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Benefits, barriers and enablers of maternity waiting homes utilization in Ethiopia: an integrative review of national implementation experience to date

Abstract

Background

Though Ethiopia has expanded Maternity Waiting Homes (MWHs) to reduce maternal and perinatal mortality, the utilization rate is low. To maximize the use of MWH, policymakers must be aware of the barriers and benefits of using MWH. This review aimed to describe the evidence on the barriers and benefits to access and use of MWHs in Ethiopia.

Methods

Data were sourced from PubMed, Google Scholars and Dimensions. Thirty-one studies were identified as the best evidence for inclusion in this review. We adopted an integrative review process based on the five-stage process proposed by Whittemore and Knafl.

Results

The key themes identified were the benefits, barriers and enablers of MWH utilization with 10 sub-themes. The themes about benefits of MWHs were lower incidence rate of perinatal death and complications, the low incidence rate of maternal complications and death, and good access to maternal health care. The themes associated with barriers to staying at MWH were distance, transportation, financial costs (higher out-of-pocket payments), the physical aspects of MWHs, cultural constraints and lack of awareness regarding MWHs, women’s perceptions of the quality of care at MWHs, and poor provider interaction to women staying at MWH. Enablers to pregnant women to stay at MWHs were availability of MWHs which are attached with obstetric services with quality and compassionate care.

Conclusion

This study synthesized research evidence on MWH implementation, aiming to identify benefits, barriers, and enablers for MWH implementation in Ethiopia. Despite the limited and variable evidence, the implementation of the MWH strategy is an appropriate strategy to improve access to skilled birth attendance in rural Ethiopia.

Peer Review reports

Background

Ethiopia, one of the countries in sub-Saharan Africa has been showing progress concerning a reduction in pregnancy-related maternal mortality that was 871 per 100,000 live births in 2000 to 412 per 100,000 live births in 2015 [1]. Even though it has been showing progress with its previous status, the country is still one of the 10 countries which had contributed to about 59% of the global maternal mortality in 2017 by losing the lives of 14,000 women as a result of pregnancy and childbirth-related complications [2]. Moreover, Ethiopia needs to accelerate its annual rate of maternal mortality reduction to achieve the SDG3.1 to record a maternal mortality rate of less than 140 per 100,000 live birth by 2030 [3].

As the majority of maternal deaths occur during childbirth and the immediate postpartum period, assistance during childbirth by skilled health personnel has been proved as one of the main strategies to decrease maternal mortality [4]. In Ethiopia however, the proportion of births assisted by skilled health personnel is less than half of the total births. Disparities in the utilization of skilled delivery care between urban and rural areas are wide and rural women, particularly those who are poor and illiterate, have limited access to healthcare with skilled health personnel [5].

Disparities in the use of this service have also been linked to supply-side limitations (access, quality, and affordability of the services) as well as demand-side limitations (mainly operating at the individual and community levels) according to prior studies in Ethiopia [6, 7]. Long distances from expectant mothers’ place of residence to the healthcare facilities, lack of transportation, and the mountainous terrain of most rural settings are among the barriers that contribute to the physical inaccessibility of skilled childbirth care services [5].

To address supply-side limitations, particularly physical accessibility, many efforts have been made by the government to avail primary health care units with basic emergency obstetric care for a maximum of 25,000 populations [8]. However, as the way of life of the rural communities in Ethiopia is not like that of towns, they are scattered over a wide geographic area and some with difficult mountains and valleys where it is not easy to construct roads, availing health facilities to all segments of the population [9]. Accordingly, the maternity waiting home strategy has been introduced to close the geographic gap between pregnant women and skilled childbirth care in a few Ethiopian hospitals in the 1980s [10, 11].

The strategy was implemented by setting up shelters near obstetric care facilities where pregnant women can stay during their final weeks of pregnancy and be quickly transferred to the care facility when they go into labor [10]. Maternity waiting home is a popular word used in the literature to refer to this accommodation facility, but similar facilities have also been referred to as maternity waiting homes or waiting areas [10, 12, 13]. As their names differ, so do the services they provide; some offer simple lodging, while others offer meal service, and still, others include health education and prenatal care [13, 14]. In terms of location, some are near or on the premises of health facilities where obstetric care is being offered, while others are standalone facilities offering accommodation services associated with the health facility with a referral link [12, 13, 15, 16].

