A Culturally Sensitive and Supportive Maternity Care Service Increases the Uptake of Maternity Waiting Homes in Ethiopia

Maternity waiting home utilization among women who gave birth in the pastoralist communities of Borana Zone, Ethiopia: A community-based mixed-method study design

Background

Maternity Waiting Home (MWH) utilization is valuable for enhancing maternal and neonatal health service utilization. Although few studies have been conducted in non-pastoral areas, more evidence is needed from pastoralist communities. Hence, the study aimed to assess the utilization of MWH and its associated factors among women in pastoralist communities in Ethiopia.

Methods

A concurrent mixed-method design was conducted from 10 Augustto15 September 2021. The cluster sampling technique was used to select the study participants. Qualitative data was collected through focus group discussions and in-depth interviews. Multivariable logistic regression analysis is used to identify significant factors. Qualitative data were thematically analyzed and triangulated with quantitative findings.

Results

Only 13 % (95%CI:10.5-15.6) of women had utilized MWHs. Husbands participation in antenatal care (AOR = 5.54, 95%CI: 2.14-14.35), having caregivers at home (AOR = 2.59, 95%CI: 1.14-4.86), attending pregnant-women conferences (AOR = 5.01, 95%CI: 2.17-11.49), the husband received information about MWH (AOR = 3.6, 95%CI: 1.54-8.49), favorable attitude towards MWH (AOR = 3.15, 95%CI:1.47-6.77), birth during the rainy season (AOR = 0.35, 95%CI: 0.15-0.81) and residing within 10 km of a health center (AOR = 0.15,95%CI:0.04-0.58) were significantly associated with MWH utilization. The main themes that emerged as barriers to MWH utilization were lack of awareness, availability and accessibility of the services, norms and perceptions, lack of decision-making power, family support and women's workload.

Conclusion

The study found low utilization of MWHs. Husbands' involvement, having information about MWHs, a favorable attitude, the season of birth, and distance were significantly associated. Lack of transportation access, norms, and limited awareness of MWH were also found to be barriers to service utilization. Health education to raise awareness about the importance of MWHs, enabling transportation access, husbands' involvement, and encouraging women to take an active role in household decision-making are crucial to boosting MWH utilization.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Provider and client perspectives on the use of maternity waiting homes in rural Rwanda

BACKGROUND

The World Health Organization recommends the implementation of maternity waiting homes (MWH) to reduce delays in access to obstetric care, particularly for high-risk pregnancies and mothers living far from health facilities, and as a result, several countries have rolled out MWHs. However, Rwanda has not implemented this recommendation on a large scale. There is only one MWH in the country, hence a gap in knowledge regarding the potential utilisation and benefits of MWHs.

OBJECTIVE

To explore providers' and clients' perspectives on facilitators and barriers to the use of MWH in rural Rwanda.

METHODS

We conducted a qualitative study to explore health providers' and clients' perspectives on facilitators and barriers to the use of MWH in Rwanda, between December 2020 and January 2021. We used key informant interviews and focus group discussions to collect data. Data were analysed using NVivo qualitative analysis software version 11.

RESULTS

Facilitators included perceptions that the MWH offered either a peaceful and home-like environment, good-quality services, or timely obstetric services, and was associated with good maternal and neonatal outcomes. Barriers included limited awareness of the MWH among pregnant women, fear of health providers to operate the MWH at full capacity, women's lack of autonomy, uncertainty over funding for the MWH, and perceived high user fees.

CONCLUSION

The Ruli MWH offers a peaceful environment for pregnant women while providing quality and timely obstetric care, resulting in positive maternal and neonatal outcomes for women. However, its existence and benefits are not widely known, and its use is limited due to inadequate resources. There is a need for increased awareness of the MWH among healthcare providers and the community, and lessons from this MWH could inform the scale up of MWHs in Rwanda.

Stakeholders' perspectives on the acceptability and feasibility of maternity waiting homes: a qualitative synthesis

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.

Determinants of maternal healthcare utilisation among pregnant women in Southern Ethiopia: a multi-level analysis

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.

Women's Perspectives on Cultural Sensitivity of Midwives During Intrapartum Care at a Maternity Ward in a National Referral Hospital in Zimbabwe

Introduction

Midwives attend intrapartum women of diverse ethnic backgrounds who each bring their cultural beliefs into the labor and delivery rooms. The International Confederation of Midwives has recommended providing culturally appropriate maternity care in its quest to increase skilled birth attendance and subsequently improve maternal and newborn health.

