Table 1 Summary of MWH studies included in the review in Ethiopia,2022

1

Girma et al. (2021) [21]

To explore the experiences and challenges faced by women during the MWHs implementation initiative

12 pregnant women, 12 lactating women, 6 HEWs,6 midwives, 8 health center heads, 50 men

A multiple case study design with qualitative data collection methods

Thematic content analysis

Jimma Zone, Oromia

Lack of essential utilities; overcrowding; inadequate furnishing; and supplies and food

Poor transportation services and the distance to MWH facilities

Mothers have good perceptions of the services, yet the services are not satisfactory, and family reluctance is present.

Lack of support to take care of children while pregnant mothers are staying in MWHs

Poor interaction between healthcare workers and women in MWHS

Lack of awareness about MWHs

2

Dalla Zuanna T, et al. (2021) [22]

To evaluate the effectiveness of MWH in reducing perinatal mortality in a secondary hospital

N = 3525 mothers 1175 cases and 2350 controls.

a retrospective study-nested case-control study and hospital / MWHs registry

multivariate logistic regression

Woliso, Oromoya

After adjusting for the confounder, the study highlighted a protective effect of MWH on perinatal mortality (OR = 0.70), and MWHs appear to reduce perinatal mortality by 55%.

MWH users were older, came from rural areas, had a worse obstetric history, higher parity, and a higher number of previous cesarean sections than non-users.

MWH users showed a significantly higher prevalence of all risk factors which are detectable during pregnancy

MWH users show a similar or even lower prevalence of obstetric complications. However, among MWH users, the cesarean section delivery proportion was twice that of nonusers.

The study also suggested the establishment of MWH, and there should be quality ANC in peripheral primary care clinics, where adequately trained healthcare professionals may recognize the occurrence of risk factors that may indicate admission to the MWH.

3

Gezimu1 et al. (2019) [23]

To assess the intention to use MWH and associated factors among pregnant women

N = 605 pregnant women

Community-based cross-sectional, face-to-face interview

Logistic regression

Kamba district, Southern Ethiopia

The study highlighted that 21.5% had stayed at MWHs, and 48.8% of pregnant women intended to use MWHs.

Factors for the positive intention were occupation (being a government employee), previous childbirth history, the experience of MWH, direct and indirect subjective norms, and perceived behavioral control of the respondents.

Those pregnant women who lived less than six months in the study area and those who delivered by cesarean section were excluded.

Community disapproval, low self-efficacy, maternal employment, history of previous childbirth, and past experiences of MWHs utilization are predictors of intention to use MWHs.

4

Asmare et al. (2020) [24] (preprint)

To determine the proportion of and factors affecting male partners’ involvement in MWH utilization

N = 403

 A community-based cross-sectional study

a multivariable logistic regression model

West Gojjam Zone, Northern Ethiopia

Male involvement in MWHs was found to be 55%.

Young knowledge about MWHs, husband decision-making power, and receiving counseling during ANC about MWH were all predictors of male involvement.

No standardized tool was used to measure the outcome variable

5

Endayehu et al. (2020 [25]

to assess pregnant women’s intentions to use MWHs and associated factors in East Bellesa district, northwest Ethiopia

N = 525 pregnant women

A community-based cross-sectional study, interviewer-administered structured

logistic regression

East Bellesa district, North Gondar

65.3% of pregnant women intended to use MWHs.

Women’s knowledge, subjective norms related to women’s perceptions of social pressure, perceived behavioral control of women on the extent to which women feel confident to utilize, wealth status, decision-making power, attendance at antenatal care, and attitude towards women’s overall evaluation of MWHs were significantly associated with the use of MWHs.

Efforts shall be made to improve women’s awareness by providing continuous health education during antenatal care visits, devising strategies to improve women’s wealth status, and strengthening decision-making power may enhance their intention to use MWHs.

6

Obola et al. (2020) (preprint) [26]

To assess intention to use MWH and associated factors among pregnant women

N = 556

 A community-based cross-sectional study, face-to-face interview

multivariable logistic regression

Hadiya Zone

44.6% of pregnant women intended to use MWH.

Mother attendance of formal education, 3 + received ANC care, MWH stays, and favorable and perceived behavior control were factors of the intention to stay at MWH.

