Plain English summary
Most maternal deaths could be averted with improved access to skilled care and facilities equipped to handle obstetric emergencies. In Zambia, where only 56% of rural women deliver in a facility, cost and distance are critical barriers to accessing care. Maternity waiting homes (MWH) have been proposed to address the distance problem. The purpose of this study was to determine if women who have access to MWH are more likely to deliver at a facility, and if the quality of the MWH matters.
Data sources from two separate studies conducted in Southern Province, Zambia, between 2011 and 2013 included survey data from 17,200 pregnant women enrolled at their first antenatal care visit and followed through delivery, and both health facility and MWH assessments. The woman-level data included background characteristics, collected during the enrollment survey, and self-reported location of delivery, collected during a household survey after delivery. The health facility and MWH assessments included indicators of capacity and quality. Statistical methods were used to examine the relationship between utilization of facilities for delivery and MWH quality.
In our study, women whose catchment area health facilities had an MWH or a designed waiting space had higher rates of facility delivery. Moreover, the higher the quality of the MWH, the more likely a woman was to deliver at a facility, regardless of the facility’s capacity to address obstetric emergencies. MWH are a potential solution to the distance problem and should be considered as one possible intervention to improve access to facility delivery in Zambia.
Background
An estimated 62% of global maternal deaths occur in sub-Saharan Africa, where a woman’s lifetime risk of maternal death is 1 in 59, far higher than the risk in all low-income countries, estimated at 1 in 160 [
1]. More than 80% of maternal deaths are due to direct causes associated with obstetric complications [
2] and could be prevented with the provision of timely and appropriate intrapartum care. The World Health Organization (WHO) has recommended skilled care at every birth, which includes having a skilled attendant (someone trained to manage normal pregnancies and to identify, manage and refer complications) present for the birth as well as access to facilities with the capacity for emergency obstetric care [
3]. In Zambia, the lifetime risk of maternal death is 1 in 38 [
1], and just about half of women living in rural areas of the country (56%) deliver at facilities, compared to 89% in urban settings [
4]. As with other low-income countries, Zambia continues to face persistent challenges to implementing the WHO skilled birth attendance recommendation.
The factors contributing to the delays in seeking, reaching and accessing quality maternal care, per the Three Delay model, are well established. Key factors affecting utilization and health outcomes include household-level illness recognition and awareness of obstetric complications; women’s status, education level, and other socioeconomic factors; perceived accessibility of health care facilities and perceived quality of care that the woman would receive; community-level transportation and referral challenges, and whether a facility actually has adequate infrastructure and clinician capacity to recognize and address clinical needs [
5,
6]. Costs, transport and distance to the facility, which lead to the second delay of reaching care, have been repeatedly identified as key drivers of the low utilization of facilities for maternity care in Zambia [
7‐
10]. While the government has abolished user fees for maternal and child services to increase financial access to health care services in 2006, about 65% of the population lives in rural areas and still face physical barriers to access. A recent analysis of the effects of the abolished user-fee policy in Zambia suggests that this reform has not overcome key barriers to utilization of public sector facilities for delivery, and that both quality of care and difficulties related to distance may be a more important determinants [
11]. Additional evidence confirms that the odds of facility delivery in rural Zambia decreases as distance to a facility increases [
12].
Maternity waiting homes (MWHs), residential lodging near a health facility, represent a potential strategy to improve accessibility and utilization of facilities for delivery. The WHO has recommended MWHs as an intervention to improve maternity care [
13]. Women who might otherwise not have access to skilled care due to the constraints posed by distance could benefit by staying at a MWH and being closer to a facility that can manage emergency obstetric complications. MWHs of some sort have been implemented since the beginning of the 20
th century in more than 18 countries around the world, including the United States, Canada and Northern Europe, Cuba, India and several countries in sub-Saharan Africa including Zimbabwe, Nigeria, Uganda, Ethiopia and Malawi [
14,
15]. However, there is mixed evidence of the effectiveness of MWH on both utilization of health facilities for maternity care and health outcomes [
16].
