DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2020 No. 166

Waqas Hameed

Muhammad Asim

July 2020

This document was produced for review by the United States Agency for

International Development.

Inequalities in Utilization of Essential Antenatal Services

for Women with Disabilities:

An Analysis of the 2017-18 Pakistan

Demographic and Health Survey

DHS Working Paper No. 166 

Inequalities in Utilization of Essential Antenatal Services 

for Women with Disabilities:

An Analysis of the 2017-18 Pakistan 

Demographic and Health Survey 

Waqas Hameed1

Muhammad Asim1

ICF 

Rockville, Maryland, USA 

July 2020 

1

 Department of Community Health Sciences, Aga Khan University, Pakistan 

Corresponding author: Waqas Hameed, Department of Community Health Sciences, Aga Khan 

University Hospital, National Stadium Road, Postal Code 74800, Karachi, Sindh; phone: (+92 21) 3486 

4919; fax: (+92 21) 34934294, 3493-2095; email: waqas.hameed@aku.edu
Acknowledgments: The authors wish to thank Shireen Assaf as mentor and Christina Juan as a co-mentor 

of the 2020 DHS Fellows Program for their technical support. The authors would also like to thank Sarah 

Saleem from the Aga Khan University, Pakistan, and Bilal Iqbal Avan from the London School of Hygiene 

and Tropical Medicine, United Kingdom, for helping us conceptualize the study and providing insights on 

the analysis and intellectual review of the report. We are thankful to United States Agency for International 

Development for funding our research through the DHS Fellows Program, which is implemented by ICF. 

Lastly, we express our gratitude to our reviewer Courtney Allen for her valuable insights, and thanks to the 

editor and formatter who supported us in finalizing the report. 

Editor: Diane Stoy 

Document Production: Joan Wardell 

This study was implemented with support from the United States Agency for International Development 

(USAID) through The Demographic Health Survey (DHS) Program (#720-OAA-18C-00083). The views 

expressed are those of the authors and do not necessarily reflect the views of USAID or the United States 

Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. For additional information about The DHS Program contact: 

DHS Program, ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA; phone: +1 301-572-0950; 

fax: +1 301-572-0999; fax: +1 301-407-6501; email: reports@dhsprogram.com; Internet: 

www.dhsprogram.com. 

Recommended citation: 

Hameed, Waqas, and Muhammad Asim. 2020. Inequalities in Utilization of Essential Antenatal Services 

for Women with Disabilities in Pakistan. DHS Working Paper No. 166. Rockville, Maryland, USA: ICF. 
iii 

CONTENTS 

TABLES .................................................................................................................................................. v 

FIGURES .............................................................................................................................................. vii 

ABSTRACT ........................................................................................................................................... ix 

1 INTRODUCTION ........................................................................................................................ 1

Background ................................................................................................................................ 1 

Country Context ......................................................................................................................... 2 

Research Questions ................................................................................................................... 3 

Conceptual Framework .............................................................................................................. 3 

2 DATA AND METHODS ............................................................................................................. 5

Data ...................................................................................................................................... 5 

Sample Derivation ...................................................................................................................... 5 

Variables .................................................................................................................................... 5 

Statistical Analysis ..................................................................................................................... 8 

3 RESULTS .................................................................................................................................. 9

Characteristics of Study Population ........................................................................................... 9 

Status of Functional Disability .................................................................................................... 9 

Utilization of Essential Antenatal Services ............................................................................... 10 

Inequalities in Utilization of Essential ANC Services between Women with and without 

Disability ............................................................................................................................ 11

4 DISCUSSION ........................................................................................................................... 17

Strengths and Limitations ........................................................................................................ 18 

5 CONCLUSIONS ....................................................................................................................... 21

REFERENCES ...................................................................................................................................... 23

APPENDICES ....................................................................................................................................... 29

v 

TABLES 

Table 1 Key dependent and independent variables ......................................................... 7 

Table 2 Sociodemographic characteristics of women age 15-49 with a live birth in 

the 5 years before the survey .............................................................................. 9 

Table 3 Prevalence of functional disability among women who had a live birth in 5 

years before the survey, according to wealth status and place of residence .... 10 

Table 4 Inequalities in the uptake of essential ANC services between women with 

and without disabilities ....................................................................................... 12 

Table 5 Inequalities in the uptake of essential antenatal services between women 

with and without disabilities, according to wealth quintile and place of 

residence ........................................................................................................... 14 

Appendix Table 1 Inequalities in the uptake of antenatal components between women with 

and without disabilities, overall and according to wealth quintile and type of 

residence ........................................................................................................... 30 

Appendix Table 2 Prevalence of any disability and severe functional disability among women 

age 15-49 years with a live birth in the 5 years preceding the survey, 

according to the domains (n=6,711) .................................................................. 31 

vii 

FIGURES 

Figure 1 Conceptual framework of the association between functional disability and 

utilization of antenatal services ............................................................................ 4 

Figure 2 Prevalence of any disability and severe functional disability among women 

age 15-49 years with a live birth in the 5 years before the survey, according 

to the domains (n=6,711) ................................................................................... 10 

Figure 3 Utilization of essential ANC omponents among women age 15-49 with a 

live birth in the 5 years before the survey .......................................................... 11 

 

ix 

ABSTRACT 

Although the number of disabled women entering motherhood is growing, there is little quantitative 

evidence about the utilization of essential antenatal care services by women with disabilities. The aim of 

this study is to examine inequalities in the use of essential antenatal services between women with and 

without disabilities. 

This study analyzed data from the Pakistan Demographic and Health Survey 2017-18 on 6,791 women (age 

15-49) who had a live birth in the 5 years before the survey. Multiple logistic regression was used to test 

the study hypothesis. 

The prevalence of any disability and any severe disability was 14.4% and 2.6%, respectively. The coverage 

of antenatal care did not differ by overall disability status or subgroup analysis. The only exception was 

found among the poorest women who had any disability and who had a 50% greater chance of receiving 

antenatal care compared with the non-disabled women. With utilization of essential antenatal care 

components, consumption of iron was lower among women with disabilities, while counseling care (advice 

on exclusive breastfeeding and balanced diet) was higher among women with disabilities as compared with 

their counterparts. 

Our study did not find glaring inequalities in the utilization of antenatal care services between disabled and 

non-disabled women. This was true for urban versus rural residence and among the poor versus rich women. 

We suggest that the country’s health system, to a great extent, is responsive to the needs of disabled women 

for antenatal services. Some measures, however, should be made to improve medication compliance among 

disabled women. 

Key words: disability, antenatal care, inequalities, quality of care, effective coverage 

1 

1 INTRODUCTION 

Background 

Over a billion people across the globe have different forms of disability, with 80% living in low- and middleincome countries (LMICs) (Bickenbach 2011). Individuals with disabilities are the world’s largest minority, 

which is constantly increasing from population growth and chronic medical conditions (WHO 2018). 

Disability is a general term that includes impairments, activity limitations, and restricted participation in 

society. There is evidence that the disabled face multiple barriers when they seek health-care and 

rehabilitation services due to poverty, vulnerability, and social exclusion (WHO 2005). According to the 

United Nations, disability is “a long-term physical, intellectual, mental, or sensory impairment, which in 

interaction with various barriers, may hinder a person’s full and effective participation in society on an 

equal basis with others” (MacKay 2007). Individuals with disabilities have the same health needs as the 

non-disabled. 

Global awareness of disability-inclusive development is increasing. The pledge of “no one is left behind” 

is the core agenda of Sustainable Development Goal 3 (SDG3), which seeks to ensure healthy lives and 

promote well-being for all people at all ages (WHO 2018). The United Nations Convention on the Rights 

of Persons with Disabilities (UNCRPD) reinforces the privileges of persons with disabilities to attain the 

highest standard of health-care services without any discrimination (MacKay 2007). However, despite 

global commitments, individuals with disabilities often live in poverty and experience poor health due to 

stigma and exclusions from employment, education, and access to health-care services (Banks, Kuper, and 

Polack 2017; Bright and Kuper 2018). The number of disabled women who are entering motherhood is 

growing (Blackford, Richardson, and Grieve 2000), although their ability to engage in a sexual relationship, 

marriage, caregiving, and mothering is often questioned (Frohmader and Ortoleva 2013; Walsh-Gallagher, 

Sinclair, and McConkey 2012; WHO and UNPFA 2009). Although women with disabilities have the same 

or even greater biological and social needs and legitimate rights for sexual and reproductive education and 

care (WHO and UNPFA 2009), they face a plethora of challenges in accessing high-quality, affordable 

sexual and reproductive health services when compared with women without disabilities (Banks, Kuper, 

and Polack 2017; Bright and Kuper 2018; Rugoho and Maphosa 2017; Lawler, Lalor, and Begley 2013). 

Discriminatory care deters these women from seeking maternal care from skilled professionals (BradburyJones et al. 2015), which leads to adverse health outcomes (Hwang et al. 2009). 

The world has made substantial progress under Millennium Development Goals (MDGs) 4 and 5 to address 

maternal and child health. However, the increase in overall coverage does not translate proportionally into 

reductions in maternal and neonatal mortality (UNICEF 2019). This is primarily due to inequalities in 

service coverage and the poor quality of services (Brizuela et al. 2019). Therefore, maternal and child 

mortality and morbidity remain a major public health concern for LMICs, particularly in South Asia 

(Alkema et al. 2016). Among several interventions, high quality of antenatal care (ANC) has been shown 

to improve maternal (Nikiema et al. 2010) and child (Kuhnt and Vollmer 2017) health outcomes. Antenatal 

care provides a unique opportunity for birth preparedness by promoting healthy practices among pregnant 

women, improving nutrition, and preparing women mentally, physically, and logistically for childbirth 

(Ekabua, Ekabua, and Njoku 2011). This care can reduce the maternal death rate by up to 20% (Nikiema et 

al. 2010). Although there has been a shift from improving the coverage of health care to improving the 
2 

quality of health care worldwide (Kruk et al. 2018), there is a dearth of literature on the quality of maternal 

care for women with disabilities (Thierry 1998; Morrison et al. 2014). 

Women with disabilities are challenged with both the structural and procedural components of care. With 

structural care, evidence shows that in most LMICs, health systems for maternal care are structured to meet 

the needs of able-bodied women, while the needs of women with disabilities are largely ignored (Devkota 

et al. 2017; The Lancet Editorial, 2011). Able-bodied women can independently access a health-care facility 

and can utilize maternity care services more efficiently than women with disabilities. The negative attitudes 

and abusive behaviors of service providers have also been identified as another challenge (WHO 2018). 

