Innovations in health care delivery are crucial to improving maternal health worldwide. Introduced in Northern Europe, Canada and the United States in the early 20th century—and now available in many areas around the world—maternity waiting homes (MWHs) provide a place for women at high risk of pregnancy complications to await labor and delivery near a qualified health facility. MWHs seek to reduce the distance to timely, high quality health care, which is often a major obstacle in the decision to seek care—especially for pregnant women living in rural areas. While the evidence on their effectiveness remains mixed, researchers have linked MWHs to reductions in maternal and perinatal mortality throughout Africa. Further research has explored the barriers that prevent use of MWHs as well as the factors that contribute to their uptake and success.
Two open access studies recently published in BMC Pregnancy and Childbirth provide insight into MWHs through the lenses of women and other stakeholders. The first, a community-based cross-sectional study conducted in the Eastern Gurage Zone of Southern Ethiopia by Vermeiden and colleagues, explored factors associated with intended use of maternity waiting homes among more than 400 recently postpartum and pregnant women. The second, a mixed-methods, cross-sectional study in Zambia’s Luapula Province by Chibuye and colleagues, investigated both expectations as well as experiences of MWHs among women, community groups and traditional leaders. While the context of each study was distinct, the findings offer three keys to unlocking the full potential of maternity waiting homes around the world.
Improve community knowledge and gain support
Vermeiden and colleagues found that less than 10% of approximately 400 recently postpartum and pregnant women had prior knowledge about MWHs. This is consistent with previous findings. In Kenya, for example, researchers found that about a quarter of women they interviewed knew about the existence of a MWH two years after it was constructed.
As outlined by the World Health Organization (WHO) more than two decades ago, community and cultural support is a crucial element in the success of MWHs. In Zambia, support from community groups—including Safe Motherhood Action Groups, Neighbourhood Health Committee members and faith-based organizations—played a major role in the development, construction and operation of MWHs, as well as communication between the community and health staff.
Address quality of care issues
As with any service along the continuum of maternal health care, MWHs must meet women’s needs in a dignified, respectful environment. Even when the concept of MWHs is accepted and valued, poor quality of care can deter women from using them. Women and community groups in Zambia expressed the need for better infrastructure, services, food, security, privacy and transportation:
“When I delivered last year, I went home immediately […] it was impossible to keep myself clean without water in the maternity ward and maternity home despite the midwife advising me to stay until the following day.”
–Woman who gave birth at a rural health center
Given that MWHs serve as a point of referral for nearby health facilities, efforts to improve quality of care must extend beyond the MWH itself. According to WHO, MWHs “…cannot function effectively in a vacuum. Rather, they are a link in a larger chain of comprehensive maternity care, all the components of which must be available and of sufficient quality to be effective and linked with the home.”
As Vermeiden and colleagues articulated, it is vital to address the needs of the whole health system:
“If the Ethiopian health care system is incapable of absorbing an influx of women for childbirth, encouraging women to use MWHs could lead to more women receiving substandard care, which may backfire on Ethiopia’s attempts to reduce maternal and neonatal morbidity and mortality.”
Adapt to context and make it sustainable
Working with the local environment and culture is critical to the uptake and success of MWHs. In rural Ethiopia, for example, former traditional birth attendants have been trained to refer women to maternity waiting areas. In rural Liberia, collaboration between traditional midwives and skilled birth attendants along with the use of MWHs was associated with increased facility-based births and decreased maternal and perinatal death.
Considering the health system structure and capacity is another fundamental element of success. Chibuye and colleagues found that most participants remained skeptical that women would pay for services at MWHs because the health system services for reproductive, maternal, neonatal and child health are free of charge in Zambia. Securing funding from governments and other sources as well as establishing strong partnerships are also key to ensuring sustainability of MWHs.
As Vermeiden and colleagues emphasize, “MWHs alone will not reduce maternal and neonatal mortality and morbidity; they are merely a tool to increase the number of women who are able to access care.” Efforts to gain community support and engagement, improve quality of care and leverage local context can help ensure that MWHs are effective in linking pregnant women to timely, life-saving services.