The tyranny of distance: maternity waiting homes and access to birthing facilities in rural Timor-Leste

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.

Pregnant women's intentions to use maternity waiting homes and its associated factors in rural districts of Hadiya Zone, Southern Ethiopia

BACKGROUND

As part of a strategy to reduce maternal and perinatal mortality, Ethiopia's government has made a significant effort to expand the number of Maternity Waiting Homes (MWHs). However, worldwide there is a substantial regional variation in pregnant women's intention to use MWHs. Therefore, the aim of this study is to assess pregnant women's intention to use maternity waiting home and its associated factors in the rural district of Hadiya Zone, Southern Ethiopia.

METHODS

This was a cross-sectional study carried out on 385 pregnant women from March 1-28, 2020. A systematic random sampling technique was used to recruit the study participants. SPSS software (version 24.0) was used to enter and analyze the data. Bivariate and multivariate logistic regression analyses were used to determine an association between each independent and dependent variables. Odds ratio with their 95% confidence intervals was computed to ascertain the existence and strength of an association, and statistical significance was affirmed at a p-value of < 0.05.

RESULTS

The prevalence of pregnant women's intension to use MWHs was observed to be 55.6%. A poor wealth status (AOR = 2.52; 95% CI:1.05-6.05), having a previous history of institutional delivery (AOR = 4.78; 95% CI:1.16-9.64), attending four or more antenatal care visits (AOR = 3.34; 95%CI:1.35-8.29), having obstetric complications during previous pregnancy (AOR = 3.76; 95% CI:1.45-9.77), and having favourable attitude towards MWHs (AOR = 13.51; 95% CI: 5.85-9.54) had a significant association with an intention to use MWHs.

CONCLUSIONS

According to the findings of this study, more than half of pregnant women have been intended to use MWHs. Therefore, boosting the uptake of the antenatal care visit, raising awareness about the risk and consequences of obstetric complications, and strengthening behavioral modification strategies is very crucial to increase pregnant women's intention to use MWHs.

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.

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 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.

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

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.

Utilization of Deworming Drugs and Its Individual and Community Level Predictors among Pregnant Married Women in Cameroon: A Multilevel Modeling

BACKGROUND

Although deworming pregnant women is one of the strategies to reduce parasites (roundworms and hookworms) causing anemia and related perinatal and maternal complications, utilization of deworming medication among pregnant women in Cameroon is suboptimal. Comprehensive assessment of individual, household (including women's autonomy), and community-level factors associated with utilization of deworming medication has not been done so far. Therefore, we investigated the individual/household and community-level factors associated with deworming among pregnant married women in Cameroon.

METHODS

Our study was limited to pregnant women because they have a greater risk due to increased chances of anemia. We used data from the 2018/19 Cameroon Demographic and Health Survey. Analysis on 5,013 pregnant married women was carried out using multilevel logistic regression. Odds ratios with a 95% confidence interval (CI) were reported.

RESULTS

Our findings showed that about 29.8% of pregnant married women received deworming medications. The individual/household level predictors of deworming medications utilization identified in this study were women's educational level, wealth quintile, and skilled antenatal care. Distance to health facility and region were identified as community-level predictors of deworming medications utilization. Higher odds of receiving deworming medication occurred among educated and wealthier pregnant married women as well as among pregnant married women who had skilled antenatal care or lived in the south region, whereas lower odds were observed among pregnant married women living in the north region.

CONCLUSION

Access to education and economic empowerment of pregnant married women in remote areas and the north region should be the primary focus of the Cameroon government to enhance deworming coverage in the country.

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

Background

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

Methods

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

Results

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

Conclusions

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

The effect of the community midwifery model on maternal and newborn health service utilization and outcomes in Busia County of Kenya: a quasi-experimental study

BACKGROUND

Poor women in hard-to-reach areas are least likely to receive healthcare and thus carry the burden of maternal and perinatal mortality from complications of childbirth. This study evaluated the effect of an enhanced community midwifery model on skilled attendance during pregnancy/childbirth as well as on maternal and perinatal outcomes against the backdrop of protracted healthcare workers' strikes in rural Kenya.

METHODS

The study used a quasi-experimental (one-group pretest-posttest) design. The study spanned three time periods: December 2016-February 2017 when doctors were on strike (P1), March-May 2017 when no healthcare providers were on strike (P2), and June-October 2017 when nurses/midwives were on strike (P3), which was also the period when the project enhanced the capacity of community midwives (CMs) to provide services at the community level. Analysis entailed comparison of frequencies/means of maternal and newborn health service utilization data across the three periods.

RESULTS

The monthly average number of clients obtaining services from CMs across the three time periods was: first antenatal care (ANC) (P1-1.8, P2-2.3, P3-9.9), fourth ANC (P1-1.4, P2-1.0, P3-7.1), skilled birth (P1-1.5, P2-1.7, P3-13.1) and the differences in means were statistically significant (p < 0.05). Over the period, the monthly average number of clients obtaining services from health facilities was: first ANC (P1-55.7, P2-70.8, P3-4.0), fourth ANC (P1-29.6, P2-38.1, P3-1.2) and skilled birth (P1-63.1, P2-87.4, P3-5.6), p < 0.05. There were no statistically significant differences in the average number of clients obtaining services from CMs or health facilities between P1 and P2 (p > 0.05). There was, however, a statistically significant increase in the average number of clients obtaining services from CMs in P3 accompanied by a statistically significant decline in the average number of clients obtaining services from health facilities (p < 0.05). First ANC increased by 68%, fourth ANC by 75%, skilled births by 68%, and postnatal care by 33% in P3 (p < 0.0001). There was a non-significant decline in macerated stillbirths and neonatal deaths in P3.

