Abstracts

Introduction

Antenatal care consists of a set of procedures and measures aimed at diagnosing, treating and preventing situations that are undesirable for women’s health - during pregnancy, delivery, postpartum - and also for the infant(¹1 World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience [Internet]. Geneva: WHO; 2016 [cited 2019 Aug 10]. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/
https://www.who.int/reproductivehealth/p... ). Currently, antenatal care is recognized as an important strategy to prevent or reduce the risk of maternal and newborn morbidity and mortality. The literature around this issue show that adequate antenatal care is closely linked to better perinatal outcomes and to a reduction in maternal and neonatal morbidity and mortality(¹1 World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience [Internet]. Geneva: WHO; 2016 [cited 2019 Aug 10]. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/
https://www.who.int/reproductivehealth/p...

2 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Saúde Brasil 2017: uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável [Internet]. Brasília: Ministério da Saúde; 2018 [cited 2019 Aug 10]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_2017_analise_situacao_saude_desafios_objetivos_desenvolvimento_sustetantavel.pdf
https://bvsms.saude.gov.br/bvs/publicaco...

3 Benova L, Tunçalp Ö, Moran AC, Campbell OMR. Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries. BMJ Glob Health. 2018 Mar;3(2):e000779. doi: http://doi.org/10.1136/bmjgh-2018-000779
http://doi.org/10.1136/bmjgh-2018-000779... -⁴4 Leal MC, Szwarcwald CL, Almeida PVB, Aquino EML, Barreto ML, Barros F. Reproductive, maternal, neonatal and child health in the 30 years since the creation of the Unified Health System (SUS). Ciênc Saúde Colet. 2018 Mar;23(6):1915-28. doi: http://doi.org/10.1590/1413-81232018236.03942018
http://doi.org/10.1590/1413-81232018236.... ).

Antenatal care encompasses various guidelines, recommendations, measures and procedures that, in some way, differ across countries. Even so, there are two fundamental elements that are the basis for good quality antenatal care: its early initiation and a minimum number of visits(¹1 World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience [Internet]. Geneva: WHO; 2016 [cited 2019 Aug 10]. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/
https://www.who.int/reproductivehealth/p... ,⁵5 World Health Organization. WHO recommendations on maternal health: guidelines approved by the WHO guidelines review committee [Internet]. Geneva: WHO; 2017 [cited 2019 Aug 10]. Available from: https://apps.who.int/iris/handle/10665/259268
https://apps.who.int/iris/handle/10665/2... ).

The vast majority of high- and middle-income countries recommend at least six antenatal visits; they also recommend initiating antenatal care between the 8^thand 12^thgestational week(⁶6 Garnelo L, Horta BL, Escobar AL, Santos RV, Cardoso AM, Welch JR, et al. Assessment of prenatal care for indigenous women in Brazil: findings from theFirst National Survey of Indigenous People’s Health and Nutrition. Cad Saúde Pública. 2019 Aug;35(Suppl 2):e00181318. doi: http://doi.org/10.1590/0102-311x00181318
http://doi.org/10.1590/0102-311x00181318... -⁷7 Heaman MI, Martens PJ, Brownell MD, Chartier MJ, Derksen SA, Helewa ME. The Association of Inadequate and Intensive Prenatal Care With Maternal, Fetal, and Infant Outcomes: A Population-Based Study in Manitoba, Canada. J Obstet Gynaecol Can. 2018 July;000(000):1-13. doi: http://doi.org/10.1016/j.jogc.2018.09.006
http://doi.org/10.1016/j.jogc.2018.09.00... ). However, some low-income countries have different recommendations regarding the number of visits, which at least four; and endorse the gestational age at which antenatal care is initiated with greater flexibility, up to the 16^thweek(⁸8 Kassaw A, Debie A, Geberu DM. Quality of prenatal care and associated factors among pregnant women at public health facilities of Wogera District, Northwest Ethiopia. J Pregnancy. 2020 Jan;2020:9592124. doi: http://doi.org/10.1155/2020/9592124
http://doi.org/10.1155/2020/9592124...

9 Afulani P, Buback L, Essandoh F, Kinyua J, Kirumbi L, Cohen CR. Quality of antenatal care and associated factors in a rural county in Kenya: an assessment of service provision and experience dimensions. BMC Health Serv Res. 2019 Oct;19:684. doi: http://doi.org/10.1186/s12913-019-4476-4
http://doi.org/10.1186/s12913-019-4476-4... -¹⁰10 Finlayson K, Downe S. Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies. PLoS Med. 2013;10(1):e1001373. doi: http://doi.org/10.1371/journal.pmed.1001373
http://doi.org/10.1371/journal.pmed.1001... ). Although there are differences in the recommendations in various contexts, the World Health Organization(WHO) recommends at least eight antenatal visits, with gestational age up to the 12^thweek at its initiation(¹1 World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience [Internet]. Geneva: WHO; 2016 [cited 2019 Aug 10]. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/
https://www.who.int/reproductivehealth/p... ,⁵5 World Health Organization. WHO recommendations on maternal health: guidelines approved by the WHO guidelines review committee [Internet]. Geneva: WHO; 2017 [cited 2019 Aug 10]. Available from: https://apps.who.int/iris/handle/10665/259268
https://apps.who.int/iris/handle/10665/2... ). It is noteworthy that these recommendations can be adapted to the socioeconomic context and to the population and health system of each country.

