The role of a maternity waiting area (MWA) in reducing maternal mortality and stillbirths in high-risk women in rural Ethiopia

Husbands' experiences and perceptions regarding the use of maternity waiting homes in rural Zambia

OBJECTIVE

To explore men's experience and beliefs regarding the use of maternity waiting homes (MWHs) in Kalomo District, Zambia.

METHODS

As part of a qualitative study, in-depth interviews with the husbands/partners of women attending the under-five clinic at a health center with a MWH were conducted between April 1 and May 31, 2014. Men aged 18-50 years whose partner/wife was of reproductive age and who had lived in the area for more than 6 months were eligible for inclusion.

RESULTS

Overall, 24 husbands/partners were interviewed in seven rural health centers. Men perceived many potential benefits of MWHs, including improved access to facility-based skilled delivery services and treatment in case of labor complications. Their many roles included decision making and securing funds for transport, food, cleaning materials, and clothes for the mother and the neonate to use during and after labor. However, limited financial resources made it difficult for them to provide for their wives and newborns, and usually led to delays in their decisions about MWH use. Poor conditions in MWHs and the lack of basic social and healthcare needs meant some men had forbidden their wives/partners from using the facilities.

CONCLUSION

Important intervention targets for improving access to MWHs and skilled birth attendance have been identified.

Causes of maternal mortality in Ethiopia: a significant decline in abortion related death

Background

Although the common direct obstetric causes of maternal mortality are known from the literature, the contribution of each cause and the change in trend over decades is unknown in Ethiopia. The objective of this review was to assess the trend of proportion of maternal mortality due to the common direct causes.

Methods

This systematic review was done on eighteen health facility based maternal mortality studies conducted between 1980 and 2012 in Ethiopia. Emphasis was given to the proportion of maternal mortality due to direct causes and their case fatality rates.

Results

The summary of the findings has shown that the top four causes of maternal mortality in the year 1980–1999 were abortion related complications (31%), obstructed labor/uterine rupture (29%), sepsis/infection (21%) and hemorrhage (12%). In the last decade, however, the top four causes of maternal mortality were obstructed labor/uterine rupture (36%), hemorrhage (22%), hypertensive disorders of pregnancy (19%) and sepsis/infection (13%).

Conclusion

Abortion and infection related maternal deaths have declined significantly in the last decade. Obstructed labor continues to be the major cause of maternal deaths; maternal deaths due to hypertensive disorders and hemorrhage showed an increasing trend. The findings in this review were somehow comparable with the WHO analysis for Africa in the same period with the exception of obstructed labor.

Improving access to skilled facility-based delivery services: Women's beliefs on facilitators and barriers to the utilisation of maternity waiting homes in rural Zambia

BACKGROUND

Maternity waiting homes (MWHs) are aimed at improving access to facility-based skilled delivery services in rural areas. This study explored women's experiences and beliefs concerning utilisation of MWHs in rural Zambia. Insight is needed into women's experiences and beliefs to provide starting points for the design of public health interventions that focus on promoting access to and utilisation of MWHs and skilled birth attendance services in rural Zambia.

METHODS

We conducted 32 in-depth interviews with women of reproductive age (15-45 years) from nine health centre catchment areas. A total of twenty-two in-depth interviews were conducted at a health care facility with a MWH and 10 were conducted at a health care facility without MWHs. Women's perspectives on MWHs, the decision-making process regarding the use of MWHs, and factors affecting utilisation of MWHs were explored.

RESULTS

Most women appreciated the important role MWHs play in improving access to skilled birth attendance and improving maternal health outcomes. However several factors such as women's lack of decision-making autonomy, prevalent gender inequalities, low socioeconomic status and socio-cultural norms prevent them from utilising these services. Moreover, non availability of funds to buy the requirements for the baby and mother to use during labour at the clinic, concerns about a relative to remain at home and take care of the children and concerns about the poor state and lack of basic social and healthcare needs in the MWHs--such as adequate sleeping space, beddings, water and sanitary services, food and cooking facilities as well as failure by nurses and midwives to visit the mothers staying in the MWHs to ensure their safety prevent women from using MWHs.

