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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Tienke Vermeiden
Safe Motherhood:
MATERNITY WAITING HOMES IN
ETHIOPIA TO IMPROVE WOMEN’S
ACCESS TO MATERNITY CARE
Design by Nina Mathijsen, takeadetour.eu
Layout and printing by Loes Kema, GVO drukkers & vormgevers B.V.
ISBN/EAN: 978-94-034-1680-9 (printed version)
ISBN/EAN: 978-94-034-1681-6 (electronic version)
Tienke Vermeiden
Safe Motherhood: Maternity Waiting Homes in Ethiopia to Improve Women’s Access to Maternity Care
Doctoral Dissertation, University of Groningen, The Netherlands.
The research presented in this thesis was carried out at the GZW Global Health – Public Health Research Department of the Research Institute SHARE of the Graduate School of Medical Sciences of the University of Groningen. This research was supported by Laerdal Foundation, Voluntary Service Overseas and Otto Kranendonk Foundation.
The funders had no role in study design, data collection and analyses, decisions to publish, preparation of manuscripts or of this thesis.
Copyright © 2019 Tienke Vermeiden
All rights reserved. No part of this thesis may be reproduced, stored or transmitted in any way or by any means without the prior permission of the author, or when applicable, of the publishers of the scientific papers.
Safe Motherhood:
Maternity Waiting Homes in Ethiopia
to Improve Women’s Access to
Maternity Care
PhD Thesis
to obtain the degree of PhD at the University of Groningen
on the authority of the Rector Magnificus prof. E. Sterken
and in accordance with the decision by the College of Deans. This thesis will be defended in public on
Monday 24 June 2019 at 16.15 hours by
Catharina Johanna Vermeiden
born on 3 October 1976 in Ridderkerk
Supervisor
Prof. J. Stekelenburg Co-supervisor
Prof. T.H. van den Akker Assessment Committee
Prof. S.A. Scherjon
Prof. J.J.M. van Roosmalen Prof. J.E.W. Broerse
CONTENTS
Chapter 1. General introduction 9
Chapter 2. Comparison of pregnancy outcomes between
maternity waiting home users and non-users at hospitals with and without a maternity waiting home: a retrospective cohort study
25
Chapter 3. Factors associated with intended use of a maternity
waiting home in Southern Ethiopia:
a community-based cross-sectional study
43
Chapter 4. Community and healthcare worker perspectives on
maternity waiting homes and facility births in rural Ethiopia: a qualitative study
63
Chapter 5. Facilitators for maternity waiting home utilisation at
Attat Hospital: a mixed-methods study based on 45 years of experience
89
Chapter 6. Emergency obstetric care provision in Southern
Ethiopia: a facility-based survey 113
Chapter 7. Commentary: Maternity waiting homes as part of an
integrated program for maternal and neonatal health improvements: women’s lives are worth saving
131
Chapter 8. General discussion and conclusion 145
Summary / samenvatting 175
Curriculum vitae 185
Acknowledgements 187
Research Institute SHARE 191
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).
1
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
1
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
1
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
1
RESEARCH AIM AND QUESTIONSThe 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 MWHs.
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.
2
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.
3
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.
4
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.
1
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Chapter 2. Comparison of pregnancy
outcomes between maternity waiting
home users and non-users at
hospitals with and without a maternity
waiting home:
a retrospective cohort study
Floris Braat *, Tienke Vermeiden *, Gashaw Getnet, Rita Schiffer,Thomas van den Akker, Jelle Stekelenburg *These authors contributed equally to this work.
International Health, Volume 10, Issue 1, 1 January 2018, Pages 47-53 (Open Access) https://doi.org/10.1093/inthealth/ihx056
ABSTRACT 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. Chi-square (χ2) or Odd Ratios (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.