This is what the Ministry of Health(MISAU) of Mozambique did, a country located in Sub-Saharan Africa and scenario of this study, which recommends a minimum number of four antenatal care visits and gestational age up to the 16^thweek at its initiation(¹¹11 Ministério da Saúde (MOZ). Normas para atenção pré-natal e cuidados pós-natal para mulheres e recém-nascidos. Maputo: MISAU; 2016 [cited 2019 Aug 10]. Available from: https://pt.scribd.com/document/321740258/Normas-Para-a-Atencao-Pre-Natal-e-Cuidados-Pos-Natal-Para-Mulheres-e-Recem-Nascidos
https://pt.scribd.com/document/321740258... -¹²12 Ministério da Saúde (MOZ). Inquérito de Indicadores de Imunização, Malária e HIV/SIDA em Moçambique - 2015 [Internet]. Maputo: MISAU; 2018 [cited 2019 Aug 10]. Available from: https://dhsprogram.com/publications/publication-ais12-ais-final-reports.cfm
https://dhsprogram.com/publications/publ... ). In that country, few studies have assessed gestational age at the beginning of antenatal care and the number of visits(¹³13 Biza A, Jille-Traas I, Colomar M, Belizan M, Harris JR, Crahay B, et al. Challenges and opportunities for implementing evidence-based antenatal care in Mozambique: A qualitative study. BMC Pregnancy Childbirth. 2015 Sep;15:200. doi: http://doi.org/10.1186/s12884-015-0625-x
http://doi.org/10.1186/s12884-015-0625-x... -¹⁴14 Zanconato G, Msolomba R, Guarenti L, Franchi M. Antenatal care in developing Countries: the need for a tailored model. Semin Fetal Neonatal Med. 2006 Feb;11(1):15-20. doi: http://doi.org/10.1016/j.siny.2005.10.002
http://doi.org/10.1016/j.siny.2005.10.00... ). A national survey showed that approximately 90% of the pregnant women in Mozambique undergo antenatal care, but only 55% attend the minimum number of four visits(¹²12 Ministério da Saúde (MOZ). Inquérito de Indicadores de Imunização, Malária e HIV/SIDA em Moçambique - 2015 [Internet]. Maputo: MISAU; 2018 [cited 2019 Aug 10]. Available from: https://dhsprogram.com/publications/publication-ais12-ais-final-reports.cfm
https://dhsprogram.com/publications/publ... ). Apparently, among other reasons, late initiation is due to the guidelines provided by the health professionals themselves, who inform women that antenatal care should be started when fetal movements are felt or when the baby can be palpated; another reason is the experience of multiparous women who start antenatal care late as they already know the guidelines of the health facilities(¹⁴14 Zanconato G, Msolomba R, Guarenti L, Franchi M. Antenatal care in developing Countries: the need for a tailored model. Semin Fetal Neonatal Med. 2006 Feb;11(1):15-20. doi: http://doi.org/10.1016/j.siny.2005.10.002
http://doi.org/10.1016/j.siny.2005.10.00... ).

Therefore, it seems that access to antenatal care in Mozambique is not necessarily the main problem in the field of reproductive health, but quality of care. The country has a high maternal mortality rate, 452per 100,000 live births(¹⁵15 Instituto Nacional de Estatística. IV Recenseamento Geral da População e Habitação 2017: resultados definitivos: Moçambique [Internet]. Maputo: INE; 2019 [cited 2019 Aug 10]. Available from: http://www.ine.gov.mz/iv-rgph-2017/mocambique/censo-2017-brochura-dos-resultados-definitivos-do-iv-rgph-nacional.pdf
http://www.ine.gov.mz/iv-rgph-2017/mocam... ), which reveals that there is a need to improve the quality of maternal health care, and antenatal care does not seem to be an exception. Given the importance of antenatal care for the promotion of maternal health, especially in a country with high rates of maternal deaths, this study has the following objectives: 1)to assess the gestational age at the beginning of antenatal care and its covariates; 2)to assess the number of antenatal visits and its covariates; and 3)to identify the reasons for the late initiation of antenatal care and for reporting less than four antenatal care visits among postpartum women living in Nampula, Mozambique.

Method

Study design

This is a quantitative, cross-sectional and analytical study, guided by the STROBE(Strengthening the Reporting of Observational Studies in Epidemiology) tool, developed to assess the quality of observational studies(case-control, cohort and cross-sectional)(¹⁶16 Cheng A, Kessler D, Mackinnon R, Chang TP, Nadkarni VM, Hunt EA, et al. Reporting Guidelines for Health Care Simulation Research. Simul Healthc J Soc Simul Healthc. 2016 Aug;11(4):238-48. doi: http://doi.org/10.1097/SIH.0000000000000150
http://doi.org/10.1097/SIH.0000000000000... ).

