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Place-specific factors associated with adverse maternal and perinatal outcomes in Southern Mozambique: a retrospective cohort study
  1. Prestige Tatenda Makanga1,
  2. Charfudin Sacoor,
  3. Nadine Schuurman2,
  4. Tang Lee3,
  5. Faustino Carlos Vilanculo4,
  6. Khatia Munguambe4,
  7. Helena Boene4,
  8. Ugochinyere Vivian Ukah5,
  9. Marianne Vidler3,
  10. Laura A Magee6,
  11. Esperanca Sevene4,7,
  12. Peter von Dadelszen6,
  13. Tabassum Firoz8
  14. On behalf of the CLIP Working Group
    1. 1 Surveying and Geomatics Department, Midlands State University Faculty of Science and Technology, Gweru, Midlands, Zimbabwe
    2. 2 Department of Geography, Simon Fraser University, Vancouver, British Columbia, Canada
    3. 3 Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
    4. 4 Centro de Investigacao em Saude de Manhica, Manhica, Maputo, Mozambique
    5. 5 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
    6. 6 Department of Obstetrics and Gynaecology, Kings College London, London, London, UK
    7. 7 Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
    8. 8 Department of Medicine, Yale New Haven Health System, New Haven, Connecticut, USA
    1. Correspondence to Dr Prestige Tatenda Makanga; makangap{at}


    Objectives To identify and measure the place-specific determinants that are associated with adverse maternal and perinatal outcomes in the southern region of Mozambique.

    Design Retrospective cohort study. Choice of variables informed by literature and Delphi consensus.

    Setting Study conducted during the baseline phase of a community level intervention for pre-eclampsia that was led by community health workers.

    Participants A household census identified 50 493 households that were home to 80 483 women of reproductive age (age 12–49 years). Of these women, 14 617 had been pregnant in the 12 months prior to the census, of which 9172 (61.6%) had completed their pregnancies.

    Primary and secondary outcome measures A combined fetal, maternal and neonatal outcome was calculated for all women with completed pregnancies.

    Results A total of six variables were statistically significant (p≤0.05) in explaining the combined outcome. These included: geographic isolation, flood proneness, access to an improved latrine, average age of reproductive age woman, family support and fertility rates. The performance of the ordinary least squares model was an adjusted R2=0.69. Three of the variables (isolation, latrine score and family support) showed significant geographic variability in their effect on rates of adverse outcome. Accounting for this modest non-stationary effect through geographically weighted regression increased the adjusted R2 to 0.71.

    Conclusions The community exploration was successful in identifying context-specific determinants of maternal health. The results highlight the need for designing targeted interventions that address the place-specific social determinants of maternal health in the study area. The geographic process of identifying and measuring these determinants, therefore, has implications for multisectoral collaboration.

    Trial registration number NCT01911494.

    • maternal health
    • global health
    • spatial epidemiology
    • geostatistics
    • health geography

    This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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    • Patient consent for publication Not required.

    • Twitter @ptmakanga, @placelaertlabs

    • Contributors PTM, CS, NS, PvD and TF made substantial contributions to conception and design of the project. FCV, CS, KM, HB and ES led the acquisition of in country data. PTM, UVU, NS and TL led the analysis and were involved together with all the authors in the interpretation of the results. PTM, LAM, TF, NS and MV made substantive contributions to writing the first complete version of the article, and all the authors were involved in revising it critically for important intellectual content. All authors approve of the final version of the paper.

    • Funding This work was part funded by Grand Challenges Canada – Stars in Global Health programme (Grant 0197) and was conducted as part of the Pre-eclampsia/Eclampsia, Monitoring, Prevention and Treatment (PRE-EMPT) initiative supported by the Bill & Melinda Gates Foundation.

    • Competing interests None declared.

    • Ethics approval Ethics approval for the study was obtained by the research and ethics boards at University of British Columbia, Simon Fraser University and Centro de Investigação em Saúde de Manhiça.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement All data that have been used in this research will be available upon request after the main papers from the Community-Level Interventions in Pre-Eclampsia (CLIP) trials have been published.

    • Collaborators CLIP Working Group: Eusébio Macete, Anifa Vala, Felizarda Amose, Rosa Pires, Zefanias Nhamirre, Marta Macamo, Rogério Chiaú, Analisa Matavele, Ariel Nhancolo, Silvestre Cutana, Ernesto Mandlate, Salésio Macuacua, Cassimo Bique, Sibone Mocumbi, Emília Gonçálves, Sónia Maculuve, Ana Ilda Biz, Dulce Mulungo, Orvalho Augusto, Paulo Filimone, Vivalde Nobela, Corsino Tchavana, Cláudio Nkumbula, Jeffrey Bone, Dustin Dunsmuir, Sharla K Drebit, Chirag Kariya, Mai-Lei Woo Kinshella, Jing Li, Mansun Lui, Beth A. Payne, Asif R Khowaja, Diane Sawchuck, Sumedha Sharma, Domena K. Tu, Ugochi V. Ukah.