Challenges and opportunities for implementing evidence-based antenatal care in Mozambique: a qualitative study

Three focus groups were conducted with women attending ANC at the time of the study, and two were conducted with women living in surrounding communities who had a recent experience with ANC and delivery services. Women attending ANC at the time of the study were recruited if they had attend at least one ANC visit at the study facilities. Health facility staff assisted in identifying potential study participants until the quota of participants for each focus group was reached. In the surrounding communities, women were identified with the help of community leaders and the permission of district authorities. Focus groups lasted approximately 90 minutes and were held in locations convenient to the participants. Snacks and beverages were offered to participants.

All focus group discussions involved 7 to 13 women and were conducted by a team including a trained facilitator fluent in Portuguese and English, an observer responsible for taking notes (IJT or AB), and a translator of other local languages or dialects to help with communication. Facilitators were selected using the educational level criteria combined with experience in data collection methods through in-depth individual interviews and conducting focus discussions, or experience in community animation (See Additional file 1 for more detailed information on the focus groups and facilitators).

Semi structured interviews were conducted with the following key informants: (i) health sector senior officers at national level in charge of policy and guideline development for maternal, newborn and child health (MNCH) including all aspects of care related to the ANC model; (ii) health sector senior officers at provincial level responsible for providing guidance on the content of MNCH strategies and for monitoring the implementation of health programs at provincial level; (iii) health sector senior officers at district level in charge of supervising the quality of MNCH services including the supply chain management; (iv) Non Governmental Organizations (NGO) representatives engaged in supporting the delivery of maternal and child health (MCH) services and/or supply chain management; (v) staff at national, provincial and district level responsible for supply chain management of medicines and other health commodities needed for ANC services; (vi) MCH nurses responsible for delivering ANC services; and (vii) in each of the selected health centers, staff involved in supply chain management of the medicines and other materials necessary for full implementation of the ANC model.

The interviews were carried out by two investigators (IJT and AB) in locations convenient to the interviewee, and lasted approximately 1 hour. Notes were taken during focus groups and interviews, translated into English, and written up in Microsoft word.

A checklist was used to assess the availability of equipment, medicines and other health commodities needed for full implementation of the ANC package. It was filled out during interviews with responsible staff in ANC consultation rooms, pharmacies, laboratories and storage rooms at the health center level, and by taking an inventory of stocks available in warehouses at the central, provincial, and district level. Registers were checked for information on stock-outs in the past. Two investigators (IJT, AB) worked closely with the staff from the Ministry of Health involved in supply chain management and logistics to examine the stocks in the three selected health centers, as well as central, provincial and district warehouses in order to follow the supply chain from when products arrive in Maputo (central level) to when they reach the health facilities via the provincial and district warehouses.

The ANC model requires availability of at least 42 different products at the health center during the first consultation (e.g. medicines, health commodities, equipment and instruments, laboratory reagents and tests). In the three study health centers, 10 different sub-supply chains provide these 42 products. None of the health centers were observed to have all of the required products available at the time of data collection.

The malfunctioning of the supply chain system is related to problems with planning, procurement, storage and distribution of goods. Barriers identified to effective planning and management include (i) fragmentation of the system due to multiplicity of chains and sub-chains; (ii) lack of coordination between each level of the supply chain (i.e. health center, district, provincial and national warehouses) due to communication problems; (iii) lack of supply chain management personnel qualified and experienced resulting in a lack of awareness of procedures; and (iv) lack of defined protocols and instructions for supply chain management.

Basic and general procedures are in place for supply chain management throughout the public health system. However they are not always followed for a variety of reasons. The current system of inventory and record keeping is poorly designed, making it a challenge for health center staff to be able to anticipate needs and to avoid stock outs. Supplies are often not re-ordered until after stock-outs have already occurred. The absence of adequate storage rooms and refrigeration at the health centers also creates problems with ensuring stock of sufficient supplies in appropriate conditions. Transportation services are not properly designated for the distribution of health sector supplies, mainly from the district level to the health centers. Consequently, ambulances, which often breakdown or are required for transport of patients, are unofficially used for this purpose.

Health care providers interviewed noted that supplies needed for the interventions are generally not easily accessible and that they spend lots of time trying to obtain them:

"We do not measure the blood pressure because we do not have the device. We have many tensiometers but we do not have the stethoscopes. We only received sphygmomanometer (…) I'm here since February, and we haven´t assessed pregnant women’s blood pressure…" [Nurse at Health Center]

Those interviewed noted that problems with the continuing education system to help providers stay up-to-date on the latest evidence-based guidelines hinders provider ability to fully implement the ANC model.

The continuing education system was designed as a "training of trainers program". This program focuses on MCH district supervisors, this model is seen by the nurses as exclusionary; it does not cover most of the nurses who directly provide services to users. Those who attend the training sessions do not replicate the trainings at the health center level; they complain on not receiving additional benefits (per diem) for participating on the sessions. Participants highlighted that they don´t find the sessions applicable to their daily practice. Transfer of information from the central level is not conducted systematically leading to insecurity and doubts regarding current care recommendations among health providers. Clinical guidelines and protocol updates are not readily available at peripheral health facilities.

