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van Braam EJ, McRae DN, Portela AG, Stekelenburg J, Penn-Kekana L. Stakeholders' perspectives on the acceptability and feasibility of maternity waiting homes: a qualitative synthesis. Reprod Health 2023; 20:101. [PMID: 37407983 PMCID: PMC10324180 DOI: 10.1186/s12978-023-01615-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/25/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Maternity waiting homes (MHWs) are recommended to help bridge the geographical gap to accessing maternity services. This study aimed to provide an analysis of stakeholders' perspectives (women, families, communities and health workers) on the acceptability and feasibility of MWHs. METHODS A qualitative evidence synthesis was conducted. Studies that were published between January 1990 and July 2020, containing qualitative data on the perspectives of the stakeholder groups were included. A combination of inductive and deductive coding and thematic synthesis was used to capture the main perspectives in a thematic framework. RESULTS Out of 4,532 papers that were found in the initial search, a total of 38 studies were included for the thematic analysis. Six themes emerged: (1) individual factors, such as perceived benefits, awareness and knowledge of the MWH; (2) interpersonal factors and domestic responsibilities, such as household and childcare responsibilities, decision-making processes and social support; (3) MWH characteristics, such as basic services and food provision, state of MWH infrastructure; (4) financial and geographical accessibility, such as transport availability, costs for MWH attendance and loss of income opportunity; (5) perceived quality of care in the MWH and the adjacent health facility, including regular check-ups by health workers and respectful care; and (6) Organization and advocacy, for example funding, community engagement, governmental involvement. The decision-making process of women and their families for using an MWH involves balancing out the gains and losses, associated with all six themes. CONCLUSION This systematic synthesis of qualitative literature provides in-depth insights of interrelating factors that influence acceptability and feasibility of MWHs according to different stakeholders. The findings highlight the potential of MWHs as important links in the maternal and neonatal health (MNH) care delivery system. The complexity and scope of these determinants of utilization underlines the need for MWH implementation strategy to be guided by context. Better documentation of MWH implementation, is needed to understand which type of MWH is most effective in which setting, and to ensure that those who most need the MWH will use it and receive quality services. These results can be of interest for stakeholders, implementers of health interventions, and governmental parties that are responsible for MNH policy development to implement acceptable and feasible MWHs that provide the greatest benefits for its users. Trial registration Systematic review registration number: PROSPERO 2020, CRD42020192219.
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Affiliation(s)
| | - Daphne N McRae
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Anayda G Portela
- Department of Maternal, Newborn, Child, and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health Unit, University Medical Centre Groningen/University of Groningen, Groningen, The Netherlands
- Department Obstetrics and Gynaecology, Leeuwarden Medical Centre, Leeuwarden, The Netherlands
| | - Loveday Penn-Kekana
- Department of Maternal Health and Health Systems, London School of Hygiene and Tropical Medicine, London, UK
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Gurara MK, Draulans V, Van Geertruyden JP, Jacquemyn Y. Determinants of maternal healthcare utilisation among pregnant women in Southern Ethiopia: a multi-level analysis. BMC Pregnancy Childbirth 2023; 23:96. [PMID: 36739369 PMCID: PMC9898958 DOI: 10.1186/s12884-023-05414-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/30/2023] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Despite efforts to make maternal health care services available in rural Ethiopia, utilisation status remains low. Therefore, this study aimed to assess maternal health care services' status and determinants in rural Ethiopia. METHODS The study used quasi-experimental pre- and post-comparison baseline data. A pretested, semi-structured, interviewer-administered questionnaire was used to collect data. A multilevel, mixed-effects logistic regression was used to identify individual and communal level factors associated with utilisation of antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC). The adjusted odds ratio (AOR) and corresponding 95% confidence intervals (CI) were estimated with a p-value of less than 0.05, indicating statistical significance. RESULTS Seven hundred and twenty-seven pregnant women participated, with a response rate of 99.3%. Four hundred and sixty-one (63.4%) of the women visited ANC services, while 46.5% (CI: 42-50%) of births were attended by SBA, and 33.4% (CI: 30-36%) had received PNC. Women who reported that their pregnancy was planned (aOR = 3.9; 95% CI: 1.8-8.3) and were aware of pregnancy danger signs (aOR = 6.8; 95% CI: 3.8-12) had a higher likelihood of attending ANC services. Among the cluster-level factors, women who lived in lowlands (aOR = 4.1; 95% CI: 1.1-14) and had easy access to transportation (aOR = 1.9; 95% CI: 1.1-3.7) had higher odds of visiting ANC services. Moreover, women who were employed (aOR = 3.1; 95% CI: 1.3-7.3) and attended ANC (aOR = 3.3; 95% CI: 1.8-5.9) were more likely to have SBA at delivery. The likelihood of being attended by SBA during delivery was positively correlated with shorter travel distances (aOR = 2.9; 95% CI: 1.4-5.8) and ease of access to transportation (aOR = 10; 95% CI: 3.6-29) to the closest healthcare facilities. Being a midland resident (aOR = 4.7; 95% CI: 1.7-13) and having SBA during delivery (aOR = 2.1; 95% CI: 1.2-3.50) increased the likelihood of attending PNC service. CONCLUSIONS Overall, maternal health service utilisation is low in the study area compared with the recommended standards. Women's educational status, awareness of danger signs, and pregnancy planning from individual-level factors and being a lowland resident, short travel distance to health facilities from the cluster-level factors play a crucial role in utilising maternal health care services. Working on women's empowerment, promotion of contraceptive methods to avoid unintended pregnancy, and improving access to health care services, particularly in highland areas, are recommended to improve maternal health service utilisation.
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Affiliation(s)
- Mekdes Kondale Gurara
- grid.442844.a0000 0000 9126 7261Department of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia ,grid.5284.b0000 0001 0790 3681Faculty of Medicine and Health Sciences, Global Health Institute, University of Antwerp, Wilrijk, Belgium ,grid.5596.f0000 0001 0668 7884Faculty of Social Sciences, Centre for Sociological Research, KU Leuven, Leuven, Belgium
| | - Veerle Draulans
- grid.5596.f0000 0001 0668 7884Faculty of Social Sciences, Centre for Sociological Research, KU Leuven, Leuven, Belgium
| | - Jean-Pierre Van Geertruyden
- grid.5284.b0000 0001 0790 3681Faculty of Medicine and Health Sciences, Global Health Institute, University of Antwerp, Wilrijk, Belgium
| | - Yves Jacquemyn
- grid.5284.b0000 0001 0790 3681Faculty of Medicine and Health Sciences, Global Health Institute, University of Antwerp, Wilrijk, Belgium ,grid.411414.50000 0004 0626 3418Department of Obstetrics and Gynaecology, Antwerp University Hospital, UZA, Antwerp, Belgium
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Uwamahoro NS, McRae D, Zibrowski E, Victor-Uadiale I, Gilmore B, Bergen N, Muhajarine N. Understanding maternity waiting home uptake and scale-up within low-income and middle-income countries: a programme theory from a realist review and synthesis. BMJ Glob Health 2022; 7:bmjgh-2022-009605. [PMID: 36180098 PMCID: PMC9528638 DOI: 10.1136/bmjgh-2022-009605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/01/2022] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Nadege Sandrine Uwamahoro
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Faculty of Medical Sciences, Newcastle University, Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Daphne McRae
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Chilliwack Division of Family Practice, Chilliwack General Hospital, Chiliwack, British Colombia, Canada
| | - Elaine Zibrowski
- Best Care COPD, Faculty of Health Sciences, Western University, London, Ontario, Canada
| | - Ify Victor-Uadiale
- Institute for Global Health and Development, Queen Margaret University, Musselburgh, UK
| | - Brynne Gilmore
- UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems, School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Ireland
| | - Nicole Bergen
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nazeem Muhajarine
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Population Health and Evaluation Research Unit, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Fontanet CP, Kaiser JL, Fong RM, Ngoma T, Lori JR, Biemba G, Munro-Kramer M, Sakala I, McGlasson KL, Vian T, Hamer DH, Rockers PC, Scott NA. Out-of-Pocket Expenditures for Delivery for Maternity Waiting Home Users and Non-users in Rural Zambia. Int J Health Policy Manag 2022; 11:1542-1549. [PMID: 34273929 PMCID: PMC9808339 DOI: 10.34172/ijhpm.2021.61] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 05/30/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Utilizing maternity waiting homes (MWHs) is a strategy to improve access to skilled obstetric care in rural Zambia. However, out-of-pocket (OOP) expenses remain a barrier for many women. We assessed delivery-related expenditure for women who used MWHs and those who did not who delivered at a rural health facility. METHODS During the endline of an impact evaluation for an MWH intervention, household surveys (n = 826) were conducted with women who delivered a baby in the previous 13 months at a rural health facility and lived >10 km from a health facility in seven districts of rural Zambia. We captured the amount women reported spending on delivery. We compared OOP spending between women who used MWHs and those who did not. Amounts were converted from Zambian kwacha (ZMW) to US dollar (USD). RESULTS After controlling for confounders, there was no significant difference in delivery-related expenditure between women who used MWHs (US$40.01) and those who did not (US$36.66) (P=.06). Both groups reported baby clothes as the largest expenditure. MWH users reported spending slightly more on accommodation compared to those did not use MWHs, but this difference represents only a fraction of total costs associated with delivery. CONCLUSION Findings suggest that for women coming from far away, utilizing MWHs while awaiting delivery is not costlier overall than for women who deliver at a health facility but do not utilize a MWH.
