB9rV5L/F053AAAAABJRU5ErkJggg==","orcid":"","institution":"Tinpswalo Research Association to Fight AIDS and TB","correspondingAuthor":true,"prefix":"","firstName":"Dulce","middleName":"","lastName":"Osório","suffix":""},{"id":591986486,"identity":"db52a910-ddf8-4662-ac05-70a53a85407f","order_by":1,"name":"Miguel Osório","email":"","orcid":"","institution":"Frontline AIDS","correspondingAuthor":false,"prefix":"","firstName":"Miguel","middleName":"","lastName":"Osório","suffix":""},{"id":591986499,"identity":"839ed6c3-9ceb-4da6-804c-47a065038e26","order_by":2,"name":"Edy Nacarapa","email":"","orcid":"","institution":"Tinpswalo Research Association to Fight AIDS and TB","correspondingAuthor":false,"prefix":"","firstName":"Edy","middleName":"","lastName":"Nacarapa","suffix":""},{"id":591986503,"identity":"06a36d58-db45-4b34-bdf7-816bf8d773af","order_by":3,"name":"Zuana Cossa","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Zuana","middleName":"","lastName":"Cossa","suffix":""},{"id":591986509,"identity":"50cf5610-297e-475d-a3f1-30f1ab3b4783","order_by":4,"name":"Percina Machava","email":"","orcid":"","institution":"Maputo Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Percina","middleName":"","lastName":"Machava","suffix":""},{"id":591986513,"identity":"5bf0d242-eafd-43fb-bf97-67999f436c7e","order_by":5,"name":"Marta Nhamuanzo","email":"","orcid":"","institution":"The University of Sydney","correspondingAuthor":false,"prefix":"","firstName":"Marta","middleName":"","lastName":"Nhamuanzo","suffix":""},{"id":591986516,"identity":"4f307db8-2cb8-4faf-aa83-51cadae7211a","order_by":6,"name":"Lídia Sanduane","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Lídia","middleName":"","lastName":"Sanduane","suffix":""},{"id":591986519,"identity":"71798404-1bb5-44ad-8aae-d1650af4c76e","order_by":7,"name":"Herval Jesus","email":"","orcid":"","institution":"University of New South Wales (UNSW)","correspondingAuthor":false,"prefix":"","firstName":"Herval","middleName":"","lastName":"Jesus","suffix":""},{"id":591986524,"identity":"32168d0a-71f5-4349-9e49-c4999441b7a9","order_by":8,"name":"Amâncio Nhangave","email":"","orcid":"","institution":"Provincial Health Directorate","correspondingAuthor":false,"prefix":"","firstName":"Amâncio","middleName":"","lastName":"Nhangave","suffix":""},{"id":591986528,"identity":"f4b45ffb-917e-45e1-a82a-c1d8b7afa28e","order_by":9,"name":"Eden Mucache","email":"","orcid":"","institution":"Mozambican Association for Health and Environment (AMOSA)","correspondingAuthor":false,"prefix":"","firstName":"Eden","middleName":"","lastName":"Mucache","suffix":""},{"id":591986532,"identity":"4c70229e-f401-4611-a643-ae092779d19a","order_by":10,"name":"Isabelle Munyangaju","email":"","orcid":"","institution":"Tinpswalo Research Association to Fight AIDS and TB","correspondingAuthor":false,"prefix":"","firstName":"Isabelle","middleName":"","lastName":"Munyangaju","suffix":""}],"badges":[],"createdAt":"2026-02-05 13:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8797817/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8797817/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102897373,"identity":"31b2f09b-0ad3-4c22-be17-8baa11b32b26","added_by":"auto","created_at":"2026-02-18 06:56:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40343,"visible":true,"origin":"","legend":"\u003cp\u003eEquity in Access to Maternal Health Services in Mozambique\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8797817/v1/31c74cc24044f2326a28ad69.png"},{"id":102897360,"identity":"bfbdd58b-1d43-48cf-871d-e1cd119190d0","added_by":"auto","created_at":"2026-02-18 06:56:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":40489,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants responses (N = 81) regarding the barriers faced by WWD accessing sexual and reproductive services in Mozambique\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8797817/v1/1612eacafee3e7ca64c7a149.png"},{"id":103049709,"identity":"2a835587-e1f5-4666-9480-61d19446e1f3","added_by":"auto","created_at":"2026-02-20 07:45:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1040979,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8797817/v1/da44897d-bc75-44b1-bd1a-217184fb815a.pdf"},{"id":102897362,"identity":"014bcb76-e8f9-4ca6-b148-94d52fd793d7","added_by":"auto","created_at":"2026-02-18 06:56:33","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":20941,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.Questionnaireforstakeholdersconsultation.docx","url":"https://assets-eu.researchsquare.com/files/rs-8797817/v1/de1b8ba1d07585fc750a7b56.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Disability Inclusion in Maternal Health Services in Mozambique: A Mixed- Methods Analysis of Barriers Experienced by Women with Disabilities","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMaternal health, defined by the World Health Organization (WHO) as the well-being of women during pregnancy, childbirth, and the postpartum period, is fundamental to the development of healthy and productive societies. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Key indicators for assessing maternal health include reductions in maternal mortality, access to sexual and reproductive health services, and progress toward universal health coverage. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Despite substantial progress in reducing maternal mortality ratios was achieved over the past decades, globally, about 800 women die every day from preventable maternal causes, most occurring in low-income countries (LIC). [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] While maternal health challenges affect women generally in many developing countries, particularly in Sub-Saharan Africa (SSA), these challenges are more pronounced among women with disabilities (WWD), who often receive less attention in health policy and service delivery. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDisability is an important public health problem globally. According to WHO, Disability is a broad term encompassing impairments, activity limitations, and participation restrictions that arise from the interaction between an individual with a health condition and their surrounding environmental factors. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Globally, around 1.3\u0026nbsp;billion people (16% of the global population), live with disabilities, with approximately 80% of them living in LMIC. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] People with disabilities face higher mortality rates, poorer health outcomes, and greater functional limitations due to health inequities driven by factors such as stigma, discrimination, poverty, exclusion from education and employment, and systemic barriers within healthcare. [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn Mozambique, around 727,620 individuals (2.7% of the population) live with disability, nearly half of whom are women. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Despite overall health gains over time, specific groups, including women and people with disability, continue to experience significant health disparities and poorer health outcomes. Structural factors, such as the socioeconomic and political environment, along with socioeconomic status, and living conditions, are key social determinants of health that contribute to these health disparities in Mozambique. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWomen with disabilities face some of the most significant health and social inequalities, particularly in sexual and reproductive health; a domain often neglected in both policy and practice. These inequities persist across the continuum of care, from family planning and antenatal care to childbirth and postpartum services. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] As a result, WWD experience disproportionately higher maternal mortality and morbidity rates, limited access to critical health information and services, and a greater incidence of pregnancy complications, preterm births, and low birth weight infants. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] The pervasive misconception that WWD are not sexually active further exacerbates their exclusion, reinforcing systemic neglect and lack of tailored maternal health services. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Together, these inequities underscore an urgent need to address disability inclusion as a central priority in maternal health.\u003c/p\u003e \u003cp\u003eThis study, therefore, explores the intersection of maternal health and disability in Mozambique, identifying barriers to inclusive care and proposing actionable strategies to strengthen equity in service delivery.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003e This study employed a mixed-methods design encompassing desk review, stakeholders\u0026rsquo; consultation and interactive workshops to comprehensively assess the intersection of maternal health and disability in Mozambique. By integrating quantitative and qualitative approaches, the study aimed to capture both policy-level insights and lived experiences of WWD and key stakeholders.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eThree complementary data collection methods were used to collect both secondary and primary data and to validate findings across stakeholder groups:\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDesk Review\u003c/b\u003e: A comprehensive review of policy documents, national guidelines, and relevant literature on maternal health and disability in Mozambique was conducted to identify existing frameworks, gaps, and best practices. Searches were performed across Google, Google Scholar, and PubMed. Eligible documents were those published in English or Portuguese, with no time restrictions applied, and relevant to maternal health, disability inclusion, or health policy in Mozambique. Documents were screened for relevance, and duplicates or those lacking reference to maternal health or disability inclusion were excluded. Information was extracted and synthesized narratively according to predefined themes, including policy frameworks, service accessibility, and disability inclusion gaps.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eStakeholder Consultations\u003c/b\u003e: Surveys were administered to stakeholders both online and in-person to ensure participation of individuals with disabilities and those with limited access to technology. Participants were selected using purposive sampling to ensure representation from different provinces, disability types, and institutional sectors. Eligible participants included WWD, healthcare providers, policymakers, and disability advocates. A structured questionnaire was specifically developed for this study in English and Portuguese. The instrument included both closed- and open-ended questions addressing access to maternal health services, experienced barriers, and proposed solutions for improving disability inclusion. The questionnaire was piloted with a small group of stakeholders to assess clarity, relevance, and comprehensibility, and minor revisions were made accordingly. The English version of the questionnaire is provided as Supplementary File 1.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eInteractive Workshop\u003c/b\u003e: One interactive workshop, lasting approximately two hours, was conducted in Maputo, with participants joining both in person and online via zoom (hybrid section). The workshop included policymakers, health workers, WWD, and disability advocates to ensure a multi-sectoral perspective. Sessions were facilitated using participatory methods; discussions were audio-recorded and summarized into key themes by note-takers. These sessions served to validate survey findings, explore emerging themes, and collaboratively discuss solutions to improve disability inclusion in maternal health services.