CONCLUSION

These findings highlight important targets for interventions and suggest a need to provide women with skills and resources to ensure decision-making autonomy and address the prevalent gender and cultural norms that debase their social status. Moreover, there is need to consider provision of basic social and healthcare needs such as adequate sleeping space, beddings, water and sanitary services, food and cooking facilities, and ensuring that nurses and midwives conduct regular visits to the mothers staying in the MWHs.

Perinatal mortality trends in Ethiopia

BACKGROUND

Although the magnitude of perinatal mortality in Ethiopia was among the highest in Sub Saharan Africa, there was no systematic review done to assess the trend and causes of perinatal death. The objective of this review was to assess the trend of perinatal mortality rate (PMR) and the causes attributed to perinatal deaths.

METHODS

Studies included in this systematic review were sixteen hospital and community based perinatal mortality studies, which were conducted between 1974 and 2013 using data concerning Ethiopia accessed either electronically or from local journals. The trend of PMR, stillbirth rate (SBR) and early neonatal mortality rate (ENMR) were given emphasis.

RESULTS

The PMRs reported from ten hospital based studies were in the range of 66 to 124 per 1000 births. The reports of the large scale community based PMRs were in the range of 37 to 52 per 1000 births. The proportion of stillbirths and early neonatal deaths reported from the hospital based and community based studies was very high (60-110 and 20-34/1000 births); the regression lines demonstrated that SBRs in the hospitals were mirror reflections of ENMRs in the community. The neonatal mortality rate (NMR), however, declined by more than 40% between 1990 and 2011.

CONCLUSION

The PMR of Ethiopia was among the highest in Sub Saharan Africa. Over the decades, both hospital based and community based studies did not show a reduction in perinatal mortality. The trend of perinatal mortality rate has been stable between 90 and 40 per 1000 total births in the hospital and community setting, respectively. The significant reduction in NMR was due to significant decline in late neonatal mortality.

Review of maternal mortality in Ethiopia: a story of the past 30 years

BACKGROUND

Ethiopia is one of the six countries which have contributed to more than 50% of all maternal deaths across the world. This country has adopted the millennium development goals (MDGs) including reducing the maternal mortality by three-quarter, and put improvement in maternal health as one of the health sector development program (HSDP) performance indicators. The purpose of this study was to review the maternal mortality ratio (MMR) in Ethiopia in the past 30 years using available literature.

METHODS

A computer based literature search in the databases of MEDLINE, PubMed, HINARI, EBASE, MEASURE DHS, The Cochrane Library, Google Search and Google Scholar was carried out. Manual search for local articles that are not available electronically in full document were also conducted. Eighteen data sources (3 nationally representative surveys, 2 secondary data analyses, 5 small scale community based studies, and 8 hospital based studies) were included in the review. The results of this review are presented in the form of line and stock graphs.

RESULTS

The national maternal mortality trend estimated by the central statistics agency of Ethiopia, The Institute for Health Metrics and Evaluation, WHO and other UN agencies showed inconsistent results. Similarly, although there were marked variations in the 95% confidence intervals among individual studies, the small scale community based and hospital based studies have shown that there has been no significant change in maternal mortality over the last three decades. A 22-year cohort analysis from Atat Hospital is the only evidence that demonstrated a very significant drop in maternal mortality among mothers who were kept in the maternity waiting area before the onset of labor.

CONCLUSION

Although the MDG and HSDP envisaged significant improvement in maternal health by this time, this review has shown that the performances are still far from the target. The multisectoral huge investment by the Ethiopian Government is a big hope to reduce the maternal mortality by three-quarters in the near future beyond 2015.

Alternative measures of spatial distribution and availability of health facilities for the delivery of emergency obstetric services in island communities

International guidelines and recommendations for availability and spatial distribution of emergency obstetric care services do not adequately address the challenges of providing emergency health services in island communities. The isolation and small population sizes that are typical of islands and remote populations limit the applicability of international guidelines in such communities. Universal access to emergency obstetric care services, when pregnant women encounter complications, is one of the three key strategies for reducing maternal and newborn mortality; the other two being family planning and skilled care during labor. The performance of selected lifesaving clinical interventions (signal functions) over a 3-month period is commonly used to assess and assign performance categories to health facilities but island communities might not have a large enough population to generate demand for all the signal functions over a 3-month period. Similarly, availability and spatial distribution recommendations are typically based on the size of catchment populations, but the populations of island communities tend to be sparsely distributed. With illustrations from six South Pacific Island states, we argue that the recommendation for availability of health facilities, that there should be at least five emergency obstetric care facilities (including at least one comprehensive facility) for every 500,000 population, and the recommendation for equitable distribution of health facilities, that all subnational areas meet the availability recommendation, can be substituted with a focus on access to blood transfusion and obstetric surgical care within 2 hours for all pregnant residents of islands. Island communities could replace the performance of signal functions over a 3-month period with a demonstrated capacity to perform signal functions if the need arises.

