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Policy review on the management of pre-eclampsia and eclampsia by community health workers in Mozambique Macuácua, Salésio; Catalão, Raquel; Sharma, Sumedha; Valá, Anifa; Vidler, Marianne; Macete, Eusébio; Sidat, Mohsin; Munguambe, Khátia; von Dadelszen, Peter; Sevene, Esperança Feb 28, 2019

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REVIEW Open AccessPolicy review on the management of pre-eclampsia and eclampsia by communityhealth workers in MozambiqueSalésio Macuácua1,3* , Raquel Catalão1, Sumedha Sharma2, Anifa Valá1, Marianne Vidler2, Eusébio Macete1,3,Mohsin Sidat4, Khátia Munguambe1,4, Peter von Dadelszen5, Esperança Sevene1,4 and the CLIP Working GroupAbstractBackground: Pre-eclampsia is one of the leading causes of maternal death in Mozambique. Limited access tohealth care facilities and a lack of skilled health professionals contribute to the high maternal morbidity andmortality rates in Mozambique and indicate a need for community-level interventions. The aim of this review wasto identify and characterise health policies related to the role of CHWs in the management of pre-eclampsia andeclampsia in Mozambique.Methods: The policy review was based on three methods: a desk review of relevant documents from theMozambique Ministry of Health (n = 7), contact with 28 key informants in the field of health policy in Mozambique(n = 5) and literature review (n = 699). Policy documents obtained included peer-reviewed articles, government andinstitutional policies, reports and action plans.Seven hundred and eleven full-text documents were assessed for eligibility and included based on pre-definedcriteria. Qualitative analysis was done to identify main themes using content analysis.Results: A total of 56 papers informed the timeline of key events. Three main themes were identified from thequalitative review: establishment of the community health worker programme and early challenges, revitalization ofthe CHW programme and the integration of maternal health in the community health tasks.In 1978, following the Alma Alta Declaration, the Mozambique government brought in legislation establishingprimary health care and the CHW programme. Between the late 1980s and early 1990s, this programme was scaleddown due to several factors including a prolonged civil war; however, the decision to revitalise the programme wasmade in 1995.In 2010, a revitalised programme was re-launched and expanded to include the management of commonchildhood illnesses, detection of warning signs of pregnancy complications, referrals for maternal health and basichealth promotion. To date, their role has not included management of emergency conditions of pregnancyincluding pre-eclampsia and eclampsia.Conclusion: The role of CHWs has evolved over the last 40 years to include care of childhood diseases and basicmaternal health counselling.Studies to assess the impact of CHWs in providing services to reduce maternal morbidity and mortality arerecommended.Keywords: CHWs, Health policy, Maternal health, Pre-eclampsia and eclampsia, Mozambique* Correspondence: salesio.macuacua@manhica.net1Centro de Investigação em Saúde de Manhiça (CISM), Manhiça,Mozambique3Ministério de Saúde, Maputo, MozambiqueFull list of author information is available at the end of the article© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Macuácua et al. Human Resources for Health           (2019) 17:15 https://doi.org/10.1186/s12960-019-0353-9BackgroundIn 2015, it was estimated that 99% (302 000) of the glo-bal maternal deaths occur in developing regions being66% (201 000) in sub-Saharan Africa [1]. They mostlyaffect vulnerable populations with poor socioeconomicbackground from remote areas with limited access tohealth care services [2]. Although Mozambique wit-nessed a 65% decrease in maternal mortality between1990 and 2015 (1390 to 489 maternal deaths per 100 000live births), this failed to meet the target set by Millen-nium Development Goal (MDG) 5A in 1990 to reducematernal mortality by two thirds by 2015 [1].Despite the difficulties in obtaining reliable data on es-timates of maternal mortality and its causes [3], hyper-tensive disorders of pregnancy are the third major causeof maternal death [4–6] and the second major cause ofnear misses in Mozambique [7].It is estimated that pre-eclampsia, a systemic syn-drome characterised by new-onset hypertension andproteinuria in pregnancy, results in 25 000 maternaldeaths in Africa annually, accounting for around 9% ofall deaths [8]. Severe pre-eclampsia is also associatedwith significant maternal morbidity (e.g. stroke and liverrupture) and adverse perinatal outcomes such as prema-turity [9]. Pre-eclampsia is a particular problem due tothe nature of the condition and the need for early identi-fication and management