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Community perspectives on the determinants of maternal health in rural southern Mozambique: a qualitative… Firoz, Tabassum; Vidler, Marianne; Makanga, Prestige T; Boene, Helena; Chiaú, Rogério; Sevene, Esperança; Magee, Laura A; von Dadelszen, Peter; Munguambe, Khátia Sep 30, 2016

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RESEARCH Open AccessCommunity perspectives on thedeterminants of maternal health in ruralsouthern Mozambique: a qualitative studyTabassum Firoz1*, Marianne Vidler2, Prestige Tatenda Makanga3,4, Helena Boene5, Rogério Chiaú5,Esperança Sevene5, Laura A. Magee6, Peter von Dadelszen6, Khátia Munguambe5 and the CLIP Working Group.AbstractBackground: Mozambique has one of the highest rates of maternal mortality in sub-Saharan Africa. The maininfluences on maternal health encompass social, economic, political, environmental and cultural determinants ofhealth. To effectively address maternal mortality in the post-2015 agenda, interventions need to consider thedeterminants of health so that their delivery is not limited to the health sector. The objective of this exploratoryqualitative study was to identify key community groups’ perspectives on the perceived determinants of maternalhealth in rural areas of southern Mozambique.Methods: Eleven focus group discussions were conducted with women of reproductive age, pregnant women,matrons, male partners, community leaders and health workers. Participants were recruited using samplingtechniques of convenience and snow balling. Focus groups had an average of nine participants each. The heads of12 administrative posts were also interviewed to understand the local context. Data were coded and analysedthematically using NVivo software.Results: A broad range of political, economic, socio-cultural and environmental determinants of maternalhealth were identified by community representatives. It was perceived that the civil war has resulted in localunemployment and poverty that had a number of downstream effects including lack of funds for accessingmedical care and transport, and influence on socio-cultural determinants, particularly gender relations thatdisadvantaged women. Socio-cultural determinants included intimate partner violence toward women, andstrained relationships with in-laws and co-spouses. Social relationships were complex as there were both negativeand positive impacts on maternal health. Environmental determinants included natural disasters and poor access toroads and transport exacerbated by the wet season and subsequent flooding.Conclusions: In rural southern Mozambique, community perceptions of the determinants of maternal healthincluded political, economic, socio-cultural and environmental factors. These determinants were closely linked withone another and highlight the importance of including the local history, context, culture and geography in thedesign of maternal health programs.Keywords: Maternal health, Pregnancy, Determinants of health, Disparities, Poverty, EquityAbbreviations: CISM, Centro de Investigação em Saúde da Manhiça; CLIP, Community level intervention forpre-eclampsia; FGD, Focus group discussions; IDI, In-depth interviews; LMIC, Low and middle-income countries;MMR, Maternal mortality ratio; RMNCH, Reproductive, maternal, neonatal and child health; SDG, Sustainabledevelopment goal; UBC, University of British Columbia* Correspondence: tfiroz@cfri.ca1Department of Medicine, University of British Columbia, 330 E. ColumbiaStreet, New Westminister, BC V3L 3LW, CanadaFull list of author information is available at the end of the article© 2016 The Author(s). 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.The Author(s) Reproductive Health 2016, 13(Suppl 2):112DOI 10.1186/s12978-016-0217-xPlain english summaryThe health of mothers depends on a wide variety of so-cial, economic, environmental and political factors. Weconducted a study in southern Mozambique to under-stand the views of women and their communities on theinfluence of these factors on the wellbeing on mothers.We interviewed chiefs of local administrative posts andheld focus groups with women, male partners, femaleelders (matrons), community leaders and health workers.Based on the perspectives of each of these groups, wefound that the broad range of social, economic, environ-mental and political factors that impact the health ofmothers are influenced by each other and also by localhistory, context and geography. These factors should beincorporated in the design and delivery of programs forpregnant women in southern Mozambique.BackgroundThe determinants of health are the conditions in whichpeople are born, grow, live, work and age; these are shapedby the distribution of money, power and resources at glo-bal, national, and local levels [1]. These crucial influenceson maternal health encompass political, economic, social,cultural and environmental dimensions [1]. MillenniumDevelopment Goal 5, while receiving unprecedentedattention from governments, policy-makers, donors, re-searchers, civil society and other stakeholders, has not suf-ficiently recognised the impact of these determinants andhas instead focused almost entirely on interventions deliv-ered by the health sector [2]. The updated Global Strategy,in the context of the of the