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eNarrative synthesis was used to integrate and summarize the findings of the desk review, grouping evidence by policy domains and thematic relevance. Quantitative survey data were entered into Microsoft Excel (Office 365, Version 2408) and analysed using descriptive statistics, including frequencies and percentages. Qualitative data from open-ended survey responses and workshop discussions were coded manually using an inductive approach to identify recurrent themes and barriers. Findings from all three components were triangulated to identify consistent patterns and to validate emerging recommendations.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003eThis study did not involve clinical interventions. The desk review relied on publicly available documents. Participation in surveys and workshops was voluntary, with informed consent obtained from participants prior to data collection. Responses were anonymized to ensure confidentiality. Ethical approval was obtained from the Institutional Bioethics Committee for Health of Gaza (Reference No. 197/CIBS-Gaza/2024). Participant responses were anonymized, and all data were stored securely with access limited to the research team.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe findings of this study are presented in two sections. Section A reports insights from the desk review, and Section B summarizes the results from stakeholder consultations and interactive workshop.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSection A: Desk review Findings\u003c/h2\u003e \u003cp\u003eThe desk review examined both peer-reviewed and Gray literature including national and international reports, policy documents and peer reviewed articles.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDisability Policies in Mozambique\u003c/h3\u003e\n\u003cp\u003eMozambique ratified the Convention on the Rights of Persons with Disabilities (CRPD) and its Optional Protocol in 2012, signalling a formal commitment to promoting and protecting the rights of persons with disabilities in line with global standards for disability rights. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Despite this progress, the national legal and policy framework continues to present significant gaps that prevent it from adequately promoting and protecting the rights of the diverse population of people with disabilities. People with disabilities face persistent barriers, including inaccessibility, limited access to information, and discriminatory practices. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] However, none of the reviewed policies explicitly address maternal health needs of WWD, reflecting a gap between general disability rights and health sector implementation. For instance, disability policies lack clear indicators or funding mechanisms for inclusive reproductive health services.\u003c/p\u003e\n\u003ch3\u003eMaternal Health in Mozambique\u003c/h3\u003e\n\u003cp\u003eMaternal health remains a major public health challenge in Mozambique, despite gradual improvements in recent decades. The Sustainable Development Goals emphasize expanding equitable access to quality healthcare and providing integrated services as key strategies for reducing maternal mortality. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Mozambique continues to report one of the highest maternal mortality rates in Sub-Saharan Africa, estimated at 223 deaths per 100,000 live births in 2023. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. No disaggregated data on maternal mortality among women with disabilities are currently available in Mozambique, making it difficult to monitor equity in maternal outcomes.\u003c/p\u003e \u003cp\u003eA significant portion of the population, approximately 32.6%, lacks access to healthcare services, highlighting the overall difficulty in accessing maternal healthcare. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Evidence shows that the access and utilisation of maternal health services is significantly lower among women who are poor, live in rural areas or less empowered. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] For WWD, challenges in accessing maternal health services are even greater compared to the general population. Public maternal healthcare services are generally under-resourced and poorly equipped to address the specific needs of WWD. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to Healthcare Access for Women with Disabilities\u003c/h2\u003e \u003cp\u003eWomen with disability often encounter multiple and intersecting barriers that hinder their access to essential maternal health services, including structural, financial, and attitudinal barriers.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eStructural Barriers\u003c/b\u003e: The healthcare infrastructure in Mozambique is not adequately equipped to serve the needs of WWD. A 2023 analysis revealed that health facilities are physically inaccessible, lacking necessary features such as ramps, adequately sized bathrooms, and specialized equipment designed to meet the needs of physically disabled individuals. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] This issue is pronounced in maternal health services, where antenatal and perinatal care are often out of reach for WWD due to shortage of appropriate resources including delivery beds that can accommodate women with physical disabilities or shorter stature. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Additionally, crucial information regarding sexual and reproductive health, family planning, and rights remain inaccessible to women with visual, hearing, intellectual, or other disabilities, who require alternative communication methods to fully understand and utilize these services. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFinancial Barriers\u003c/b\u003e: Financial constraints represent a substantial obstacle for people with disabilities. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] The economic burden associated with disability often includes additional costs for medical care, assistive devices, transportation, and other necessities, which can strain limited financial resources. In Mozambique, where poverty is widespread, these financial challenges are exacerbated for people with disabilities, who already face reduced earning potential due to systemic discrimination in employment and education. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Furthermore, health facilities are often located at long distances from communities, leading to additional transportation costs, which further limit access for WWD. Women with disabilities face even fewer employment opportunities compared to women without disabilities, intensifying their financial vulnerability and reducing their ability to afford necessary healthcare services. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eAttitudinal and Communication Barriers\u003c/b\u003e: Stigmatization and discriminatory behaviour from some healthcare professionals are common experiences for WWD in Mozambique. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Additionally, women with visual and hearing impairments encounter communication barriers due to the lack of sign language interpreters and alternative communication methods such as materials in Braille or easy-to-read formats of. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThese barriers compound across the continuum of maternal care, from antenatal visits to delivery and postnatal follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSection B: Stakeholders\u0026rsquo; consultation and Workshop\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eParticipant Characteristics\u003c/h2\u003e \u003cp\u003eA total of 81 stakeholders participated in the survey, representing diverse regions across the country, with the highest proportion (44%, n\u0026thinsp;=\u0026thinsp;36) from Maputo City. Participants included public healthcare workers (40%, n\u0026thinsp;=\u0026thinsp;32), policymakers (6%, n\u0026thinsp;=\u0026thinsp;5), non-governmental organization representatives (37%, n\u0026thinsp;=\u0026thinsp;30), and people with disabilities (17%, n\u0026thinsp;=\u0026thinsp;14). The majority (90%) reported five or more years of experience working with women or in maternal health.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePerceptions of Maternal Health Services\u003c/h2\u003e \u003cp\u003eOf 81 respondents, 57% rated maternal health services as unsatisfactory or very unsatisfactory. With regard to equity accessing maternal healthcare for WWD, 63% of participants described it as rarely equitable or not equitable (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Additionally, two in five respondents (40%) reported that maternal health services fail to meet the specific needs of WWD at all, while 33% indicated that they only partially meet these needs. Furthermore, approximately 80% of participants reported that healthcare providers are not adequately trained to address the needs of WWD.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eBarriers and Challenges to Maternal Health Services\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the key barriers identified by participants, grouped into four main categories (structural, financial, attitudinal and communication barriers) along with their relative frequency based on survey responses. Structural barriers, including inaccessible buildings, lack of adapted delivery beds, and absence of ramps or accessible bathrooms, were the most frequently cited, reported by 84% of respondents. Financial barriers, such as transportation costs and inability to pay for assistive devices or consultations, were reported by approximately 33% participants. Attitudinal and communication barriers, including discriminatory behaviours and lack of sign-language or Braille materials, were mentioned by 62% and 82% of participants respectively. Together, these findings reveal that barriers to maternal healthcare for WWD in Mozambique are multidimensional and mutually reinforcing.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBarriers to maternal health services for women with disabilities, grouped by category and frequency of reporting\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpecific Barriers Identified\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% of Participants Reporting (N\u0026thinsp;=\u0026thinsp;81)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIllustrative Quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStructural/physical Barriers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of ramps and accessible toilets; narrow doorways; non-adjustable delivery beds; absence of adapted equipment.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84%\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;The main challenges are distance, the lack of ramps in some health facilities, and beds that are not appropriate for women with physical disabilities.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;lack of accessibility for people with disabilities\u0026mdash;for example, as a person with short stature, I cannot get onto the beds and there is no assistance to help me. There is a lack of ramps, inappropriate showers...\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFinancial Barriers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCost of transport to health facilities; absence of disability-friendly transport; out-of-pocket payments for services or assistive devices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41%\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;The lack of transportation, such as ambulances, and in some cases the long distances to the health facility.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;Extreme poverty.