Mheta and Mashamba-Thompson Systematic Reviews (2017) 6:99
DOI 10.1186/s13643-017-0494-7
PROTOCOL
Open Access
Barriers and facilitators of access to
maternal services for women with
disabilities: scoping review protocol
Doreen Mheta and Tivani P. Mashamba-Thompson*
Abstract
Background: The Sustainable Development Goals (SDGs) emphasises the increasing equitable coverage of quality
health care and provision of integrated services as means of reducing maternal mortality. Despite so much effort
being placed on improved access to maternity health care, studies show that women with disabilities are being
systemically excluded from the mainstream maternal health services. The proposed scoping review aims to map
literature on the barriers and facilitators of access to maternal services for women with disabilities.
Methods and analysis: The search strategy for this scoping review study will involve electronic databases including
Pubmed, MEDLINE via EBSCOhost, CINAHL Plus with full text via EBSCOhost, Africa-Wide Info via EBSCOhost, JSTOR and
Proquest Health and Medical Complete. Articles will also be searched through the “Cited by” search as well as citations
included in the reference lists of included articles. A two-stage mapping strategy would be conducted. Stage 1 would
be to screen studies through examining their titles. Furthermore, we will screen abstracts of the identified studies
descriptively and by focus and method as stipulated by the inclusion and exclusion criteria. In stage 2, we will extract
data from the included studies. A parallel screening and data extraction will be undertaken by two reviewers. We will
access the quality of the included studies using the mixed methods appraisal tool (MMAT). We will use NVIVO version
10 to extract the relevant outcomes and thematic analysis of the studies.
Discussion: We anticipate to find relevant studies reporting evidence on the barriers and facilitators of access to
maternal health services in Sub-Saharan Africa. The evidence obtained from the included studies when summarised
will help guide future research. The study findings will be disseminated electronically and in print. In addition, it will be
presented at conferences related to sexual reproductive health, maternal health care and reproductive health.
Keywords: Maternal health, Disability, Health care, Access, Sub-Saharan Africa
Background
Maternal health is a global health priority which emphasises the reduction of maternal mortality in developing
countries. The recently adopted Sustainable Development
Goals (SGDs) focuses on increasing equitable coverage of
quality health care and provision of integrated services as
means to reduce maternal mortality [1]. Most governments in Sub-Saharan Africa are prioritising maternal
health [2, 3]. However, the majority of the countries in this
region are faced with poor referral systems, shortages of
skilled health personnel and poor transport infrastructure
* Correspondence: Mashamba-Thompson@ukzn.ac.za
Discipline of Public Health Medicine, School of Nursing and Public Health,
University of KwaZulu-Natal, Durban 4001, South Africa
[4]. While most developed countries and some low and
middle income countries (LMICs) experienced some declines in maternal mortality ratios, most of the countries
in Sub-Saharan regions still experience high maternal
mortality rates [5]. As a result, Sub-Saharan Africa did not
achieve the millennium development goal of reducing maternal mortality by 75% [6].
South Africa is one of the developing countries that are
in the forefront in the prioritising of maternal health
through increasing primary health care clinics [3]. This is
evidenced by the removal of user fees for maternal and
child health services at the levels of primary health care and
district hospital [7]. Despite these measures being put in
place, women particularly the vulnerable and disadvantaged
still face numerous challenges in accessing these services in
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Mheta and Mashamba-Thompson Systematic Reviews (2017) 6:99
South Africa [8]. While the factors that militate against maternity services for women in general are well documented
in Sub-Saharan Africa, there is little research that documents the factors that inhibit or enhance access to maternity and child services for women with disabilities [9–11].
Though there are numerous definitions of disabilities, in
this review, disabilities will refer to long-term visual, hearing, mental and physical impairment [8].
Access to health care is a complex phenomenon
which is influenced by multiple factors. Disparities in
access to health result in adverse health outcomes,
thus posing a public health problem [12]. There is no
single definition of access to health care services;
however, a comprehensive view of access pertains to
the dimensions of availability, accessibility, accommodation, affordability and acceptability [13]. For this review, access to maternal health will be explored
through the availability, affordability, acceptability and
quality of the services [13]. Some of the challenges
that are specifically faced by women with disabilities
include survival rates, maternal mortality and morbidity, accessing information on sexual reproductive
health, family planning services, and prenatal and post
natal services [14]. In addition, research reveals that
women with disabilities have higher pregnancy complications, preterm deliveries and low birth infants
[15]. Despite that there is a growing recognition that
health systems should develop appropriate and accessible maternal health care services for women with
disabilities [11, 14, 16], there is paucity of evidence
on the experiences of women with disabilities on
accessing maternal health care services [16].