Context

The study was conducted in the city of Nampula, located in the inland of the province with the same name, in northern Mozambique, Africa. According to the Human Development Report of the United Nations Development Program(UNDP), in 2015 Mozambique was among the nine countries in the world with the lowest Human Development Index(HDI), ranking in the 180^thplace out of a total of 188(¹⁷17 Programa das Nações Unidas para o Desenvolvimento. Relatório do Desenvolvimento Humano 2015: o trabalho como motor do desenvolvimento humano [Internet]. Brasília: PNUD; 2015 [cited 2019 Aug 10]. Available from: http://hdr.undp.org/sites/default/files/hdr15_overview_pt.pdf
http://hdr.undp.org/sites/default/files/... ). Data from the population census conducted in 2017 indicate that there are almost 28 million inhabitants, with nearly 67% of the population living in rural areas(¹⁵15 Instituto Nacional de Estatística. IV Recenseamento Geral da População e Habitação 2017: resultados definitivos: Moçambique [Internet]. Maputo: INE; 2019 [cited 2019 Aug 10]. Available from: http://www.ine.gov.mz/iv-rgph-2017/mocambique/censo-2017-brochura-dos-resultados-definitivos-do-iv-rgph-nacional.pdf
http://www.ine.gov.mz/iv-rgph-2017/mocam... ). The mean life expectancy is 56.5 years old(¹⁵15 Instituto Nacional de Estatística. IV Recenseamento Geral da População e Habitação 2017: resultados definitivos: Moçambique [Internet]. Maputo: INE; 2019 [cited 2019 Aug 10]. Available from: http://www.ine.gov.mz/iv-rgph-2017/mocambique/censo-2017-brochura-dos-resultados-definitivos-do-iv-rgph-nacional.pdf
http://www.ine.gov.mz/iv-rgph-2017/mocam... ) and the total fertility rate is 5.3 children per woman(¹²12 Ministério da Saúde (MOZ). Inquérito de Indicadores de Imunização, Malária e HIV/SIDA em Moçambique - 2015 [Internet]. Maputo: MISAU; 2018 [cited 2019 Aug 10]. Available from: https://dhsprogram.com/publications/publication-ais12-ais-final-reports.cfm
https://dhsprogram.com/publications/publ... ).

Period

The research was conducted from August to December 2019.

Population

The study population consisted of postpartum women aged between 18 and 49 years old.

Selection criteria

The inclusion criteria were all women whose delivery had taken place within the previous 24 hours, in maternity hospitals, and women whose delivery had taken place within the previous 15 days, at their own homes, as long as they reported being physically and emotionally willing to answer the questionnaire. The exclusion criterion was having antenatal care classified as high risk.

Sample definition

The sample size considered the proportion of Mozambican women with four or more antenatal visits:p=54.6(¹²12 Ministério da Saúde (MOZ). Inquérito de Indicadores de Imunização, Malária e HIV/SIDA em Moçambique - 2015 [Internet]. Maputo: MISAU; 2018 [cited 2019 Aug 10]. Available from: https://dhsprogram.com/publications/publication-ais12-ais-final-reports.cfm
https://dhsprogram.com/publications/publ... ), female population of Nampula of 337,839 women at the time of the study(¹⁵15 Instituto Nacional de Estatística. IV Recenseamento Geral da População e Habitação 2017: resultados definitivos: Moçambique [Internet]. Maputo: INE; 2019 [cited 2019 Aug 10]. Available from: http://www.ine.gov.mz/iv-rgph-2017/mocambique/censo-2017-brochura-dos-resultados-definitivos-do-iv-rgph-nacional.pdf
http://www.ine.gov.mz/iv-rgph-2017/mocam... ), significance level of 95% and 5% margin of error. Sample calculation indicated the need to interview 381 women.

Study variables

The dependent variables were gestational age at the beginning of antenatal care(up to the 16^thweek and after the 16^thweek), number of antenatal care visits(up to three and four or more) and access to basic antenatal care, herein defined as the one in which women initiated antenatal care up to the 16^thgestational week and reported four or more antenatal care visits(dichotomous).

The independent variables referring to the sociodemographic characteristics were age group(18-24; 25-29; ≥30 years-old); schooling in years: elementary education(≤7), high school education(8-12) or higher education(>12); religion(Islamic, Catholic or others); place of residence: peripheral region(neighborhoods of Marrere, Murrapaniua, Mutauanha, Mutavarex, Memória, Muatala, Natikiri, Namicopo, Namutequeliua/Nampaco, Carrupeia) or urban region(neighborhoods of Napipine, Muhala/Muhala expansion, Muahivire, BairroCentral); paid jobs(no or yes); use of private healthcare services(no or yes); and living with a partner(no or yes). Regarding reproductive history, the number of pregnancies, including the current one(1-3 or ≥4) was assessed, as well as antenatal care in previous pregnancies(first pregnancy, in some pregnancies or in all pregnancies). As for the planning of the last pregnancy, the instrument called London Measure of Unplanned Pregnancy(LMUP) was used, validated for the Portuguese language(¹⁸18 Borges ALV, Barrett G, Santos OA, Nascimento NC, Cavalhieri FB, Fujimori E. Evaluation of the psychometric properties of the London Measure of Unplanned Pregnancy in Brazilian Portuguese. BMC Pregnancy Childbirth. 2016 Aug;16(1):244. doi: http://doi.org/10.1186/s12884-016-1037-2
http://doi.org/10.1186/s12884-016-1037-2... ). Regarding the antenatal care, we assessed antenatal care visits(no or yes); the reasons for late initiation of antenatal care[multiple choice: I didn’t know I was pregnant, I didn’t think early antenatal care was important, I didn’t have anyone to accompany me(partner), care was time-consuming, the healthcare facility was far or difficult to access, difficulties related to work/school(lack of time to go to the visits), I didn’t have anyone to leave my children with, I was sick and couldn’t go to the hospital, I found my belly small, and I didn’t want this pregnancy, among others]; and the reasons for attending less than four visits[multiple choice: I didn’t want this pregnancy, I didn’t have anyone to accompany me(partner), I didn’t have anyone to leave my children with, care was time-consuming, I didn’t think it was important to attend many antenatal visits, the health center was far or difficult to access, I didn’t like the service professionals and transportation difficulties, among others].