Faith-based organizations have pioneered the construction of MWH in the late 1980s and later in 2015, it has been included in maternal health programs of the country as a means of overcoming distance-related barriers and increasing women’s access to life-saving emergency obstetric and neonatal care, particularly in the rural part of Ethiopia. Furthermore, in areas where the majority of births occur outside health institutions, all pregnant women are advised to stay at maternity waiting homes, especially those formerly regarded as “high risk” of developing childbirth complications [17, 18].

The National Reproductive Health Strategy 2016–2020 included a recommendation to scale up MWHs initiatives at health centers for women from remote areas to get quality of care on time, and adopted a target of 75% coverage by 2020. Accordingly, most of the health centers in Ethiopia have established MWHs [19], and in 2015, a standardized health facility guideline for the implementation was also approved by the Federal Ministry of Health. Some studies examined different aspects of MWHs in Ethiopia and underscored the variability in expansion, utilization, and benefits of maternity waiting homes across the country. Furthermore, previous research employed diverse methodological approaches thus a review that accommodates varied methodologies to identify the benefit, barriers and enablers to use the existing MWH services are needed. Thus, this integrative review will provide a comprehensive assessment of the literature on MWH strategy in Ethiopia.

Methods

We adopted an integrative review to summarize literature to provide a more comprehensive understanding of MWHs implementation in Ethiopia. The study protocol was registered with the International Prospective Register of Systematic Reviews under the registration number CRD42019125308. Systematic reviews, while important to evidence-based practice, tend to focus on experimental studies, specifically randomized clinical trials, usually used to determine to evaluate the effectiveness of an intervention. However, the primary literature in the MWH aspect was diverse in methodology including descriptive, observational, and qualitative research. Therefore, an integrative literature review was chosen because it allows for a greater breadth of research to be analyzed and plays an important role in evidence-based practice in healthcare [20]. We adopted an integrative review process based on the five-stage process proposed by Whittemore and Knafl: Developing the review question, searching the literature, Data evaluation, Data analysis, and presentation of integrated findings [20].

Databases and search

We conducted a systematic literature search across the three electronic databases: PubMed, Google Scholars and Dimensions, which encompass a wide range of research relevant to the healthcare domain.

Boolean connectors AND, OR and NOT were used to combine search terms and the keywords used were Health Services Accessibility“[MeSH Terms] OR “maternity waiting home*“[Text Word] OR “maternity waiting area*“[Text Word] OR “maternity waiting*“[Text Word]) AND (“Ethiopia“[MeSH Terms] OR “Ethiopia“[Text Word]). We have presented the detailed search strategies of PubMed in Additional file 1.

We also manually searched the reference lists of potentially relevant studies to find out studies that had not been identified during the search of electronic databases. We have contacted the corresponding authors for studies through the Research gate platform for the research we do have limited access due to a pay-wall restriction. We tried to employ a variety of search methods to ensure a broad representation of evidence from peer-reviewed journals and grey literature related to the subject matter.

Eligibility criteria

The inclusion criteria for the type of document included (1) published in the English language, (2) from Ethiopia, (3) experimental, quasi-experimental or non-experimental design, (4) investigated maternity waiting homes benefit, barriers and enablers. Studies were excluded if they were reviews, protocols, commentaries, conference proceedings, and editorials.

Data extraction and evaluation

The database search generated 1234 records. Searches were imported into the Mendeley Desktop, an external citation manager, for further screening. After removing duplicates, 991 potential studies were identified and preliminary screening was done by checking the titles and abstracts of the remaining studies. Two authors independently screened the titles and abstracts against the inclusion criteria and identified 42 studies. In the case of disparities, a consensus was achieved by examining the full-text and collaborative discussion. After scanning reference lists of included and review papers, three studies were identified. Lastly, full-text reviews were conducted, and articles were removed if they did not meet the inclusion criteria. The final 31 articles were then, systematically reviewed; the screening and selection process is outlined in a PRISMA flow chart in Fig. 1. Information was pulled together in a summary matrix table (Tables 1 and 2) to highlight similarities and differences between studies. The extraction form included the following items: authors (publication year), the title of the study, purpose/aim, sample size and study population, research design and data collection, method of analysis, and key MWHs outcomes (barriers, benefits, and enablers).

