Within the last three decades, much progress has been made to improve sexual and reproductive and rights (SRHRs) worldwide. As a result, global maternal mortality ratio has decreased from 380 to 210 per 100,000 live births between 2000 and 2013 . This progress notwithstanding, many women still lack access to life-saving sexual and reproductive health (SRH) services in many low-income countries, including Ghana. One group that has particularly been disadvantaged but has nevertheless received little attention in low-income settings is People with Disabilities (PWDs). According to the World Report on Disability 2011, disability is the umbrella term for impairments, activity limitations and participation restrictions, referring to the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors) . Globally, PWDs constitute 15% of the world’s population, of which over 80% lives in low-income countries . PWDs remain one of the most marginalized and socially excluded groups, and this disadvantage transcends several spheres: PWDs have generally poorer health, lower education achievements, fewer economic opportunities and higher rates of poverty than people without disabilities [2–4]. In particular, women with disabilities (WWDs) are more likely to be poorer and have lower social and economic status than their counterparts who have no disability [3, 4].
In the context of sexual, reproductive, and maternal health more specifically, a number of recent studies note that WWDs have largely been ignored in research and programming [2, 5, 6–17]. Part of the reason for this neglect is that WWDs are often thought not to be sexually active, and less likely to marry or to want to have children than non-disabled women [5–17]. Others attribute this neglect to a complex web of discrimination made up of negative social attitudes and cultural assumptions as well as environmental barriers including policies, laws, structures and services, which result in marginalization and social exclusion [6–18]. Although attitudes may be changing in some contexts , stigma and prejudice against WWDs often prevent them from accessing sexual, reproductive, and maternal healthcare information and services . Meanwhile, recent data shows that rates of sexual activity, need for family planning (FP), and childbirth services among WWDs are comparable to those of non-disabled women [19–21]. This challenge is compounded by the fact that research on disability and reproductive health is even far more limited in many low-income contexts, including Africa [5, 22–24]. A recent study puts this issue quite bluntly: ‘There is a complete lack of published literature in peer reviewed journals on the reproductive health status of women with disabilities’ .
Ghana, like many countries in Sub-Saharan Africa (SSA), has made progress over the last several decades to improve the health of its citizens. Despite this progress, Ghana’s health sector still faces critical healthcare service delivery challenges in the areas of SRM health, including low use of modern contraceptives. Data from Ghana’s 2014 Demographic and Health Survey (DHS) suggest that while knowledge of modern contraceptive methods is universal (> 99%), only 27% of married women are using any contraceptive method . Unmet need for FP among married women is still 30%. There are however local and regional variations, with the Northern Region (where this study will be implemented) having the highest unmet need for birth spacing (21.7%). Similar disparities exist for skilled attendance at birth: at the national level, 74% of births are attended skilled personnel compared to 36.4% of births in the Northern region . At the same time, traditional birth attendants (TBAs) deliver some 41% of births in the Northern Region .
One group that has particularly been disadvantaged but has nevertheless received little attention in Ghana is PWDs [22, 24]. Approximately 3% of Ghana’s population has some disability . This prevalence however varies from one geographic location to another and across different socio-economic groups. For instance, recent estimates suggest that among women of reproductive age (15–49 years) in Ghana, 10.2% have some kind of disability . The three most prevalent types of disability in Ghana are those related to physical disabilities, visual impairment, and hearing impairment . Although Ghana is a signatory to the United Nations Convention on the Rights of Persons with Disabilities (UNCRPWDs) , and also enacted the Persons with Disability Act (Act 715) in 2006 , widespread enforcement of these laws is yet to be reported. Indeed, previous research by Ganle and colleagues have highlighted critical challenges WWDs still face in accessing modern contraceptive and skilled maternal healthcare services in Ghana . For instance, the authors showed that many WWDs who are sexually active, and do want to receive contraception and skilled maternal healthcare information and services often encounter grave barriers, including healthcare providers' insensitivity and lack of knowledge about the sexual health, FP and maternity care needs of WWDs; unfriendly or inaccessible healthcare infrastructure; health information that lacks specificity in addressing the special SRH needs of WWDs; and lack of social support at community and health facility levels to assist WWDs access unfriendly physical health infrastructure to receive appropriate SRHRs information and services . Consequently, many WWDs often turn to other sources of care, including use of untrained TBAs during childbirth .
Recent global emphasis on the rights of PWDs in the UNCRPWDs as well as current emphasis on shared economic growth and prosperity under the Sustainable Development Goals (SDGs) have re-emphasized the necessity of addressing disabled women/girls’ SRHRs. What is currently lacking in many African contexts, however, is how to innovatively address the SRHRs needs and challenges of WWDs. Although there are some interventions in high-income settings [25, 30], this is not the case in many settings in Africa, including Ghana. Currently, targeted and proven interventions to reach WWDs with essential SRHS are lacking . To address this challenge, the current study proposes to implement an integrated set of interventions to address some key barriers WWDs face accessing SRHRs information and services in Ghana. Specifically, the study seeks to i) determine awareness and use of SRH services among WWDs before intervention; ii) estimate and compare the effect of exposing WWDs to different components of an integrated intervention on awareness about, and use of FP/modern contraceptive services, antenatal care attendance and skilled birth services; iii) identify other significant determinants of SRH care services utilization among WWDs; and iv) assess the cost-effectiveness of implementing either the integrated package of three interventions, or only the health facility or individual level interventions.