to prevent complications [10].Although there is no universally accepted standard ofcare for the condition, which is dependent on the locallyavailable resources and facilities, it is widely agreed thatrisk reduction for women with pre-eclampsia includesstandardised assessment and surveillance, managementof severe hypertension and prevention and managementof the seizures of eclampsia [10].In many low- and middle-income countries (LMIC),access to health care facilities and skilled health profes-sionals able to respond to obstetric complications, in-cluding pre-eclampsia and eclampsia, is limited [11]. InMozambique, only 50% of the population has access toprimary health care, and just 36% live within 30min of ahealth facility [12]. Antenatal care and delivery servicesare free of charge in Mozambican public health facilities;however, lack of access to transport and life-saving drugspresent strong barriers for care seeking [13]. The un-availability of trained and qualified health workers is asignificant problem. Although the number of healthworkers is increasing, it fails to reach the growing needsof the population. In 2000, there were 2.5 doctors and21.25 nurses per 100 000 people in Mozambique, signifi-cantly less than the African average of 21.7 doctors and117 nurses per 100 000 people [14]. These barriers tohealthcare access influenced the decision to revitalise thecountry’s community health worker (CHW) programme[15]. Despite several challenges, Mozambique has alongstanding programme of CHWs, called Agentes Poliva-lentes Elementares (APEs) [16], who are lay people se-lected by the community where they live to serve as a linkbetween the community and the primary health care sys-tem. They do not have a formal or professional education.However, they are trained to deliver health promotion anddisease prevention advice in hard-to-reach rural popula-tions, under the supervision of local health care providers[16, 17].CHWs have been found to have a role in the reductionof maternal mortality in other settings; therefore, CHWsmay also be instrumental in improving maternal healthin Mozambique [18].The aim of this review was to describe policies relatedto the role of CHWs in the management of pre-eclamp-sia and eclampsia in Mozambique since the creation ofthe programme.MethodsStudy areaMozambique is a low-income country with around 60%of the population living below the poverty line of 1.25dollars a day [19]. Most of the population (62% in 2014)lives in rural areas, and a large proportion has no accessto health facilities [20]. Almost two thirds (62%) ofwomen aged 15–49 report problems in accessing healthservices; distance to health facilities was the most com-monly cited barrier [21]. In the 5 years between 2007and 2011, the proportion of births attended by a skilledhealth professional was 54% [21, 22].Study designThis descriptive study was based on a formative researchexercise conducted in preparation for the CommunityLevel Interventions for Pre-eclampsia (CLIP) Trial, amulti-country study that aims to reduce the burden ofadverse maternal and perinatal outcomes related topregnancy hypertension through community engage-ment and mobile health-supported task-sharing to com-munity health care providers (NCT01911494).The policy review was based on three methods: (1) adesk review of relevant documents from Mozambique’sMinistry of Health (MoH), (2) key informants consulta-tions and (3) a literature review.Desk reviewFor the desk review, formal government and institutionalpolicies and other relevant official documents, such ascommunity involvement strategies, community healthworker training programmes, monitoring and evaluationmanuals, feasibility study reports and meeting’s minuteswere collected from Mozambique’s MoH. Some of theseofficial documents were accessed through the MozambicanGovernment Portal; others were only available in hardcopyMacuácua et al. Human Resources for Health           (2019) 17:15 Page 2 of 9within the MoH. To access hardcopy documents, theresearchers visited the MoH office in Maputo, where rele-vant documents were shared for review and notes weretaken regarding key findings related to CHWs inMozambique. The search of the government portalwas conducted using the following keywords: CHWs,CHW training, CHW curriculum, CHW programme,health policy, community policy, maternal health,eclampsia and pre-eclampsia. This search was limitedto documents published in English or Portuguesefrom 1970 to October 2017.The documents were reviewed by SM and RC to deter-mine the timeline of policy development and key events.Key informantsA total of 28 key informants (Table 1) were approachedfor further information regarding the documents foundin the desk review. The informants were heads of rele-vant programmes and organisations, or equivalent, suchas CHW programme