CONCLUSIONS

The findings underscore the importance of integrating community-level health service providers (CMs and health volunteers) into the primary health care system to complement service delivery according to their level of expertise, especially in low-resource settings.

Maternity waiting homes in times of crisis: Can current models meet women's needs?

BACKGROUND

Maternity waiting homes (MWHs) located close to birthing facilities are a conditional recommendation by the World Health Organisation, based on very low-quality evidence that they contribute to improvements in maternal or perinatal health outcomes. In addition, several studies suggest that more vulnerable women are less likely to use them. Yet significant investments continue to be made in building and running MWHs within conflict-affected and under-resourced health systems.

AIMS

We critically examine the literature to shed light on the challenges and opportunities provided by MWHs during health emergencies and in conflict situations.

FINDINGS AND DISCUSSION

MWHs are difficult to utilise during crises because they require women to be away from home, are often designed as dormitories, can lack security and be over-crowded. Some MWHs have been adapted during situations of political conflict to incorporate birthing and broader reproductive health care, thereby improving the availability of care away from over-burdened health facilities. How MWHs are adapted during times of crisis may provide insights into what systems of care are more appropriate in meeting women's needs more broadly.

CONCLUSION

The current global pandemic is an important time to reflect on whether MWHs are meeting the needs of a diverse range of women, in times of stability and during emergencies, and engage in genuine dialogue with women about the kinds of maternity care they want. We need to co-create those systems now so that they are more resilient during the inevitable crises we will face in the future.

Maternity waiting homes in Liberia: Results of a countrywide multi-sector scale-up

Objective

Descriptions of maternity waiting homes (MWHs) as an intervention to increase facility delivery for women living in remote geographic areas dates back to the 1950s, yet there is limited information on the scale-up and sustainability of MWHs. The objective of this study was to describe the evolutionary scale-up of MWHs as a component of health system strengthening efforts and document the successes, challenges, and barriers to sustainability in Liberia.

Methods

Data were collected from a national sample of 119 MWHs in Liberia established between 2010–2018. The study used a mixed method design that included focus group discussions, individual interviews, logbook reviews, and geographic information systems. Qualitative data were grouped into themes using Glaser’s constant comparative method. Quantitative data were analyzed using negative binomial regression to measure the differences in the counts of monthly stays at facilities with different funding sources and presence of advisory committee. Additionally, each MWH was geo-located for purposes of geo-visualization.

Results

In the years since the original construction of five MWHs, an additional 114 MWHs were constructed in 14 of the 15 counties in Liberia. Monthly stays at facilities funded by community were 2·5 times those funded by NGOs (IRR, 2·46, 95% CI 1·33–4·54). Attributes of sustainability included strong local leadership/active community engagement and community ownership and governance.

Conclusion

Success factors for scale-up and sustainability included strong government support through development of public policy, local and county leadership, early and sustained engagement with communities, and self-governance. A multi-pronged approach with strong community engagement is key to the scale-up and sustainability of MWHs as an intervention to increase facility delivery for women living the farthest from a healthcare facility.

Factors influencing women's access to the maternity waiting home in rural Southwest Ethiopia: a qualitative exploration

Background

Maternity Waiting Homes (MWHs) have been advocated to improve the utilization of skilled birth attendants. Nevertheless, delivery attended by skilled personnel is low in Ethiopia and may indicate that the utilization of MWH is also low. The aim of this study is to explore the factors influencing women’s access to the MWHs in rural Southwest Ethiopia.

Methods

Qualitative data were collected through focus group discussions with MWHs users and in-depth interviews with MWHs non-users, health extension workers and the clinicians. Four focus group discussions and 18 in-depth interviews were conducted between May 1 and June 1, 2017. Furthermore, observations were made to assess the availability of basic facilities at selected MWHs. Data were thematically analyzed using NVivo version 7. The concept of access defined by Thiede et al was applied to guide the analysis.

Results

Women had interest on MWHs and are aware of the existence of MWHs in their immediate vicinity. Health information disseminations and referral linkages by frontline health workers enabled women to timely access the MWHs. However, Women didn’t understand the aims and benefits of MWHs. At the facility level, there were attempts to improve the acceptability of MWHs by allowing women to choose their delivery positions. But, participants claimed lack of privacy and presence of disrespectful care. Physical barriers (long distance, unavailability of transport options & unfavorable roads) were considered as potential problems for women residing in remote areas. MWH users mentioned absences of sufficient basic facilities, poor quality and varieties of food. Because of insufficient facilities, the cost of living was high for most users. The communities try to overcome the indirect costs through contributions in-kind and in-cash.

Conclusions

The factors influencing women’s access to the MWHs were structural and individual and resonate with Thiede et al. dimensions of access. A better understanding of which factors are most influential in preventing women’s access to the MWHs in rural Southwest Ethiopia is needed to appropriately target interventions.