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Affiliation(s)
- Constance P. Fontanet
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Jeanette L. Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Rachel M. Fong
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Thandiwe Ngoma
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | - Jody R. Lori
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Godfrey Biemba
- National Health Research Authority, Pediatric Centre of Excellence, Lusaka, Zambia
| | - Michelle Munro-Kramer
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | | | - Kathleen Lucile McGlasson
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Taryn Vian
- Department of Global Health, School of Nursing and Health Professions, University of San Francisco, San Francisco, CA, USA
| | - Davidson H. Hamer
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA
| | - Peter C. Rockers
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Nancy A. Scott
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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Fong RM, Kaiser JL, Ngoma T, Vian T, Bwalya M, Sakanga VR, Lori JR, Kuhfeldt KJ, Musonda G, Munro-Kramer M, Rockers PC, Hamer DH, Ahmed Mdluli E, Biemba G, Scott NA. 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. BMJ Open 2022; 12:e058512. [PMID: 35879007 PMCID: PMC9328096 DOI: 10.1136/bmjopen-2021-058512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Rachel M Fong
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jeanette L Kaiser
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Taryn Vian
- University of San Francisco - School of Nursing and Health Professions, San Francisco, California, USA
| | | | | | - Jody R Lori
- Office for Global Affairs & PAHO/WHO Collaborating Center, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Kayla J Kuhfeldt
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Michelle Munro-Kramer
- Health Behavior & Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Peter C Rockers
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Davidson H Hamer
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Godfrey Biemba
- Pediatric Centre of Excellence, National Health Research Authority, Lusaka, Zambia
| | - Nancy A Scott
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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Buser JM, Bakari A, Moyer CA. Viability of an urban maternity waiting home in Kumasi, Ghana: a qualitative needs assessment. Midwifery 2022; 110:103349. [DOI: 10.1016/j.midw.2022.103349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/20/2020] [Accepted: 04/20/2022] [Indexed: 11/25/2022]
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Smith S, Henrikson H, Thapa R, Tamang S, Rajbhandari R. Maternity Waiting Home Interventions as a Strategy for Improving Birth Outcomes: A Scoping Review and Meta-Analysis. Ann Glob Health 2022; 88:8. [PMID: 35087708 PMCID: PMC8782095 DOI: 10.5334/aogh.3496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Samantha Smith
- Brigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, USA
| | - Hannah Henrikson
- Brigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, USA
| | - Rita Thapa
- Nick Simons Institute, Sanepa, Lalitpur, Nepal
| | | | - Ruma Rajbhandari
- Brigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Mount Auburn Hospital, Department of Medicine, Division of Gastroenterology, Cambridge, Massachusetts, USA
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Scott NA, Kaiser JL, Ngoma T, McGlasson KL, Henry EG, Munro-Kramer ML, Biemba G, Bwalya M, Sakanga VR, Musonda G, Hamer DH, Boyd CJ, Bonawitz R, Vian T, Kruk ME, Fong RM, Chastain PS, Mataka K, Ahmed Mdluli E, Veliz P, Lori JR, Rockers PC. If we build it, will they come? Results of a quasi-experimental study assessing the impact of maternity waiting homes on facility-based childbirth and maternity care in Zambia. BMJ Glob Health 2021; 6:e006385. [PMID: 34876457 PMCID: PMC8655557 DOI: 10.1136/bmjgh-2021-006385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 10/23/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Maternity waiting homes (MWHs) aim to increase access to maternity and emergency obstetric care by allowing women to stay near a health centre before delivery. An improved MWH model was developed with community input and included infrastructure, policies and linkages to health centres. We hypothesised this MWH model would increase health facility delivery among remote-living women in Zambia. METHODS We conducted a quasi-experimental study at 40 rural health centres (RHC) that offer basic emergency obstetric care and had no recent stockouts of oxytocin or magnesium sulfate, located within 2 hours of a referral hospital. Intervention clusters (n=20) received an improved MWH model. Control clusters (n=20) implemented standard of care. Clusters were assigned to study arm using a matched-pair randomisation procedure (n=20) or non-randomly with matching criteria (n=20). We interviewed repeated cross-sectional random samples of women in villages 10+ kilometres from their RHC. The primary outcome was facility delivery; secondary outcomes included postnatal care utilisation, counselling, services received and expenditures. Intention-to-treat analysis was conducted. Generalised estimating equations were used to estimate ORs. RESULTS We interviewed 2381 women at baseline (March 2016) and 2330 at endline (October 2018). The improved MWH model was associated with increased odds of facility delivery (OR 1.60 (95% CI: 1.13 to 2.27); p<0.001) and MWH utilisation (OR 2.44 (1.62 to 3.67); p<0.001). The intervention was also associated with increased odds of postnatal attendance (OR 1.55 (1.10 to 2.19); p<0.001); counselling for family planning (OR 1.48 (1.15 to 1.91); p=0.002), breast feeding (OR 1.51 (1.20 to 1.90); p<0.001), and kangaroo care (OR 1.44 (1.15, 1.79); p=0.001); and caesarean section (OR 1.71 (1.16 to 2.54); p=0.007). No differences were observed in household expenditures for delivery. CONCLUSION MWHs near well-equipped RHCs increased access to facility delivery, encouraged use of facilities with emergency care capacity, and improved exposure to counselling. MWHs can be useful in the effort to increase delivery at advanced facilities in areas where substantial numbers of women live remotely. TRIAL REGISTRATION NUMBER NCT02620436.
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Affiliation(s)
- Nancy A Scott
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Thandiwe Ngoma
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | - Kathleen L McGlasson
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Elizabeth G Henry
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Michelle L Munro-Kramer
- Department of Health Behavior & Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Godfrey Biemba
- National Health Research Authority Zambia, Lusaka, Zambia
| | - Misheck Bwalya
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | | | | | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Carol J Boyd
- Center for the Study of Drugs, Alcohol, Smoking and Health, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Rachael Bonawitz
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Taryn Vian
- University of San Francisco - School of Nursing and Health Professions, San Francisco, California, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rachel M Fong
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Parker S Chastain
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | | | - Philip Veliz
- Applied Biostatistics Laboratory, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Jody R Lori
- Center for Global Affairs & PAHO/WHO Collaborating Center, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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Lee H, Maffioli EM, Veliz PT, Sakala I, Chiboola NM, Lori JR. Direct and opportunity costs related to utilizing maternity waiting homes in rural Zambia. Midwifery 2021; 105:103211. [PMID: 34894428 PMCID: PMC8811481 DOI: 10.1016/j.midw.2021.103211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 11/13/2021] [Accepted: 11/24/2021] [Indexed: 11/18/2022]
Abstract
Lack of financial resources is a critical barrier to utilising Maternity Waiting Homes (MWHs) in low-income countries (LICs). Food and user fees are most frequent expenditures for women utilising MWHs in rural Zambia. 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.
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Affiliation(s)
- HaEun Lee
- School of Nursing, University of Michigan, 400 N Ingalls St. Ann Arbor, MI 48104, United States.
| | - Elisa M Maffioli
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, United States
| | - Philip T Veliz
- School of Nursing, University of Michigan, 400 N Ingalls St. Ann Arbor, MI 48104, United States
| | - Isaac Sakala
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road, Ibex Hill, Box 33921 Lusaka, Zambia
| | - Nchimunya M Chiboola
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road, Ibex Hill, Box 33921 Lusaka, Zambia
| | - Jody R Lori
- School of Nursing, University of Michigan, 400 N Ingalls St. Ann Arbor, MI 48104, United States
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Erickson AK, Abdalla S, Serenska A, Demeke B, Darmstadt GL. Association between maternity waiting home stay and obstetric outcomes in Yetebon, Ethiopia: a mixed-methods observational cohort study. BMC Pregnancy Childbirth 2021; 21:482. [PMID: 34217232 PMCID: PMC8254337 DOI: 10.1186/s12884-021-03913-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/24/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Anne K Erickson
- Stanford University School of Medicine, Stanford, CA, USA.,Present address: Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Safa Abdalla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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11
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Lori JR, Munro-Kramer ML, Liu H, McGlasson KL, Zhang X, Lee H, Ngoma T, Kaiser JL, Bwalya M, Musonda G, Sakala I, Perosky JE, Fong RM, Boyd CJ, Chastain P, Rockers PC, Hamer DH, Biemba G, Vian T, Bonawitz R, Lockhart N, Scott NA. Increasing facility delivery through maternity waiting homes for women living far from a health facility in rural Zambia: a quasi-experimental study. BJOG 2021; 128:1804-1812. [PMID: 33993600 PMCID: PMC8518771 DOI: 10.1111/1471-0528.16755] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report on the effectiveness of a standardised core Maternity Waiting Home (MWH) model to increase facility deliveries among women living >10 km from a health facility. DESIGN Quasi-experimental design with partial randomisation at the cluster level. SETTING Seven rural districts in Zambia. POPULATION Women delivering at 40 health facilities between June 2016 and August 2018. METHODS Twenty intervention and 20 comparison sites were used to test whether MWHs increased facility delivery for women living in rural Zambia. Difference-in-differences (DID) methodology was used to examine the effectiveness of the core MWH model on our identified outcomes. MAIN OUTCOME MEASURES Differences in the change from baseline to study period in the percentage of women living >10 km from a health facility who: (1) delivered at the health facility, (2) attended a postnatal care (PNC) visit and (3) were referred to a higher-level health facility between intervention and comparison group. RESULTS We detected a significant difference in the percentage of deliveries at intervention facilities with the core MWH model for all women living >10 km away (DID 4.2%, 95% CI 0.6-7.6, P = 0.03), adolescent women (<18 years) living >10 km away (DID 18.1%, 95% CI 6.3-29.8, P = 0.002) and primigravida women living >10 km away (DID 9.3%, 95% CI 2.4-16.4, P = 0.01) and for women attending the first PNC visit (DID 17.8%, 95% CI 7.7-28, P < 0.001). CONCLUSION The core MWH model was successful in increasing rates of facility delivery for women living >10 km from a healthcare facility, including adolescent women and primigravidas and attendance at the first PNC visit. TWEETABLE ABSTRACT A core MWH model increased facility delivery for women living >10 km from a health facility including adolescents and primigravidas in Zambia.