at central and at the provinciallevel, maternal health programme, community engage-ment programme, Associação Moçambicana de Obste-tras e Ginecologistas (AMOG), NGOs, communityleaders and Mozambican training institutions with in-siders’ knowledge of health policy development in thecountry. SM and ES approached the key informants attheir working sectors to conduct about an hour longface-to-face informal conversations; field notes of rele-vant information were taken. Discussions focused on thepolicy strategies and guidelines, events and timeline,CHWs role and its evolution in maternal health.Literature reviewAn electronic search was conducted in two databases:PubMed and HINARI. Keywords related to the studysubject were combined with MeSH terms for the search:‘Mozambique’ and ‘community health workers’, ‘commu-nity practices’, ‘evidence-informed policy’, ‘communitypolicies’, ‘health policies’, ‘health systems’, ‘pregnancy’,‘maternal health’, ‘pre-eclampsia’, ‘eclampsia’ and ‘hyper-tensive disorders of pregnancy’.The following limits were used: studies published be-tween 1970 and October 2017, in either Portuguese orEnglish language, based on both quantitative and quali-tative research methodologies. The electronic search wasindependently performed by the first author (SM) andthen replicated by the co-author (RC).After the above-described literature search, all ab-stracts were extracted and screened by both SM and RC.The relevant papers as well as the documents obtainedvia key informants and desk review were included in thisstudy (PRISMA diagram) using criteria in Table 2.A qualitative content analysis was performed of alldocuments and articles that met the inclusion criteria. Amanifest analysis approach was used. RC and SM inde-pendently familiarised themselves with included docu-ments and then manually coded these for meaning units.RC, SM and ES met and agreed on the inductively de-rived meaning units, making sure all aspects of contenthad been covered in relation to the study aim. Themeswere then derived from the data.ResultsUsing the above-described combination of methods, a totalof 699 papers were identified from the literature searchand a total of 12 papers were obtained via the other twomethods of data collection (see Fig. 1). Seven of the docu-ments were obtained from desk review, and five of thedocuments were retrieved from key informants (Table 3).After assessing the papers using the eligibility criteriaoutlined in Table 2, a total of 56 papers were included(Fig. 1) which allowed identification of the timeline ofkey events in the development of the community healthworker programme in Mozambique and evolution ofCHW’s role in maternal health. A diagram illustratingthe key events in the history of Mozambique and devel-opment of the CHW programme can be found in Fig. 2.In addition, three main themes were identified fromour qualitative content analysis: the foundation of theCHW programme and early challenges, revitalization ofthe CHW programme, and CHWs and maternal health,each of which is described below.Table 1 Key informantsKey informants Number of key informantsCHW programmes in MoH,Maputo and Gaza province5Maternal health programme in MoH 2Pharmaceutical Department in MoH 1Associação Moçambicana de Obstetras eGinecologistas (AMOG)2Mozambican training institutions 4NGOs 2Community leaders 12Total 28Table 2 Criteria for inclusion of published papers anddocuments in the study- Related to community health workers in Mozambique- Post 1975- Published in either Portuguese or English language- Include information about maternal health- Be peer-reviewed or published by a reputable government agencyor NGO- Full text availableMacuácua et al. Human Resources for Health           (2019) 17:15 Page 3 of 9Foundation of the CHW programme and early challenges(1975–2000)In 1975, when Mozambique gained independence, thegovernment introduced new policies at the time of cre-ation of the National Health Service (NHS) to benefit allMozambicans [23]. The new policies aimed tostrengthen and extend primary health care to rural com-munities, where there were a disproportionately lownumber of health workers [17]. This led to the imple-mentation of the CHW programme in 1978 [24]. InMozambique, CHWs are known as Agentes PolivalentesElementares (APEs), meaning ‘essential multi-purposeagents’; their initial focus was to provide primary health-care services to remote rural communities [25–27].CHWs were selected by the health authorities andtrained to carry out health promotion and disease pre-vention activities for the general population without spe-cific focus to maternal health [25].A 16-year civil war following independence (1976–1992)dramatically damaged the health system as hundreds ofhealth posts were destroyed, and many health workerswere unable to perform their duties [28]. The