ABSTRACT:
Climate change is intensifying environmental exposures that elevate risks during pregnancy, yet maternal health research often treats geography as contextual rather than constitutive of risk. Consequently, the spatial organisation of climate exposures, social vulnerability, and access to care remains insufficiently integrated into pregnancy risk pathways. We developed and applied a health geography framework to capture how climate-sensitive physical and social environments shape maternal risk across African settings. We developed geographically explicit indicators through evidence synthesis, community-informed knowledge, and geospatial modelling. Physical indicators included temperature, precipitation, humidity, PM₂.₅, vegetation (NDVI), spatial isolation, transport infrastructure, and access to health facilities. Social geographic indicators were derived from PRECISE cohort survey data to represent autonomy, inclusion, and support. Indicators were operationalised using population-weighted and community-level approaches and applied within the PRECISE pregnancy cohort in Kenya, Mozambique, and The Gambia. Substantial heterogeneity in climate-related and social exposures was observed within all countries. Median NDVI ranged from 0.49 in Mozambique and 0.42 in Kenya to 0.25 in The Gambia. Median land surface temperatures ranged from 24.2°C(Mozambique) to 30.6°C(The Gambia), with extremes reaching 36.9°C(P95). Air pollution burdens differed: PM₂.₅ (CAMS) medians were 12.5–15.7 µg/m³ in Kenya and Mozambique compared with 55.8 µg/m³in The Gambia (P95: 113.2 µg/m³). Access to care was skewed: median travel time to the facility visited was 6–7 minutes, but exceeded 42 minutes(P95), while walking times reached 280 minutes(P95). Social inequities were evident, with general financial autonomy reported by 19.4% of women in Kenya, 8.2% in Mozambique, and 0.9% in The Gambia. Operationalising geography as a mediator of climate exposure, an organising principle for measurement, and a basis for geographically precise action enables identification of climate-vulnerable pregnant populations and actionable entry points beyond the clinic. Embedding such indicators into maternal health and climate adaptation strategies is essential for reducing climate-related inequities in pregnancy outcomes.