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Affiliation(s)
- J R Lori
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | | | - H Liu
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - K L McGlasson
- Boston University School of Public Health, Boston, MA, USA
| | - X Zhang
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - H Lee
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - T Ngoma
- Zambia Centre for Applied Health Research and Development, Lusaka, Zambia
| | - J L Kaiser
- Boston University School of Public Health, Boston, MA, USA
| | - M Bwalya
- Zambia Centre for Applied Health Research and Development, Lusaka, Zambia
| | | | | | - J E Perosky
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - R M Fong
- Boston University School of Public Health, Boston, MA, USA
| | - C J Boyd
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - P Chastain
- Boston University School of Public Health, Boston, MA, USA
| | - P C Rockers
- Boston University School of Public Health, Boston, MA, USA
| | - D H Hamer
- Boston University School of Public Health, Boston, MA, USA
| | - G Biemba
- Paediatric Centre of Excellence, National Health Research Authority, Lusaka, Zambia
| | - T Vian
- Boston University School of Public Health, Boston, MA, USA
| | - R Bonawitz
- Boston University School of Public Health, Boston, MA, USA
| | - N Lockhart
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - N A Scott
- Boston University School of Public Health, Boston, MA, USA
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12
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Owen MD, Cassidy AL, Weeks AD. Why are women still dying from obstetric hemorrhage? A narrative review of perspectives from high and low resource settings. Int J Obstet Anesth 2021; 46:102982. [PMID: 33903002 DOI: 10.1016/j.ijoa.2021.102982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 03/02/2021] [Accepted: 03/14/2021] [Indexed: 11/30/2022]
Abstract
The possibility of hemorrhage will always co-exist with pregnancy, whether anticipated or not. It remains the unwelcome guest in the corner of every delivery room, stealing the lives of young women every day across the globe. In 2014, the World Health Organization reported that hemorrhage was the leading contributor to maternal mortality worldwide, with nearly 75% of maternal deaths due to postpartum hemorrhage. In low resource settings, while maternal mortality is decreasing, hemorrhage remains the single most important contributor to maternal death. Hospital-based deliveries with skilled birth attendants have been encouraged to improve outcomes and, as a result, hospital births have dramatically increased. However, access to higher levels of emergency obstetric care as well as blood products and therapeutic resources remain limiting factors. Meanwhile, in high resource settings, maternal mortality from hemorrhage is increasing, particularly among women of color. While very rare, mortality from hemorrhage generally follows medical interventions such as surgical management of placenta accreta or emergency cesarean section. Primary prevention therefore requires careful selection and conduct of medical interventions, as well as the provision of high quality, supportive, and safe maternity care. It is clear that there is not one single solution in preventing obstetric hemorrhage on a global scale. The international community must employ creative solutions to reduce this ever-present problem.
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Affiliation(s)
- M D Owen
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - A L Cassidy
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - A D Weeks
- Department of Women's and Children's Health, University of Liverpool (for Liverpool Health Partners), Liverpool, UK
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13
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How maternity waiting home use influences attendance of antenatal and postnatal care. PLoS One 2021; 16:e0245893. [PMID: 33481942 PMCID: PMC7822518 DOI: 10.1371/journal.pone.0245893] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/08/2021] [Indexed: 11/19/2022] Open
Abstract
As highlighted in the International Year of the Nurse and the Midwife, access to quality nursing and midwifery care is essential to promote maternal-newborn health and improve survival. One intervention aimed at improving maternal-newborn health and reducing underutilization of pregnancy services is the construction of maternity waiting homes (MWHs). The purpose of this study was to assess whether there was a significant change in antenatal care (ANC) and postnatal care (PNC) attendance, family planning use, and vaccination rates before and after implementation of the Core MWH Model in rural Zambia. A quasi-experimental controlled before-and-after design was used to evaluate the impact of the Core MWH Model by assessing associations between ANC and PNC attendance, family planning use, and vaccination rates for mothers who gave birth to a child in the past 13 months. Twenty health care facilities received the Core MWH Model and 20 were identified as comparison facilities. Before-and-after community surveys were carried out. Multivariable logistic regression were used to assess the association between Core MWH Model use and ANC and PNC attendance. The total sample includes 4711 mothers. Mothers who used the Core MWH Model had better ANC and PNC attendance, family planning use, and vaccination rates than mothers who did not use a MWH. All mothers appeared to fare better across these outcomes at endline. We found an association between Core MWH Model use and better ANC and PNC attendance, family planning use, and newborn vaccination outcomes. Maternity waiting homes may serve as a catalyst to improve use of facility services for vulnerable mothers.
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14
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Fontanet CP, Fong RM, Kaiser JL, Bwalya M, Ngoma T, Vian T, Biemba G, Scott NA. A Qualitative Exploration of Community Ownership of a Maternity Waiting Home Model in Rural Zambia. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:344-357. [PMID: 33008852 PMCID: PMC7541113 DOI: 10.9745/ghsp-d-20-00136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 07/07/2020] [Indexed: 11/17/2022]
Abstract
Community-based maternal child health programs should foster a sense of community ownership to promote sustainability. In rural Zambia, health interventions should be accessible to target communities and clear roles should be established among stakeholders for effective governance. Context: Ownership is an important construct of sustainability for community-based health programming, though it is often not clearly defined or measured. We implemented and evaluated a community-driven maternity waiting home (MWH) model in rural Zambia. We engaged stakeholders at all levels and provided intensive mentorship to an MWH governance committee comprised of community-selected members. We then examined how different stakeholders perceive community ownership of the MWH. Methods: We conducted 42 focus group discussions with community stakeholders (pregnant women, fathers, elders, and community health volunteers) and 161 in-depth interviews with MWH stakeholders (health facility staff, district health officials, and MWH governance committee and management unit members) at multiple time-points over 24 months. We conducted a content analysis and triangulated findings to understand community ownership of the MWH and observe changes in perceptions of ownership over time. Results: Community members’ perceptions of ownership were related to their ability to use the MWH and a responsibility toward its success. Community and MWH stakeholders described increasingly more specific responsibilities over time. Governance committee and management unit members perceived their ability to represent the community as a crucial component of their role. Multiple respondent types saw collaboration between the governance committee and the health facility staff as key to allowing the MWH to meet its goal of serving the community. Conclusion: The perceptions of community ownership evolved as the intervention became more established. Use of the MWH, and clear understanding of roles and responsibilities in management of the MWH, seemed to foster feelings of community ownership. To improve the sustainability of community-based maternal and child health programs, interventions should be accessible to target communities and clear roles should be established among stakeholders.
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Affiliation(s)
- Constance P Fontanet
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
| | - Rachel M Fong
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Misheck Bwalya
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Thandiwe Ngoma
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | - Taryn Vian
- School of Nursing and Health Professions, University of San Francisco, San Francisco, CA, USA
| | - Godfrey Biemba
- National Health Research Authority, Pediatric Centre of Excellence, Lusaka, Zambia
| | - Nancy A Scott
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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15
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Buser JM, Moyer CA, Boyd CJ, Zulu D, Ngoma-Hazemba A, Mtenje JT, Jones AD, Lori JR. Cultural beliefs and health-seeking practices: Rural Zambians' views on maternal-newborn care. Midwifery 2020; 85:102686. [PMID: 32172077 PMCID: PMC7249502 DOI: 10.1016/j.midw.2020.102686] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 02/22/2020] [Accepted: 02/28/2020] [Indexed: 01/27/2023]
Abstract
Mothers caring for newborns have a maternal dualism between cultural and health system obligations. Traditional newborn protective rituals were identified to help nurses provide health education. Family and community expressed a strong need to protect the newborn using traditional belief systems.
Background - Far too many newborns die or face serious morbidity in Zambia, as in many other sub-Saharan African countries. New knowledge is needed to enhance our understanding of newborn care and the cultural factors influencing the ways mothers seek newborn care. This study adds to the literature about rural Zambians’ cultural beliefs and practices related to newborn care and health-seeking practices that influence maternal-newborn health. Objective - The goal of this study was to describe the factors associated with newborn care in rural Zambia. Design - Sixty focus groups were conducted. Each group contained a minimum of 8 and maximum of 12 participants. Recruitment was conducted orally by word of mouth through the nurse in charge at the health facilities and village chiefs. Setting – Data were collected between June and August 2016 in 20 communities located in Zambia's rural Lundazi (Eastern province), Mansa, and Chembe (Luapula province) Districts. Participants - The study included community members (n = 208), health workers (n = 225), and mothers with infants younger than 1-year-old (n = 213). Findings - The following themes emerged. From mothers with infants, the dominant theme concerned traditional and protective newborn rituals. From community members, the dominant theme was a strong sense of family and community to protect the newborn, and from health workers, the major theme was an avoidance of shame. A fourth theme, essential newborn care, was common among all groups. Key conclusions – Together the themes pointed toward a maternal dualism for mothers in rural Zambia. Mothers with infants in rural Zambia likely experience a dualistic sense of responsibility to satisfy both cultural and health system expectations when caring for their newborns. Mothers are pulled to engage in traditional protective newborn care rituals while at the same time being pushed to attend ANC and deliver at the health facility. These findings can be used to understand how mothers care for their newborns to develop interventions aimed at improving maternal-child health outcomes. Implications for practice - There were findings about the culture-specific prevention of cough, care of the umbilical cord, and early introduction of traditional porridge that carry implications for nursing practice. There is an obvious need to reinforce the importance of partner testing for STIs during routine ANC even though there is a desire to preserve dignity.