Intentions to use maternity waiting homes and associated factors in Northwest Ethiopia

Background

Maternity Waiting Homes (MWHs) are residential facilities located within hospitals or health centers to accommodate women in their final weeks of pregnancy to bridge the geographical gap in obstetric care. Little is known, however, about women’s intentions to use MWHs. Thus, this study aimed to assess pregnant women’s intentions to use MWHs and associated factors in East Bellesa district, northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted among 525 pregnant women in East Bellesa district from March to May 2018. Study participants were selected using systematic random sampling. Binary logistic regression was used for analysis. Adjusted Odds Ratio (aOR) with 95% Confidence Interval (CI), and p-value < 0.05 were used to identify factors associated with intentions to use MWHs.

Results

In the study area, 326/499 (65.3%) pregnant women had the intention to use MWHs. Pregnant women who had good knowledge about maternal healthcare and obstetric complications (aOR 6.40; 95% CI 3.6–11.5), positive subjective norms related to women’s perceptions of social pressure (aOR 5.14; 95% CI 2.9–9.2), positive perceived behavioral control of women on the extent to which women feel confident (aOR 4.74; 95% CI 2.7–8.4), rich wealth status (aOR 4.21; 95% CI 2.1–8.4), women who decided by themselves to use maternal services (aOR 2.74; 95% CI 1.2–6.2), attended antenatal care (aOR 2.24; 95% CI 1.2–4.1) and favorable attitudes towards women’s overall evaluation of MWHs (aOR 1.86; 95% CI 1.0–3.4) had higher odds of intentions to use MWHs.

Conclusion

Two thirds (65.3%) of pregnant women had intentions to use MWHs. Factors such as women’s knowledge, subjective norms related to women’s perceptions of social pressure, perceived behavioral control of women on the extent to which women feel confident to utilize, and wealth status, decision-making power, attending antenatal care and attitude towards women’s overall evaluation of MWHs were significantly associated with the intention to use MWHs. Therefore, improving women’s awareness by providing continuous health education during antenatal care visits, devising strategies to improve women’s wealth status, and strengthening decision-making power may enhance their intention to use MWHs.

Innovations in maternal and child health: case studies from Uganda

Background

Nearly 300 children and 20 mothers die from preventable causes daily, in Uganda. Communities often identify and introduce pragmatic and lasting solutions to such challenging health problems. However, little is known of these solutions beyond their immediate surroundings. If local and pragmatic innovations were scaled-up, they could contribute to better health outcomes for larger populations. In 2017 an open call was made for local examples of community-based solutions that contribute to improving maternal and child health in Uganda. In this article, we describe three top innovative community-based solutions and their contributions to maternal health.

Main text

In this study, all innovations were implemented by non-government entities. Two case studies highlight the importance of bringing reproductive health and maternal delivery services closer to populations, through providing accessible shelters and maternity waiting homes in isolated areas. The third case study focuses on bringing obstetric imaging services to lower level rural health facilities, which usually do not provide this service, through task-shifting certain sonography services to midwives. Various health system and policy relevant lessons are highlighted.

Conclusions

The described case studies show how delays in access to health care by pregnant women in rural communities can be systematically removed, to improve pregnancy and delivery outcomes. Emphasis should be put on identification, capacity building and research to support the scale up of these community-based health solutions.

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.

Health care expenditure for delivery care between maternity waiting home users and nonusers in Ethiopia

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.

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

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Facilitators for maternity waiting home utilisation at Attat Hospital: a mixed-methods study based on 45 years of experience

OBJECTIVE

To describe facilitators for maternity waiting home (MWH) utilisation from the perspectives of MWH users and health staff.

METHODS

Data collection took place over several time frames between March 2014 and January 2018 at Attat Hospital in Ethiopia, using a mixed-methods design. This included seven in-depth interviews with staff and users, three focus group discussions with 28 users and attendants, a structured questionnaire among 244 users, a 2-week observation period and review of annual facility reports. The MWH was built in 1973; consistent records were kept from 1987. Data analysis was done through content analysis, descriptive statistics and data triangulation.

RESULTS

The MWH at Attat Hospital has become a well-established intervention for high-risk pregnant women (1987-2017: from 142 users of 777 total attended births [18.3%] to 571 of 3693 [15.5%]; range 142-832 users). From 2008, utilisation stabilised at on average 662 women annually. Between 2014 and 2017, total attended births doubled following government promotion of facility births; MWH utilisation stayed approximately the same. Perceived high quality of care at the health facility was expressed by users to be an important reason for MWH utilisation (114 of 128 MWH users who had previous experience with maternity services at Attat Hospital rated overall services as good). A strong community public health programme and continuous provision of comprehensive emergency obstetric and neonatal care (EmONC) seemed to have contributed to realising community support for the MWH. The qualitative data also revealed that awareness of pregnancy-related complications and supportive husbands (203 of 244 supported the MWH stay financially) were key facilitators. Barriers to utilisation existed (no cooking utensils at the MWH [198/244]; attendant being away from work [190/244]), but users considered these necessary to overcome for the perceived benefit: a healthy mother and baby.

CONCLUSIONS

Facilitators for MWH utilisation according to users and staff were perceived high-quality EmONC, integrated health services, awareness of pregnancy-related complications and the husband's support in overcoming barriers. If providing high-quality EmONC and integrating health services are prioritised, MWHs have the potential to become an accepted intervention in (rural) communities. Only then can MWHs improve access to EmONC.

