Reaching vulnerable women through maternity waiting homes in Malawi

Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data

INTRODUCTION

Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care-typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity.

METHODS

Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity≥5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators.

RESULTS

This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%-29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda.

DISCUSSION

Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.

Determinants of maternity waiting home utilization among women who gave birth in public health facilities in the Gedeo Zone, southern Ethiopia: an unmatched case-control study

Background

Maternal mortality remains unacceptably high in Ethiopia, although most of its causes are preventable. One way of tackling this problem is by establishing a maternal waiting home (MWH) close to a health facility. Although the benefits of an MWH have been well-documented, the determinants of its use have not been well-studied. This study aims to identify the determinants of utilization of an MWH among women who gave birth in public health facilities in the Gedeo Zone, southern Ethiopia.

Methods

A facility-based unmatched case-control study was conducted between January 2020 and February 2020) among 129 patients belonging to the case group and 257 belonging to the control group. The data were entered into the Epi-Data version 3.1 and exported to the SPSS version 20 statistical package for analysis. Descriptive statistics such as frequency, means, and standard deviations were computed. The association between variables was checked using logistic regression analysis, and odds ratios (ORs) with 95% confidence interval (CI) were used to determine the strength of this association. A p-value of < 0.05 was used as a cutoff point to measure statistical significance.

Result

A total of 378 respondents (126 cases and 252 controls) were included in the study, successfully achieving a response rate of 97.9%. The mean age of the participants was 27.4 (±5.6 SD) years, which was 28.4 (±5.5 SD) years for case group patients and 26.9 (±5.69 SD) years for control group patients. The educational status of women [adjusted odds ratio (AOR): 8.49, 95% CI: 2.91-24.7], travel time (AOR: 2.92, 95% CI:1.41-4.67), antenatal care visits (AOR: 3.54, 95% CI: 1.33-9.38), those having more than two children under the age of 5 years (AOR: 0.12, 95% CI: 0.06-0.26), those with a history of complications in previous childbirths (AOR: 4.52 95% CI: 2.41-8.47), previous place of delivery (AOR: 6.30, 95% CI: 2.71-14.78), and a lack of awareness (AOR: 5.8, 95% CI: 2.23-15.2) were all significantly associated with the utilization of an MWH.

Conclusion

Educational status, antenatal care follow-up, number of children under 5 years old in the household, previous place of delivery, lack of awareness regarding maternal waiting home service, and travel time were all determinants of MWH use. This implies that interventions focusing on promoting antenatal care visits, institutional delivery, and raising awareness of the benefits of MWHs are important for improving their rate of utilization.

Interventions, outcomes and outcome measurement instruments in stillbirth care research: A systematic review to inform the development of a core outcome set

BACKGROUND

A core outcome set could address inconsistent outcome reporting and improve evidence for stillbirth care research, which have been identified as an important research priority.

OBJECTIVES

To identify outcomes and outcome measurement instruments reported by studies evaluating interventions after the diagnosis of a stillbirth.

SEARCH STRATEGY

Amed, BNI, CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO, and WHO ICTRP from 1998 to August 2021.

SELECTION CRITERIA

Randomised and non-randomised comparative or non-comparative studies reporting a stillbirth care intervention.

DATA COLLECTION AND ANALYSIS

Interventions, outcomes reported, definitions and outcome measurement tools were extracted.

MAIN RESULTS

Forty randomised and 200 non-randomised studies were included. Fifty-eight different interventions were reported, labour and birth care (52 studies), hospital bereavement care (28 studies), clinical investigations (116 studies), care in a multiple pregnancy (2 studies), psychosocial support (28 studies) and care in a subsequent pregnancy (14 studies). A total of 391 unique outcomes were reported and organised into 14 outcome domains: labour and birth; postpartum; delivery of care; investigations; multiple pregnancy; mental health; emotional functioning; grief and bereavement; social functioning; relationship; whole person; subsequent pregnancy; subsequent children and siblings and economic. A total of 242 outcome measurement instruments were used, with 0-22 tools per outcome.

CONCLUSIONS

Heterogeneity in outcome reporting, outcome definition and measurement tools in care after stillbirth exists. Considerable research gaps on specific intervention types in stillbirth care were identified. A core outcome set is needed to standardise outcome collection and reporting for stillbirth care research.

