If we build it, will they come? Results of a quasi-experimental study assessing the impact of maternity waiting homes on facility-based childbirth and maternity care in Zambia

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); p<0.001) and MWH utilisation (OR 2.44 (1.62 to 3.67); p<0.001). The intervention was also associated with increased odds of postnatal attendance (OR 1.55 (1.10 to 2.19); p<0.001); counselling for family planning (OR 1.48 (1.15 to 1.91); p=0.002), breast feeding (OR 1.51 (1.20 to 1.90); p<0.001), and kangaroo care (OR 1.44 (1.15, 1.79); p=0.001); and caesarean section (OR 1.71 (1.16 to 2.54); p=0.007). No differences were observed in household expenditures for delivery.ConclusionMWHs 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.

A mobile cesarean birth center as a solution to improve access to surgical birth in rural Ethiopia: a mixed methods research protocol

Background As an evidence-based intervention to prevent maternal and neonatal morbidity and mortality, cesarean birth at rates of under 2%, which is the case in rural Southwest Ethiopia, is an unacceptable public health problem and represents an important disparity in the use of this life-saving treatment compared to more developed regions. The objective of this study is to explore an innovative clinical solution (a mobile cesarean birth center) to low cesarean birth rates resulting from the Three Delays to emergency obstetric care in isolated and underserved regions of Ethiopia, and the world. Methods We will use mixed but primarily qualitative methods to explore and prepare the mobile cesarean birth center for subsequent implementation in communities in Bench Sheko and West Omo Zones. This will involve interviews and focus groups with key stakeholders and retreat settings for user-centered design activities. We will present stakeholders with a prototype surgical truck that will help them conceive of the cesarean birth center concept and discuss implementation issues related to staffing, supplies, referral patterns, pre- and post-operative care, and relationship to locations for vaginal birth. Discussion Completion of our study aims will allow us to describe participants’ perceptions about barriers and facilitators to cesarean birth and their attitudes regarding the appropriateness, acceptability, and feasibility of a mobile cesarean birth center as a solution. It will also result in a specific, measurable, attainable, relevant, and timely (SMART) implementation blueprint(s), with implementation strategies defined, as well as recruitment plans identified. This will include the development of a logic model and process map, a timeline for implementation with strategies selected that will guide implementation, and additional adaptation/adjustment of the mobile center to ensure fit for the communities of interest. Trial registration There is no healthcare intervention on human participants occurring as part of this research, so the study has not been registered.

Male Role in Emergency Obstetric Care in Rural Niger Delta, Nigeria

After more than two decades of continuous democratic rule and government policies geared towards improved emergency obstetric care (EmOC) access in Nigeria, maternal mortality remains a fundamental public health challenge. Although many studies have emphasized the significance of the male role in female reproductive health-seeking behavior in the country, there is insufficient empirical evidence on the male role in accessing EmOC in Nigeria’s Niger Delta region, the bastion of the nation’s petroleum industry. This study explored women’s perspectives, beliefs, and experiences concerning the role of their husbands on reproductive health by collecting quantitative and qualitative data in an economically disadvantaged community of Bayelsa State. A semi-structured questionnaire was administered to 616 women aged 15-49 years. Focus Group Discussions (16) were conducted among purposively selected male and female participants. Men play positive roles toward accessing EmOC by women in rural Bayelsa. At least eight out of ten women reported that their husbands were present during pregnancy or birth complications; five out of ten claimed they followed them to hospitals or clinics for treatment. Men also provided the finance for the specialized care during emergencies. This study provides empirical evidence of a positive male role in accessing EmOC in the study area. More deliberate promotion of male involvement in the reproductive health of their wives will contribute significantly to the reduction of maternal mortality in a patriarchal society such as Bayelsa.

Maternal Mortality from Induced Abortion in Malawi: What Does the Latest Evidence Suggest?

It is commonly claimed that thousands of women die every year from unsafe abortion in Malawi. This commentary critically assesses those claims, demonstrating that these estimates are not supported by the evidence. On the contrary, the latest evidence—itself from 15 to 20 years ago—suggests that 6–7% of maternal deaths in Malawi are attributable to induced and spontaneous abortion combined, totalling approximately 70–150 deaths per year. I then offer some evidence suggesting that a substantial proportion of these are attributable to spontaneous abortion. To reduce maternal mortality by large margins, emergency obstetric care should be prioritised, which will also save women from complications of induced and spontaneous abortion.