Promoting access: the use of maternity waiting homes to achieve safe motherhood

OBJECTIVE

to examine the structural and sociocultural factors influencing maternity waiting home (MWH) use through the lens of women, families, and communities in one rural county in postconflict Liberia.

DESIGN

an exploratory, qualitative descriptive design using focus groups and in-depth, individual interviews was employed. Content analysis of data was performed using Penchansky and Thomas's (1981) five A's of access as a guiding framework.

SETTING

rural communities in north-central Liberia.

PARTICIPANTS

a convenience sampling was used to recruit participants. Eight focus groups were held with 75 participants from congruent groups of (1) MWH users, (2) MWH non-users, (3) family members of MWH users, and (4) family members of MWH non-users. Eleven individual interviews were conducted with clinic staff or community leaders.

FINDINGS

the availability of MWHs decreased the barrier of distance for women to access skilled care around the time of childbirth. Food insecurity while staying at a MWH was identified as a potential barrier by participants.

KEY CONCLUSIONS

examining access as a general concept within the specific dimensions of availability, accessibility, accommodation, affordability, and acceptability provides a way to describe the structural and sociocultural factors that influence access to a MWH and skilled attendance for birth.

IMPLICATIONS FOR PRACTICE

MWHs can address the barrier of distance in accessing skilled care for childbirth in a rural setting with long distances to a facility.

Barriers to the use of maternity waiting homes in indigenous regions of Guatemala: a study of users' and community members' perceptions

Maternal mortality among indigenous women in Guatemala is high. To reduce deaths during transport from far-away rural communities to the hospital, maternity waiting homes (MWH) were established near to hospitals where women with high-risk pregnancies await their delivery before being transferred for labour to the hospital. However, the homes are under-utilised. We conducted a qualitative study with 48 stakeholders (MWH users, family members, community leaders, MWH staff, Mayan midwives and health centre and hospital medical staff) in Huehuetenango and Cuilco to identify barriers before, during and after the women's stay in the homes. The women most in need - indigenous women from remote areas - seemed to have least access to the MWHs. Service users' lack of knowledge about the existence of the homes, limited provision of culturally appropriate care and a lack of sustainable funding were the most important problems identified. While the strategy of MWHs has the potential to contribute to the prevention of maternal (as well as newborn) deaths in rural Guatemala, they can only function effectively if they are planned and implemented with community involvement and support, through a participatory approach.

Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries

BACKGROUND

A maternity waiting home (MWH) is a facility within easy reach of a hospital or health centre which provides emergency obstetric care (EmOC). Women may stay in the MWH at the end of their pregnancy and await labour. Once labour starts, women move to the health facility so that labour and giving birth can be assisted by a skilled birth attendant. The aim of the MWH is to improve accessibility to skilled care and thus reduce morbidity and mortality for mother and neonate should complications arise. Some studies report a favourable effect on the outcomes for women and their newborns. Others show that utilisation is low and barriers exist. However, these data are limited in their reliability.

OBJECTIVES

To assess the effects of a maternity waiting facility on maternal and perinatal health.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 January 2012), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to January 2012), EMBASE (1980 to January 2012), CINAHL (1982 to January 2012), African Journals Online (AJOL) (January 2012), POPLINE (January 2012), Dissertation Abstracts (January 2012) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomised controlled trials including quasi-randomised and cluster-randomised trials that compared perinatal and maternal outcome in women using a MWH and women who did not.

DATA COLLECTION AND ANALYSIS

There were no randomised controlled trials or cluster-randomised trials identified from the search.

MAIN RESULTS

There were no randomised controlled trials or cluster-randomised trials identified from the search.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effectiveness of maternity waiting facilities for improving maternal and neonatal outcomes.