The existing literature indicates that there is a need to
understand the barriers and facilitators of access to maternal services as well as the different models of maternity health care services that could facilitate choices for
women with disabilities [17]. Moreover, there is a need
for strategies to improve access to maternal health care
services for this population [14]. This may facilitate the
development of horizontal approaches towards the reduction of maternal mortality in Sub-Saharan Africa.
This scoping review therefore aims at mapping literature
on the barriers and facilitators of access to maternal
health care services for women with disabilities. The objectives of this scoping review are as follows:
➢ To review published literature on the barriers and
facilitators of access to maternal health services for
women with disabilities
➢ To review the literature on existing maternity health
care models for women with disabilities
➢ To review literature on the existing interventions to
improve access to maternity health care for women
with disabilities
Page 2 of 6
The findings from this study will enable the researchers
to examine the extent and range and nature of research
activity on the barriers and facilitators of access to maternity services for women with disabilities. In addition, the
findings will enable the researchers to identify the different maternity health care models and interventions that
improve access to maternal health care services.
Methodology
Scoping review
We will conduct a scoping review of peer-reviewed literature on the barriers and facilitators of access to maternal services for women with disabilities. A scoping
review method was selected as it facilitates the mapping
of new concepts, types of evidence and gaps related [18].
For the proposed review, we would be guided by Arksey
and O’Malley framework [19]. The framework involves
(i) identifying the research question, (ii) identifying relevant studies, (iii) study selection, (iv) charting the data,
and (v) collating, summarising and reporting results.
Identifying the research question
The research question is what is known from the existing literature about the barriers and facilitators of access
to maternal health services in Sub-Saharan Africa?
The sub-research questions are as follows:
1. What are the existing models of maternal health care
services in Sub-Saharan Africa?
2. What are the available interventions for facilitating
access to maternal services for women with
disabilities in Sub-Saharan Africa?
Eligibility of research question
The study will use an amended PICOS (Population,
Intervention, Comparison, Outcomes and Study setting)
framework to determine the eligibility of the research
question (Table 1).
Identifying relevant studies
Primary studies that have a clear empirical base utilising
qualitative, quantitative and mixed methods published in
peer-reviewed journals as well as in grey literature that address the research question will be included. All study designs would be included. An electronic search will be
conducted in the following electronic databases: MEDLINE/Pubmed, CINAHL Plus with full text (EBSCO) and
Africa-Wide information, Google Scholar and Proquest.
Websites such as the World Health Organisation (WHO),
UNICEF and governmental websites would be searched for
policies and reports on access to maternal services for
women with disabilities. Studies will be identified by searching literature that was published in any language and those
Mheta and Mashamba-Thompson Systematic Reviews (2017) 6:99
Table 1 PICOS framework for determination of eligibility of
review question
Criteria
Determinants
Population
The population of this study will be women with
disabilities (that is, visual, hearing, mental and physical
impairment) who are seeking maternal health care
services (antenatal, perinatal and immediate postpartum).
Intervention
Access to maternal health care services (antenatal,
perinatal and immediate post-partum)
Comparison
Women without disabilities
Outcomes
Access to maternal health care services
Study setting Sub-Saharan Africa
While the review focuses mainly on studies from SubSaharan Africa, due to the paucity of literature on access
to maternal services for women with disabilities in this
region, the setting has been opened to include studies
from all over the world.
studies that are translatable to English from January 2000
to December 2015.
Articles will also be searched through the “Cited by”
search as well as citations included in the reference lists of
included articles. The search terms will include maternal
health, disability, health care, access, and Sub-Saharan
Africa. Database-specific thesaurus terms (e.g. MeSH
terms) as well as free-text terms will be used to search articles. After searching, the studies will be screened against
the inclusion and exclusion criteria.
Page 3 of 6
with disabilities seeking health care services other
than maternal health care services: This review will
exclude studies that have women without disabilities
as the population of interest due to the fact that
women with disabilities have their own challenges
that are specific to them. Studies that report on
women without disabilities may not bring out the
barriers and facilitators of access to maternal
services specific to women with disabilities
Studies that report on drug and procedural
interventions and
Studies that are published before January 2000
and after December 2015: Studies conducted
during the year 2016 as it is now a new era of
the SDGs whereas during the years 2000 to 2015,
it was the MDG era. Studies publish after
December may have another focus which is
completely different from the one in the MDG
era. Furthermore, before 2000, the emphasis on
reducing maternal deaths by three quarters did
not exist and the Convention on the Rights of
Persons with Disabilities (CRPD) had not been
adopted by the United Nations. As result, the
issues of women with disabilities were not
emphasised as they were after 2006.
