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Olivas ET, Valdez M, Muffoletto B, Wallace J, Stollak I, Perry HB. Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 6. Management of pregnancy complications at Community Birthing Centers (Casas Maternas Rurales). Int J Equity Health 2023; 21:204. [PMID: 36855147 PMCID: PMC9976365 DOI: 10.1186/s12939-022-01758-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND In Guatemala, Indigenous women have a maternal mortality ratio over twice that of non-Indigenous women. Long-standing marginalization of Indigenous groups and three decades of civil war have resulted in persistent linguistic, economic, cultural, and physical barriers to maternity care. Curamericas/Guatemala facilitated the development of three community-built, -owned, and -operated birthing centers, Casas Maternas Rurales (referred to here as Community Birthing Centers), where auxiliary nurses provided physically accessible and culturally acceptable clinical care. The objective of this paper is to assess the management of complications and the decision-making pathways of Birthing Center staff for complication management and referral. This is the sixth paper in the series of 10 articles. Birthing centers are part of the Expanded Census-based, Impact-oriented Approach, referred to as CBIO+. METHODS We undertook an explanatory, mixed-methods study on the handling of pregnancy complications at the Birthing Centers, including a chart review of pregnancy complications encountered among 1,378 women coming to a Birthing Center between 2009 and 2016 and inductively coded interviews with Birthing Center staff. RESULTS During the study period, 1378 women presented to a Birthing Center for delivery-related care. Of the 211 peripartum complications encountered, 42.2% were successfully resolved at a Birthing Center and 57.8% were referred to higher-level care. Only one maternal death occurred, yielding a maternal mortality ratio of 72.6 maternal deaths per 100,000 live births. The qualitative study found that staff attribute their successful management of complications to frequent, high-quality trainings, task-shifting, a network of consultative support, and a collaborative atmosphere. CONCLUSION The Birthing Centers were able to resolve almost one-half of the peripartum complications and to promptly refer almost all of the others to a higher level of care, resulting in a maternal mortality ratio less than half that for all Indigenous Guatemalan women. This is the first study we are aware of that analyzes the management of obstetrical complications in such a setting. Barriers to providing high-quality maternity care, including obtaining care for complications, need to be addressed to ensure that all pregnant women in such settings have access to a level of care that is their fundamental human right.
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Affiliation(s)
- Elijah T Olivas
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mario Valdez
- Curamericas/Guatemala, Calhuitz, San Sebastián Coatán, Huehuetenango, Guatemala
| | | | | | - Ira Stollak
- Curamericas Global, Raleigh, North Carolina, USA
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Fong RM, Kaiser JL, Ngoma T, Vian T, Bwalya M, Sakanga VR, Lori JR, Kuhfeldt KJ, Musonda G, Munro-Kramer M, Rockers PC, Hamer DH, Ahmed Mdluli E, Biemba G, Scott NA. Barriers and facilitators to facility-based delivery in rural Zambia: a qualitative study of women's perceptions after implementation of an improved maternity waiting homes intervention. BMJ Open 2022; 12:e058512. [PMID: 35879007 PMCID: PMC9328096 DOI: 10.1136/bmjopen-2021-058512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Women in sub-Saharan Africa face well-documented barriers to facility-based deliveries. An improved maternity waiting homes (MWH) model was implemented in rural Zambia to bring pregnant women closer to facilities for delivery. We qualitatively assessed whether MWHs changed perceived barriers to facility delivery among remote-living women. DESIGN We administered in-depth interviews (IDIs) to a randomly selected subsample of women in intervention (n=78) and control (n=80) groups who participated in the primary quasi-experimental evaluation of an improved MWH model. The IDIs explored perceptions and preferences of delivery location. We conducted content analysis to understand perceived barriers and facilitators to facility delivery. SETTING AND PARTICIPANTS Participants lived in villages 10+ km from the health facility and had delivered a baby in the previous 12 months. INTERVENTION The improved MWH model was implemented at 20 rural health facilities. RESULTS Over 96% of participants in the intervention arm and 90% in the control arm delivered their last baby at a health facility. Key barriers to facility delivery were distance and transportation, and costs associated with delivery. Facilitators included no user fees, penalties for home delivery, desire for safe delivery and availability of MWHs. Most themes were similar between study arms. Both discussed the role MWHs have in improving access to facility-based delivery. Intervention arm participants expressed that the improved MWH model encourages use and helps overcome the distance barrier. Control arm participants either expressed a desire for an improved MWH model or did not consider it in their decision making. CONCLUSIONS Even in areas with high facility-based delivery rates in rural Zambia, barriers to access persist. MWHs may be useful to address the distance challenge, but no single intervention is likely to address all barriers experienced by rural, low-resourced populations. MWHs should be considered in a broader systems approach to improving access in remote areas. TRIAL REGISTRATION NUMBER NCT02620436.