Fig. 1
figure 1

Article search and selection process using PRISMA flowchart

Table 1 Summary of MWH studies included in the review in Ethiopia,2022
Table 2 Concept matrix mapping on benefits and barriers to stay at MWHs in Ethiopia from the included studies, 2022

Study quality and bias

While it is agreed that potential studies for inclusion in the review should be evaluated for quality and bias, the best approach for assessing research quality in an integrated review is still up for debate. To evaluate the various forms of the methodology employed in the studies, various sorts of quality criterion tools can be applied. To assess the quality of the research included, Joanna Briggs Institute Critical Appraisal tools for qualitative and quantitative study [48]. Studies with statistically insignificant or negative outcomes, or study topics that may not be relevant to the journals’ scope, are less likely to be published than studies with significant or positive results. As a result, many completed studies are never published. To make the evaluation more comprehensive, we have also included unpublished studies (dissertations, theses, conference papers, and preprints after they were evaluated against the inclusion criteria [48].

Data analysis and synthesis of results

Data analysis in research reviews requires that the data from primary sources are ordered, coded, categorized, and summarized into a unified and integrated conclusion about the research problem [20]. A constant comparison method: extracted data are compared item by item so that similar data are categorized and grouped. The method consists of data reduction (qualitative, quantitative, and mixed), data display, data comparison, conclusion drawing, and verification were also made [20]. Given the diversity of quantitative studies in terms of research questions, methods, samples, study settings, outcomes and outcome measures used, we undertook a narrative synthesis. The findings from the narrative synthesis of quantitative findings and the thematic analysis of the qualitative findings were then synthesized to identify common themes. A summary table was generated synthesizing the data from included studies (Table 1).

Results

Study characteristics

Analysis of the study characteristics presented in Table 1 revealed that 18 of the 31 articles reviewed were from the southern part of the country, 8 from Oromiya, 3 from the northern part, and the remaining two articles based on two or more regions. Though our search was not restricted by publication dates, the search produced studies published from 1990 to 2021. Thirty of the thirty-one studies were published between 2010 and 2021, which clearly shows an increasing demand and trend in the examination of MWHs. Of the 31 studies that met the inclusion criteria, 26 studies utilized a variety of quantitative study types including mixed-method designs.

Of the 31 studies that met the inclusion criteria most focused on the intention to use MWHs and factors that affect MWH use [23, 26, 28, 30,31,32, 35, 39, 43]. Few studies have looked retrospectively at the impact of MWH on maternal health and service utilization [13,14,15, 22, 47]. Only one clustered controlled trial looked at how upgrading MWH affects institutional delivery utilization, and the results were promising, though statistically insignificant [31, 33]. The use of MHW was found to be low in all studies.

Key themes

The key themes reflect the review aims were the benefits, barriers and enablers of MWH utilization. Thematic analysis revealed 10 major sub-themes (Table 2). The themes of benefits were lower incidence rate of perinatal deaths and complications, the low incidence rate of maternal complications and deaths and improved access to maternal health care. The themes associated with barriers to staying at MWH were distance, transportation, financial costs (higher out-of-pocket payments), the physical aspects of MWHs, cultural constraints and lack of awareness regarding MWHs, women’s perceptions of the quality of care at MWHs, and poor provider interaction to women staying at MWH. Enablers to pregnant women to stay at MWHs were availability of MWHs which are attached with obstetric services with quality and compassionate care and additional promotional intervention at MWHs.

Benefits of MWHs

Lower incidence rate of maternal death and complications

Seven of the studies showed that pregnant women admitted to obstetric hospitals through MWH had a lower risk of maternal complications and death [13,14,15, 37, 44, 45, 47]. MWH utilization was linked to a 77% lower risk of childbirth complications [15], users were less likely to have obstructed labor, and there were no cases of uterine rupture among MWH users, compared to nine cases among non-users [15, 37]. According to Braat et al. study, all maternal deaths and uterine ruptures occurred during the study period among women who did not utilize the MWH [14]. Moreover, Poovan et al. had reported that there were no maternal deaths among the 142 MWH users, but there were 13 maternal deaths among the 635 MWH nonusers [47].