Strengthened family planning is critical to help accelerate the reduction of maternal mortality in Indonesia

The still stubbornly high maternal mortality ratio challenges Indonesia to improve health program strategies to achieve the Sustainable Development Goal 3.1 target of a maternal mortality ratio below 70 per 100,000 live births by 2030. Indonesia has already adopted maternal-neonatal health experts’ recommendation of four core program strategies to reduce maternal mortality: (1) family planning with related reproductive health services; (2) skilled care during pregnancy and childbirth; (3) timely emergency obstetric care; and (4) immediate postnatal care (WHO, 1996). These four core strategies would reduce maternal mortality through reduced high-risk births. To be effective, however, these four core program strategies require continued strong quality assurance and central and local government support to ensure program effectiveness yielded towards widely accessible, sustained, quality family planning and maternal and neonatal emergency services. This paper provides evidence for the importance of family planning to help health program strategies to accelerate maternal mortality reduction.

Building a Country-Wide Fistula Treatment Network in Kenya: Results From the First Six Years (2014-2020)

It is estimated that one million women worldwide live with untreated fistula, a devastating injury primarily caused by prolonged obstructed labor when women do not have access to timely emergency obstetric care. Women with fistula are incontinent of urine and/or feces and often suffer severe social and psychological consequences such as profound stigma and depression. Obstetric fistula affects economically vulnerable women and garners little attention on the global health stage. Exact figures on fistula incidence and prevalence are not known. In Kenya, results from a population-based survey suggest that approximately 120,000 reproductive-aged women have experienced fistula-like symptoms.In 2013, Fistula Foundation designed a program to significantly increase country-wide fistula treatment capacity in Kenya by addressing key barriers that limit women’s ability to receive treatment. Launched as Action on Fistula, and later becoming the Fistula Treatment Network, this model created a network of hospitals, a training center for surgeons and healthcare providers, and robust community outreach and reintegration activities. The Fistula Treatment Network was implemented by Fistula Foundation in collaboration with the Ministry of Health and Kenyan non-governmental and community-based organizations. Fistula Foundation and its donors provided the program’s funding, with seed funding, representing about 30% of the program budget, provided by Astellas Pharma EMEA.Over a six-year period, 2014-2020, the network supported 6,223 surgeries at seven hospitals, established a fistula training center and trained eleven surgeons, trained 424 Community Health Volunteers, conducted extensive outreach to all 47 counties in Kenya, and contributed to the National Strategic Framework to End Female Genital Fistula. At 12 months post fistula repair, 96% of women in a community setting reported that they were dry and not experiencing any incontinence and the proportion of women reporting normal functioning increased from 18% at baseline to 85% at twelve-months. The Fistula Foundation’s Fistula Treatment Network model increased access to fistula care services, strengthened the healthcare workforce, improved understanding of fistula and reduced stigma in a community setting. This integrated approach is an effective and replicable model for building capacity to deliver comprehensive fistula care services in other countries where the burden of fistula is high.

Evaluation of Comprehensive Emergency Management of Obstetric and Newborn Care Program Implementation at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: A Case Study Design

Background: Maternal healthcare service is the care given for the woman during her gestation, delivery and postpartum period. The Maternal Mortality Ratio (MMR) was remains high and a public health problem in Ethiopia. Sub-Saharan African (SSA) countries including Ethiopia account two-thirds of the total maternal deaths. To curb such high burden related with child births, comprehensive emergency obstetric care is designed as one of the strategies for maternal healthcare services. However, its implementation status was not well investigated. This study aims to evaluate the implementation of comprehensive emergency obstetric care program at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. Methods: A case study design was employed from 01 to 30 April 2021. A total of 265 clients for acceptability, 13 key informant interviews (KIIs), 49 observations and two months document review were conducted. Availability, compliance and acceptability dimensions were evaluated using 32 indicators. Binary logistic regression model was fitted to identify factors associated with acceptability of the services. Adjusted Odds Ratio (AOR) with 95% confidence interval (CI) and p-value < 0.05 were also used to identify the predictor variables associated with acceptability. The qualitative data were recorded using tape recorder, transcribed in Amharic and translated to English language. Thematic analysis was done to supplement the quantitative findings. Results: The overall implementation of comprehensive emergency obstetric and newborn care (CEmONC) was 81.6%. Moreover, acceptability, availability and care provider’s compliance with the guideline accounted 81, 88.9 and 74.8%, respectively. There were stocked-out of some essential drugs, such as methyldopa, nifidipine, gentamycin and vitamin K injection. CEmONC training gaps, inadequate number of autoclaves, shortage of water supply and long-distance delivery ward to laboratory unit were also the barriers for the CEmONC service. Short waiting time of clients (AOR=2.40; 95%CI: 1.16, 4.90) and maternal educational level (AOR= 5.50, 95%CI: 1.95, 15.60) were positively associated with acceptability of CEmONC services.Conclusion: The implementation status of CEmONC program was good as per our judgment parameter. Compliance of healthcare providers with the guideline was fair and needed improvement. Essential emergency drugs, equipment and supplies were stocked-out. The University of Gondar Comprehensive Specialized Hospital was therefore had better to give great emphasis to expand maternity rooms/ units. The hospital had better to avail the resources and provide continuous capacity building for healthcare providers to enhance the program implementation.