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

Objective

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

Methods

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

Results

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

Conclusions

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

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.

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

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

Assessment of the quality of care in Maternity Waiting Homes (MWHs) in Mulanje District, Malawi

Aim

Maternal Mortality Ratio (MMR)in Malawi remains high at 439 deaths per 100,000 live births, primarily due to limited access to skilled birth care. Although Malawi established Maternity Waiting Homes (MWHs) to improve access to skilled labour, the quality of care provided in the homes has received limited assessment. The aim of this study was to assess quality of care in the Maternity Waiting Homes in Mulanje, Malawi.

Methods

We conducted a descriptive qualitative study in three MWHs in Mulanje district, Malawi, from December 2015 to January 2016. We conducted a non-participatory observation using a checklist, to assess the physical layout of the facilities, six face-to-face in-depth interviews (IDIs)with health providers and four focus group discussions (FGDs) with 27 pregnant women admitted for more than 48 hours in MWHs. We digitally recorded all FGDs and IDIs simultaneously transcribing and translating them verbatim into English. Data were analysed using thematic analysis.

Results

There were mixed perceptions towards the quality of care in the MWHs. Factors that were perceived to indicate higher quality included a quiet environment at the MWH and midwifery services. Lack of cooking spaces, lack of 24-hour nursing care, absence of food and recreation services and sleeping on the floor negatively affected perceptions of quality.

Conclusion

The study has shown that care provided in MWHs varied across facilities. Perceptions of the quality of care were not uniform and a lack of standards contributed to the differences. Efforts should be made to improve, sustain and standardize care in MWHs in order to improve perceptions of quality of care in MWHs.

Factors associated with intended use of a maternity waiting home in Southern Ethiopia: a community-based cross-sectional study

Background

Although Ethiopia is scaling up Maternity Waiting Homes (MWHs) to reduce maternal and perinatal mortality, women’s use of MWHs varies markedly between facilities. To maximize MWH utilization, it is essential that policymakers are aware of supportive and inhibitory factors. This study had the objective to describe factors and perceived barriers associated with potential utilization of an MWH among recently delivered and pregnant women in Southern Ethiopia.

Methods

A community-based cross-sectional study was conducted between March and November 2014 among 428 recently delivered and pregnant women in the Eastern Gurage Zone, Southern Ethiopia, where an MWH was established for high-risk pregnant women to await onset of labour. The structured questionnaire contained questions regarding possible determinants and barriers. Logistic regression with 95% Confidence Intervals (CI) was used to examine association of selected variables with potential MWH use.

Results

While only thirty women (7.0%) had heard of MWHs prior to the study, 236 (55.1%), after being explained the concept, indicated that they intended to stay at such a structure in the future. The most important factors associated with intended MWH use in the bivariate analysis were a woman’s education (secondary school or higher vs. no schooling: odds ratio [OR] 6.3 [95% CI 3.46 to 11.37]), her husband’s education (secondary school or higher vs. no schooling: OR 5.4 [95% CI 3.21 to 9.06]) and envisioning relatively few barriers to MWH use (OR 0.32 [95% CI 0.25 to 0.39]). After adjusting for possible confounders, potential users had more frequently suffered complications in previous childbirths (adjusted odds ratio [aOR] 4.0 [95% CI 1.13 to 13.99]) and envisioned fewer barriers to MWH use (aOR 0.3 [95% CI 0.23 to 0.38]). Barriers to utilization included being away from the household (aOR 18.1 [95% CI 5.62 to 58.46]) and having children in the household cared for by the community during a woman’s absence (aOR 9.3 [95% CI 2.67 to 32.65]).

Conclusions

Most respondents had no knowledge about MWHs. Having had complications during past births and envisioning few barriers were factors found to be positively associated with intended MWH use. Unless community awareness of preventive maternity care increases and barriers for women to stay at MWHs are overcome, these facilities will continue to be underutilized, especially among marginalized women.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1670-z) contains supplementary material, which is available to authorized users.

A look back on how far to walk: Systematic review and meta-analysis of physical access to skilled care for childbirth in Sub-Saharan Africa

OBJECTIVES

To (i) summarize the methods undertaken to measure physical accessibility as the spatial separation between women and health services, and (ii) establish the extent to which distance to skilled care for childbirth affects utilization in Sub-Saharan Africa.

METHOD

We defined spatial separation as the distance/travel time between women and skilled care services. The use of skilled care at birth referred to either the location or attendant of childbirth. The main criterion for inclusion was any quantification of the relationship between spatial separation and use of skilled care at birth. The approaches undertaken to measure distance/travel time were summarized in a narrative format. We obtained pooled adjusted odds ratios (aOR) from studies that controlled for financial means, education and (perceived) need of care in a meta-analysis.

RESULTS

57 articles were included (40 studied distance and 25 travel time), in which distance/travel time were found predominately self-reported or estimated in a geographic information system based on geographic coordinates. Approaches of distance/travel time measurement were generally poorly detailed, especially for self-reported data. Crucial features such as start point of origin and the mode of transportation for travel time were most often unspecified. Meta-analysis showed that increased distance to maternity care had an inverse association with utilization (n = 10, pooled aOR = 0.90/1km, 95%CI = 0.85-0.94). Distance from a hospital for rural women showed an even more pronounced effect on utilization (n = 2, pooled aOR = 0.58/1km increase, 95%CI = 0.31,1.09). The effect of spatial separation appears to level off beyond critical point when utilization was generally low.