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAttitudinal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscriminatory behaviours and stigmatizing assumptions about WWD. Many participants described negative experiences, including health workers questioning the legitimacy of WWD\u0026rsquo;s pregnancies, lack of privacy, judgmental treatment, and in some cases, obstetric violence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62%\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;There is judgment because of our disability and discrimination. People need to get it out of their heads that a woman with a disability cannot have sex and have children.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026ldquo;The maternity ward has no privacy. I always have to bring a companion to the health facility, which is uncomfortable because I do not speak freely and sometimes have personal concerns.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommunication Barriers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsence of sign-language interpreters; lack of materials in Braille or easy-to-read formats\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;Lack of communication (absence of professionals who can communicate in sign language, lack of communication in Hebraic).\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMore than 80% of participants cited physical and communication barriers as critical obstacles (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePolicy Awareness and Gaps\u003c/h2\u003e \u003cp\u003eWhen asked about existing policies or programs addressing WWD, only 35% of participants were aware of such initiatives, most often citing the National Action Plan for Disability and the Strategy for People with Disabilities in Public Services. Among those aware of existing frameworks, 42% considered them ineffective or insufficient in improving maternal health service accessibility for WWD.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWomen with disability face significant challenges accessing maternal health services, particularly in settings where health systems are already under strain. This study examined the intersection of maternal health and disability in Mozambique, a country where maternal mortality remains among the highest in SSA and where WWD are particularly underserved. Despite Mozambique\u0026rsquo;s formal commitments to disability rights through ratification of the CRPD in 2012, findings from the desk review, stakeholder consultations and workshop reveal a profound gap between policy intent and implementation. WWD continue to experience inequitable access to maternal health services due to inaccessible infrastructure, financial constraints, communication challenges, and stigmatizing provider attitudes. These barriers occur within an already strained health system, reflecting the structural and systemic nature of exclusion.\u003c/p\u003e \u003cp\u003eThe barriers identified in this study align with evidence from other SSA contexts, where WWD consistently report profound difficulties accessing and utilising maternity services including antenatal care, facility delivery and post-natal care. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Previous studies have consistently reported that visually impaired women struggle with inaccessible information and facility design, while women with hearing impairments face major communication challenges due to the absence of sign-language interpreters or adapted materials. Physically disabled women encounter facilities without ramps, small consultation rooms, and non-adjustable beds. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] These obstacles mirror those identified in Mozambique, suggesting that such barriers are systemic across the region rather than context specific.\u003c/p\u003e \u003cp\u003eNegative and discriminatory attitudes from healthcare providers emerged as one of the most pervasive barriers in this study. Participants described being judged or questioned about their right to motherhood. These findings are consistent with global evidence and studies from SSA showing that stigma and negative provider attitudes are major deterrents to equitable maternal health for WWD. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Further supporting discriminatory attitudes from health workers, a study in Ghana found that some health professionals had negative perceptions questioning the need of WWD getting pregnant and maintaining it. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Stigma and implicit bias in provider\u0026ndash;patient interactions undermine not only access but also the quality of care and trust in the health system. Nearly four in five stakeholders in our consultations stated that healthcare workers were not adequately trained to address the specific needs of WWD, a pattern consistent with findings across SSA. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] These attitudes, rooted in social stigma and lack of professional training, highlight the urgent need for institutional reforms to embed disability inclusion within all levels of health-worker education.\u003c/p\u003e \u003cp\u003eThese barriers are not only inconveniences; they represent a fundamental weakness of the healthcare system to recognize and address the diverse needs of WWD. Evidence consistently shows that WWD face elevated risks of adverse maternal outcomes, underscoring the need for care that is not only accessible but also inclusive and responsive to their specific needs. [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] The pervasive nature of these challenges across the region suggests a broader systemic problem, in which healthcare infrastructure, policies, and practices have not evolved sufficiently to accommodate all individuals. This lack of inclusivity perpetuates health disparities and social inequalities, highlighting the urgent need for comprehensive reforms that prioritize accessibility, equity, and quality of care for vulnerable populations.