new Sustainable DevelopmentGoal (SDG) agenda, thus urges for a more integrated andtransformative approach to maternal health, with muchgreater cross-sectoral links across social, economic andenvironmental pillars [1]. By widening the scope to in-clude the determinants of health, progress on maternalhealth can be accelerated.Mozambique has one of the highest rates of maternalmortality in sub-Saharan Africa with a maternal mortalityratio (MMR) of 480 per 100,000 live births [3]. Mozambi-que’s recent Health Sector Strategic Plan (2014–2019)comprises seven objectives based on the principles of pri-mary health care, equity and improved quality of services[4]. Within these objectives, there is a strong focus on thedeterminants of health, particularly geographic inequities,nutrition and food security, access to safe water andsanitation, gender inequality, illiteracy and poverty, [4] andthe importance of cross-sectoral cooperation [4]. The stra-tegic plan is aligned with the African Union Multi-SectorFramework on Reproductive, Maternal, Neonatal andChild Health (RMNCH) that was developed to ensure inte-gration of continental, sub-regional and country-levelpolicy and budget action across all health and socialdeterminant sectors [5].The literature has identified a number of determinantsthat influence maternal health in Mozambique. A recentstudy from Maputo Province found that the high numberof maternal deaths and severe maternal morbidities wereinfluenced by lack of money for transportation and med-ical costs, lack of decision making power and distancefrom health facilities [6]. Studies from rural Mozambiqueconfirm similar findings including spatial disparities ingeographic access to reproductive health services and gen-der inequality in decision making in pregnancy [7, 8].Chapman in her ethnographic work on perceived repro-ductive risk in central Mozambique found vulnerabilitywas intensified by poverty, economic austerity, land short-ages, increasing social conflict and inequality and lack ofmale support [9, 10].However, most of the literature on the determinants ofmaternal health does not include the perspectives ofwomen and their communities. Their perspectives canoffer important insights into uncovering and understand-ing the determinants, as well as the interactions betweenthem, and can guide the development and implementationof health interventions. Often programmes and interven-tions are designed without the input of those directlyaffected by their implementation and thus, uptake may bepoor. An example from the maternal health literature ofthis oversight is demonstrated in a qualitative meta-synthesis examining antenatal care utilisation in low- andmiddle-income countries (LMIC); this study found mis-alignment between current antenatal care provision andthe social and cultural context. [11] Given that antenatalcare provision may be theoretically and contextually atodds with local beliefs and experiences, even high-qualityantenatal care may not be utilized unless their views andconcerns are addressed and incorporated into care [11].One of the priority interventions from Mozambique’sNational Strategic Plan for Maternal and Perinatal Mor-tality Reduction is to empower communities to partici-pate actively in the process of identification and analysisof their own health problems [12]. This is supported byEnding Preventable Maternal Mortality, a human rightsapproach to maternal and newborn health, which callsfor including women, girls, families and communities byenabling participation and thereby influencing how thehealth system works [13]. Therefore, we conducted an ex-ploratory qualitative study in rural southern Mozambiqueto uncover and describe community perspectives of thedeterminants of maternal health and the resulting healthbehaviours.MethodsThis study was conducted as part of a large-scale mixedmethods feasibility study, Community Level Interventionfor Pre-eclampsia (CLIP), that aims to reduce maternalmortality and morbidity due to pre-eclampsia [14].The Author(s) Reproductive Health 2016, 13(Suppl 2):112 Page 124 of 162Within this study framework, we sought to explore the re-lationship between the determinants of health and mater-nal morbidity and mortality. To understand the contextwithin which women live, in-depth interviews (IDI) wereconducted with 12 administrative post chiefs in Gaza andMaputo (Fig. 1). The heads of administrative posts werechosen as they are familiar with the geography, politics,history and infrastructure of their communities. The re-cruitment process consisted of visiting each administrativepost and making a formal appointment with the chief toinvite them to participate in the study.A total of 10 focus group discussions (FGD) were con-ducted with pregnant women, reproductive age women,matrons (elderly women in the community who serve astraditional birth attendants), male partners, communityleaders, and health workers (Table 1). The study area forfocus groups consisted of four administrative posts, twoin Gaza and two in Maputo province (Fig. 1).The site characteristics are described elsewhere in moredetail [14, 15]. Administrative posts were purposely se-lected to reflect the diversity of socioeconomic anddemographic characteristics in southern Mozambique,such as level of urbanization, population density, distanceto a trading centre, presence of referral health facilities,and physical access to them. The administrative posts se-lected for this study are served by one to two primaryhealth care centres with variable numbers of maternalchild health nurses and community workers, locallynamed Agentes Polivalentes Elementares (APEs). EachFig. 