CONCLUSION

Although the reporting and measurements of spatial separation in low-resource settings needs further development, we found evidence that a lack of geographic access impedes use. Utilization is conditioned on access, researchers and policy makers should therefore prioritize quality data for the evidence-base to ensure that women everywhere have the potential to access obstetric care.

Understanding the implementation of maternity waiting homes in low- and middle-income countries: a qualitative thematic synthesis

Background

Maternity waiting homes (MWHs) are accommodations located near a health facility where women can stay towards the end of pregnancy and/or after birth to enable timely access to essential childbirth care or care for complications. Although MWHs have been implemented for over four decades, different operational models exist. This secondary thematic +analysis explores factors related to their implementation.

Methods

A qualitative thematic analysis was conducted using 29 studies across 17 countries. The papers were identified through an existing Cochrane review and a mapping of the maternal health literature. The Supporting the Use of Research Evidence framework (SURE) guided the thematic analysis to explore the perceptions of various stakeholders and barriers and facilitators for implementation. The influence of contextual factors, the design of the MWHs, and the conditions under which they operated were examined.

Results

Key problems of MWH implementation included challenges in MWH maintenance and utilization by pregnant women. Poor utilization was due to lack of knowledge and acceptance of the MWH among women and communities, long distances to reach the MWH, and culturally inappropriate care. Poor MWH structures were identified by almost all studies as a major barrier, and included poor toilets and kitchens, and a lack of space for family and companions. Facilitators included reduced or removal of costs associated with using a MWH, community involvement in the design and upkeep of the MWHs, activities to raise awareness and acceptance among family and community members, and integrating culturally-appropriate practices into the provision of maternal and newborn care at the MWHs and the health facilities to which they are linked.

Conclusion

MWHs should not be designed as an isolated intervention but using a health systems perspective, taking account of women and community perspectives, the quality of the MWH structure and the care provided at the health facility. Careful tailoring of the MWH to women’s accommodation, social and dietary needs; low direct and indirect costs; and a functioning health system are key considerations when implementing MWH. Improved and harmonized documentation of implementation experiences would provide a better understanding of the factors that impact on successful implementation.

Barriers to utilization of childbirth services of a rural birthing center in Nepal: A qualitative study

Background

Maternal mortality and morbidity are public health problems in Nepal. In rural communities, many women give birth at home without the support of a skilled birth attendant, despite the existence of rural birthing centers. The aim of this study was to explore the barriers and provide pragmatic recommendations for better service delivery and use of rural birthing centers.

Methods

We conducted 26 in-depth interviews with service users and providers, and three focus group discussions with community key informants in a rural community of Rukum district. We used the Adithya Cattamanchi logic model as a guiding framework for data analysis.

Results

Irregular and poor quality services, inadequate human and capital resources, and poor governance were health system challenges which prevented service delivery. Contextual barriers including difficult geography, poor birth preparedness practices, harmful culture practices and traditions and low level of trust were also found to contribute to underutilization of the birthing center.

Conclusion

The rural birthing center was not providing quality services when women were in need, which meant women did not use the available services properly because of systematic and contextual barriers. Approaches such as awareness-raising activities, local resource mobilization, ensuring access to skilled providers and equipment and other long-term infrastructure development works could improve the quality and utilization of childbirth services in the rural birthing center. This has resonance for other centers in Nepal and similar countries.

Patient Satisfaction With Maternity Waiting Homes in Liberia: A Case Study During the Ebola Outbreak

INTRODUCTION

Liberia in West Africa has one of the highest maternal mortality ratios in the world (990/100,000 live births). Many women in Liberia live in rural, remote villages with little access to safe maternity services. The World Health Organization has identified maternity waiting homes (MWHs) as one strategy to minimize the barrier of distance in accessing a skilled birth attendant. However, limited data exist on satisfaction with MWHs or maternal health care in Liberia.

METHODS

This mixed-methods case study examines women's satisfaction with their stay at a MWH and compares utilization rates before and during the Ebola outbreak. From 2012 to 2014, 650 women who stayed at one of 6 MWHs in rural Liberia during the perinatal or postnatal period were surveyed. Additionally, 60 semi-structured interviews were conducted with traditional providers, skilled birth attendants, and women utilizing the MWHs. Quantitative analyses assessed satisfaction rates before and during the Ebola outbreak. Content analysis of semi-structured interviews supplemented the quantitative data and provided a lens into the elements of satisfaction with the MWHs.

RESULTS

The majority of women who utilized the MWHs stated they would suggest the MWH to a friend or relative who was pregnant (99.5%), and nearly all would utilize the home again (98.8%). Although satisfaction with the MWHs significantly decreased during the Ebola outbreak (P < .001), participants were satisfied overall with the MWHs. Content analysis identified areas of satisfaction that encompassed the themes of restful and supportive environment as well as areas for improvement such as lacking necessary resources and loneliness.

DISCUSSION

This case study demonstrated that women using MWHs in Bong County, Liberia are generally satisfied with their experience and plan to use an MWH again during future pregnancies to access a skilled birth attendant for birth. Women are also willing to encourage family and friends to use MWHs.

