An in-depth look at antenatal care quality in Nampula, Mozambique based on women's experiences and implementation research findings.
When Maria, a young woman from Nampula province in northern Mozambique, became pregnant with her first child, she knew exactly what to do. She attended all her antenatal appointments, just as healthcare officials recommended. Yet, when she emerged from the health center after each visit, she carried with her not just a growing baby, but a lingering sense that something was missing. The care she received felt rushed, impersonal, and left many of her questions unanswered. Her experience reflects a troubling paradox across Mozambique: while antenatal care coverage is remarkably high, with nearly 90% of pregnant women attending at least one visit, the quality of that care remains alarmingly low 1 .
Mozambique has one of the highest maternal mortality rates in the world, with 452 maternal deaths per 100,000 live births 1 .
This disconnect between access and quality carries grave consequences. The situation is particularly dire in Nampula, a province struggling with limited healthcare resources and infrastructure. What if the key to saving mothers' lives lies not just in getting them to clinics, but in truly listening to their experiences and improving the quality of care they receive?
Recent implementation research conducted in Nampula sought to do exactly that—by asking women like Maria about their experiences and opinions of the antenatal services they received. The findings reveal critical gaps in what the healthcare system provides and what women actually need and deserve during their pregnancies.
In global health circles, Mozambique presents a puzzling scenario. The country has achieved impressive numbers in getting pregnant women through clinic doors—yet these contacts aren't translating into better health outcomes as expected. The reason, researchers discovered, lies in a profound quality chasm separating official guidelines from actual clinical practice.
According to the Ministry of Health of Mozambique, quality antenatal care should include at least eight essential components: an appointment in the first 16 weeks of gestation, four or more antenatal appointments, at least one laboratory test, four or more clinical-obstetric procedures, three doses of intermittent preventive treatment for malaria, two doses of the tetanus vaccine, and counselling related to general health care 2 . When measured against these standards, the results are startling: only 13% of women receive care that meets all these quality indicators 2 .
But the quality shortfalls don't stop there. Women report consistently missing out on essential elements of care: not being screened for anemia or proteinuria, not receiving necessary medications, and not getting crucial information about pregnancy risks 2 . These aren't minor oversights—they represent missed opportunities to detect and manage conditions that can turn deadly during pregnancy and childbirth.
To understand how to bridge this quality gap, researchers from Lúrio University and the University of Saskatchewan conducted an innovative study at Marrere Hospital Maternity in Nampula. Their approach was simple yet radical: they asked the women themselves.
The research team employed a pre-post study design, conducting two cross-sectional surveys with postpartum women—one after five training sessions for healthcare professionals, and another after six additional trainings 9 . In total, 116 postpartum women shared their experiences, providing unprecedented insight into the realities of maternity care from the patient's perspective 9 .
The training sessions for healthcare providers covered critical areas like obstetric emergencies, newborn resuscitation, antenatal consultation, family-friendly consultation, humanized care, and sexual and reproductive health 9 . Each training lasted five days, totaling 20 hours, and aimed to enhance the skills and sensitivity of healthcare workers in delivering maternal care.
116
Postpartum women surveyed
| Characteristic | 2018 (after 5 trainings) | 2019 (after 11 trainings) | Change |
|---|---|---|---|
| Average Age | 23.6 years (SD: 5.7) | Same | None |
| Illiteracy Rate | 42.4% | Same | None |
| Residence in Natikiri District | 83% | 97.8% | +18% |
| Previous Home Births | 12.5% | 24.2% | +94% |
The surveys assessed multiple dimensions of care quality, including whether women felt welcomed, whether they received clear communication, whether their privacy was respected, and whether they had continuous support during labor 9 . The results would reveal not just whether clinical tasks were performed, but how women felt about their interactions with the healthcare system.
The findings from the Marrere Hospital study revealed a troubling disconnect: despite extensive training of healthcare professionals, women reported little improvement in their care experiences. In some areas, conditions had actually deteriorated between the first and second surveys 9 .
| Aspect of Care | Reported Availability/Quality | Trend |
|---|---|---|
| Option to have labor companion | 75% | Improved |
| Traditional birth attendant as companion | 34% | Improved |
| Continuous professional support during labor | 68% | Improved |
| Adequate privacy protection | 33% | No improvement |
| Confidentiality maintained | 57% | No improvement |
| Feeling welcomed | Not reported | Declined |
The study authors speculated about the reasons for this disappointing outcome. They noted that the high turnover rate of healthcare staff might mean that trained professionals were frequently transferred elsewhere, draining the facility of newly acquired expertise 9 . Additionally, they questioned whether the training methods needed revision to more effectively change both provider behavior and institutional culture 9 .