Health center informants identified the scarcity of supervision and monitoring visits as a barrier for full implementation of the ANC model. They indicated that the bi-annual supervision visits are not completed as planned. They perceive that increased supervision and training would be useful to refresh their skills, as well as for mentoring purposes and to help them address any difficulties they are facing.

Women identified long waiting times and inadequate infrastructure as barriers to seeking ANC at the health centers. Women reported that they have to wait a long time for ANC due to the absence of an appointment system and shortage of human resources. Nurses typically work in the morning and all ANC consults, therefore, must occur in the morning hours. Women report lack of privacy of the exam rooms for counseling and other ANC services. These conditions also negatively impact the motivation of nurses to provide care.

Health care providers reported that data were not routinely collected at the health centers because they often run out of data collection tools due to chronic shortages of office supplies. From their perspective, they do not receive the training needed to guarantee good quality of data collection and analysis.

There is an absence of protocols for data analysis, for example, and for sharing clinical results with health care providers and other staff. Moreover, multiple reporting systems co-exist, leading to registration duplicates and inefficiencies in the quality control process.

Health care providers expressed a lack of awareness of current clinical guidelines and protocols (e.g. screening for HIV and syphilis or deworming protocols). Also, blood samples are often not adequately taken. Providers often take less blood than necessary and/or wait less time than indicated to obtain accurate results for HIV testing. Both situations might lead to invalid test results.

Health care providers are unable to deliver the full ANC package since they cannot establish a routine and effective workflow due to frequent stock outs of different supplies. Health care providers expressed that lack of time impairs their relationships with their clients. Even when the provider is aware of the existence of protocols, lack of time and adequate supervision impinges on their ability to fully implement them.

Authorities stated that health care providers are unmotivated and have a resistant attitude towards their responsibilities. Nurses contend that the circumstances they face in the health system result in negativity and a loss of motivation.

Although supply stock outs, an unfriendly environment, and long waiting times discourage women from seeking ANC, women recognize the importance of ANC to check their own health status and their unborn baby’s health.

"… It is important to know my health and also how the baby is. Sometimes I feel sick and I don´t know what's going on. Nowadays there are many diseases, I´m afraid to have them…" [Focus Group with ANC Users]

When asked about the importance of each of the components of the ANC package, however, women were unable to respond. Women’s beliefs affected their adherence to some of the recommendations in the ANC model. For example, women’s adherence to the full vaccination plan is poor due to their belief that receiving the first dose of tetanus vaccine is sufficient for the wellbeing of the baby and that other doses are not so necessary.

Women acknowledged that they are more open to receiving ANC at the health center than previous generations, and perceive a benefit to receiving care from both the formal public health system and from relatives or traditional community midwives.

"Most women come to the hospital now, those who do not want to come, trust on their relatives, others trust on the matrons working in neighborhoods" [FGD with ANC Users]

Women are motivated to seek ANC since they perceive that accessing ANC will give them formal entrance into the health system. Both women and nurses interviewed recognize that the main motivation for seeking ANC at the health center is the so called “opening the card” during the first consultation. This refers to the ANC registration card used in the health centers. It is considered a “passport” for access to maternity wards, as well as care after delivery for the mother and newborn. Women perceive that those who do not seek ANC may be mistreated or penalized during delivery and the postpartum period.

“Some women arrive at the clinic during the second or third month of pregnancy in order to “open the card”. [Nurse at a Health Center]

Usually the first visit for ANC occurs during the second trimester of pregnancy. Women explained that this is often because they cannot receive services without pregnancy confirmation. Given that health centers do not have pregnancy tests available, confirmation of pregnancy is limited to visual or physical examination of a women’s belly. Primiparous women in the study area traditionally do not seek care until the pregnancy can be visually confirmed:

"Depends… and sometimes varies, but it is not common for a two month pregnant woman to go to the clinic, they must first expect to receive advice at home. (…) According to our tradition we have to wait until the belly is visible, that confirms the pregnancy" [Focus Group with women at the community]

“When they arrive on the second month and we can´t confirm the pregnancy by the physical examination we request them to buy a test at a private pharmacy or come back when the pregnancy is visible. If I can´t feel the pregnancy we can´t open the file because I'm not sure if the woman is pregnant" [Nurse at a Health Center]

There is a tradition that the first delivery should take place at home because it is the opportunity for the primiparous to learn from older and experienced women traditional knowledge regarding maternity. However we have observed that in general, women agree that it is important to give birth at maternities. They noted that women who did not attend ANC –and do not have the ANC registration card– would not dare to go for institutional delivery as they are afraid of being mistreated by the nurses. These women go to the health centers only for the postpartum visit.

Lack of transportation and distance to facilities were recognized as barriers to seeking ANC by women and health care providers interviewed. Some health centers do not offer testing services, and must refer women to the nearest health facility where laboratory facilities are available. This creates an additional cost for women who must travel to another health center for testing. Women often, as a consequence, opt as an alternative to visit a traditional community midwife who is more accessible.

Regarding anemia tests: "We used to have hemoglobinometers but they are broken since March (for more than 3 months at the moment of the interview). Now we send the women to the laboratory, they have the blood extraction there, however many times the results are not collected, it is not easy for the women to return to collect them because of the distance" [Health Center Official]

Furthermore, the success of syphilis treatment ─which is free for pregnant women in Mozambique─ depends on families assuming the cost of treatment for partners in order to avoid reinfection.