Despite the large shift toward facility-based childbirths occurred during the last 15 years in several low resource settings, including in Mozambique, the burden of maternal mortality and morbidity remain considerable. Obstetric fistula is one of the most devastating of all maternal morbidities which still prevalent and is entirely avoidable.

The aim of this thesis was to evaluate and explore the provision of childbirth care, focusing on obstetric fistula as one of its complications, in a rural Mozambican setting of high facility delivery rate.

The four studies constituting this thesis were implemented in Maputo and Gaza provinces, southern Mozambique, between April 2016 and March 2017. We included 4385 women having given birth up to 12 months the study identified from a cohort of women of reproductive age (12-49 years). We identified women with constant urine leakage, assess them clinically, confirm the diagnosis and estimate the incidence of obstetric fistula. In-depth interviews with selected women with and without fistula (n=28), were used to describe the women’s experiences of maternal care and pinpoint those experiences that are unique to women with fistula. During the same cross-sectional survey (n=4385) we also assessed the women’s experiences of care and satisfaction with care during childbirth. We complemented the women’s survey with a survey among 175 health workers of the study area to assess their perception of their work context.

The incidence of fistulae was 1.1 per recently pregnant women (95% CI 0.14-2.16). Delays in receiving definite care at referral hospitals despite having reached the primary health facility in time, were reported by the women who had fistulae. Women without fistula, blamed the fistula condition on women’s physiological and behavioural characteristics. Most (92.5%) of the 4358 women interviewed reported to be satisfied with care during childbirth and would recommend a family member to deliver in the same facility. Women who gave birth in primary level facilities tended to be more satisfied than those gave birth in hospitals, and presence of a companion had a positive influence on the satisfaction, irrespective of age, education and socio-economic background. Health workers rated highly the items on all dimensions of context when asked to evaluate their work context using the Context Assessment for Community Health (COACH) tool, although still above the scale midpoint, the organizational resources dimension had the lowest score.

This thesis demonstrates a high incidence of obstetric fistula despite a high coverage of facility-based childbirths in a rural context where services are generally perceived as adequate by childbearing women and health providers. To reduce maternal morbidity by fistula, major interventions are needed to improve the quality of childbirth care, including complication recognition and decision-making for referral, health facility preparedness as well as to improve the health providers’ work environment.