Understanding maternity waiting home uptake and scale-up within low-income and middle-income countries: a programme theory from a realist review and synthesis

Introduction

Maternity waiting homes (MWHs) link pregnant women to skilled birth attendance at health facilities. Research suggests that some MWH-facility birth interventions are more success at meeting the needs and expectations of their intended users than others. We aimed to develop theory regarding what resources work to support uptake and scale-up of MHW-facility birth interventions, how, for whom, in what contexts and why.

Methods

A four-step realist review was conducted which included development of an initial programme theory; searches for evidence; selection, appraisal and extraction of data; and analysis and data synthesis.

Results

A programme theory was developed from 106 secondary sources and 12 primary interviews with MWH implementers. The theory demonstrated that uptake and scale-up of the MWH-facility birth intervention depends on complex interactions between three adopter groups: health system stakeholders, community gatekeepers and pregnant women and their families. It describes relationships between 19 contexts, 11 mechanisms and 31 outcomes accross nine context-mechanism-outcome configurations (CMOCs) which were grouped into 3 themes: (1) Engaging stakeholders to develop, integrate, and sustain MWH-facility birth interventions, (2) Promoting and enabling MWH-facility birth utilisation and (3) Creating positive and memorable MWH-facility birth user experiences. Belief, trust, empowerment, health literacy and perceptions of safety, comfort and dignity were mechanisms that supported diffusion and adoption of the intervention within communities and health systems. Examples of resources provided by implementers to trigger mechanisms associated with each CMOC were identified.

Conclusions

Implementers of MWHs cannot merely assume that communities will collectively value an MWH-facility birth experience over delivery at home. We posit that MWH-facility birth interventions become vulnerable to under-utilisation when implementers fail to: (1) remove barriers that hinder women’s access to MWH and (2) ensure that conditions and interactions experienced within the MWH and its affiliated health facility support women to feel treated with compassion, dignity and respect.

PROSPERO registration number

CRD42020173595.

Maternity Waiting Home Interventions as a Strategy for Improving Birth Outcomes: A Scoping Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

Over 300 000 women worldwide die due to pregnancy-related complications annually, with most occurring in developing countries where access to skilled obstetric care is limited. Maternity waiting homes (MWHs) are one intervention designed to increase access to skilled prenatal care in resource-limited settings. MWHs are defined as accommodations at or near a health facility where pregnant women can stay in the final weeks of their pregnancy so they can be easily transferred to the health facility to give birth. While MWHs have existed for decades, evidence regarding their effectiveness in reducing adverse birth outcomes has been mixed. The objective of this study is to comprehensively assess all available MWH research reporting quantitative maternal and childbirth data to determine whether MWHs are an effective maternal health strategy in resource-limited settings.

METHODOLOGY

We conducted a scoping review and meta-analysis of existing literature on MWHs according to PRISMA guidelines. Descriptive statistics and odds ratios were calculated for the following birth outcomes: maternal mortality, perinatal mortality, and caesarian section. Quantitative analysis was conducted in RStudio and Stata Version 16.

RESULTS

One hundred seventy-one records were retrieved from our initial database search, of which 66 were identified as relevant. Only 15 of these records reported quantitative data on the health outcomes of interest and therefore met inclusion criteria for our meta-analysis. All studies reporting maternal mortality demonstrated a protective effect of MWHs (aggregate OR: 0.19 [0.10, 0.40]), as did all studies reporting perinatal mortality (aggregate OR: 0.29 [0.16, 0.53]). Studies reporting caesarian section were more varied and indicated less of a protective effect (aggregate OR: 1.80 [1.18, 2.75]).

CONCLUSIONS

There is some indication that MWHs are an effective strategy for reducing maternal and perinatal mortality in resource-limited settings. However, our analysis was constrained by the observational design of most prior MWH studies. More rigorous MWH evaluations, ideally in the form of randomized-control trials, are needed to better determine MWH effectiveness.

Association between maternity waiting home stay and obstetric outcomes in Yetebon, Ethiopia: a mixed-methods observational cohort study

Background

A strategy for reducing adverse pregnancy outcomes is the expanded implementation of maternity waiting homes (MWHs). We assessed factors influencing MWH use, as well as the association between MWH stay and obstetric outcomes in a hospital in rural Ethiopia.

