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Antenatal care in Mozambique: Number of visits and gestational age at the beginning of antenatal care

Objective: 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 attending less than four visits among postpartum women living in Nampula, Mozambique. Method: cross-sectional study conducted with 393 mothers who answered a structured instrument in face-to-face interviews. Logistic regression was used to analyze the covariates of having initiated antenatal care up to the 16thgestational week, having attended four or more antenatal visits, and reporting both situations simultaneously. Results: all postpartum women underwent antenatal care, but only 39.9% started it until the 16thgestational week, 49.1% attended four or more visits, and 34.1% reported both events. Having concluded high school (ORadj=1.99; 95%CI=1.19-3.31) or college (ORadj=3.87; 95%CI=1.47-10.18) were aspects associated with reporting both situations. The reasons for the late initiation of antenatal care and attending less than four visits were as follows: not finding it important to attend several visits, not having easy access to the health facility, not being aware about pregnancy, and not having a companion for the visits. Conclusion: the gestational age at the beginning of antenatal care and the number of antenatal visits are lower than the current recommendations in the country.


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 (1) .
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 (1)(2)(3)(4) .
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 (1,5) .
The vast majority of high-and middle-income countries recommend at least six antenatal visits; they also recommend initiating antenatal care between the 8 th and 12 th gestational week (6)(7) . However, some lowincome 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 th week (8)(9)(10) .
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 th week at its initiation (1,5) . 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 th week at its initiation (11)(12) . In that country, few studies have assessed gestational age at the beginning of antenatal care and the number of visits (13)(14) . 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 (12) .
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 (14) .
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, 452 per 100,000 live births (15) , 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.

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 (casecontrol, cohort and cross-sectional) (16) .

Context
The study was conducted in the city of Nampula,  (17) . 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 (15) .
The mean life expectancy is 56.5 years old (15) and the total fertility rate is 5.3 children per woman (12) .

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 www.eerp.usp.br/rlae 3 Reis-Muleva B, Duarte LS, Silva CM, Gouveia LMR, Borges ALV.
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 (12) , female population of Nampula of 337,839 women at the time of the study (15) , 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  (18)

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 Google Forms, 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.

Ethical aspects
The project was approved by the Institutional

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  (Table 1).

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 (11) . 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 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 (3,8,19) . It is noteworthy that, despite the different political, economic and social contexts across these countries, the results are similar. Although Considering that early initiation of antenatal care and more visits allow for more qualified care and better maternal and fetal results (1,5) , 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 (13)(14) and in other regions of the world (10,19) . 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 (20) .
In addition to promoting access to rapid pregnancy for the pregnancy (10) . 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 (8)(9)(21)(22)(23)(24)(25)(26) . Education enables women to develop 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 (8,24) . 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 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 (32) .
This study has some limitations. In the first place, countries that still struggle to achieve the best possible levels of maternal health.

Conclusion
Our findings showed that, despite the universal