Table 3 Barriers and enablers to implementation of MWHs analysed using the SURE framework
| Level | Barriers | Article | Enablers | Article |
|---|---|---|---|---|
| Main Stakeholders from the Community-women & families | Knowledge and Skills | |||
| Lack of knowledge of MWH |
- Mramba et al. 2010 - Ruiz et al. 2013 - Shrestha et al. 2007 | Awareness of MWHs and services offered through community outreach and mobilization is high among women |
- Garcia Prado et al. 2012 - Gaym et al. 2012 - Kelly et al. 2010 - Poovan et al. 1990 - Schooley et al. 2009 - Wild et al. 2012 | |
| Women do not remember the date of their last period, so unsure about expected due date-point of entry into MWH and duration of stay uncertain and may be prolonged |
- Eckermann et al. 2008 - Spaans et al. 1998 | |||
| Attitudes regarding programme acceptability, appropriateness and credibility | ||||
| Traditional childbirth practices not accommodated |
- Eckermann et al. 2008 - Ruiz et al. 2013 | Integration of cultural norms and expectations into the care provided at the MWH and associated health facility |
- Fraser 2008 - Lori et al. 2013b - Ruiz et al. 2013 - Schooley et al. 2009 | |
| Family members (husbands and mothers in law) don’t allow women to use MWHs and no one left at home to do household chores or provide child care |
- Mramba et al. 2010 - Garcia Prado et al. 2012 - Lori et al. 2013b - Ruiz et al. 2013 - Nhindiri et al. 1996 | High awareness of benefits and acceptability of MWHs and facility birth among family and community members. Family and community actively involved through educational outreach and involved in decision-making. |
- Garcia Prado et al. 2012 - Gaym et al. 2012 - Kelly et al. 2010 - Lori et al. 2013a - Ruiz et al. 2013 - Schooley et al. 2009 - Wild et al. 2012 | |
| High acceptability of facility births and use of MWHs among women |
- Gaym et al. 2012
- Kelly et al. 2010 | |||
| Health workers and users of MWH have different ethnicities which result in communication problems | - Ruiz et al. 2013 | |||
| Companion not allowed or unable to accompany |
- Eckermann et al. 2008 - Gaym et al. 2012 - Ruiz et al. 2013 - Schooley et al. 2009 - Wild et al. 2012 | |||
| Healthcare Providers Involved in Implementing MWH | Knowledge and Skills | |||
| Without access to technologies, not possible for health workers to predict date of delivery so duration of stay is uncertain and prolonged stay at MWH might occur | - Eckermann et al. 2008 | |||
| Attitudes regarding programme acceptability, appropriateness and credibility | ||||
| Health workers and users of MWH have different ethnicities which result in communication problems | - Ruiz et al. 2013 | |||
| Other Stakeholders | Knowledge and Skills | |||
| Training TBAs and integrating TBAs into the birthing process helped encourage women to use MWHs and deliver in facilities |
- Andemichael et al. 2009
- Lori et al. 2013a - Lori et al. 2013b - Poovan et al. 1990 - Schooley et al. 2009 | |||
| Health Service Delivery Factors | Accessibility of care | |||
|
Geographical - MWH is too far |
- Schooley et al. 2009 - Shrestha et al. 2007 | MWH located close to the hospital | - Nhindiri et al. 1996 | |
|
Cost - MWH users incur costs for travel - MWH users incur costs of staying at facility - MWH use leads to costs of subsequent delivery in health facility |
- Eckermann et al. 2008 - Garcia Prado et al. 2012 - Gaym et al. 2012 - Ruiz et al. 2013 - Schooley et al. 2009 - Spaans et al. 1998 - Wessel et al. 1990 - Wilson et al. 1997 | Removal/reduction of costs associated with using the MWH and/or subsequent institutional delivery |
- Kelly et al. 2010 - Ruiz et al. 2013 - Spaans et al. 1998 - Wessel 1990 | |
| Health Service Delivery Factors | Training | |||
| No regular visits by health workers or link to obstetric care are insufficient and unclear |
- Wilson et al. 1997 - Mramba et al. 2010 - Gaym et al. 2012 | Daily visits to the MWH by midwives | - Poovan et al. 1990 | |
| Intensive training of health providers in MWH and facilities to provide good quality of care |
- Fraser 2008 - Gorry 2011 | |||
| Communication | ||||
| No clear communication of what to expect at the MWH while at the MWH | - Mramba et al. 2010 | |||
| Health workers attitudes are not good |
- Garcia Prado et al. 2012 - Lori et al. 2013b - Wilson et al. 1997 | |||
| Information Systems | ||||
| No registration and linkage of MWH records with health information system | - Danel et al. 2003 | |||
| Strong referral and communication systems between MWH and associated facilities, including transportation and communication equipment |
- Chandramohan et al. 1995
- Gaym et al. 2012 - van Lonkhuij-zen et al. 2003 | |||
| Facilities | ||||
|
- Lack of privacy in MWH - No space for relatives or companions to stay - Poor toilet and bathing facilities - Kitchen facilities are poor or inadequate - Food not provided leading to differential access to food for MWH users. Women had to travel back to their homes to replenish supplies - A lack of space for postpartum women |
- Eckermann et al. 2008 - Gaym et al. 2012 - Kelly et al. 2010 - Lori et al. 2013b - Mramba et al. 2010 - Nhindiri et al. 1996 - Ruiz et al. 2013- Schooley et al. 2009 - Shrestha et al. 2007 - Wild et al. 2012 - Wilson et al. 1997 | MWH provides and maintains all needed facilities, including basic infrastructure such as electricity, kitchen/food facilities, and bathing and toilets. MWH also provided a space for companions and family members to stay with the pregnant woman. |
- Lori et al. 2013a - Mramba et al. 2010 - Nhindiri et al. 1996 - Ruiz et al. 2013 | |
| Useful activities to occupy women’s time and provide knowledge and skills are not organised or insufficient (for example: entertainment, income generation skills, health education) |
- Eckermann et al. 2008 - Ruiz et al. 2013 - Mramba et al. 2012 - Lori et al. 2013b | Activities to occupy women’s time, including education and income generation activities, helped improve acceptability and use of MWH among women |
- Gorry 2011 - Ruiz et al. 2013 - Tumwine et al. 1996 - Wessel 1990 | |
| Intervention integrity | ||||
| Comprehensive provision of good quality care, across the continuum of care, in both the MWH and health facilities associated with the MWH |
- Gorry 2011 - Poovan et al. 1990 - Schooley et al. 2009 - Tumwine et al. 1996 | |||
| Social and Political Factors | Legislation or regulations | |||
| Enabling policy environment, which included inclusion of supportive MWH policies in national and/or local legislation |
- Fraser 2008 - Gorry 2011 - Lori et al. 2013b - Millard et al. 1991 | |||
| Sustainability | ||||
| Lack of community involvement in MWH set up, support and maintenance |
- Poovan et al. 1990
- Kelly et al. 2010 - Lori et al. 2013a - Ruiz et al. 2013 - Shrestha et al. 2007 - Wilson et al. 1997 | Involve community members and family in the design, development, and maintenance of the MWH |
- Lori et al. 2013b - Poovan et al. 1990 - Schooley et al. 2009 | |
| - | MWH and facilities are able to adapt to changing health needs of women. For example, in Cuba, an economic crisis meant needing to focus and integrate nutrition improvement for pregnant women in the MWH | - Gorry 2011 | ||