Methods

Data from medical records of the Glenn C. Olson Memorial Primary Hospital obstetric ward were cross matched with records from the affiliated MWH between 1 and 2011 to 31 March 2014. Poisson regression with robust variance was conducted to estimate the relative risk (RR) of childbirth complications associated with MWH use vs. non-use. Five key informant interviews of a convenience sample of three MWH staff and two users were conducted and a thematic analysis performed of social, cultural, and economic factors underlying MWH use.

Results

During the study period, 489 women gave birth at the hospital, 93 of whom were MWH users. Common reasons for using the MWH were post-term status, previous caesarean section/myomectomy, malposition/malpresentation, and low-lying placenta, placenta previa, or antepartum hemorrhage, and hypertension or preeclampsia. MWH users were more likely than non-users to have had a previous caesarean Sec. (15.1 % vs. 5.3 %, p < 0.001) and to be post-term (21.5 % vs. 3.8 %, p < 0.001). MWH users were also more likely to undergo a caesarean Sec. (51.0 % vs. 35.4 %, p < 0.05) and less likely (p < 0.05) to have a spontaneous vaginal delivery (49.0 % vs. 63.6 %), obstructed labor (6.5 % vs. 14.4 %) or stillbirth (1.1 % vs. 8.6 %). MWH use (N = 93) was associated with a 77 % (adjusted RR = 0.23, 95 % Confidence Interval (CI) 0.12–0.46, p < 0.001) lower risk of childbirth complications, a 94 % (adjusted RR = 0.06, 95 % CI 0.01–0.43, p = 0.005) lower risk of fetal and newborn complications, and a 73 % (adjusted RR = 0.27, 95 % CI 0.13–0.56, p < 0.001) lower risk of maternal complications compared to MWH non-users (N = 396). Birth weight [median 3.5 kg (interquartile range 3.0-3.8) vs. 3.2 kg (2.8–3.5), p < 0.001] and 5-min Apgar scores (adjusted difference = 0.25, 95 % CI 0.06–0.44, p < 0.001) were also higher in offspring of MWH users. Opportunity costs due to missed work and need to arrange for care of children at home, long travel times, and lack of entertainment were suggested as key barriers to MWH utilization.

Conclusions

This observational, non-randomized study suggests that MWH usage was associated with significantly improved childbirth outcomes. Increasing facility quality, expanding services, and providing educational opportunities should be considered to increase MWH use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03913-3.

The effectiveness of maternity waiting homes in reducing perinatal mortality: a case-control study in Ethiopia

Background

The 2030 Agenda for Sustainable Development aims to reduce neonatal mortality to at least 12 per 1000 live births. Most of the causes can be prevented or cured. Access to quality healthcare during pregnancy and labour is the key to reduce perinatal deaths, and maternity waiting homes (MWHs) may have an impact, especially for women who live far from the healthcare system. We conducted a case–control study to evaluate the effectiveness of MWH in reducing perinatal mortality in a secondary hospital in Ethiopia.

Methods

We did a nested case–control study from January 2014 through December 2017. The enrolled cases were mothers whose childbirth resulted in stillbirth or early neonatal death. The controls were mothers with an alive baby at 7 days or with an alive baby on discharge. We collected demographic, anamnestic, pregnancy-related and obstetric-related data. The effectiveness of the MWH on perinatal death was assessed by a logistic regression model, adjusted for all other variables investigated as potential confounders. We also did a sensitivity analysis to explore the role of twin pregnancies.

Results

We included 1175 cases and 2350 controls. The crude analysis showed a protective effect of the MWH towards perinatal mortality (OR=0.700; 95% CI: 0.505 to 0.972), even more protective after adjustment for confounders (adjusted OR (AOR)=0.452; 95% CI: 0.293 to 0.698). Sensitivity analyses showed a consistent result, even excluding twin pregnancies (AOR=0.550; 95% CI: 0.330 to 0.917).

Conclusion

MWHs appear to reduce perinatal mortality by 55%. Our findings support the decision to invest in MWH to support pregnant women with higher quality and more comprehensive healthcare strategy, including quality antenatal care in peripheral primary care clinics, where risk factors can be recognised and women can be addressed for admission to MWH.

Who are dying and why? A case series study of maternal deaths in Nepal

OBJECTIVES

To identify delays and associated factors for maternal deaths in Nepal.