Exclusion criteria
The search strategies will be piloted to check the
appropriateness of the selected databases and key
words. Articles will be searched from the databases
by one reviewer who will share the Endnote library
with the second reviewer. The two reviewers will
conduct a comprehensive title screening guided by
the eligible criteria. All eligible studies will be
exported into EndNote X7.5 reference management
software. EndNote X7 program will be used to check
for duplication of articles and to delete the duplicated articles. Table 2 below illustrates how the electronic data search will be recorded.
Abstracts and full articles of the included studies
will be screened for eligibility. This will be conducted
independently by two reviewers to identify study analysis and assessment. Where there is no agreement
between the two reviewers, the studies will be passed
on to a third reviewer for consideration. We will seek
for assistance from the UKZN library services for articles that are difficult to find. We will also write to
the authors to ask for papers in cases of difficult to
find articles. Table 4 in the appendix presents the results of the pilot search.
Studies will be excluded if they meet the following
characteristics:
Table 2 Electronic search record
Study selection
The eligibility criteria were developed to ensure that the
included studies contain the specific information needed
to answer the research question on the barriers and facilitators of access to maternal health care services for
women with disabilities.
Eligibility criteria
Inclusion criteria
For studies to be included, they should meet the following
criteria:
There would be no language restriction.
Focus on women with disabilities seeking maternal
health care services.
Published from January 2000 to December 2015.
Report on experiences of women with disabilities
when accessing maternal health care services.
Studies which do not have women with disabilities
as part of the study population focus on women
Keyword search Search engine used Number of publications retrieved
Mheta and Mashamba-Thompson Systematic Reviews (2017) 6:99
The study selection procedure will be summarised
using a PRISMA chart as indicated in Fig. 1.
Page 4 of 6
Table 3 Data charting form
Author and date
Study title
Charting the data
Journal full reference
An analytical method would be utilised to extract the
background information and process oriented information of each included study. A data charting form
would be developed and piloted. The variables and
themes to include in order to answer the question
will be determined as indicated in Table 3. The data
charting form will be constantly updated.
Aims or research question
Participant characteristics
Recruitment context (e.g. where people were recruited).
Sampling method
Study design
Theoretical background
Data collection (what data collection methods were used?)
Data analysis (how was the data analysed?)
The aim of this study is to map the existing evidence
and to summarise the findings as presented across articles. A narrative account of the data extracted from
the included studies will be analysed using the thematic content analysis. Data will be extracted around
the following outcomes: models of maternity health
care services, barriers of access to maternity health
care services, and facilitators of access to maternal
health care services. Emerging themes will also be
coded. NVIVO software version 10 would be utilised
collectively to code the data from the included studies
based on the above categories [20]. The below
process would be followed;
Intervention
Screening
Identification
Collating, summarising and reporting of results
Records identified through database
searching
(n = )
Intervention outcome
Most relevant findings
Conclusions
Comments
Additional records identified through
other sources
(n = )
Records after duplicates removed
(n = )
Records screened
(n = )
Included
Eligibility
Full-text articles assessed for
eligibility
(n = )
Fig. 1 Study selection procedure
Coding data from the included articles
Categorising the codes into major themes
Displaying the data
Identifying key patterns in the data and identify subthemes
Studies included in data
extraction
(n = )
Studies included in
qualitative synthesis
(thematic analysis)
(n = )
Records excluded
(n = )
Full-text articles excluded,
with reasons
(n = )
Mheta and Mashamba-Thompson Systematic Reviews (2017) 6:99
Summarising
Synthesis
We will analyse the resulting themes and critically
examine their relationship to the research question.
The reviewers will also analyse the meanings of the
findings in relation to the aim of the study and the
implications of these findings for future research,
policy and practice.
Quality appraisal
The quality of the studies will be determined
through study appraisal using the mixed method appraisal tool (MMAT)-Version 2011 [21]. The tool
will be utilised to examine the appropriateness of
the aim of the study, adequacy and methodology,
study design, participant recruitment, data collection,
data analysis, presentation of findings, authors’ discussions and conclusions. The quality of the article
will be determined from the examination of the
above mentioned aspects.
Page 5 of 6
quality maternal health care services are available to
those who need the services. Therefore, this review
excludes studies that report on drug and procedural
interventions as the main focus is on access (availability, affordability, acceptability and quality of the
services). The studies on drug and procedural interventions report on women with disabilities who
have already accessed the services and the intervention is not the focus of this study.