7

Nigussie et al. (2020) [27]

To assess the predictors of intention to use MWH

N = 829 women

A community-based cross-sectional study

hierarchical linear regression

Bench Maji Zone, Southwest Ethiopia

42.6% of the study participants had an intention to use MWH, and 39% of the respondents ever used MWH

ANC utilization, attitude toward MWH, subjective norm, and perceived behavioral control were significant predictors of intention to use MWH.

8

Hailu et al. (2021) [28]

To investigate the use of health institution for delivery and factor that determines institutional delivery.

N = 426 142 cases and 284 controls

A community-based unmatched case-control study

backward stepwise logistic regression

Omo Nada district, Ethiopia

61.4% of the women who used MWHs have delivered in health facilities

Husbands and mothers themselves have a negative attitude towards MWHs. Therefore, the significant determinants for institutional delivery were mothers’ education, husband education, and ANC follow-up besides staying at MWH.

The use of MWHs increased institutional delivery service use.

However, it remains unclear whether the two groups are comparable or not other than the presence of disease in cases (health facility delivery) or the absence of disease in controls (home delivery).

9

Getachew et al. (2021) [29]

To describe establishment cost, essential services provided and operating costs of MWHs (MWH)

N = 812 postpartum women 8 eight health facilities with MWHs

cross-sectional study, MWH users exit interviews, observation, record review

descriptive analysis

Gurage Zone of Ethiopia

Most MWHs provide essential clinical services and basic amenities. However, not all MWHs provide meals to the users.

The majority of the cost of MWH was attributed to building construction costs. However, if the building cost is annualized, the unit cost of an MWH service is in an acceptable range which encourages the government to consider expansion of the service in rural areas.

The type of MWH varied between the sites, from traditional huts to semi-modern or modern and well furnished, built from natural materials or concrete bricks.

The average initial costs for construction and furnishing an MWH were $ 2,245 US. The annual operating cost of an MWH was $2,882 US.

10

Erickson et al. (2021) [15]

To assess factors influencing MWH use, as well as the association between MWH stay and obstetric outcomes in a hospital in rural Ethiopia

N = 489 women gave birth at the hospital, 93 MWH users

a mixed methods observational cohort study/ Medical records, Key informant interviews of a convenience sample

Logistic regression, a thematic analysis performed

Gurage in southwest Ethiopia

Of four hundred eighty-nine births, only 19.0% of MWH stay. Clients were admitted to MWH for both medical and socio-cultural-economic reasons.

Opportunity costs as the result of staying at MWH due to missed work and need to arrange for care of children at home, long travel times, and lack of entertainment during stay

MWH users were significantly more likely than non-users to have a cesarean section.

MWH use was associated with a 77% lower risk of childbirth complications, a 94% lower risk of fetal and newborn complications, and a 73% lower risk of maternal complications compared to MWH non-users

Users were less likely to experience obstructed labor or stillbirth; no cases of uterine rupture among users, whereas nine women experienced it among non-users (2.3% of 396) though the difference was not statistically significant.

Birth weight and 5-min Apgar scores were also higher in offspring of MWH users.

If communities have involved in designing MWHs, they may serve as centers for women’s empowerment, education, and income generation, impacting women and families far beyond birth outcomes.

11

Asnake et al. (2020) (preprint) [30]

To assess the contribution of MWHs in immediate Postpartum FP in Ethiopia

N = 884 postpartum women

a comparative cross-sectional study design, interview

logistic regression

USAID Transform: Primary Health Care project in 4 regions

41% of women had used MWHs before delivery. Of the women who used MWHs and received postpartum family planning counseling, more than half (54%) accepted family planning.

The prevalence of IPPFP use among women who used MWHs was 44%, and 36% among those who did not use MWHs.

It is agreed that providing a comprehensive package of services, including FP counseling and services in MWHs, would positively impact FP uptake.

It is challenging to attribute the change in the percentage between users and non-users due to MWH.

12

Gurara et al. (2021) [31]

To assessed barriers to MWHs

N = 807

Mixed methods design, both quantitative and qualitative methods of data collection employed.

logistic regression analysis

Gamo Zone

8.43% of the participants used MWHs during their last pregnancy.

Out of the 68 women, 67% mentioned transportation problems, 75% absence of food catering at the MWHs, and 16% poor availability of utensils and attitudes of the providers toward the expectant mothers were the main challenges they faced.

