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Maternal Healthcare in Mozambique A BALANCE OF TRADITIONS AND INSTITUTIONS

For families expecting a baby in Mozambique, hidden costs in healthcare can impede access to vital services. Just ask Rute José, who at the time of her pregnancies needed to pay illicit charges to receive treatment at a hospital, despite Mozambique’s national public healthcare system, where such services should be free.

“When a woman goes to deliver, they [healthcare providers] usually ask for money,” Rute said. “If you don’t give money, you’re kept waiting.”

Not only did Rute pay for hospital care when her daughter was born, but the family began saving immediately for the delivery of their next baby. Paying these illicit charges means immediate access to medical professionals. For a heavily pregnant woman, there is nothing more dangerous — for herself and her baby — than endless waiting after her waters break and she goes into labor.

“My husband agrees,” Rute said. “It’s a health issue.”

Maternal healthcare is also an issue of governance, accountability, and dignity. Access to healthcare is a constitutional right in Mozambique, and although state-run maternal healthcare services are meant to provide free essential care to pregnant women and families, patients often mistrust official healthcare professionals. Patients’ wariness stems not only from allegations of healthcare workers requesting illicit charges, but also from the verbal abuse and disrespect they have experienced. In addition, these largely urban services are difficult for rural women and families to access. COVID-19 has reinforced these barriers to access, further reducing the numbers of pregnant women accessing state-run maternal healthcare.

Pregnant women living in rural and remote areas often travel considerable distances to receive care at health centers.

Traditional birth attendants offer an alternative to state-run maternal healthcare. Traditional birth attendants are Mozambican women who serve, often for free, other local women who are unable or unwilling to use state maternal health services. Historically, traditional birth attendants have been the main caregivers for Mozambican women during childbirth. They often carry trust with communities that formal maternal health providers may not.

However, despite providing a vital service, traditional birth attendants typically lack formal training, learning most skills from their families and passing them through the generations. They also do not always have access to personal protective equipment and other vital medical resources. Some traditional birth attendants, albeit a small minority, take advantage of their position within the community. Known by some as “witchdoctors,” they sometimes request gifts and tributes for their services, exploiting expectant mothers for their own gain.

As a result, for many years, Mozambicans have chosen between these two maternal healthcare systems: the formal state-run system delivered by healthcare professionals and the informal local system delivered by traditional birth attendants.

With funding from UK aid, POTENCIAR seeks to improve the maternal healthcare landscape by understanding the range of experiences that Mozambicans have with their healthcare system and catalyzing positive, system-wide change. The program supports initiatives that make the state more responsive to citizen needs, promoting a fair distribution of resources and services by cultivating dialogue and joint initiatives between citizens, civil society, and government bodies. These initiatives range from reforming the reporting mechanisms that patients use to divulge abuses to regular coordination meetings between local formal and informal healthcare organizations to align activities and maximize collective resources across sectors.

Nurse and midwife Laura Inácio José (left) and her two colleagues at the Carapira Health Unit in Nampula Province. “In one month, we have between 130–140 women who come to give birth here in the unit.”

The Problems Facing Mozambique's National Health Service

The state-run maternal healthcare service can provide pregnant women with more regulated, safe, and formalized assistance. The evidence shows that maternal care is improving. Since 1990, Mozambique’s mortality rate for children under five years of age has reduced from 240 per 1000 live births to 70 per 1,000 in 2020. However, the country’s formal healthcare system faces a plethora of issues. Facilities often have limited access to running water, electricity, medications, basic equipment for operations, and even bedsheets. In some cases, hospital beds have sheets so old that it is not unusual to see patients or their families lay their own clothes on top of facility beds. There is also a lack of qualified staff.

The facilities and systems that Mozambican health centers rely on are often basic.

Additionally, health centers can be difficult to reach for those living in remote communities, particularly when these individuals are heavily pregnant and entering the first stages of labor. Interviews have also documented women experiencing humiliation and verbal abuse from healthcare workers. Often, a worker’s negative perceptions of a patient’s education and social status drive and maintain this negative behavior.

The request for illicit charges by some healthcare providers is perhaps the most counterproductive issue plaguing the state health service. Its prevalence can be traced back to the early years of Mozambique’s healthcare system. After the country’s independence from Portugal in 1975, the government enacted policies to provide basic services to its population. Many elements of this system still provide Mozambicans with care today. Delivering basic healthcare services required increased spending. This spending grew from 4.6% to 9.7% of the government’s budget only a year after the construction of a primary healthcare system based on principles in the transformative Alma-Ata Declaration of 1978 — which emphasized that primary healthcare is a fundamental human right.

Mozambique found itself independent but debt-laden, and initiated a structural adjustment program that consisted of macroeconomic austerity policies to spur economic growth and repay debt. This program required significant cuts in public spending, but the healthcare system, which was mostly free of charge for users, needed significant investment after the civil war in the 1980s. Additionally, health worker salaries plummeted below the poverty line.

Children, mothers, and healthcare workers mingle outside the Carapira Health Unit in Nampula Province.

As a result, some health workers nationwide began requesting payments from patients to make ends meet. Since then, illicit fees sometimes appear in parts of the health sector, whereas, a traditional birth attendant’s services are typically or largely free supported usually only by voluntary or in-kind contributions that families can afford.

