University of Groningen
Safe Motherhood: Maternity Waiting Homes in Ethiopia to Improve Women’s Access to
Maternity Care
Vermeiden, Catharina Johanna
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Publication date: 2019
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Vermeiden, C. J. (2019). Safe Motherhood: Maternity Waiting Homes in Ethiopia to Improve Women’s Access to Maternity Care. University of Groningen.
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BACKGROUND AND JUSTIFICATION
In 2013, the Gurage Zonal Health Department in Southern Ethiopia requested that Butajira General Hospital set up a Maternity Waiting Home (MWH) (Textbox 1), to help bridge the gap between its mostly rural population and the hospital. Until then, almost all women (90%) gave birth at home without a skilled birth attendant. Many women and babies were dying (676 maternal deaths per 100,000 live births; 46 perinatal deaths per 1,000 live births), and most of these deaths could have been prevented had they received timely care of sufficient quality (2, 3). This study was initiated to identify the contextual factors that could affect implementation of this MWH on hospital
grounds. Our research plans followed a recommendation by the World Health Organization (WHO) to perform a needs assessment in the community before establishing an MWH, to identify the level of existing health services, whether women use these services and possible constraints to uptake (4). The 2012 Cochrane on MWHs reports that while some MWHs were successful, others remained empty, due to various factors inhibiting access (1).
The first MWH in Ethiopia was established as early as 1973, at Attat Our Lady of Lourdes Catholic Primary Hospital. The largest observational study on MWHs to date was conducted at this hospital, which revealed significantly fewer maternal deaths and stillbirths among MWH users compared to non-users (5). In 2012, Gaym et al. described services provided at the nine functioning MWHs throughout the country, eight of which were located at hospitals (6). In 2014, we learned that the MWH intervention would be rolled out nationwide, which changed the scope of this study. In addition to guiding local implementation, this study then acquired the potential to play a role in upscaling the intervention in Ethiopia and provide evidence-base to a range of stakeholders, from policy makers to health providers who intended to establish an MWH.
My personal motivation to contribute towards reducing maternal and perinatal mortality is related to our youngest child, Sara. She is Ethiopian. After a long journey, her biological mother was bleeding when she arrived at Butajira Hospital, where my husband Floris Braat and I were working through Voluntary Service Overseas (VSO). She gave birth to a premature baby girl of 900 grams. Sara’s chances of survival were slim, even more so when her
Textbox 1 Definition maternity waiting homes
Maternity waiting homes offer temporary accommodation near a health centre or hospital where women with high-risk pregnancies and/or living far from a facility can await birth during the final week(s) of pregnancy close to 24-hour emergency obstetric and newborn care. Once labour starts or complications arise, women can easily access the facility to give birth. Some MWHs also offer post-natal care (1).
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birth mother left her in the hospital after a few days for personal reasons. I still do not know how Sara’s birth mom managed to reach hospital in time. But I know it saved Sara’s life. Through this research, I hope to make a contribution, however modest, towards realizing every human being’s right to timely, acceptable and affordable health care (7).
PROBLEM STATEMENT
Globally, the maternal mortality ratio fell by nearly 44% between 1990 and 2015, from approximately 385 to 216 per 100,000 live births (3). Despite this notable reduction, an immense challenge still lies ahead. In 2015, still 303,000 women died worldwide during pregnancy and following childbirth (8). Moreover, between 6 and 9 million women experienced acute or chronic morbidity, 2.6 million babies were stillborn, 2.7 million babies died in the first 7 days of life, and 30 million newborns required specialized/intensive care in a hospital. The vast majority of these tragedies (in total almost 13 million per year!) occurred in low- and middle-income countries, as a result of tremendous inequities between and within countries (9-12).
Ensuring that all women have timely access to skilled care during childbirth is an important strategy to reduce maternal and perinatal mortality and morbidity (13). Access to care is still a major challenge in low- and middle-income countries, with less than one-third of women with obstetric complications reaching an facility that provides emergency obstetric and newborn care (EmONC) (14).
The well-established Three Phases of Delay Model by Thaddeus and Maine helps to better understand the factors contributing to preventable maternal and perinatal mortality and morbidity (Textbox 2) (15).