With governments eager to find feasible solutions to the distance problem, there is a resurgence of interest in constructing MWH and developing policies around their implementation. However, it is not yet clear if this will be a worthwhile investment among competing priorities. Evidence from Zimbabwe suggests that when a facility has an MWH women are much more likely to deliver there [
17]. The perceived quality of the MWH, among other factors such as direct and indirect costs of staying at the MWH, may also play a role in rates of MWH utilization, including in rural Zambia [
15,
18]. However, there is no evidence on whether or not the actual quality of the MWH is associated with utilization of facilities for delivery.
In Zambia, women are more likely to deliver in facilities better equipped to handle obstetric emergencies, independent of distance to the facility, suggesting that quality of care is also an important factor in decision making about facility-based birth [
12]. It is important, therefore, to also understand whether the relationship between MWH quality and facility utilization would remain regardless of the quality of the health facility in terms of capacity to deal with obstetric emergencies. It is possible that the quality of the health facility is the key driver of facility delivery, rather than the quality of the MWH. The purpose of our study was two-fold: to determine whether the existence of an MWH at a facility would predict women’s utilization of the facility for delivery, and to determine whether the quality level of the MWH would predict the magnitude of this relationship, adjusting for facility quality to handle obstetric emergencies.
Results
Sample characteristics
A total of 17,200 women were included in the final analysis. Women had a median age 25.0 (IQR 20.0-31.0), 85.4% were married and more than 91% had at least some primary education (Table
1). Just over 22% had no children prior to this pregnancy, and 37% reported living more than two hours from a health facility (regardless of type of transportation used). Just over 5% of women were recorded as HIV positive on their ANC cards. More than half of women in our sample (58.5%) delivered at any facility (
n = 10,069). Woman’s age, marital status, education level, parity, ANC visits, HIV status and distance to facility were all associated with facility delivery. Older women, women who were married, had fewer years of education, more than one child, lived more than two hours away from a health facility, had less than the four recommended ANC visits, and were not HIV positive were less likely to deliver in a facility. Just over half of women (55%) lived in catchment areas with an existing MWH or designated waiting space for pregnant mothers.
Table 1
Characteristics of the women with and without facility delivery and unadjusted odds of facility delivery
Woman’s age in years (%) |
15–19 | 22.4 | 25.6 | 17.8 | 1.0 |
20–24 | 27.5 | 26.6 | 28.8 | 0.64 (0.59, 0.70)*** |
25–34 | 36.3 | 34.6 | 38.8 | 0.62 (0.57, 0.67)*** |
35–49 | 13.8 | 13.3 | 14.5 | 0.64 (0.57, 0.71)*** |
Age in years (median, IQR) | 25.0 (20.0-31.0) | 24.0 (19.0-30.0) | 25.0 (21.0-31.0) | |
Household size (median, IQR) | 6.0 (4.0-8.0) | 6.0 (4–8) | 6.0 (4–8) | |
Currently married (%) |
No | 14.6 | 17.4 | 10.6 | 1.0 |
Yes | 85.4 | 82.6 | 89.4 | 0.56 (0.51, 0.62)*** |
Mother’s highest education (%) |
None (0) | 8.3 | 7.0 | 10.2 | 1.0 |
Any primary (1–7) | 55.0 | 50.0 | 62.1 | 1.17 (1.05, 1.31)** |
More than primary (7+) | 36.7 | 43.0 | 27.7 | 2.27 (2.02, 2.55)*** |
Asset quartile (%) |
First/poorest | 26.6 | 25.7 | 27.7 | 1.0 |
Second | 24.5 | 22.9 | 26.9 | 0.92 (0.84, 0.99)* |
Third | 24.7 | 24.8 | 24.6 | 1.09 (0.99, 1.18) |
Fourth/highest | 24.2 | 26.6 | 20.8 | 1.38 (1.27, 1.51)*** |
Parity (%) |
0 | 22.3 | 27.7 | 15.6 | 1.0 |
1 | 17.7 | 17.5 | 18.1 | 0.51 (0.46, 0.56)*** |