Preliminary evidence shows that individual with disabilities and their families often endure poor 

communication and challenging attitudes of health-care providers (Walsh-Gallagher, Sinclair, and Mc 

Conkey 2012). Notably, women’s experiences of maternity care vary according to the type of impairment 

(Homer and Hoope-Bender 2016; Redshaw et al. 2013), with women with multiple disabilities the least 

satisfied with the care offered to them (Redshaw et al. 2013). Deeply rooted discriminatory attitudes and 

practices, as well as the lack of laws and policy enforcement, continue to violate the legitimate rights of 

people with disabilities (Ortoleva and Lewis 2012; Lipson 2000; Prilleltensky 2003). In addition, healthcare professionals may lack the knowledge and skills they need to provide care to pregnant women with 

disabilities (Lipson 2000). The international community has emphasized disability-inclusive health services 

by strengthening health systems to recognize and accommodate the needs of those with disabilities 

(Khasnabis et al. 2010; Krahn, Walker, and Correa-De-Araujo 2015). To improve health outcomes for all 

women and children, there is a need to organize and deliver services that are technically appropriate, 

culturally acceptable, socially sensitive, and equitably distributed to all women with and without 

disabilities. 

Country Context 

With a population of 207 million (Pakistan Bureau of Statistics 2017), Pakistan failed to achieve optimal 

targets to reduce maternal and child mortality that were pledged under MDGs 4 and 5 by the United Nations 

(Victora et al. 2016). The country has one of the highest rates of maternal mortality in the world (NIPS and 

Macro International 2008), and is ranked unsafe for the survival of newborns (You et al. 2015). There are 

stark inequalities in maternal, reproductive, and child health indicators, and the situation among women 

who are uneducated, belong to the poorest wealth quintile, and live in rural areas is far worse (Barros et al. 

2012; NIPS 2018). The country is among the top 10 countries where health-care interventions are the most 

inequitable (Barros et al. 2012). Although 15% of childbearing women in Pakistan suffer from some 

disability (NIPS 2018), there is a dearth of literature on the challenges faced by these disabled women. 

High-quality ANC is essential to improve maternal and child health. Although the general coverage of ANC 

from a skilled professional is quite high (86.2%) in Pakistan, most often all aspects of essential antenatal 

care are not included in the care provided to the pregnant women (NIPS 2018; Tappis et al. 2015; Hameed 

and Avan 2018). 

We hypothesize that the utilization of essential ANC services will be lower among women with disabilities 

as compared with non-disabled women, and that this may lead to undesirable, adverse health outcomes for 

mothers and newborns. After considering the global movement on disability-inclusive health-care services 

and the scarce evidence worldwide and in Pakistan, we conducted a secondary analysis of the most recent 

nationwide Demographic Health Survey of Pakistan (PDHS). Our purpose is to inform a better 
3 

understanding of the inequalities in the use of essential ANC services between women with and without 

disability, and the potential drivers of these inequalities. 

Research Questions 

This study attempts to answer the following research questions: 

1. What are the levels of inequalities in the use of essential ANC services between women with and 

without disabilities, and by the type of disability? 

2. How is the relationship between women’s disability and the utilization of essential ANC antenatal 

moderated by women’s wealth status and urban versus rural residence? 

Conceptual Framework 

Our conceptual framework reflects our objective to assess the association between functional disabilities 

and utilization of essential ANC services. We used multiple outcomes related to ANC such as: coverage as 

either a) received ANC and b) 4 or more ANC visits; and components as a) received tetanus toxoid 

injections, b) took iron tablets or syrup, c) had blood pressure measured, d) had urine sample taken, e) had 

blood sample taken, f) received advice on early initiation of breastfeeding, g) advised about exclusive 

breastfeeding, and h) advised about maintaining balanced diet. The measures of disability included a) any 

severe disability in one or more domain, and b) any disability in one or more domain such as any disability 

in vision, cognition, walking, hearing, communication, or self-care. These associations were also assessed 

by place of residence and household wealth status to test if the disability-ANC relationship differs by 

residence and socioeconomic status. Several pertinent covariates that were considered included age, 

primigravida (women having first pregnancy), education, place of residence, and wealth quintile. 
4 

Figure 1 Conceptual framework of the association between functional disability and utilization of 

antenatal services 
5 

2 DATA AND METHODS 

Data 

This study employed publicly available data from the most recent PDHS collected in 2017-18. With a 

stratified two-stage sample design, the survey obtained information from a nationally representative sample 

of the population of Pakistan (NIPS 2018). A total of 16 urban-rural strata for each of the eight regions were 

created, followed by a two-stage independent selection process. At the first stage, 580 clusters (enumeration 

blocks) were selected by using probability proportional to the number of households in each cluster. At the 

second, a fixed 28 households per cluster (16,240 in total) were selected systematically with an equal 

probability of selection. 

Sample Derivation 

A total of 15,068 ever-married women age 15-49 were interviewed in the survey. However, we reduced our 

sample to two levels in accordance with our study objectives and sample representativeness. At the first 

stage, women who resided in the Gilgit Baltistan (n=984) and Azad Jammu and Kashmir (n=1,720) regions 

were excluded because these two regions used a separate sampling procedure and a separate weight, and 

could not be combined with the other regions (NIPS 2018). At the second stage, we excluded women 

(n=5,561) who did not have a live birth in the 5 years before the survey. Consequently, we performed our 

analysis on an unweighted sample of 6,803 women (weighted sample 6,711). Information about ANC was 

only collected and analyzed for the most recent birth. 

Variables 

We created several independent (exposure) and dependent (outcome) variables for disability and utilization 

of ANC, respectively. The following section describes the construction of these variables. 

Dependent variables 

The utilization of essential ANC services for the most recent birth was the outcome variable for this study. 

The construction of outcome variables was guided by the World Health Organization’s Integrated 

Management of Pregnancy and Childbirth guidelines, which detail the essential maternal health services 

that should be provided to women (WHO 2015). For maternal health-care-seeking, we used two measures: 

(i) received ANC and (ii) completed four or more ANC visits. We also created an overall measure to 

ascertain if the women received all the essential components of ANC (WHO 2015). These components were 

classified as: (I) Counseling as (a) received advice on early initiation of breastfeeding, (b) received advice 

on exclusive breastfeeding, and (c) received advice on maintaining a balanced diet during pregnancy; (II) 

Examination as (a) blood pressure measurement, (b) blood test, and (c) urine test; and (III) Treatment as (a) 

received two or more tetanus toxoid injections during pregnancy, and (b) took iron tablets or syrup. For the 

overall measure of utilization of essential components of ANC, women were coded with a ‘1’ if they had 

received all eight essential ANC components and ‘0’ otherwise. Finally, each component was included as a 

separate variable in the analysis. 
6 

Independent variables 

A standard disability module was administered for collecting information on the six core functional domains 

of disability that included seeing, hearing, communication, cognition, walking, and self-care. This 

questionnaire about disability was originally developed by the Washington Group on Disability (Madans, 

Loeb, and Altman 2011). The module was based on the framework of the World Health Organization’s 

International Classification of Functioning, Disability, and Health. The response to each question was 

classified as 0=no difficulty, 1=some difficulty, 2=a lot of difficulty, or 3=cannot function at all in the 

specified domain. 

We created two separate measures for the overall status of disability, as well as for each of the six domains 

of functional disability. The two measures were classified as women with any disability and women with 

severe disability. For the overall measure of any disability, we created a dichotomous variable with women 

coded as ‘1’ if they reported at least ‘some difficulty’ for one or more domains of disability, and ‘0’ for ‘no 

difficulty’ in all six domains. Six separate measures were created for each of the six domains of disability 

with women coded as ‘1’ if they reported at least ‘some difficulty’ in that respective domain and ‘0’ 

otherwise. 

In addition, we created separate measures for women with severe disability. For any severe disability,

women who reported experiencing ‘a lot of difficulty’ or ‘cannot function at all’ in one or more domains of 

disability were given a code of ‘1’ and ‘0’ otherwise. Using a similar strategy, we created six separate 

measures of severe disability with women coded as ‘1’ if they reported ‘a lot of difficulty’ or ‘cannot 

function at all’ in the respective domain and ‘0’ otherwise. 

 
7 

Table 1 Key dependent and independent variables

Variable Definition 

Key dependent variables 

Received antenatal care 

(ANC) 

Percentage of women utilized ANC from a skilled provider for the most recent pregnancy 

Codes:

0 = No ANC from skilled provider; 1 = received ANC 

Four or more ANC visits 

Percentage of women with four or more ANC visits for their most recent pregnancy 

Codes:

0 = Fewer than 4 visits; 1 = Four or more visits 

Key independent variables 

Any disability 

The variables combined women's responses to the following question: 

1) Do you have any difficulty in seeing? 

2) Do you have any difficulty in hearing? 

3) Do you have any difficulty in communicating? 

4) Do you have any difficulty in remembering or concentrating? 

5) Do you have any difficulty in walking or climbing stairs? 

6) Do you have any difficulty in washing all over or dressing? 

Possible responses: 0=no difficulty; 1=some difficulty; 2=a lot of difficulty; 3=cannot function at all 

Codes:

Women were coded as ‘1’ if they reported at least ‘some difficulty’ for one or more domains of disability, 

and ‘0’ for ‘no difficulty’ 

Any severe disability 

The variables combined women's responses to the following question: 

1) Do you have any difficulty in seeing? 

2) Do you have any difficulty in hearing? 

3) Do you have any difficulty in communicating? 

4) Do you have any difficulty in remembering or concentrating? 

5) Do you have any difficulty in walking or climbing stairs? 

6) Do you have any difficulty in washing all over or dressing? 