1 Study areasTable 1 Focus Group DiscussionsTarget group Number of FGDsconductedWomen of reproductive age and matrons 2Pregnant women 1Male decision makers 2Local health care providers: community healthworkers2Community leaders 2Traditional healers 1The Author(s) Reproductive Health 2016, 13(Suppl 2):112 Page 125 of 162administrative post had access to secondary and/or ter-tiary care facilities as well.A study by our group using spatio-temporal modellingfound that most women in our study area either walkedor used public transport to access maternal care at theprimary level, while most primary facilities providedtransport to higher level facilities. 13 of the 417 commu-nities in the study area were completely isolated frommaternal health services as a result of flooding at sometime during the study timeline [16].Focus group participants were identified through com-munity leaders after describing the inclusion and exclu-sion criteria and seeking permission. FGDs were usuallyconducted out-doors at círculos (the centre point of thevillage where the community usually gathers) or at thecommunity leaders’ houses. Participants were recruitedusing sample of convenience and snow-balling. Focusgroups had an average of nine participants.The minimum number of FGDs was pre-determinedbased on previous experiences of reaching saturationregarding similar topics [14, 15]. Both across and within-group saturation was assessed and for this study, satur-ation of themes was reached. All of the administrativepost chiefs were interviewed to capture singularities ofadministrative posts historical, political, geographicaland structural contexts. Data collection was conductedbetween December 2013 and April 2014. This processwas led by two Mozambican social scientists (KM, HB)assisted by four local interviewers. All data collectorswere fluent in Portuguese and the local language,Changana. IDIs with chiefs were conducted in Portuguesewhereas FGDs were conducted in Changana andPortuguese. Interviews and focus groups were translatedto English by qualified translators. Signed informedconsent and permission to record conversations wereobtained from each participant of the IDIs and FGDs.Ethical approval for this study was obtained from theCentro de Investigação em Saúde da Manhiça (CISM)Institutional Review Board (CIBS – CISM) in Mozambiqueand the University of British Columbia (UBC) ClinicalResearch Ethics Board.Three of the authors (TF, PTM and MV) from UBCcoded the data. Two transcripts were coded by all threeauthors to confirm that there was agreement. Six tran-scripts were randomly selected for supplementary codingby two Mozambican social scientists (KM and HB) toensure that the context of the text was not lost in trans-lation. Data analysis was performed using NVivo version10.0 (QSR International Pty. Ltd. 2012). A thematicanalysis approach was taken. The thematic categories(political, economic, socio-cultural and environmental)were determined in advance based on the current litera-ture and relevant policy frameworks. The coding structurewas developed through collaboration among allresearchers. New sub-themes were added as they emergedfrom the data. Data were analysed for the relationships be-tween these sub-themes. Emergent propositions weretested through systematic searches of coded text and alter-native explanations were explored through systematicsearches of uncoded text. Fig. 2 describes the codingstructure.ResultsPolitical determinantsMozambique has a recent history of internal war andstate economic and health reform policies that have hadprofound impact on society [6]. Thus, all administrativepost chiefs in the study area were asked to describe thelasting impact of the Mozambican civil war, commonlyreferred to as the “Sixteen Years War”. According toparticipants, the war resulted in the loss of lives, infra-structure and livestock, and led to unemployment withsignificant impact on the practice of animal husbandry.While women, male partners, community leaders andhealth workers did not directly comment on the linkbetween the war and maternal health, unemploymentwas consistently mentioned by women of reproductiveage more than the other groups as an important factorcontributing to wellbeing. Some women mentioned thatthey cultivated crops to make money while othersmentioned that they sought domestic work (maid/house-keeper) as a means of employment. However, most womenmentioned that there are no jobs.