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Reliable statistics on maternal morbidity and mortality are scarce in low and middle-income countries, especially in rural areas. This is the case in Mozambique where many births happen at home. Furthermore, a sizeable number of facility births have inadequate registration. Such information is crucial for developing effective national and global health policies for maternal and child health. The aim of this study was to generate reliable baseline socio-demographic information on women of reproductive age as well as to establish a demographic surveillance platform to support the planning and implementation of the Community Level Intervention for Pre-eclampsia (CLIP) study, a cluster randomized controlled trial. This study represents a census of all women of reproductive age (12–49 years) in twelve rural communities in Maputo and Gaza provinces of Mozambique. The data were collected through electronic forms implemented in Open Data Kit (ODK) (an app for android based tablets) and household and individual characteristics. Verbal autopsies were conducted on all reported maternal deaths to determine the underlying cause of death. Between March and October 2014, 50,493 households and 80,483 women of reproductive age (mean age 26.9 years) were surveyed. A total of 14,617 pregnancies were reported in the twelve months prior to the census, resulting in 9,029 completed pregnancies. Of completed pregnancies, 8,796 resulted in live births, 466 resulted in stillbirths and 288 resulted in miscarriages. The remaining pregnancies had not yet been completed during the time of the survey (5,588 pregnancies). The age specific fertility indicates that highest rate (188 live births per 1,000 women) occurs in the age 20–24 years old. The estimated stillbirth rate was 50.3/1,000 live and stillbirths; neonatal mortality rate was 13.3/1,000 live births and maternal mortality ratio was 204.6/100,000 live births. The most common direct cause of maternal death was eclampsia and tuberculosis was the most common indirect cause of death. This study found that fertility rate is high at age 20–24 years old. Pregnancy in the advanced age (>35 years of age) in this study was associated with higher poor outcomes such as miscarriage and stillbirth. The study also found high stillbirth rate indicating a need for increased attention to maternal health in southern Mozambique. Tuberculosis and HIV/ AIDS are prominent indirect causes of maternal death, while eclampsia represents the number one direct obstetric cause of maternal deaths in these communities. Additional efforts to promote safe motherhood and improve child survival are crucial in these communities.
The census was conducted in 2014 to identify the socio-demographic information of the population: number and membership of each household, names, ages, reproductive history, and mortality. The census included all women of reproductive age in 12 rural areas in two provinces in southern Mozambique, namely Maputo and Gaza. The methodology used was based on the process in use by the Health Demographic and Surveillance System (HDSS), this facilitated follow-up all women surveyed [4, 12]. Each of the twelve rural areas was defined by a geographic region, which contained a minimum population size of 25,000 inhabitants. This number was defined as the minimum total population that would result in at least one maternal death per year as per the data from the 2007 national census of Mozambique [13]. The national administrative structure used to delimit each region was the Administrative Posts (AP) that represents the 3rd administrative level in Mozambique after the Province and Districts; in cases where the AP had insufficient population, an additional AP was added and in situations where the AP had more than 25,000 inhabitants a delimitation of portions of the AP was done by excluding some localities or neighbourhoods. As census data, will be used in the CLIP cluster randomized control trial, the selection of study regions aimed to avoid contamination between regions. To avoid contamination, no areas were geographically contiguous; all regions were separated by non-inhabited areas such as wide bush and forest, swampy areas, rivers and areas of inundation. The data used to define the 12 clusters were based on statistics from the National Census of 2007 carried out by National Institute of Statistics of Mozambique [13]. As shown in Fig 1, in Maputo Province there were four clusters namely: Maluana & Maciana, Calanga & Ilha Josina, 3 de Fevereiro and Magude while in Gaza there were eight clusters: Messano, Mazivila, Xilembene, Chissano, Chicumbane, Chongoene, Malehice and Chaimite. All households with one or more woman of reproductive age (12 to 49 years) in the selected clusters were included in the census. Further, in order to be included in the census, the women must have lived in the household for more than 30 days prior to the date of the census and had the intention to live in this