DESIGN

A cross-sectional case series study of maternal deaths. An integrated verbal and social autopsy tool was used to collect quantitative and qualitative information regarding three delays. We recorded death accounts and conducted social autopsy by means of community Focus Group Discussions for each maternal death; and analysed data by framework analysis.

SETTING

Sixty-two maternal deaths in six districts in three provinces of Nepal.

RESULTS

Nearly half of the deceased women (45.2%) were primiparous and one-third had no formal education. About 40% were from Terai/Madhesi and 30.6% from lower caste. The most common place of death was private hospitals (41.9%), followed by public hospitals (29.1%). Nearly three-fourth cases were referred to higher health facilities and median time (IQR) of stay at the lower health facility was 120 (60-180) hours. Nearly half of deaths (43.5%) were attributable to more than one delay while first and third delay each contributed equally (25.8%). Lack of perceived need; perceived cost and low status; traditional beliefs and practices; physically inaccessible facilities and lack of service readiness and quality care were important factors in maternal deaths.

CONCLUSIONS

The first and third delays were the equal contributors of maternal deaths. Interventions related to birth preparedness, economic support and family planning need to be focused on poor and marginalised communities. Community management of quick transportation, early diagnosis of pregnancy risks, accommodation facilities near the referral hospitals and dedicated skilled manpower with adequate medicines, equipment and blood supplies in referral hospitals are needed for further reduction of maternal deaths in Nepal.

Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants

Nepal made impressive progress in reducing maternal mortality until 2015. Since then, progress has stagnated, coinciding with Nepal’s transition to a federation with significant devolution in health management. In this context, we conducted key informant interviews (KII) to solicit perspectives on policies responsible for the reduction in maternal mortality, reasons for the stagnation in maternal mortality, and interventions needed for a faster decline in maternal mortality. We conducted 36 KIIs and analysed transcripts using standard framework analysis methods. The key informants identified three policies as the most important for maternal mortality reduction in Nepal: the Safe Motherhood Policy, Skilled Birth Attendant Policy, and Safe Abortion Policy. They opined that policies were adequate, but implementation was weak and ineffective, and strategies needed to be tailored to the local context. A range of health system factors, including poor quality of care, were identified by key informants as underlying the stagnation in Nepal’s maternal mortality ratio, as well as a few demand-side aspects. According to key informants, to reduce maternal deaths further Nepal needs to ensure that the current family planning, birth preparedness, financial incentives, free delivery services, abortion care, and community post-partum care programmes reach marginalised and vulnerable communities. Facilities offering comprehensive emergency obstetric care need to be accessible, and in hill and mountain areas, access could be supported by establishing maternity waiting homes. Social accountability can be strengthened through social audits, role models, and empowerment of health and management committees.

The effect of maternity waiting homes on perinatal mortality is inconclusive: a critical appraisal of existing evidence from Sub-Saharan Africa

OBJECTIVES

To assess the appropriateness of the statistical methodology used in a recent meta-analysis investigating the effect of maternity waiting homes (MWHs) on perinatal mortality in Sub-Saharan Africa.

RESULTS

A recent meta-analysis published in BMC Research Notes used a fixed-effect model to generate an unadjusted summary estimate of the effectiveness of MWHs in reducing perinatal mortality in Africa using ten observational studies (pooled odds ratio 0.15, 95% confidence interval 0.14-0.17). The authors concluded that MWHs reduce perinatal mortality by over 80% and should be incorporated into routine maternal health care services. In the present article, we illustrate that due to the contextual and methodological heterogeneity present in existing studies, the authors' conclusions about the effectiveness of MWHs in reducing perinatal mortality were likely overstated. Additionally, we argue that because of the selection bias and confounding inherent in observational studies, unadjusted pooled estimates provide little causal evidence for effectiveness. Additional studies with robust designs are required before an appropriately designed meta-analysis can be conducted; until then, the ability to draw causal inferences regarding the effectiveness of MWHs in reducing perinatal mortality is limited.

Maternity waiting homes as component of birth preparedness and complication readiness for rural women in hard-to-reach areas in Ethiopia

Background

In rural areas of Ethiopia, 57% of births occur at home without the assistance of skilled birth attendants, geographical inaccessibility being one of the main factors that hinder skilled birth attendance. Establishment of maternity waiting homes (MWH) is part of a strategy to improve access to skilled care by bringing pregnant women physically close to health facilities. This study assessed barriers to MWHs in Arba Minch Zuria District, Southern Ethiopia.

