Search

ObjectivesWomen in sub-Saharan Africa face well-documented barriers to facility-based deliveries. An improved maternity waiting homes (MWH) model was implemented in rural Zambia to bring pregnant women closer to facilities for delivery. We qualitatively assessed whether MWHs changed perceived barriers to facility delivery among remote-living women.DesignWe administered in-depth interviews (IDIs) to a randomly selected subsample of women in intervention (n=78) and control (n=80) groups who participated in the primary quasi-experimental evaluation of an improved MWH model. The IDIs explored perceptions and preferences of delivery location. We conducted content analysis to understand perceived barriers and facilitators to facility delivery.Setting and participantsParticipants lived in villages 10+ km from the health facility and had delivered a baby in the previous 12 months.InterventionThe improved MWH model was implemented at 20 rural health facilities.ResultsOver 96% of participants in the intervention arm and 90% in the control arm delivered their last baby at a health facility. Key barriers to facility delivery were distance and transportation, and costs associated with delivery. Facilitators included no user fees, penalties for home delivery, desire for safe delivery and availability of MWHs. Most themes were similar between study arms. Both discussed the role MWHs have in improving access to facility-based delivery. Intervention arm participants expressed that the improved MWH model encourages use and helps overcome the distance barrier. Control arm participants either expressed a desire for an improved MWH model or did not consider it in their decision making.ConclusionsEven in areas with high facility-based delivery rates in rural Zambia, barriers to access persist. MWHs may be useful to address the distance challenge, but no single intervention is likely to address all barriers experienced by rural, low-resourced populations. MWHs should be considered in a broader systems approach to improving access in remote areas.Trial registration numberNCT02620436.

The Saving Mothers, Giving Life initiative employed 2 key strategies to improve the ability of pregnant women to reach maternal care: (1) increase the number of emergency obstetric and newborn care facilities, including upgrading existing health facilities, and (2) improve accessibility to such facilities by renovating and constructing maternity waiting homes, improving communication and transportation systems, and supporting community-based savings groups. These interventions can be adapted in low-resource settings to improve access to maternity care services., Background: Between June 2011 and December 2016, the Saving Mothers, Giving Life (SMGL) initiative in Uganda and Zambia implemented a comprehensive approach targeting the persistent barriers that impact a woman's decision to seek care (first delay), ability to reach care (second delay), and ability to receive adequate care (third delay). This article addresses how SMGL partners implemented strategies specifically targeting the second delay, including decreasing the distance to facilities capable of managing emergency obstetric and newborn complications, ensuring sufficient numbers of skilled birth attendants, and addressing transportation challenges. Methods: Both quantitative and qualitative data collected by SMGL implementing partners for the purpose of monitoring and evaluation were used to document the intervention strategies and to describe the change in outputs and outcomes related to the second delay. Quantitative data sources included pregnancy outcome monitoring data in facilities, health facility assessments, and population-based surveys. Qualitative data were derived from population-level verbal autopsy narratives, programmatic reports and SMGL-related publications, and partner-specific evaluations that include focus group discussions and in-depth interviews. Results: The proportion of deliveries in any health facility or hospital increased from 46% to 67% in Uganda and from 63% to 90% in Zambia between baseline and endline. Distance to health facilities was reduced by increasing the number of health facilities capable of providing basic emergency obstetric and newborn care services in both Uganda and Zambia—a 200% and 167% increase, respectively. Access to facilities improved through integrated transportation and communication services efforts. In Uganda there was a 6% increase in the number of health facilities with communication equipment and a 258% increase in facility deliveries supported by transportation vouchers. In Zambia, there was a 31% increase in health facilities with available transportation, and the renovation and construction of maternity waiting homes resulted in a 69% increase in the number of health facilities with associated maternity waiting homes. Conclusion: The collective SMGL strategies addressing the second delay resulted in increased access to delivery services as seen by the increase in the proportion of facility deliveries in SMGL districts, improved communication and transportation services, and an increase in the number of facilities with associated maternity waiting homes. Sustaining and improving on these efforts will need to be ongoing to continue to address the second delay in Uganda and Zambia.

Financial constraints are one of the biggest barriers for women of low-income countries to receive necessary reproductive health services. Educating women about the importance of saving money has been incorporated as a component of antenatal care (ANC) contacts, but little is known whether ANC contacts influence women’s saving. A secondary analysis was conducted on data from a cross-sectional household survey study of 1109 women who recently gave birth in two rural districts of Zambia. Receiving ANC contacts early and often and discussing saving money during ANC were associated with saving money for the mother’s birth, but not with saving enough money for the most recent birth. Continued effort is needed to encourage women to attend ANC contacts earlier and more frequently. Additionally, the importance of saving money for birth should be discussed during ANC contacts. Future studies need to explore why women’s action in saving does not necessarily lead to saving enough for childbirth.