household as permanent resident for at least six months following the census. In addition, women of reproductive age who died in the 12 months preceding the survey were included to provide mortality data on this group. The data were collected using android tablets equipped with Open Data Kit (ODK https://opendatakit.org) suited with ODK Collect version 1.4. The data collection forms contained questions on household characteristics, socio-demographic characteristics, obstetric and medical histories. Before implementation, the electronic forms were tested by members of the IT team as well as piloted in the field. Data was uploaded to a central server from tablets on a weekly basis. Household information included questions regarding the materials used in construction, the number of buildings, the presence of a latrine and kitchen, the source of drinking water, the use of electricity and the main type of fuel for cooking. WRA were asked their name, date of birth, relationship with the head of household, level of education, occupation, religion, marital status. To determine the causes of death, a verbal autopsy (VA) was conducted for all deaths among WRA. The VA required an interview with family members or caregivers about the circumstances of the death. Verbal autopsies are regularly used in areas where routine death registration is non-existent or inadequate [14]. The 2012 WHO VA tool was translated to Portuguese and customized for electronic use with ODK for this study. All the field workers were local residents; both male and female, most had a minimum education level of grade 12. In areas with few grade 12 candidates, data collectors were recruited with as little as 10th grade completed. The enumeration of households included painting household IDs on the door; this was done by 38 field workers. These IDs represent the locality and neighbourhood of the household. In addition to the 38 field officers mentioned above, 208 interviewers were recruited. All electronic data was returned to the central office at Centro de Investigação em Saúde da Manhiça (CISM) for upload onto the server every Friday. A few select sites in Gaza used a remote 3G secure connection to upload the data. After each upload, all the data were removed from the tablets to ensure patient confidentiality. To determine the cause of maternal deaths verbal autopsy and physician review was used. Three independent physicians reviewed each verbal autopsy using the International Classification of Diseases (ICD-10) to assign a maximum of two diagnoses responsible for the death. The cause of death was determined based on agreement of diagnoses of physicians. Descriptive analyses were performed using Stata13 package (version 13.1, Stata Corp, Texas, US). No inferential statistics (p-values or 95%CI) is presented because the data came from a census, therefore the population parameters are directly calculated. The indicators presented were based on internationally accepted definitions. The age-specific fertility rate (ASFR) was defined as the number of live births per 1,000 WRA in a specific age interval. Stillbirth rate (SBR) was defined as the number of foetal deaths after 28 weeks divided by total live births plus stillbirths per thousands. Neonatal mortality ratio (NMR) was defined as infant deaths under 28 days divided by total live births. The maternal mortality ratio (MMR) was defined as all deaths of women as a result of pregnancy, childbirth and post-partum up to 42 days divided by total live births. Finally, the death rate for WRA was derived from all deaths of women of reproductive age (12–49 years) per 1,000 population[15, 16]. The first component of the Principal component analysis (PCA) was used to generate the poverty index from household characteristics: type of wall, type of latrine, access to transport, source of drinking water, electricity in the household and ownership of numerous household items (TV, radio, bed, clock or watch, and iron) among other. This index was categorized into quintiles of poverty [17, 18]. To mitigate recall bias of the number of children reported we also asked about children not leaving with the mother and the family. We did consistency checks of the total pregnancies and pregnancies outcomes in the last 12 months prior to the census per woman. Women who reported more than 3 pregnancies are truncated to just 3. If the total amount of pregnancies and outcomes matched, we consider the pregnancies in the last 12 months to be complete. Otherwise, 1 of the pregnancy is still incomplete. Informed consent was obtained from each head of the household and woman of reproductive age surveyed. A comprehensive understanding and agreement to participate was confirmed by signature or fingerprint of all participants prior to data collection. Ethical approval for the census was obtained from the Institutional Ethics Review Board for Health at CISM (CIBS-CISM) and from the CLIP co-ordinating centre at the University of British Columbia, prior to data collection.