Methods

A community-based cross-sectional study was undertaken from February 01 to 28, 2019. Study participants were selected by computer-generated random numbers from a list of women who gave birth from 2017 to 2018 in Arba Minch Health and Demographic Surveillance System site. Data were collected using a pre-tested and interviewer-administered questionnaire. Stata software version-15 was used for data management and analysis, and variables with p-values ≤ 0.2 in bivariate analysis were considered for multivariable logistic regression analysis. Level of statistical significance was declared at a p-value < 0.05. Qualitative data were analyzed manually based on thematic areas.

Results

MWH utilization was found to be 8.4%. Wealth index (lowest wealth quintile aOR 7.3; 95% CI 1.2, 42), decisions made jointly with male partners (husbands) for obstetric emergencies (aOR 3.6; 95% CI 1.0, 12), birth preparedness plan practice (aOR 6.5; 95% CI 2.3, 18.2), complications in previous childbirth (aOR 3; 95% 1.0, 9), history of previous institutional childbirth (aOR 12; 95% CI 3.8, 40), residence in areas within two hours walking distance to the nearest health facility (aOR 3.3; 95% CI: 1.4, 7.7), and ease of access to transport in obstetric emergencies (aOR 8.8; 95% CI: 3.9, 19) were factors that showed significant associations with MWH utilization.

Conclusions

A low proportion of women has ever used MWHs in the study area. To increase MWH utilization, promoting birth preparedness practices, incorporating MWH as part of a personalized birth plan, improving access to health institutions for women living far away and upgrading existing MWHs are highly recommended.

Association of maternity waiting home utilization with women's perceived geographic barriers and delivery complications in Ethiopia

OBJECTIVES

The aim of this study is to identify the influence of perceived geographic barriers to the utilization of maternity waiting homes (MWHs) and to explore factors associated with current delivery complications among MWH users and nonusers.

METHODS

An observational cross-sectional study was conducted between December 2017 and June 2018 in eight health facilities with MWH in the Gurage zone of Ethiopia. The associated factors were identified by using the combination of a directed acyclic graph (DAG) concept and multiple logistic regression for data analysis.

RESULTS

A total of 716 women were included in the study, of whom 358 were MWH users. MWH users had lower odds of having delivery complications. Lower odds of delivery complications were found among women who gave birth in non-cesarean section (CS) facilities. Women with pregnancy complications and did not used MWH were more likely to develop delivery complications. Women with delivery complications had higher odds of undergoing cesarean delivery and neonatal death.

CONCLUSIONS

Geographic barriers influenced the utilization of MWH. The women who used MWH had lower delivery complications. This study strengthens the evidence of MWH utilization as a useful strategy to overcome geographic barriers and lower delivery complications.

Factors associated with maternity waiting home use among women in Jimma Zone, Ethiopia: a multilevel cross-sectional analysis

OBJECTIVE

To identify individual-, household- and community-level factors associated with maternity waiting home (MWH) use in Ethiopia.

DESIGN

Cross-sectional analysis of baseline household survey data from an ongoing cluster-randomised controlled trial using multilevel analyses.

SETTING

Twenty-four rural primary care facility catchment areas in Jimma Zone, Ethiopia.

PARTICIPANTS

3784 women who had a pregnancy outcome (live birth, stillbirth, spontaneous/induced abortion) 12 months prior to September 2016.

OUTCOME MEASURE

The primary outcome was self-reported MWH use for any pregnancy; hypothesised factors associated with MWH use included woman's education, woman's occupation, household wealth, involvement in health-related decision-making, companion support, travel time to health facility and community-levels of institutional births.

RESULTS

Overall, 7% of women reported past MWH use. Housewives (OR: 1.74, 95% CI 1.20 to 2.52), women with companions for facility visits (OR: 2.15, 95% CI 1.44 to 3.23), wealthier households (fourth vs first quintile OR: 3.20, 95% CI 1.93 to 5.33) and those with no health facility nearby or living >30 min from a health facility (OR: 2.37, 95% CI 1.80 to 3.13) had significantly higher odds of MWH use. Education, decision-making autonomy and community-level institutional births were not significantly associated with MWH use.

