Maternity waiting homes as an intervention to increase facility delivery in rural Zambia

Effectiveness of couple-based health education on utilization of maternity waiting homes among pregnant women in rural Ethiopia: A study protocol for cluster-randomized trial

Background

Maternity waiting homes are used to enhance women's access to health facilities in low-resource settings; however, its use remains low in Ethiopia. It is important to investigate strategies that can enhance the usage of maternity waiting homes in Ethiopia.

Methods

The purpose of his study is to assess how well couple-focused health education works to increase maternal knowledge, attitudes, and use of maternity waiting homes in rural Ethiopia. A cluster-randomized trial with two parallel groups will be the study's design. Three hundred twenty samples will be drawn from 16 clusters (160 in each group). Clusters will be assigned to intervention or control groups using a restricted randomization with a 1:1 allocation ratio. Women who are in their 14-16 weeks of gestation, or in the early stages of their second trimester, along with their male partners, will participate in the study. Health education, home visits, and the distribution of leaflets will be the intervention packages.

Discussion

The trial results will provide conclusive evidence on whether couple-based health education can improve women's access to maternity waiting homes in rural Ethiopia.

Recommendations to improve maternal mortality among Rohingya women in Bangladeshi refugee camps

Despite current humanitarian efforts, The Rohingya in Bangladesh's refugee camps have among the highest maternal mortality worldwide. The authors review maternal mortality within Rohingya refugee populations in Bangladesh, citing the camp conditions and cultural norms that affect the Maternal Mortality Ratio (MMR). Next, the authors review current humanitarian efforts made by the UNFPA toward improving reproductive health. Finally, the authors recommend a three-pronged approach to reducing maternal mortality among the Rohingya in Bangladeshi refugee camps. We suggest using Maternity Waiting Homes, Mama Rickshaws, and Traditional Birth Attendants to improve maternal health. These solutions address the three-delays model and place ownership into the community. Ultimately, the authors address a much-needed gap in the literature addressing Rohingya maternal mortality.

Effect of couple-based health education on male-partners knowledge and attitude towards maternity waiting homes in rural Ethiopia: a cluster-randomized trial

This cluster-randomized controlled trial examined the effect of couple-based health education on male partners' knowledge and attitude towards maternity waiting homes (MWH) in rural Ethiopia. Sixteen clusters and 320 couples were randomly assigned to intervention group (receiving group health education, home visits and print health messages alongside usual care) or control group (receiving usual care). The Chi-square test was used to estimate statistical differences, and the difference-in-differences model was used to estimate the effect of the intervention. The generalized linear regression model was used to determine the odds of outcomes between the groups. Statistical significance was set at p < 0.05, with a 95% CI. There were no significant differences in baseline characteristics between the control and intervention groups. The net effect of the intervention on improving knowledge about MWHs, and attitude towards MWHs were 35.6% and 36.2%, respectively. The participants in the intervention group were 5.5 times more likely to have good knowledge about MWH (AOR 5.55, 95% CI 3.37-9.14) and 5.6 times more likely to have a favorable attitude towards MWH (AOR 5.61, 95% CI 3.45-9.10) compared to their counterparts. Health education provided to couples significantly improved male partners' knowledge and attitude towards MWHs in rural Ethiopia.Trial registration: ClinicalTrials.gov Identifier: NCT05015023.

Factors associated with knowledge and attitude towards maternity waiting homes among pregnant women: baseline results from a cluster-randomized trial in rural Ethiopia

Ethiopia has implemented maternity waiting homes over the last several decades; however, its utilization is low. This study aimed to assess the factors associated with knowledge of and attitude towards maternity waiting homes among pregnant women in rural Ethiopia. The baseline survey was conducted from September 15 to October 30, 2022, in rural Southern Ethiopia. Survey data were collected from 320 women in their second trimester of pregnancy. The data analysis was performed using SPSS version 25. The mean age of the participants was 27.79 (SD ± 6.242) years. Nearly two-thirds (57.5%) of the participants had no formal education and more than three-fourths (72.5%) were housewives. Only approximately one-fourth (23.75%) of the participants used maternity waiting homes. Furthermore, 33.75% had good knowledge, 28.75% had favorable attitudes, and around one-fourth (26.25%) had good male partner involvement. Age group 30 to 39 years (AOR 4.78, 95% CI 1.12-20.36), household income (AOR 6.41, 95% CI 2.78-14.81), having pregnancy intention (AOR 2.63, 95% CI 1.21-5.73), and history of obstetric complications (AOR 6.72, 95% CI 2.81-16.07) were significantly associated with good knowledge about maternity waiting homes. Similarly, age group 30 to 39 years (AOR 4.23, 95% CI 1.14-15.65), household income (AOR 7.12, 95% CI 3.26-15.55), having pregnancy intention (AOR 2.57, 95% CI 1.21-5.47), and history of obstetric complications (AOR 5.59, 95% CI 2.30-13.59) were significantly associated with favorable attitudes towards maternity waiting homes. Providing health education and promoting male partner participation through educating couples may improve women's access to maternity waiting homes.