Possible responses: 0=no difficulty; 1=some difficulty; 2=a lot of difficulty; 3=cannot function at all 

Codes:

If the women responded 'a lot of difficulty' or 'cannot function at all' on one or more domains, they were 

coded as '1' otherwise '0' 

Any disability in vision 

Percentage of women reported at least some level of difficulty in seeing 

Possible responses: 0=no difficulty; 1=some difficulty; 2=a lot of difficulty; 3=cannot function at all 

Codes:

If the women responded at least 'some difficulty' in vision, they were coded as '1' otherwise '0' 

Any disability in cognition 

Percentage of women reported at least some level of difficulty in remembering or concentrating 

Possible responses: 0=no difficulty; 1=some difficulty; 2=a lot of difficulty; 3=cannot function at all 

Codes:

If the women responded at least 'some difficulty' in cognition, they were coded as '1' otherwise '0' 

Any disability in walking 

Percentage of women reported at least some level of difficulty in walking or climbing stairs 

Possible responses: 0=no difficulty; 1=some difficulty; 2=a lot of difficulty; 3=cannot function at all 

Codes:

If the women responded at least 'some difficulty' in walking, they were coded as '1' otherwise '0' 

Covariates 

We included a range of covariates in our analysis that had the potential to be confounders. These included 

women’s age in three distinct categories (age 15–24, 25–34, and 35–49), place of residence (urban/rural), 

women’s education (no formal education/any formal education), women with first pregnancy–primigravida 

(yes/no), and wealth quintile (poorest, poorer, middle, richer, richest). The wealth index was computed by 

the DHS Program with principal component analysis (Rutstein and Johnson 2004). 
8 

Effect modifiers 

To develop a deeper understanding of the relationship between the status of functional disability and ANC, 

we performed subgroup analysis by wealth status and place of residence, and assessed if the disability-ANC 

relationship differed by place of residence and socioeconomic status. The wealth quintile variable was 

dichotomized with women belonging to ‘poorest’ or ‘poorer’ quintiles grouped and coded as ‘0’, and the 

‘richer’ and richest’ grouped and coded as ‘1’. The category of ‘middle’ was left blank and these women 

were excluded from the poor-rich subgroup analysis. 

Statistical Analysis 

We performed the statistical analyses in different phases: descriptive, bivariate, and multivariate analysis. 

Descriptive analysis was used to describe the sociodemographic characteristics of the sample by means, 

standard deviation, frequencies, and percentages. We estimated the prevalence (95% CIs) of overall 

disability and for each of the six domains of functional disability, and the percentage (95% CIs) utilization 

of each essential ANC component. Next, we used Pearson’s chi-square to test if the prevalence of disability 

varied by the wealth status and place of residence. 

Second, we ran the bivariate analysis with the Pearson’s chi-square test to determine the crude association 

between utilization of ANC and the women’s disability status. 

In the third phase, we applied multivariate logistic regression to examine the relationship between each 

measure of disability and each ANC outcome in the overall sample, and then by place of residence 

(urban/rural) and wealth status (poor/rich). A series of models were fit separately on the full dataset, and 

the urban-rural and poor-rich subgroups. Finally, to ascertain the role of place of residence and wealth status 

as effect modifiers, we developed separate logistic regression models to test interactions of the disability 

measures with place of residence (urban/rural) and wealth status (poor/rich).The multivariate models also 

accounted for other covariates such as age, education, place of residence, primigravida, and wealth quintile 

to produce adjusted odds ratios. It is important to note that the prevalence of severe disability in the six 

domains was very low, as well as in the three domains of any disability (such as hearing, communication, 

and self-care). Thus, the relationship between these variables and ANC outcomes was not examined 

separately because of insufficient cell counts. 

The data were analyzed with Stata version 16.0 (StataCorp LP, College Station, TX, US). All analyses were 

adjusted for the complex survey design, strata, primary sampling units (clusters), and probability sampling 

using individual weights. P-values of <0.05 were considered significant. 
9 

3 RESULTS 

Characteristics of Study Population 

Table 2 shows the background characteristics of the 6,711 women age 15-49 who had a live birth in the 5 

years before the survey. Nearly two-thirds (66.5%) of the women lived in rural areas. The mean age of 

women was 29.6 (SD=6.4) with more than half (55.5%) between age 25-34. Approximately half (47.9%) 

of the women had no formal education, and one in five women (19.9%) was primigravida. 

Table 2 Sociodemographic characteristics of women age 15-49 with a live birth in the 5 years 

before the survey 

Characteristics n % 

Place of Residence 

Urban 2,248 33.5 

Rural 4,463 66.5 

Women's age 

15–24 1,545 23.0 

25–34 3,725 55.5 

35–49 1,440 21.5 

Mean (SD) 29.6 (6.4) 

Education 

No formal education 3,212 47.9 

Any formal education 3,499 52.1 

Primigravida 

Yes 1,337 19.9 

No 5,374 80.1 

Total 6,711 100.0 

Status of Functional Disability 

Figure 2 presents the prevalence of overall functional disability and by each domain. About 14.1% (95% 

CI 12.7–15.7) of the women had any disability (at least some level of difficulty) in one or more domains, 

while 2.6% (95% CI 2.1–3.2) had any severe disability (either have a lot of difficulty or cannot function at 

all) in at least one of the specified domains. With any disability, the most prevalent forms of functional 

disabilities were vision (7.0%, 95% CI 2.1%–3.2%), walking (4.8%, 95% CI 4.1%–5.7%), and cognition 

(4.8%, 95% CI 4.0%–5.8%), while fewer than 1% (0.7%, 95% CI 0.4%–1.0%) reported at least some 

difficulty in communicating. With any severe disability, the most commonly cited domain was walking 

disability at 1.2% (95% CI 0.8%–1.6%). The prevalence of severe disability in other domains was less than 

1%. (Please see Appendix Table 2 for actual values of 95% CI of the prevalence of disability.) 
10 

Figure 2 Prevalence of any disability and severe functional disability among women age 15-49 years with 

a live birth in the 5 years before the survey, according to the domains (n=6,711) 

A comparison of functional disability between urban and rural, and poor and rich segments of the population 

is shown in Table 3. The prevalence of functional disability does not differ significantly according to the 

place of residence or wealth status of the household. The only exception was that the women who live in 

urban areas had significantly higher prevalence (6.1%) of walking disability as compared with women 

(4.2%) living in rural areas (p-value = 0.024). 

Table 3 Prevalence of functional disability among women who had a live birth in 5 years before 

the survey, according to wealth status and place of residence 

Characteristics 

Any severe 

disability in one 

or more 

domains 

Any disability in 

one or more 

domains 

Any disability in 

vision 

Any disability in 

cognition 

Any disability in 

mobility 

Number of 

women 

Place of residence 

Urban 2.4 14.9 7.4 4.2 6.1 2,248 

Rural 2.7 13.7 6.7 5.1 4.2 4,463 

p-value 0.643 0.441 0.559 0.300 0.024 

 

Wealth Status* 

Poor 2.7 14.3 7.1 5.4 3.8 2,743 

Rich 2.1 12.9 6.1 4.2 5.2 2,597 

p-value 0.330 0.345 0.310 0.219 0.082 

Note: Wealth status excluded women who belonged to the ‘middle’ quintile. 

Utilization of Essential Antenatal Services 

Figure 3 presents ANC coverage and the receipt of essential ANC components among the sampled women. 

Nearly 9 in 10 women received any ANC and half (51.4%) completed four or more ANC visits. Three in 

five (61.2%, 95% CI 58.5%–63.8%) women reported receiving advice on maintaining a balanced diet 

during pregnancy, while fewer than half received counseling on the early initiation of breastfeeding (45.8%, 

95% CI 43.3%–48.3%) and exclusive breastfeeding (47.7%, 95% CI 45.1%–50.4%). About 41% (95% CI 

38.4%–43.6%) received counseling on all three components. With ANC visits, approximately 78.5% (95% 

CI 76.1%–80.7%) had their blood pressure checked, while urine and blood samples were taken from 

approximately three in five women. Just over half (55.5%, 95% CI 52.2%–58.7%) of the women reported 

14.1

7.0

4.8 4.8

1.8

1.0 0.7

2.6

0.8 0.6 1.2

0.3 0.3 0.1

One or more

disabilities

Vision Cognition Mobility Hearing Self-care Communication

Percentage

Any disability Severe disability
11 

receiving all three examination components. Fewer than half of the women (45.1%, 95% CI 42.5%– 47.7%) 

received the recommended doses of tetanus toxoid (TT) and consumed iron tablets or syrup during 

pregnancy. Only one in five women (21.8%, 95% CI 19.5%–24.2%) received all eight components of ANC 

during pregnancy. 

Figure 3 Utilization of essential ANC components among women age 15-49 with a live birth in the 5 years 

before the survey 

Inequalities in Utilization of Essential ANC Services between Women with 

and without Disability 

Table 4 shows the results of the overall analysis from bivariate and multivariate logistic regression analysis 

in the form of crude percentages and adjusted odds ratios. Column 2 in the table shows the percentage of 

outcomes among women with disability and non-disabled women. These models were adjusted for the 

range of covariates as described in the analysis section above. The overall measures of disability showed 

no association with the ANC coverage indicators. However, we found a positive association between 

disability status and uptake of certain ANC components. Women with any severe disability in at least one 

domain had 1.7 times the odds (AOR=1.7, 95% CI 1.0–2.8; p-value<0.05) of taking a urine test, and 1.6 

times the odds (AOR=1.6, 95% CI 1.1–2.4; p-value<0.05) of receiving advice of about exclusive 

breastfeeding as opposed to the non-disabled women. Similarly, as compared with non-disabled women, 

those women who experienced at least some level of difficulty in one or more domains had 30% (AOR=1.3, 

95% CI 1.0–1.6; p-value<0.05) greater odds of receiving advice on maintaining a balanced diet during 

pregnancy. The only exception was that women with any severe disability in one or more domain were 40% 

less likely to consume iron tablets or syrup (AOR=0.6, 95% CI 0.4–1.0). 

