This study was conducted to better understand the potential of CHWs, particularly in the provision of obstetric care at community level, with focus on pre-eclampsia and eclampsia. There were no previously published studies regarding the knowledge or competency of CHWs in identifying or managing HDPs in Mozambique. This analysis showed that despite the fact that CHWs had no specific training for identification, management and referral of pregnant women with pre-eclampsia and eclampsia, a considerable number of them reported that can identify some warning signs commonly occurring in pregnancy including: convulsions, headache, swelling among other signs. The finding that most CHWs agreed that they knew the warning signs in pregnancy likely results from the training that they receive on this topic in preparation to becoming CHWs. The ability of CHWs to identify warning signs in pregnancy is somewhat encouraging, not enough especially with regards to the link between the warning signs and the respective conditions, considering that identification of pregnant women with complications is included in their responsibilities. There is further need to improve their knowledge about pre-eclampsia and eclampsia, particularly raising their awareness on the link between hypertension and convulsions during pregnancy and on need of urgent referring pregnant women with pre-eclampsia and eclampsia being both life-threatening conditions.

Few studies assessed CHW knowledge and competencies specifically related to HDP. One study in Ghana, however, showed that CHWs reported a range of blood pressure thresholds in pregnancy, and these providers did not uniformly mention that hypertension in pregnancy was warning sign that needing referral [23]. Another study, in South Africa reviewed CHW knowledge, beliefs and attitudes related to hypertension in the general population, and found that CHWs were unaware of the causes, outcomes, prevention, and management of it. Moreover, they tended to believe in the use of traditional treatments for hypertension instead of evidence-based biomedical care, leading researchers to ultimately conclude that these health workers had insufficient biomedical knowledge related to hypertension [24].

Gender and age were the demographic characteristics which showed association with knowledge. The impact of age on this outcomes may be related to life cumulative experience as alone the years of practices as CHW did not shown any differences. It was surprising that male CHWs showed more knowledge in relation to warning signs of hypertension when compared to female CHWs. This is an important topic for further discussions and should be addressed while scaling up the intervention taking into account that gender issues can pose barriers to implementation of maternal care [25]. This study did not find significant differences in CHW knowledge according to the level of education or years of work as CHW. Despite this result, supervisors believe that CHWs’ education level was insufficient for the provision of treatment for pre-eclampsia or eclampsia. The ability to identify warning signs demonstrates that the training content is adequately recalled by CHWs, suggesting that when are well trained they can acquire practical knowledge and implement community-based interventions that can contribute to reduce maternal mortality.

Moreover, CHWs currently have health promotion and management responsibilities for other diseases such as malaria, diarrhoea and upper respiratory tract infections. The implementation of these activities has been successfully reported in various settings, suggesting that despite their low level of literacy and numeracy, with appropriate training and supervision they are capable of providing more differentiated health services at the community-level [26].

It was evident from questionnaire responses, that CHWs are not currently equipped to identify and manage hypertension in pregnancy. This is in accordance with the absence of these topics in their training manuals. Further studies to evaluate the impact of providing equipment and adequate training to assess blood pressure, measure proteinuria and manage pre-eclampsia and eclampsia should be promoted in Mozambique. It has been demonstrated in Nepal that with appropriate training of maternal health interventions, knowledge, competencies and skills can be substantially improved among village midwives [27].

This study has shown that CHWs were under pressure to refer pregnant women with pregnancy complications to the health facilities as recommended during their training, but their inability to identify most of the warning signs specific for pre-eclampsia and eclampsia may delay these referrals. A study of risk factors for eclampsia in Mozambique revealed that most referral cases reported no blood pressure measurements in antenatal clinics, indicating poor identification of women at risk [28].

CHWs seem to accept to expand their role to include management of pre-eclampsia and eclampsia although few showed confidence in administering injectable medication which is essential for the management of severe cases. This low self-confidence is also reflected among supervisors, medical officers, including specialists who believe that the CHWs are not prepared to identify and manage any complications raised from the administration of magnesium sulphate or other injectable drugs. This general scepticism can also be attributed to the fact that CHW training does not currently include administration of injectable drugs. This should be properly addressed for the successful expansion of programmes based on community interventions in the Mozambican context, also taking into account factors such as burden of work due to additional interventions, duration and quality of CHWs training, regular supervision and medication stock management [29]. Misconceptions amongst some in the medical community regarding the potential dangers of magnesium sulphate has contributed to the drug’s non-use [30]. Such misunderstandings may also lead to suboptimal practice, such as infrequent blood pressure and proteinuria measurement, and the use of diazepam in place of magnesium sulphate [31, 32]_. At PHC level midwives are trained to, and therefore should be able to, identify and treat women with pre-eclampsia [33]. However, in Afghanistan, midwives did not identify the need for continued antihypertensive therapy in 34 % of cases [32]. Midwives, nurses and medical doctors alike have demonstrated poor performance on knowledge-based exams regarding pregnancy complications in Benin, Ecuador, Jamaica and Rwanda, the scores ranged from 51 % to 78 % on HDP-related questions [34]. Nurses and Auxiliary Nurse Midwives in Nepal similarly showed poor knowledge and skills, related to diagnosis, management and monitoring of severe pre-eclampsia and eclampsia [27]. Nevertheless, a study in Afghanistan has shown encouraging findings, the midwives where highly confident in the administration of magnesium sulphate (79 % were very confident, while 16 % had some reservations) [32].