Instruments used to collect the information

The instrument used for data collection consisted of a specific form, prepared by the main researcher, which contained questions about the dependent and independent variables, in addition to the LMUP. LMUP is an instrument that measures pregnancy planning retrospectively, regardless of the outcome of pregnancy, birth or abortion. The classification regarding the planning of the last pregnancy is obtained by the sum of points for each question; the total score can vary from zero to 12. Women who scored between 0 and 3 points are classified as having an unplanned pregnancy; between 4 and 9 points, as ambivalent, that is, simultaneous prevalence of apparently contradictory feelings and actions about pregnancy planning and non-planning; and between 10 and 12 points as having a planned pregnancy.

Data collection

Data collection took place in a maternity hospital and at the women’s residence. Selection of the women took place through information from the puerperium registry book available at the Health Sciences College/UniLúrio and from the maternity hospital, where information on all births that took place in the city is available. Women were interviewed using a structured instrument created in GoogleForms, pre-tested and applied using a tablet, respecting their privacy. The questionnaire included information regarding sociodemographic characteristics, reproductive history, planning of the last pregnancy and antenatal care.

Data treatment and analysis

Analyses were performed using the Stata 15.0 software. To describe the sociodemographic characteristics, reproductive history and antenatal care, absolute and relative numbers, mean, median and standard deviation were used. The test of difference between two proportions(Chi-Square or Fisher’s Exact) was applied to verify differences between gestational age at the beginning of antenatal care, number of visits and access to basic antenatal care, and the sociodemographic characteristics, women’s reproductive history, and planning of the last pregnancy. The analysis of the covariates was performed using univariate and multiple logistic regression. In the multiple logistic regression analysis, the variables were simultaneously inserted into the model. A5% significance level was considered statistically significant.

Ethical aspects

The project was approved by the Institutional Bioethics Committee for Health of the Lúrio University(Comitê Institucional de Bioética para Saúde da Universidade Lúrio,CIBSUL) of Nampula, Mozambique, under No.26/August/CIBSUL/19.

Results

A total of 416 women were invited to the take part in the study, but 17 refused to participate. Another six women were not found at their homes to conduct the interview after three attempts; thus, the final sample consisted of 393 women. The mean age was 26.0 years old(SD=5.8), most had elementary education(52.4%), lived in the peripheral region of the city(75.3%), used public health system(91.1%) and lived with a partner(88.8%). Nearly one out of 10 women had a paid job(10.9%). Almost half reported professing the Islamic religion(43.4%), number of pregnancies greater than or equal to four(44.5%) and had their pregnancies classified as planned(41.0%) (Table 1).

All women reported having undergone antenatal care in their last pregnancy(which is being considered in this study), and 39.9%(n=157) started antenatal care up to the 16^thgestational week; 49.1%(n=193) reported at least four antenatal visits, and 34.1%(n=134) were categorized as having undergone basic antenatal care, that is, they started antenatal care up to the 16^thgestational week and had at least four antenatal visits(data not shown in the table).

Among women who started antenatal care after the 16^thgestational week(n=236,60.1%), the main reasons were thinking that the belly was small(42.6%), not having a spouse as a companion for the visits(24.1%) and not knowing that they were pregnant(19.8%), among others. Among women who reported less than four antenatal visits(n=200,50.9%), the main reasons were not finding it important to have several antenatal visits(36.0%), not having a spouse as a companion for the visits(25.5%) and not having easy access to the health facility or living far from the health service(24.5%), among others(Table 2).

The analysis of the aspects associated with the initiation of antenatal care up to the 16^thweek is presented in Table 3. Women with high school education(OR=1.89; 95%CI=1.23-2.92) or higher education(OR=4.25; 95%CI=1.99-9.07) were more likely to start antenatal care up to the 16^thweek, when compared to those with elementary education. Women who reported having used the private healthcare system(OR=2.45; 95%CI=1.20-4.98) were more likely to start antenatal care up to the 16^thweek, when compared to those who used the public healthcare system, as was also the case of the women with paid job(OR=2.56; 95%CI=1.34-4.89). In the multiple model, adjusted for all the variables entered simultaneously, only education remained associated with the initiation of antenatal care up to the 16^thweek, considering both women with high school education(ORadj=1.66; 95%CI=1.02-2.69) and with higher education(ORadj=2.70; 95%CI=1.05-6.96), when compared to those with elementary education.