civil war alsonegatively impacted the CHW programme as it hinderedoutreach capacity, appropriate supervision and technicalsupport of CHWs [29, 30].CHWs also worked based on an outdated curriculum(last updated in 1977) with no opportunities forprofessional development [23, 29]. The number of healthworkers decreased due to lack of funding; however, severalCHWs continued working supported by non-governmen-tal organisations (NGO) [16]. As a result of this systemcollapse, the CHWs shifted their focus from the prevent-ive tasks that offered little or no financial return towardscurative activities they could charge for, but none of themwere pregnancy related. [23, 29].In the late 1980s and early 1990s, increasing numbersof foreign aid agencies and NGOs directed their effortstowards Mozambique in order to tackle the humanitar-ian crisis created by the civil war. During this period,CHW training implemented by NGOs resulted in mul-tiple ‘vertical programmes’ focussing on singular inter-ventions such as those targeting HIV/AIDS ortuberculosis [29, 31]. NGOs implemented a system ofsubsidies and provided additional incentives for CHWsinvolved in these programmes, which led to frustrationamong volunteer CHWs [32]. In addition to the divisionFig. 1 PRISMA diagramMacuácua et al. Human Resources for Health           (2019) 17:15 Page 4 of 9of the responsibilities and the above-mentioned compen-sation of the CHWs, both government-trained andNGO-incentivised CHWs lacked supervision from theMoH [23, 29]. Despite that some of the interventionsimplemented by NGOs involved in somehow maternalhealth aspects that were not the priority of theseorganisations.It has been argued that the implementation of verti-cal programmes has fragmented the health system,undermining the local control of health programmes,and has contributed to the reduction of opportunitiesto introduce new components to the maternal healthservices [31].Acknowledging some of these problems, several do-nors signed the ‘Kaya Kwanga Code of Conduct’ in May2000 which pledged to ensure that technical assistanceis driven by MoH priorities and the avoidance of depart-ure of qualified personnel through contracting of civilservants for donor consultancies as well as departure ofCHWs to join vertical programmes run by NGOs offer-ing higher salaries [33].Revitalization of the CHW programme (2007–October 2017)The government made sporadic attempts to revive theCHW programme, for instance through the revision oftraining and support manuals produced in 1992 and1993. The MoH continued to supply CHWs with es-sential medications through a kit system adopted inthe 1980s that was updated to reflect the World HealthOrganization (WHO) essential medicines list [16].Table 3 Key documents and corresponding events in the development and evolution of the community health worker programmein Mozambique (1977–October 2017)Year Title Issuing authority Source of document Description1977 ‘Formação de Agentes Polivalentes Elementares,II Cadernos de Saúde, II Serie, Número 1’Ministry of Health(MoH) of MozambiqueKey informant CHW training manual describing thetraining package of the first APEprogramme with focus on healthpromotion activities1978 Portaria 46/75 6 de Setembro MoH Desk review Governmental legislation establishingprimary health care1984 The Evolution of Health Policy in Mozambique:Towards a People’s health service.Walt G, Melamed A,editors, Zed Books Ltd.Desk review A peer review article assessing theevolution of health policies inMozambique post-independencementioning community engagement2004 Estratégia de Envolvimento Comunitário MoH Desk review Community engagement strategy forhealth description of communityengagement activities and role of CHWsin the treatment of diseases2007–2012 Plano Estratégico do Sector da Saúde (PESS) MoH Desk review Strategic plan for health included a newintegrated package of services toimprove maternal and child health2009 Plano Integrado para o Alcance dos Objectivos4 e 5 de Desenvolvimento do Milênio2009–2012MoH Desk review Strategic plan to reach MillenniumDevelopment Goals 4 and 5 (maternaland child health goals) details the roleof APE in promoting maternal health2010 Programa de Revitalização de AgentesPolivalentes ElementaresMoH Desk review CHW training programme: detaileddescription of the new CHWprogramme, its new scope of workand training2011 Conteúdo do novo Kit de Agente PolivalenteElementar (APE)MoH Key informant CHW training programme: list ofcontents of the kit provided to CHWsin the revitalised programme2011 Manual de Formação de Agentes PolivalentesElementares (APEs): Manual do ParticipanteMoH Key informant New manual for training of CHWsregarding the CHW revitalisedprogramme2011 Avaliação e Testagem dos Materiaisde Formação dos APEs. Relatório FinalMoH Key informant Final report of the