MWHs are used to bring pregnant women closer to institutionalized care before labour starts, thereby potentially reducing first and second delays. MWHs were first introduced in the early 1900s in North America and Europe for young,
The “Three Delays” in relation to causes of maternal mortality
The First Delay Delays at community level in recognizing an emergency situation, and/or delays in the decision to seek care at a health facility
The Second Delay Delays in reaching appropriate care due to lack of access to transport or lack of resources to pay for transport
The Third Delay Delays in receiving appropriate care - including adequate quality of care - after arrival at a health facility
single pregnant women (16, 17). From the 1950s, MWHs were established in amongst others Nigeria, Malawi and Colombia (18). By 2017, the intervention had been implemented in over 25 countries to increase women’s access to institutionalized maternity care. The intervention is primarily implemented in low- and middle-income countries, including Ethiopia, but the governments of Canada and Australia have also applied it to bring indigenous women from remote areas closer to institutionalized care (19, 20).
ETHIOPIA
At the time of our study, Ethiopia had one of the world’s highest maternal mortality ratios in the world (2). The government’s vast and increasing health expenditures and important humanitarian aid contributions from donors have resulted in substantial progress (Table 1), but still not enough to ensure good health for all (Table 2). In 2015, the WHO advised Ethiopia to prioritize expanding the health workforce, improve the quality of reproductive, maternal, newborn and child health, increase public health financing, and focus on (operational) research to examine what works in the Ethiopian context (21). Between 2008 and 2016, the number of health facilities increased by 375% (Table 1). The health workforce also increased immensely by rapid expansion of pre-service education of doctors, nurses and midwives, which appeared to be accompanied by a reduction in the quality of education (Table 1) (22, 23).
In the 2015-2020 Health Sector Transformation Plan, MWHs were included as part of community ownership projects by the Health Development Armies. Health Development Armies have the objective to mobilise the community to take control over their own health and the factors affecting it (24). A national MWH guideline was drawn up in 2015 (25). By December 2016, 2,001 maternity waiting homes/rooms were realized (at 53% of all health facilities), most of which at health centres (91% of all MWHs) (Table 1) (26).
Table 1. Indicators health infrastructure in Ethiopia
Health infrastructure (6, 26, 27) 2000-2012 2014-2016 EmONC facilities 2008-2016 (including percentage of
the UN recommended number) 797 (11%) 3,804 (40%) Ambulances (introduced in 2012) 2014-2016 840 1,417 (85%
operational)
MWHs 2012-2016 9 2,001
Doctors, nurses and midwives density per 1,000
population 2000-2015 (SDG threshold 4.45) 0.25 0.80
EmONC: Emergency Obstetric and Newborn Care; MWH: maternity waiting home; SDG: Sustainable Development Goal; UN: United Nations
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Table 2. Indicators maternal healthcare in Ethiopia
Maternal healthcare in Ethiopia (2, 28, 29) 2000 2016 SDG target by 2030 Maternal mortality ratio
(per 100,000 live births) 871 412 199
Neonatal mortality rate
(per 1,000 live births) 49 29 10
Perinatal mortality rate
(stillbirths + deaths within first week of life, per 1,000 live births)
52 33 Not included
Antenatal care attendance at least once 27% 62% Not included Antenatal care attendance four or more times 10% 32% Not included
Facility births 5% 26% 90%
Postnatal care 10% 17% Not included
Problems in accessing healthcare 96%
(in 2005) 70% Not included
The Federal Democratic Republic of Ethiopia is divided into nine regions: Afar, Amhara, Beneshangul-Gumuz, Gambella, Harari, Oromia, Southern Nations, Nationalities, and Peoples, Somali and Tigray (Figure 1) (30). With over 100 million people, Ethiopia is the most populous African country after Nigeria (31). In 2016, Ethiopia ranked 174 out of 188 countries on the Human Development Index, a summary measure based on (healthy) life expectancy, access to knowledge and standard of living. The Netherlands ranked 7th (32,
33). Likewise, Ethiopia ranks low on the Gender Inequality Index (121st of
189 countries) (34).
This study took place in the Gurage Zone (Figure 1), a predominantly rural area in the Southern Nations, Nationalities, and Peoples’ Region, consisting of 13 woreda (districts) and two city administrations: Welkite and Butajira. The Gurage Zone is a semi-mountainous and semi-fertile area where most of the estimated 1.5 million people live in rural areas (85%) and of subsistence farming (35-37). Major religious denominations are Orthodox Christianity and Islam. In 2013/2014, the Gurage Zone had three hospitals (one government hospital and two faith-based hospitals) providing maternity care, plus 63 health centres and 400 health posts (personal communication). At the time of our study, the zone counted three paved roads, two from north to south (Addis Ababa - Welkite; Addis Ababa - Butajira - and beyond to Hosaena), and one from west to east (Welkite - Butajira - and beyond to Ziway in Oromia region). The Gurage culture has been described as male-centred and greatly respecting the elderly ‘Baliqu’. Until the early 2000s, marriages arranged by the men of both families were the norm. Increasingly, women have some
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say in whom they want to marry, but still need their family’s approval and are expected to prioritise social obligations over personal preference (38). Gender-based violence against women and girls is common in Ethiopia. A 2015 systematic review found a lifetime prevalence of domestic violence against women by their husband of 20 to 78%. Two of the ten included studies were done within the Gurage Zone, which reported levels of 45% and 72% for 2005 and 2009, respectively (39). No zonal data were found on educational levels, but nationally, 48% of women aged 15-49 years had no education, compared to 28% of men. Physical violence against women has a strong negative correlation with a woman’s educational level (28).