The association between women’s characteristics and reporting at least four antenatal care visits is shown in Table 4. Women who were more likely to report at least four antenatal visits were those with high school education(OR=2.50; 95%CI=1.63-3.85) or higher education(OR=19.43; 95%CI=5.75-65.65), who lived with a partner(OR= 2.87; 95%CI=1.43-5.76), who used the private healthcare system(OR=2.83; 95%CI=1.32-6.06), and who had paid job(OR=9.56; 95%CI=3.68-24.87). Among these characteristics, in the adjusted model, women with high school education(ORadj=2.12; 95%CI=1.29-3.46) or higher education(ORadj=11.78; 95%CI=2.91-47.71), who lived with a partner(ORadj= 3.11; 95%CI=1.39-6.92), and who reported paid job (ORadj=4.80; 95%CI=1.65-13.96) were more likely to report at least four antenatal care visits.

The analysis of the aspects associated with having accessed basic antenatal care is shown in Table 5. Women who were more likely to access basic antenatal care were those with high school education(OR=2.33; 95%CI=1.48-3.68) or higher education(OR=6.31; 95%CI=2.92-13.61), who were Catholics(OR=1.74; 95%CI=1.08-2.80), who used the private healthcare system(OR=2.51; 95%CI=1.24-5.06) and who had paid job(OR=3.43; 95%CI=1.79-6.58). In the final model, only education remained statistically significant. Thus, women with high school education(ORadj=1.99; 95%CI=1.19-3.31;) or higher education(ORadj=3.87; 95%CI=1.47-10.18) were more likely to access basic antenatal care.

Discussion

This study aimed at assessing both the gestational age at the beginning of antenatal care and the number of antenatal care visits and their associated aspects; as well as identifying the reasons for the late initiation of antenatal care and less than four visits, according to the MISAU recommendations(¹¹11 Ministério da Saúde (MOZ). Normas para atenção pré-natal e cuidados pós-natal para mulheres e recém-nascidos. Maputo: MISAU; 2016 [cited 2019 Aug 10]. Available from: https://pt.scribd.com/document/321740258/Normas-Para-a-Atencao-Pre-Natal-e-Cuidados-Pos-Natal-Para-Mulheres-e-Recem-Nascidos
https://pt.scribd.com/document/321740258... ). Antenatal care coverage was found to be universal in the municipality of Nampula, Mozambique. However, the quality of prenatal care was still low, as less than half of women started antenatal care early and attended the minimum number of recommended visits. When these two indicators are analyzed together, the condition of access to basic antenatal care seemed even more fragile.

Our findings are similar to the few studies already conducted in Mozambique on the topic. In a qualitative study conducted in the provinces of Cabo Delgado, Tete and Maputo, which represented the three regions of the country(North, Central and South), it was observed that, in general, women started antenatal care at the end of the second trimester, and that the reasons for this late initiation were lack of a pregnancy test in the health services and waiting for the presence of visible signs of pregnancy(¹³13 Biza A, Jille-Traas I, Colomar M, Belizan M, Harris JR, Crahay B, et al. Challenges and opportunities for implementing evidence-based antenatal care in Mozambique: A qualitative study. BMC Pregnancy Childbirth. 2015 Sep;15:200. doi: http://doi.org/10.1186/s12884-015-0625-x
http://doi.org/10.1186/s12884-015-0625-x... ). Similar findings were identified in another study conducted in five Mozambican provinces, in which 55% of pregnant women started antenatal care between 20 and 28 weeks of gestational age(¹⁴14 Zanconato G, Msolomba R, Guarenti L, Franchi M. Antenatal care in developing Countries: the need for a tailored model. Semin Fetal Neonatal Med. 2006 Feb;11(1):15-20. doi: http://doi.org/10.1016/j.siny.2005.10.002
http://doi.org/10.1016/j.siny.2005.10.00... ). Therefore, it seems that little progress has been made on Mozambican context regarding women`s ability of making full use of antenatal care, starting it early and accessing a greater number of contacts with health professionals.

Such results were also observed in other countries that adopted similar antenatal quality parameters: 9%to 48%variation in the adequacy of gestational age at the beginning of antenatal care and 27% to 45% in the number of visits, considering other African countries, as well as countries in the American and Asian continents(³3 Benova L, Tunçalp Ö, Moran AC, Campbell OMR. Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries. BMJ Glob Health. 2018 Mar;3(2):e000779. doi: http://doi.org/10.1136/bmjgh-2018-000779
http://doi.org/10.1136/bmjgh-2018-000779... ,⁸8 Kassaw A, Debie A, Geberu DM. Quality of prenatal care and associated factors among pregnant women at public health facilities of Wogera District, Northwest Ethiopia. J Pregnancy. 2020 Jan;2020:9592124. doi: http://doi.org/10.1155/2020/9592124
http://doi.org/10.1155/2020/9592124... ,¹⁹19 Kanyangarara M, Munos MK, Walker N. Quality of antenatal care service provision in health facilities across sub-Saharan Africa: evidence from nationally representative health facility assessments. J Glob Health. 2017 Dec;7(2):021101. doi: http://doi.org/10.7189/jogh.07.021101
http://doi.org/10.7189/jogh.07.021101... ). It is noteworthy that, despite the different political, economic and social contexts across these countries, the results are similar. Although our findings cannot be directly compared with other studies that assess the quality of antenatal care, as we analyzed only two indicators and some other studies often consider other indicators, the access to adequate antenatal carein Mozambique was observed in 45% of the pregnancies elsewhere(¹³13 Biza A, Jille-Traas I, Colomar M, Belizan M, Harris JR, Crahay B, et al. Challenges and opportunities for implementing evidence-based antenatal care in Mozambique: A qualitative study. BMC Pregnancy Childbirth. 2015 Sep;15:200. doi: http://doi.org/10.1186/s12884-015-0625-x
http://doi.org/10.1186/s12884-015-0625-x... ). That said, our results confirm that are still limitations in the health services regarding the early recruitment of pregnant women in the country.