Objective

This study aimed to examine midwives' cultural sensitivity during intrapartum care from women's perspectives, and how this relates to women's satisfaction with maternity care services.

Methods

A qualitative phenomenological design was employed. Two focus group discussions were conducted with 16 women who had delivered in the labor ward of the selected national referral maternity unit. An interpretive phenomenological approach was used to analyze the data.

Results

This study revealed ineffective midwife-woman collaboration that excludes the incorporation of women's cultural beliefs in the design of maternity care plans. Emotional, physical, and informational support in the care provided to women during labor and childbirth was found to be incompetent. This suggests that midwives are not sensitive to cultural norms and do not provide woman-centered intrapartum care.

Conclusion

Various factors implying midwives' lack of cultural sensitivity in their provision of intrapartum care were identified. Resultantly, women's expectations of labor are not met and this could negatively affect future maternity care-seeking behaviors. This study's findings provide policy makers, midwifery program managers and implementers with better insights for developing targeted interventions to improve cultural sensitivity for the delivery of respectful maternity care. Identifying factors that affect the implementation of culture-sensitive care by midwives could guide the adjustments required in midwifery education and practice.

Knowledge and attitude of women towards maternity waiting homes and associated factors among women who gave birth in the last twelve months in Dega Damot district, northwest Ethiopia

Background

Maternal waiting homes have been identified as one strategy to reduce maternal and perinatal mortality by bringing women living in hard-to-reach areas closer to a health facility that provides emergency obstetric care. Even if utilization of maternal waiting homes is repeatedly assessed, there is a scarcity of evidence in Ethiopia regarding women's knowledge and attitude towards maternal waiting homes.

Objective

This study aimed to assess women's knowledge and attitude towards maternity waiting homes and associated factors among women who gave birth in the last twelve months in northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted from January 1st to February 30th, 2021. A total of 872 participants were selected by using a stratified cluster sampling technique. Data were collected by face-to-face interviews using a structured, pretested, and interviewer-administered questionnaire. Data were entered into EPI data version 4.6 and analysis was done through SPSS version 25. The multivariable logistic regression model was fitted and the level of significance was declared at a p-value of ≤0.05.

Result

Women's adequate knowledge and positive attitude towards maternal waiting homes were 67.3% (95% CI: 64-70) and 73% (95% CI: 70-76), respectively. Had antenatal care visit, the shortest distance to reach the nearby health facility, had history of maternal waiting homes utilization, always involved in health care decision, and sometimes involved in health care decisions were significantly associated with women's knowledge regarding maternal waiting homes. Moreover, secondary and above educational level of women, short distance to reach the nearby health facility and had antenatal care visit were significantly associated with women's attitude towards maternity waiting homes.

Conclusion

About two-third of women had adequate knowledge and nearly three-fourth of women had a positive attitude towards maternity waiting homes. It is better to improve the accessibility and utilization of maternal health services Furthermore, it is better to promote women's decision making power and create motivation to have better academic achievement of women.

Benefits, barriers and enablers of maternity waiting homes utilization in Ethiopia: an integrative review of national implementation experience to date

Background

Though Ethiopia has expanded Maternity Waiting Homes (MWHs) to reduce maternal and perinatal mortality, the utilization rate is low. To maximize the use of MWH, policymakers must be aware of the barriers and benefits of using MWH. This review aimed to describe the evidence on the barriers and benefits to access and use of MWHs in Ethiopia.

Methods

Data were sourced from PubMed, Google Scholars and Dimensions. Thirty-one studies were identified as the best evidence for inclusion in this review. We adopted an integrative review process based on the five-stage process proposed by Whittemore and Knafl.

Results

The key themes identified were the benefits, barriers and enablers of MWH utilization with 10 sub-themes. The themes about benefits of MWHs were lower incidence rate of perinatal death and complications, the low incidence rate of maternal complications and death, and good access to maternal health care. The themes associated with barriers to staying at MWH were distance, transportation, financial costs (higher out-of-pocket payments), the physical aspects of MWHs, cultural constraints and lack of awareness regarding MWHs, women’s perceptions of the quality of care at MWHs, and poor provider interaction to women staying at MWH. Enablers to pregnant women to stay at MWHs were availability of MWHs which are attached with obstetric services with quality and compassionate care.