Women's experiences of maternity waiting homes in sub-Saharan Africa: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to synthesize women's experiences related to the use of maternity waiting homes in sub-Saharan Africa.

INTRODUCTION

Most maternal deaths occur within resource-limited settings. Sub-Saharan Africa and Southern Asia account for around 86% of all maternal deaths worldwide, with sub-Saharan Africa alone contributing roughly two-thirds of all maternal deaths. The long distances that women must travel to reach health facilities has been highlighted as the main cause of maternal death. Maternity waiting homes have been recognized as a strategy to enhance maternal health outcomes by bringing women living in geographically isolated locations closer to health facilities. However, maternity waiting home utilization rates are low and vary across different settings.

INCLUSION CRITERIA

The study population will be women (15 to 49 years of age) living in sub-Saharan Africa who have experiences related to maternity waiting home use. This may include experiences with service provisions during the final weeks of pregnancy and 2 weeks after childbirth. Stays of at least 1 day will be considered for inclusion.

METHODS

Databases including MEDLINE, Web of Science, Scopus, and Hinari will be searched. Gray literature sources will include Google Scholar and MedNar. Studies published in English from January 2000 onward will be included. Two independent reviewers will screen the titles and abstracts, followed by an examination of full-text papers. Any disagreements will be handled through discussion or consultation with a third reviewer. Two reviewers will independently assess the methodological quality of included studies and extract the data. The articles will be meta-aggregated and presented in tabular or narrative format.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022306003.

Barriers and facilitators to facility-based delivery in rural Zambia: a qualitative study of women's perceptions after implementation of an improved maternity waiting homes intervention

OBJECTIVES

Women in sub-Saharan Africa face well-documented barriers to facility-based deliveries. An improved maternity waiting homes (MWH) model was implemented in rural Zambia to bring pregnant women closer to facilities for delivery. We qualitatively assessed whether MWHs changed perceived barriers to facility delivery among remote-living women.

DESIGN

We administered in-depth interviews (IDIs) to a randomly selected subsample of women in intervention (n=78) and control (n=80) groups who participated in the primary quasi-experimental evaluation of an improved MWH model. The IDIs explored perceptions and preferences of delivery location. We conducted content analysis to understand perceived barriers and facilitators to facility delivery.

SETTING AND PARTICIPANTS

Participants lived in villages 10+ km from the health facility and had delivered a baby in the previous 12 months.

INTERVENTION

The improved MWH model was implemented at 20 rural health facilities.

RESULTS

Over 96% of participants in the intervention arm and 90% in the control arm delivered their last baby at a health facility. Key barriers to facility delivery were distance and transportation, and costs associated with delivery. Facilitators included no user fees, penalties for home delivery, desire for safe delivery and availability of MWHs. Most themes were similar between study arms. Both discussed the role MWHs have in improving access to facility-based delivery. Intervention arm participants expressed that the improved MWH model encourages use and helps overcome the distance barrier. Control arm participants either expressed a desire for an improved MWH model or did not consider it in their decision making.

CONCLUSIONS

Even in areas with high facility-based delivery rates in rural Zambia, barriers to access persist. MWHs may be useful to address the distance challenge, but no single intervention is likely to address all barriers experienced by rural, low-resourced populations. MWHs should be considered in a broader systems approach to improving access in remote areas.

TRIAL REGISTRATION NUMBER

NCT02620436.

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.

Direct and opportunity costs related to utilizing maternity waiting homes in rural Zambia

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Lack of financial resources is a critical barrier to utilising Maternity Waiting Homes (MWHs) in low-income countries (LICs).

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Food and user fees are most frequent expenditures for women utilising MWHs in rural Zambia.

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Being away from various household chores, the loss of income generating activities (IGAs), may also be a financial constraint in utilising MWHs.

Aim

To assess the direct and opportunity costs involved in utilising maternity waiting homes.

Method

A cross-sectional admission survey administered to women who used ten maternity waiting homes across two rural districts in Zambia. A total of 3,796 women participated in the survey. Descriptive analysis was conducted on three domains of the data: demographic characteristics of women, direct costs, and opportunity costs.