“Here in our community, there is no other plan,because here there is no farm to be able to wake up inthe morning and go to work…. there is only hunger,that is the way we live here in our community”[Focus group discussion with women of reproductiveage, Ilha Josina, Maputo]Economic determinantsThe lack of employment and subsequently, poverty im-pacted women in several ways. Women of reproductiveage as well as health workers stated that financial con-straints limited women’s ability to access transport andcare, especially to buy medications. At the facilities,women often incurred additional expenses beyond thecost of services, such as the purchase of food while incare, however, women were frequently unable to complydue to lack of funds. Women stated that if their partnerscould not assume the medical expenses during preg-nancy or did not share their salaries, it could lead tovulnerability or complications. Women described thatat times they walked to facilities because they couldnot afford transport. The same observation was madeby health workers, who are often frontline health careproviders. Furthermore, unemployment impactedThe Author(s) Reproductive Health 2016, 13(Suppl 2):112 Page 126 of 162pregnant women through the inability to raise communalfunds to practice xitique, which is a common informalsavings and credit arrangement [15].While health care workers and women had similarviews about the impact of unemployment on well-beingin pregnancy, male partners and community leaderswere divided. Some male partners pointed out that ifthey were unemployed, they were unable to provide foodfor their pregnant wives. Other men claimed “moneydoes not solve anything and the one who solves is God”[Focus group discussion with male partners, Chongoene,Gaza]. While all community leaders acknowledged thatpoverty was linked to difficulties in pregnancy, onementioned that having money to purchase “tablets” wasinsufficient to avoid complications.Socio-cultural determinantsA woman’s marital status during pregnancy was identifiedas an important health determinant by women, healthworkers and community leaders. Women perceived singlewomen (women whose partners abandoned them afterfinding out the pregnancy) as vulnerable particularly dueto financial constraints. During focus group discussions,pregnant women described that single women havemore complications because they had “to fulfil all therequirements of the house” [Focus group discussion withpregnant women, Manhica]. Community leaders believedwidows had the greatest chance of complications becausethey were poor. In contrast, health workers identifieddivorced women as at high risk, explaining that “itaffects [them] psychologically… it even causes trouble… be-cause she thinks, I’m pregnant but because of [lack of] sus-tenance, what will be of that child tomorrow, if it happensto be born” [Focus group discussion with health workers,Chongoene, Gaza]. These respondents also felt thatseparated women were vulnerable because of a lackof support.“She does not have anybody who can support herduring the gestational period, different from thewoman who has a spouse. He can take her forpre-natal examination, he can take her shoppingat the market and they can be together anywhere.”[Focus group discussion with health workers,Chongoene, Gaza]A perception shared by both women and commu-nity leaders was that relationships tended to change ifwomen became sick during pregnancy. Reproductiveage women, health workers and community leadersdescribed that partners of sick women no longerwanted to take care of them and would at timesabandon them. A community leader described a situ-ation in his neighbourhood:“I, as a leader, I see a lot of things. Some people dolobola [a traditional practice of giving money,livestock, fabric etc. to the woman’s family by thehusband at the time of marriage] and when she getssick they abandon her, saying they don’t want heranymore. Even this month, we are faced with asituation of someone being hit by a motorcycle. Hetook her to the hospital but he no longer cares. He nolonger wants to know her.” [Focus group discussionwith community leaders, Chongoene, Gaza]At the same time, some community leaders linkedpregnancy complication to a woman’s behaviour “she getspregnant without knowing the person who impregnated her[and] it brings complications” [Focus group discussionwith community leaders, 3 de Fevereiro, Maputo].Women identified that for those in polygamous rela-tionships, complications may arise if there was a bad rela-tionship among co-spouses. They also found it stressfulwhen male partners favoured one co-spouse over another.Determinants of HealthCommunity GroupsRelationships of Pregnant WomenDecision MakingEmployment FinancesCommunity EnvironmentCivil WarTransportFig. 2 Coding structureThe Author(s) Reproductive Health 2016, 13(Suppl 2):112 Page 127 of 162The relationship with in-laws was highlighted as particu-larly significant by several respondents. Pregnant womenstated that if they were living with in-laws, they wouldhave complications because “everyone is looking” and that“she is thinking a lot”. Health workers expressed similaropinions and stated “there are mothers-in-law who livewith the daughter-in-law while the husbands live in SouthAfrica. A small thing, a little failure while the daughter-in-law is pregnant- this is serious trouble, and the pregnantwoman can develop hypertension”. [Focus group discussionwith health workers, 3 de Fevereiro, Maputo]Intimate partner violence was described as importantfactor affecting health and well-being in pregnancy.