Considering that early initiation of antenatal care and more visits allow for more qualified care and better maternal and fetal results(¹1 World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience [Internet]. Geneva: WHO; 2016 [cited 2019 Aug 10]. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/
https://www.who.int/reproductivehealth/p... ,⁵5 World Health Organization. WHO recommendations on maternal health: guidelines approved by the WHO guidelines review committee [Internet]. Geneva: WHO; 2017 [cited 2019 Aug 10]. Available from: https://apps.who.int/iris/handle/10665/259268
https://apps.who.int/iris/handle/10665/2... ), the reasons for its late initiation and lower number of recommended visits were also investigated in this study. Considering the women’s reports, the reasons that stood out the most were the fact that they did not think it was important to attend several visits; did not have easy access to the health facility; found their belly small; did not know that they were pregnant, and did not have a companion for the visits. Similar data were found in studies carried out in Mozambique(¹³13 Biza A, Jille-Traas I, Colomar M, Belizan M, Harris JR, Crahay B, et al. Challenges and opportunities for implementing evidence-based antenatal care in Mozambique: A qualitative study. BMC Pregnancy Childbirth. 2015 Sep;15:200. doi: http://doi.org/10.1186/s12884-015-0625-x
http://doi.org/10.1186/s12884-015-0625-x... -¹⁴14 Zanconato G, Msolomba R, Guarenti L, Franchi M. Antenatal care in developing Countries: the need for a tailored model. Semin Fetal Neonatal Med. 2006 Feb;11(1):15-20. doi: http://doi.org/10.1016/j.siny.2005.10.002
http://doi.org/10.1016/j.siny.2005.10.00... ) and in other regions of the world(¹⁰10 Finlayson K, Downe S. Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies. PLoS Med. 2013;10(1):e1001373. doi: http://doi.org/10.1371/journal.pmed.1001373
http://doi.org/10.1371/journal.pmed.1001... ,¹⁹19 Kanyangarara M, Munos MK, Walker N. Quality of antenatal care service provision in health facilities across sub-Saharan Africa: evidence from nationally representative health facility assessments. J Glob Health. 2017 Dec;7(2):021101. doi: http://doi.org/10.7189/jogh.07.021101
http://doi.org/10.7189/jogh.07.021101... ). This is a very worrying finding, as it shows the influence of beliefs and values on access to and continuity of antenatal care in the city of Nampula(²⁰20 Dias EG, Oliveira CKN, Souza ELS. Barriers found by adolescent moms for early adherence to prenatal care. J Health NPEPS. 2020;5(1):160-73. doi: http://doi.org/10.30681/252610104435
http://doi.org/10.30681/252610104435... ). In addition to promoting access to rapid pregnancy diagnosis methods, which allow for earlier recruitment of the pregnant woman, to encouraging the partner’s participation in antenatal visits, to supporting women who do not want their pregnancy, and to reframing strategies that facilitate access to the healthcare facilities, it is fundamental to demystify certain cultural aspects related to pregnancy.

Furthermore, a systematic review study on the perception of the importance of antenatal care and barriers to access in 15 low-income countries, including Mozambique(¹⁰10 Finlayson K, Downe S. Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies. PLoS Med. 2013;10(1):e1001373. doi: http://doi.org/10.1371/journal.pmed.1001373
http://doi.org/10.1371/journal.pmed.1001... ), showed that women perceive pregnancy as a normal life event, that is, as a physiological event in which antenatal care is only necessary in situations of disease. Thus, little understanding of the benefits of antenatal care and a preference for popular care methods are observed. In addition to that, antenatal care visits demand long wait at the healthcare services, and this time could be used for household chores and for taking care of other children; in addition to the fact that the inadequate transportation structure in some regions of Mozambique represents exposure to risks for the pregnancy(¹⁰10 Finlayson K, Downe S. Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies. PLoS Med. 2013;10(1):e1001373. doi: http://doi.org/10.1371/journal.pmed.1001373
http://doi.org/10.1371/journal.pmed.1001... ). Our results confirm the findings of the aforementioned review.

Women with more years of schooling were more likely to start antenatal care early, report the appropriate number of visits and report both situations simultaneously, which is widely documented in several other studies(⁸8 Kassaw A, Debie A, Geberu DM. Quality of prenatal care and associated factors among pregnant women at public health facilities of Wogera District, Northwest Ethiopia. J Pregnancy. 2020 Jan;2020:9592124. doi: http://doi.org/10.1155/2020/9592124
http://doi.org/10.1155/2020/9592124... -⁹9 Afulani P, Buback L, Essandoh F, Kinyua J, Kirumbi L, Cohen CR. Quality of antenatal care and associated factors in a rural county in Kenya: an assessment of service provision and experience dimensions. BMC Health Serv Res. 2019 Oct;19:684. doi: http://doi.org/10.1186/s12913-019-4476-4
http://doi.org/10.1186/s12913-019-4476-4... ,²¹21 Mekonnen T, Dune T, Perz J, Ogbo FA. Trends and determinants of antenatal care service use in Ethiopia between 2000 and 2016. Int J Environ Res Public Health. 2019 Mar;16(5):748. doi: http://doi.org/10.3390/ijerph16050748
http://doi.org/10.3390/ijerph16050748...