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INTRODUCTIONMost of the 303,000 maternal deaths, 2.6 million stillbirths and 2.7 million early neonatal deaths that are estimated to have occurred in 2015 could have been prevented through timely access to skilled maternity care (1-3). Access is still a major challenge in many low- and middle-income countries (LMICs) (4). A 2015 systematic review showed that less than one-third of women with obstetric complications actually reached a facility that provided emergency obstetric and newborn care (5). Barriers to access are lack of a nearby facility and transport, long travel times due to poor roads or traffic, as well as economic and cultural factors (4, 6, 7).
In some LMICs, subsidized routine and emergency transport systems are available for women seeking obstetric care. The number of ambulances, for instance, is growing rapidly. Their impact, however, is still limited because fully functional transport systems require considerable additional investments as well as a high level of logistic coordination (4). Maternity Waiting Homes (MWHs) near health facilities, where women are encouraged to spend the final weeks of pregnancy, are a means to bypass resource-intensive transport requirements and provide ready access to the clinic as soon as labour starts or complications arise (8, 9). MWHs are present in over 25 countries but the evidence that these homes actually improve maternal and neonatal outcome is limited (8). The World Health Organization has therefore stated that research on the effectiveness of MWHs needs to be prioritized (10). A Cochrane meta-analysis on MWHs found no randomized controlled trials and only six observational studies that evaluated the effect of MWHs on maternal and perinatal outcome, of which four reported better outcomes among users compared to non-users (8). Main point of criticism on these studies is that delivery outcomes of MWH users were compared to non-MWH users within the same hospital. This may lead to selection bias, since the latter group of women were more likely to start labour at home and seek help only after developing complications. Their outcomes were often poor, which may give overestimation of the protective effect of the MWH (8).
The rationale behind this present study is to improve on the population group comparisons by including a population of labouring women in a hospital without an MWH, which will contain women with high-risk pregnancies who might have used an MWH if the hospital had had one available. These women likely expressed different health-seeking behaviour compared to women who only go to hospital in case complications arise. Hence, by bringing into the comparison a population of labouring women without access to an MWH, aforementioned selection bias would be reduced.
The objective of this study was to examine the impact of an MWH by comparing pregnancy outcomes between three groups of women who gave
birth in Attat Hospital and Butajira Hospital: MWH users vs non-MWH users in Attat Hospital, MWH users in Attat Hospital vs Butajira Hospital and non-MWH users in Attat Hospital vs Butajira Hospital.
MATERIALS AND METHODS Design and study area
Using a structured questionnaire, sociodemographic data were collected in 2014 among sampled MWH and non-MWH users who gave birth in Attat Hospital and among post-labour women in Butajira Hospital. Using a retrospective cohort design, data were abstracted from routine hospitals records of all women who gave birth at Attat Hospital and Butajira Hospital from January 2011 until December 2014.
Setting
This study took place in Ethiopia, where the maternal mortality ratio decreased from 871 to 412 deaths per 100,000 live births between 2000 and 2016. In that same period, institutional births increased from 6 to 26% (11). Attat and Butajira Hospitals were selected as study sites because these health facilities are similar in several regards, as summarized in Table 1. They are both located in the same zone: the Gurage Zone in the Southern Nations, Nationalities, and Peoples’ Region, where 85% of the estimated 1.5 million people live in rural areas and 70,000 births are counted annually (12, 13). The major difference between the two hospitals is that Attat Hospital had an MWH with 48 beds, where 500 to 700 women stay annually; Butajira Hospital did not have one at the time of the study.