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Affiliation(s)
- Rachel M Fong
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jeanette L Kaiser
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Taryn Vian
- University of San Francisco - School of Nursing and Health Professions, San Francisco, California, USA
| | | | | | - Jody R Lori
- Office for Global Affairs & PAHO/WHO Collaborating Center, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Kayla J Kuhfeldt
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Michelle Munro-Kramer
- Health Behavior & Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Peter C Rockers
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Davidson H Hamer
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Godfrey Biemba
- Pediatric Centre of Excellence, National Health Research Authority, Lusaka, Zambia
| | - Nancy A Scott
- Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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Smith S, Henrikson H, Thapa R, Tamang S, Rajbhandari R. Maternity Waiting Home Interventions as a Strategy for Improving Birth Outcomes: A Scoping Review and Meta-Analysis. Ann Glob Health 2022; 88:8. [PMID: 35087708 PMCID: PMC8782095 DOI: 10.5334/aogh.3496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Over 300 000 women worldwide die due to pregnancy-related complications annually, with most occurring in developing countries where access to skilled obstetric care is limited. Maternity waiting homes (MWHs) are one intervention designed to increase access to skilled prenatal care in resource-limited settings. MWHs are defined as accommodations at or near a health facility where pregnant women can stay in the final weeks of their pregnancy so they can be easily transferred to the health facility to give birth. While MWHs have existed for decades, evidence regarding their effectiveness in reducing adverse birth outcomes has been mixed. The objective of this study is to comprehensively assess all available MWH research reporting quantitative maternal and childbirth data to determine whether MWHs are an effective maternal health strategy in resource-limited settings. METHODOLOGY We conducted a scoping review and meta-analysis of existing literature on MWHs according to PRISMA guidelines. Descriptive statistics and odds ratios were calculated for the following birth outcomes: maternal mortality, perinatal mortality, and caesarian section. Quantitative analysis was conducted in RStudio and Stata Version 16. RESULTS One hundred seventy-one records were retrieved from our initial database search, of which 66 were identified as relevant. Only 15 of these records reported quantitative data on the health outcomes of interest and therefore met inclusion criteria for our meta-analysis. All studies reporting maternal mortality demonstrated a protective effect of MWHs (aggregate OR: 0.19 [0.10, 0.40]), as did all studies reporting perinatal mortality (aggregate OR: 0.29 [0.16, 0.53]). Studies reporting caesarian section were more varied and indicated less of a protective effect (aggregate OR: 1.80 [1.18, 2.75]). CONCLUSIONS There is some indication that MWHs are an effective strategy for reducing maternal and perinatal mortality in resource-limited settings. However, our analysis was constrained by the observational design of most prior MWH studies. More rigorous MWH evaluations, ideally in the form of randomized-control trials, are needed to better determine MWH effectiveness.
