Purpose This study investigates a complex interplay of socio-ecological aspects that increases maternal health vulnerability (MHV) in rural Sindh, Pakistan. Design/methodology/approach This study uses a cross-sectional design involving 352 women aged 18–49 years from rural Sindh, Pakistan. The analysis included descriptive statistics and parametric and nonparametric tests, including t-test, ANOVA with Tukey's correction and Spearman's correlation test. A four-step multiple linear regression was used to identify SEM-level factors associated with MHV. Data analysis was done in STATA version 17.0. Findings MHV was higher among women with post-natal health issues (β = 2.67, 95% CI: 1.11–4.23), no hospital nearby (β = 5.17, 95% CI: 4.06–6.28), irregular LHW visits with those receiving only one visit (β = 5.11, 95% CI: 2.63–7.59), significant gender inequality (β = 0.98, 95% CI: 0.74–1.23) and poverty (β = 0.42, 95% CI: 0.29–0.56) while lower vulnerability was linked to ANC at public facilities (β = −0.72, 95% CI: 2.20–0.74) and exposure to health information through lady heath workers (β = −4.12, 95% CI: 7.16 to −1.08). Originality/value This study identifies several interconnected barriers to accessing maternal health services. Many women lack the education necessary to make timely decisions, which leads to delays in attending antenatal care (ANC) visits. Additionally, the combination of educational gaps and structural factors, including poverty, often drives women to rely on traditional birth attendants for assistance. The study underscores the importance of using a variety of approaches to tackle gender inequalities, improve health knowledge and invest in women's social connections. This means building support networks, trust and sharing information, which can significantly impact women's health habits and pregnancy results.
Agha et al. (2026) studied this question.