CONCLUSIONS

Utilisation inequities exist; women with less wealth and companion support experienced more difficulties in accessing MWHs. Short duration of stay and failure to consider MWH as part of birth preparedness planning suggests local referral and promotion practices need investigation to ensure that women who would benefit the most are linked to MWH services.

The significant association between maternity waiting homes utilization and perinatal mortality in Africa: systematic review and meta-analysis

OBJECTIVE

A proper uptake of maternity waiting homes (MWHs) is important to improve maternal and child health (MCH). The aim of this review is to generate the best existing evidences concerning the MWHs utilization and its impact on perinatal mortality (PNM) among pregnant mothers in Africa. Both relevant quantitative and qualitative studies, investigated and reported from databases were explored. Meta-analysis of the studies was displayed by tables and forest plots. The Stata version 14 was used with the fixed effect model and 95% confidence interval.

RESULTS

In this review, a total of 68,805 births were recorded in this review. About 1.6% and 7.2% PNM occurred among non-exposed and exposed mothers respectively. Fifty percent of the studies showed there is a significant association between MWHs use and PNM. Meta-analysis revealed that utilizing MWHs have a significant effect in a reducing PNM by 82.5% (80.4%-84.5%), I2 = 96.5%. Therefore, use of MWHs has a potential to reduce PNM among pregnant mothers. The review revealed that MWHs relevance to achieving sustainable development goals (SDGs) concerning reducing newborn mortality. Therefore, the utilization rate of MWHs must be enhanced to achieve SDGs.

Evaluation of a maternity waiting home and community education program in two districts of Malawi

BACKGROUND

The implementation of Maternity Waiting Homes (MWHs) is a strategy to bring vulnerable women close to a health facility towards the end of their pregnancies. To date, while MWHs are a popular strategy, there is limited evidence on the role that MWHs play in reaching women most in need. This paper contributes to this topic by examining whether two program-supported MWHs in Malawi are reaching women in need and if there are changes in women reached over time.

METHODS

Two rounds of exit interviews (2015 and 2017) were conducted with women within 3 months of delivery and included both MWH users and non-MWH users. These exit interviews included questions on sociodemographic factors, obstetric risk factors and use of health services. Bivariate statistics were used to compare MWH users and non-MWH users at baseline and endline and over time. Multivariable logistic regression was used to determine what factors were associated with MWH use, and Poisson regression was used to study factors associated with HIV knowledge. Descriptive data from discharge surveys were used to examine satisfaction with the MWH structure and environment over time.

RESULTS

Primiparous women were more likely to use a MWH compared to women of parity 2 (p < 0.05). Women who were told they were at risk of a complication were more likely to use a MWH compared to those who were not told they were at risk (p < 0.05). There were also significant findings for wealth and time to a facility, with poorer women and those who lived further from a facility being more likely to use a MWH. Attendance at a community event was associated with greater knowledge of HIV (p < 0.05).

CONCLUSIONS

MWHs have a role to play in efforts to improve maternal health and reduce maternal mortality. Education provided within the MWHs and through community outreach can improve knowledge of important health topics. Malawi and other low and middle income countries must ensure that health facilities affiliated with the MWHs offer high quality services.

Role of maternity waiting homes in the reduction of maternal death and stillbirth in developing countries and its contribution for maternal death reduction in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Every family expect to have a healthy mother and new born baby after pregnancy. Especially for parents, pregnancy is a time of great anticipation. Access to maternal and child health care insures safer pregnancy and its outcome. MWHs is one the strategy. The objective was to synthesize the best available evidence on effectiveness of maternity waiting homes on the reduction of maternal mortality and stillbirth in developing countries.

METHODS

Before conducting this review non-occurrences of the same review is verified. To avoid introduction of bias because of errors, two independent reviewers appraised each article. Maternal death and stillbirth were the primary outcomes. Review Manager 5 were used to produce a random-effect meta-analysis. Grade Pro software were used to produce risk of bias summary and summary of findings.

RESULT

In developing countries, maternity waiting homes users were 80% less likely to die than non-users (OR = 0. 20, 95% CI [0.08, 0.49]) and there was 73% less occurrence of stillbirth among users (OR = 0.27, 95% CI [0.09, 0.82]). In Ethiopia, there was a 91% reduction of maternal death among maternity waiting homes users unlike non-users (OR = 0.09, 95% CI [0.04, 0.19]) and it contributes to the reduction of 83% stillbirth unlike non-users (OR = 0.17, 95% CI [0.05, 0.58]).