“Yes it happens because when the man is alreadyangry, he no longer looks where he hits.” [Focus groupdiscussion with community leaders, 3 de Fevererio,Maputo]Community leaders tended to discuss gender roles andnorms in the context of intimate partner violence. Theydiscussed that several factors would lead a man to bephysically aggressive such as woman “insulting him”,“making noise” and “misusing money”. One communityleader described his relationship as “me and my wife, wehave been married for forty seven years and I never beather because she follows the rules”. [Focus group discus-sion with community leaders, Chongoene, Gaza]. Maleleaders did not cite reasons for physical violence butrather acknowledged that beating a pregnant womanis “not good” and could lead to complications such asabortion and premature delivery.Pregnant women described a change in women’s ac-ceptance of intimate partner violence in recent years.While in the past women were perceived as being silentabout intimate partner violence, they are now are vocalabout it. “In past times she would stay at home evenwhen beaten, still bearing children and even dying athome. But nowadays women no longer like to be beatenand there are men who, when they beat pregnant women,do not look where they hit and they can even hit in thebelly. It can even be where the baby’s head is and thebaby may be stillborn. In the past they would be beatenand did not return to their (maternal) homes but stayedin the household”. [Focus group discussion with pregnantwomen, Manhica] They explained that women are vocalabout violence and will bring up this issue in a publicforum like community circles. This had consequences forthe man as he could be “put in jail”. Male partners ac-knowledged that “the problem of beating women is notgood because women when pregnant [have] to be very welltaken care of…and [beating] can provoke an unhealthypregnancy. So it’s not good to beat them.” [Focus groupdiscussion with male partners, 3 de Fevereiro, Maputo]Women of reproductive age, including pregnant womenparticipating in the FGDs, described a complex relation-ship with neighbours and their immediate communities.A good relationship with neighbours was identified asbeing an important determinant of maternal health.Women, health workers and community leaders all feltthat if women did not “get along” with neighbours or “ifthere was no understanding” between neighbours, it couldresult in difficulties or complications during pregnancy.Women described “here when they don’t like you, they dobad things, so that when the time arrives for childbirth,you have complications, and they do things so that you arealways arguing with people.” [Focus group discussion withpregnant women, Manhinca]. Although this was not ex-plored further in the focus groups, women’s understand-ing of the relationship with neighbours could be similar toChapman’s work in which she characterized a domain ofreported pregnancy illness episodes as personalistic harmcaused by a human or spirit foe that women in her studycalled “illnesses provoked by bad spirits” [10]. She foundthat women reported that witchcraft and sorcery causedreproductive problems [10].At the same time, all groups recognised that neighbourswere a vital source of support for pregnant women. Com-munity leaders mentioned “it is not only responsibility ofthe pregnant woman to take care of herself, but all of us,we should help her”. [Focus group discussion with com-munity leaders, Chongoene, Gaza] Neighbours assisted inthe event of pregnancy complications and labour, and ac-companied women to health facilities. Administrative postchiefs highlighted that at times community members lendeach other vehicles for transport. Matrons were acknowl-edged to be an especially important source of support forpregnant women. In the absence of government healthworkers in some rural communities, women relied on ma-trons for advice during pregnancy, assistance with birthsand accompanying them to health facilities. Matrons men-tioned that they were also involved in mediating maritalproblems and reconciling couples.Women identified that informal community groupswere important as without them, women in thesecommunities could not organise structured activitieslike xitique. A community health worker describedthe relationship in the following manner “There arefriends or adult women or neighbours with whom shemust be open, with whom she must talk. She needs tohave confidantes, it may be at home, it may be withneighbours, it may be at work, in the farm, at themarket. She goes to look for somebody be it a friendwith whom she feels free, the person that she is goingto consider a confidante, isn’t it? She is going to tellher, that I am in this condition”. [Focus groupdiscussion with health workers, Chongoene, Gaza]The Author(s) Reproductive Health 2016, 13(Suppl 2):112 Page 128 of 162Environmental determinantsAdministrative chief posts described that the localitieshad faced several natural disasters including floods,droughts and cyclones. Several study areas were sandyand therefore, required large 4x4 vehicles for transport.Other areas were described as muddy or had potholes.Many of the administrative chief posts mentioned thatcould impede access to health services and worsen ma-ternal health. An important consideration for accessingroads was seasonality, particularly the rainy seasonwhere many regions are prone to floods. Women identi-fied mosquitos as an environmental factor and linked itto malaria. When asked about transportation, they men-tioned that often do not have access and that vehiclesare used “only