Maternity Waiting Homes in Rural Districts in Africa; A Cornerstone of Safe Motherhood?

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

Introduction

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

Methods

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

Results

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

Conclusions

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

PROSPERO registration number

CRD42020173595.

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

OBJECTIVES

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

DESIGN

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

SETTING AND PARTICIPANTS

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

INTERVENTION

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

NCT02620436.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of maternity waiting homes on facility delivery among remote households in Zambia: protocol for a quasiexperimental, mixed-methods study

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.

Built spaces and features associated with user satisfaction in maternity waiting homes in Malawi

OBJECTIVE

To assess satisfaction with maternity waiting home built spaces and features in women who are at risk for underutilizing maternity waiting homes (i.e. residential facilities that temporarily house near-term pregnant mothers close to healthcare facilities that provide obstetrical care). Specifically we wanted to answer the questions: (1) Are built spaces and features associated with maternity waiting home user satisfaction? (2) Can built spaces and features designed to improve hygiene, comfort, privacy and function improve maternity waiting home user satisfaction? And (3) Which built spaces and features are most important for maternity waiting home user satisfaction?

DESIGN

A cross-sectional study comparing satisfaction with standard and non-standard maternity waiting home designs. Between December 2016 and February 2017 we surveyed expectant mothers at two maternity waiting homes that differed in their design of built spaces and features. We used bivariate analyses to assess if built spaces and features were associated with satisfaction. We compared ratings of built spaces and features between the two maternity waiting homes using chi-squares and t-tests to assess if design features to improve hygiene, comfort, privacy and function were associated with higher satisfaction. We used exploratory robust regression analysis to examine the relationship between built spaces and features and maternity waiting home satisfaction.

SETTING

Two maternity waiting homes in Malawi, one that incorporated non-standardized design features to improve hygiene, comfort, privacy, and function (Kasungu maternity waiting home) and the other that had a standard maternity waiting home design (Dowa maternity waiting home).

PARTICIPANTS

322 expectant mothers at risk for underutilizing maternity waiting homes (i.e. first-time mothers and those with no pregnancy risk factors) who had stayed at the Kasungu or Dowa maternity waiting homes.

FINDINGS

There were significant differences in ratings of built spaces and features between the two differently designed maternity waiting homes, with the non-standard design having higher ratings for: adequacy of toilets, and ratings of heating/cooling, air and water quality, sanitation, toilets/showers and kitchen facilities, building maintenance, sleep area, private storage space, comfort level, outdoor spaces and overall satisfaction (p = <.0001 for all). The final regression model showed that built spaces and features that are most important for maternity waiting home user satisfaction are toilets/showers, guardian spaces, safety, building maintenance, sleep area and private storage space (R² = 0.28).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The design of maternity waiting home built spaces and features is associated with user satisfaction in women at risk for underutilizing maternity waiting homes, especially related to toilets/showers, guardian spaces, safety, building maintenance, sleep area and private storage space. Improving maternity waiting home built spaces and features may offer a promising area for improving maternity waiting home satisfaction and reducing barriers to maternity waiting home use.

Personal and environmental factors associated with the utilisation of maternity waiting homes in rural Zambia

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 1^st July to 31^st 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.

Reaching vulnerable women through maternity waiting homes in Malawi

OBJECTIVE

To determine whether two maternity waiting homes (MWHs) supported by the Safe Motherhood Initiative are reaching vulnerable women during the early phase of their implementation.

METHODS

A cross-sectional interview-based study was conducted among women who attended two centers in Malawi with attached MWHs (Area 25 Health Centre, Lilongwe; and Kasungu District Hospital, Kasungu). Between April and June 2015, exit interviews were conducted among MWH users and non-users.

RESULTS

Compared with non-users, MWH users at Area 25 were significantly more likely to report a prior spontaneous abortion (10/46 [21.7%] vs 5/95 [5.3%]; P=0.006) and to be in the lowest wealth quintile (4/87 [4.6%] vs 0/150; P=0.029). Although not significant, a greater percentage of MWH users at Kasungu District Hospital than non-users had a prior stillbirth (6/84 [7.1%] vs 0/77) or spontaneous abortion (3/84 [3.6%] vs 2/77 [2.6%]), and were in the lowest wealth quintile (15/175 [8.6%] vs 5/141 [3.5%]). MWH users at Kasungu lived further from the hospital than did non-MWH users, although the difference was not significant (mean 6.81±9.1 km vs 4.05±7.42 km; P=0.067).