CONCLUSION

Maternity waiting home contributes more than 80% to the reduction of maternal death among users in developing countries and Ethiopia. Its contribution for reduction of stillbirth is good. More than 70% of stillbirth is reduced among the users of maternity waiting homes. In Ethiopia maternity waiting homes contributes to the reduction of more than two third of stillbirths.

Comparison of pregnancy outcomes between maternity waiting home users and non-users at hospitals with and without a maternity waiting home: retrospective cohort study

Objective

To examine the impact of a maternity waiting home (MWH) by comparing pregnancy outcomes between users and non-users at hospitals with and without an MWH.

Methods

We conducted a retrospective cohort study in Ethiopia comparing one hospital with an MWH (Attat) to a second hospital without one (Butajira). A structured questionnaire among sampled women in 2014 and hospital records from 2011 to 2014 were used to compare sociodemographic characteristics and pregnancy outcomes between Attat MWH users and non-MWH users, Attat MWH users and Butajira, and Attat non-MWH users and Butajira. χ2 or ORs with 95% CIs were calculated.

Results

Compared with Attat non-MWH users (n=306) and Butajira women (n=153), Attat MWH users (n=244) were more often multiparous (multipara vs primigravida: OR 4.43 [95% CI 2.94 to 6.68] and OR 3.58 [95% CI 2.24 to 5.73]), less educated (no schooling vs secondary school: OR 2.62 [95% CI 1.53 to 4.46] and OR 5.21 [95% CI 2.83 to 9.61], primary vs secondary school: OR 4.84 [95% CI 2.84 to 8.25] and OR 5.19 [95% CI 2.91 to 9.27]), poor (poor vs wealthy: OR 8.94 [95% CI 5.13 to 15.61] and OR 12.34 [95% CI 6.78 to 22.44] and further from the hospital (2 h 27 min vs 1 h 00 min and 1 h 12 min: OR 3.08 [95% CI 2.50 to 3.80] and OR 2.18 [95% CI 1.78 to 2.67]). Comparing hospital records of Attat MWH users (n=2784) with Attat non-users (n=5423) and Butajira women (n=9472), maternal deaths were 0 vs 20 (0.4%; p=0.001) and 31 (0.3%; p=0.003), stillbirths 38 (1.4%) vs 393 (7.2%) (OR 0.18 [95% CI 0.13 to 0.25]) and 717 (7.6%) (OR 0.17 [95% CI 0.12 to 0.24]) and uterine ruptures 2 (0.1%) vs 40 (1.1%) (OR 0.05 [95% CI 0.01 to 0.19]) and 122 (1.8%) (OR 0.04 (95% CI 0.01 to 0.16]). No significant differences were found regarding maternal deaths and stillbirths between Attat non-users and Butajira women.

Conclusions

Attat MWH users had less favourable sociodemographic characteristics but better birth outcomes than Attat non-users and Butajira women.

A new use for an old tool: maternity waiting homes to improve equity in rural childbirth care. Results from a cross-sectional hospital and community survey in Tanzania

Limited quality of childbirth care in sub-Saharan Africa primarily affects the poor. Greater quality is available in facilities providing advanced management of childbirth complications. We aimed to determine whether Maternity Waiting Homes (MWHs) may be a tool to improve access of lower socio-economic women to such facilities. Secondary analysis of a cross-sectional hospital survey from Iringa District, Tanzania was carried out. Women who delivered between October 2011 and May 2012 in the only District facility providing comprehensive Emergency Obstetric Care were interviewed. Their socio-economic profile was obtained by comparison with District representative data. Multivariable logistic regression was used to compare women who had stayed in the MWH before delivery with those who had accessed the hospital directly. Out of 1072 study participants, 31.3% had accessed the MWH. In multivariable analysis, age, education, marital status and obstetric factors were not significantly associated with MWH stay. Adjusted odds ratios for MWH stay increased progressively with distance from the hospital (women living 6-25 km, OR 4.38; 26-50 km, OR 4.90; >50 km, OR 5.12). In adjusted analysis, poorer women were more likely to access the MWH before hospital delivery compared with the wealthiest quintile (OR 1.38). Policy makers should consider MWH as a tool to mitigate inequity in rural childbirth care.