Regarding evidence of the implementation of community based management of pregnant women, a study in Uganda suggests that trained CHW can safely provide injectable contraceptives [35]. A literature review by Malarcher (2010) also found consistent evidence that CHWs could provide injections safely, were comfortable with their ability to administer injections, and their clients were satisfied [36]. A study in Madagascar confirmed that clients were satisfied with services received from the CHW (including their administration of contraceptive injections) [37]. Many other countries have illustrated the importance of the work provided by CHWs and how they are highly regarded in their communities [33]. It is therefore reassuring that this is a window of opportunity to include tasks that are critical for maternal survival, such as administration of antihypertensive drugs. There is a need of further research addressing the ability to administer injectables by CHW in Mozambique.

Besides CHW, matrons are important and well recognised cadres of community-based maternal health care providers. However, the results of this study have shown that they are discouraged to assist emergencies and deliveries at home. Similar results were found in Ghana, where the traditional birth attendants (TBAs) were discouraged to undertake deliveries but to refer cases to health centres [38]. The role of matrons in pregnancy management may be reconsidered due to the shortage of health professionals in remote areas. The accuracy and effectiveness of matrons’ knowledge and competence is not well known, as most matrons do not receive formal training. Their skills are acquired on the basis of experience and usually taught by older and more experienced matrons [18, 19]. Training, supervision and provision of basic equipment and better coordination between matrons and health facilities would add value to their contribution in pregnancy care. It is increasingly recognized that TBAs or matrons may have a role to play in improving health outcomes in developing countries because of their access to communities and the relationship they share with women in local communities especially if women are unable to access skilled care due to long distance from health facilities, lack of money, lack of available transportation and poor health facility conditions [38, 39].

Efforts to include specific maternal health care interventions within the CHW package of training could contribute to a reduction in maternal morbidity and mortality.

This study was conducted to better understand the potential of CHWs, particularly in the provision of obstetric care at community level, with focus on pre-eclampsia and eclampsia. There were no previously published studies regarding the knowledge or competency of CHWs in identifying or managing HDPs in Mozambique. This analysis showed that despite the fact that CHWs had no specific training for identification, management and referral of pregnant women with pre-eclampsia and eclampsia, a considerable number of them reported that can identify some warning signs commonly occurring in pregnancy including: convulsions, headache, swelling among other signs. The finding that most CHWs agreed that they knew the warning signs in pregnancy likely results from the training that they receive on this topic in preparation to becoming CHWs. The ability of CHWs to identify warning signs in pregnancy is somewhat encouraging, not enough especially with regards to the link between the warning signs and the respective conditions, considering that identification of pregnant women with complications is included in their responsibilities. There is further need to improve their knowledge about pre-eclampsia and eclampsia, particularly raising their awareness on the link between hypertension and convulsions during pregnancy and on need of urgent referring pregnant women with pre-eclampsia and eclampsia being both life-threatening conditions.

Few studies assessed CHW knowledge and competencies specifically related to HDP. One study in Ghana, however, showed that CHWs reported a range of blood pressure thresholds in pregnancy, and these providers did not uniformly mention that hypertension in pregnancy was warning sign that needing referral [23]. Another study, in South Africa reviewed CHW knowledge, beliefs and attitudes related to hypertension in the general population, and found that CHWs were unaware of the causes, outcomes, prevention, and management of it. Moreover, they tended to believe in the use of traditional treatments for hypertension instead of evidence-based biomedical care, leading researchers to ultimately conclude that these health workers had insufficient biomedical knowledge related to hypertension [24].

Gender and age were the demographic characteristics which showed association with knowledge. The impact of age on this outcomes may be related to life cumulative experience as alone the years of practices as CHW did not shown any differences. It was surprising that male CHWs showed more knowledge in relation to warning signs of hypertension when compared to female CHWs. This is an important topic for further discussions and should be addressed while scaling up the intervention taking into account that gender issues can pose barriers to implementation of maternal care [25]. This study did not find significant differences in CHW knowledge according to the level of education or years of work as CHW. Despite this result, supervisors believe that CHWs’ education level was insufficient for the provision of treatment for pre-eclampsia or eclampsia. The ability to identify warning signs demonstrates that the training content is adequately recalled by CHWs, suggesting that when are well trained they can acquire practical knowledge and implement community-based interventions that can contribute to reduce maternal mortality.

