Challenges and opportunities for implementing evidence-based antenatal care in Mozambique: a qualitative study.
BACKGROUND
Maternal mortality remains a daunting problem in Mozambique and many other low-resource countries. High quality antenatal care (ANC) services can improve maternal and newborn health outcomes and increase the likelihood that women will seek skilled delivery care. This study explores the factors influencing provider uptake of the recommended package of ANC interventions in Mozambique.


METHODS
This study used qualitative research methods including key informant interviews with stakeholders from the health sector and a total of five focus group discussions with women with experience with ANC or women from the community. Study participants were selected from three health centers located in Maputo city, Tete, and Cabo Delgado provinces in Mozambique. Staff responsible for the medicines/supply chain at national, provincial and district level were interviewed. A check list was implemented to confirm the availability of the supplies required for ANC. Deductive content analysis was conducted.


RESULTS
Three main groups of factors were identified that hinder the implementation of the ANC package in the study setting: a) system or organizational: include chronic supply chain deficiencies, failures in the continuing education system, lack of regular audits and supervision, absence of an efficient patient record system and poor environmental conditions at the health center; b) health care provider factors: such as limited awareness of current clinical guidelines and a resistant attitude to adopting new recommendations; and c) Users: challenges with accessing ANC, poor recognition amongst women about the purpose and importance of the specific interventions provided through ANC, and widespread perception of an unfriendly environment at the health center.


CONCLUSIONS
The ANC package in Mozambique is not being fully implemented in the three study facilities, and a major barrier is poor functioning of the supply chain system. Recommendations for improving the implementation of antenatal interventions include ensuring clinical protocols based on the ANC model. Increasing the community understanding of the importance of ANC would improve demand for high quality ANC services. The supply chain functioning could be strengthened through the introduction of a kit system with all the necessary supplies for ANC and a simple monitoring system to track the stock levels is recommended.
International Center for Reproductive Health (ICRH-Mozambique), Maputo, Mozambique. adrianobiza@gmail.com.
Adriano
A
Biza
International Center for Reproductive Health (ICRH-Mozambique), Maputo, Mozambique. ingeborg@jille.org.
Ingeborg
I
Jille-Traas
Montevideo Clinical and Epidemiological Research Unit (UNICEM), Montevideo, Uruguay. mcolomar@unicem-web.org.
Mercedes
M
Colomar
Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina. mbelizan@iecs.org.ar.
Maria
M
Belizan
Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. jrequejo@jhsph.edu.
Jennifer
J
Requejo Harris
International Center for Reproductive Health (ICRH-Mozambique), Maputo, Mozambique. beatrice.crahay@gmail.com.
Beatrice
B
Crahay
Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland. merialdim@gmail.com.
Mario
M
Merialdi
Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland. nguyenh@who.int.
My Huong
MH
Nguyen
Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina. falthabe@iecs.org.ar.
Fernando
F
Althabe
Montevideo Clinical and Epidemiological Research Unit (UNICEM), Montevideo, Uruguay. aaleman@unicem-web.org.
Alicia
A
Aleman
Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina. bergel@gmail.com.
Eduardo
E
Bergel
Mozambique Country Office, World Health Organization, Maputo, Mozambique. carbonella@who.int.
Alicia
A
Carbonell
Mozambique Ministry of Health, Maputo, Mozambique. leochavane@gmail.com.
Leonardo
L
Chavane
Institute of Tropical Medicine, Antwerp, Belgium. TDelvaux@itg.be.
Therese
T
Delvaux
International Center for Reproductive Health (ICRH-Mozambique), Maputo, Mozambique. geelhoed.d.w@gmail.com.
Diederike
D
Geelhoed
Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland. gulmezoglum@who.int.
Metin
M
Gülmezoglu
Central de Medicamentos e Artigos Médicos, Maputo, Mozambique. CelsaMalapende@cmam.gov.mz.
Celsa Regina
CR
Malapende
Mozambique Ministry of Health, Maputo, Mozambique. lagicy@yahoo.com.br.
Armando
A
Melo
International Center for Reproductive Health (ICRH-Mozambique), Maputo, Mozambique. nafissa.osman@gmail.com.
Nafissa Bique
NB
Osman
Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland. widmerm@who.int.
Mariana
M
Widmer
Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland. temmermanm@who.int.
Marleen
M
Temmerman
Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland. betrana@who.int.
Ana Pilar
AP
Betrán
D000293:Adolescent; D000328:Adult; D057189:Checklist; D003430:Cross-Sectional Studies; D003906:Developing Countries; D019317:Evidence-Based Medicine; D005260:Female; D017144:Focus Groups; D006801:Humans; D007407:Interviews as Topic; D008427:Maternal Health Services / Q000458:organization & administration*; D009073:Mozambique; D020380:Needs Assessment; D017063:Outcome Assessment, Health Care; D010342:Patient Acceptance of Health Care; D011203:Poverty; D011247:Pregnancy; D011295:Prenatal Care / Q000592:standards*; D036301:Qualitative Research; D018570:Risk Assessment; D055815:Young Adult