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Affiliation(s)
- Samantha Smith
- Brigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, USA
| | - Hannah Henrikson
- Brigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, USA
| | - Rita Thapa
- Nick Simons Institute, Sanepa, Lalitpur, Nepal
| | | | - Ruma Rajbhandari
- Brigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Mount Auburn Hospital, Department of Medicine, Division of Gastroenterology, Cambridge, Massachusetts, USA
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Scott NA, Kaiser JL, Ngoma T, McGlasson KL, Henry EG, Munro-Kramer ML, Biemba G, Bwalya M, Sakanga VR, Musonda G, Hamer DH, Boyd CJ, Bonawitz R, Vian T, Kruk ME, Fong RM, Chastain PS, Mataka K, Ahmed Mdluli E, Veliz P, Lori JR, Rockers PC. If we build it, will they come? Results of a quasi-experimental study assessing the impact of maternity waiting homes on facility-based childbirth and maternity care in Zambia. BMJ Glob Health 2021; 6:e006385. [PMID: 34876457 PMCID: PMC8655557 DOI: 10.1136/bmjgh-2021-006385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 10/23/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Maternity waiting homes (MWHs) aim to increase access to maternity and emergency obstetric care by allowing women to stay near a health centre before delivery. An improved MWH model was developed with community input and included infrastructure, policies and linkages to health centres. We hypothesised this MWH model would increase health facility delivery among remote-living women in Zambia. METHODS We conducted a quasi-experimental study at 40 rural health centres (RHC) that offer basic emergency obstetric care and had no recent stockouts of oxytocin or magnesium sulfate, located within 2 hours of a referral hospital. Intervention clusters (n=20) received an improved MWH model. Control clusters (n=20) implemented standard of care. Clusters were assigned to study arm using a matched-pair randomisation procedure (n=20) or non-randomly with matching criteria (n=20). We interviewed repeated cross-sectional random samples of women in villages 10+ kilometres from their RHC. The primary outcome was facility delivery; secondary outcomes included postnatal care utilisation, counselling, services received and expenditures. Intention-to-treat analysis was conducted. Generalised estimating equations were used to estimate ORs. RESULTS We interviewed 2381 women at baseline (March 2016) and 2330 at endline (October 2018). The improved MWH model was associated with increased odds of facility delivery (OR 1.60 (95% CI: 1.13 to 2.27); p<0.001) and MWH utilisation (OR 2.44 (1.62 to 3.67); p<0.001). The intervention was also associated with increased odds of postnatal attendance (OR 1.55 (1.10 to 2.19); p<0.001); counselling for family planning (OR 1.48 (1.15 to 1.91); p=0.002), breast feeding (OR 1.51 (1.20 to 1.90); p<0.001), and kangaroo care (OR 1.44 (1.15, 1.79); p=0.001); and caesarean section (OR 1.71 (1.16 to 2.54); p=0.007). No differences were observed in household expenditures for delivery. CONCLUSION MWHs near well-equipped RHCs increased access to facility delivery, encouraged use of facilities with emergency care capacity, and improved exposure to counselling. MWHs can be useful in the effort to increase delivery at advanced facilities in areas where substantial numbers of women live remotely. TRIAL REGISTRATION NUMBER NCT02620436.