Lower incidence rate of perinatal death and complications

MWHs were found to reduce the rate of perinatal problems and death among pregnant women admitted directly to hospitals and those who stayed in MWHs [13,14,15, 22, 44, 45, 47]. According to Zunna et al., MWHs have a protective effect against prenatal death, and it appears to reduce perinatal mortality by 55% [22]. Moreover, MWH users had normal birth weight and Apgar scores newborn, and they were also less likely to have a stillbirth [15]. Perinatal death and complications were much lower in MWH users than in non-user [44], stillbirth rates were significantly lower in women admitted via MWH [13].

Better access to maternal health services and health information

Nine of the studies showed a correlation between MWHs and improved access to maternal health services, particularly skilled childbirth care [14, 28, 30, 32, 33, 37, 43, 45, 46]. MWHs strategy has been a means for increasing the demand for maternity care, improving geographic access to childbirth, addressing the second delay, delay in reaching a health center and enabling more timely and comprehensive obstetric care [14, 28, 33, 37, 39, 46]. Four of the included studies reported that women who stay at MWH have better access to health information than women who did not stay at MWH [16, 33, 43, 49]. Those mothers staying at MWHs can share experiences with other pregnant mothers and receive postpartum health education about family planning, infant feeding, and the importance of maternal health services utilizations including PNC services for both mothers and new-borns [16, 33, 43, 49].

Barriers to using MWHs

Distance

Factors that influenced a woman’s decision and ability to stay at MWH during her pregnancy included distance (accessibility) and transport (absence of ambulance services to and from MWHs) [15, 16, 31, 35, 37, 39, 42]. Women who had long travel times to reach health facilities were more often advised to stay in MWH to overcome a geographic barrier, but geographic barriers also had an impact on MWH use [37]. Women who had long travel tomes to reach health facilities were more often advised to stay in MWH to overcome a geographic barrier, but geographic barriers also impacted access to MWH use [37]. The majority of MWH users came from the vicinities closer to the location of MWHs, implying that distance is a potential barrier to MWH use for women who reside in remote settings [31] and that women who had to travel for more than 60 minutes were less likely to use MWH [43]. While the use of MWH is promoted as a way to overcome distance and transportation barriers to access skilled birth attendance, women's ability to use MWHs has primarily depended on transportation [16, 31, 33, 37]. The lack of readily accessible and timely transportation to take a women from her residence to MWH and from MWH to hospital considerabily limited the use of existing MWH facilities [16, 31, 33, 37]. The lack of available transportation for referal was a problem that was not alleviated by the exisance of the MWH itself in circumstances when MWHs are not located to the hospital but rather a considerable distance away [13, 31, 43].

Financial costs (higher out-of-pocket payments)

Although the Ethiopian government provides free maternity care in public facilities across the country, including stays at MWHs, MWH users face higher out-of-pocket payments than MWH nonusers [40]. The costs include transportation to and from the MWH, meal service during their stay (not all MWHs provide meals to the users), and fees associated with non-medical services [15, 29, 35, 40].

The physical aspects of MWHs and services provided

MWHs vary in physical structure, level, and service type. In some areas, MWHs resemble a 'tukul' according to the local and cultural living style [47], and in other parts, they look like a modern corrugated iron house [46]. According to studies, issues relating to the physical structure have been observed, with a single room in particular circumstances required to accommodate more than two women at a time, resulting in users being unable to maintain their privacy [36]. In terms of the services offered by MWHs, some studies have indicated that MWH is a simple structure that provides full accommodation for users, including food catering, water, a place to sleep, ANC care, and health education for pregnant mothers [15, 29]. Whereas other reported that physically, MWHs are available in some areas but do not provide all-encompassing services. As a result, women who planned to stay there were required to bring their food and basic household supplies from home, such as mattresses and kitchen utensils for the duration of their stay [14, 21, 31, 35, 36]. 

Cultural restriction

The refusal of a husband or parent to use MWH was demonstrated to be a barrier to MWH use. Pregnant women who desire to stay at MWH are expected to leave their children at home, and there is a societal view that leaving children alone at home without someone to support is a sign of a refusal of social responsibility [21, 31, 35, 36, 40].