> = 2 | 60.0 | 54.8 | 67.4 | 0.43 (0.39, 0.46)*** |
Distance to health facility ≥ 2 h (%)**a
|
No | 62.7 | 69.1 | 53.6 | 1.0 |
Yes | 37.3 | 30.9 | 46.4 | 0.52 (0.49, 0.55)*** |
4 ANC visits (%) |
No | 55.0 | 48.7 | 63.9 | 1.0 |
Yes | 45.0 | 51.3 | 36.1 | 1.87 (1.75, 1.99)*** |
Mother HIV positive (%) |
No | 94.4 | 92.8 | 96.8 | 1.0 |
Yes | 5.6 | 7.2 | 3.2 | 2.34 (2.00, 2.74)*** |
Characteristics of health facilities, both those with and without affiliated MWHs, as well as those that accommodate pregnant women by designating some space for waiting, are included in Table
2. On the 11-point scale for the composite score, facility scores ranged from 2 points to 9 points with a mean of 5.8 (SD 1.8). Facilities with an MWH, as well as those that provide space for waiting pregnant women, appeared to differ systematically from those that did not have a MWH, with those with an MWH having a higher overall score of 6.8 (SD 1.5) compared to those without (4.8 (SD 1.6)). Nearly 60% of facilities with an MWH had performed four or more signal functions, compared to only 16% of those without a MWH. A much higher proportion of facilities with a MWH had administered antibiotics for maternal infections in the past three months (100.0% versus 42.1%). This trend was the same for nearly all signal functions, though not always as pronounced. None of the facilities without a MWH had electricity, whereas seven facilities with a MWH did. Nearly all facilities had access to clean water, provided obstetric services 24/7 and, except for two facilities with a MWH, had at least one skilled provider trained in deliveries on staff. On average those facilities with an MWH had a higher average number of deliveries per month (22.4 (SD 17.2)) than in those without an MWH (17.2 (SD 15.0)). Facilities with a designated waiting space had the highest average number of deliveries, with a mean of 25.0 (SD 14.0).
Table 2
Characteristics of health facilities, with and without Maternity Waiting Homes (MWH)a
| 40 (100.0) | 19 (100.0) | 18 (100.0) | 3 (100.0) |
Signal functions |
Four or more signal functions | 15 (37.5) | 3 (15.8) | 11 (61.1) | 1 (33.3) |
Parenteral antibiotics for maternal infection | 27 (67.5) | 8 (42.1) | 18 (100.0) | 1 (33.3) |
Parenteral oxytocic drugs for hemorrhage | 38 (95.0) | 18 (94.7) | 17 (94.4) | 3 (100.0) |
Parenteral magnesium sulfate for eclampsia | 9 (22.5) | 3 (15.7) | 4 (22.2) | 2 (96.7) |
Manual removal of the placenta | 10 (25.0) | 3 (15.7) | 6 (33.3) | 1 (33.3) |
Removal of retained products of conception | 10 (25.0) | 2 (10.5) | 7 (38.9) | 1 (33.3) |
Assisted vaginal delivery | 4 (10.0) | 0 (0.0) | 4 (22.2) | 0 (0.0) |
Resuscitation with bag and mask of non-breathing baby | 24 (60.0) | 7 (36.8) | 15 (83.3) | 2 (66.7) |
Infrastructure and human resources |
Electricity | 8 (20.0) | 0 (0.00) | 7 (38.9) | 1 (33.3) |
Water supply | 37 (92.5) | 17 (89.5) | 17 (94.4) | 3 (100.0) |
Service availability 24/7 | 36 (95.0) | 15 (79.0) | 18 (100.0) | 3 (100.0) |
At least 1 skilled provider | 38 (95.0) | 19 (100.0) | 16 (88.9) | 3 (100.0) |
Total composite score |
Mean (SD) | 5.8 (1.8) | 4.8 (1.6) | 6.8 (1.5) | 6.3 (2.5) |
Median (Range) | 6.0 (2.0-9.0) | 5.0 (2.0-8.0) | 7.0 (4.0-9.0) | 6.0 (4.0-9.0) |
Average number of deliveries (monthly) | 20.1 (15.9) | 17.2 (15.0) | 22.4 (17.2) | 25.0 (14.0) |
MWHs in our study were generally in poor condition. All MWHs had some type of water supply, toilet, and sanitation inside and outside the shelter. Nearly all of the MWHs had some type of floor, roof and general structural integrity (Table
3). However, most did not have beds or mattresses, nor separate bathing areas for women. We observed wide variation in quality between MWHs, with composite scores ranging from 12 to 66 out of a possible 75, and a median of 28.5 with an inter-quartile range (IQR) of 23–41.
