84
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Barriers and facilitators to health care seeking behaviours in pregnancy in rural communities of southern Mozambique

      research-article

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          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.

          Trial registration

          NCT01911494

          Electronic supplementary material

          The online version of this article (doi:10.1186/s12978-016-0141-0) contains supplementary material, which is available to authorized users.

          Resumo

          Antecedentes

          Em países como Moçambique onde a mortalidade materna permanece alta, os membros de comunidades pobres e vulneráveis, residentes em zonas rurais e remotas com acesso limitado a serviços de saúde são os que mais contribuem para esta mortalidade. O presente estudo, teve como objectivo analisar comportamentos de busca de cuidados de saúde durante a gravidez, tomando em consideração as barreiras sociais, culturais e estruturais para o acesso atempado a cuidados apropriados de saúde nas províncias de Maputo e Gaza, no Sul de Moçambique.

          Métodos

          Neste estudo etnográfico os dados foram colhidos através de entrevistas em profundidade e discussões em grupos focais com mulheres em idade reprodutiva (incluíndo mulheres grávidas), decisores ao nível do agregado familiar (parceiros, mães e sogras de mulheres grávidas), praticantes de medicina tradicional (PMTs), matronas e provedores de cuidados de saúde primários. Os dados foram analisados tematicamente usando NVivo 10.

          Resultados

          A consulta pré-natal (CPN) era procurada pelas mulheres com o fim de abrirem a ficha pré-natal, pois mulheres sem ficha temiam represálias durante o parto na unidade sanitária. A CPN era também procurada para resolver queixas comuns tais como dores de cabeça, sintomas sugestivos de gripe, dores no corpo e de coluna. No entanto, os parceiros das mulheres grávidas consideravam as dores no baixo-ventre como o único sintoma merecedor de busca de cuidados e desencorajavam as suas mulheres a revelarem a gravidez nas primeiras semanas de gestação. Os provedores de cuidados saúde para mulheres grávidas incluíam os profissionais de saúde baseados nas unidades sanitárias, mas também matronas, anciãs, parteiras tradicionais e agentes polivalentes elementares (APES). Culturalmente as mulheres grávidas são desencorajadas a buscar cuidados junto a PMTs; no entanto observou-se que PMTs prestam serviços pré- e pós- natais. Para além dos decisores ao nível do agregado familiar, as matronas, os APEs e vizinhos são actores chaves no acto de referir a mulher grávida para a unidade sanitária. O processo de tomada de decisão envolve muitos actores e pode ser moroso e complexo, particularmente em circunstâncias de emergência em que nenhum dos decisores mencionados está presente. O acesso limitado ao transporte e a fundos para custear despesas imediatas torna este processo ainda mais complexo.

          Conclusões

          As mulheres procuram cuidados pré natais de rotina nas unidades sanitárias, apesar da presença de outros provedores de saúde na comunidade. Existem factores importantes que impedem a busca de cuidados atempados e apropriados no início da gestação, bem como em situações de emergência obstétrica e parto. Fraco conhecimento dos sinais de perigo, particularmente entre os parceiros, a revelação tardia da gravidez, os processos complexos e morosos de tomada de decisão em situações de emergência, receio de maus tratos na unidade sanitária, falta de transporte e constrangimentos financeiros foram as barreiras mais mencionadas. Mulheres em idade reprodutiva poderiam beneficiar de esquemas comunitários de poupanças para transporte e medicação, que por sua vez iriam melhorar o seu grau de preparação para emergências e parto; mais ainda o seguimento da gravidez deveria envolver actores chaves no agregado familiar e vizinhança, bem como provedores de saúde baseados na comunidade, no sentido de encorajar referências atempadas à unidade sanitária sempre que necessário.

          Número de registo do ensaio clínico

          NCT01911494

          Electronic supplementary material

          The online version of this article (doi:10.1186/s12978-016-0141-0) contains supplementary material, which is available to authorized users.

          Related collections

          Most cited references29

          • Record: found
          • Abstract: found
          • Article: found

          Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

          The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery. We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values. 292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland. Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa. Bill & Melinda Gates Foundation. Copyright © 2014 Elsevier Ltd. All rights reserved.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            Profile: Manhiça Health Research Centre (Manhiça HDSS).