22 Mário DN, Rigo L, Boclin KMS, Malvestio LMM, Anziliero D, Horta BL et al. Quality of Prenatal Care in Brazil: National Health Research 2013. Ciênc Saúde Coletiva. 2019 Mar;24(3):1223-32. doi: http://doi.org/10.1590/1413-81232018243.13122017
http://doi.org/10.1590/1413-81232018243....

23 Okedo-Alex IN, Akamike IC, Ezeanosike OB, Uneke CJ. Determinants of antenatal care utilisation in sub-Saharan Africa: a systematic review. BMJ Open. 2019;9:e031890. doi: http://doi.org/10.1136/bmjopen-2019-031890
http://doi.org/10.1136/bmjopen-2019-0318...

24 Muchie KF. Quality of antenatal care services and completion of four or more antenatal care visits in Ethiopia: a finding based on a demographic and health survey. BMC Pregnancy Childbirth. 2017;17:300. doi: http://doi.org/10.1186/s12884-017-1488-0
http://doi.org/10.1186/s12884-017-1488-0...

25 Fagbamigbe AF, Idemudia ES. Assessment of quality of antenatal care services in Nigeria: evidence from a population-based survey. Reprod Health. 2015 Sep;12:88. doi: http://doi.org/10.1186/s12978-015-0081-0
http://doi.org/10.1186/s12978-015-0081-0... -²⁶26 Bagambe PG, Umubyeyi A, Luginaah I. Effect of pregnancy intention on the timing and sustained use of antenatal care services in Rwanda. Afr J Reprod Health. 2021 Feb;25(1):90. doi: http://doi.org/10.29063/ajrh2021/v25i1.11
http://doi.org/10.29063/ajrh2021/v25i1.1... ). Education enables women to develop the confidence needed to make decisions about their own body and health and to more easily understand the importance of the antenatal care services; in addition to the fact that a higher schooling level is generally related to greater autonomy in the decision to seek antenatal care. Other studies have also shown that women with more years of schooling are the ones who most perform preconception preparation and who experience less unplanned pregnancies(²⁷27 Borges ALV, Gonçalves RRS, Chofakian CBN, Nascimento NC, Figueiredo RMMD, Fujimori E, et al. Uso da anticoncepção de emergência entre mulheres usuárias de Unidades Básicas de Saúde em três capitais Brasileiras. Ciênc Saúde Coletiva [Internet]. 2020 Jan [cited 2020 Jul 07]. Available from: http://www.cienciaesaudecoletiva.com.br/artigos/uso-da-anticoncepcao-de-emergencia-entre-mulheres-usuarias-de-unidades-basicas-de-saude-em-tres-capitais-brasileiras/17487?id=17487&id=17487&id=17487
http://www.cienciaesaudecoletiva.com.br/... -²⁸28 Nascimento NC, Borges ALV, Fujimori E. Preconception health behaviors among women with planned pregnancies. Rev Bras Enferm. 2019 Dec;72(Suppl 3):17-24. doi: http://doi.org/10.1590/0034-7167-2017-0620
http://doi.org/10.1590/0034-7167-2017-06... ), events that are markedly related to better levels of maternal health. Therefore, investment in women’s education will benefit women and their fetuses.

Having a paid job was associated with attending four or more antenatal visits which is similar to other studies(⁸8 Kassaw A, Debie A, Geberu DM. Quality of prenatal care and associated factors among pregnant women at public health facilities of Wogera District, Northwest Ethiopia. J Pregnancy. 2020 Jan;2020:9592124. doi: http://doi.org/10.1155/2020/9592124
http://doi.org/10.1155/2020/9592124... ,²⁴24 Muchie KF. Quality of antenatal care services and completion of four or more antenatal care visits in Ethiopia: a finding based on a demographic and health survey. BMC Pregnancy Childbirth. 2017;17:300. doi: http://doi.org/10.1186/s12884-017-1488-0
http://doi.org/10.1186/s12884-017-1488-0... ). It is understood that women with paid job are often those with greater autonomy in the decision to seek antenatal care and better schooling. In addition to that, paid job enables economic independence so that woman can pay for the costs of transportation to the healthcare service, which enables access to healthcare.