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.

"I go I die, I stay I die, better to stay and die in my house": understanding the barriers to accessing health care in Timor-Leste

BACKGROUND

Despite public health care being free at the point of delivery in Timor-Leste, wealthier patients access hospital care at nearly twice the rate of poorer patients. This study seeks to understand the barriers driving inequitable utilisation of hospital services in Timor-Leste from the perspective of community members and health care managers.

METHODS

This multisite qualitative study in Timor-Leste conducted gender segregated focus groups (n = 8) in eight districts, with 59 adults in urban and rural settings, and in-depth interviews (n = 8) with the Director of community health centres. Communication was in the local language, Tetum, using a pre-tested interview schedule. Approval was obtained from community and national stakeholders, with written consent from participants.

RESULTS

Lack of patient transport is the critical cross-cutting issue preventing access to hospital care. Without it, many communities resort to carrying patients by porters or on horseback, walking or paying for (unaffordable) private arrangements to reach hospital, or opt for home-based care. Other significant out-of-pocket expenses for hospital visits were blood supplies from private suppliers; accommodation and food for the patient and family members; and repatriation of the deceased. Entrenched nepotism and hospital staff denigrating patients' hygiene and personal circumstances were also widely reported. Consequently, some respondents asserted they would never return to hospital, others delayed seeking treatment or interrupted their treatment to return home. Most considered traditional medicine provided an affordable, accessible and acceptable substitute to hospital care. Obtaining a referral for higher level care was not a significant barrier to gaining access to hospital care.

CONCLUSIONS

Onerous physical, financial and socio-cultural barriers are preventing or discouraging people from accessing hospital care in Timor-Leste. Improving access to quality primary health care at the frontline is a key strategy for ensuring universal access to health care, pursued alongside initiatives to overcome the multi-faceted barriers to hospital care experienced by the vulnerable. Improving the availability and functioning of patient transport services, provision of travel subsidies to patients and their families and training hospital staff in standards of professional care are some options available to government and donors seeking faster progress towards universal health coverage in Timor-Leste.

Barriers to Hospital Deliveries among Ethnic Minority Women with Religious Beliefs in China: A Descriptive Study Using Interviews and Survey Data

Background: China has made great progress in improving hospital delivery-the coverage of hospital delivery has increased to above 95% in most regions- some regions lag behind owing to geographic and economic inequality, particularly the poor ethnic minority areas of the Sichuan Province. This study explores factors which may influence hospital delivery from multiple perspectives, with implications for practice and policy. Methods: A framework analysis approach was used to identify and categorize the main barriers and levers to hospital delivery. Our analysis draws on basic information from the sampled counties (Butuo and Daofu). Results: The hospital delivery rate was below 50% in the two sampled areas. In both areas, the “New Rural Cooperative Medical Scheme” and “Rural hospital delivery subsidy” were introduced, but only Butuo county had a transportation subsidy policy. Socioeconomically disadvantaged women in both counties who delivered their babies in hospitals could also apply for financial assistance. A lack of transport was among the main reasons for low hospital delivery rates in these two counties. Furthermore, while the hospital delivery costs could be mostly covered by “New Rural Cooperative Medical Scheme” or “Rural Hospital Delivery Subsidy”, reimbursement was not guaranteed. People in Daofu county might be affected by their Buddhism religion for hospital delivery. Women in Butuo following the Animism religion would refuse delivery in hospitals because of language barriers. Traditional lay beliefs were the main factor that influenced hospital delivery; their understandings of reproductive health varied, and many believed that childbirth should not be watched by strangers and that a home delivery was safe. Conclusions: This study has highlighted a number of barriers and levers to hospital delivery in rural poor ethnic minority areas which could inform and improve the access and rate of hospital delivery rate; thereby reducing health inequalities in maternal and child health in China.

Community-based birth waiting homes in Northern Sierra Leone: Factors influencing women's use

OBJECTIVE

to explore the factors influencing women's use of birth waiting homes in the Northern Bombali district, Sierra Leone.

DESIGN

this was a descriptive exploratory study using qualitative research methodology, which included in depth interviews, key informant interviews, focus group discussions, document review and observations.

SETTING

two chiefdoms in the Northern Bombali district, Sierra Leone.

PARTICIPANT

eight interviews were conducted with women who had delivered in the past one year and used birth waiting homes; eight key informant interviews with a project manager, birth waiting homes hosts, and community members; thirteen women who delivered in the past year without using birth waiting homes (four interviews and two focus group discussions).

FINDINGS

there are several factors influencing the use of birth waiting homes (BWHs) including: past experience of childbirth, promotion of the birth waiting homes by traditional birth attendance, distance and costs of transport to the homes, child care and other family commitments, family's views of the importance of the homes, the costs of food during women's stay, and information given to women and families about when and how to use the homes.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

some barriers, especially those related to family commitments and costs of food, are challenging to solve. In order to make a BWH a user-friendly and viable option, it may be necessary to adjust ways in which BWHs are used. Good linkage with the health system is strength of the programme. However, further strengthening of community participation in monitoring and managing the BWHs is needed for the long term success and sustainability of the BWHs.