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Affiliation(s)
- Julie M Buser
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, 400 N. Ingalls, Ann Arbor, MI, 48109, United States.
| | - Cheryl A Moyer
- Global REACH, University of Michigan Medical School, United States; Departments of Learning Health Sciences and, Obstetrics & Gynecology, University of Michigan Medical School, United States
| | - Carol J Boyd
- Center for the Study of Drugs, Alcohol, Smoking & Health (DASH Center), University of Michigan, United States; Women's Studies, LS&A, University of Michigan; Institute for Research on Mothers & Gender, University of Michigan, United States
| | - Davy Zulu
- Republic of Zambia Ministry of Health, Lundazi, Zambia
| | - Alice Ngoma-Hazemba
- School of Public Health, Department of Community and Family Medicine, University of Zambia, Lusaka, Zambia
| | | | - Andrew D Jones
- Nutritional Sciences, Center for Human Growth and Development, School of Public Health, United States
| | - Jody R Lori
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, United States
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16
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Kaiser JL, Fong RM, Ngoma T, McGlasson KL, Biemba G, Hamer DH, Bwalya M, Chasaya M, Scott NA. The effects of maternity waiting homes on the health workforce and maternal health service delivery in rural Zambia: a qualitative analysis. HUMAN RESOURCES FOR HEALTH 2019; 17:93. [PMID: 31801578 PMCID: PMC6894259 DOI: 10.1186/s12960-019-0436-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 11/04/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Maternity waiting homes (MWHs) are a potential strategy to address low facility delivery rates resulting from access-associated barriers in resource-limited settings. Within a cluster-randomized controlled trial testing a community-generated MWH model in rural Zambia, we qualitatively assessed how MWHs affect the health workforce and maternal health service delivery at their associated rural health centers. METHODS Four rounds of in-depth interviews with district health staff (n = 21) and health center staff (n = 73) were conducted at intervention and control sites over 24 months. We conducted a content analysis using a mixed inductive-deductive approach. Data were interpreted through the lens of the World Health Organzation Health Systems Framework. RESULTS Nearly all respondents expressed challenges with understaffing and overwork and reported that increasing numbers of facility-based deliveries driven by MWHs contributed substantively to their workload. Women waiting at MWHs allow staff to monitor a woman's final stage of pregnancy and labor onset, detect complications earlier, and either more confidently manage those complications at the health center or refer to higher level care. District, intervention, and control site respondents passionately discussed this benefit over all time points, describing it as outweighing challenges of additional work associated with MWHs. Intervention site staff repeatedly discussed the benefit of MWHs in providing a space for postpartum women to wait after the first few hours of clinical observation through the first 48 h after delivery. Additionally, intervention site staff perceived the ability to observe women for longer before and after delivery allowed them to better anticipate and plan their own work, adjust their workloads and mindset accordingly, and provide better and more timely care. When understaffing and overwork were frequently discussed, this satisfaction in providing better care was a meaningful departure. CONCLUSIONS MWHs may benefit staff at rural health centers and the health system more broadly, allowing for the provision of more timely and comprehensive obstetric care. We recommend future studies consider how MWHs impact the workforce, operations, and service delivery at their associated health facilities. Considering the limited numbers of skilled birth attendants available in rural Zambia, it is important to strategically select locations for new MWHs. TRIAL REGISTRATION Clinicaltrials.gov, NCT02620436. Registered December 3, 2015, https://clinicaltrials.gov/ct2/show/NCT02620436.
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Affiliation(s)
- Jeanette L. Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
| | - Rachel M. Fong
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
| | - Thandiwe Ngoma
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | | | - Godfrey Biemba
- National Health Research Authority, Pediatric Centre of Excellence, Lusaka, Zambia
| | - Davidson H. Hamer
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA USA
| | - Misheck Bwalya
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | | | - Nancy A. Scott
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
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17
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Bonawitz R, McGlasson KL, Kaiser JL, Ngoma T, Fong RM, Biemba G, Bwalya M, Hamer DH, Scott NA. Quality and utilization patterns of maternity waiting homes at referral facilities in rural Zambia: A mixed-methods multiple case analysis of intervention and standard of care sites. PLoS One 2019; 14:e0225523. [PMID: 31774838 PMCID: PMC6881034 DOI: 10.1371/journal.pone.0225523] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 11/06/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Maternity waiting homes, defined as residential lodging near a health facility, are recommended by the WHO. An improved MWH model, responsive to community standards for functionality and comfort, was implemented at two purposively selected health facilities in rural Zambia providing comprehensive emergency obstetric and neonatal care (CEmONC) services (intervention MWHs), and compared to three existing standard-of-care MWHs (comparison MWHs) at other CEmONC sites in the same districts. METHODS We used a mixed-methods time-series design for this analysis. Quantitative data including MWH quality, MWH utilization, and demographics of women utilizing MWHs were collected from September 2016 through May 2018 to capture pre-post intervention trends. Qualitative data were obtained from two focus group discussions conducted with pregnant women at intervention MWHs in August 2017 and May 2018. The primary outcomes were quality scoring of the MWHs and maternal utilization of the MWHs. RESULTS MWH quality was similar at all sites during the pre-intervention time period, with a significant change in overall quality scores between intervention (mean score 83.8, SD 12) and comparison (mean score 43.1, SD 10.2) sites after the intervention (p <0.0001). Women utilizing intervention and comparison MWHs at all time points had very similar demographics. After implementation of the intervention, there were marked increases in MWH utilization at both intervention and comparison sites, with a greater percentage increase at one of two intervention sites. CONCLUSIONS An improved MWH model can result in measurably improved quality scores for MWHs, and can result in increased utilization of MWHs at rural CEmONC facilities. MWHs are part of the infrastructure that might be needed for health systems to provide high quality "right place" maternal care in rural settings.
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Affiliation(s)
- Rachael Bonawitz
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Division of Hospital Medicine, Saint Christopher’s Hospital for Children, Philadelphia PA, United States of America
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, PA, United States of America
- * E-mail: , ,
| | - Kathleen L. McGlasson
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
| | - Jeanette L. Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
| | - Thandiwe Ngoma
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | - Rachel M. Fong
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
| | - Godfrey Biemba
- National Health Research Authority, Pediatric Centre of Excellence, Lusaka, Zambia
| | - Misheck Bwalya
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | - Davidson H. Hamer
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, United States of America
| | - Nancy A. Scott
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
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Chiu C, Scott NA, Kaiser JL, Ngoma T, Lori JR, Boyd CJ, Rockers PC. Household saving during pregnancy and facility delivery in Zambia: a cross-sectional study. Health Policy Plan 2019; 34:102-109. [PMID: 30768183 PMCID: PMC6481286 DOI: 10.1093/heapol/czz005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2019] [Indexed: 11/25/2022] Open
Abstract
Financial barriers cause many women in low- and middle-income countries to deliver outside of a health facility, contributing to maternal and neonatal mortality. Savings accrued during pregnancy can increase access to safe delivery services. We investigated the relationship between household saving during pregnancy and facility delivery. A cross-section of 2381 women who delivered a child in the previous 12 months was sampled from 40 health facility catchment areas across eight districts in three provinces in Zambia in April and May of 2016. During a household survey, women reported on their perceptions of the adequacy of their household savings during their recent pregnancy. Households were categorized based on women’s responses as: did not save; saved but not enough; and saved enough. We estimated crude and adjusted associations between perceived adequacy of savings and facility delivery. We also explored associations between savings and expenditures on delivery. Overall, 51% of women surveyed reported that their household saved enough for delivery; 32% reported saving but not enough; and 17% did not save. Household wealth was positively associated with both categories of saving, while earlier attendance at antenatal care was positively associated with saving enough. Compared with women in households that did not save, those in households that saved but not enough (aOR 1.63; 95% CI: 1.17, 2.25) and saved enough (aOR 2.86; 95% CI: 2.05, 3.99) had significantly higher odds of facility delivery. Both categories of saving were significantly associated with higher overall expenditure on delivery, driven in large part by higher expenditures on baby clothes and transportation. Our findings suggest that interventions that encourage saving early in pregnancy may improve access to facility delivery services.
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Affiliation(s)
- Calvin Chiu
- Innovations for Poverty Action Zambia, Plot 26, Mwambula Street, Jesmondine, Lusaka, Zambia.,School of Public Health, University of California, 2121 Berkeley Way, Berkeley, CA, USA
| | - Nancy A Scott
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, USA
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, USA
| | - Thandiwe Ngoma
- Right to Care - Zambia, 11059 Off Brentwood Road, Longacres, Lusaka, Zambia
| | - Jody R Lori
- University of Michigan School of Nursing, Center for Global Affairs & PAHO/WHO Collaborating Center, 426 N Ingalls St, Ann Arbor, MI, USA
| | - Carol J Boyd
- Alcohol, Smoking and Health, University of Michigan School of Nursing, Center for the Study of Drugs, 426 N Ingalls St, Ann Arbor, MI, USA
| | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, USA
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Getachew B, Liabsuetrakul T, Gebrehiwot Y. Association of maternity waiting home utilization with women's perceived geographic barriers and delivery complications in Ethiopia. Int J Health Plann Manage 2019; 35:e96-e107. [PMID: 31691379 DOI: 10.1002/hpm.2940] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/10/2019] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Biniam Getachew
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | | | - Yirgu Gebrehiwot
- Obstetrics and Gynecology Department, Addis Ababa University, Addis Ababa, Ethiopia
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20
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Kaiser JL, McGlasson KL, Rockers PC, Fong RM, Ngoma T, Hamer DH, Vian T, Biemba G, Lori JR, Scott NA. Out-of-pocket expenditure for home and facility-based delivery among rural women in Zambia: a mixed-methods, cross-sectional study. Int J Womens Health 2019; 11:411-430. [PMID: 31447591 PMCID: PMC6682766 DOI: 10.2147/ijwh.s214081] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 06/19/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose Out-of-pocket expenses associated with facility-based deliveries are a well-known barrier to health care access. However, there is extremely limited contemporary information on delivery-related household out-of-pocket expenditure in sub-Saharan Africa. We assess the financial burden of delivery for the most remote Zambian women and compare differences between delivery locations (primary health center, hospital, or home). Methods We conducted household surveys and in-depth interviews among randomly selected remote Zambian women who delivered a baby within the last 13 months. Women reported expenditures for their most-recent delivery for delivery supplies, transportation, and baby clothes, among others. Expenditures were converted to US dollars for analysis. Results Of 2280 women sampled, 2223 (97.5%) reported spending money on their delivery. Nearly all respondents in the sample (95.9%) spent money on baby clothes/blanket, while over 80% purchased delivery supplies such as disinfectant or cord clamps, and a third spent on transportation. Women reported spending a mean of USD28.76 on their delivery, with baby clothes/blanket (USD21.46) being the main expenditure and delivery supplies (USD3.81) making up much of the remainder. Compared to women who delivered at home, women who delivered at a primary health center spent nearly USD4 (p<0.001) more for their delivery, while women who delivered at a level 1 or level 2 hospital spent over USD7.50 (p<0.001) more for delivery. Conclusion These expenses account for approximately one third of the monthly household income of the poorest Zambian households. While the abolition of user fees has reduced the direct costs of delivering at a health facility for the poorest members of society, remote Zambian women still face high out-of-pocket expenses in the form of delivery supplies that facilities should provide as well as unofficial policies/norms requiring women to bring new baby clothes/blanket to a facility-based delivery. Future programs that target these expenses may increase access to facility-based delivery.