87.8

51.4

41.0

45.8

47.7

61.2

55.5

78.5

62.2

61.8

45.1

67.8

58.5

21.8

Received any ANC

Four or more ANC visit

Counseling (received all three)

Early initiation of breastfeeding

Exclusive breastfeeding

Balanced diet during pregnancy

Examination (received all three)

Blood pressure measured

Urine sample taken

Blood sample taken

Treatment (received both services)

Received two or more TT injections

Took iron tablets or syrup

Received all eight components of ANC

Antenatal

coverage Antenatal components
12 

Table 4 Inequalities in the uptake of essential ANC services between women with and without 

disabilities 

Variables 

Full dataset 

Disabled/nondisabled AOR (95% CI) 

ANC Coverage 

Received ANC 

Any severe disability in one or more domains 87.8 / 88.2 1.3 (0.7 - 2.6) 

Any disability in one or more domains 87.6 / 89.2 1.3 (0.9 - 1.7) 

4+ ANC visits 

Any severe disability in one or more domains 51.4 / 54.1 1.5 (0.9 - 2.4) 

Any disability in one or more domains 51.7 / 46.9 1.0 (0.8 - 1.2) 

Treatment 

Received two or more tetanus toxoid injections 

Any severe disability in one or more domains 69.8 / 67.8 1.3 (0.8 - 2.2) 

Any disability in one or more domains 70.7 / 67.4 1.2 (1.0 - 1.5) 

Took iron tablets or syrup 

Any severe disability in one or more domains 45.6 / 58.8* 0.6 (0.4 - 1.0)* 

Any disability in one or more domains 54.1 / 59.2* 0.8 (0.7 - 1.0) 

Examination 

Blood pressure measured 

Any severe disability in one or more domains 77.7 / 78.5 1.1 (0.7 - 1.9) 

Any disability in one or more domains 78.2 / 78.5 1.0 (0.8 - 1.3) 

Urine sample taken 

Any severe disability in one or more domains 68.4 / 62 1.7 (1.0 - 2.8)* 

Any disability in one or more domains 61.3 / 62.3 1.0 (0.8 - 1.3) 

Blood sample taken 

Any severe disability in one or more domains 54.5 / 62.0 1.0 (0.6 - 1.6) 

Any disability in one or more domains 60.1 / 62.1 0.9 (0.7 - 1.2) 

Counseling 

Advice on early initiation of breastfeeding 

Any severe disability in one or more domains 49.9 / 45.7 1.4 (0.9 - 2.1) 

Any disability in one or more domains 47.0 / 45.6 1.1 (0.9 - 1.3) 

Advice on exclusive breastfeeding 

Any severe disability in one or more domains 55.0 / 47.5 1.6 (1.1 - 2.4)* 

Any disability in one or more domains 42.3 / 47.5 1.1 (0.9 - 1.4) 

Advice on maintaining balanced diet during pregnancy 

Any severe disability in one or more domains 62.1 / 61.1 1.2 (0.8 - 1.9) 

Any disability in one or more domains 65.6 / 60.4* 1.3 (1.0 - 1.6)* 

Received all essential ANC components 

Any severe disability in one or more domains 21.8 / 21.8 1.1 (0.6 - 2.0) 

Any disability in one or more domains 20.0 / 22.1 0.9 (0.7 - 1.1) 

Significant criteria for p-values: *p<0.05; **p<0.01; ***p<0.001 

The results of subgroup analysis from bivariate and multivariate logistic regression analysis are presented 

in Table 5. The p-values for the models that contain the full dataset with either the poor-rich or urban-rural 

interaction terms with the disability measures are also reported in the table. With the exception of the use 

of iron tablets, none of the interaction terms in the full model was found to be significant, which suggests 

that the relationship between disability and utilization of ANC does not differ by wealth status and place of 

residence. The p-value for the poor-rich interaction in the iron tablets model was significant (pvalue=0.040), which indicated that the uptake of iron tablets by women with any severe disability is 

dependent on wealth status. 

Columns 2, 4, 7, and 9 in the table show the percentage of outcomes among women with disability and 

non-disabled women along with the results of the association tests. The adjusted odds ratios (AOR) shown 

in the table are derived from the regression models from the subgroup analysis for poor, rich, urban, and 

rural women separately. These models were adjusted for the covariates as described in the analysis section 
13 

above. Most of the interactions were not significant, although there were a few significant AORs in the 

subgroup analysis. 

Among the poor segment of the population, women with any disability in one or more domain had a 

significantly greater (AOR=1.5, 95% CI 1.1–2.1; p-value<0.05) odds of receiving ANC as opposed to their 

counterparts. Among the rich segment of population, women with any severe disability in one or more 

domain had almost 10 times greater odds (AOR=9.7, 95% CI 1.1–82.5; p-value<0.05) of receiving ANC as 

opposed to their counterparts. However, given the wide range in the confidence interval and the marginal 

significance of this estimate, this finding should be interpreted with caution. 

In the poor-rich subgroup analysis, we observed no inequalities in the utilization of essential ANC 

components between women with and without disabilities. Among the poor segment of population, women 

with at least some level of difficulty in one or more domains had 60% (AOR=1.6, 95% CI 1.2–2.0; pvalue<0.05) greater odds of receiving advice on maintaining a balanced diet during pregnancy. In contrast, 

women with disabilities had significantly lower odds of consuming iron tablets or syrup as compared with 

their counterparts both in poor (AOR=0.3, 95% CI 0.2–0.7; p-value<0.05) and rich (AOR=0.6, 95% CI 

0.4–0.8; p-value<0.05) segments of population. 

We observed similar findings in the urban-rural subgroup analysis. Among the rural segment of population, 

women who have at least some level of difficulty in one or more domains had 30% (AOR=1.3, 95% CI 

1.0–1.7; p-value<0.05) greater odds of receiving advice on maintaining a balanced diet during pregnancy. 

In contrast, women with disabilities had significantly lower odds of consuming iron tablets or syrup as 

compared with their counterparts both in rural (AOR=0.5, 95% CI 0.3–0.8; p-value<0.05) and urban 

(AOR=0.7, 95% CI 0.5–1.0; p-value<0.05) segment of population. 
14 

Table 5 Inequalities in the uptake of essential antenatal services between women with and without disabilities, according to wealth quintile and place of 

residence 

Variables 

Wealth Status Place of residence 

Poor Rich 

P-value for 

Poor-rich 

difference 

Urban Rural 

P-value for 

Urban-rural 

difference 

Disabled/nondisabled AOR (95% CI) Disabled/non- disabled AOR (95% CI) Disabled/non- disabled AOR (95% CI) Disabled/non- disabled AOR (95% CI) 

ANC Coverage 

Received ANC 

Any severe disability in one or more 

domains 75.8 / 76.9 1.2 (0.6-2.8) 98.1 / 99.7 9.7 (1.1 - 82.5)* 0.105 95.8 / 97.5 2.7 (0.8-8.7) 83.8 / 83.9 1.2 (0.6-2.5) 0.246

Any disability in one or more domains 75.0 / 80.8* 1.5 (1.1-2.1)* 98.1 / 98.0 1.2 (0.4 - 3.5) 0.541 95.9 / 95.2 1.1 (0.5-2.1) 83.5 / 86.0 1.32 (1.0-1.8) 0.541 

4+ ANC visits

Any severe disability in one or more 

domains 28.1 / [30.2] 1.2 (0.6-2.3) 77.0 / 71.2 0.9 (0.4-1.9) 0.501 70.7 / 72.9 1.7 (0.7-3.6) 41.6 / (45.6) 1.4 (0.8-2.5) 0.809

Any disability in one or more domains 28.4 / 26.6 0.9 (0.7-1.2) 77.1 / 74.9 0.9 (0.6-1.4) 0.925 71.5 / 66.4 0.9 (0.7-1.3) 41.9 / 40.8 1.0 (0.7-1.4) 0.727 

Treatment 

Received two or more tetanus toxoid injections 

Any severe disability in one or more 

domains 54.6 / 50.8 1.3 (0.7-2.7) 88.0 / 84.5 1.57 (0.6-3.9) 0.677 76.2 / 79.4 1.1 (0.5-2.4) 66.7 / 62.0 1.5 (0.8-2.7) 0.520 

Any disability in one or more domains 54.5 / 50.3 1.2 (0.8-1.7) 87.2 / 84.2 1.34 (0.8-2.1) 0.562 80.0 / 79.2 1.3 (0.9-1.8) 65.5 / 61.5 1.2 (0.9-1.6) 0.921 

Took iron tablets or syrup 

Any severe disability in one or more 

domains [21.1] / 46.2** 0.3 (0.2-0.7)** 72.3 / 73.7 1.0 (0.4-2.3) 0.04* 64.0 / 66.8 1.1 (0.5-2.2) [37.2] / 54.8** 0.5 (0.3-0.8)* 0.090 

Any disability in one or more domains 43.3 / 45.8 0.9 (0.7-1.2) 64.7 / 75.0** 0.6 (0.4-0.8)** 0.116 58.6 / 68.2** 0.7 (0.50-1.0)* 51.6 / 54.7 0.9 (0.7-1.2) 0.297 

Examination 

Blood pressure measured 

Any severe disability in one or more 

domains 61.9 / 62.3 1.09 (0.6-2.2) 91.6 / 93.7 0.9 (0.2-3.4) 0.762 89.9 / 89.4 0.8 (0.3-1.9) 74.9 / 73.0 1.3 (0.7-2.4) 0.429 

Any disability in one or more domains 63.7 / 62.0 1.1 (0.8-1.5) 92.2 / 93.9 0.8 (0.4-1.5) 0.448 86.2 / 89.8 0.8 (0.5-1.2) 73.8 / 73.0 1.1 (0.8-1.4) 0.312 

Urine sample taken 

Any severe disability in one or more 

domains [44.3] / 40.0 1.3 (0.7-2.7) 91.7 / 85.0 2.3 (0.6-8.3) 0.458 84.5 / 79.5 1.9 (0.8-4.7) 61.1 / 53.1 1.6 (0.9-2.9) 0.767 

Any disability in one or more domains 41.2 / 39.9 1.1 (0.8-1.5) 82.6 / 85.5 0.8 (0.5-1.3) 0.389 74.1 / 80.6* 0.7 (0.5-1.1) 54.2 / 53.2 1.1 (0.9-1.5) 0.140 

Blood sample taken 

Any severe disability in one or more 

domains [32.5] / 41.9 0.7 (0.4-1.5) 81.7 / 83.0 1.1 (0.4-2.7) 0.541 48.1 / 53.7 1.3 (0.6-2.9) 78.0 / 78.4 0.9 (0.5-1.6) 0.484 

Any disability in one or more domains 42.8 / 41.4 1.1 (0.8-1.5) 81.0 / 83.2 0.9 (0.6-1.3) 0.532 52.2 / 53.7 0.84 (0.6-1.2) 74.4 / 79.0 1.0 (0.7-1.3) 0.677 

Counselling 

Advice on early initiation of 

breastfeeding Any severe disability in one or more 

domains {27.7} / 27.6 1.0 (0.5-2.2) 66.7 / 64.3 1.2 (0.6-2.6) 0.750 67.7 / 60.7 1.5 (0.8-2.9) [41.8] / 38.2 1.3 (0.7-2.4) 0.618