Moreover, CHWs currently have health promotion and management responsibilities for other diseases such as malaria, diarrhoea and upper respiratory tract infections. The implementation of these activities has been successfully reported in various settings, suggesting that despite their low level of literacy and numeracy, with appropriate training and supervision they are capable of providing more differentiated health services at the community-level [26].

It was evident from questionnaire responses, that CHWs are not currently equipped to identify and manage hypertension in pregnancy. This is in accordance with the absence of these topics in their training manuals. Further studies to evaluate the impact of providing equipment and adequate training to assess blood pressure, measure proteinuria and manage pre-eclampsia and eclampsia should be promoted in Mozambique. It has been demonstrated in Nepal that with appropriate training of maternal health interventions, knowledge, competencies and skills can be substantially improved among village midwives [27].

This study has shown that CHWs were under pressure to refer pregnant women with pregnancy complications to the health facilities as recommended during their training, but their inability to identify most of the warning signs specific for pre-eclampsia and eclampsia may delay these referrals. A study of risk factors for eclampsia in Mozambique revealed that most referral cases reported no blood pressure measurements in antenatal clinics, indicating poor identification of women at risk [28].

CHWs seem to accept to expand their role to include management of pre-eclampsia and eclampsia although few showed confidence in administering injectable medication which is essential for the management of severe cases. This low self-confidence is also reflected among supervisors, medical officers, including specialists who believe that the CHWs are not prepared to identify and manage any complications raised from the administration of magnesium sulphate or other injectable drugs. This general scepticism can also be attributed to the fact that CHW training does not currently include administration of injectable drugs. This should be properly addressed for the successful expansion of programmes based on community interventions in the Mozambican context, also taking into account factors such as burden of work due to additional interventions, duration and quality of CHWs training, regular supervision and medication stock management [29]. Misconceptions amongst some in the medical community regarding the potential dangers of magnesium sulphate has contributed to the drug’s non-use [30]. Such misunderstandings may also lead to suboptimal practice, such as infrequent blood pressure and proteinuria measurement, and the use of diazepam in place of magnesium sulphate [31, 32]_. At PHC level midwives are trained to, and therefore should be able to, identify and treat women with pre-eclampsia [33]. However, in Afghanistan, midwives did not identify the need for continued antihypertensive therapy in 34 % of cases [32]. Midwives, nurses and medical doctors alike have demonstrated poor performance on knowledge-based exams regarding pregnancy complications in Benin, Ecuador, Jamaica and Rwanda, the scores ranged from 51 % to 78 % on HDP-related questions [34]. Nurses and Auxiliary Nurse Midwives in Nepal similarly showed poor knowledge and skills, related to diagnosis, management and monitoring of severe pre-eclampsia and eclampsia [27]. Nevertheless, a study in Afghanistan has shown encouraging findings, the midwives where highly confident in the administration of magnesium sulphate (79 % were very confident, while 16 % had some reservations) [32].

Regarding evidence of the implementation of community based management of pregnant women, a study in Uganda suggests that trained CHW can safely provide injectable contraceptives [35]. A literature review by Malarcher (2010) also found consistent evidence that CHWs could provide injections safely, were comfortable with their ability to administer injections, and their clients were satisfied [36]. A study in Madagascar confirmed that clients were satisfied with services received from the CHW (including their administration of contraceptive injections) [37]. Many other countries have illustrated the importance of the work provided by CHWs and how they are highly regarded in their communities [33]. It is therefore reassuring that this is a window of opportunity to include tasks that are critical for maternal survival, such as administration of antihypertensive drugs. There is a need of further research addressing the ability to administer injectables by CHW in Mozambique.

Besides CHW, matrons are important and well recognised cadres of community-based maternal health care providers. However, the results of this study have shown that they are discouraged to assist emergencies and deliveries at home. Similar results were found in Ghana, where the traditional birth attendants (TBAs) were discouraged to undertake deliveries but to refer cases to health centres [38]. The role of matrons in pregnancy management may be reconsidered due to the shortage of health professionals in remote areas. The accuracy and effectiveness of matrons’ knowledge and competence is not well known, as most matrons do not receive formal training. Their skills are acquired on the basis of experience and usually taught by older and more experienced matrons [18, 19]. Training, supervision and provision of basic equipment and better coordination between matrons and health facilities would add value to their contribution in pregnancy care. It is increasingly recognized that TBAs or matrons may have a role to play in improving health outcomes in developing countries because of their access to communities and the relationship they share with women in local communities especially if women are unable to access skilled care due to long distance from health facilities, lack of money, lack of available transportation and poor health facility conditions [38, 39].

Efforts to include specific maternal health care interventions within the CHW package of training could contribute to a reduction in maternal morbidity and mortality.