if the person is serious”. Male partnersalso similarly identified that women walked long dis-tances to reach facilities. They also identified that fire-wood smoke was a concern for pregnant women, whilecommunity leaders identified pollution as an importantfactor for health.DiscussionOur study has found that women and their communitiesin rural southern Mozambique identified a broad rangeof inter-related determinants that influence maternalhealth. All respondents highlighted the significance ofpoverty that was then described as having a number ofdownstream effects including the inability to pay fortransport and medical costs, gender inequality and in-timate partner violence, and lack of structured commu-nity groups like xitique. Single, divorced and widowedwomen, were described as a particularly vulnerablegroups due to lack of financial and emotional support.At the same time, married women were vulnerable whentheir partners withheld money or food or if they haddifficult relationships with co-spouses or in-laws.In our study, we included discussions of the local com-munity’s history that allowed us to contextualise findings,particularly those related to poverty and unemployment.While our study did not explore the broader impact of thewar on disruption of social organisation, we foundthat women cited similar magnitude of impact due tounemployment and poverty resulting from the war.Our interpretation is similar to that of Chapman whodescribed that Mozambique’s history of internal warhad a profound impact on the societal structure andwomen’s reproductive vulnerability in her ethnographicwork [9, 10]. She describes that violence, material scarcity,dislocation of rural populations, and continued male labormigration has resulted in the high burden of reproductivemorbidity [9, 10].The full health impacts of war on women’s health in-cludes the harm and trauma during all phases of militaryactivity that disrupt and destroy their shelter, food andhealth systems, their children’s education, their personallife, and their community’s cohesiveness [17]. Women areuniquely harmed by war-related disintegration of health,education and social services, by the breakdown of civil so-ciety and security, and by the loss of basic environmentalassets, including potable water, sanitation, land, food, andfuel sources [17]. Women are harmed discriminately bythe increased intimate partner violence within the military,as targets of rape and sexual exploitation fueled by armedconflict, and by the increased intimate partner violencethat persists beyond war [17]. Programs and policies needto take a broad approach in addressing the lasting effectsof war on women at multiple levels. It is critical to increasewomen’s participation in reconstruction by giving womenaccess to rooms where decisions are made [18]. In post-conflict economies, tailoring education and vocationalskills training towards long-term, sustainable employmentwill allow women to have economic independence [18]. InMozambique and other post conflict countries, maternalhealth programs should include a focus on intimate part-ner violence which often persists beyond war.Our findings show that maternal health programsshould engage not only women but also male partnersand the community at large. In our study, we found thatthe perspectives of community leaders varied signifi-cantly from women and male partners when it came tointimate partner violence. Community leaders appearedto have gender stereotypes about the role of women andhad gendered expectations of women’s behaviours. Thishighlights the importance of engaging older male mem-bers such as community leaders and including discus-sion around gender norms and gender roles. Our studyalso highlights the importance of educating male part-ners and community leaders about birth preparedness.While women recognized the links between poverty andpoor health, male partners and community leaders weredivided in their perspective about the importance ofmoney in avoiding pregnancy complications.In addition to the political, economic and socio-cultural determinants, community informants identifiedseveral environmental factors that prohibit easy accessto roads and transport thus, leading to difficulties inreaching health facilities. In Thadeus and Maine’s sem-inal work Too Far To Walk, a delay in accessing healthservices is described as one of the three major delays inmaternal health [19]. Although women did not specific-ally mention distance to facility, some mentioned thatdue to economic constraints, they walked to facilities. Arecent study from Tanzania found that large distances tohospital contribute to high levels of direct obstetric mor-tality [20]. Women and other community members alsoidentified pollution and smoke as other environmentaldeterminants which are also described in literature [21].While there is limited published literature on maternalThe Author(s) Reproductive Health 2016, 13(Suppl 2):112 Page 129 of 162health and environmental determinants [21–26], key glo-bal health institutions like the World Health Organizationand United Nations have been drawing attention to gen-der sensitive responses to the effects of the environmental,particularly climate change [27, 28].Our study confirms the need for a broader approach tomaternal health programmes. Community participationwill