Any disability in one or more domains 27.9 / 27.6 0.1 (0.7-1.4) 65.6 / 64.1 1.1 (0.8-1.4) 0.663 62.5 / 60.5 1.1 (0.8-1.6) 38.5 / 38.2 1.0 (0.8-1.4) 0.570 

Advice on exclusive breastfeeding 

Any severe disability in one or more 

domains [33.2] / 29.0 1.3 (0.6-2.5) 72.0 / 66.7 1.4 (0.6-3.2) 0.405 70.8 / 63.4 1.7 (0.8-3.3) 47.6 / 39.5 1.6 (0.9-2.7) 0.874 

Any disability in one or more domains 32.7 / 28.5 1.2 (0.9-1.6) 66.2 / 66.9 0.9 (0.7-1.4) 0.405 63.0 / 63.6 1.03 (0.7-1.5) 41.8 / 39.4 1.1 (0.9-1.5) 0.770 

Advice on maintaining balanced diet 

during pregnancy 

Any severe disability in one or more 

domains 41.5 / 40.3 1.1 (0.6-2.1) 76.9 / 80.4 0.9 (0.4-2.0) 0.706 80.8 / 74.7 1.9 (0.8-4.8) 53.7 / 54.3 1.0 (0.6 - 1.9) 0.347 

Any disability in one or more domains 49.8 / 38.8 *** 1.6 (1.2-2.0)** 80.6 / 80.3 1.0 (0.7-1.5) 0.105 76.2 / 74.6 1.3 (0.9-1.9) 59.8 / 53.4* 1.3 (1.0 - 1.7)* 0.595 

Received all essential ANC 

components Any severe disability in one or more 

domains {3.3} / 7.3 0.5 (0.1-2.9) [40.0] / 39.8 1.1 (0.5-2.3) 0.331 [32.4] / 34.5 1.1 (0.5-2.4) [15.6] / 15.4 1.2 (0.6-2.6) 0.900 

Any disability in one or more domains 5.3 / 7.6 0.7 (0.3-1.4) 36.1 / 40.3 0.8 (0.6-1.1) 0.494 31.2 / 35.0 0.9 (0.6-1.2) 13.9 / 15.6 0.9 (0.6-1.3) 0.973 

Figures in square brackets are based on 25-49 unweighted cases. Figures in curly brackets indicates that a figure is based on fewer than 25 unweighted cases. 

Significant criteria for p-values: *p<0.05; **p<0.01; ***p<0.001 
15 

Following a similar pattern, the tables in Appendix 1 show the results of receiving any ANC, four or more 

ANC, and an additional analysis of the different measures of type of disability and each of the eight ANC 

components. In the overall dataset, women with any walking disability had 30% (AOR=0.7, 95% CI 0.5–

0.9; p value<0.05) lower odds of receiving iron tablets and syrup as compared with women with no 

disabilities. In subgroup analysis for rural areas, women with any disability in vision also had 30% 

(AOR=0.7, 95% CI 0.5–1.00; p value<0.05) lower odds of receiving iron tablets and syrup as compared 

with the non-disabled women. In the overall sample, women with any walking disability had 1.6 times 

(AOR=1.6, 95% CI 1.2–2.2; p-value<0.05) greater odds of receiving advice on maintaining a balanced diet 

during pregnancy as compared with women with no walking disability. A similar trend was noted among 

women living in rural areas (AOR=1.6, 95% CI 1.1–2.3; p-value<0.05) and women in the high-income 

group (AOR=1.9, 95% CI 1.1–3.7; p-value<0.05) in the subgroup analysis. Moreover, women with any 

disability in vision had 50% (AOR=1.5, 95% CI 1.0–1.2; p value <0.05) greater odds of receiving advice 

on maintaining balanced diet during pregnancy in subgroup analysis. 

17 

4 DISCUSSION 

Women with disabilities have been an imperceptible population in maternity care and reproductive health. 

Globally, there is a dearth of empirical literature on the maternal and reproductive health needs of disabled 

women, particularly in LMICs. Our study is the first of its kind to examine inequalities in the utilization of 

essential ANC services between women with and without disabilities in Asia. This study found that a 

substantial proportion (14.1%) of women of childbearing age have some level of difficulty in at least one 

domain of disability, while 2.6% have a lot of difficulty or cannot function at all. A multi-country study 

conducted in Africa had reported the prevalence of functional disabilities for women age 15-39 and 40-49. 

Among women age 15-39, the prevalence of any severe disability was estimated to be around 0.5%–1.3% 

and 5.9%–7.6% for any moderate or severe disability, while among women age 40-49, the prevalence 

ranged from 1.2%–3.8% and 15.3%–21.9%, respectively (Mitra 2018). The prevalence of disability among 

women of reproductive age in Pakistan is similar to other LMICs. In contrast, studies from United States 

and United Kingdom reported that 12% (Brault et al. 2009) and 6.1% (Murthy et al. 2014) of women of 

reproductive age are disabled (any disability), respectively. This indicated that the prevalence of disability 

among women of childbearing age in Pakistan is relatively higher than in high-income countries. Consistent 

with trends in other countries (Mitra 2018), the most common forms of functional disabilities were related 

to vision (7.0%), walking (4.8%), and cognition (4.8%), while difficulty in communicating was the least 

prevalent. 

We observed no clear trend of disability with wealth status. However, some studies have found that poor 

people are more likely to have disability due to factors such as ill health, malnourishment, unsafe work, and 

the inability to afford medical care that may prevent disability (Thompson 2017; Plantinga et al. 2012). We 

found no significant differences in the prevalence of functional disability by urban-rural residence. The only 

exception was the domain of walking disability, which was more commonly found in urban areas as 

compared with the rural areas. One study in African countries also reported varying patterns in the 

prevalence of urban-rural disabilities across countries (Mitra 2018). However, another recent study from 

the United States (US) found a significantly higher prevalence of disability in rural settings versus the urban 

areas (Zhao et al. 2019). Comparisons should be made with caution because these studies reported disability 

for either the adult (US) or the entire population (African countries), whereas our estimates are based on 

childbearing women. 

Notably, in this study, 88% of women sought ANC but only 20% received all eight essential ANC 

components. This stark difference clearly highlights a critical gap in the quality of ANC in our health-care 

system, a gap that requires urgent interventions to improve the quality of health-care services. Health 

inequalities including utilization of ANC among disabled women are common across the globe (WHO 

2018). However, our study could not find major inequalities in the utilization of ANC by disabled women 

in Pakistan. We found limited evidence of the association between functional disability and utilization of 

ANC services. Although we were unable to locate any comparable study, this finding is in agreement with 

a systematic review from LMICs that found no difference in coverage of maternal health services between 

women with and without disabilities (Bright and Kuper 2018). The same association has also been 

documented in other studies conducted in India and United Kingdom where utilization of ANC and 

pregnancy outcomes were not different in women with and without disability (Murthy et al. 2014; Redshaw 

et al. 2013). 
18 

We found that the uptake of all eight ANC components was lower among women with disability as 

compared with non-disabled women. These inequalities may be attributed to significant underutilization of 

iron tablets or syrup by women with disability. Among all the ANC components, consumption of iron 

tablets/syrup relies on the women’s choice to take the iron rather than receiving a prescription by a service 

provider. This suggests that disabled women tend to struggle adhering to a provider’s suggestion to take 

iron tablets/syrup on their own. This was suggested in another study that found lower adherence among 

people with disabilities (Bright and Kuper 2018). It may also be possible that fewer women with disability 

were prescribed medication by their service providers. From the programmatic perspective, we suggest that 

during consultations, service providers might also inform the accompanying person or other members of 

household about the medication and encourage the women to take their medication. 

In some cases, women with certain functional disabilities have reported higher utilization of ANC 

components such as advice on exclusive breastfeeding and maintenance of a balanced diet during pregnancy 

as compared with non-disabled women. This could be due to the fact that in general, disabled women are 

considered high risk during their pregnancy (Walsh-Gallagher, Sinclair, and McConkey 2012) and require 

more ANC and medical examinations than non-disabled women (Mitra et al. 2015). This could also be 

explained by sympathetic behavior of health-care providers toward women with disabilities. However, one 

study from Nepal found that the attitude of health-care providers toward the disabled was negative and that 

the providers had limited knowledge and skills about providing services for the disabled. Few participants 

reported that the attitude of health-care providers was kind, respectful, caring or helpful towards women 

with disabilities (Devkota et al. 2017). Furthermore, disabled women in Pakistan receive social and 

economic support from family members, neighbors, and society, which may encourage them to seek better 

ANC. Redshaw and colleagues reported that women with disabilities in the UK use maternity services more 

than non-disabled women and had sufficient access and involvement in maternity care services (Redshaw 

et al. 2013). Thus, there are conflicting arguments about the health service utilization by women with 

disabilities. When there is a good health infrastructure, women with disabilities may benefit even more 

from health systems than women with no disabilities. We noticed that this trend of higher utilization of 

ANC services was primarily found in ANC counseling, in the overall analysis as well as among the poor 

population and those who reside in the rural areas. This pattern of favorable care for disabled women could 

also be attributed to the active involvement of community health workers (officially called the Lady Health 

Workers (LHWs)) who are responsible for providing basic maternal and child health-care services 

(including ANC counseling) during their routine household visits (WHO 2008). The LHWs are residents 

of the same community, and can relate to other women and navigate local norms, languages, and social 

relationships more effectively than outsiders (Mumtaz et al. 2013). 

Strengths and Limitations 

To the best of our knowledge, this is the first study that specifically examined the relationship between 

disability and utilization of ANC services, particularly among LMICs. The results are based on the most 

recent national survey in Pakistan. Our study presents a comprehensive analysis of the disability-ANC 

relationship that used numerous independent and dependent variables, and performed subgroup analyses. 
19 

Our study has some limitations. First, since the analysis used cross-sectional data, we cannot draw 

inferences about causal relationships between disability and ANC. Second, since we excluded two regions 

because their use of a different sampling frame, our findings cannot be generalized to the excluded regions, 

and they are not representative of Pakistan as a whole. The few significant disability-ANC associations in 

the subgroup analyses should be interpreted with caution because the unweighted cell count was less than 

25 or 50. Moreover, we only included three domains of any disability (vision, walking, and cognition) in 

our multivariate model to assess the association with ANC outcomes, because the other domains of 

disability were excluded due to low prevalence. Similarly, no domains of severe disability were included 

for the same reason. Finally, the focus of our study was utilization of essential ANC services, while the 

interpersonal aspects of care such as the social and emotional support extended to women by the service 

providers were not included and are also important to consider. 