Financial constraints are one of the biggest barriers for women of low-income countries to receive necessary reproductive health services. Educating women about the importance of saving money has been incorporated as a component of antenatal care (ANC) contacts, but little is known whether ANC contacts influence women's saving.A secondary analysis was conducted on data from a cross-sectional household survey study of 1109 women who recently gave birth in two rural districts of Zambia.Receiving ANC contacts early and often and discussing saving money during ANC were associated with saving money for the mother's birth, but not with saving enough money for the most recent birth.Continued effort is needed to encourage women to attend ANC contacts earlier and more frequently. Additionally, the importance of saving money for birth should be discussed during ANC contacts. Future studies need to explore why women's action in saving does not necessarily lead to saving enough for childbirth.

Objective: To report on the effectiveness of a standardized core Maternity Waiting Home (MWH) model to increase facility deliveries and access to reproductive health services among women living farthest from a health facility (>10km) using facility-based data. Design: Quasi-experimental design. Setting: Seven rural districts in Zambia. Population: Women delivering at 40 health facilities between June 2016 to August 2018. Methods: 20 intervention sites and 20 comparison sites were used to test if MWHs increased access to reproductive health services for women living in rural Zambia. The difference-in-differences (DID) methodology was used to examine the effectiveness of the core MWH model on our primary outcomes. Main Outcome Measures: Differences in the change from baseline to endline in the percentage of women who: 1) traveled greater than 10 km for delivery, (2) attended a postnatal visit at 6 days postpartum, and (3) were referred to a higher-level health facility between intervention and comparison group. Results: We detected a significant difference for the percentage of deliveries at intervention facilities with the core MWH model for all women living >10km away (p=0.03), adolescent women ( 10km away (p=0.002), and primigravida women living >10km away (p=0.01). There were no significant differences for women attending a postnatal care visit at 6 days postpartum (p=0.07) or for women referred to the next level of care (p=0.29). Conclusion: The core MWH model was successful in reaching women with historically low rates of facility delivery, those living >10km from a healthcare facility, including adolescent women and primigravidas.

INTRODUCTION Skilled care is indicated as a measure to prevent the deaths of pregnant women across sub-Saharan Africa. Despite this, many women continue to give birth at home. There has been little attention as to how the experience of intimate partner violence (IPV) or autonomous decision-making about place of birth influences home births in rural Zambia. This study explores how markers of sociocultural gender inequities (prevalence of IPV and autonomous decision-making) correlate with home birth in rural Zambia. METHODS This secondary analysis uses quantitative data from a baseline household survey with women who had given birth within the past 13 months in rural Zambia. Control variables shown to be significant in the literature were included in the model, and binary logistic regression was used to assess the influence of IPV and autonomous decision-making on home birth. RESULTS This sample included 2381 women from rural Zambia, of whom 384 reported a home birth within the past 13 months. Women who were autonomously making the decision about where to give birth were more likely to have a home birth (adjusted odds ratio [AOR], 1.729; SE, 0.210; 95% CI, 1.362-2.194; P < .001). Self-report of experiencing physical IPV in the past 2 weeks was not significant in predicting home birth (AOR, 0.783; SE, 0.181; 95% CI, 0.496-1.234; P = .293). Women who self-identified as Tumbuka or other, were able to afford school fees, had completed secondary education or higher, were married, and had 4 or more antenatal care visits were significantly less likely to report a home birth. DISCUSSION This quantitative analysis did not corroborate findings from other research that implicates IPV as a predictor of home birth. Additionally, autonomous decision-making was not associated with a decrease in home births. Future work should incorporate qualitative or mixed methods strategies to comprehensively explore household- and facility-level interventions to promote facility birth.

IntroductionMaternity waiting homes (MWHs) aim to increase access to maternity and emergency obstetric care by allowing women to stay near a health centre before delivery. An improved MWH model was developed with community input and included infrastructure, policies and linkages to health centres. We hypothesised this MWH model would increase health facility delivery among remote-living women in Zambia.MethodsWe conducted a quasi-experimental study at 40 rural health centres (RHC) that offer basic emergency obstetric care and had no recent stockouts of oxytocin or magnesium sulfate, located within 2 hours of a referral hospital. Intervention clusters (n=20) received an improved MWH model. Control clusters (n=20) implemented standard of care. Clusters were assigned to study arm using a matched-pair randomisation procedure (n=20) or non-randomly with matching criteria (n=20). We interviewed repeated cross-sectional random samples of women in villages 10+ kilometres from their RHC. The primary outcome was facility delivery; secondary outcomes included postnatal care utilisation, counselling, services received and expenditures. Intention-to-treat analysis was conducted. Generalised estimating equations were used to estimate ORs.ResultsWe interviewed 2381 women at baseline (March 2016) and 2330 at endline (October 2018). The improved MWH model was associated with increased odds of facility delivery (OR 1.60 (95% CI: 1.13 to 2.27); pConclusionMWHs near well-equipped RHCs increased access to facility delivery, encouraged use of facilities with emergency care capacity, and improved exposure to counselling. MWHs can be useful in the effort to increase delivery at advanced facilities in areas where substantial numbers of women live remotely.Trial registration numberNCT02620436.