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Affiliation(s)
- Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Kathleen L McGlasson
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Rachel M Fong
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Thandiwe Ngoma
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Taryn Vian
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,School of Nursing and Health Professions, University of San Francisco, San Francisco, CA, USA
| | - Godfrey Biemba
- National Health Research Authority, Pediatric Centre of Excellence, Lusaka, Zambia
| | - Jody R Lori
- Department of Research, Office of Global Affairs and Pan American Health Organization/ World Health Organization Collaborating Center, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Nancy A Scott
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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21
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Lori JR, Perosky J, Munro-Kramer ML, Veliz P, Musonda G, Kaunda J, Boyd CJ, Bonawitz R, Biemba G, Ngoma T, Scott N. Maternity waiting homes as part of a comprehensive approach to maternal and newborn care: a cross-sectional survey. BMC Pregnancy Childbirth 2019; 19:228. [PMID: 31272402 PMCID: PMC6610940 DOI: 10.1186/s12884-019-2384-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 06/27/2019] [Indexed: 11/10/2022] Open
Abstract
Background Increased encounters with the healthcare system at multiple levels have the potential to improve maternal and newborn outcomes. The literature is replete with evidence on the impact of antenatal care and postnatal care to improve outcomes. Additionally, maternity waiting homes (MWHs) have been identified as a critical link in the continuum of care for maternal and newborn health yet there is scant data on the associations among MWH use and antenatal/postnatal attendance, family planning and immunization rates of newborns. Methods A cross-sectional household survey was conducted to collect data from women who delivered a child in the past 13 months from catchment areas associated with 40 healthcare facilities in seven rural Saving Mothers Giving Life districts in Zambia. Multi-stage random sampling procedures were employed with a final sample of n = 2381. Logistic regression models with adjusted odds ratios and 95% confidence intervals were used to analyze the data. Results The use of a MWH was associated with increased odds of attending four or more antenatal care visits (OR = 1.45, 95% CI = 1.26, 1.68), attending all postnatal care check-ups (OR = 2.00, 95% CI = 1.29, 3.12) and taking measures to avoid pregnancy (OR = 1.31, 95% CI = 1.10, 1.55) when compared to participants who did not use a MWH. Conclusions This is the first study to quantitatively examine the relationship between the use of MWHs and antenatal and postnatal uptake. Developing a comprehensive package of services for maternal and newborn care has the potential to improve acceptability, accessibility, and availability of healthcare services for maternal and newborn health. Maternity waiting homes have the potential to be used as part of a multi-pronged approach to improve maternal and newborn outcomes. Trial registration National Institutes of Health Trial Registration NCT02620436, Impact Evaluation of Maternity Homes Access in Zambia, Date of Registration - December 3, 2015.
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Affiliation(s)
- Jody R Lori
- Office of Global Affairs, PAHO/WHO Collaborating Center, School of Nursing, 400 N. Ingalls, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Joseph Perosky
- School of Nursing, University of Michigan, 400 N. Ingalls, Ann Arbor, MI, 48109, USA
| | | | - Phil Veliz
- School of Nursing, University of Michigan, 400 N. Ingalls, Ann Arbor, MI, 48109, USA
| | - Gertrude Musonda
- Africare-Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road, Ibex Hill, Box, 33921, Lusaka, Zambia
| | - Jameson Kaunda
- Africare-Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road, Ibex Hill, Box, 33921, Lusaka, Zambia
| | - Carol J Boyd
- Center for the Study of Drugs, Alcohol, Smoking and Health, School of Nursing, University of Michigan, Ann Arbor, MI, 48109, USA.,Institute for Research on Women and Gender, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Rachael Bonawitz
- School of Public Health, Boston University, Boston, MA, 02118, USA
| | - Godfrey Biemba
- Boston University, School of Public Health, Director/CEO, National Health Research Authority (NHRA), Lusaka, Zambia
| | | | - Nancy Scott
- School of Public Health, Boston University, Boston, MA, 02118, USA
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Perosky JE, Munro-Kramer ML, Lockhart N, Musonda GK, Naggayi A, Lori JR. Maternity waiting homes as an intervention to increase facility delivery in rural Zambia. Int J Gynaecol Obstet 2019; 146:266-267. [PMID: 31099092 DOI: 10.1002/ijgo.12864] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/01/2019] [Accepted: 05/15/2019] [Indexed: 11/09/2022]
Abstract
This study indicates a higher rate of facility delivery at clinics with a maternity waiting home in rural Zambia.
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Affiliation(s)
- Joseph E Perosky
- School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Nancy Lockhart
- School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | - Jody R Lori
- School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
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23
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Sakanga VIR, Chastain PS, McGlasson KL, Kaiser JL, Bwalya M, Mwansa M, Mataka K, Kalaba D, Scott NA, Vian T. Building financial management capacity for community ownership of development initiatives in rural Zambia. Int J Health Plann Manage 2019; 35:36-51. [PMID: 31120153 PMCID: PMC7043374 DOI: 10.1002/hpm.2810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Building financial management capacity is increasingly important in low- and middle-income countries to help communities take ownership of development activities. Yet, many community members lack financial knowledge and skills. METHODS We designed and conducted financial management trainings for 83 members from 10 community groups in rural Zambia. We conducted pre-training and post-training tests and elicited participant feedback. We conducted 28 in-depth interviews over 18 months and reviewed financial records to assess practical application of skills. RESULTS The training significantly improved knowledge of financial concepts, especially among participants with secondary education. Participants appreciated exercises to contextualize financial concepts within daily life and liked opportunities to learn from peers in small groups. Language barriers were a particular challenge. After trainings, sites successfully adhered to the principles of financial management, discussing the benefits they experienced from practicing accountability, transparency, and accurate recordkeeping. CONCLUSION Financial management trainings need to be tailored to the background and education level of participants. Trainings should relate financial concepts to more tangible applications and provide time for active learning. On-site mentorship should be considered for a considerable time. This training approach could be used in similar settings to improve community oversight of resources intended to strengthen developmental initiatives.
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Affiliation(s)
| | | | - Kathleen L McGlasson
- Biostatistics and Epidemiology Data Coordinating Center, Boston University School of Public Health, Boston, MA, USA
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Misheck Bwalya
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | - Melvin Mwansa
- Department of Research, Monitoring and Evaluation, Society for Family Health, Lusaka, Zambia
| | - Kaluba Mataka
- Department of Production, Akros, Inc., Lusaka, Zambia
| | - David Kalaba
- Department of Finance and Administration, Eastern and Southern African Management Institute, Arusha, Tanzania
| | - Nancy A Scott
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Taryn Vian
- School of Nursing and Health Professions, University of San Francisco, San Francisco, CA, USA
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Getachew B, Liabsuetrakul T. Health care expenditure for delivery care between maternity waiting home users and nonusers in Ethiopia. Int J Health Plann Manage 2019; 34:e1334-e1345. [PMID: 30924204 DOI: 10.1002/hpm.2782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/01/2019] [Accepted: 03/04/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To compare the health care expenditures between maternity waiting home (MWH) users and nonusers in Ethiopia. METHODS A cross-sectional study was done in Ethiopia between December 2017 and June 2018. The study setting included eight health facilities in the Gurage zone of Ethiopia. Health expenditure for delivery care was the outcome variable that was then classified into out-of-pocket (OOP) payments, women's costs, total costs, and overall costs. Those health expenditures were then compared among MWH users and nonusers. OOP payments were further analyzed using quantile regression to explore associated factors. RESULTS A total of 812 postpartum women were included in this study of whom half were MWH users. Significantly higher OOP payment, women's costs, total costs, and overall cost were found among MWH users compared with nonusers regardless of duration of MWH stay. The MWH users were more likely to have higher OOP payment compared with MWH nonusers in linear and quantile regressions for both unadjusted and adjusted analyses. Higher OOP payments were observed for longer distance traveled and cesarean section (CS) delivery women at the 75th and 90th quantiles of expenditure. Using public transportation was significantly associated with higher OOP payment in all quantile levels. CONCLUSION Utilization of MWH incurred higher OOP payments, total costs, women's costs, and overall costs compared with MWH nonusers. Higher OOP payments for delivery care among MWH users were observed in all quantiles of expenditure.