assessment of thenew training materials for CHWs2012 Estudo de Base Para Availação do Impactodo Programa de Revitalização dos AgentesPolivalentes Elementares (APEs) na SaúdeComunitária em MoçambiqueMoH Key informant Background study to assess the impactof the CHW revitalisation programme inthe community health of Mozambique2014 Relatório Anual das Actividades do Programade Agentes Polivalentes Elementares (APEs)do Ano 2013MoH Desk review Annual report on the CHW programmeyear 2013Macuácua et al. Human Resources for Health           (2019) 17:15 Page 5 of 9However, these attempts were not successful in reviv-ing the programme due to several sustainability-relatedfactors including the exodus of CHWs to work forNGOs [23].The 25th anniversary of the Alma Ata Declaration [34]in 2003, which endorsed primary health care as meansto provide universal access to health, renewed inter-national efforts for community-based health services andpromoted meetings on community involvement at theinternational and national level [35, 36]. In 2007, the‘National Meeting on Community Involvement’ tookplace, where a national strategy for the involvement ofthe community in health was presented [37].The national strategy for community involvement inhealth included the re-launch of the CHW programme(Fig. 2), recognising the important role CHWs play inhealth promotion and disease prevention in the commu-nity [12, 37]. The government aimed to expand healthservices to 20% of the uncovered population [23]. As ofDecember 2013, there were 2270 CHWs trained across117 districts, covering 12% of the total population [38].The revitalised programme required CHWs to visitpeople in their homes, rather than work from healthposts as they had done previously. Each CHW is cur-rently expected to serve a population of 500 to 2000inhabitants, and their activities can cover a distanceof 5–8 km from the referral health facility [23]. Inthe new model, they belong to the community theyserve, are selected by community leaders and en-dorsed by community members. CHWs must be over18 years of age, be able to speak the local languagefluently and read and perform simple arithmetic;though they can be of any gender, preference is givento women [23].Acknowledging the role of poor supervision in the fail-ure of the previously established CHW programmes, the2010 programme established protocols for supervisioninvolving interaction between the province and districtsupervisors, district and health facility supervisors andhealth facility supervisors and CHWs [39]. Furthermore,the CHWs are now part of the MoH and receivemonthly subsidies [23]. However, the subsidy is minimal,equivalent to 21 US dollars [23], lower than the nationalminimum wage of 55 US dollars [40].CHWs and maternal health careIn 2000, Mozambique signed the Millennium Declarationcommitting itself to work towards the MDGs, a commondevelopment framework shared by the 189 participatingcountries. Mozambique integrated these objectives in its‘National Agenda for the Fight Against Poverty’, the ‘2010Gender, Environmental and Climate Change Strategy andAction Plan’ and in presidential initiatives such as the‘2008 Presidential Initiative on Maternal and Child Health’[41]. The 2007–2012 National Health Strategic Plan[Plano Estratégico do Sector da Saúde (PESS), (Table 3)]included a new integrated package of services to improvematernal and child health.As a result of this strategic plan, the focus is now onhealth promotion and disease prevention, with officialguidelines indicating that 80% of CHW’s time should bespent on these activities and only 20% on curative ser-vices [23]. Their 4-month residential training reflects theemphasis on preventive medicine, being curative careonly centred on child health [42].CHWs are provided with equipment to aid in the de-livery of services including malaria rapid diagnostic tests,oral rehydration solution for diarrhoea, andFig. 2 Timeline of relevant events to CHW programme in MozambiqueMacuácua et al. Human Resources for Health           (2019) 17:15 Page 6 of 9antimicrobials for acute respiratory infections andmalaria treatment. These medications are part of theIntegrated Community Case Management (iCCM) ofchildhood illness programme embedded in their curricu-lum and financed mainly by international organisationsand NGOs. It has been argued that strong support fromthese partners led to actions to strengthen iCCM ofchildhood diseases which culminated with the launchingof the CHW revitalization programme [16]. No similarprogramme for the management of specific maternalhealth conditions was integrated neither in the CHW’spackage of care nor in their training curriculum. In fact,CHW’s curriculum is limited to health promotion inpregnancy. CHWs are trained to encourage pregnantwomen to attend antenatal clinics, to receive screening(for