Table 3
Characteristics of 18 existing Maternity Waiting Homes (WH), Kalomo and Choma Districts
Beds | 2 (11.1) | 0.6 (1.6) | 0.0 (0–0) |
Mattresses | 3 (16.7) | 0.7 (1.7) | 0.0 (0–0) |
Electricity | 6 (33.3) | 1.4 (2.1) | 0.0 (0–4) |
Sanitation inside | 18 (100.0) | 3.1 (1.1) | 3.0 (2–4) |
Sanitation outside | 18 (100.0) | 2.8 (1.1) | 2.5 (2–3) |
Security | 18 (100.0) | 3.1 (1.6) | 3.0 (1–5) |
Water supply | 18 (100.0) | 2.9 (0.8) | 3.0 (2–3) |
Toilet | 18 (100.0) | 2.6 (0.9) | 3.0 (2–3) |
Community support | 6 (33.3) | 0.7 (1.1) | 0.0 (0–2) |
Structure integrity | 18 (100.0) | 3.2 (1.2) | 3.0 (2–4) |
Roof | 18 (100.0) | 1.0 (0) | 1.0 (2–5) |
Floor surface | 18 (100.0) | 4.2 (1.5) | 5.0 (2–5) |
Shower/bathing area | 5 (27.8) | 0.7 (1.2) | 0.0 (0–0) |
Cooking area | 18 (100.0) | 2.2 (1.3) | 2.0 (1–3) |
Total score | NA | 32.7 (13.9) | 28.5 (23–41) |
Relationship between maternity home quality and facility delivery
The rate of facility delivery for women whose catchment area had any MWH (including a designated space for waiting) was 60.7 (5698/9385), compared with 55.9 (4371/7815) for those without any MWH or waiting space, an absolute difference of 4.7 points. Adjusting for maternal age, any maternal education, household asset quartile, parity, maternal HIV status, four or more ANC visits, distance to health facility, and whether or not the SMGL program was operational in the district when the mother went for delivery (but not facility capacity for emergency response), there was a 37% relative increase in the odds of facility delivery for women living in catchment areas with an MWH or designated space, compared to women whose catchment areas did not have any MWH (OR: 1.37, 95% CI: 1.27, 1.46) (results not shown in table). Additionally, we tested for any effect the ZamCAT intervention may have had on facility delivery rates. The unadjusted relationship between women living in ZamCAT intervention areas, as compared to non-intervention areas, and facility delivery was non-significant (p = 0.08, OR: 0.947, 95% CI: 0.89, 1.01) (results not shown in table) and therefore was not included in the adjusted model.
Our results also indicate that facility capacity for emergency response has an independent effect on utilization of facilities for delivery. As quality of the facility increases, women are more likely to delivery there (1.10, 95% CI: 1.08, 1.12) (results not shown). This relationship is still significant when we adjust for confounders (maternal age, any maternal education, household asset quartile, parity, maternal HIV status, four or more ANC visits, distance to health facility, and whether or not the SMGL program was operational in the district when the mother went for delivery) (1.10, 95% CI: 1.08, 1.12). When we then revisited the relationship between having an MWH (or designated space) and facility delivery but adjusted for facility capacity, as well as the covariates listed above, the odds of facility delivery was still 19% higher for those with any MWH or accommodation than those without (1.19, 95% CI: 1.10, 1.29) (Table
4).