21 

5 CONCLUSIONS 

Pakistan has a considerable population of disabled women in reproductive age. The prevalence of disability 

does not differ linearly by wealth quintile (highest among poorest and lowest among richest) or urban-rural 

geographies. Overall, the proportion of effective ANC coverage is very low and requires urgent measures 

for quality improvement. Our analyses indicate that the utilization of essential ANC services among 

disabled women is not different or lower than non-disabled women. This pattern is seen for urban-rural 

geographies and among the poor-rich segments of the population. We conclude that the country’s health 

system, to a great extent, is responsive to the needs of disabled women for ANC services. However, 

adherence to medication (in this study, iron tablets/syrup) may be challenging for women with disabilities 

and could be improved by engaging a companion from same household to encourage compliance. Moving 

forward, there is a need in Pakistan to conduct qualitative studies that enhance our understanding of how 

our health system is meeting the unique needs of disabled women, to develop greater insights into how the 

psychosocial needs of disabled women are addressed during the provision of care, and to replicate 

disability-inclusive best practices in a broader context. 

23 

REFERENCES 

Alkema, L., D. Chou, D. Hogan, S. Zhang, A. Moller, A. Gemmill, D. M. Fat, T. Boerma, M. 

Temmerman, C. Mathers, et al. 2016. “Global, Regional, and National Levels and Trends in Maternal 

Mortality between 1990 and 2015, with Scenario-based Projections to 2030: A Systematic Analysis by 

the UN Maternal Mortality Estimation Inter-agency Group.” The Lancet 387 (10017): 462–474. 

https://doi.org/10.1016/S0140-6736(15)00838-7. 

Banks, L. M., H. Kuper, and S. Polack. 2017. “Poverty and Disability in Low- and Middle-Income 

Countries: A Systematic Review.” PLOS ONE 13 (9): e0204881. 

https://doi.org/10.1371/journal.pone.0204881. 

Barros, A. D., C. Ronsmans, H. Axelson, E. Loaiza, A. D. Bertoldi, G. A. França, J. Bryce, J. T. Boerma, 

and C. G. Victora. 2012. “Equity in Maternal, Newborn, and Child Health Interventions in Countdown to 

2015: A Retrospective Review of Survey Data from 54 Countries.” The Lancet 379 (9822): 1225–1233. 

https://doi.org/10.1016/S0140-6736(12)60113-5. 

Bickenbach, J. 2011. “The World Report on Disability.” Disability & Society 26 (5): 655–68. 

https://doi.org/10.1080/09687599.2011.589198. 

Blackford, K. A., H. Richardson, and S. Grieve. 2000. “Prenatal Education for Mothers with Disabilities.” 

Journal of Advanced Nursing 32 (4): 898–904. https://doi.org/10.1046/j.1365-2648.2000.t01-1-01554.x. 

Bradbury-Jones, C., J. P. Breckenridge, J. Devaney, F. Duncan, T. Kroll, A. Lazenbatt, and J. Taylor. 

2015. “Priorities and Strategies for Improving Disabled Women’s Access to Maternity Services when 

They Are Affected by Domestic Abuse: A Multi-method Study using Concept Maps.” BMC Pregnancy 

and Childbirth 15 (1): 350. https://doi.org/10.1186/s12884-015-0786-7. 

Brault, M. W., J. Hootman, C. G. Helmick, K. A. Theis, and B. S. Armour. 2009. “Prevalence and Most 

Common Causes of Disability among Adults–United States, 2005.” Morbidity and Mortality Weekly 

Report 58 (16): 421–426. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5816a2.htm. 

Bright, T., and H. Kuper. 2018. “A Systematic Review of Access to General Healthcare Services for 

People with Disabilities in Low and Middle Income Countries.” International Journal of Environmental 

Research and Public Health 15 (9): 1879. https://doi.org/10.3390/ijerph15091879. 

Brizuela, V., H. H. Leslie, J. Sharma, A. Langer, and Ö. Tunçalp. 2019. “Measuring Quality of Care for 

All Women and Newborns: How Do We Know If We Are Doing It Right? A Review of Facility 

Assessment Tools.” The Lancet Global Health 7 (5): e624–e632. https://doi.org/10.1016/S2214-

109X(19)30033-6. 

Devkota, H. R., E. Murray, M. Kett, and N. Groce. 2017. “Healthcare Provider’s Attitude towards 

Disability and Experience of Women with Disabilities in the Use of Maternal Healthcare Service in Rural 

Nepal.” Reproductive Health 14 (1): 79. https://doi.org/10.1186/s12978-017-0330-5. 
24 

Ekabua, J., K. Ekabua, and C. Njoku. 2011. “Proposed Framework for Making Focused Antenatal Care 

Services Accessible: A Review of the Nigerian Setting.” ISRN Obstetrics and Gynecology 2011: 

25253964. https://doi.org/10.5402/2011/253964. 

Frohmader, C., and S. Ortoleva. 2013. “Issues Paper: The Sexual and Reproductive Rights of Women and 

Girls with Disabilities.” Paper presented at the ICPD BEYOND 20I4 International Conference on Human 

Rights. Noordwijk, the Netherlands, July 1, 2013. 

https://womenenabled.org/pdfs/issues_paper_srr_women_and_girls_with_disabilities_final.pdf. 

Hameed, W., and B. I. Avan. 2018. “Women’s Experiences of Mistreatment during Childbirth: A 

Comparative View of Home- and Facility-based Births in Pakistan.” PLOS ONE 13 (3): e0194601. 

https://doi.org/10.1371/journal.pone.0194601. 

Homer, C. S. E., and P. T. Hoope-Bender. 2016. “Supporting Women, Families, and Care Providers after 

Stillbirths.” The Lancet 387 (10018): 516–517. https://doi.org/10.1016/S0140-6736(15)01278-7. 

Hwang, K., M. Johnston, D. Tulsky, K. Wood, T. Dyson-Hudson, and E. Komaroff. 2009. “Access and 

Coordination of Health Care Service for People with Disabilities.” Journal of Disability Policy Studies 20 

(1): 28–34. https://doi.org/10.1177%2F1044207308315564. 

Khasnabis, C., M. K. Heinicke, K. Achu, K. A. Jubah, S. Brodtkorb, P. Chervin, P. Coleridge, M. Davies, 

S. Deepak, K. Eklindh, et al. 2010. Community-based Rehabilitation: CBR Guidelines. Geneva, 

Switzerland: World Health Organization. https://www.ncbi.nlm.nih.gov/books/NBK310940/. 

Krahn, G. L., D. K. Walker, and R. Correa-De-Araujo. 2015. “Persons with Disabilities as an 

Unrecognized Health Disparity Population.” American Journal of Public Health 105 (S2): S198–S206. 

https://doi.org/10.2105/AJPH.2014.302182. 

Kruk, M. E., A. D. Gage, C. Arsenault, K. Jordan, H. H. Leslie, S. Roder-DeWan, O. Adeyi, P. Barker, B. 

Daelmans, S. V. Doubova, et al. 2018. “High-quality Health Systems in the Sustainable Development 

Goals Era: Time for a Revolution.” The Lancet Global Health 6 (11): e1196–e1252. 

https://doi.org/10.1016/S2214-109X(18)30386-3. 

Kuhnt, J., and S. Vollmer. 2017. “Antenatal Care Services and Its Implications for Vital and Health 

Outcomes of Children: Evidence from 193 Surveys in 69 Low-income and Middle-income Countries.” 

BMJ Open 7 (11): e017122. https://bmjopen.bmj.com/content/7/11/e017122.full. 

Lawler, D., J. Lalor, and C. Begley. 2013. “Access to Maternity Services for Women with a Physical 

Disability: A Systematic Review of the Literature.” International Journal of Childbirth 3 (4): 203–217. 

http://dx.doi.org/10.1891/2156-5287.3.4.203. 

Lipson, J. G. 2000. “Pregnancy, Birth, and Disability: Women’s Health Care Experiences.” Health Care 

for Women International 21 (1): 11–26. https://doi.org/10.1080/073993300245375. 

MacKay, D. 2007. “The United Nations Convention on the Rights of Persons with Disabilities.” Syracuse 

Journal of International Law & Commerce. 34 (2): 323. 
25 

Madans, J. H., M. E. Loeb, and B. M. Altman. 2011. “Measuring Disability and Monitoring the UN 

Convention on the Rights of Persons with Disabilities: The Work of the Washington Group on Disability 

Statistics.” BMC Public Health 11: S4. https://doi.org/10.1186/1471-2458-11-S4-S4. 

Mitra, M., K. M. Clements, J. Zhang, L. I. Iezzoni, S. C. Smeltzer, and L. M. Long-Bellil. 2015. 

“Maternal Characteristics, Pregnancy Complications and Adverse Birth Outcomes among Women with 

Disabilities.” Medical Care 53 (12): 1027-1032. https://journals.lww.com/lwwmedicalcare/Abstract/2015/12000/Maternal_Characteristics,_Pregnancy_Complications,.6.aspx. 

Mitra, S. 2018. “Prevalence of Functional Difficulties.” In Disability, Health and Human Development, 

Palgrave Studies in Disability and International Development: 61–88. New York: Palgrave Pivot. 

https://doi.org/10.1057/978-1-137-53638-9_4. 

Morrison, J., M. Basnet, B. Budhathoki, D. Adhikari, K. Tumbahangphe, D. Manandhar, A. Costello, and 

N. Groce. 2014. “Disabled Women’s Maternal and Newborn Health Care in Rural Nepal: A Qualitative 

Study.” Midwifery 30 (11): 1132–1139. https://doi.org/10.1016/j.midw.2014.03.012. 

Mumtaz, Z., Sarah S. C. Nykiforuk, A. Bhatti, A. Ataullahjan, and B. Ayyalasomayajula. 2013. “The 

Role of Social Geography on Lady Health Workers’ Mobility and Effectiveness in Pakistan.” Social 

Science & Medicine 91: 48–57. https://doi.org/10.1016/j.socscimed.2013.05.007. 

Murthy, G. V. S., N. John, J. Sagar, and South India Disability Evidence Study Group. 2014. 

“Reproductive Health of Women with and without Disabilities in South India, the SIDE Study (South 

India Disability Evidence) Study: A Case Control Study.” BMC Women’s Health 14 (1): 146. 

https://doi.org/10.1186/s12905-014-0146-1. 