be key in achieving a multi-sectoral approach to ma-ternal health. The African Union advocates for the involve-ment of communities in the identification of maternalhealth problems, as well as in the planning, financing andimplementation of solutions [29]. The rationale for com-munity participation, broadly defined as members of acommunity getting involved in planning, designing, imple-menting, and/or adapting health strategies, has includedresponding better to communities’ needs, designingprogrammes that account for contextual influences onhealth (such as the effects of local knowledge or culturalpractices), increasing public accountability for health, andit being a desirable end in itself [30].Participatory approaches for improving maternal healthhave been investigated in the context of effectiveness ofspecific interventions, either on their own or in combinedpackages and most show benefits [30]. There is a paucity ofliterature on community participation and its effect on thedeterminants of health. Studies from other areas of healthsuch as alcohol related violence, public safety and breastcancer, have shown that community participation can im-prove understanding of the socio-environmental causes ofill health [30]. We can draw from lessons from these otherareas of health and apply them to maternal health.ConclusionThe political, socio-cultural, economic and environmentaldeterminants of health are critical influences on maternalhealth. In rural southern Mozambique, the history of civilwar has resulted in unemployment, which was recognisedby community members as an important determinant ofhealth in the community. They also identified key relation-ships that influence well-being in pregnancy including thatwith partners, co-spouses, in-laws and neighbours. Inabilityto access roads and transport due to the terrain, seasonalityand natural disasters was highlighted as a potential envir-onmental barrier to improved maternal health.Frameworks for improving maternal health shouldinclude a wide array of health determinants in order todevelop comprehensive strategies to reduce mortality andmorbidity. Determinants not only influence access andcoverage of health interventions but also shape behav-iours. Programmes should address gender violence andgender inequality. It is critical to involve the communityat all levels to design solutions that are appropriately tar-geted and contextualised. Cross-cutting multi-sectoralprogramme delivery is needed to effectively address andadvance maternal health.Additional fileAdditional file 1: Reviewer reports. (PDF 327 kb)AcknowledgementsThis study was funded by the Grand Challenges Canada- Stars in GlobalHealth program. The authors gratefully acknowledge the contributions of theCommunity Level Interventions for Pre-eclampsia (CLIP) Working Group: RosaPires, Zefanias Nhamirre, Rogério Chiau, Analisa Matavele, Adérito Tembe,Lina Machai, Delino Nhalungo, Beth Payne, Sharla Drebit, Chirag Kariya andSumedha Sharma.DeclarationsThis article has been published as part of Reproductive Health Volume 13Supplement 2, 2016: Building community-level resilience for the case ofwomen with pre-eclampsia. The full contents of the supplement are availableonline at http://reproductive-health-journal.biomedcentral.com/articles/supplements/volume-13-supplement-2. Publication charges for thissupplement were funded by the University of British Columbia PRE-EMPT(Pre-eclampsia/Eclampsia, Monitoring, Prevention and Treatment) initiativesupported by the Bill & Melinda Gates Foundation.Authors’ contributionTF conceptualized and drafted the manuscript. HB, RC and KM coordinateddata collection and assisted in analysis. TF, MV and PTM coded the data.All authors provided input and revised the manuscript. All authors read andapproved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Peer reviewReviewer reports for this article are included in Additional file 1.Author details1Department of Medicine, University of British Columbia, 330 E. ColumbiaStreet, New Westminister, BC V3L 3LW, Canada. 2Department of Obstetricsand Gynaecology and the Child and Family Research Institute, University ofBritish Columbia, 950 W 28th Ave, Vancouver, British Columbia V5Z 4H4,Canada. 3Department of Geography, Simon Fraser University, Burnaby, BritishColumbia V5A1S6, Canada. 4Department of Surveying and Geomatics,Midlands State University, P Bag 9055 Gweru, Zimbabwe. 5Centro deInvestigação em Saúde da Manhiça (CISM), Bairro Cambeve, Rua 12, Distritoda Manhiça, CP 1929 Manhiça, Mozambique. 6Department of Obstetrics andGynaecology, St George’s, University of London, Cranmer Terrace, LondonSW17 0RE, UK.Published: 30 September 2016References1. World Health Organization. Social determinants of health [Internet]. Geneva:World Health Organization. 2016. Available from: www.who.int/topics/social_determinants/en/.2. 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Rosato M, Levarack G, Grabman LH, Tripathy P, Nair N, Mwansambo C, AzadK, Morrison J, Bhutta Z, Perry H, Rifkin S, Costello A. Communityparticipation: lessons for maternal, newborn, and child health. Lancet. 2008;372(9462):962–97.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:The Author(s) Reproductive Health 2016, 13(Suppl 2):112 Page 131 of 162

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