Developing a community driven sustainable model of maternity waiting homes for rural Zambia
Introduction
Pregnancy and childbirth continue to be risky in Zambia, and represent a leading cause of death and disability for women of childbearing age. Lifetime risk of maternal death in Zambia - the probability that a 15 year old girl will eventually die from a complication related to childbirth - is 1 in 79 (World Health Organization, 2014). The country ranks 26th out of 184 for maternal deaths (Central Intelligence Agency, 2010) and a reported maternal mortality ratio of 398/100,000 live births (Central Statistical Office (CSO) [Zambia] et al., 2014). In response to the high mortality rates, the Zambian government has instituted an initiative encouraging women to give birth in a health care facility with a skilled birth attendant, such as a midwife or nurse (Ministry of Health Zambia, 2011).
While many maternal deaths are preventable (e.g. postpartum haemorrhage, pre-eclampsia/eclampsia, sepsis) with appropriate and timely care during labour and within 24 hours post partum, women continue to die from the ‘three-delays’ in resource poor settings (Lori and Starke, 2012, Combs et al., 2012). The three delays include: (1) delays in decision to seek care (cultural beliefs and myths, gender roles in the decision making process, lack of awareness); (2) delays in reaching the health facility in time (distance, bad terrain, lack of transport); and (3) delays in receiving adequate care once at the health facility (lack of skilled care, equipment, supplies) (Thaddeus and Maine, 1994). Due to these delays, home births remain common in Zambia - on average only 64% of deliveries are attended by a skilled birth attendants (SBA) decreasing to 52% in rural areas (CSO [Zambia], et.al., 2014).
While all the delays are equally important, one of the most important unanswered questions in the maternal health field remains the ‘distance problem’ women face when trying to reach a midwife or nurse who works at a health facility. Namely, how can we best bring women closer to higher-quality childbirth and immediate postpartum care with a SBA? This remains particularly challenging in rural and remote areas where delays in seeking care exist due to challenging terrain, vast distances between communities and facilities ill equipped and understaffed to provide high quality care, and a lack of reliable transportation options that restrict women's access to care (Greeson et al., 2016).
Maternity waiting homes (MWHs) are residential dwellings located near health facilities where women stay to await childbirth with a SBA and receive immediate postpartum services. They have been used in a variety of settings as a ‘geographic bridge’ to overcome distance and transportation barriers that can prevent women from receiving timely skilled midwifery or obstetric care (Lee et al., 2009). Studies indicate MWHs are a potential solution to these barriers and have shown a correlation between MWH utilisation and improved maternal and newborn health outcomes in variety of low resource countries (Cardoso, 1986, Chandramohan et al., 1995, Spaans et al., 1998, Eckermann, 2006, Bhutta et al., 2009, Lee et al., 2009, Lori et al., 2013a). Unfortunately, conclusions regarding the effectiveness of MWHs are constrained because the evidence-base is weak and implementation tends to be small-scale, unstandardised, and with limited attention to replicability (Stekelenburg et al., 2006, van Lonkhuijzen et al., 2012).
Maternity waiting homes already exist in Zambia; however, there is currently no model to ensure that the MWHs are meeting the needs of the women in their communities or that there is a plan for sustainability of the MWH. Thus, many of the pre-existing MWHs are in disrepair and underutilized. Two qualitative studies conducted in the rural Kalomo region of Zambia found that both men and women interviewed recognised the role of MWHs in improving maternal health outcomes, but had concerns about the condition of the homes such as sleeping space, kitchen facilities, water, and sanitation (Sialubanje et al., 2016; Sialubanje et al., 2015). These concerns coupled with financial constraints resulted in low use of maternal health services, such as MWHs. This has been documented in previous studies in Zambia (Gabrysch et al., 2011; Sialubanje et al., 2014; Stekelenburg et al., 2004). There is a gap in the literature on the community engagement principles used to involve a community in planning for MWHs prior to building the homes; although community involvement is assumed if the MWH is to be used and sustainable.
The purpose of this study was to explore stakeholders’ beliefs surrounding the acceptability, feasibility and sustainability of MWHs in two districts within Zambia. The research questions were: (1) What do stakeholders believe is the acceptability and feasibility of establishing MWHs in the target districts? and (2) What is the ideal community approach for a sustainable MWH model in rural Zambia? Data presented here were collected to inform the development of a core model and provide input into the design for potential funding agencies planning to construct MWHs in Zambia.
Section snippets
Methods
A qualitative study design employing a semi-structured interview guide for individual interviews and focus groups was used to explore the acceptablity, feasiblity, and sustainablity of MWH in rural Zambia. Demographic data were collected on all participants. The Maternal and Newborn Quality of Care Survey, Essential Inventory (USAID, 2012) was used to collect descriptive health care facility data. Latent content analysis was used to analyze focus group and individual interview data. All
Findings
Demographic data were collected on all participants (see Table 1). The sample included 546 participants comprised of SMAGs, husbands, and women of reproductive age, The SMAGs were both male (39%) and female (61%) and averaged 30.6 years in the communities, representing a stable presence in the communities they serve. Nearly 90% of husbands in the study worked as farmers. Women of reproductive age in the sample reported 0 to 8 children (M=3.20). Finally, key community leaders participated in the
Discussion
Participants in our study overwhelmingly supported MWHs as a way to address the barrier of distance to health facilities. However, certain conditions were articulated regarding acceptability. Our data suggest participants want and expect high quality, respectful care when birthing at a facility. High quality care is valued by the community; indeed, it serves as a critical draw. The quality of care must be considered when identifying communities for MWHs as an intervention to increase
Conclusion
Findings from our study contribute to a growing body of evidence on the use of MWHs as an intervention to bring women closer to facility-based care and skilled birth attendants for child birth. Participants in our study were overwhelmingly in favour of MWHs to address the issue of distance to a facility and provide women with a place to stay near a health facility capable of providing BEmONC at the time of birth.
Maternity waiting homes have been identified as a potential strategy to overcome
Acknowledgements
The research presented in this manuscript was supported by funding from Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, through its MSD for Mothers programme and in part by a research grant from Fogarty International, National Institutes of Health (1 K01 TW008763-01A1). The content of this publication is solely the responsibility of the authors and does not represent the official views of MSD or MSD for Mothers.
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