Health geography

The health geography component of PRECISE is led by Dr Prestige Tatenda Makanga  and aims to understand and disseminate knowledge and best practices concerning the geographical influences on the occurrence and outcomes of placental disorders of pregnancy.

We have developed a 9-step guideline for gathering and creating framework GIS data in a data-poor setting.  Using this approach, we conducted a facility assessment in Maputo and Gaza provinces, Mozambique, to classify 56 health centres.  GPS co-ordinates of the health facilities were acquired from the Ministry of Health while roads were digitised and classified from high-resolution satellite images.  Data related to the geographic distribution of populations of women of reproductive age, pregnancies and births, and transport options available to pregnant women were collected by household census.  Daily precipitation and flood data were used to model the impact of severe weather on access for a 17-month epoch. Travel times to the nearest health facilities were calculated using the closest facility tool in ArcGIS software. 46% and 87% of pregnant women lived within 1h of the nearest primary care centre by walking or public transport, respectively.  The populations within these catchments dropped by 9% and 5% respectively at the peak of the wet season.  Similarly, the population of women within 2h of life-saving care dropped by 9% for secondary facilities and 18% for tertiary facilities during the wet season (see lower image on right for example of data visualisation).  Therefore, seasonal variation in maternal care access should not be viewed through a dichotomous, static lens of wet and dry seasons, as access continually fluctuates.  This spatio-temporal access modelling approach, which will be adopted in the proposed programme in sub-Saharan Africa, permits GIS output use for both health services planning and near real-time community-level delivery of health services.

To examine interactions between time, place, infectious risk, food security, and placental disorders, we will integrate real-time, and location-specific, health geography to estimate community- and individual-level resilience to placental disorders using the innovative methods described above to map new areas in the Gambia, Senegal, and Kenya.

Air Quality and WASH

We will complement our health geography, nutrition and social science foci within PRECISE with expertise in air pollution personal exposure assessment, using a combination of small personal sensors, satellite aerosol optical depth data and outdoor air quality models as well as individual level human exposure models. 

Water, sanitation and hygiene (WASH): Due to the multiple pathways through which poor access to water, sanitation and hygiene (WASH) may have adverse impacts on maternal and newborn health (MNH) outcomes, PRECISE will assess the contributions of WASH within the complexity of the project.  Due to their interdependent nature, these three core issues (i.e., water, sanitation and hygiene) are grouped together to represent a growing research and implementation sector; their interdependence is illustrated by the facts that, without toilets, water sources become contaminated; without clean water, basic hygiene practices are impossible.

We will put the required elements in place by:

  • A combination of remote communication, discussion with PRECISE colleagues and visits to the countries, to establish what air quality measurements, traffic and other emissions, and WASH source data exist and plan for further data collection if necessary
  • To establish the level of housing information available, including indoor sources of air pollution, fuel used, and WASH facilities
  • The availability of routinely collected health data, its suitability for future epidemiological analysis and to plan for further data collection, if necessary
  • To develop an analysis plan whereby outdoor and indoor personal exposure estimates and WASH data can be linked with health data for future analysis
  • To begin feeding these data into the COLLECT database, as part of a ‘beta’ test of the system, and to adjust the analysis plan where necessary

Access and maternity health system delivery

There are important factors preventing timely care-seeking and effective system response for obstetric emergencies and delivery.  Delay due to unfamiliarity with warning signs, especially among family members, discouragement from revealing pregnancy early in gestation, gender inequalities, complex and untimely decision-making processes, fear of mistreatment by health-care providers, lack of recognition by frontline staff and delay in escalation within the health system, lack of transport and financial constraints were the most commonly cited barriers9;10. In rural Mozambique, we determined that women do seek antenatal care at health facilities, despite other health care providers being in the community. 

We will draw on our less-developed country-based research to address health system contexts, barriers and facilitators in each of the different countries and in rural and urban settings.  This will include investigation of the contribution of micro-financing, and health systems strengthening within the context of WHO standards to improve quality of care.

We will draw on social and implementation sciences to explore enabling and impeding factors for pregnant women, with and without pregnancy complications at all levels of a woman’s journey through care, including assessment of health system responsiveness.  We will use ethnographic and mixed methods research across all sites using a realist evaluation approach to develop explanations that address the questions about how complex programmes, ‘what works, for whom, under what circumstances, and how’, providing insights into implementation contexts.  This will include investigation of the contribution of context and sociocultural factors, the role of microcredit and changes in women’s decision-making power to improve access to healthcare.

Access, Barriers and Systems of Care (ABSoC)

The Access, Barriers and Systems of Care (ABSoC) thematic working group has been set up to study the health system contexts within which maternity services are provided in the PRECISE countries, to explore the barriers and facilitators to accessing care, and to examine the quality of care that is provided, including whether this care is respectful of mothers’ and babies’ needs and preferences.

Mothers and newborns need access to safe, efficient and high-quality health services along the maternal and neonatal health continuum of care, spanning the pregnancy, birth and postnatal periods. This is particularly important for mothers and babies with placental disorders. On the demand side, factors that may prevent timely care-seeking may include unfamiliarity with warning signs, especially among family members, discouragement from revealing pregnancy early in gestation, gender inequalities, complex and untimely decision-making processes, fear of mistreatment by health-care providers, lack of transport and financial constraints.

However, it is not enough to reach a facility, the care available there must be timely, of good quality, and respectful. Quality care can only be provided within functional health systems, which need to have efficient and equitable financing, adequately-trained and motivated human resources, effective governance and accountability structures, functioning referral pathways, sufficient physical resources and well-functioning information systems. As outlined in the WHO Quality of Care Framework for maternal and newborn health care (see figure), the concept of quality of care itself includes both the provision and the experience of care. The provision of care includes the coverage of key practices at different contact points, that vary on a case-by-case basis depending on clinical need. In addition, care should be respectful, in that it protects women’s privacy and dignity, is equitable, ensures women and newborns are free from harm and mistreatment, and respects individual preferences, contributing to a positive experience.

Different work streams within the ABSoC group will draw on the social and implementation sciences and use a range of qualitative and quantitative research methods to explore this wide range of factors that enable or impede access to quality care for all women, including those related to the supply of and demand for services. We also plan to investigate how receiving good or poor-quality care interacts with other individual characteristics to determine more or less favourable physical and mental health outcomes for mothers and babies, with a specific focus on those with placental disorders.