Poor awareness and women’s perceptions of the quality of care at MWHs

The current review also showed that a lack of knowledge about MWHs and their related benefits was a barrier to staying at MWH [16, 21, 23,24,25,26, 28, 31, 35, 36, 39, 40]. Moreover, previous experience has been also cited as a barrier, particularly the poor interaction between health professionals and women at MWH [16, 31].

Enablers

Availability of MWHs

The contribution of MWHs as a crucial link for other maternal health services, as well as their availability as a way to overcome the geographic gap in access to healthcare facilities, were identified as typical enablers in the literature. Women staying at MWH have the opportunity to share experiences with other pregnant mothers, postpartum health education about family planning, infant feeding, and connecting women to the health facility and PNC services for both mothers and newborns [34].

Provision of quality and compassionate care

Providing high-quality, compassionate care to mothers at MWH enabled the mother to return to the facility and serve as a role model to other clients [34, 40].

Discussion

This study synthesized research evidence on MWH implementation, aiming to identify the benefits, barriers and enablers for MWH implementation in Ethiopia. Despite the limited and variable evidence, the implementation of the MWH strategy is an appropriate strategy to improve access to skilled birth attendance for women who reside in rural and remote settings.

According to the included studies, MWH has been shown to have benefits such as improved access to skilled birth attendants, a lower risk of perinatal death, the potential to reduce stillbirth rate, a lower incidence of obstructed labor, and uterine rupture, improved access to maternal health care  [13,14,15, 22, 47]. Furthermore, it allows healthcare providers to convey health-related information, such as newborn feeding, family planning, and immunization to pregnant women at MWH. It also gives pregnant women the chance to discuss their experiences with one another and adopt behaviors that are crucial for safe motherhood  [21, 31, 36].

Our review found a disparity in the proportion of maternal deaths among MWH users compared with non-users, which could suggest the positive association of making use of MWHs on the reduction of maternal deaths. This finding is consistent with the findings of other systematic reviews and meta-analyses conducted in developing countries  [50, 51]. The result can be explained by the fact that pregnant women who used MWHs had timely access to emergency obstetric care compared to those women who attempted home delivery (without SBA) or were admitted directly to HIs. This could indicate that non-users might have been delayed in accessing emergency obstetric care as a result of geographical barriers like long travel distances to the HIs and lack of transportation  [52]. However, the increased risks of maternal death among non-users might not necessarily be attributable to the non-use of MWH as the studies were not adjusted for confounders. Pregnant women who didn’t stay at MWH may also be disadvantaged in other ways, such as a lack of money or other resources, familial prohibition, or a lack of understanding or education about the need for obstetric care, all of which may be linked to poor maternal health outcomes.

Our review has shown that MWH users had significantly lower rates of uterine rupture than non-users. A possible explanation might be that non-users developed obstetric complications (obstructed labor) due to their late arrival at HIs, leading to rupture of the uterus and subsequent maternal death [13, 14, 47]. Moreover, this finding strengthens the prime concept behind the establishment of MWHs: MWHs help keep pregnant women near HIs with emergency obstetric care; therefore, they are less likely to experience any delay in obtaining emergency care when need be. On the contrary, women who give birth at home or get directly admitted to HIs are more likely to develop complications due to lack of skilled care or delay in reaching the HIs [17]. This is evident in the fact that major childbirth complications, which adversely affect maternal survival, have been reduced in areas where MWH services have been considered as part of maternity care [53].

However, the level of obstetric care available, as well as the quality of care offered at the health facility to which the MWH is linked, all have a role in the improved pregnancy outcome [54, 55]. The poor pregnancy outcomes among pregnant women admitted to the hospital may be also due to substandard care provided at the care facilities after the women arrived  [18, 56]. We further believe that the difference cannot be attributed to the use of MWHs since the confounding variables such as social support, wealth, awareness of MWH services, awareness of the need of delivering at a facility, availability of transportation, and distances to MWHs were not properly controlled in the included studies. These characteristics may have influenced the women’s decision to stay in MWHs, and those who did not may not have had comparable risk to maternal mortality and morbidity outcomes.