National Institute of Population Studies (NIPS) [Pakistan], and Macro International Inc. 2008. Pakistan 

Demographic and Health Survey 2006-07. Islamabad, Pakistan: National Institute of Population Studies 

and Macro International Inc. https://dhsprogram.com/pubs/pdf/FR200/FR200.pdf. 

National Institute of Population Studies (NIPS) [Pakistan] and ICF. 2018. Pakistan Demographic and 

Health Survey 2017-18. Islamabad, Pakistan, and Rockville, Maryland, USA: NIPS and ICF. 

https://dhsprogram.com/pubs/pdf/FR354/FR354.pdf. 

Nikiema, L., Y. Kameli, G. Capon, B. Sondo, and Y. Martin-Prével. 2010. “Quality of Antenatal Care 

and Obstetrical Coverage in Rural Burkina Faso.” Journal of Health, Population, and Nutrition 28 (1): 

67. https://doi.org/10.3329/jhpn.v28i1.4525. 

Ortoleva, S., and H. Lewis. 2012. “Forgotten Sister–A Report on Violence against Women with 

Disabilities: An Overview of its Nature, Scope, Causes and Consequences.” Northeastern University 

School of Law Research Paper, No. 104. Boston, MA, USA: Northeastern University School of Law. 

https://repository.library.northeastern.edu/files/neu:332599/fulltext.pdf. 

Pakistan Bureau of Statistics, Government of Pakistan. 2017. “Population & Housing Census 2017.” 

http://www.pbs.gov.pk/content/block-wise-provisional-summary-results-6th-population-housing-census2017-january-03-2018. 
26 

Plantinga, L., K. L. Johansen, D. Schillinger, and N. R. Powe. 2012. “Lower Socioeconomic Status and 

Disability among US Adults with Chronic Kidney Disease, 1999-2008.” Preventing Chronic Disease 9: 

100052. http://dx.doi.org/10.5888/pcd9.110052. 

Prilleltensky, O. 2003. “A Ramp to Motherhood: The Experiences of Mothers with Physical Disabilities.” 

Sexuality and Disability 21 (1): 21–47. https://doi.org/10.1023/A:1023558808891. 

Redshaw, M., R. Malouf, H. Gao, and R. Gray. 2013. “Women with Disability: The Experience of 

Maternity Care during Pregnancy, Labour and Birth and the Postnatal Period.” BMC Pregnancy and 

Childbirth 13 (1): 174. https://doi.org/10.1186/1471-2393-13-174. 

Rugoho, T., and F. Maphosa. 2017. “Challenges Faced by Women with Disabilities in Accessing Sexual 

and Reproductive Health in Zimbabwe: The Case of Chitungwiza Town.” African Journal of Disability 6: 

1–8. https://doi.org/10.4102/ajod.v6i0.252. 

Rutstein, S. O., and K. Johnson. 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. 

Calverton, MD, USA: ORC Macro. https://dhsprogram.com/pubs/pdf/CR6/CR6.pdf. 

Tappis, H., A. Kazi, W. Hameed, Z. Dahar, A. Ali, and S. Agha. 2015. “The Role of Quality Health 

Services and Discussion about Birth Spacing in Postpartum Contraceptive Use in Sindh, Pakistan: A 

Multilevel Analysis.” PLOS ONE 10 (10): e0139628. https://doi.org/10.1371/journal.pone.0139628. 

The Lancet Editorial. 2011. “Championing Good Health for People with Disabilities.” The Lancet 37 

(9807): 1895. https://doi.org/10.1016/S0140-6736(11)61825-4. 

Thierry, J. M. 1998. “Observations from the CDC: Promoting the Health and Wellness of Women with 

Disabilities.” Journal of Women’s Health 7 (5): 505–507. https://doi.org/10.1089/jwh.1998.7.505. 

Thompson, S. 2017. “Disability Prevalence and Trends.” K4D Helpdesk Report. Brighton, UK: Institute 

of Development Studies. http://www.gsdrc.org/wp-content/uploads/2017/09/179-Disability-prevalenceand-trends.pdf. 

UNICEF. 2019. “World Not Delivering Quality Maternal Health Care to Poorest Mothers.” New York, 

USA: UNICEF. https://www.unicef.org.uk/press-releases/world-not-delivering-quality-maternal-healthcare-to-poorest-mothers/. 

Victora, C. G., J. H. Requejo, A. J. D. Barros, P. Berman, Z. Bhutta, T. Boerma, M. Chopra, A. D. 

Francisco, B. Daelmans, E. Hazel, et al. 2016. “Countdown to 2015: A Decade of Tracking Progress for 

Maternal, Newborn, and Child Survival.” The Lancet 387 (10032): 2049–2059. 

https://doi.org/10.1016/S0140-6736(15)00519-X. 

Walsh-Gallagher, D., M. Sinclair, and R. McConkey. 2012. “The Ambiguity of Disabled Women’s 

Experiences of Pregnancy, Childbirth and Motherhood: A Phenomenological Understanding.” Midwifery

28 (2): 156–162. https://doi.org/10.1016/j.midw.2011.01.003. 
27 

World Health Organization (WHO). 2008. Global Health Workforce Alliance. Pakistan’s Lady Health 

Worker Programme: Global Health Workforce Alliance. World Health Organization, Case study. Geneva: 

World Health Organization. 

https://www.who.int/workforcealliance/knowledge/case_studies/CS_Pakistan_web_en.pdf?ua=1 

World Health Organization (WHO). 2005. “Disability, including Prevention, Management and 

Rehabilitation.” Geneva, Switzerland: WHO. 

https://www.who.int/disabilities/WHA5823_resolution_en.pdf?ua=1. 

WHO. 2015. “Pregnancy, Childbirth, Postpartum and Newborn Care. A Guide for Essential Practice." 3rd 

Ed. Geneva, Switzerland: WHO. 

https://apps.who.int/iris/bitstream/handle/10665/249580/9789241549356-

eng.pdf;jsessionid=B225C0641049542278C080637536DFFB?sequence=1. 

WHO. 2018. “Disability and Health.” Geneva, Switzerland: WHO. https://www.who.int/news-room/factsheets/detail/disability-and-health. 

WHO and UNPFA. 2009. “Promoting Sexual and Reproductive Health for Persons with Disabilities: 

WHO/UNFPA Guidance Note.” Geneva, Switzerland: WHO. 

https://apps.who.int/iris/handle/10665/44207. 

You, D., L. Hug, S. Ejdemyr, P. Idele, D. Hogan, C. Mathers, P. Gerland, J. R. New, and L. Alkema. 

2015. “United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Global, Regional, 

and National Levels and Trends in Under-5 Mortality between 1990 and 2015, with Scenario-based 

Projections to 2030: A Systematic Analysis by the UN Inter-agency Group for Child Mortality 

Estimation.” The Lancet 386 (10010): 2275–86. https://doi.org/10.1016/S0140-6736(15)00120-8. 

Zhao, G., C. A. Okoro, J. Hsia, W. S. Garvin, and M. Town. 2019. “Prevalence of Disability and 

Disability Types by Urban–Rural County Classification—US, 2016.” American Journal of Preventive 

Medicine 57 (6): 749–756. https://doi.org/10.1016/j.amepre.2019.07.022. 

29 

APPENDICES 
30 

Appendix Table 1 Inequalities in the uptake of antenatal components between women with and without disabilities, overall and according to wealth quintile 

and type of residence 

Variables 

Full dataset 

Wealth Status Place of residence 

Poor Rich P-value for 

Poor-rich 

difference 

Urban Rural P-value for 

Urban-rural 

difference 

Disabled/nondisabled AOR (95% CI) Disabled/non- disabled AOR (95% CI) Disabled/non- disabled AOR (95% CI) Disabled/non- disabled AOR (95% CI) Disabled/non- disabled AOR (95% CI) 

ANC Coverage 

Received ANC 

Any disability in vision 87.7 / 89.1 1.2 (0.8 - 1.8) 75.4 / 80.5 1.4 (0.9-2.2) 98.1 / 98.5 1.7 (0.3-11.4) 0.968 95.7 / 97.2 2.1 (1.0-4.8) 83.8 / 84.6 1.1 (0.7-1.8) 0.268 Any disability in cognition 87.9 / 86.7 1.1 (0.7 - 1.7) 75.7 / 77.3 1.2 (0.8-2.0) 98.2 / 96.1 0.4 (0.1-1.7) 0.174 95.8 / 96.3 1.2 (0.3-4.9) 83.9 / 82.8 1.1 (0.7-1.7) 0.918 

Any disability in walking 87.8 / 87.7 0.9 (0.5 - 1.5) 75.8 / 76.8 1.1 (0.6-2.2) 98.3 / 95.1 0.5 (0.2-1.4) 0.111 96.1 / 90.8 0.5 (0.2-1.2) 83.7 / 85.4 1.1 (0.6-2.0) 0.097 

4+ ANC visits 

Any disability in vision 51.5 / 50.7 1.0 (0.7 - 1.4) 28.1 / 28.3 1.0 (0.62-1.6) 76.8 / 78.3 1.1 (0.60-2.2) 0.699 71.1 / 66.6 1.0 (0.7-1.5) 47.7 / 42.0 1.0 (0.7-1.6) 0.784 

Any disability in cognition 51.7 / 46.0 0.9 (0.6 - 1.3) 28.4 / 22.3 0.8 (0.5-1.3) 77.0 / 74.0 0.9 (0.5-1.6) 0.831 70.8 / 68.6 0.9 (0.5-1.7) 42.0 / 36.8 0.9 (0.6-1.4) 0.864 

Any disability in walking 51.3 / 54.8 1.1 (0.8 - 1.6) 28.1 / 28.5 1.01 (0.6-1.8) 77.0 / 73.7* 0.9 (0.5-1.6) 0.792 70.9 / 67.8* 1.1 (0.6-2.0) 41.6 / 45.2 1.5 (0.7-1.9) 0.919 

Treatment 

Received two or more 

tetanus toxoid injections Any disability in vision 69.8 / 67.7 1.1 (0.8 - 1.6) 51.4 / 50.9 1.0 (0.6-1.7) 88.5 / 84.4 1.5 (0.8-2.7) 0.289 81.1 / 79.1 1.3 (0.8-2.1) 63.6 / 62.0 1.0 (0.7-1.6) 0.619 