The findings of this study may be of interest to
policy makers and stakeholders involved in the
provision of maternal health care services, and stakeholders advocating for equity of access and health
systems strengthening. In addition, the findings of
this study will be of interest to researchers by
highlighting gaps in evidence that may require further investigation.
Appendix
Table 4 Results of the pilot database search
Keyword search
Discussion
The scoping review will be conducted as a first part
of the study on the barriers and facilitators of access to maternity services for women with disabilities in South Africa. The review is aimed mapping
the existing evidence and summarising the findings
as presented across the studies on the barriers and
facilitators of access to maternal health care services
for women with disabilities. In addition, the review
will on identify the existing maternity models and
interventions that enhance access to maternal health
care services for women with disabilities. Despite
that there is a growing recognition that health systems should develop appropriate and accessible maternal health care services for women with
disabilities [11, 14, 16], there is paucity of evidence
on the experiences of women with disabilities on
accessing maternal health care services [16]. In
order to enable development of disability friendly
maternal health care services, there is a need to explore the maternal health care needs, barriers and
facilitators of access to maternal services for women
with disabilities especially in low and middle income
countries [15].
Studies that report on drugs and procedural interventions would be excluded because focus of this
review is on access to maternal health services.
Most maternal deaths could be avoided if the
Date of Search
Number of
search engine used publications
retrieved
(((“disabled persons”[MeSH 11 April MEDLINE via 1115
Terms] OR (“disabled”[All
2017
Pubmed
Fields] AND “persons”[All
Fields]) OR “disabled
persons”[All Fields] OR
“disabled”[All Fields]) AND
(“women”[MeSH Terms] OR
“women”[All Fields])) AND
(access[All Fields] AND
(“maternal health
services”[MeSH Terms] OR
(“maternal”[All Fields] AND
“health”[All Fields] AND
“services”[All Fields]) OR
“maternal health
services”[All Fields] OR
(“maternal”[All Fields] AND
“health”[All Fields] AND
“care”[All Fields]) OR
“maternal health care”[All
Fields]) AND services[All
Fields])) OR (models[All
Fields] AND (“maternal
health services”[MeSH
Terms] OR (“maternal”[All
Fields] AND “health”[All
Fields] AND “services”[All
Fields]) OR “maternal health
services”[All Fields])) AND
((“loattrfull text”[sb] AND
hasabstract[text] AND
“loattrfree full text”[sb])
AND (“2000/01/01”[PDAT] :
“2015/12/31”[PDAT]) AND
“humans”[MeSH Terms])
Mheta and Mashamba-Thompson Systematic Reviews (2017) 6:99
Abbreviations
CRPD: Convention on the Rights of Persons with Disabilities; LMIC: Low and
middle income countries.; MDG: Millennium development goals;
MMAT: Mixed methods appraisal tool; PICOS: Population intervention
outcomes study setting; SDG: Sustainable Development Goals
Page 6 of 6
9.
10.
Acknowledgements
The authors would like thank the College of Health Sciences, University of
KwaZulu-Natal for financially supporting the development of this research
study.
Funding
The University of KwaZulu-Natal College of Health Sciences PhD Scholarship
funded this research study.
Availability of data and materials
All data generated or analysed during this study will be included in the
published scoping review article
Author’s contributions
DM conceptualised the study and prepared the draft proposal under the
supervision of TPM-T. Both DM and TPM-T contributed to the development
of the background and planned output of the research as well as the design
of the study. TPM-T contributed to the development of the methods relating
to the review and synthesis of data including the sifting and data extraction
process. DM prepared the manuscript, and TPM-T reviewed it. Both authors
(DM and TPM-T) contributed to the reviewed draft version of the manuscript
and approved the final version.
11.
12.
13.
14.
15.
16.
17.
18.
Competing interests
The authors declare that they have no competing interests.
19.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not applicable.
Publisher’s Note
20.
21.
reference.sabinet.co.za/webx/access/electronic_journals/healthr/healthr_
2014_2015_a9.pdf. Accessed on 16 Dec 2016
Ahumuza SE, Matovu JKB, Ddamulira JB, Muhanguzi FK. Challenges in
accessing sexual and reproductive health services by people with physical
disabilities in Kampala. Uganda Reproductive Health. 2014;11(1):59.
Bremer K, Cockburn L, Ruth A. Reproductive health experiences among
women with physical disabilities in the Northwest Region of Cameroon. Int
J Gynaecol Obstet. 2010;108(3):211–3.