Additionally, women who lived with their partners were more likely to attend four or more visits when compared to those who did not live with a partner, a fact that is similar to results obtained in studies carried out in Brazil(²⁹29 Goudard MJF, Simões VMF, Batista RFL, Queiroz RCS, Alves MTSSB, Coimbra LC, et al. Inadequacy of the content of prenatal care and associated factors in a cohort in the northeast of Brazil. Ciênc Saúde Coletiva. 2016 Apr;21(4):1227-38. doi: http://doi.org/10.1590/1413-81232015214.12512015
http://doi.org/10.1590/1413-81232015214.... -³⁰30 Saavedra JS, Cesar JA. Uso de diferentes critérios para avaliação da inadequação do pré-natal: um estudo de base populacional no extremo Sul do Brasil. Cad Saúde Pública. 2015 May;31(5):1003-14. doi: http://doi.org/10.1590/0201-311X00085014
http://doi.org/10.1590/0201-311X00085014... ). Thus, the absence of a partner can constitute a potential weakness for accessing antenatal care. This may be because the presence of a partner encourages the performance of high quality antenatal care, since the presence of men in antenatal visits offers well-being to women and, somehow, encourages adherence to the treatment and to preventive measures(¹1 World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience [Internet]. Geneva: WHO; 2016 [cited 2019 Aug 10]. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/
https://www.who.int/reproductivehealth/p... ,⁵5 World Health Organization. WHO recommendations on maternal health: guidelines approved by the WHO guidelines review committee [Internet]. Geneva: WHO; 2017 [cited 2019 Aug 10]. Available from: https://apps.who.int/iris/handle/10665/259268
https://apps.who.int/iris/handle/10665/2... ).

On the other hand, the lack of support from an intimate partner or from family members leaves women more fragile and vulnerable and, in turn, negatively affects the search for adequate antenatal care. Culturally, pregnancies outside marriage can be considered disapproved and considered a shameful act in many African societies, and this may discourage single or unaccompanied women from seeking antenatal visits(³¹31 Mohammed S, Yakubu I, Awal I. Sociodemographic factors associated with women’s perspectives on male involvement in antenatal care, labour, and childbirth. J Pregnancy. 2020;2020:6421617. doi: http://doi.org/10.1155/2020/6421617
http://doi.org/10.1155/2020/6421617... ). Social support from family members and/or friends can be strengthening for pregnant women who are not in a stable relationship.

Although we have only considered variables related to the women’s individual characteristics in our analysis of the covariates of the initiation of antenatal care up to the 16^thgestational week and reporting a minimum of four antenatal care visits, it is necessary to highlight that the responsibility for improving the access and offering high-quality antenatal care lies in the MISAU, as well as in the healthcare services themselves, which need to respond to the health needs of pregnant women or those planning to become pregnant.

To our knowledge, this is the first study in Nampula, Mozambique, which assessed the covariates of gestational age at the beginning of antenatal care, the number of visits, and the simultaneity of these two events. Another potential of our study lies in the fact that we used a validated instrument to assess pregnancy planning. Knowing the profile of women with access to so-called basic antenatal care contributes to the proposal of public health and social policies that effectively improve women’s health, as well as that of their future children. Thus, it is necessary to think of strategies so that women with low schooling and without any paid job may, through the public healthcare service, diagnose pregnancy early and access information about the importance of starting antenatal care early and, consequently, attend more antenatal care visits.

Health professionals, especially nurses and maternal nurses, common in Mozambique, can also act to demystify beliefs and values, such as finding the belly small and not considering it important to attend antenatal care; they can also contribute to expanding access to reproductive planning, as some women reported not knowing that they were pregnant and not knowing how to take care of a future pregnancy.

In addition to that, Mozambique adopts a system of fewer antenatal care visits than the number recommended by the WHO. It is noteworthy that countries that adopt a reduced number of antenatal visits present a reduction in the associated cost without changes in the maternal mortality rates, with the aggravating factor of an increase in perinatal mortality and lower women’s satisfaction(³²32 Dowswell T, Carroli G, Duley L, Gates S, Gülmezoglu AM, Khan-Neelofur D, Piaggio G. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2015 July;(7):CD000934. doi: http://doi.org/10.1002/14651858.CD000934.pub3
http://doi.org/10.1002/14651858.CD000934... ).

This study has some limitations. In the first place, women living in a single municipality and attending the Mozambican National Healthcare System were evaluated; therefore, the findings cannot be generalized to Mozambican women in general, nor to those who use the private healthcare system. However, considering that antenatal care coverage should be universal, results of research implemented around the quality of public health services may help to improve the quality of antenatal care for every women, irrespective if attending public or private services. In the second place, our data were obtained from the women’s reports and memory bias can have occurred, as some women may have omitted or forgotten some information during the interviews. To minimize this bias, interviews were done with postpartum women(24-hour period, among women who gave birth in the maternity ward, and up to 14 days postpartum, among women who gave birth at their homes).

Our study also contributes by identifying the difficulties of the antenatal care services in a country in Sub-Saharan Africa, which may support the implementation of initiatives aimed at increasing the number of visits and anticipating the initiation of antenatal care, such as increasing the schooling of children, adolescents and women; offering support so that they can reach the health facility without major difficulties; and providing information so that pregnant women understand the importance of antenatal care. Such initiatives are not only necessary in African countries, but also in other low- and middle-income countries that still struggle to achieve the best possible levels of maternal health.

Conclusion

Our findings showed that, despite the universal coverage of antenatal care, the gestational age at the beginning of antenatal care and the number of visits are lower than the current recommendations in Mozambique. For the social and public health policy-makers, improvements are suggested in the access to health care facilities, in the early recruitment of pregnant women, in the demystification of beliefs for adherence to antenatal care, and in the provision of care on reproductive planning to support women who plan to become pregnant.

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