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Affiliation(s)
- Nancy A Scott
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Thandiwe Ngoma
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | - Kathleen L McGlasson
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Elizabeth G Henry
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Michelle L Munro-Kramer
- Department of Health Behavior & Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Godfrey Biemba
- National Health Research Authority Zambia, Lusaka, Zambia
| | - Misheck Bwalya
- Department of Research, Right to Care Zambia, Lusaka, Zambia
| | | | | | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Carol J Boyd
- Center for the Study of Drugs, Alcohol, Smoking and Health, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Rachael Bonawitz
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Taryn Vian
- University of San Francisco - School of Nursing and Health Professions, San Francisco, California, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rachel M Fong
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Parker S Chastain
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | | | - Philip Veliz
- Applied Biostatistics Laboratory, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Jody R Lori
- Center for Global Affairs & PAHO/WHO Collaborating Center, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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Lori JR, Munro-Kramer ML, Liu H, McGlasson KL, Zhang X, Lee H, Ngoma T, Kaiser JL, Bwalya M, Musonda G, Sakala I, Perosky JE, Fong RM, Boyd CJ, Chastain P, Rockers PC, Hamer DH, Biemba G, Vian T, Bonawitz R, Lockhart N, Scott NA. Increasing facility delivery through maternity waiting homes for women living far from a health facility in rural Zambia: a quasi-experimental study. BJOG 2021; 128:1804-1812. [PMID: 33993600 PMCID: PMC8518771 DOI: 10.1111/1471-0528.16755] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report on the effectiveness of a standardised core Maternity Waiting Home (MWH) model to increase facility deliveries among women living >10 km from a health facility. DESIGN Quasi-experimental design with partial randomisation at the cluster level. SETTING Seven rural districts in Zambia. POPULATION Women delivering at 40 health facilities between June 2016 and August 2018. METHODS Twenty intervention and 20 comparison sites were used to test whether MWHs increased facility delivery for women living in rural Zambia. Difference-in-differences (DID) methodology was used to examine the effectiveness of the core MWH model on our identified outcomes. MAIN OUTCOME MEASURES Differences in the change from baseline to study period in the percentage of women living >10 km from a health facility who: (1) delivered at the health facility, (2) attended a postnatal care (PNC) visit and (3) were referred to a higher-level health facility between intervention and comparison group. RESULTS We detected a significant difference in the percentage of deliveries at intervention facilities with the core MWH model for all women living >10 km away (DID 4.2%, 95% CI 0.6-7.6, P = 0.03), adolescent women (<18 years) living >10 km away (DID 18.1%, 95% CI 6.3-29.8, P = 0.002) and primigravida women living >10 km away (DID 9.3%, 95% CI 2.4-16.4, P = 0.01) and for women attending the first PNC visit (DID 17.8%, 95% CI 7.7-28, P < 0.001). CONCLUSION The core MWH model was successful in increasing rates of facility delivery for women living >10 km from a healthcare facility, including adolescent women and primigravidas and attendance at the first PNC visit. TWEETABLE ABSTRACT A core MWH model increased facility delivery for women living >10 km from a health facility including adolescents and primigravidas in Zambia.
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Affiliation(s)
- J R Lori
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | | | - H Liu
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - K L McGlasson
- Boston University School of Public Health, Boston, MA, USA
| | - X Zhang
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - H Lee
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - T Ngoma
- Zambia Centre for Applied Health Research and Development, Lusaka, Zambia
| | - J L Kaiser
- Boston University School of Public Health, Boston, MA, USA
| | - M Bwalya
- Zambia Centre for Applied Health Research and Development, Lusaka, Zambia
| | | | | | - J E Perosky
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - R M Fong
- Boston University School of Public Health, Boston, MA, USA
| | - C J Boyd
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - P Chastain
- Boston University School of Public Health, Boston, MA, USA
| | - P C Rockers
- Boston University School of Public Health, Boston, MA, USA
| | - D H Hamer
- Boston University School of Public Health, Boston, MA, USA
| | - G Biemba
- Paediatric Centre of Excellence, National Health Research Authority, Lusaka, Zambia
| | - T Vian
- Boston University School of Public Health, Boston, MA, USA
| | - R Bonawitz
- Boston University School of Public Health, Boston, MA, USA
| | - N Lockhart
- University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - N A Scott
- Boston University School of Public Health, Boston, MA, USA
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Sarriot E, Shaar AN. Community Ownership in Primary Health Care-Managing the Intangible. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:327-331. [PMID: 33008849 PMCID: PMC7541110 DOI: 10.9745/ghsp-d-20-00427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 11/15/2022]
Abstract
Although enduringly intangible, community ownership is foundational to primary health care. This intangibility is a reminder of what programs can and should do (create space for dialogue, question their own choices, expand diversity in stakeholder voices making sense of program-induced changes, including through evaluation) and what they cannot do (manage someone else’s ownership).
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Affiliation(s)
| | - Ali Nashat Shaar
- Palestinian Child Institute, An-Najah National University, Nablus, Palestine
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