Table 1. Reasons for selecting study sites of Attat and Butajira Hospitals
Characteristic Attat Hospital Butajira Hospital
Location (14) · Close to Welkite town (estimated population: 52,223 inhabitants) · Western Gurage Zone · 175 km southwest of referral
hospital in Addis Ababa
· In Butajira town (estimated population: 60,515 inhabitants)
· Eastern Gurage Zone · 150 km south of referral
hospital in Addis Ababa Childbirth
services(13) · Comprehensive emergency obstetric and newborn care, 24 h/d, 7 d/wk
· Family planning, antenatal and postnatal care services
· Comprehensive emergency obstetric and newborn care, 24 h/d, 7 d/wk
· Family planning, antenatal and postnatal care services Labour ward
staff (15, 16) 1 obstetrician/gynaecologist, 1 surgeon, 1 anaesthetist, 4 health officers, 5 midwives
1 obstetrician/gynaecologist, 1 surgeon, 3 anaesthetists, 1 medical doctor,1 health officer, 12 midwives
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Labour ward beds 5 5 Average number of annual deliveries 2011-2014 2,052 2,368 Registrationof deliveries Registration book Ethiopian Federal Ministry of Health Registration book Ethiopian Federal Ministry of Health
The MWH at Attat Hospital was established in 1973. Admission criteria are based on risks relating to previous obstetric history, the current pregnancy or distance to a facility (see Table 2 for most common reasons for admission among our sample of MWH users). MWH users stay 20 days on average, visit the antenatal clinic daily for check-ups and to participate in health education sessions on maternal health related topics (17). They are asked to bring an attendant, usually their husband. Untill the beginning of 2013, the user fee at Attat Hospital was 50 Ethiopian Birr (approximately $2) for the MWH stay as well as the delivery. This fee was dropped following the introduction of a law on free delivery services. MWH users generally provide for their own transport, food and firewood; hospital meals are given to poor MWH users and their attendants.
Table 2. Main reasons for admission to the MWH among a sample of MWH users at Attat Hospital (n = 244)
Medical reason(s) for admission to the MWH n (%)*
Obstetric history
Previous Caesarean section 76 (31.1) Previous stillbirth/early neonatal loss 48 (19.7)
Current pregnancy
Multiple pregnancy 36 (14.8)
Mal or breech presentation 25 (10.2)
Anaemia 20 (8.2)
Primigravida 19 (7.8)
Grand multiparity 17 (7.0)
Pre-eclampsia 16 (6.6)
Antepartum haemorrhage 13 (5.3)
MWH = Maternity waiting home, n = frequency, % = percentage
* The percentages add up to more than 100% as some women had more than one reason for admission
Procedure
Sociodemographic data were collected using a structured questionnaire in the three aforementioned groups of women. For Attat Hospital, the sample size was calculated using Epi Info StatCalc, with a 5% margin of error and a 95% confidence interval (CI), based on the annual number of MWH users and non-MWH users who gave birth at Attat Hospital in 2012. In total, 244 MWH users and 306 non-MWH users were conveniently sampled from the MWH and post-labour ward, respectively. Data collection among MWH users took place between May and December 2014 and among non-MWH users in November and December 2014. In the post-labour ward of Butajira Hospital, we were able to collect sociodemographic data from 153 women. Based on the annual number of births in Butajira Hospital in 2012, this sample has a margin of error of 7.5% and a CI of 95%. Women were sampled in the post-labour ward of Butajira Hospital between May and October 2014.
Hospital staff members were trained to collect the sociodemographic data. In the MWH in Attat Hospital and the post-labour ward of Butajira Hospital, data were collected using a larger questionnaire on MWHs for which data collectors received a two-day training session that included study objectives, topics related to maternal health, interviewing skills, role-playing, and test questionnaires. Data collectors in the post-labour ward in Attat Hospital received targeted training on how to conduct the one-page questionnaire. Data collectors were supervised by the investigators GG and RS. The following variables were included: age category, parity, religion, literacy, educational level, relative household wealth, travel time to the hospital of admission, and specifically for MWH users, reason(s) for admission to the MWH. Data collectors estimated the respondent’s age, since most women did not know their age. Parity was recorded and recoded into two categories: primigravida and multigravida. Respondents’ religion was recorded and recoded into “Christian” or “Muslim”. To test literacy, respondents were asked to read a written sentence out loud. Respondents who could not read the entire sentence were categorized as non-literate. To determine their educational
level, respondents were asked to indicate the highest level of school they
had attended. Respondents were asked to compare their household wealth with those around them on a four-point scale (very wealthy, wealthy, poor, very poor). In the analyses, a combined score was used: (very) wealthy and (very) poor. Furthermore, we asked how long it took respondents to travel
from their household to the hospital of admission in hours (h) and minutes
(min). Finally, reason(s) for admission to the MWH were registered using 13 pre-defined categories (previous Caesarean section, previous stillbirth/ early neonatal loss, multiple pregnancy, malpresentation, breech presentation, anaemia, primigravida, grand multiparity, pre-eclampsia, antepartum haemorrhage, polyhydramnios, previous fistula repair, and other). Data were entered into SPSS version 22 by investigators FB and TV. Subsequently, data were double-checked variable by variable by TV.