If training healthcare professionals alone doesn't dramatically improve women's experiences, what factors actually determine whether pregnant women feel satisfied with their care? Research from southern Mozambique provides fascinating insights.
A comprehensive study of 951 pregnant women across four provinces revealed that 85.9% reported being satisfied with their antenatal care overall . But beneath this seemingly positive statistic lay revealing patterns about which aspects of care most influenced their satisfaction.
The study identified several critical factors that diminished women's satisfaction:
The research also highlighted how women's characteristics influenced their care experiences. Those with higher education levels were more likely to both start care early and attend the recommended number of visits 1 . This education advantage extended to partners as well—women whose partners had more education also received better care 5 .
Economic factors played a similar role. Women from wealthier households and those engaged in agriculture or other employment attended more antenatal visits 5 . These patterns reveal that social and economic inequities create significant barriers to quality care, with the most vulnerable women often receiving the poorest services.
The challenges in delivering quality antenatal care extend far beyond what happens in examination rooms. Women in Mozambique, particularly in rural areas like Nampula, face daunting structural barriers that limit their access to timely, respectful care.
Distance and transportation problems represent one of the most significant hurdles. Women who had to travel longer than an hour to reach a health facility were significantly less likely to attend the recommended four antenatal visits 8 . This travel burden disproportionately affects rural women, who make up approximately 66.6% of Mozambique's population .
Cultural and interpersonal factors also create obstacles. Women reported that "not having a companion for visits" was a key reason for either starting care late or attending fewer appointments 1 . Similarly, needing to secure permission from others to seek care and not wanting to go alone negatively affected visit numbers 5 .
Perhaps most heartbreaking are the reasons women themselves give for not seeking adequate care: some simply don't believe multiple antenatal visits are important 1 . Others don't recognize their pregnancies early 1 . These perspectives suggest a critical need for better community health education alongside improvements in clinical quality.
| Barrier Category | Specific Barriers | Impact |
|---|---|---|
| Structural | Long distances to facilities, transportation difficulties, cost | Reduces number of visits |
| Social/Cultural | Need for permission, lack of companion, not wanting to go alone | Delays care initiation and reduces visits |
| Educational | Not believing in importance of multiple visits, lack of pregnancy awareness | Reduces motivation for care |
| Economic | Poverty, unemployment, subsistence livelihood | Limits access to care |
The research evidence points to an inescapable conclusion: improving maternal health in Mozambique requires a fundamental reimagining of what antenatal care should be. The traditional focus on simply increasing patient volume must give way to a more nuanced approach that prioritizes quality, responsiveness, and respect.
An innovative kit system introduced in Mozambique demonstrated dramatic improvements in care quality when healthcare workers had reliable access to necessary supplies 6 .
Modest changes like ensuring sufficient consultation time, creating more comfortable waiting areas, and eliminating punitive policies for late arrivals could significantly enhance patient satisfaction .
Effective antenatal care must extend beyond clinic walls through community health education that helps women recognize pregnancy earlier, understand the importance of care, and navigate social barriers to access 1 .
A uniform national policy cannot address the diverse needs of women across Mozambique's regions. Flexible approaches that account for local realities are essential 5 .
The challenges in Nampula's antenatal care system reflect broader struggles in global health—the tension between quantitative targets and qualitative experiences, between clinical protocols and human relationships. By listening to women's voices and honoring their experiences, Mozambique has an opportunity to transform not just antenatal care, but the very meaning of maternal healthcare.
As one research team concluded: "The criteria recommended for quality antenatal care are not incorporated into clinical practice in Mozambique" 2 . Closing this implementation gap will require more than training healthcare workers or building clinics—it will demand a fundamental commitment to seeing antenatal care through women's eyes, and building a system that truly meets their needs.
The path forward is clear: when quality improves, satisfaction follows. And when women are satisfied with their care, they are more likely to engage with the health system, follow recommendations, and ultimately experience safer pregnancies and childbirths. In the end, listening to women isn't just about respect—it's about survival.