Data collection took place at various locations within the Gurage Zone: 1. Attat Our Lady of Lourdes Catholic Primary Hospital (hereafter referred to
as “Attat Hospital” in the western Gurage Zone;
2. Butajira General Hospital (hereafter referred to as “Butajira Hospital”) in the eastern Gurage Zone;
3. All 20 health centres in the eastern Gurage Zone;
4. In each of the five Kebeles (neighbourhoods) in the Butajira city administration;
5. In the vicinity of 14 health centres in the districts Mareko, Meskan and Soddo within the eastern Gurage Zone.
CONCEPTUAL FRAMEWORK
Gabrysch and Campbell (2009) argue that the Three Delays Model implicitly looks at homebirths with complications, without bearing in mind women who opt for a “preventive” facility birth (40). Thus, they expanded the original framework by conceptually distinguishing between emergency care-seeking and preventive care-seeking for childbirth (Figure 1). As stated by Gabrysch and Campbell (2009):
‘While similar factors are involved, their relative importance may differ or they may act in different ways. Cost of transport, for instance, is likely to be a greater deterrent for preventive than for emergency care-seeking. Physical accessibility may exert its role on preventive care-seeking mainly through influencing the decision to seek care, while in the case of emergency care-seeking, reaching the facility in time may be the main problem.’ [(40), p3]
Since using an MWH is a preventive measure to ensure facility birth, this study used the determinants of the Adapted Three Delays Model (Figure 2) to design, analyse and describe factors affecting MWH utilisation in the Gurage Zone, Southern Ethiopia.
Figure 2 Adapted Three Delays Model (38)
Textbox 3 lists the 20 determinants that Gabrysch and Campbell identified from their literature review. Factors affecting MWH utilisation were summarized in two systematic reviews, which included publications from 1979 to 2013 (1, 41). Most of 28 included studies used a qualitative design; two studies were done in Ethiopia (5, 6). An important sociocultural factor that affected MWH use was (the lack of) community involvement in the design, development and maintenance of an MWH. Providing culturally adapted services at an MWH and health facility, as well as involving traditional birth attendants were reported as enabling factors in some settings. Several studies reported that family members did not allow MWH use because women were needed at home. Factors relating to perceived benefit/need concerned the level of awareness about the presence and benefits of MWHs. Many studies reported that MWHs were not economically accessible, due to costs of amongst others transport, food and medical services. Concerning physical accessibility, women reported not wanting to use an MWH that was located in an area that was considered unsafe or still too far from the health facility. Many studies described the negative effect of poor MWH facilities and services on their use, while some also related limited MWH use to perceived low quality of care at the health facility. Lonkhuijzen et al. (2012) stress the importance of careful planning for successful introduction of an MWH (1).
Textbox 3 Determinants and variables of the Adapted Three Delays Model perception Sociocultural factors Perceived benefit/need Economic Accessibility Physical Accessibility Receiving normal delivery care at health facility Preventing maternal death Development of COMPLICATIONS
Emergency care seeking Preventive care seeking
Before delivery
Quality of emergency care
Quality of
preventive care Referral
Development of COMPLICATIONS Phase 1: Deciding to seek preventive care for delivery Phase 2: Identifying and reaching health facility Home delivery Phase 1: Deciding to seek preventive care for complication Phase 2: Identifying and reaching health facility Phase 3: Receiving adequate and appropriate treatment for complication
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RESEARCH AIM AND QUESTIONS
The aim of this PhD thesis was to explore factors affecting MWH utilisation in a rural setting in Southern Ethiopia. Applying a convergent parallel design, we conducted five studies to answer our three research questions (see Table 3). The first research question concerns the impact of MWH use on maternal and perinatal outcomes. Over 25 countries are using the intervention, but evidence on their effectiveness is limited and of low quality (1). The World Health Organization has therefore stated that research on the effectiveness of MWHs needs to be prioritized (42). The rationale behind the second research question was to identify contextual factors that could affect implementation of the MWH at Butajira Hospital. Insights into these factors have the potential to appeal to a wider audience involved in maternal and newborn health in low- and middle-income countries. The third research question was added when we learned that most MWHs were established at health centres. If women await birth at an MWH in the final week(s) of pregnancy, it is important to know whether health centres are capable of providing the necessary life-saving care in case of obstetric complications.