Table 4
Likelihood of facility-based birth by Maternity Home: any and quality level
MWH or Waiting Space at Facility |
Noa
| 7815 | 4371 (55.9) | 1.00 | 1.00 |
Yes | 9385 | 5698 (60.7) | 1.22 (1.15, 1.29) | 1.19 (1.10, 1.29) |
Type of Waiting Space |
Nonea
| 7815 | 4371 (55.9) | 1.00 | 1.00 |
Space but no MWH | 1392 | 1055 (75.8) | 2.47 (2.17, 2.81) | 2.13 (1.85, 2.46) |
MWH | 7993 | 4643 (58.1) | 1.09 (1.03, 1.16) | 1.07 (0.98, 1.16) |
Rank of MWHc
|
Lowa
| 3142 | 1550 (49.3) | 1.00 | 1.00 |
Medium/High | 4851 | 3093 (63.8) | 1.81 (1.65, 1.98) | 1.95 (1.76, 2.16) |
When we differentiate between facilities that had an actual MWH structure and those that had only designated accommodations for pregnant waiting mothers, such as space in the wards, as compared to those without any place for waiting, there is a less pronounced positive relationship between facility delivery and MWH among those with just a structure (OR: 1.09, 95% CI:1.03, 1.16), but a large increase in the odds of facility delivery among those women whose catchment areas provided space but no formal MWH structure (OR:2.47, 95% CI: 2.17, 2.81). Adjusting for the same covariates as above, the odds of facility delivery becomes non-significant for those with just an MWH, compared to those with none (1.07, 95% CI: 0.98, 1.16) but the effect is still positive for those with a designated space (OR: 2.13, 95% CI: 1.85, 2.46).
When we examined the level of quality of the MWH, only among those that were scored (excluding those with waiting spaces as they did not have the same criteria upon which they could be measured), the rate of facility delivery in those with a low quality MWH was 49.3%. This was lower than the rate of facility delivery in catchment areas with a medium or high-level quality MWH (63.8%). When we examined the relationship between MWH quality and facility delivery, again limiting our analysis only to those facilities with existing MWH structures and controlling for those covariates listed above, including facility capacity score, there was a 95% relative increase in the odds of facility delivery for high or medium-ranking MWHs compared to low-ranking shelters, adjusting for covariates (OR: 1.95, 95% CI: 1.76,2.16).
Discussion
Women in our study were more likely to deliver at health facilities when their catchment area health facility had an MWH or a designated space for waiting on the premises than those women with no immediate access to an MWH or waiting space. When controlling for facility capacity to handle obstetric emergencies, the relationship between presence of an MWH or designated space for waiting and utilization of facility for delivery remained. This is consistent with findings from previous work in Zambia that showed that the absence of a suitable shelter for expecting mothers was a contributing factor to low utilization of maternal health services [
30] and a study in Liberia where availability of MWHs decreased the distance barrier for women to access skilled care for childbirth [
31].
The finding that those women with a designated space had a much higher odds of facility delivery than those with no MWH or space suggests that there may be a characteristics about the facility, such as perceived supportive staff that are willing to accommodate waiting women when no space is formally available, that may influence women’s decisions to deliver there. Women’s cultural beliefs and perceptions of facility-based care have been found to be major drivers of facility delivery [
32]. In Tanzania, a woman’s previous or current experience with the health system, including whether or not she was treated with respect during ANC or delivery, was found to be more important that the perceived quality of the facility itself [
33]. Our study findings indicate there is something unique about facilities that provide waiting space for mothers, and this warrants further investigation.
In our study the quality of the MWH is an important determinant of utilization. Among those facilities that had an MWH structure, women were more likely to deliver at facilities if the structures were of higher quality. The low-quality MWH had about the same utilization rates as those with no MWH at all. This suggests that if MWH are constructed in the future, particular attention should be paid to both the inclusion and the quality of components such as proper bedding, private spaces for bathing, and areas for cooking, among others. These findings are consistent with results from a review of MWH utilization which cited several factors that influence a woman’s decision to stay in an MWH, including the small size of the home and the lack of proper hygiene of the facilities [
16]. In our region of Zambia, the poor state of the MWHs, including inadequate sleeping spaces and bedding, water and sanitary services, have been cited as factors that deterred women from utilizing MWH [
18]. Additional research from Zambia has illuminated that poor conditions of the MWH led some husbands to forbid their wives from using them [
34]. Community acceptance and support have been shown to be critical factors in the successful introduction of MWHs in Ethiopia [
35]. Our findings provide additional evidence that considering the needs of the community will be integral to the potential success of the utilization of MWH in Zambia.
