Community perspectives on the determinants of maternal health in rural southern Mozambique: a qualitative study

Our study has found that women and their communities in rural southern Mozambique identified a broad range of inter-related determinants that influence maternal health. All respondents highlighted the significance of poverty that was then described as having a number of downstream effects including the inability to pay for transport and medical costs, gender inequality and intimate partner violence, and lack of structured community groups like xitique. Single, divorced and widowed women, were described as a particularly vulnerable groups due to lack of financial and emotional support. At the same time, married women were vulnerable when their partners withheld money or food or if they had difficult relationships with co-spouses or in-laws.

In our study, we included discussions of the local community’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 the war on disruption of social organisation, we found that women cited similar magnitude of impact due to unemployment and poverty resulting from the war. Our interpretation is similar to that of Chapman who described that Mozambique’s history of internal war had a profound impact on the societal structure and women’s reproductive vulnerability in her ethnographic work [9, 10]. She describes that violence, material scarcity, dislocation of rural populations, and continued male labor migration has resulted in the high burden of reproductive morbidity [9, 10].

The full health impacts of war on women’s health includes the harm and trauma during all phases of military activity that disrupt and destroy their shelter, food and health systems, their children’s education, their personal life, and their community’s cohesiveness [17]. Women are uniquely harmed by war-related disintegration of health, education and social services, by the breakdown of civil society and security, and by the loss of basic environmental assets, including potable water, sanitation, land, food, and fuel sources [17]. Women are harmed discriminately by the increased intimate partner violence within the military, as targets of rape and sexual exploitation fueled by armed conflict, and by the increased intimate partner violence that persists beyond war [17]. Programs and policies need to take a broad approach in addressing the lasting effects of war on women at multiple levels. It is critical to increase women’s participation in reconstruction by giving women access to rooms where decisions are made [18]. In post-conflict economies, tailoring education and vocational skills training towards long-term, sustainable employment will allow women to have economic independence [18]. In Mozambique and other post conflict countries, maternal health programs should include a focus on intimate partner violence which often persists beyond war.

Our findings show that maternal health programs should engage not only women but also male partners and the community at large. In our study, we found that the perspectives of community leaders varied significantly from women and male partners when it came to intimate partner violence. Community leaders appeared to have gender stereotypes about the role of women and had gendered expectations of women’s behaviours. This highlights the importance of engaging older male members such as community leaders and including discussion around gender norms and gender roles. Our study also highlights the importance of educating male partners and community leaders about birth preparedness. While women recognized the links between poverty and poor health, male partners and community leaders were divided in their perspective about the importance of money in avoiding pregnancy complications.

In addition to the political, economic and socio-cultural determinants, community informants identified several environmental factors that prohibit easy access to roads and transport thus, leading to difficulties in reaching health facilities. In Thadeus and Maine’s seminal work Too Far To Walk, a delay in accessing health services is described as one of the three major delays in maternal health [19]. Although women did not specifically mention distance to facility, some mentioned that due to economic constraints, they walked to facilities. A recent study from Tanzania found that large distances to hospital contribute to high levels of direct obstetric mortality [20]. Women and other community members also identified pollution and smoke as other environmental determinants which are also described in literature [21]. While there is limited published literature on maternal health and environmental determinants [21–26], key global health institutions like the World Health Organization and United Nations have been drawing attention to gender sensitive responses to the effects of the environmental, particularly climate change [27, 28].

Our study confirms the need for a broader approach to maternal health programmes. Community participation will be key in achieving a multi-sectoral approach to maternal health. The African Union advocates for the involvement of communities in the identification of maternal health problems, as well as in the planning, financing and implementation of solutions [29]. The rationale for community participation, broadly defined as members of a community getting involved in planning, designing, implementing, and/or adapting health strategies, has included responding better to communities’ needs, designing programmes that account for contextual influences on health (such as the effects of local knowledge or cultural practices), increasing public accountability for health, and it being a desirable end in itself [30].

Participatory approaches for improving maternal health have been investigated in the context of effectiveness of specific interventions, either on their own or in combined packages and most show benefits [30]. There is a paucity of literature on community participation and its effect on the determinants of health. Studies from other areas of health such as alcohol related violence, public safety and breast cancer, have shown that community participation can improve understanding of the socio-environmental causes of ill health [30]. We can draw from lessons from these other areas of health and apply them to maternal health.