HIV and other diseases), vaccinations (for tetanustoxoid), and for assessments of foetal size and heart rate.They also help women plan for delivery by encouragingthem to organise transport and save money in case of anobstetric emergency. CHWs are also taught to recognisedanger signs in pregnancy such as vaginal bleeding andseizures and to facilitate a safe transfer to a local healthfacility if appropriate [43].Accordingly, the Integrated Plan for the Achievementof the MDG 4 and 5 [Plano Integrado para o Alcancedos Objectivos 4 e 5 de Desenvolvimento do Milénio2009–2012 (Table 3)], developed by the Mozambique’sMoH in collaboration with WHO and other inter-national organisations, incorporated CHWs in the mini-mum care package required to be delivered to achievethese objectives, and singled out family planning andprevention and screening of HIV and other sexuallytransmitted infections as CHWs main duties regardingmaternal health. No curative or other screening pro-grammes, such as blood pressure measurement, arementioned in the national plan [44].The government’s new plan for CHW curriculum hasa small focus on maternal health as stated above. How-ever, it does not include the assessment or managementof hypertensive disorders of pregnancy such aspre-eclampsia and eclampsia which are excluded fromthe training programme [43]. Furthermore, CHWs arenot trained or provided with a blood pressure device toidentify women with hypertension in the community[45]. Although CHWs are expected to recognise dangersigns in pregnancy, including seizures and oedema,which can be related to hypertensive disorders of preg-nancy, they are not trained nor equipped to confirmdiagnosis or provide appropriate treatment [43, 45, 46].DiscussionIn Mozambique, limited access to healthcare and skilledmedical personnel contributes to high rates of maternalmortality. Many of these deaths would be preventable ifadequate obstetric emergency care was available [47].Systematic reviews examining CHW programmes world-wide have found that CHWs are effective in reducingmaternal, neonatal and child mortality in resource-poorsettings [48, 49], even when the focus of the programmeis on prevention [50]. Mozambique has had a CHWprogramme since 1978, which did not include maternalhealth components. The programme survived severalchallenges and was revitalised in 2010. Despite theMDGs influence on the revitalization of the programme,contrary to what was observed regarding new ap-proaches to the management of childhood illnesses atcommunity level through the iCCM model [51], mater-nal health was introduced only with the focus on healthprevention and promotion, and no effort to incorporatemanagement of specific complications of pregnancy,such as pre-eclampsia and eclampsia, was made [52].This can be in part explained by the fact that the WHO-and UNICEF-supported iCCM is purely centred on themanagement of the three deadliest illnesses in Sub-SaharanAfrica (malaria, pneumonia and diarrhoea) for childrenunder five [53]. However, more recently, there is increasinginterest in expanding the iCCM of childhood illnesses toinclude other areas such as maternal health [54].Despite the evidence that hypertensive disorders ofpregnancy contribute significantly to maternal mortalityin Mozambique [4–6] and that blood pressure assessmentand management of hypertension can prevent morbidityand mortality due to pre-eclampsia [10], the absence ofpolicy prevented the development of tools and trainings toappropriately equip CHWs to identify and managethese complications [45]. Unfortunately, even after therevitalization fostered by the MDGs, the revisedCHW programme does not include pre-eclampsia andeclampsia-specific management [43].It would be useful to evaluate whether training CHWsto provide diagnosis and management of pre-eclampsiaand eclampsia with the aid of blood pressure devices,proteinuria tests, antihypertensive medications and mag-nesium sulphate could reduce maternal mortality andmorbidity in settings where prompt access to health fa-cilities is a challenge. These requirements for changes,however, may be met with significant opposition. For in-stance, there are laws preventing CHWs from prescrib-ing certain medications [55]. Furthermore, concernsregarding the CHWs’ technical capacity to deal withmore complex health conditions were identified as bar-riers in the implementation of iCCM of childhood ill-nesses in 2014 [51]. Finally, such tasks would have to becovered by adequate policies and guidelines. The Com-munity Level Interventions for Pre-eclampsia (CLIP)Trial, which aims to reduce the weight of pre-eclampsiaand eclampsia in maternal, perinatal and neonatal mor-bidity and mortality through the inclusion of screeningMacuácua et al. Human Resources for Health           (2019) 17:15 Page 7 of 9and early management of