title: Barriers and facilitators to health care seeking behaviours in pregnancy in rural communities of southern Mozambique.
abstract: BACKGROUND
  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. 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.
  
  
  METHODS
  This 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.
  
  
  RESULTS
  Antenatal 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.
  
  
  CONCLUSIONS
  Women 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.
  
  
  BACKGROUND
  NCT01911494.
authors.affiliation: Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique. khatia.munguambe@manhica.net.|Universidade Eduardo Mondlane, Faculdade de Medicina, Maputo, Mozambique. khatia.munguambe@manhica.net.
authors.forename: Khátia
authors.initials: K
authors.lastname: Munguambe
authors.affiliation: Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique.
authors.forename: Helena
authors.initials: H
authors.lastname: Boene
authors.affiliation: Department of Obstetrics and Gynaecology, and the Child and Family Research Unit, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Marianne
authors.initials: M
authors.lastname: Vidler
authors.affiliation: Ministério da Saúde, Maputo, Mozambique.
authors.forename: Cassimo
authors.initials: C
authors.lastname: Bique
authors.affiliation: Department of Obstetrics and Gynaecology, and the Child and Family Research Unit, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Diane
authors.initials: D
authors.lastname: Sawchuck
authors.affiliation: Department of Obstetrics and Gynaecology, and the Child and Family Research Unit, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Tabassum
authors.initials: T
authors.lastname: Firoz
authors.affiliation: Department of Obstetrics and Gynaecology, and the Child and Family Research Unit, University of British Columbia, Vancouver, British Columbia, Canada.|Department of Geography, Simon Fraser University, Burnaby, British Columbia, Canada.
authors.forename: Prestige Tatenda
authors.initials: PT
authors.lastname: Makanga
authors.affiliation: Division of Women and Child Health, Aga Khan University, Karachi, Sindh, Pakistan.
authors.forename: Rahat
authors.initials: R
authors.lastname: Qureshi
authors.affiliation: Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique.|Ministério da Saúde, Maputo, Mozambique.
authors.forename: Eusébio
authors.initials: E
authors.lastname: Macete
authors.affiliation: Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique.|Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain.
authors.forename: Clara
authors.initials: C
authors.lastname: Menéndez
authors.affiliation: Department of Obstetrics and Gynaecology, and the Child and Family Research Unit, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: von Dadelszen
authors.affiliation: Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique.|Universidade Eduardo Mondlane, Faculdade de Medicina, Maputo, Mozambique.
authors.forename: Esperança
authors.initials: E
authors.lastname: Sevene
mesh_terms: D000293:Adolescent; D000328:Adult; D003657:Decision Making; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data*; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D009073:Mozambique; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D011247:Pregnancy; D012424:Rural Population; D012959:Socioeconomic Factors; D055815:Young Adult
keywords: Care-seeking; Maternal health; Maternal health services; Mozambique; Pregnancy; Prenatal care