For pregnant women living in remote areas where access to maternity services is limited, MWH is widely recommended as a strategy to improve maternal health, but previous studies have shown that the level of utilization of the existing MWHs is lower than expected  [39, 42]. As a result, pregnant women have continued to give birth without the assistance of skilled birth attendants [5]. To improve the current uptake of existing MWH facilities, issues that may negatively affect women’s ability to use MWHs need to be addressed; in particular, greater awareness should be created about the facilities and attention should also be paid to their physical condition and the quality of care they provide [57]. Other studies have also suggested that some interventions like providing the women with food and basic supplies for the duration of their stay while ensuring basic sanitation would significantly improve the uptake of existing MWH services [34]. Besides, fostering a sense of communal ownership, improving women’s education, and promoting the importance of MWHs among health care providers and community leaders may have a significant impact on the sustainability of the service.

Most importantly, the success of the MWH strategy lies in the assumption that women staying in these homes can be transferred to obstetric facilities as soon they start showing signs of labor, where they can get skilled professional care including cesarean delivery at the right time [58]. Therefore, there is a need for functional and standardized referral systems which connect MWHs and obstetric facilities with operative delivery [12].

Gaps in the literature

Despite the growing popularity of MWHs since the 1970s as an intervention to reduce maternal mortality, no attempt was made to test its effectiveness using strong designs except one conducted in Jimma zone southern Ethiopia [33]. We have conducted this review with currently available evidence to provide important insights and up-to-date information on the national implementation of MWHs strategy with a particular emphasis on the benefits, barriers and enablers of MWH in Ethiopia.

As far as our search is concerned, more than half of the included studies were from southern Ethiopia. Therefore, this review may not be the full representation of the scenario in the context of Ethiopia. The existence of heterogeneity between studies all the observed differences in the outcome variables between the MWH users and non-users cannot be attributed to the use of MWHs. Most of the original studies included in the review did not provide details about how outcome variables were ascertained, wherefore it could be difficult to ascertain that the difference in perinatal and maternal complication and death maternal death between users and non-users were due to MWH use or not use. In addition, it was not also considered the level of care at the care facilities attached to MWHs, the risk status of pregnant women separately as these were likely to impact pregnancy outcomes.

Conclusion

This study synthesized research evidence on MWH implementation, aiming to identify the benefits, factors and enablers for MWH implementation in Ethiopia. Despite the limited and variable evidence, the implementation of the MWH strategy is an appropriate strategy to improve access to skilled birth attendance for rural and remote women.

Because there are so many different MWH models and so many variations in the baseline characteristics of the population under study, more studies are needed to determine the contribution while accounting for these differences. As research to date has primarily used non-experimental observational study designs, experimental studies, such as randomized controlled trials or quasi-experimental studies, may be best suited for this goal. In addition, studies must look at differences in baseline obstetric risk and intention to give birth in a facility. Demographic characteristics (confounding factors) that could indicate that women who have access to MWHs are better off in many ways, such as socioeconomic status, education, age, and distance from the facility, and therefore it is these factors that are influencing better outcomes.

Availability of data and materials

All data generated during this study are included in this published article and its supplementary information files.

Abbreviations

MWH:

Maternity waiting home

HIs:

Health institutions

SSA:

sub-Saharan Africa

WHO:

World Health Organization

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Acknowledgements

We are very grateful to Arba Minch University Librarian for helping us in accessing articles from the main database.

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This review was part of the project under Arba Minch University and the Inter-university collaboration of the vril-uos program.

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MKG, YJ, JPVG, and VD contributed towards the design and conduct of the review, including research questions addressed; MKG and GGU contributed towards literature review and analysis of information. MKG prepared the draft manuscript, with substantial inputs from YJ, VD, JVG, and GGU. All authors have reviewed and approved this final draft of the manuscript.

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Correspondence to Mekdes Kondale Gurara.

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Gurara, M.K., Jacquemyn, Y., Ukke, G.G. et al. Benefits, barriers and enablers of maternity waiting homes utilization in Ethiopia: an integrative review of national implementation experience to date. BMC Pregnancy Childbirth 22, 675 (2022). https://doi.org/10.1186/s12884-022-04954-y

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Keywords

  • Maternal mortality
  • Maternal morbidity
  • Waiting home
  • Maternity waiting home
  • Access
  • Ethiopia