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Affiliation(s)
- Biniam Getachew
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Tippawan Liabsuetrakul
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Ngoma T, Asiimwe AR, Mukasa J, Binzen S, Serbanescu F, Henry EG, Hamer DH, Lori JR, Schmitz MM, Marum L, Picho B, Naggayi A, Musonda G, Conlon CM, Komakech P, Kamara V, Scott NA. Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S68-S84. [PMID: 30867210 PMCID: PMC6519669 DOI: 10.9745/ghsp-d-18-00367] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 11/13/2018] [Indexed: 12/22/2022]
Abstract
The Saving Mothers, Giving Life initiative employed 2 key strategies to improve the ability of pregnant women to reach maternal care: (1) increase the number of emergency obstetric and newborn care facilities, including upgrading existing health facilities, and (2) improve accessibility to such facilities by renovating and constructing maternity waiting homes, improving communication and transportation systems, and supporting community-based savings groups. These interventions can be adapted in low-resource settings to improve access to maternity care services. Background: Between June 2011 and December 2016, the Saving Mothers, Giving Life (SMGL) initiative in Uganda and Zambia implemented a comprehensive approach targeting the persistent barriers that impact a woman's decision to seek care (first delay), ability to reach care (second delay), and ability to receive adequate care (third delay). This article addresses how SMGL partners implemented strategies specifically targeting the second delay, including decreasing the distance to facilities capable of managing emergency obstetric and newborn complications, ensuring sufficient numbers of skilled birth attendants, and addressing transportation challenges. Methods: Both quantitative and qualitative data collected by SMGL implementing partners for the purpose of monitoring and evaluation were used to document the intervention strategies and to describe the change in outputs and outcomes related to the second delay. Quantitative data sources included pregnancy outcome monitoring data in facilities, health facility assessments, and population-based surveys. Qualitative data were derived from population-level verbal autopsy narratives, programmatic reports and SMGL-related publications, and partner-specific evaluations that include focus group discussions and in-depth interviews. Results: The proportion of deliveries in any health facility or hospital increased from 46% to 67% in Uganda and from 63% to 90% in Zambia between baseline and endline. Distance to health facilities was reduced by increasing the number of health facilities capable of providing basic emergency obstetric and newborn care services in both Uganda and Zambia—a 200% and 167% increase, respectively. Access to facilities improved through integrated transportation and communication services efforts. In Uganda there was a 6% increase in the number of health facilities with communication equipment and a 258% increase in facility deliveries supported by transportation vouchers. In Zambia, there was a 31% increase in health facilities with available transportation, and the renovation and construction of maternity waiting homes resulted in a 69% increase in the number of health facilities with associated maternity waiting homes. Conclusion: The collective SMGL strategies addressing the second delay resulted in increased access to delivery services as seen by the increase in the proportion of facility deliveries in SMGL districts, improved communication and transportation services, and an increase in the number of facilities with associated maternity waiting homes. Sustaining and improving on these efforts will need to be ongoing to continue to address the second delay in Uganda and Zambia.
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Affiliation(s)
| | - Alice R Asiimwe
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Joseph Mukasa
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Susanna Binzen
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, and Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jody R Lori
- School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Michelle M Schmitz
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lawrence Marum
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia. Now retired
| | - Brenda Picho
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | | | - Patrick Komakech
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Vincent Kamara
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Nancy A Scott
- Department of Global Health, Boston University School of Public Health, and Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
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26
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Bonawitz R, McGlasson KL, Kaiser JL, Ngoma T, Lori J, Boyd C, Biemba G, Hamer DH, Scott NA. Maternity Waiting Home Use by HIV-positive Pregnant Women in Zambia: Opportunity for Improved Prevention of Maternal to Child Transmission of HIV. Int J MCH AIDS 2019; 8:1-10. [PMID: 30899603 PMCID: PMC6423550 DOI: 10.21106/ijma.267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Maternity waiting homes (MWHs), defined as residential lodging near health facilities, are an intervention to improve access to maternal care recommended by the World Health Organization. Little is known about utilization of MWHs by HIV-positive women. This paper describes: 1) maternal awareness and utilization of MWHs in rural Zambia among HIV-positive women, and 2) health outcomes for HIV-positive women and their infants with regards to utilization of MWHs. METHODS Data were collected from recently delivered women (delivered after 35 weeks in the previous 12 months) living >9.5 km from 40 health facilities in rural Zambia. For our analysis, primary outcomes were compared between self-identified HIV-positive and HIV-negative women in the sample. Primary outcomes include: 1) awareness of MWHs and 2) utilization of MWHs. We summarized simple descriptive statistics, stratified by maternal self-reported HIV status. We conducted bivariate analyses using chi-square tests, t-tests and Wilcoxon rank sum test. RESULTS Among 2,381 women, 50 (2.4%) self-identified as HIV-positive. HIV-positive women were older and had more pregnancies and children than HIV-negative women (p<0.001). There was no difference in awareness of MWHs, but HIV-positive women were more likely to use a MWH than HIV-negative women. There was no difference in receipt of infant antiretroviral prophylaxis between women who did or did not stay at a MWH. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS Though HIV prevalence in this sample was lower than expected, MWHs may represent a useful strategy to improve prevention of mother to child transmission of HIV in high prevalence, low-resource settings.
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Affiliation(s)
- Rachael Bonawitz
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3 Floor, Boston, MA, USA.,Department of Pediatrics, Drexel University College of Medicine, 160 East Erie Avenue, Philadelphia, PA, USA
| | - Kathleen Lucy McGlasson
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3 Floor, Boston, MA, USA
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3 Floor, Boston, MA, USA
| | - Thandiwe Ngoma
- Right to Care, 11059, Off Brentwood Road Mikwala House, Longacres, Lusaka, ZAMBIA
| | - Jody Lori
- Center for Global Affairs & PAHO/WHO Collaborating Center, University of Michigan School of Nursing, 426 N Ingalls St, Ann Arbor, MI, USA
| | - Carol Boyd
- Center for the Study of Drugs, Alcohol, Smoking and Health, University of Michigan School of Nursing, 426 N Ingalls St, Ann Arbor, MI, USA
| | - Godfrey Biemba
- National Health Research Authority, University Teaching Hospital Pediatric Centre of Excellence, P.O. Box 30075, Lusaka, ZAMBIA
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3 Floor, Boston, MA, USA.,Section of Infectious Diseases, Department of Medicine, 1 Boston Medical Center Place, Boston, MA, USA
| | - Nancy A Scott
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center 3 Floor, Boston, MA, USA
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27
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Lori JR, Boyd CJ, Munro-Kramer ML, Veliz PT, Henry EG, Kaiser J, Munsonda G, Scott N. Characteristics of maternity waiting homes and the women who use them: Findings from a baseline cross-sectional household survey among SMGL-supported districts in Zambia. PLoS One 2018; 13:e0209815. [PMID: 30596725 PMCID: PMC6312364 DOI: 10.1371/journal.pone.0209815] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/12/2018] [Indexed: 11/19/2022] Open
Abstract
Objective Maternity waiting homes (MWHs) have been identified as one solution to decrease maternal morbidity and mortality by bringing women living in hard-to-reach areas closer to a hospital or health center that provides emergency obstetric care. The objective of this study was to obtain data on current MWH characteristics and the women who use them as well as women’s perceptions and experiences with MWHs among seven Saving Mothers Giving Life (SMGL) supported districts in Zambia. Methods A cross-sectional household survey design was used to collect data from 2381 mothers who delivered a child in the past 13 months from catchment areas associated with 40 health care facilities in seven districts. Multi-stage random sampling procedures were employed with probability proportionate to population size randomly selected. Logistic regression models, Chi-square, and independent t-tests were used to analyze the data. Results Women who lived 15–24 km from a health care facility were more likely to use a MWH when compared to women who lived 9.5–9.9 km from the nearest facility (AOR: 1.722, 95% CI: 1.450, 2.045) as were women who lived 25 km or more (AOR: 2.098, 95% CI: 1.176, 3.722.881). Women who were not married had lower odds of utilizing a MWH when compared to married women (AOR: 0.590, 95% CI: 0.369, 0.941). Over half of mothers using a MWH prior to delivery reported problems at the MWH related to boredom (42.4%), management oversight (33.3%), safety (33.4%), and quality (43.7%). While the study employs a robust design, it is limited by its focus in Saving Mothers Giving Life districts. Conclusion MWHs, which currently take many forms in Zambia, are being used by over a third of women delivering at a health facility in our study. Although over half of women using the existing MWHs noted crowdedness and nearly a third reported problems with the physical quality of the building as well as with their interaction with staff, these MWHs appear to be bridging the distance barrier for women who live greater than 9.5 km from a health care facility.