Findings

Waiting to deliver (86.3%), safe birth (70.8%), and distance (56.0%) were the most frequent reasons women reported for using a maternity waiting home. In terms of direct costs, roughly 65% of the women brought seven days or fewer days' worth of food to the maternity waiting homes, with salt, mealie meals, and vegetables being the most frequently brought items. Only 5.8% of the women spent money on transport. More than half of the women reported paying user fees that ranged from 1 to 5 or more kwacha (US$0.10- 0.52). In terms of opportunity costs, 52% of the women participated in some form of income generating activities (IGAs) when at home. Approximately 35% of the women reported they lost earned income (1 to 50 or more kwacha) by staying at a maternity waiting home.

Conclusion

A large proportion of women paid for food and user fees to access a maternity waiting home, while a low number of women paid for transport. Even though it is difficult to assign monetary value to women's household chores, being away from these responsibilities and the potential loss of earned income appear to remain a cost to accessing maternity waiting homes. More research is needed to understand how to overcome these financial constraints and assist women in utilising a maternity waiting home.

A systematic review and meta-analysis of the effectiveness of maternity waiting homes in low- and middle-income countries

Maternity waiting homes (MWHs) in low- and middle-income countries (LMICs) provide women with accommodation close to a health facility to enable timely access to skilled care at birth. We examined whether MWH use and availability compared with non-use/unavailability were associated with facility birth, birth with a skilled health professional, attendance at postnatal visit(s) and/or improved maternal and newborn health, in LMICs. We included (non-)randomized controlled, interrupted time series, controlled before-after, cohort and case-control studies published since 1990. Thirteen databases were searched with no language restrictions. Included studies (1991-2020) were assessed as either moderate (n = 9) or weak (n = 10) on individual quality using the Effective Public Health Practice Project tool. Quality was most frequently compromised by selection bias, confounding and blinding. Only moderate quality studies were analyzed; no studies examining maternal morbidity/mortality met this criterion. MWH users had less relative risk (RR) of perinatal mortality [RR 0.65, 95% confidence intervals (CIs): 0.48, 0.87] (3 studies) and low birthweight (RR 0.34, 95% CI: 0.20, 0.59) (2 studies) compared with non-users. There were no significant differences between MWH use and non-use for stillbirth (RR 0.75, 95% CI: 0.47, 1.18) (3 studies) or neonatal mortality (RR 0.51, 95% CI: 0.25, 1.02) (2 studies). Single study results demonstrated higher adjusted odds ratios (aOR) for facility birth (aOR 5.8, 95% CI: 2.6, 13.0) and attendance at all recommended postnatal visits within 6 weeks of birth (aOR 1.99, 95% CI: 1.30, 3.07) for MWH users vs. non-users. The presence vs. absence of an MWH was associated with a 19% increase in facility birth (aOR 1.19, 95% CI: 1.10, 1.29). The presence vs. absence of a hospital-affiliated MWH predicted a 47% lower perinatal mortality rate (P  <  0.01), but at a healthcare centre-level a 13 higher perinatal mortality rate (P  <  0.01). Currently, there remains a lack of robust evidence supporting MWH effectiveness. We outline a six-point strategy for strengthening the evidence base.

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.

A qualitative exploration of barriers to health-facility-based delivery in Bomachoge-Borabu and Kaloleni, Kenya

OBJECTIVE

To explore barriers to utilization of health-facility-based delivery in Kenya, use of which is associated with reduced maternal mortality.

METHODS

In April 2017, a qualitative study utilizing key informant interviews (KIIs) and focus group discussions (FGDs) was carried out in Bomachoge-Borabu and Kaloleni, Kenya. Twenty-four KIIs were performed including health service providers, community health workers, religious leaders, local government representatives, Ministry of Health representatives, and representatives of women's organizations. Sixteen FGDs were held separately with adolescent females, adult females, adult males, and Community Health Committee members. Data were transcribed, coded, and categorized thematically to illustrate supply-side and demand-side barriers to use of health-facility-based delivery services.

RESULTS

Supply-side barriers included staff shortages, inadequate supplies and space, poor interpersonal relations, few trained staff, long distance to services, poor transport infrastructure, and limited service hours. Demand-side barriers included financial constraints, limited spousal support, observance of birthing traditions, limited knowledge on importance of health-facility-based delivery, and fear of health-facility procedures.

CONCLUSIONS

Diverse barriers continue to influence use of health-facility-based delivery services in Kenya. Practical, integrated interventions are urgently needed to reduce barriers noted, to further reduce the maternal mortality rate.