OUTLINE OF THE THESIS
The second chapter of this thesis examines the effect of MWH use on birth outcomes and mode of birth by comparing MWH users to non-users at hospitals with and without an MWH. The third chapter documents which determinants of the Adapted Three Delays Model are associated with intended use of an MWH in the catchment area of Butajira Hospital. The fourth chapter describes a qualitative exploration of community members’ and frontline healthcare workers’ perspectives on MWH use and facility births. Chapter five looks closely at the MWH intervention at Attat Hospital, which was established
Figure 2 Adapted Three Delays Model (38)
Textbox 3 lists the 20 determinants that Gabrysch and Campbell identified from their literature review. Factors affecting MWH utilisation were summarized in two systematic reviews, which included publications from 1979 to 2013 (1, 41). Most of 28 included studies used a qualitative design; two studies were done in Ethiopia (5, 6). An important sociocultural factor that affected MWH use was (the lack of) community involvement in the design, development and maintenance of an MWH. Providing culturally adapted services at an MWH and health facility, as well as involving traditional birth attendants were reported as enabling factors in some settings. Several studies reported that family members did not allow MWH use because women were needed at home. Factors relating to perceived benefit/need concerned the level of awareness about the presence and benefits of MWHs. Many studies reported that MWHs were not economically accessible, due to costs of amongst others transport, food and medical services. Concerning physical accessibility, women reported not wanting to use an MWH that was located in an area that was considered unsafe or still too far from the health facility. Many studies described the negative effect of poor MWH facilities and services on their use, while some also related limited MWH use to perceived low quality of care at the health facility. Lonkhuijzen et al. (2012) stress the importance of careful planning for successful introduction of an MWH (1).
Textbox 3 Determinants and variables of the Adapted Three Delays Model
Sociocultural factors • Maternal age • Marital status
• Ethnicity, religion, traditional beliefs + • Family composition • Woman's education + • Husband’s education + • Woman’s autonomy + Perceived benefit/need • Information availability + • Health knowledge + • Pregnancy wanted • ANC use
• Previous facility birth • Birth order • Complications Economic accessibility • Woman’s occupation • Husband’s occupation • Ability to pay + Physical accessibility • Region, urban/rural • Distance, transport, roads + Quality of care
• Perceived quality of care + +: variables included in studies on
in 1973 and was used from the start. To learn from their experience, we explored which factors facilitated uptake. The sixth chapter examines basic emergency obstetric care provision at all 20 health centres in the catchment area of Butajira Hospital. Chapter seven is a commentary on MWHs that was published in the Journal of Midwifery and Women’s Health alongside two studies on MWHs in Zambia and Liberia. In the eighth and last chapter, the most important study findings are summarized and put into a broader perspective.
Table 3. Research questions and methodologies
Research questions Studies & methodologies Chapter A. What is the impact
of MWH use on birth outcomes?
1. A retrospective cohort study using hospital records comparing three groups of women who gave birth: a) MWH users at Attat Hospital, b) non-users at Attat Hospital, c) women who gave birth at Butajira Hospital without an MWH.
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B. What are facilitators and barriers to MWH use in the Gurage Zone, Southern Ethiopia?
2. A community-based cross-sectional study design using a structured questionnaire among recently delivered and pregnant women in the eastern Gurage Zone.
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3. A qualitative study using in-depth
interviews and five focus group discussions with community members and frontline healthcare workers in the eastern Gurage Zone.
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4. An exploratory sequential mixed methods study design at Attat Hospital in the western Gurage Zone consisting of in-depth interviews with staff and MWH users, focus group discussions with users and attendants, a structured questionnaire among users, an observation period and review of annual facility reports.
5 C. What is the capacity of health centres to provide basic emergency obstetric and newborn care in the eastern Gurage Zone, Ethiopia?
5. A facility-based survey at all health centres in the eastern Gurage Zone, using an abbreviated version of the Averting Maternal Death and Disability needs assessment tool for emergency obstetric and neonatal care.
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