Conclusion

This study synthesized research evidence on MWH implementation, aiming to identify benefits, barriers, and enablers for MWH implementation in Ethiopia. Despite the limited and variable evidence, the implementation of the MWH strategy is an appropriate strategy to improve access to skilled birth attendance in rural Ethiopia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04954-y.

Planning for Maternity Waiting Home Bed Capacity: Lessons from Rural Zambia

Background:

Maternity waiting homes (MWH) allow pregnant women to stay in a residential facility close to a health center while awaiting delivery. This approach can improve health outcomes for women and children. Health planners need to consider many factors in deciding the number of beds needed for an MWH.

Objective:

The objective of the study is to review experience in Zambia in planning and implementing MWHs, and consider lessons learned in determining optimal capacity.

Methods:

We conducted a study of 10 newly built MWH in Zambia over 12 months. For this case study analysis, data on beds, service volume, and catchment area population were examined, including women staying at the homes, bed occupancy, and average length of stay. We analyzed bed occupancy by location and health facility catchment area size, and categorized occupancy by month from very low to very high.

Findings:

Most study sites were rural, with 3 of the 10 study sites rural-remote. Four sites served small catchment areas (<9 000), 3 had medium (9 000–11 000), and 3 had large (>11 000) size populations. Annual occupancy was variable among the sites, ranging from 13% (a medium rural site) to 151% (a large rural-remote site). Occupancy higher than 100% was accommodated by repurposing the MWH postnatal beds and using extra mattresses. Most sites had between 26–69% annual occupancy, but monthly occupancy was highly variable for reasons that seem unrelated to catchment area size, rural or rural-remote location.

Conclusion:

Planning for MWH capacity is difficult due to high variability. Our analysis suggests planners should try to gather actual recent monthly birth data and estimate capacity using the highest expected utilization months, anticipating that facility-based deliveries may increase with introduction of a MWH. Further research is needed to document and share data on MWH operations, including utilization statistics like number of beds, mattresses, occupancy rates and average length of stay.

Maternity waiting homes utilization and associated factors among childbearing women in rural settings of Finfinnee special zone, central Ethiopia: A community based cross-sectional study

BACKGROUND

Maternity waiting home (MWH) is one of the strategies designed for improved access to comprehensive obstetric care for pregnant women living far from health facilities. Hence, it is vital to promote MWHs for pregnant women in Ethiopia, where most people reside in rural settings and have a high mortality rate. Therefore, this study aimed to assess MWHs utilization and associated factors among women who gave birth in the rural settings of Finfinnee special zone, central Ethiopia.

METHODS

A community-based cross-sectional study was conducted from 15th October to 20th November 2019 among women who gave birth in the last six months before data collection. Multistage random sampling was employed among 636 women from six rural kebeles to collect data through a face-to-face interview. Multivariable logistic regression analysis was fitted, and a 95% confidence level with a p-value <0.05 was used to determine the level and significance of the association.

RESULTS

Overall, MWHs utilization was 34.0% (30.3% - 37.7%). The higher age (AOR: 4.77; 95% CI: 2.76-8.24), career women (AOR: 0.39 95% CI: 0.20-0.74), non-farmer husband (AOR: 0.28; 95% CI: 0.14-0.55), rich women (AOR:1.84; 95% CI: 1.12-3.02), living greater than 60 minutes far from a health facility (AOR: 1.80; 95% CI: 1.16-2.80), and four and more livebirths (AOR: 5.72; 95% CI: 1.53-21.35) significantly associated with MWHs utilization. The common services provided were latrine, bedding, and health professional checkups with 98.2%, 96.8%, and 75.4%, respectively. Besides, feeding service was provided by 39.8%. The primary reason not to use MWHs was the absence of enough information on MWHs.

CONCLUSION

One-third of the women who delivered within the last six months utilized MWHs in the Finfinnee special zone. Our results support the primary purpose of MWHs, that women far from the health facility are more likely to utilize MWHs, but lack of adequate information is the reason not to use MWHs. Therefore, it is better to promote MWHs to fill the information gap among women with geographical barriers to reach health facilities.

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

BACKGROUND AND OBJECTIVE

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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