CONCLUSION

MWHs offer a promising strategy to reduce maternal mortality in Malawi and other low-income countries.

Factors associated with postnatal care utilisation in Rwanda: A secondary analysis of 2010 Demographic and Health Survey data

BACKGROUND

Postnatal care (PNC) in the first seven days is important for preventing morbidity and mortality in mothers and new-borns. Sub-Saharan African countries, which account for 62 % of maternal deaths globally, have made major efforts to increase PNC utilisation, but utilisation rates remains low even in countries like Rwanda where PNC services are universally available for free. This study identifies key socio-economic and demographic factors associated with PNC utilisation in Rwanda to inform improved PNC policies and programs.

METHODS

This is a secondary analysis of the 2010 Demographic and Health Survey, a national multi-stage, cross-sectional survey. In bivariate analysis, we used chi-square tests to identify demographic and socio-economic factors associated with PNC utilisation at α = 0.1. Pearson's R statistic (r > 0.5) was used to identify collinear covariates, and to choose which covariate was more strongly associated with PNC utilisation. Manual backward stepwise logistic regression was performed on the remaining covariates to identify key factors associated with PNC utilisation at α = 0.05. All analyses were performed in Stata 13 adjusting for sampling weights, clustering, and stratification.

RESULTS

Of the 2,748 women with a live birth in the last two years who answered question about PNC utilisation, 353 (12.8 %) returned for PNC services within seven days after birth. Three factors were positively associated with PNC use: delivering at a health facility (OR: 2.97; 95 % CI: 2.28-3.87), being married but not involved with one's own health care decision-making (OR: 1.69; 95 % CI: 1.17, 2.44) compared to being married and involved; and being in the second (OR: 1.46; 95 % CI: 1.01-2.09) or richest wealth quintile (OR: 2.04; 95 % CI: 1.27-3.29) compared to the poorest. Mother's older age at delivery was negatively associated with PNC use (20-29 - OR: 0.51, 95 % CI: 0.29-0.87; 30-39 - OR: 0.47, 95 % CI: 0.27-0.83; 40-49 - OR: 0.32, 95 % CI: 0.16-0.64).

CONCLUSIONS

Low PNC utilisation in Rwanda appears to be a universal problem though older age and poverty are further barriers to PNC utilisation. A recent change in the provision of BCG vaccination to new-borns might promote widespread PNC utilisation. We further recommend targeted campaigns to older mothers and poorest mothers, focusing on perceptions of health system quality, cultural beliefs, and pregnancy risks.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DESIGN

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

SETTING

rural communities in north-central Liberia.

PARTICIPANTS

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

FINDINGS

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

KEY CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

Antenatal care and perinatal outcomes in Kwale district, Kenya

BACKGROUND

The importance of antenatal care (ANC) for improving perinatal outcomes is well established. However access to ANC in Kenya has hardly changed in the past 20 years. This study aims to identify the determinants of attending ANC and the association between attendance and behavioural and perinatal outcomes (live births and healthy birthweight) for women in the Kwale region of Kenya.

METHOD

A Cohort survey of 1,562 perinatal outcomes (response rate 100%) during 2004-05 in the catchment areas for five Ministry of Health dispensaries in two divisions of the Kwale region. The associations between background and behavioural decisions on ANC attendance and perinatal outcomes were explored using univariate analysis and multivariate logistic regression models with backwards-stepwise elimination. The outputs from these analyses were reported as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Only 32% (506/1,562) of women reported having any ANC. Women with secondary education or above (adjusted OR 1.83; 95% CI 1.06-3.15) were more likely to attend for ANC, while those living further than 5 km from a dispensary were less likely to attend (OR 0.29; 95% CI 0.22-0.39). Paradoxically, however, the number of ANC visits increased with distance from the dispensary (OR 1.46; 95% CI 1.33-1.60). Women attending ANC at least twice were more likely to have a live birth (vs. stillbirth) in both multivariate models. Women attending for two ANC visits (but not more than two) were more likely to have a healthy weight baby (OR 4.39; 95% CI 1.36-14.15).

CONCLUSION

The low attendance for ANC, combined with a positive relationship between attendance and perinatal outcomes for the women in the Kwale region highlight the need for further research to understand reasons for attendance and non-attendance and also for strategies to be put in place to improve attendance for ANC.