Innovative approaches for improving maternal and newborn health--A landscape analysis

Background

Essential interventions can improve maternal and newborn health (MNH) outcomes in low- and middle-income countries, but their implementation has been challenging. Innovative MNH approaches have the potential to accelerate progress and to lead to better health outcomes for women and newborns, but their added value to health systems remains incompletely understood. This study’s aim was to analyze the landscape of innovative MNH approaches and related published evidence.

Methods

Systematic literature review and descriptive analysis based on the MNH continuum of care framework and the World Health Organization health system building blocks, analyzing the range and nature of currently published MNH approaches that are considered innovative. We used 11 databases (MedLine, Web of Science, CINAHL, Cochrane, Popline, BLDS, ELDIS, 3ie, CAB direct, WHO Global Health Library and WHOLIS) as data source and extracted data according to our study protocol.

Results

Most innovative approaches in MNH are iterations of existing interventions, modified for contexts in which they had not been applied previously. Many aim at the direct organization and delivery of maternal and newborn health services or are primarily health workforce interventions. Innovative approaches also include health technologies, interventions based on community ownership and participation, and novel models of financing and policy making. Rigorous randomized trials to assess innovative MNH approaches are rare; most evaluations are smaller pilot studies. Few studies assessed intervention effects on health outcomes or focused on equity in health care delivery.

Conclusions

Future implementation and evaluation efforts need to assess innovations’ effects on health outcomes and provide evidence on potential for scale-up, considering cost, feasibility, appropriateness, and acceptability. Measuring equity is an important aspect to identify and target population groups at risk of service inequity. Innovative MNH interventions will need innovative implementation, evaluation and scale-up strategies for their sustainable integration into health systems.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0784-9) contains supplementary material, which is available to authorized users.

Barriers in physical access to maternal health services in rural Ethiopia

Background

Identifying women with poor access to health services may inform strategies for improving maternal and child health outcomes. The aim of this study was to explore risk factors associated with access to health facilities (in terms of physical distance) among women of reproductive age (15–49 years) in Dabat district, a rural area of north-western Ethiopia.

Methods

A randomly selected cross sectional survey of 1,456 rural households was conducted. Data were collected during home visits. Data on household assets and socio-demographic data (including age, education level, occupation, religion and ethnicity) were collected on 1,420 women. A geographic information system (GIS) was used to map locations of all households, the district health centre and the smaller health posts. Travel time from households to health facilities was estimated, incorporating information on the topography and terrain of the area. The primary outcomes were: 1) travel time from household to nearest health post 2) travel time from household to health centre. Analysis was conducted using multiple linear regression models and likelihood ratio tests.

Results

This study found evidence that educated women lived closer to health centres than uneducated women (adjusted mean difference (adj MD) travel time −41 min (95 % CI: −50,–31)) in this community. Woman’s age was also associated with distance to the health centre. Women aged 15–20 years were more likely to live in a poor access area compared with women aged 21–30 years (adj MD travel time −11 min (95 % CI: −23, 0)), and with women aged 31–49 years (adj MD travel time −32 min (95 % CI: −47,-17)). There was no evidence to suggest that travel time to the health centre was associated with household wealth.

Conclusions

Our main aim was to address the almost total lack of research evidence on what socio-demographic characteristics of women of reproductive age influence access to health facilities (in terms of physical distance). We have done so by reporting that our study found an association that women with no education and women who are younger live, on average, further away from a health facility in this rural Ethiopian community. While we have generated this valuable information to those who are responsible for providing maternal and child health services locally, to fully understand access in health care and to promote equitable access to health care, our study could thus be extended to other components of access and explore how our findings fit into the wider context of other factors influencing maternal health outcomes and utilisation of maternal health services such as antenatal care or delivery at health facility.

Agenda Setting and Evidence in Maternal Health: Connecting Research and Policy in Timor-Leste

The evidence-based policy (EBP) movement has received significant attention in the scientific literature; however, there is still very little empirical research to provide insight into how policy decisions are made and how evidence is used. The lack of research on this topic in low- and middle-income countries is of particular note. We examine the maternity waiting home policy in Timor-Leste to understand the role of context, policy characteristics, individual actors, and how evidence is used to influence the policy agenda. The research tracked the maternity waiting home policy from 2005 to 2009 and is based on in-depth interviews with 31 senior policy-makers, department managers, non-government organization representatives, and United Nations advisors. It is also informed by direct observation, attendance at meetings and workshops, and analysis of policy documents. The findings from this ethnographic case study demonstrate that although the post-conflict context opened up space for new policy ideas senior Ministry of Health officials rather than donors had the most power in setting the policy agenda. Maternity waiting homes were appealing because they were a visible, non-controversial, and logical solution to the problem of accessing maternal health services. Evidence was used in a variety of ways, from supporting pre-determined agendas to informing new policy directions. In the pursuit of EBP, we conclude that the power of research to inform policy lies in its timeliness and relevance, and is facilitated by the connection between researchers and policy-makers.

Strategies to increase demand for maternal health services in resource-limited settings: challenges to be addressed

Background

Universal health access will not be achieved unless women are cared for in their own communities and are empowered to take decisions about their own health in a supportive environment. This will only be achieved by community-based demand side interventions for maternal health access. In this review article, we highlight three common strategies to increase demand-side barriers to maternal healthcare access and identify the main challenges that still need to be addressed for these strategies to be effective.

