Abstract
BackgroundIn countries, such as Mozambique, where maternal mortality remains high, the greatest contribution of mortality comes from the poor and vulnerable communities, who frequently reside in remote and rural areas with limited access to health care services. This study aimed to understand women’s health care seeking practices during pregnancy, taking into account the underlying social, cultural and structural barriers to accessing timely appropriate care in Maputo and Gaza Provinces, southern Mozambique.MethodsThis ethnographic study collected data through in-depth interviews and focus group discussions with women of reproductive age, including pregnant women, as well as household-level decision makers (partners, mothers and mothers-in-law), traditional healers, matrons, and primary health care providers. Data was analysed thematically using NVivo 10.ResultsAntenatal care was sought at the heath facility for the purpose of opening the antenatal record. Women without antenatal cards feared mistreatment during labour. Antenatal care was also sought to resolve discomforts, such as headaches, flu-like symptoms, body pain and backache. However, partners and husbands considered lower abdominal pain as the only symptom requiring care and discouraged women from revealing their pregnancy early in gestation. Health care providers for pregnant women often included those at the health facility, matrons, elders, traditional birth attendants, and community health workers. Although seeking care from traditional healers was discouraged during the antenatal period, they did provide services during pregnancy and after delivery. Besides household-level decision-makers, matrons, community health workers, and neighbours were key actors in the referral of pregnant women. The decision-making process may be delayed and particularly complex if an emergency occurs in their absence. Limited access to transport and money makes the decision-making process to seek care at the health facility even more complex.ConclusionsWomen do seek antenatal care at health facilities, despite the presence of other health care providers in the community. There are important factors that prevent timely care-seeking for obstetric emergencies and delivery. Unfamiliarity with warning signs, especially among partners, discouragement from revealing pregnancy early in gestation, complex and untimely decision-making processes, fear of mistreatment by health-care providers, lack of transport and financial constraints were the most commonly cited barriers. Women of reproductive age would benefit from community saving schemes for transport and medication, which in turn would improve their birth preparedness and emergency readiness; in addition, pregnancy follow-up should include key family members, and community-based health care providers should encourage prompt referrals to health facilities, when appropriate.Trial registrationNCT01911494Electronic supplementary materialThe online version of this article (doi:10.1186/s12978-016-0141-0) contains supplementary material, which is available to authorized users.
Highlights
In countries, such as Mozambique, where maternal mortality remains high, the greatest contribution of mortality comes from the poor and vulnerable communities, who frequently reside in remote and rural areas with limited access to health care services
Women of reproductive age would benefit from community saving schemes for transport and medication, which in turn would improve their birth preparedness and emergency readiness; in addition, pregnancy follow-up should include key family members, and community-based health care providers should encourage prompt referrals to health facilities, when appropriate
Interview and focus group discussion respondents The core data for this study component was generated from 33 focus group discussions (FGD) involving 196 participants, which included women of reproductive age (WRA), mothers, mothers-in-law, and partners of WRA, nurses, midwives, medical assistants, matrons, and traditional birth attendants (TBA)
Summary
In countries, such as Mozambique, where maternal mortality remains high, the greatest contribution of mortality comes from the poor and vulnerable communities, who frequently reside in remote and rural areas with limited access to health care services. It is estimated that 303,000 maternal deaths will occur worldwide by the end of 2015. Maternal haemorrhage, and hypertensive disorders of pregnancy collectively account for nearly 50 % of all maternal deaths [1]. The highest mortality rates cluster among the marginalized and poor, who frequently reside in remote and rural areas with limited access to health care services [4]. In Mozambique, the latest maternal mortality ratio (MMR) estimates range from 249–480 per 100,000 live births [2]. The magnitude of unmet need for emergency obstetric care is yet to be comprehensively addressed and is not well documented [6, 9]
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