Smith E, Murray SF, Yousafzai AK, Kasonka L. Barriers to accessing safe
motherhood and reproductive health services: the situation of women with
disabilities in Lusaka. Zambia Disability Rehabilitation. 2004;26(2):121–7.
Graves A. A model for assessment of potential geographical accessibility: a
case for GIS. Online J Rural Nurs Health Care. 2009;9(1):46.
Levesque JF, Harris MF, Russell G. Patient-centred access to health care:
conceptualising access at the interface of health systems and populations.
Int J Equity Health. 2013;12(1):18.
Bradbury-Jones C, Breckenridge JP, Devaney J, Duncan F, Kroll T, Lazenbatt A,
et al. 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. 2015;15(350):350.
Hwang K, Johnston M, Tulsky D, Wood K, Dyson-Hudson T, Komaroff E.
Access and coordination of health care service for people with disabilities. J
Disability Policy Studies. 2009;20(1):28–34.
Morrison J, Basnet M, Budhathoki B, Adhikari D, Tumbahangphe K,
Manandhar D, et al. Disabled women’s maternal and newborn health care
in rural Nepal: a qualitative study. Midwifery. 2014;30(11):1132–9.
Lawler D, Lalor J, Begley C. Access to maternity services for women with a physical
disability: a systematic review of the literature. Int J Childbirth. 2013;3(4):203.
Colquhoun HL, Levac D, O’Brien KK, Straus S, Tricco AC, Perrier L, et al.
Scoping reviews: time for clarity in definition, methods, and reporting. J Clin
Epidemiol. 2014;67(12):1291–4.
Arksey H, O’Malley L. Scoping studies: towards a methodological framework.
Int J Soc Res Methodol. 2005;8(1):19–32.
Castleberry A. NVivo 10 [software program]. Version 10. QSR International;
2012. American journal of pharmaceutical education. 2014;78(1).
Pluye P, Robert E, Cargo M, Bartlett G, O’Cathain A, Griffiths F, et al. Proposal:
a mixed methods appraisal tool for systematic mixed studies reviews.
Montreal: McGill University, Department of Family Medicine; 2011. Mixed
methods appraisal tool (MMAT) version 2011.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Received: 17 February 2017 Accepted: 3 May 2017
References
1. Regmi P, Van Teijlingen E, Hundley V, Simkhada P, Sharma S, Mahato PK.
Sustainable Development Goals: relevance to maternal and child health in
Nepal. Health Prospect: J Public Health. 2016;15(1):9–10.
2. Kinney MV, Kerber KJ, Black RE, Cohen B, Nkrumah F, Coovadia H, et al. SubSaharan Africa’s mothers, newborns, and children: where and why do they
die? PLoS Med. 2010;7(6):e1000294.
3. Chopra M, Daviaud E, Pattinson R, Fonn S, Lawn JE. Health in South Africa 2.
Saving the lives of South Africa’s mothers, babies, and children: can the
health system deliver? LANCET. 2009;374(9692):835–46.
4. Kyei-Nimakoh M, Carolan-Olah M, McCann TV. Barriers to obstetric care at
health facilities in Sub-Saharan Africa—a systematic review protocol.
Systematic reviews. 2015;4(1):54.
5. Ononokpono DN. Maternal health care in Nigeria: Do community factors
moderate the effects of individual-level education and ethnic origin? Etude
de la Population Africaine. 2015;29(1):1554.
6. Nyamtema AS, Mwakatundu N, Dominico S, Mohamed H, Pemba S,
Rumanyika R, Nzabuhakwa C. Enhancing Maternal and Perinatal Health in
Under-Served Remote Areas in Sub-Saharan Africa: A Tanzanian Model.
PLoS One. 2016;11(3):e0151419.
7. Chola L, Pillay Y, Barron P, Tugendhaft A, Kerber K, Hofman K. Cost and impact
of scaling up interventions to save lives of mothers and children: taking South
Africa closer to MDGs 4 and 5. Glob Health Action. 2015;8:1–14.
8. Sherry K. Disability and rehabilitation : essential considerations for equitable,
accessible and poverty-reducing health care in South Africa2014 [cited
[“Sherry, Kate - University of Cape Town”]:[89-99 pp.]. Available from: http://
Submit your next manuscript to BioMed Central
and we will help you at every step:
• We accept pre-submission inquiries
• Our selector tool helps you to find the most relevant journal
• We provide round the clock customer support
• Convenient online submission
• Thorough peer review
• Inclusion in PubMed and all major indexing services
• Maximum visibility for your research
Submit your manuscript at
www.biomedcentral.com/submit