            The Manhiça Health Research Centre, established in 1996 in a rural area of southern Mozambique, currently follows around 92 000 individuals living in approximately 20 000 enumerated and geo-positioned households. Its main strength is the possibility of linking demographic data and clinical data to promote and conduct biomedical research in priority health areas. Socio-demographic data are updated twice a year and clinical data are collected on a daily basis. The data collected in Manhiça HDSS comprises household and individual characteristics, household socio-economic assets, vital data, migration, individual health history and cause of death, among others. Studies conducted in this HDSS contributed to guide the health authorities and decision-making bodies to define or adjust health policies such as the introduction of Mozambique's expanded programme of immunization with different vaccines (Haemophilus influenzae type b, Pneumococcus) or the development of the concept of Intermittent Preventive Treatment for Infants (IPTi) that led to the World Health Organization recommendation of this method as best practice for the control of malaria among infants. Manhiça's data can be accessed through a formal request to Diana Quelhas (diana.quelhas@manhica.net) accompanied by a proposal that will be analysed by the Manhiça HDSS internal scientific and ethics committees.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: found
              Is Open Access

              High ANC coverage and low skilled attendance in a rural Tanzanian district: a case for implementing a birth plan intervention

              Background In Tanzania, more than 90% of all pregnant women attend antenatal care at least once and approximately 62% four times or more, yet less than five in ten receive skilled delivery care at available health units. We conducted a qualitative study in Ngorongoro district, Northern Tanzania, in order to gain an understanding of the health systems and socio-cultural factors underlying this divergent pattern of high use of antenatal services and low use of skilled delivery care. Specifically, the study examined beliefs and behaviors related to antenatal, labor, delivery and postnatal care among the Maasai and Watemi ethnic groups. The perspectives of health care providers and traditional birth attendants on childbirth and the factors determining where women deliver were also investigated. Methods Twelve key informant interviews and fifteen focus group discussions were held with Maasai and Watemi women, traditional birth attendants, health care providers, and community members. Principles of the grounded theory approach were used to elicit and assess the various perspectives of each group of participants interviewed. Results The Maasai and Watemi women's preferences for a home birth and lack of planning for delivery are reinforced by the failure of health care providers to consistently communicate the importance of skilled delivery and immediate post-partum care for all women during routine antenatal visits. Husbands typically serve as gatekeepers of women's reproductive health in the two groups - including decisions about where they will deliver- yet they are rarely encouraged to attend antenatal sessions. While husbands are encouraged to participate in programs to prevent maternal-to-child transmission of HIV, messages about the importance of skilled delivery care for all women are not given emphasis. Conclusions Increasing coverage of skilled delivery care and achieving the full implementation of Tanzania's Focused Antenatal Care Package in Ngorongoro depends upon improved training and monitoring of health care providers, and greater family participation in antenatal care visits.
                Bookmark

                Author and article information

                Contributors
                khatia.munguambe@manhica.net
                Journal
                Reprod Health
                Reprod Health
                Reproductive Health
                BioMed Central (London )
                1742-4755
                8 June 2016
                8 June 2016
                2016
                : 13
                Issue : Suppl 1 Issue sponsor : Publication charges for this supplement were funded by the University of British Columbia PRE-EMPT (Pre-eclampsia/Eclampsia, Monitoring, Prevention and Treatment) initiative supported by the Bill & Melinda Gates Foundation. The articles have undergone the journal's standard peer review process for supplements. The Supplement Editor declares that they have no competing interests.
                : 31
                Affiliations
                [ ]Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
                [ ]Department of Obstetrics and Gynaecology, and the Child and Family Research Unit, University of British Columbia, Vancouver, British Columbia Canada
                [ ]Ministério da Saúde, Maputo, Mozambique
                [ ]Universidade Eduardo Mondlane, Faculdade de Medicina, Maputo, Mozambique
                [ ]Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
                [ ]Division of Women and Child Health, Aga Khan University, Karachi, Sindh Pakistan
                [ ]Department of Geography, Simon Fraser University, Burnaby, British Columbia Canada
                Article
                141
                10.1186/s12978-016-0141-0
                4943506
                27356968
                76dcd944-1d18-4d22-8525-32930228128c
                © Munguambe et al. 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Categories
                Research
                Custom metadata
                © The Author(s) 2016

                Obstetrics & Gynecology
                care-seeking,maternal health,mozambique,prenatal care,pregnancy,maternal health services,busca de cuidados de saúde,saúde materna,moçambique,cuidados pré-natais,gravidez,serviços de saúde materna

                Comments

                Comment on this article