Background Increased encounters with the healthcare system at multiple levels have the potential to improve maternal and newborn outcomes. The literature is replete with evidence on the impact of antenatal care and postnatal care to improve outcomes. Additionally, maternity waiting homes (MWHs) have been identified as a critical link in the continuum of care for maternal and newborn health yet there is scant data on the associations among MWH use and antenatal/postnatal attendance, family planning and immunization rates of newborns. Methods A cross-sectional household survey was conducted to collect data from women who delivered a child in the past 13 months from catchment areas associated with 40 healthcare facilities in seven rural Saving Mothers Giving Life districts in Zambia. Multi-stage random sampling procedures were employed with a final sample of n = 2381. Logistic regression models with adjusted odds ratios and 95% confidence intervals were used to analyze the data. Results The use of a MWH was associated with increased odds of attending four or more antenatal care visits (OR = 1.45, 95% CI = 1.26, 1.68), attending all postnatal care check-ups (OR = 2.00, 95% CI = 1.29, 3.12) and taking measures to avoid pregnancy (OR = 1.31, 95% CI = 1.10, 1.55) when compared to participants who did not use a MWH. Conclusions This is the first study to quantitatively examine the relationship between the use of MWHs and antenatal and postnatal uptake. Developing a comprehensive package of services for maternal and newborn care has the potential to improve acceptability, accessibility, and availability of healthcare services for maternal and newborn health. Maternity waiting homes have the potential to be used as part of a multi-pronged approach to improve maternal and newborn outcomes. Trial registration National Institutes of Health Trial Registration NCT02620436, Impact Evaluation of Maternity Homes Access in Zambia, Date of Registration - December 3, 2015.

This study indicates a higher rate of facility delivery at clinics with a maternity waiting home in rural Zambia.

Objective To examine the demographic characteristics and mental health of women in rural Zambia who experienced physical intimate partner violence (IPV) postpartum. Methods The present secondary analysis was conducted using baseline data from an impact evaluation of a maternity waiting home intervention in rural Zambia. A quantitative household survey was conducted over 6 weeks, from mid‐April to late May, 2016, at 40 rural health facility catchment areas among 2381 postpartum women (13 months after delivery; age ≥15 years). Results A total of 192 (8.1%) women reported experiencing any type of physical IPV in the preceding 2 weeks; 126 had experienced severe physical IPV (had been kicked, dragged, beat, and/or choked by a husband or partner). High levels of depression were recorded for 174 (7.3%) women in the preceding 2 weeks. Being a female head of household was associated with an increased likelihood of experiencing severe physical IPV (aOR 2.64, 95% CI 1.70–4.10). Women with high depression scores were also at an increased risk of experiencing any physical IPV (aOR 17.1, 95% CI 8.44–34.9) and severe physical IPV (aOR 15.4, 95% CI 5.17–45.9). Conclusion Future work should consider the implications of government and educational policies that could impact the screening and treatment of pregnant women affected by all forms of physical IPV and depression in rural Zambia., Postpartum physical intimate partner violence among women in rural Zambia was associated with being a female head of household and high levels of depression.

Background maternity waiting homes (MWHs) are residential dwellings located near health facilities where women in the late stages of pregnancy stay to await childbirth and receive immediate postpartum services. These shelters help overcome distance and transportation barriers that prevent women from receiving timely skilled obstetric care. Objective the purpose of this study was to explore Zambian stakeholders' beliefs regarding the acceptability, feasibility, and sustainability of maternity waiting homes (MWHs) to inform a model for rural Zambia. Design a qualitative design using a semi-structured interview guide for data collection was used. Setting two rural districts in the Eastern province of Zambia. Participants individual interviews were conducted with community leaders ( n =46). Focus groups were held with Safe Motherhood Action Groups, husbands, and women of childbearing age in two rural districts in Zambia ( n =500). Measures latent content analysis was used to analyze the data. Findings participants were overwhelmingly in support of MWHs as a way to improve access to facility-based childbirth and address the barrier of distance. Data suggest that participants can describe features of high quality care, and the type of care they expect from a MWH. Stakeholders acknowledged the need to contribute to the maintenance of the MWH, and that community involvement was crucial to MWH sustainability. Key conclusions access to facility childbirth remains particularly challenging in rural Zambia and delays in seeking care exist. Maternity waiting homes offer a feasible and acceptable intervention to reduce delays in seeking care, thereby holding the potential to improve maternal outcomes. Implications for practice this study joins a growing literature on the acceptability, feasibility, and sustainability of MWHs. It is believed that MWHs, by addressing the distance and transportation barriers, will increase the use of skilled birth attendants, thereby reducing maternal and neonatal morbidity and mortality in rural, low resource areas of Zambia. We recommend that any initiative, such as MWHs, seeking to increase facility-based births with a skilled birth attendant also concurrently addresses any local deficiencies in quality of care.