There are several limitations to this analysis. First, although we have the self-reported type of facility at which a woman delivered, we were not able to determine the actual delivery location of the woman, whether at her health facility catchment area (HFCA), or a neighboring facility or hospital. Our study is assuming that most women delivered in their catchment area’s facility, and would have been influenced by the presence or absence of an MWH in their HFCA. It is possible that women delivered outside of their catchment area, and were influenced by the state of their HFCA’s MWH and/or that of a neighboring HFCA.
It is important to note that our data only indicate an association between quality of MWH and utilization of facilities for delivery. We do not know if an MWH is scored as higher quality because it was improved due to an increase of facility deliveries at that site, or if the volume of deliveries changed as a result of the introduction of or improved quality of an MWH. It is also possible that there were substantial changes to the condition of the MWH and/or the facility between the time period for which we captured data on women’s deliveries. It is possible that when the MWH were assessed in 2013, they had deteriorated significantly since 2011, and therefore we are overestimating the rate of facility delivery at low-quality shelters that had previously been medium or high quality shelters. However, this would bias results towards the null and therefore our estimates are likely to be conservative. Another study (Henry et al., under review) suggests that there was very little change in the health facilities’ capacity for EmONC between 2011 and 2013 in Kalomo District during SMGL implementation. We also controlled for SMGL implementation, which would have likely accounted for any improvements at the facilities and the MWH in Kalomo during that time, as well as significant investments in the training and support of Safe Motherhood Actions Groups (SMAGs), community health volunteers who promote safe delivery and birth practices at the household level.
There are additional deterrents to MWH utilization that we were not able to capture in our study, including an increase in costs of delivery at a facility compared to delivery at home in MWHs, lack of privacy, and lack of respect from health staff [
16]. Other factors may be operating in women’s decision making about utilizing facilities for delivery, such as attitudes, personal norms, and behavioral control [
7,
36]. The lack of either provision of food or help with cooking and the limited availability of water and firewood for cooking, were among other factors related to quality that affected a woman’s staying in an MWH in both the global review of MWH utilization as well as the study in Zambia [
16,
18]. We were not able to systematically assess these factors in our study, though they may also have had an influence. It also not clear whether or not there are unmeasurable characteristics about the communities that have MWHs that contribute to women’s choosing to deliver at a facility, such as a supportive community environment for maternal health, community outreach activities independent of SMGL, or community chiefs and leadership promoting facility delivery more than in other areas.
Lastly, the generalizability of the findings may be limited, as data were collected from only two districts in Southern Province. Findings are perhaps most generalizable to other primarily rural districts that are culturally or geographically similar to the two study sites.
Acknowledgements
The authors would like to thank and acknowledge the work of the ZamCAT study team, the Maternity Waiting Homes Formative Evaluation study team, SMGL program staff in Zambia, and the Ministry of Health, District and Provincial Medical Offices and Chiefs of Southern Province. We especially thanks those who worked with us on the collection of this data including Rachel Fong, Jeanette Kaiser, Thandiwe Ngoma, Sara Gille, as well as RTC Fellows Pam Polino and Jaron Link. We also would like to express our gratitude to the women, their newborns and their families who participated in ZamCAT and to the health facility staff who participated in the MWH formative study. The activities discussed in the manuscript were partially supported by funding from Merck through its Merck for Mothers program and the RTC Fellowship. The content of this manuscript is solely the responsibility of the authors and does not represent the official views of Merck. This manuscript is based partially on data from a study funded by the Bill & Melinda Gates Foundation. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation.