An Analysis of the Quality of New-Born Health Services in Nampula, Mozambique.

New-born morbidity and mortality are high in Africa, including Mozambique. One important factor to reduce this public health burden is ensuring the frequency and quality of new-born visits, with the availability of ecient, timely, patient centred care. To contribute to the reduction of new-born mortality rate in Nampula, the Lúrio University and the University of Saskatchewan, carried out an implementation research project which included training activities for health professionals in maternal and child health care. We planned a mid-project evaluation, to assess the impact of health professionals training on the quality of services at Marrere Health Centre. The low number and quality of new-born visits contributes to a high new-born mortality in Mozambique. To approach health problem, we carried out an implementation research project with training activities for health professionals in child health care. We planned a mid-project evaluation, to assess the impact of health professionals training on the quality of services at Marrere Health Centre. This was a quantitative study, applying two cross-sectional surveys about new-born visits service quality, the rst after two health professionals’ training sessions, the second after ve more sessions. Subjects were carers of infants up to 28 days of age in Marrere Health Centre. This research was approved by the bioethics committees at Lúrio University and at the University of Saskatchewan. A total of 188 child carers were surveyed at Marrere Health Centre, about new-born services quality. Most areas showed no improvement. Positive improvements were a 31% increase in health professionals encouraging mothers to have a person of their choice to accompany them during labour, suggesting a traditional birth attendant (97%). The quality of care at Marrere Health Centre did not improve. Reviewing health professionals learning approach and developing continuous capacity building, would be the next steps to improve quality of new-born centred care.


Introduction
Child mortality has its highest incidence in the rst year of life and is concentrated in the rst month. 1 Access to and quality of child health services, is essential to achieve Sustainable Development Goal number 3, 2 especially in low-income countries, including reduction of morbidity and mortality rates in children, which in Mozambique is among the highest in Africa and the world. To reduce new-born mortality, the World Health Organisation (WHO), produced in 2016 speci c recommendations to the countries. 3 In 2008, the Mozambican Ministry of Health (MISAU) developed a strategy to accelerate maternal and new-born mortality rates reduction, 4 but in 2013, the country registered 27,8 deaths of children less than 28 days of age per 1000 live births, and 88.5 under ve years, 5 with higher mortality risk for those born in Nampula and other northern provinces. 6 Though child mortality rate decreased in Mozambique in the last three decades, 7 it is still high (67.3 deaths of children less than one year of age per 1000 live births, 2017). 8 Among the main causes are the reduced number of quali ed health professionals (HPs), lack of equipment and supplies. Additionally, are poor quality of care, de cient referral system, long distances, and lack of transport to access the health unit (HU), poor communication between HPs and the community, and gender issues. These barriers are common to low-and-middle income countries, 9 mainly in sub-Saharan Africa. 10,11 Although MISAU de ned policies to promote child health in primary care at Healthy and at Risk Children Services since 2011, 12 in the last decade, the low quality of maternal and child health (MCH) services in Mozambique, has hardly improved. 13 An assessment of quality and access to health care, in 195 countries in 2016, placed Mozambique in position 179. 14 These facts led the Faculty of Health Sciences (FHS) of the Lúrio University (UniLúrio) and the University of Saskatchewan in Canada, to develop an implementation research on MCH, in the administrative post of Natikiri, in Nampula province, Mozambique, called Alert Community to a Prepared Hospital care continuum (ACPH). A baseline study showed a low level of knowledge about sexual and reproductive health (SRH) and rights in the Natikiri population and poor family planning (FP) practice. 15 Project activities stimulated community participation and SRH and FP education, empowering population health knowledge, attitudes and practice. Another strategy was to improve training of HPs in obstetric emergencies, new born resuscitation, SRH rights, ante-natal consultation and humanization of care in Marrere Health Centre (MHC); some equipment and supplies were also provided, knowing that most newborn deaths can be prevented by effective interventions. 16 This paper pertains to the results of a planned mid-project evaluation, intended to estimate the impact of HPs training in new-born visits, demonstrated to have a positive impact in the quality of services. 17 Given the importance of feedback from users to evaluate health services, with regards to the quality of care issues, communication, information, and advice, our implementation research method to collect data, targeted participants citizenship and health empowerment, informing and educating the population.