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The number of births, maternal deaths, uterine ruptures, live births, stillbirths, and birth mode were abstracted from the hospitals’ monthly labour ward reports. Butajira Hospital registered uterine ruptures and assisted vaginal deliveries (vacuum extractions and forceps deliveries) from August 2012, thus these retrospective data are available from that month until December 2014.Data analysis
Proportions were calculated for sociodemographic variables using the total number of respondents per sample. Because of some missing values, percentages will not always add up to 100.0%. Bivariate logistic regression was used to calculate crude Odds Ratios (OR) with 95% CI comparing sociodemographic data of the three groups of women who gave birth in Attat and Butajira Hospitals.
In addition to reporting frequencies and proportions on pregnancy outcomes, the hospitals’ maternal mortality ratios and stillbirth rates were calculated. Furthermore, OR with 95% CI compared birth outcomes of the same three groups mentioned above. Since it was not possible to calculate OR for maternal deaths (one of the values was zero), Chi-Square (χ2) was calculated for this outcome variable.
RESULTS
Sociodemographic profile
Table 3 provides an overview of sociodemographic characteristics of MWH- and non-MWH users in Attat Hospital and of women who gave birth in Butajira Hospital.
Comparing MWH users in Attat Hospital to non-MWH users in Attat Hospital and to women in Butajira Hospital, MWH users were more likely to be aged 35 years or above than non-users, but no significant differences were found between users and women giving birth in Butajira Hospital. Furthermore, MWH users in Attat Hospital had higher odds of being multiparous, less educated and poorer than non-users in Attat Hospital and women in Butajira Hospital. They also travelled significantly longer to hospital. No significant differences were found regarding religion or literacy between users and non-users at the two hospitals.
Comparing non-MWH users in Attat Hospital to women giving birth in Butajira Hospital, non-users were less often 35 years or older, had more frequently attended primary school but less frequently secondary school or higher, and their travel time was on average 12 minutes shorter. No significant differences were found regarding parity, religion, literacy and household wealth between non-users in Attat and women in Butajira Hospital.
Birth outcomes
In total, 17,679 births were attended to in Attat and Butajira Hospitals. No maternal deaths occurred in the MWH-group in Attat Hospital, compared with 20 (0.4%) in the non-MWH-group in Attat Hospital (p=0.001) and 31 (0.3%) in Butajira Hospital (p=0.003). These data are equivalent to maternal mortality ratios of 0, 368.8 and 327.3 per 100,000 live births, respectively. No significant differences were found regarding maternal deaths between the non-MWH-group in Attat Hospital and in Butajira Hospital (Table 4).
The number of stillbirths was significantly lower among MWH users (38/1.4%) than among non-MWH users (393/7.2%) and women in Butajira Hospital (717/7.6%). The corresponding stillbirth rates were 13.6, 72.5 and 75.7 per 1,000 live births, respectively. No significant differences were found regarding stillbirths between the non-MWH-group in Attat Hospital and in Butajira Hospital (Table 4).
Birth modes
MWH users had the highest proportion of Caesarean sections (41.1%), compared to 22.0% among non-MWH users in Attat Hospital and 17.9% in Butajira Hospital (Table 4). Non-MWH users in Attat Hospital had the highest proportion of assisted vaginal deliveries (20.9%), compared to 13.5% among MWH users and 11.7% in Butajira Hospital.
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Table 3. Sociod emographic cha racteristics of selected samples of women who gave birth in Atta t Hospital (MWH and non-MWH) and Butajira Hospital (N = 703)Variables & categories
Attat Hospital MWH (n = 244), n (%) Attat Hospital non-MWH (n = 306), n (%) Butajira Hospital (n = 153), n (%) OR (95% CI) Attat MWH vs non- MWH OR (95% CI) Attat MWH vs Butajira OR (95% CI) Attat non-MWH vs Butajira
Age 24 years or younger 63 (25.8) 99 (32.4) 43 (28.1) 1 1 1 25-34 years 152 (62.3) 19 1 62 .4 ) 91 (59.5) 1.25 (0.85-1.83) 1.14 (0.72-1.82) 0.91 (0.59-1.41) 35 + years 27 ( 11 .1 ) 16 (5.2) 17 ( 11 .1 ) 2.65 (1.32- 5.31)* 1.08 (0.53 -2.23) 0.41 (0.19-0.88)* Age - repeated 25-34 years 1 1 1 35 + years 2.12 (1.10- 4.08)* 0.95 (0.49 -1.84) 0.45 (0.22 -0.93)* Parity 0 births 39 (16.0) 196 (35.6) 62 (40.5) 1 1 1 1 or more births 205 (84.0) 354 (64.4) 91 (59.5) 4.43 (2.94-6.68)* 3.58 (2.24 -5.73)* 0.81 (0.55 -1.20) Religion Christian 117 (48.0) 269 (48.9) 61 (39.9) 1 1 1 Muslim 123 (50.4) 277 (50.4) 91 (59.5) 1.03 (0.74-1.45) 0.71 (0.47-1.06) 0.68 (0.46 -1.01) Literacy Literate 99 (40.6) 24 2 (4 4. 0) 73 ( 47 .7 ) 1 1 1 Non-literate 141 (57.8) 300 (54.6) 76 (49.7) 1.23 (0.87-1.73) 1.37 (0.91-2.06) 1.11 (0.75-1.65)
Educational level Secondary
school and higher 23 (9.4) 11 7 (2 1. 3) 54 (35.3) 1 1 1 Primary school 91 (37.3) 220 (40.1) 41 (26.8) 4.84 (2.84-8.25)* 5.19 (2.91-9.27)* 1.07 (0.67-1.72) No schooling 126 (51.6) 209 (38.0) 57 (37.3) 2.62 (1.53-4.46)* 5.21 (2.83-9.61)* 1.99 (1.22-3.25)* Educational level - repeated Primary school 1 1 1 table continues
No schooling 1.85 (1.27-2.70)* 1.00 (0.62-1.62) 0.54 (0.33-0.87)*
Relative household wealth (Very)
wealthy 16 (6.6) 13 4 (2 4. 4) 71 ( 46 .4 ) 1 1 1 (Very) poor 228 (93.4) 416 (75.6) 82 (53.6) 8.94 (5.13-15.61)* 12.34 (6.78-22 .4 4) * 1.38 (0.93-2.04) Travel time to hospital in hours and minutes (mean ± SD) 2h27min± 1h27min 1h± 52min 1h12min ± 1h7min 3.08 (2.50-3.80)* 2.18 (1.78-2.67)* 0.81 (0.66-0.98)* * p < 0.05, MWH: maternity waiting home Table 4. Comparison of birth outcomes and birth mode of wom en in Butajira and Atta t Hospital (MWH and no n-MWH) bet ween 2 011 and 2014 (N = 17,679) Variables Attat Hospital MWH (n = 2,784), n (%) Attat Hospital non-MWH (n = 5,423), n (%) Butajira Hospital (n = 9,472), n (%) OR (95% CI) Attat MWH vs. non-MWH OR (95% CI) Attat MWH vs. Butajira OR (95% CI) Attat non-MWH vs. Butajira
Birth outcome Maternal
deaths 0 (0.0) 20 (0.4) 31 (0.3) _a _b 1.13 (0.64-1.98) Stillbirths 38 (1.4) 393 (7.2) 71 7 (7 .6 ) 0.18 (0.13-0.25)* 0.17 (0.12-0.24)* 0.95 (0.84-1.08) Uterine ruptures c 2 (0.1) 40 (1.1) 12 2 (1 .8 ) 0.05 (0.01-0.19)* 0.04 (0.01-0.16)* 0.62(0.43-0.88)*
Birth mode Assiste
d vaginal delive rie s c, d 377 (13.5) 1,133 (20.9) 799 (11.7) 0.46 (0.40-0.52)* 1.18 (1.04-1.35)* 2.14 (1.92-2.38)* Caesarean sections d 1, 14 5 (4 1. 1) 72 2 (2 2. 0) 1,692 (1 7.9) 2.14 (1.92-2.38)* 3.21 (2.93-3.52)* 1. 21 ( 1. 12 -1 .3 2) * MWH: maternity waiting home. a χ 2= 10.292 (df 1), p = 0.001 b χ 2= 9,135 (df 1), p = 0.003 c Data available for 29 months only d Reference category for assisted vaginal deliveries = n - assisted vagin al deliveries; Reference category for Caesarean sections = n - deliveries by Caesarean section * p < 0.05