Any disability in cognition 69.1 / 67.8 1.2 (0.8 - 1.6) 54.6 / 50.7 1.3 (0.8-2.0) 87.4 / 84.5 1.2 (0.5-2.8) 0.977 85.7 / 79.0 1.7 (0.7-4.1) 62.3 / 62.1 1.0 (0.8-1.5) 0.398 Any disability in walking 74.1 / 67.5 1.3 (0.9 - 2.0) 59.1 / 50.6 1.5 (0.8-2.6) 87.7 / 84.4 1.3 (0.6-3.0) 0.960 77.1 / 79.4 1.1 (0.6-1.9) 71.9 / 61.7* 1.5 (0.9-2.6) 0.261 

Took iron tablets or syrup 

Any disability in vision 49.3 / 59.2 *** 0.7 (0.5 - 0.9)* 39.4 / 46.0 0.8 (0.5-1.1) 59.4 / 74.6*** 0.5 (0.3-0.7)** 0.182 56.9 / 67.5* 0.7 (0.5-1.0) 45.2 / 55.0* 0.7 (0.5-1.0)* 0.868 

Any disability in cognition 55.5 / 58.6 1.0 (0.7 - 1.3) 45.4 / 45.5 1.0 (0.7-1.6) 61.1 / 74.3 0.52 (0.3-0.9)* 0.098 67.2 / 66.7 1.1 (0.6-2.0) 50.7 / 54.5 0.9 (0.6-1.3) 0.658 

Any disability in walking 57.7 / 58.5 1.0 (0.7 - 1.3) 39.6 / 45.7 0.8 (0.5-1.4) 72.4 / 73.8 0.9 (0.5-1.9) 0.590 60.9 / 67.1 0.9 (0.6-1.3) 55.3 / 52.3 1.00 (0.7-1.6) 0.664 

Examination 

Blood pressure measured 

Any disability in vision 78.9 / 78.7 1.1 (0.8 - 1.5) 65.2 / 65.0 1.2 (0.8-1.7) 94.5 / 93.6 1.3 (0.5-3.2) 0.870 91.4 / 89.1 1.6 (0.8-3.1) 72.0 / 73.1 0.9 (0.7-1.4) 0.193 

Any disability in cognition 73.4 / 78.6 0.8 (0.5 - 1.2) 56.0 / 62.6 0.8 (0.5-1.3) 89.4 / 93.9 0.5 (0.2-1.6) 0.519 85.4 / 89.4 0.7 (0.2-1.8) 68.5 / 73.3 0.9 (0.5-1.3) 0.687 

Any disability in walking 76.6 / 75.6 0.8 (0.5 - 1.1) 54.6 / 62.5 0.7 (0.4-1.2) 91.3 / 93.8 0.8 (0.3-1.7) 0.874 82.0 / 89.7* 0.6 (0.3-1.1) 72.6 / 73.1 0.9 (0.6-1.4) 0.321 

Urine sample taken 

Any disability in vision 60.7 / 62.7 1.0 (0.7 - 1.3) 42.2 / 39.9 1.1 (0.7-1.7) 84.3 / 85.2 1.0 (0.5-1.7) 0.737 77.6 / 79.8 1.0 (0.6-1.7) 51.4 / 53.5 1.0 (0.7-1.4) 0.790 

Any disability in cognition 56.3 / 62.5 0.9 (0.6 - 1.3) 36.7 / 40.3 1.0 (0.6-1.6) 77.7 / 85.4 0.6 (0.3-1.1) 0.345 74.9 / 79.9 0.7 (0.3-1.6) 48.7 / 53.6 0.9 (0.6-1.5) 0.693 

Any disability in walking 64.8 / 62 1.0 (0.7 - 1.5) 37.4 / 40.2 0.9 (0.5-1.6) 84.1 / 85.2 1.0 (0.5-1.8) 0.821 75.8 / 79.9 0.9 (0.5-1.6) 56.7 / 53.2 1.1 (0.7-1.7) 0.619 

Blood sample taken 

Any disability in vision 61.0 / 61.9 1.0 (0.7 - 1.4) 46.9 / 41.2 1.3 (0.8-1.9) 83.9 / 82.9 1.1 (0.6-1.8) 0.655 51.3 / 53.7 1.2 (0.8-1.9) 78.8 / 78.3 0.9 (0.6-1.4) 0.389 

Any disability in cognition 57.3 / 62.1 0.9 (0.6 - 1.3) 37.5 / 41.9 0.9 (0.6-1.5) 81.6 / 83.0 0.9 (0.4-1.9) 0.959 48.5 / 53.8 1.1 (0.5-2.3) 78.9 / 78.3 0.9 (0.6-1.4) 0.684 Any disability in walking 61.0 / 61.9 0.9 (0.6 - 1.2) 31.5 / 42.0 0.6 (0.4-1.3 83.7 / 83.0 1.1 (0.5-2.3) 0.181 51.9 / 53.6 0.8 (0.4-1.5) 72.5 / 78.7 0.9 (0.6-1.2) 0.870 

Counselling

Advice on early initiation 

of breastfeeding

Any disability in vision 46.5 / 45.8 1.0 (0.8 - 1.4) 26.7 / 27.7 0.9 (0.6-1.5) 66.3 / 64.2 1.1 (0.7-1.6) 0.528 67.9 / 60.3 1.5 (0.9-2.4) 43.7 / 38.5 0.8 (0.6-1.2) 0.057 

Any disability in cognition 39.6 / 46.1 0.8 (0.6 - 1.1) 18.5 / 28.2 0.6 (0.3-1.1) 61.4 / 64.4 0.8 (0.5-1.5) 0.385 63.7 / 60.7 1.1 (0.6-2.1) 29.8 / 38.7 0.7 (0.4-1.0) 0.232 

Any disability in walking 53.1 / 45.5* 1.3 (0.9 - 1.7) 27.1 / 27.6 0.9 (0.6-1.5) 71.0 / 63.9 1.4 (0.8-2.3) 0.258 63.3 / 60.7 1.2 (0.7-1.9) 45.7 / 37.9 1.3 (0.9-2.0) 0.877 

Advice on exclusive 

breastfeeding 

Any disability in vision 49.9 / 47.6 1.1 (0.8 - 1.4) 35.8 / 28.6 1.4 (0.9-2.0) 68.9 / 66.7 1.1 (0.7-1.7) 0.479 67.2 / 63.3 1.3 (0.8-2.1) 40.3 / 39.7 1.0 (0.7-1.4) 0.443 

Any disability in cognition 44.9 / 47.9 0.9 (0.6 - 1.4) 29.5 / 29.1 1.0 (0.6-1.9) 60.0 / 67.1 0.8 (0.3-1.3) 0.407 66.7 / 63.4 1.1 (0.6-2.3) 36.0 / 40.0 0.9 (0.5-1.4) 0.523 Any disability in walking 54.3 / 47.4 1.2 (0.9 - 1.7) 30.3 / 29.1 1.0 (0.6-1.7) 68.6 / 67.0 1.1 (0.6-1.7) 0.258 64.7 / 63.5 1.2 (0.7-2.0) 46.6 / 39.5 1.3 (0.8-1.9) 0.829 

Advice on maintaining 

balanced diet during pregnancy

Any disability in vision 64.7 / 60.9 1.2 (0.9 - 1.6) 50.0 / 39.6* 1.5 (1.0-1.1)* 80.2 / 80.4 1.0 (0.6-1.6) 0.230 77.4 / 74.6 1.4 (0.8-2.4) 57.8 / 54.0 1.1 (0.8 -1.7) 0.772 

Any disability in cognition 57.8 / 61.3 0.9 (0.6 - 1.3) 40.3 / 40.3 1.0 (0.6-1.7) 76.9 / 80.5 0.7 (0.4-1.4) 0.506 81.4 / 74.6 1.6 (0.8-3.3) 84.1 / 54.6 0.8 (0.5-1.2) 0.129 

Any disability in walking 71.9 / 60.6** 1.6 (1.2 - 2.2)** 44.7 / 40.2 1.2 (0.7-1.9) 87.2 / 80.0 1.8 (1.0-3.3) 0.863 80.0 / 74.5 1.7 (1.1-2.2)* 66.0 / 53.7* 1.6 (1.0-2.3)* 0.949 

Received all essential 

ANC components 

Any disability in vision 19.6 / 21.9 0.9 (0.6 - 1.2) {6.5} / 7.3 0.8 (0.3-2.2) 36.6 / 40.1 0.8 (0.5-1.3) 0.914 33.1 / 34.6 1.0 (0.6-1.5) [12.1] / 15.6 0.8 (0.4-1.3) 0.330 

Any disability in cognition 15.8 / 22.1 0.7 (0.4 - 1.1) {3.6} / 7.4 0.5 (0.1-1.8) 27.3 / 40.4 0.5 (0.3-0.9)* 0.864 32.6 / 34.5 0.9 (0.5-1.6) [8.9] / 15.7 0.5 (0.3-1.0) 0.246 Any disability in walking 24.4 / 21.6 1.1 (0.7 - 1.6) {2.1} / 7.4 0.3 (0.1-1.2) 41.6 / 39.7 1.0 (0.6-1.7) 0.082 36.9 / 34.3 1.3 (0.8-2.1) [15.3] / 15.4 0.9 (0.5-1.7) 0.345 

Figures in square brackets are based on 25-49 unweighted cases. Figures in curly brackets indicates that a figure is based on fewer than 25 unweighted cases 

Significant criteria for p-values: *p<0.05; **p<0.01; ***p<0.001 
31 

Appendix Table 2 Prevalence of any disability and severe functional disability among women age 

15-49 years with a live birth in the 5 years preceding the survey, according to 

the domains 

Domains of disability 

Any disability 

% (95% CI) 

Severe disability 

% (95% CI) 

Number of 

women 

One or more disability 14.1 (12.7 - 15.7) 2.6 (2.1 - 3.2) 6,711 

Vision 7.0 (6.0 - 8.1) 0.8 (0.6 - 1.2) 6,711 

Cognition 4.8 (4.0 - 5.8) 0.6 (0.4 - 0.9) 6,711 

Mobility 4.8 (4.1 - 5.7) 1.2 (0.8 - 1.6) 6,711 

Hearing 1.8 (1.4 - 2.3) 0.3 (0.1 - 0.5) 6,711 

Self-care 1.0 (0.7 - 1.4) 0.3 (0.1 - 0.6) 6,711 

Communication 0.7 (0.4 - 1.0) 0.1 (0.0 - 0.3) 6,711