Study design
This was a quantitative pre-post study, applying two cross-sectional surveys on user's opinion about newborn care services quality, the rst being conducted after two training sessions on new-born resuscitation (during the 3rd semester of the project, 2018) and the second after ve more training sessions, two on new-born resuscitation, two on family-friendly consultation and humanized care, and one in SRH (during the 6th semester of the project, 2019); each training lasted ve days, 20 hours in total, given to 30 HPs over the seven modules.

Setting
Surveys with user groups were privately carried out at the healthy child service, child at risk service and emergency room, in MHC.

Sample
To calculate representative samples of mothers with children with less than one month of age at MHC, Natikiri administrative post, Nampula, we considered the monthly average number of post-partum visits, 143 in 2018, with a margin of error of 10% and a con dence interval of 90%, attaining 47 women; for the second survey we considered the monthly average number of post-partum visits with children less than one month, 178 in 2019, with a margin of error of 5% and a con dence interval of 95%, attaining 122 women, and we added 10% to compensate registering errors, attaining 134 child' carers.
The two groups are made up of different subjects.
Data collection: participants were submitted to a closed ended survey, previously tested, in Portuguese or Emakhuwa (local language) according to the participant's preference, administered by UniLúrio FHS' students, after being adequately trained and signing ethical and scienti c commitment forms. Mothers of new-born children were questioned in private at the MHC facilities, from the 24th to 31st of July 2018 and from the 28th of November to 6th of December 2019. All women were informed they were free to participate voluntarily, or abandon the survey if they wanted, without any consequences in access or quality of care, and signed an informed consent form, including an informed assent term for adolescents under the age of 18 years.
The survey questions (28) with multi option choice, were answered using a 5-point Likert scale (i.e., totally agree, agree, indifferent, disagree, strongly disagree; or, always, often, sometimes, very infrequently, never); and three in depth open questions were also applied by the interviewers. Data collection instruments were evaluated on the quality of completion.

Data analysis
Quantitative data were introduced into REDCap (Research Eletronic Data Capture) at https://rev.unilurio.ac.mz/umestumafam/redcap, by the same students, accompanied by an FHS lecturer to be consulted as needed. The data were then analysed by a statistics professor to assess frequency, percentage, average and standard deviation.
This study was approved by the Institutional Committee on Bioethics for Health at UniLúrio and the Bioethics Committee at the University of Saskatchewan and followed all Helsinki Declaration (2013) guidelines.

Results
We surveyed 188 women with children of less than one month of age at the MHC Healthy and at Risk Child services (48 after two HPs trainings, 140 after a total of seven training sessions), with a mean age of 23.38 years (standard deviation 5.8), minimum 14 and maximum 45 years (4.9% with less than 18 and 4.1% withy more than 35 years). Concerning education level, 34.3% are illiterate, 49.3% completed primary and 15% secondary, with two (1.4%) with higher education. The participants' characteristics are detailed in Table I. The proportions of residence locations changed, with an increase in Natikiri neighbourhood; there was a slight increase in previous pregnancies number and the percentage of home deliveries increased fourfold; there was no change in the percentage of women referring miscarriage. The assessment of principles of good care, although con rmed by more than half participants in most questions, show a negative evolution in all areas, including reception, communication with patients, privacy and con dentiality, care during labour and childcare.
Patients felt less (-10%) welcome at the services, HPs did not greet and offer a seat (-30%), asked less (-25%) the name, if they had any doubts (-42%), did not encourage them to ask questions (-27%) and state their expectations at the beginning of the consultation (-49%), and did not explain what they would do, before performing physical examination or other interventions (-13%), did not encourage the husband participation caring for the new-born (-28%).
Some positive points were identi ed about care during labour: they informed more (48%) the mothers that they had the right to speak to any HP about their di culties, they were best (31%) given the option to have a person of their choice to accompany them during labour, notably a traditional birth attendant (97%), and were said they could deliver in a position of their choice (89%).
The last question summarizes the ndings of participants perception, asking the children carers how they evaluate their overall experience at MHC: most rated their experience as excellent (34%) and good (58%), but the evolution of this service, however, was unfavourable with 10% increase of unsatis ed users (see Table 2). Asked about what they would change to make the service better, we had a reduction of 29.3% of those who would do nothing, 32 (23.2%) suggested improving the reception of patients by HPs, better their punctuality and eliminate illicit charges, and 6 (4,3%) to improve medication availability.

