Navigating cervical cancer care in Maputo: a mixed-methods analysis of socioeconomic inequities in patient pathways and health system barriers.

backgroundCervical cancer is largely preventable and curable when detected early, yet late diagnosis remains common in sub-Saharan Africa. In Mozambique, diagnostic pathways are multi-step and may fail through weak referral continuity, administrative bottlenecks, and delayed diagnostic confirmation. Evidence is limited on where delays accumulate and whether constraints are socially patterned.

methodsWe conducted an explanatory sequential mixed-methods study among 165 women with histologically confirmed cervical cancer receiving care at Maputo Central Hospital, the national tertiary referral facility in Maputo Province, Mozambique. Structured questionnaires and medical record abstraction were used to characterise diagnostic pathways and to examine prolonged symptom-to-diagnosis delay (≥ 180 days) across household wealth quintiles using multivariable regression models. Subsequently, in-depth interviews with a purposive subsample of 20 women were analysed using Tanahashi's coverage framework and the Model of Pathways to Treatment. Quantitative and qualitative findings were integrated through joint display analysis and mechanism-oriented meta-inference to elucidate how socioeconomic position shaped diagnostic delay.

resultsDiagnostic delay was common, and care pathways were complex across wealth groups. Nearly two-thirds of women experienced prolonged delay, with no independent association with household wealth after adjustment. Prolonged delay was associated with higher navigation burden, reflected in multiple pre-diagnosis visits, and greater distance to primary care. Borrowing money to seek care was socially patterned. Qualitative findings indicated that early delays reflected symptom normalization, whereas post-entry diagnostic delays were driven by system-level navigation failures, including unclear referrals, repeated returns, administrative breakdowns, and service disruptions affecting women across socioeconomic strata.

conclusionsAmong women who successfully reached tertiary oncology care in Maputo, prolonged diagnostic delays appeared to reflect shared health-system constraints within referral and diagnostic pathways rather than marked socioeconomic exclusion after entry into formal care. Strengthening referral continuity, diagnostic coordination, and effective coverage across primary and secondary care levels may help reduce delays more equitably and narrow gaps in diagnostic completion within the public referral system. Because the study population was limited to women who successfully accessed tertiary services, these findings may underestimate socioeconomic inequities occurring earlier in the pathway, including barriers to initial access and referral completion.