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DISCUSSIONMWH users in Attat Hospital were less educated, poorer, and had to travel longer to reach a hospital compared with both non-MWH users in Attat Hospital and women who gave birth in Butajira Hospital. While poverty and inequity are factors known to negatively impact the survival of women and neonates, the more vulnerable group of women in our study had better birth outcomes than women with higher socio-economic status who did not use an MWH (18, 19).
The sociodemographic characteristics of the three groups of women in this study were similar regarding religion and literacy. Overall, women who gave birth in Butajira Hospital were more educated, wealthier and lived closer to hospital than women who gave birth in Attat Hospital, which may have been caused by sampling bias. Levels of education were higher among women in Butajira Hospital, which is located in town and serves more urban women, who generally have higher levels of education compared to women who live in rural areas (20). In addition, user fees were higher for Butajira Hospital compared with Attat Hospital until the beginning of 2014, which may have negatively impacted service utilization (21). This may explain why women who gave birth in Butajira Hospital were wealthier on average. MWH-women travelled an average of two and a half hours to Attat Hospital, while non-MWH users were on average only one hour away. Women in Butajira Hospital travelled on average 12 minutes longer than non-users in Attat Hospital. This may be explained by the fact that Butajira Hospital did not have an MWH available that would have allowed for risk selection based on distance. Between 2011 and 2014, all maternal deaths and nearly all stillbirths and uterine ruptures in Attat Hospital occurred among women who did not use the MWH. No data were collected to ascertain circumstances surrounding deaths. Our findings are consistent with the results from Kelly et al. covering the period 1987-2008 in the same hospital, although we found remarkably lower proportions of maternal deaths, uterine ruptures and stillbirths in the non-MWH group than the Kelly study (22). Comparing the period 2011-2014 to 1987-2008, the hospital’s maternal mortality ratio reduced by 72% and its stillbirth rate by 62%. These findings follow the Ethiopian trend with a 53% reduction in maternal mortality ratio in approximately the same period, which is likely the result of large investments in the Ethiopian health system (11). Both our study and the Kelly study found extremely large differences between MWH users and non-users in Attat Hospital. Other studies comparing MWH users to women admitted directly to hospital reported smaller or even no differences (23-28). The findings from Attat Hospital could be the result of effective risk selection for MWH admission in Attat Hospital, in combination with the long-standing custom in Ethiopia of having a home delivery unless complications occur (29).