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Affiliation(s)
- Jody R. Lori
- School of Nursing, University of Michigan, Ann Arbor, MI, United States of America
- * E-mail:
| | - Carol J. Boyd
- School of Nursing, University of Michigan, Ann Arbor, MI, United States of America
| | | | - Philip T. Veliz
- School of Nursing, University of Michigan, Ann Arbor, MI, United States of America
| | - Elizabeth G. Henry
- School of Public Health, Boston University, Boston, MA, United States of America
| | - Jeanette Kaiser
- School of Public Health, Boston University, Boston, MA, United States of America
| | | | - Nancy Scott
- School of Public Health, Boston University, Boston, MA, United States of America
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28
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Singh K, Speizer IS, Kim ET, Lemani C, Tang JH, Phoya A. Evaluation of a maternity waiting home and community education program in two districts of Malawi. BMC Pregnancy Childbirth 2018; 18:457. [PMID: 30470256 PMCID: PMC6251123 DOI: 10.1186/s12884-018-2084-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 11/07/2018] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Kavita Singh
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Ilene S. Speizer
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Eunsoo Timothy Kim
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Clara Lemani
- UNC Project-Malawi, c/o Kamuzu Central Hospital, 100 Mzimba Road, Private Bag, A-104 Lilongwe, Malawi
| | - Jennifer H. Tang
- UNC Project-Malawi, c/o Kamuzu Central Hospital, 100 Mzimba Road, Private Bag, A-104 Lilongwe, Malawi
- Department of Obstetrics & Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Ann Phoya
- UNC Project-Malawi, c/o Kamuzu Central Hospital, 100 Mzimba Road, Private Bag, A-104 Lilongwe, Malawi
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Scott NA, Henry EG, Kaiser JL, Mataka K, Rockers PC, Fong RM, Ngoma T, Hamer DH, Munro-Kramer ML, Lori JR. Factors affecting home delivery among women living in remote areas of rural Zambia: a cross-sectional, mixed-methods analysis. Int J Womens Health 2018; 10:589-601. [PMID: 30349403 PMCID: PMC6181475 DOI: 10.2147/ijwh.s169067] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Access to skilled care and facilities with capacity to provide emergency obstetric and newborn care is critical to reducing maternal mortality. In rural areas of Zambia, 42% of women deliver at home, suggesting persistent challenges for women in seeking, reaching, and receiving quality maternity care. This study assessed the determinants of home delivery among remote women in rural Zambia. METHODS A household survey was administered to a random selection of recently delivered women living 10 km or more from their catchment area health facility in 40 sites. A subset of respondents completed an in-depth interview. Multiple regression and content analysis were used to analyze the data. RESULTS The final sample included 2,381 women, of which 240 also completed an interview. Households were a median of 12.8 km (interquartile range 10.9, 16.2) from their catchment area health facility. Although 1% of respondents intended to deliver at home, 15.3% of respondents actually delivered at home and 3.2% delivered en route to a facility. Respondents cited shorter than expected labor, limited availability and high costs of transport, distance, and costs of required supplies as reasons for not delivering at a health facility. After adjusting for confounders, women with a first pregnancy (adjusted OR [aOR]: 0.1, 95% CI: 0.1, 0.2) and who stayed at a maternity waiting home (MWH) while awaiting delivery were associated with reduced odds of home delivery (aOR 0.1, 95% CI: 0.1, 0.2). Being over 35 (aOR 1.3, 95% CI: 0.9, 1.9), never married (aOR 2.1, 95% CI: 1.2, 3.7), not completing the recommended four or more antenatal visits (aOR 2.0, 95% CI: 1.5, 2.5), and not living in districts exposed to a large-scale maternal health program (aOR 3.2, 95% CI: 2.3, 4.5) were significant predictors of home delivery. After adjusting for confounders, living nearer to the facility (9.5-10 km) was not associated with reduced odds of home delivery, though the CIs suggest a trend toward significance (aOR 0.7, 95% CI: 0.4, 1.1). CONCLUSION Findings highlight persistent challenges facing women living in remote areas when it comes to realizing their intentions regarding delivery location. Interventions to reduce home deliveries should potentially target not only those residing farthest away, but multigravida women, those who attend fewer antenatal visits, and those who do not utilize MWHs.
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Affiliation(s)
- Nancy A Scott
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | - Elizabeth G Henry
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | | | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | - Rachel M Fong
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
| | | | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA,
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Michelle L Munro-Kramer
- Department of Health Behavior & Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Jody R Lori
- Department of Health Behavior & Biological Sciences, University of Michigan, School of Nursing, Ann Arbor, MI USA
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Munro-Kramer ML, Scott N, Boyd CJ, Veliz PT, Murray SM, Musonda G, Lori JR. Postpartum physical intimate partner violence among women in rural Zambia. Int J Gynaecol Obstet 2018; 143:199-204. [PMID: 30125966 PMCID: PMC6221031 DOI: 10.1002/ijgo.12654] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/25/2018] [Accepted: 08/17/2018] [Indexed: 11/15/2022]
Abstract
Objective To examine the demographic characteristics and mental health of women in rural Zambia who experienced physical intimate partner violence (IPV) postpartum. Methods The present secondary analysis was conducted using baseline data from an impact evaluation of a maternity waiting home intervention in rural Zambia. A quantitative household survey was conducted over 6 weeks, from mid‐April to late May, 2016, at 40 rural health facility catchment areas among 2381 postpartum women (13 months after delivery; age ≥15 years). Results A total of 192 (8.1%) women reported experiencing any type of physical IPV in the preceding 2 weeks; 126 had experienced severe physical IPV (had been kicked, dragged, beat, and/or choked by a husband or partner). High levels of depression were recorded for 174 (7.3%) women in the preceding 2 weeks. Being a female head of household was associated with an increased likelihood of experiencing severe physical IPV (aOR 2.64, 95% CI 1.70–4.10). Women with high depression scores were also at an increased risk of experiencing any physical IPV (aOR 17.1, 95% CI 8.44–34.9) and severe physical IPV (aOR 15.4, 95% CI 5.17–45.9). Conclusion Future work should consider the implications of government and educational policies that could impact the screening and treatment of pregnant women affected by all forms of physical IPV and depression in rural Zambia. Postpartum physical intimate partner violence among women in rural Zambia was associated with being a female head of household and high levels of depression.
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Affiliation(s)
- Michelle L Munro-Kramer
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Nancy Scott
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Carol J Boyd
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Philip T Veliz
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI, USA.,Applied Biostatistics Laboratory, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Sarah M Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Jody R Lori
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI, USA
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Scott NA, Kaiser JL, Vian T, Bonawitz R, Fong RM, Ngoma T, Biemba G, Boyd CJ, Lori JR, Hamer DH, Rockers PC. Impact of maternity waiting homes on facility delivery among remote households in Zambia: protocol for a quasiexperimental, mixed-methods study. BMJ Open 2018; 8:e022224. [PMID: 30099401 PMCID: PMC6089313 DOI: 10.1136/bmjopen-2018-022224] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Maternity waiting homes (MWHs) aim to improve access to facility delivery in rural areas. However, there is limited rigorous evidence of their effectiveness. Using formative research, we developed an MWH intervention model with three components: infrastructure, management and linkage to services. This protocol describes a study to measure the impact of the MWH model on facility delivery among women living farthest (≥10 km) from their designated health facility in rural Zambia. This study will generate key new evidence to inform decision-making for MWH policy in Zambia and globally. METHODS AND ANALYSIS We are conducting a mixed-methods quasiexperimental impact evaluation of the MWH model using a controlled before-and-after design in 40 health facility clusters. Clusters were assigned to the intervention or control group using two methods: 20 clusters were randomly assigned using a matched-pair design; the other 20 were assigned without randomisation due to local political constraints. Overall, 20 study clusters receive the MWH model intervention while 20 control clusters continue to implement the 'standard of care' for waiting mothers. We recruit a repeated cross section of 2400 randomly sampled recently delivered women at baseline (2016) and endline (2018); all participants are administered a household survey and a 10% subsample also participates in an in-depth interview. We will calculate descriptive statistics and adjusted ORs; qualitative data will be analysed using content analysis. The primary outcome is the probability of delivery at a health facility; secondary outcomes include utilisation of MWHs and maternal and neonatal health outcomes. ETHICS AND DISSEMINATION Ethical approvals were obtained from the Boston University Institutional Review Board (IRB), University of Michigan IRB (deidentified data only) and the ERES Converge IRB in Zambia. Written informed consent is obtained prior to data collection. Results will be disseminated to key stakeholders in Zambia, then through open-access journals, websites and international conferences. TRIAL REGISTRATION NUMBER NCT02620436; Pre-results.
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Affiliation(s)
- Nancy A Scott
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Taryn Vian
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Rachael Bonawitz
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Rachel M Fong
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Godfrey Biemba
- National Health Research Authority, Pediatric Centre of Excellence, Lusaka, Zambia
| | - Carol J Boyd
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Jody R Lori
- Center for Global Affairs and PAHO/WHO Collaborating Center, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Davidson H Hamer
- Section of Infectious Diseases, Department of Medicine, Boston University, Boston, Massachusetts, USA
| | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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Fogliati P, Straneo M, Mangi S, Azzimonti G, Kisika F, Putoto G. 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. Health Policy Plan 2018; 32:1354-1360. [PMID: 29040509 PMCID: PMC5886146 DOI: 10.1093/heapol/czx100] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2017] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Sabina Mangi
- Tosamaganga Council Designated Hospital, Iringa, Tanzania
| | | | - Firma Kisika
- District Medical Office, Iringa District Council, Tanzania
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Lufumpa E, Doos L, Lindenmeyer A. Barriers and facilitators to preventive interventions for the development of obstetric fistulas among women in sub-Saharan Africa: a systematic review. BMC Pregnancy Childbirth 2018; 18:155. [PMID: 29747604 PMCID: PMC5946543 DOI: 10.1186/s12884-018-1787-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 04/26/2018] [Indexed: 11/22/2022] Open
Abstract
Background Obstetric fistula is a debilitating childbearing injury that results from poorly managed obstructed labour, leading to the development of holes between the vagina and bladder and/or rectum. Effects of this injury are long-lasting, as women become incontinent and are often marginalised from their communities. Despite continuous occurrence of this injury in lower-income countries, it is preventable, as evidenced in high-income countries. This systematic review aims to identify and understand barriers and facilitators to interventions aimed at the prevention of obstetric fistulas in sub-Saharan African women. Methods Electronic databases and grey literature were searched. We included studies written in English that discussed interventions to prevent obstetric fistulas implemented in sub-Saharan Africa, and their associated barriers and facilitators. Quality of the studies was assessed, and data including: country of implementation, preventive interventions, and barriers and facilitators to the interventions were extracted. They were then categorised based on the Three Phase Delay Model. Results Our search yielded 537 studies, of which 18 were included from sub-Saharan countries including Ethiopia, Nigeria, and Zambia. The most noted barrier to prevention addressed the first phase of delay: the decision to seek care, particularly lack of awareness of the dangers of unsupervised labours. The most noted facilitator addressed the decision to seek care and the quality of care received at a facility, through partnerships between health facilities and governments, and other organisations that provided both financial and resource support. Conclusion Despite being categorised by the three phases of the delay model, barriers and facilitators were found to play a role in multiple phases. The topic of obstetric fistula needs to be researched more extensively, particularly the effectiveness of preventive interventions. Electronic supplementary material The online version of this article (10.1186/s12884-018-1787-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eniya Lufumpa
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Lucy Doos
- Institute for Research into Superdiversity, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Antje Lindenmeyer
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Scott NA, Vian T, Kaiser JL, Ngoma T, Mataka K, Henry EG, Biemba G, Nambao M, Hamer DH. Listening to the community: Using formative research to strengthen maternity waiting homes in Zambia. PLoS One 2018; 13:e0194535. [PMID: 29543884 PMCID: PMC5854412 DOI: 10.1371/journal.pone.0194535] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 03/05/2018] [Indexed: 12/24/2022] Open
Abstract
Background The WHO recommends maternity waiting homes (MWH) as one intervention to improve maternal and newborn health. However, persistent structural, cultural and financial barriers in their design and implementation have resulted in mixed success in both their uptake and utilization. Guidance is needed on how to design a MWH intervention that is acceptable and sustainable. Using formative research and guided by a sustainability framework for health programs, we systematically collected data from key stakeholders and potential users in order to design a MWH intervention in Zambia that could overcome multi-dimensional barriers to accessing facility delivery, be acceptable to the community and be financially and operationally sustainable. Methods and findings We used a concurrent triangulation study design and mixed methods. We used free listing to gather input from a total of 167 randomly sampled women who were pregnant or had a child under the age of two (n = 59), men with a child under the age of two (n = 53), and community elders (n = 55) living in the catchment areas of four rural health facilities in Zambia. We conducted 17 focus group discussions (n = 135) among a purposive sample of pregnant women (n = 33), mothers-in-law (n = 32), traditional birth attendants or community maternal health promoters (n = 38), and men with a child under two (n = 32). We administered 38 semi-structured interviews with key informants who were identified by free list respondents as having a stake in the condition and use of MWHs. Lastly, we projected fixed and variable recurrent costs for operating a MWH. Respondents most frequently mentioned distance, roads, transport, and the quality of MWHs and health facilities as the major problems facing pregnant women in their communities. They also cited inadequate advanced planning for delivery and the lack of access to delivery supplies and baby clothes as other problems. Respondents identified the main problems of MWHs specifically as over-crowding, poor infrastructure, lack of amenities, safety concerns, and cultural issues. To support operational sustainability, community members were willing to participate on oversight committees and contribute labor. The annual fixed recurrent cost per 10-bed MWH was estimated as USD543, though providing food and charcoal added another $3,000USD. Respondents identified water pumps, an agriculture shop, a shop for baby clothes and general goods, and grinding mills as needs in their communities that could potentially be linked with an MWH for financial sustainability. Conclusions Findings informed the development of an intervention model for renovating existing MWH or constructing new MWH that meets community standards of safety, comfort and services offered and is aligned with government policies related to facility construction, ownership, and access to health services. The basic strategies of the new MWH model include improving community acceptability, strengthening governance and accountability, and building upon existing efforts to foster financial and operational sustainability. The proposed model addresses the problems cited by our respondents and challenges to MWHs identified by in previous studies and elicits opportunities for social enterprises that could serve the dual purpose of meeting a community need and generating revenue for the MWH.