The verbal abuse from health workers that women report also persists despite government attempts to humanize services. A 2019 study on facility-based childbirth in southern Mozambique revealed that the prevalence of disrespect and abuse ranged from 24% in the central hospital to 80% in district hospitals. The main types of disrespect and abuse reported were being denied confidentiality or privacy, left alone, shouted at and scolded, and subjected to treatment without permission.

Health Unit Director José Artur completes vital paperwork at the Carapira Health Unit in Nampula Province. “We have been listening to the communities to judge their level of satisfaction with the health unit. We are creating a plan of action to correct what is failing and to improve.”

Reassuring pregnant women that they will be treated respectfully at healthcare facilities requires giving them good reason to believe that the authorities will receive and resolve all complaints promptly and appropriately. POTENCIAR is working with civil society organizations and health authorities in Nampula Province of northern Mozambique to review the complaints mechanisms at healthcare centers. It supports these organizations in overhauling how women and families report complaints and how facilities manage these reports to resolve issues quickly and hold abusive staff accountable. This work is essential to infusing confidence into maternity services, ensuring that existing abuses are rooted out and that there is no tolerance for new abuses.

Traditional Birth Attendant Muaquera Momade stands in her Nampula home. She says that the needs of pregnant women led her down this career path. “I can’t leave a person in pain when I know how to help.”

Learning from Traditional Birth Attendants

Traditional birth attendants may lack resources and training, but their communities often respect them because of the vital role they play in lieu of state-run healthcare. This role extends beyond the birth process to include advising young women on matters such as menstruation, pregnancy, and marriage. This social connection has proven to be a deciding factor for expectant Mozambican mothers. It is not easy to gauge the percentage of births that traditional birth attendants oversee, but in 2020 evidence suggested that 80% of Mozambicans primarily use traditional healthcare.

The example set by traditional birth attendants suggests that a more community-focused, less transactional approach to patients’ healthcare may improve use of state-run healthcare facilities.

Traditional birth attendants, such as Muaquera Momade, often perform several socially significant roles in their communities.

Encouragingly, some state healthcare providers are starting to recognize the value of collaborating with traditional birth attendants. “The [traditional birth attendants] now work in coordination with us, mobilizing communities, explaining methods of family planning, and if necessary, referring people to the health unit,” said Health Unit Director José Artur. “We have been training the [traditional birth attendants] for this work.”

Health Center Midwife Laura Inácio emphasizes this rapport between professional healthcare providers and traditional birth attendants. “These traditional birth attendants know that if there are birth complications in the community, they can always count on us to help the patient. If necessary, we can even transfer that patient to a more capable unit — for example, with cesarean section services, to save the patient and her baby.”

Laura Inácio José (left) and José Artur (right) tend to patients at Carapira Health Unit in Nampula Province. They work with traditional birth attendants to improve relations between the health center and local communities.

POTENCIAR fosters this type of mutually beneficial relationship. Developing new ways for different groups to communicate and collaborate will improve women’s access to quality maternal services. For example, public communications initiatives, such as radio, provide a platform for mothers and citizens to air concerns. Healthcare providers can, in turn, publicly recognize problems, which may spark trust-building dialogue with potential patients.

A healthcare worker prepares to take measurements from a patient.

Convening the Healthcare Community Around Shared Goals

Understanding the complex relationships that comprise the maternal healthcare ecosystem in Mozambique, from healthcare providers to NGOs working on improving access to healthcare, is the first step towards creating a more cohesive and effective system for all. Essential to this process is also uniting those actors with local communities to design and address issues together. Building a coalition of partners representing healthcare, government, and civil society will create trust between service providers and users and break down income, culture, and literacy barriers.

Program manager Eulália Leonor from Niwanane compares notes with her colleague. A civil society platform, Niwanane connects different actors in maternal healthcare. “What we do is to show the advantages of going to the health units.”

POTENCIAR improves citizens’ trust in and use of state healthcare services by strengthening key health actors’ accountability. Its initiatives support many partners to identify priorities and develop tools to improve services in ways that sustain institutional and system-wide reform.

POTENCIAR convenes actors from across the spectrum of the Mozambican healthcare system. By connecting local and national healthcare bodies that may not otherwise coordinate, the program facilitates a collaborative approach to planning and learning. The hope is to build consensus around tackling issues such as illicit fees, disrespect, and abuse.

The program provides support to advocacy groups, such as Campaign Against Obstetric Violence, that influence policymaking processes and change the provision of basic services. It also undertakes research and analytical work to support decision-makers on building accountable and inclusive public services in Mozambique.

Traditional birth attendant Zainabo Cipriano with two of her children. She explains how she works with the local health unit: “After helping the mother give birth, I accompany her to the hospital so she can be seen by professionals.”

Mozambique’s National Health Service was built on solid principles of equality, but its troubles have challenged the way citizens perceive it. Although it provides vital services, these services are weighed down by illicit charges and other issues. By bringing state and nonstate actors together, POTENCIAR builds the foundation of trust necessary to identify and resolve priority issues and, in turn, transform healthcare delivery. The core to this approach is embedding strong accountability: the accountability of healthcare providers to healthcare users as well as the accountability of the government toward its citizens. POTENCIAR’s role in empowering these organizations will ensure that women such as Rute José won’t have to choose between imperfect options but will instead have access to an effective and cohesive healthcare system.

Photography: All photos in this story by Emidio Josine.

Content: Thanks to Marion Baumgart dos Santos for providing valuable insights on the state and history of maternal healthcare in Mozambique and the role of traditional birth attendants.

Created By
Sam Viney
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