\u003c/p\u003e \u003cp\u003eAlthough Mozambique has adopted policies such as the National Action Plan for Disability and the Strategy for People with Disabilities in Public Services, their impact remains limited. Participants in this study perceived these frameworks as largely symbolic, with insufficient enforcement, monitoring, and funding. Weak coordination between disability and maternal-health programs, poor dissemination of guidelines, and the absence of accountability mechanisms contribute to implementation failure, a problem similarly reported by policymakers in earlier analyses of women\u0026rsquo;s health programs in Mozambique. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] These challenges mirror broader structural issues in SSA, where ambitious health policies often falter during implementation due to resource constraints, limited local ownership, and workforce shortages [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Collectively, these findings suggest that without stronger accountability mechanisms, sustained investments, and disability-sensitive training for healthcare workers, policy commitments will remain largely symbolic, with limited impact on equitable access to maternal health services for WWD.\u003c/p\u003e \u003cp\u003eApplying the WHO Health Systems Building Blocks lens [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], the barriers identified span multiple domains. Service delivery remains constrained by the absence of ramps, adapted delivery beds, and disability-friendly toilets. Health workforce gaps include inadequate pre-service and in-service training on disability inclusion, lack of sign-language skills, and minimal sensitivity to gender and disability rights. Health information systems do not disaggregate data by disability, preventing effective monitoring of outcomes and policy progress. Governance and leadership remain weak, with limited accountability and coordination across sectors. Addressing these deficiencies requires cross-cutting reforms that combine infrastructure investment, training, inclusive policy enforcement, and strong community partnerships.\u003c/p\u003e \u003cp\u003eEngaging disability associations and community health workers could help to strengthen outreach, reduce stigma, and facilitate patient feedback mechanisms. Community-based initiatives, including participatory audits of facility accessibility, have proven effective in other settings and could be adapted for Mozambique. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] Moreover, integrating disability indicators into national health-information systems would enable systematic monitoring of service access and maternal outcomes for WWD, closing the current data gap.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study provides novel insights by integrating policy analysis with first-hand perspectives from WWD, healthcare providers, and policymakers, offering a comprehensive assessment of disability inclusion gaps in maternal health. A key strength of the study is its mixed-methods design, which triangulates evidence from policy review, quantitative survey\u0026rsquo;s findings, and qualitative insights from key stakeholders across multiple regions of the country. This methodological triangulation enhanced the depth and validity of the findings by capturing both documentary evidence and lived experiences. Importantly, the inclusion of WWD as active participants added essential lived perspectives that are often overlooked in maternal-health research.\u003c/p\u003e \u003cp\u003eDespite these strengths, several limitations must be acknowledged. First, there is lack data on maternal health and disability in Mozambique, with the existing literature primarily focusing on general maternal health indicators or disability rights but rarely examining the specific challenges faced by WWD in accessing maternal healthcare. Second, the small and non-random sample of the survey limits generalizability, and reliance on self-reported perceptions may introduce recall or social-desirability bias. Additionally, data collection was conducted during a period of socio-political unrest, which may have constrained participation from some regions. Despite these challenges, triangulation across data sources enhanced the validity of findings and ensured that key themes were consistently observed across stakeholder groups providing valuable evidence in an underexplored topic and offering important insights to inform future research, policy development, and programmatic efforts to strengthen inclusive maternal health services for WWD in Mozambique.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Policy and Practice\u003c/h2\u003e \u003cp\u003eThe findings of this study highlight critical opportunities to strengthen disability inclusion within Mozambique\u0026rsquo;s maternal health system. Addressing barriers to accessibility, provider training, and policy implementation is essential to align national commitments with service delivery. Progress in these areas would contribute to national maternal health goals and advance the Sustainable Development Goals, particularly Goal 3 (health and well-being) and Goal 10 (reduced inequalities). [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSeveral key areas of actions are recommended based on the findings of this study in order to enhance accessibility and inclusiveness of maternal health services for WWD:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eInfrastructure and Equipment\u003c/b\u003e: Adapt health facilities by constructing ramps, accessible bathrooms, and appropriately designed consultation rooms; ensure the availability of adjustable examination tables, assistive devices, and clear signage to improve physical accessibility.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eTraining for Healthcare Professionals\u003c/b\u003e: Integrate disability content into pre- and in-service curricula; provide continuous training in sign language, inclusive communication, respectful care, and the rights of WWD to address stigma and attitudinal barriers.