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Affiliation(s)
- Nancy A. Scott
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | - Taryn Vian
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Jeanette L. Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Thandiwe Ngoma
- Zambia Center for Applied Health Research and Development (ZCAHRD), Lusaka, Zambia
| | - Kaluba Mataka
- Zambia Center for Applied Health Research and Development (ZCAHRD), Lusaka, Zambia
| | - Elizabeth G. Henry
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Godfrey Biemba
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Zambia Center for Applied Health Research and Development (ZCAHRD), Lusaka, Zambia
| | - Mary Nambao
- Department of Public Health, Ministry of Health, Lusaka, Zambia
| | - Davidson H. Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, United States of America
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Chibuye PS, Bazant ES, Wallon M, Rao N, Fruhauf T. Experiences with and expectations of maternity waiting homes in Luapula Province, Zambia: a mixed-methods, cross-sectional study with women, community groups and stakeholders. BMC Pregnancy Childbirth 2018; 18:42. [PMID: 29370773 PMCID: PMC5785796 DOI: 10.1186/s12884-017-1649-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 12/28/2017] [Indexed: 11/28/2022] Open
Abstract
Background Luapula Province has the highest maternal mortality and one of the lowest facility-based births in Zambia. The distance to facilities limits facility-based births for women in rural areas. In 2013, the government incorporated maternity homes into the health system at the community level to increase facility-based births and reduce maternal mortality. To examine the experiences with maternity homes, formative research was undertaken in four districts of Luapula Province to assess women’s and community’s needs, use patterns, collaboration between maternity homes, facilities and communities, and promising practices and models in Central and Lusaka Provinces. Methods A cross-sectional, mixed-methods design was used. In Luapula Province, qualitative data were collected through 21 focus group discussions with 210 pregnant women, mothers, elderly women, and Safe Motherhood Action Groups (SMAGs) and 79 interviews with health workers, traditional leaders, couples and partner agency staff. Health facility assessment tools, service abstraction forms and registers from 17 facilities supplied quantitative data. Additional qualitative data were collected from 26 SMAGs and 10 health workers in Central and Lusaka Provinces to contextualise findings. Qualitative transcripts were analysed thematically using Atlas-ti. Quantitative data were analysed descriptively using Stata. Results Women who used maternity homes recognized the advantages of facility-based births. However, women and community groups requested better infrastructure, services, food, security, privacy, and transportation. SMAGs led the construction of maternity homes and advocated the benefits to women and communities in collaboration with health workers, but management responsibilities of the homes remained unassigned to SMAGs or staff. Community norms often influenced women’s decisions to use maternity homes. Successful maternity homes in Central Province also relied on SMAGs for financial support, but the sustainability of these models was not certain. Conclusions Women and communities in the selected facilities accept and value maternity homes. However, interventions are needed to address women’s needs for better infrastructure, services, food, security, privacy and transportation. Strengthening relationships between the managers of the homes and their communities can serve as the foundation to meet the needs and expectations of pregnant women. Particular attention should be paid to ensuring that maternity homes meet quality standards and remain sustainable. Electronic supplementary material The online version of this article (10.1186/s12884-017-1649-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Eva S Bazant
- Jhpiego, an affiliate of Johns Hopkins University, 1615 Thames Street, Baltimore, MD, 21231-3492, USA
| | - Michelle Wallon
- Walko Global Development Partners, LLC, 805 Sycamore Place, Ann Arbor, MI, 48104, USA
| | - Namratha Rao
- Jhpiego, an affiliate of Johns Hopkins University, 1615 Thames Street, Baltimore, MD, 21231-3492, USA
| | - Timothee Fruhauf
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205-2103, USA
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Sialubanje C, Massar K, Hamer DH, Ruiter RAC. Personal and environmental factors associated with the utilisation of maternity waiting homes in rural Zambia. BMC Pregnancy Childbirth 2017; 17:136. [PMID: 28472945 PMCID: PMC5418767 DOI: 10.1186/s12884-017-1317-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 04/25/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the association between the presence of maternity waiting homes (MWHs) and the personal and environmental factors that affect the use of MWHs has been explained in qualitative terms, it has never been tested in quantitative terms. The aim of this study was to test the association between the presence of MWHs and personal and environmental factors that affect the use of MWHs. METHODS A cross-sectional study was conducted using an interviewer-administered questionnaire from 1st July to 31st August, 2014 among 340 women of reproductive age in 15 rural health centres in Kalomo district, Zambia. Tests of association (chi square, logistic regression analysis, odds ratio) were conducted to determine the strength of the association between the presence of MWHs and personal and environmental factors. Differences between respondents who used MWHs and those who did not were also tested. RESULTS Compared to respondents from health centres without MWHs, those from centres with MWHs had higher odds of expressing willingness to use MWHs (adjusted odds ratio [aOR] = 4.58; 95% confidence interval [CI]:1.39-15.17), perceived more benefits from using a MWH (aOR =8.63; 95% CI: 3.13-23.79), perceived more social pressure from important others to use MWH (aOR =27.09; 95% CI: 12.23-60.03) and higher personal risk from pregnancy and childbirth related complications (aOR =11.63; 95% CI: 2.52-53.62). Furthermore, these respondents had higher odds of staying at a health centre before delivery (aOR =1.78; 95% CI: 1.05-3.02), giving birth at a health facility (aOR = 3.36; 95% CI: 1.85-6.12) and receiving care from a skilled birth attendant (aOR =3.24; 95% CI: 1.80-5.84). In contrast, these respondents had lower odds of perceiving barriers regarding the use of MWHs (aOR =0.27; 95% CI: 0.16-0.47). Factors positively associated with the use of MWHs included longer distances to the nearest health centre (p = 0.004), higher number of antenatal care (ANC) visits (p = 0.001), higher proportions of complications during ANC (p = 0.09) and women's perception of benefits gained from staying in a MWH while waiting for delivery at the health centre (p = 0.001). CONCLUSION These findings suggest a need for health interventions that focus on promoting ANC use, raising awareness about the risk and severity of pregnancy complications, promoting family and community support, and mitigating logistical barriers.
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Affiliation(s)
- Cephas Sialubanje
- Ministry of Health, Monze District Medical Office, P.O. Box 660144, Monze, Zambia. .,Department of Work and Social Psychology, Maastricht University, P.O. Box 616, 6200MD, Maastricht, The Netherlands.
| | - Karlijn Massar
- Department of Work and Social Psychology, Maastricht University, P.O. Box 616, 6200MD, Maastricht, The Netherlands
| | - Davidson H Hamer
- Zambia Centre for Applied Health Research and Development, P.O. Box 30910, Lusaka, Zambia.,Centre for Global Health and Development Boston University, Crosstown 3rd floor, 801 Massachusetts Avenue, Boston, MA, 02118, USA.,Department of Global Health, Boston University School of Public Health, Crosstown 3rd floor, 801 Massachusetts Avenue, Boston, MA, 02118, USA
| | - Robert A C Ruiter
- Department of Work and Social Psychology, Maastricht University, P.O. Box 616, 6200MD, Maastricht, The Netherlands
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