severe pre-eclampsia byCHWs at the community, is currently underway inMaputo and Gaza provinces (NCT01911494) [56].The revitalised CHW programme as a whole still facesnumerous challenges due to significant discrepancies be-tween policies and implementation. These include gaps inCHW coverage, as there are still not enough CHWs tomeet the health needs of the population, and limited skills,training and supervision [16, 39]. Further, owing to the ex-perienced difficulty in accessing health services, the com-munity demands for curative and other services that arenot formally recognised as part of CHWs’ tasks [27], invit-ing the enticement to perform some tasks illicitly.There is uncertainty about the integration of CHWs intocivil service and their long-term retention. In addition, re-liance on NGOs and donor funding has led to an unevendistribution of CHWs in relation to the areas they serve aswell as a disproportionate distribution of tasks to respondbetween preventive, curative, maternal and child healthneeds. Going forward, the dependence on external fund-ing for the continuation of the CHW programme, whenboth external and government funding is declining, mayhamper sustainability [16].Although there seems to be a great deal of qualitativedata supporting the potential role of CHWs in providingspecific services other than health promotion [57], thereis no quantitative data corroborating the effectiveness ofCHWs in improving health outcomes in Mozambique.Further studies that assess the impact and sustainabilityof the revitalised programme are necessary before newplans to broaden its scope emerge.ConclusionIn Mozambique, where almost half of the population hasno access to healthcare services, community healthworkers play a significant role in providing care to remotecommunities. Despite encouraging trends, maternal mor-tality remains high and the hypertensive disorders of preg-nancy are one of the main contributors. Policies regardingthe provision of prenatal care by CHWs are limited tohealth promotion and do not include the identification oremergency management of pregnancy complications, in-cluding pre-eclampsia. Studies to assess the impact ofCHWs in providing maternal care to reduce maternalmorbidity and mortality are recommended.AbbreviationsAIDS: Acquired immunodeficiency syndrome; AMOG: AssociaçãoMoçambicana de Obstetras e Ginecologistas; APE: Agente polivalente elementar;CHW: Community health worker; CISM: Centro de Investigação em Saúde deManhiça; CLIP: Community Level Interventions for Pre-eclampsia; HIV: Humanimmunodeficiency virus; iCCM: Integrated Community Case Management;LMIC: Low- and middle-income countries; MDG: Millennium DevelopmentGoals; MoH: Ministry of health; NGO: Non-governmental organisation;UBC: University of British Columbia; UNAIDS: Joint United NationsProgramme on HIV/AIDS; UNICEF: United Nations International Children’sEmergency Fund; WHO: World Health OrganizationAcknowledgementsThanks to the UBC CLIP working group: Jeffrey Bone, Alison Maclean, MaggieWoo Kinshella, Tang Lee, Jing Li, Beth A Payne, Kien NhanTu, Sharla Drebit,Asif Raza, Dustin Dunsmuir.Thanks to the CISM CLIP working group: Ana Ilda Biza, Dulce Mulungo,Ernesto Maximiano, Silvestre Cutana, Charfudin Sacoor, Helena Boene,Felizarda Amosse, Paulo Filimone, Corssino Tchavana.FundingThis work is part of the University of British Columbia PRE-EMPT (Pre-eclampsia-Eclampsia, Monitoring, Prevention and Treatment), funded by the Bill andMelinda Gates Foundation (Grant number: OPP1017337).Availability of data and materialsNot applicableAuthors’ contributionsSM and ES designed the study. SM, RC and ES gathered information andwrote the manuscript. PVD, ES and KM conceived the Community LevelInterventions for Pre-eclampsia (CLIP) trial (NCT01911494) related to thismanuscript and provided guidance to the article. SM, MV, EM and MSprovided additional inputs into the manuscript and corrected the Englishlanguage. All authors read and approved the final manuscript.Ethics approval and consent to participateNot applicableConsent for publicationNot applicableCompeting interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Centro de Investigação em Saúde de Manhiça (CISM), Manhiça,Mozambique. 2Department of Obstetrics and Gynaecology, University ofBritish Columbia (UBC), Vancouver, British Columbia, Canada. 3Ministério deSaúde, Maputo, Mozambique. 4Universidade Eduardo Mondlane, Faculdadede Medicina, Maputo, Mozambique. 5School of Life Course Sciences, Facultyof Life Sciences and Medicine, King’s College London, London, UnitedKingdom.Received: 11 December 2017 Accepted: 15 February 2019References1. WHO. Trends in maternal mortality: 1990 to 2015. Estimates by WHO,UNICEF, UNFPA, World Bank Group and the United Nations PopulationDivision. 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