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eInclusive Policies and Programs\u003c/b\u003e: Develop or revise maternal health policies to explicitly address disability inclusion; establish robust monitoring and evaluation frameworks; and create mechanisms for WWD to participate meaningfully in policy development and feedback processes.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eCommunity Engagement and Awareness\u003c/b\u003e: Strengthen community outreach and public campaigns to reduce stigma, raise awareness of the rights of WWD, and involve community and religious leaders in promoting inclusive maternal health practices.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFinancial Support and Resource Allocation\u003c/b\u003e: Allocate dedicated budgets for infrastructure adaptation and capacity building; provide financial incentives or support mechanisms to reduce economic barriers; and foster partnerships with NGOs and disability associations to scale up implementation efforts.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eData monitoring\u003c/b\u003e: integrating disability indicators into national health-information systems would enable systematic monitoring of service access and maternal outcomes for WWD, closing the current data gap.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eCollectively, these measures would help ensure that maternal health services become more inclusive, equitable, and responsive to the needs of WWD, aligning practice with policy commitments and leaving no woman behind in accessing essential sexual and reproductive health services.\u003c/p\u003e \u003cp\u003eFuture research should prioritize generating disaggregated data on maternal health outcomes among WWD, as current national health statistics do not capture these disparities. Additionally, intervention-based studies are needed to evaluate the effectiveness of specific strategies such as provider training, infrastructural adaptations, and financial support mechanisms, in improving equitable access and outcomes for WWD.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eCollectively, the findings demonstrate that disability inclusion within Mozambique\u0026rsquo;s maternal-health system remains weak and uneven. The persistence of physical, attitudinal, communication and systemic barriers reveals that policy commitments have not yet translated into equitable service delivery. To advance inclusive maternal health, Mozambique must prioritize sustained investment in accessible infrastructure, disability-sensitive provider training, and integration of disability considerations into all health-sector planning and monitoring frameworks. Strengthening community engagement and accountability will be essential for transforming inclusion from policy rhetoric into lived reality. Achieving these reforms would contribute directly to the realization of the CRPD and the Sustainable Development Goals, ensuring that no woman is left behind in the pursuit of maternal health equity.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Institutional Bioethics Committee for Health of Gaza (Reference No. 197/CIBS-Gaza/2024). Informed consent was obtained from all participants prior to their participation in the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e \u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis study was supported by a small grant from the Australia Awards Africa program attributed to the first author, linked to her Master of Global Health and Infectious Diseases Intelligence at the University of New South Wales, Sydney. The small grant aimed to support student\u0026rsquo;s academic projects to enhance the On-Award experience. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualisation: D.O; Funding Acquisition: D.O; Investigation: D.O, M.O and I.M; Data collection and stakeholder engagement D.O, M.O, E.N, E.M and I.M; Formal analysis: D.O; Visualisation: D.O; Writing \u0026ndash; original draft preparation: D.O., M.O, E.N and I.M; Writing \u0026ndash; review and editing: D.O, M.O, I.M, EN, Z.C, P.M, M.N, L.S, H.J, A.N, E.M. All authors provided intellectual input during data interpretation and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank the women with disabilities who generously shared their experiences and perspectives for this study. We also acknowledge the contributions of healthcare providers and policymakers who participated in the consultation surveys, and the stakeholder workshop. We are grateful to the Mozambican Association of Women with Disabilities for their support with community engagement and recruitment. We also acknowledge the Ministry of Health of Mozambique for their institutional support and collaboration. We thank colleagues at the University of New South Wales for academic guidance and technical support throughout the study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDe-identified data underlying the findings are available from the corresponding author upon reasonable request. Relevant policy documents analysed in this study are publicly available and can be accessed through the references provided.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (WHO). Maternal Health 2024 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/health-topics/maternal-health#tab=tab_1\u003c/span\u003e\u003cspan address=\"https://www.who.int/health-topics/maternal-health#tab=tab_1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization (WHO). Maternal Mortality 2024 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/maternal-mortality\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/maternal-mortality\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLong-Bellil L, Valentine A, Mitra M. 