A Mixed Methods Analysis of Behavioural and Structural Drivers of Matenal, Sexual and Reproductive Health Services Disruption During and Post Covid-19 in Zimbabwe

Abstract The COVID‑19 pandemic severely disrupted maternal, sexual, and reproductive health (MSRH) services in Zimbabwe, a system already weakened by chronic underfunding, health worker shortages, and economic instability. We investigated the behavioural, social, and structural drivers of MSRH access and uptake during and after the pandemic to inform transformative health system resilience. A convergent parallel mixed‑methods study was conducted across all ten provinces of Zimbabwe. We held 59 focus group discussions (n = 472) with diverse groups (adolescent mothers, persons with disabilities, healthcare workers) and 79 key informant interviews with national to district health officials. A structured survey was administered to 167 mothers of children aged > 5 years and 439 adults/youth on COVID‑19 vaccination. Data were analysed using reflexive thematic analysis and descriptive/inferential statistics (SPSS, Stata), integrated at the interpretation stage and guided by the WHO Behavioural and Social Drivers framework. Findings indicated that the pandemic generated a “dual fear” of COVID‑19 and of facilities as infection hubs. Pervasive vaccine misinformation eroded confidence: only 66% of pregnant women received COVID‑19 vaccination, and booster uptake was 21%. Perceived vaccine safety was strongly associated with uptake (69.1% vs 11.8%; χ²=84.4, p < 0.001). Social influences were bidirectional, traditional leaders boosted acceptance while some religious groups resisted. The patient‑provider relationship deteriorated, with healthcare workers described as harsh and stigmatising, especially to adolescents. Structural barriers were severe: despite a free maternity policy, women uniformly paid for sundries; urban clinics charged registration fees; >90% of clinics lacked ambulances; only 17% of deliveries were doctor‑assisted. We identify the “Ubuntu Paradox”, a contradiction between the communal ethic of collective responsibility and a system that individualises the financial and logistical burden of care. The pandemic audited a fragmented MSRH system. The Ubuntu Paradox calls for a reorientation from commodified, individualised care to a model rooted in social solidarity.