Multidimensional barriers to women’s access to maternal health services in Herat Province, Afghanistan: a cross-sectional study

Abstract

Maternal health remains a critical public health priority in Afghanistan, which has one of the highest maternal mortality ratios. Women’s access to maternal health services is influenced by multiple interacting dimensions; however, comprehensive evidence on the relative contribution of structural, sociocultural, and informational barriers in provincial contexts remains limited. This study aimed to examine the multidimensional barriers to women’s access to health services in Herat Province, Afghanistan. A cross-sectional study was conducted between September 2025 and January 2026 among 365 reproductive-age women in Herat province. A multi-stage stratified cluster sampling method was employed, with participants selected from public health facilities using systematic random sampling. Data were collected using a structured questionnaire assessing sociodemographic characteristics, structural and sociocultural barriers, maternal health awareness, and service quality. Reliability was confirmed using Cronbach’s alpha (0.704–0.811). An exploratory factor analysis was conducted to identify the underlying structure of the barriers. The Kaiser-Meyer-Olkin (KMO) measure was 0.680, indicating borderline but acceptable sampling adequacy for factor analysis. Nonparametric tests (Mann-Whitney U and Kruskal–Wallis tests), Spearman’s correlation, and nominal logistic regression were used for data analysis. The mean age of the participants was 30.36 ± 9.87 years. The majority were illiterate (76.7%), resided in rural areas (67.7%), and had monthly incomes below 7,000 Afghanis (90.7%). Exploratory factor analysis revealed four dimensions: structural access barriers, sociocultural barriers, maternal care and awareness, and service quality. Sociocultural barriers had the greatest impact on access (mean = 3.15), followed by structural barriers (mean = 2.83). A moderate positive correlation was observed between structural and sociocultural barriers (ρ = 0.298, p < 0.01), whereas sociocultural barriers were negatively correlated with awareness (ρ = -0.301, p < 0.01). Lower education was the strongest predictor of barriers, with illiterate women having significantly higher odds of access limitations (Exp(B) = 21.535), distance barriers (Exp(B) = 23.155), need for permission (Exp(B) = 9.541), and shame/Haya (Exp(B) = 6.131). Rural residence was associated with higher structural and sociocultural barriers and lower awareness levels. Service quality was rated favorably (mean = 3.36); however, it did not compensate for access limitations. Access to maternal health services in Herat Province is shaped by multiple interacting dimensions, with sociocultural barriers predominating over structural constraints. Education was the strongest protective factor. Improving maternal health outcomes in Afghanistan requires integrated interventions that simultaneously address cultural norms, structural barriers, and educational disparities, with particular emphasis on women’s education and community engagement to reduce sociocultural constraints.