Discussion

Common demand side strategies can be grouped into three categories:(i) Financial incentives/subsidies; (ii) Enhancing patient transfer, and; (iii) Community involvement. The main challenges in assessing the effectiveness or efficacy of these interventions or strategies are the lack of quality evidence on their outcome and impact and interventions not integrated into existing health or community systems. However, what is highlighted in this review and overlooked in most of the published literature on this topic is the lack of knowledge about the context in which these strategies are to be implemented.

Summary

We suggest three challenges that need to be addressed to create a supportive environment in which these demand-side strategies can effectively improve access to maternal health services. These include: addressing decision-making norms, engaging in intergenerational dialogue, and designing contextually appropriate communication strategies.

Effectiveness of demand and supply side interventions in promoting institutional deliveries--a quasi-experimental trial from rural north India

BACKGROUND

We assessed the differential and sequential effects of a Government of India conditional cash transfer scheme for the socio-economically disadvantaged (Janani Suraksha Yojana; JSY) and the strengthening of the primary health centre (PHC) network to provide 24/7 obstetric care in promoting institutional deliveries.

METHODS

This study used 7796 births from the Ballabgarh Health and Demographic Surveillance Site between April 2006 and March 2010 when both schemes were implemented in a staggered manner. The multiple baseline design took advantage of interventions separated by time and geographical zone to compute difference in differences in the rate of institutional deliveries. Logistic regression was used to estimate increases in the odds of institutional deliveries after adjustment for caste and maternal education.

RESULTS

Compared with villages with poor access, institutional deliveries nearly doubled among villages with access to 24/7 delivery services; odds ratio (OR) 1.9 [95% confidence interval (CI): 1.3, 2.6]. Introduction of JSY in villages with poor access resulted in a 1.4-fold (95% CI: 1.1, 1.8) increase in institutional deliveries and a 1.1-fold (95% CI: 0.9, 1.4) increase in villages served by PHCs 24/7. However, the introduction of PHC 24/7 care to villages served by JSY doubled the rate of institutional deliveries; OR 2.1 (95% CI: 1.5, 2.8). Among the disadvantaged, institutional deliveries increased by 34.4%, compared with 24.8% among the non-disadvantaged. Introduction of PHC 24/7 care in this group increased institutional deliveries 4-fold; OR 4.2 (95% CI: 1.9, 9.0) compared with 3-fold for JSY alone; OR 3.2 (95% CI: 1.8, 5.6).

CONCLUSIONS

Both demand and supply side strategies are effective and promote equity. Improving service delivery in a population previously primed by demand side intervention appears to be the most useful.

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.

Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries

BACKGROUND

A maternity waiting home (MWH) is a facility within easy reach of a hospital or health centre which provides emergency obstetric care (EmOC). Women may stay in the MWH at the end of their pregnancy and await labour. Once labour starts, women move to the health facility so that labour and giving birth can be assisted by a skilled birth attendant. The aim of the MWH is to improve accessibility to skilled care and thus reduce morbidity and mortality for mother and neonate should complications arise. Some studies report a favourable effect on the outcomes for women and their newborns. Others show that utilisation is low and barriers exist. However, these data are limited in their reliability.

OBJECTIVES

To assess the effects of a maternity waiting facility on maternal and perinatal health.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 January 2012), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to January 2012), EMBASE (1980 to January 2012), CINAHL (1982 to January 2012), African Journals Online (AJOL) (January 2012), POPLINE (January 2012), Dissertation Abstracts (January 2012) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomised controlled trials including quasi-randomised and cluster-randomised trials that compared perinatal and maternal outcome in women using a MWH and women who did not.

DATA COLLECTION AND ANALYSIS

There were no randomised controlled trials or cluster-randomised trials identified from the search.

MAIN RESULTS

There were no randomised controlled trials or cluster-randomised trials identified from the search.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effectiveness of maternity waiting facilities for improving maternal and neonatal outcomes.

Unintended Consequences of Policy Decisions to Reduce Maternal Mortality in the Asia Pacific

OBJECTIVES:To describe the role of midwives and maternity care in three low resource settings and to challenge some policy options introduced to reduce maternal mortality for women residing in rural and remote areas.

APPROACH:A series of retrospective analyses were undertaken drawing on work the authors have conducted in rural and remote China, Timor-Leste, and Samoa over the past 5–20 years. Sources include our own empirical research, grey literature, as well as published secondary sources.

FINDINGS:In China, hospital birthing is promoted as a major strategy in reducing maternal mortality. This has greatly increased financial burdens for women and their families. In Samoa, traditional birth attendants (TBAs) are integrated into Samoa’s health system alongside midwives and other health professionals, and they play a critical role in providing support for pregnant and birthing women. In Timor-Leste, the government has moved away from training TBAs and has shifted the focus from skilled attendance to facility-based delivery. Evaluation of a national maternity waiting home strategy, designed to improve access to facility-based delivery, did not improve access for women in remote areas.

CONCLUSIONS:Low-income countries need to be cautious when adopting global solutions, such as facility-based delivery, to tackle maternal deaths. Women-centered and cost-effective care should be provided locally. Culturally compatible maternity care can be achieved in concert with safety and emergency obstetric care. Midwives can create the bridges between social and professional systems that allow this to happen.