More Caesarean sections were performed in Attat Hospital than in Butajira Hospital. The proportion of Caesarean sections in the MWH group was especially high, indicating the high-risk status of the women admitted to the MWH. Similar findings were described by Kelly et al. in 2010 (22). Moges et al. reported that 90% of Caesarean sections in Attat Hospital were performed as an emergency, with the following indications accounting for 83% of cases: cephalopelvic disproportion, previous Caesarean section, foetal distress, malpresentation and malposition, and antepartum haemorrhage (30). Other studies comparing MWH users with women admitted directly to hospital also reported higher proportions of Caesarean sections in the MWH group, but the differences between the groups were smaller (24, 27). The assisted vaginal delivery rate at both hospitals was comparable to those in high-income countries such as the United Kingdom and Canada (31). Vacuum extraction was more common in the non-MWH group compared to the MWH group. Kelly et al. indicated it to be due to the high number of women in the non-MWH group with an intra-uterine foetal death on arrival in the labour ward, which are mainly delivered by vacuum extraction (22). However, the stillbirth rate of Attat Hospital is comparable to that of Butajira Hospital, yet the latter had a much lower proportion of assisted vaginal deliveries. This may be due to differences between health providers in the way they manage childbirth. Another possible explanation is that part of women in the non-MWH-group who had an assisted vaginal delivery would have had an elective Caesarean section if they had stayed at the MWH. Further research is needed to better understand the high vacuum extraction rate among non-users.
The MWH at Attat Hospital reached rural, poor, uneducated women with high-risk pregnancies. This may be the result of an extensive community health promotion campaign that started in 1982. A study from Malawi reported similar findings, whereas a study from Timor-Leste concluded that the intervention only reached women within five kilometres of the health facility (32, 33). An important difference between the MWHs in Timor-Leste and the one at Attat Hospital is the number of years that the MWHs were operational at the time of the study (one to three years compared to 38 years, respectively).
This is the first observational study comparing pregnancy outcomes between MWH users and non-users at one hospital with a second hospital without an MWH. The study design clearly has its limitations. Firstly, data were abstracted from routine hospital records. Registers are often incomplete and underreporting is a common problem in LMICs (1, 34). No records were kept about high-risk pregnancies, preventing comparisons between high- and low-risk pregnancies. Secondly, the study design does not allow us to establish causality, only associations. A possible confounding effect could be the different ways that health providers at the two hospitals manage labour. Also, health providers at Attat Hospital may have treated MHW-users differently than non-MHW-users, with more attention and vigilance, and by
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encouraging MWH users to be pro-active. Lastly, possible sampling bias may have caused sociodemographic differences, which means that our findings should be interpreted with caution. Nevertheless, since MWH users had significantly better outcomes than women who did not use an MWH, our data suggest that MWHs contribute to reducing maternal deaths, stillbirths and uterine ruptures, thereby providing an important service to women living in rural areas that have difficulty accessing facilities providing emergency obstetric and neonatal care.Randomized controlled trials provide the highest level of scientific evidence, but are ethically challenging in a setting with high barriers to accessing maternity care. Given these challenging circumstances, it would be worthwhile to further study the effectiveness of an MWH by comparing outcomes of both home and facility births in communities with an MWH to those in communities without an MWH.
CONCLUSIONS
Women with high-risk pregnancies that used an MWH in rural Ethiopia had less favourable sociodemographic characteristics but better birth outcomes than women who gave birth at the same hospital but did not use it and women who gave birth at a hospital without an MWH. The use of an MWH appears to improve birth outcomes by enabling women with high-risk pregnancies with timely access to childbirth services and interventions in case they develop complications. This study provides additional evidence on the effectiveness of MWHs, which may guide policy makers to further implement this intervention in Ethiopia and throughout the region.
Acknowledgements
We are grateful to the staff of Butajira and Attat Hospitals for their support. Particular gratitude is extended to the women who participated in the study.
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Chapter 3. Factors associated with
intended use of a maternity waiting
home in Southern Ethiopia:
a community-based cross-sectional
study
Tienke Vermeiden, Floris Braat, Girmay Medhin, Asheber Gaym, Thomas van den Akker, Jelle Stekelenburg
BMC Pregnancy and Childbirth BMC series 2018, 18:38 (Open Access) https://doi.org/10.1186/s12884-018-1670-z
ABSTRACT 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 women with high-risk pregnancies 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]).
Conclusion
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.