Discussion
Most participants live in the three communal units of Natikiri neighbourhoods (Marrere, Natikiri, Murrapaniua), with an increasing trend over time, and have a low education level, making health preventive attitudes rare in this population.
The mean number of pregnancies per women remains under the national average (5.2), with more than half having three or less pregnancies, probably due to the low group' mean age. Home births increased, or women felt more at ease to reveal it.
Miscarriages (spontaneous and provoked) show no change.
As recommended by the WHO and MISAU, HPs informed delivering women that they had the option to have a person of their choice to accompany them during labour, and this is a low-cost and effective intervention to improve the quality of MCH care. 18 In 2019, most children carers in MHC healthy children consultation and children at risk consultation were satis ed with the service, but we can see a more critic evaluation, translating user's health education empowerment.
Although more than half of the participants refer that HPs are practicing within the principle of good care, they do not systematically proceed according to the MISAU policy and MCH protocol; they have de ciencies in patients' reception, information, and communication, and in matters of con dentiality.
Lack of medicines also remains a challenge, recognised in several low-income countries. 19,20 HPs respectful and appropriate attitudes towards child carers and their education, are essential to ensure the quality of child health services. 21 It is recognised that maternal care directly impacts in new-born outcomes.
Our evaluation reveals no signi cant impact of HPs trainings on child attendance quality at MHC. This nding might be related to the high turnover of MHC professionals, and their reduction, causing an overload of work to those remaining, associated with a decrease in material resources due to economic shortcomings. On top of this, we veri ed that one of the seven training modules was not evaluated; in the six evaluated, we had 24% participants missing in the post-test and mean evaluation of progress was weak (13%).
However, child health indicators show a general positive quantitative evolution over time, high above the population increase rate (2,8% per year), despite the lack of MCH professionals (see Table 3).
Nevertheless, nutritional monitoring, a fundamental strategy approaching malnutrition concerning Mozambican children, showed marked decrease. Facility assessment tools are valuable to assess quality of new-born care and guide priority measures to reduce the burden of child mortality, 22 but it is necessary to strength health system and data collection methods. 23 We recommend a national MCH HPs training campaign, continuous, 24 and regular, about skills, values, transforming attitudes, and interpersonal communication. This must be combined with an improvement on HPs working conditions. Those needs have been identi ed by MISAU since 2009, 25 and are developed in the Global strategy for women's, children's, and adolescents' health (2016-2039). 26 Study limitations: as study limitations we point out the location of interviews in MHC, that might have in uenced some answers. Another issue is the application of the Likert scale to a population with perceived di culty in abstract conceptualization, in which the terms totally and partially, or always and most times, may have been not well understood. Another limiting factor in comparing the two studies is the use of a 90% con dence interval and 10% margin of error in the rst sample, different from the second (95% and 5% respectively).

Conclusion
Health systems face new (antimicrobial resistance, climate emergency, Covid-19 pandemic) and old (in Africa, traditional taboos) challenges, and will be forced to develop new intervention methods.
MCH HPs are subjected to a heavy workload, and they do not systematically practice according to protocol, having several shortcomings in patient's reception, information, con dentiality, and communication.
Although most users were satis ed with the care provided, and the child health statistical indicators show improvement in the number of post-partum consultations with children less than one month and less than one year, child mortality incidence remains high.
The Mozambican national health system continually faces challenges, with the scarcity of HPs and low funding, therefore looking for new tools for action. Continuous health sector investment for capacity building, such as HPs training and better working conditions are keys to achieve behaviour change, and better child health services quality. These interventions depend on MISAU innovative and investment to:  We followed all Helsinki Declaration (2013) recommendations, all participants were volunteers, anonymity guaranteed, free to desist if uncomfortable without any negative condition, signing or recording an informed declaration consent term. This research had no risk or remuneration to participants. They agreed to give their time and opinion on this topic to bene t the population, contribute to improve public health policy interventions and implementation research, and empower inhabitants with SRH knowledge.
The study did not involve the use of animals.

Consent for publication
This manuscript does not contain data from any individual person. Not applicable.
The authors declare they have reviewed this manuscript and agree to submit it to BioMed Central Reproductive Health Journal. The FHS at UniLúrio has authorised this publication.

Availability of data and materials
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.