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Using the World Health Organization health system building blocks through survey of healthcare professionals to determine the performance of public healthcare facilities. Archives Public Health. 2017;75(1):50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization (WHO). Good practices on disability-inclusive health: The WHO European framework to achieve the highest attainable standard of health for people with disabilities. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuper H, Gatta DR, Rotenberg S, Banks LM, Smythe T, Heydt P. Building disability-inclusive health systems. Lancet Public Health. 2024;9(5):e316\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIndicators S. Global indicator framework for the Sustainable Development Goals and targets of the 2030 Agenda for Sustainable Development. URL: https://unstats un \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eorg/sdgs/indicators/indicators-list/(дата обращения\u003c/span\u003e\u003cspan address=\"http://org/sdgs/indicators/indicators-list/(дата обращения\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e: 2002 2023). 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstitute for Health Metrics and Evaluation (IHME). Health-related SDGs 2023 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.healthdata.org/data-tools-practices/interactive-visuals/health-related-sdgs\u003c/span\u003e\u003cspan address=\"https://www.healthdata.org/data-tools-practices/interactive-visuals/health-related-sdgs\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"maternal health, women with disabilities, Mozambique, health equity, inclusion","lastPublishedDoi":"10.21203/rs.3.rs-8797817/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8797817/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn Sub-Saharan Africa, maternal health remains a significant public health challenge, and women with disabilities (WWD) experience profound inequities in access to essential healthcare services. In Mozambique, although national strategies promote disability inclusion, systemic and structural barriers continue to undermine equitable access to maternal health services. This study explores the intersection of maternal health and disability inclusion in Mozambique, identifying barriers faced by WWD and opportunities to improve service accessibility and quality.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods design was employed, integrating a desk review with stakeholder consultations and interactive workshops. The desk review examined national policies and relevant literature on maternal health and disability inclusion. Stakeholder consultations were conducted via surveys across multiple regions, engaging women WWD, healthcare providers, policymakers, and disability advocates. Key findings were validated and refined through participatory workshops involving diverse stakeholders. Quantitative data were analysed descriptively, while qualitative responses were thematically analysed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study found that WWD face multifaceted barriers to maternal health, including inaccessible infrastructure, lack of adapted medical equipment, financial constraints, inadequate provider training, communication gaps and stigmatizing attitudes. Among 81 surveyed participants, over 80% reported physical and communication barriers as major obstacles, while 65% reported inadequate medical equipment. Although some participants noted the existence of policies such as the National Action Plan for Disability and the Strategy for People with Disabilities in Public Services, their implementation was widely perceived as ineffective or insufficient in improving maternal health service accessibility for WWD.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDisability inclusion within Mozambique\u0026rsquo;s maternal health system remains limited, with policy commitments insufficiently translated into practice. Achieving equitable and inclusive maternal healthcare for WWD in Mozambique requires sustained investment in accessible infrastructure, provider training, community engagement, and effective accountability mechanisms. Addressing these systemic barriers is critical to improving maternal health outcomes and advancing health equity for all women in Mozambique.\u003c/p\u003e","manuscriptTitle":"Disability Inclusion in Maternal Health Services in Mozambique: A Mixed- Methods Analysis of Barriers Experienced by Women with Disabilities","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 06:55:04","doi":"10.21203/rs.3.rs-8797817/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-06T23:37:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-31T11:22:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-20T18:57:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-06T13:53:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"92199813754796515659597149255657295890","date":"2026-02-23T09:21:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32903029082162859370011200246159319832","date":"2026-02-21T15:35:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62231072341796786560077667127972601373","date":"2026-02-21T11:02:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16083617852399696925343963777539148014","date":"2026-02-15T19:39:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-13T11:35:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-13T11:27:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-12T11:10:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-12T11:06:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-02-12T10:53:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f2ba4da7-f429-437d-b77a-31df2b1051e3","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T12:23:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 06:55:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8797817","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8797817","identity":"rs-8797817","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}