Previous childbirth complications, poor transport alternatives, long-distance travels through mountainous terrains to the facilities, and their husbands’ consent as factors

The women’s economic status, decisions made jointly with male partners (husbands) for an obstetric emergency, history of previous institutional childbirth, BPCR practice, history of previous childbirth complications, < 2 h travel distance to the nearest HI, and ease of access to transport in case of obstetric emergency

13

Teshome et al. (2020) (preprint) [32]

To assess MWH utilization and associated factors among women

N = 530 women

Community-based cross-sectional study, face-to-face interview

logistics regressions

Arsi Zone, Oromia,

23.6% of the respondents used MWH

Traveling time < = 60 min from a nearby health facility, women’s decision power, no antenatal care, and having more than three children were factors in using MWH

The absence of someone who cares for children at home (31.5%), past favorable conditions during home delivery (26.2%), and no means of transport (20%) was reported as major challenges for not using MWH.

14

Kurji1 et al. (2020) [33]

To evaluate the effectiveness of functional MWHs combined with community mobilization by trained local leaders in improving institutional births

24 PHCUs and 7593 women were

A parallel, three-arm, stratified, cluster-randomized controlled trial design,

intention to treat approach

Jimma zone Ethiopia

The combined MWH & leader training and the leader training alone intervention led to a small but non-significant increase in institutional births compared to usual care.

In the end line, institutional births were slightly higher in the MWH + training (54%) and training only arms (65%) compared to usual care (51%).

MWH use at baseline was 6.7% and 5.8% at the end line. Both intervention groups exhibited a non-statistically significantly higher odd of institutional births than usual care.

Low MWH use has often been linked to the poor quality of services offered (15% of women in the end line from the MWH + training arm were dissatisfied with the quality of services.

Travel time and distance have been reported to be inversely correlated with MWH us

Implementation challenges and short intervention duration may have hindered intervention effectiveness.

15

Tenaw et al. (2020) (preprint) [34]

To estimate the magnitude of MWH utilization and identify its associated factors in Sidama Zone

N = 748

Community-based cross-sectional study, Interviewer administered

Multivariable logistic regression analysis

Sidama zone

The utilization of MWH was 67.25%. Young age, socioeconomic status (high monthly income), and good knowledge make them more likely to use MWH.

Women who knew MWH, women who had a husband who could read and write, and women who were protestant religion followers have higher probabilities of MWH utilization.

Health education about MWH utilization, spouse education, and women’s economic empowerment are crucial to enhancing MWH utilization.

16

Kebede et al. (2020) [35]

To explore the factors influencing women’s access to the MWHs in rural Southwest Ethiopia.

N = 30 4 FGDs and 18 IDIs

A community-based cross-sectional study, qualitative data

thematical analysis

Southwest Ethiopia

Women were interested in MWHs and aware of their existence in their immediate vicinity. However, women did not understand the aims and benefits of MWHs.

Health information dissemination and referral linkages by frontline health workers enabled women to timely access the MWHs.

At the facility level, there were attempts to improve the acceptability of MWHs by allowing women to choose their delivery positions. However, participants claimed a lack of privacy and the presence of disrespectful care

Physical barriers (long-distance, unavailability of transport options & unfavorable roads) were considered potential problems for women residing in remote areas.

MWH users mentioned absences of sufficient basic facilities, poor quality and varieties of food. Because of insufficient facilities, the cost of living was high for most users. Therefore, the communities try to overcome the indirect costs through in-kind contributions and cash.

17

Selbana et al. (2020) [36]

to assess the utilization of MWHs and associated factors.

N = 379 women

A community-based cross-sectional study, face-to-face interview

Logistic regression analysis

Keffa Zone

42.5% of pregnant women stayed at MWHs.

Women’s decision-making capacity, women having someone who can care for their children and husband at home; MWHs offering food service; offering and allowing women to practice their cultural ceremony (allowing to cook their food type, porridge, coffee, Etc.) and women’s attitude towards MWHs were factors significantly associated with the utilization of MWHs.

Integrating culturally sensitive and supportive maternity services and a participatory community approach would increase the utilization of MWHs and consequently contribute to achieving the SDGs related to maternal health.

18

Getachew et al. (2020) [37]

To identify the influence of perceived geographic barriers to the utilization of MWHs

N = 716 women (358 were MWH users)

Observational cross-sectional study

Directed Acyclic Graph concept and multiple logistic regression

Gurage Zone of Ethiopia

MWH users had lower odds of having delivery complications.

Women with pregnancy complications who did not use MWH were more likely to develop delivery complications. In addition, women with delivery complications had higher odds of undergoing cesarean delivery and neonatal death.

Women who gave birth in non-cesarean section facilities had lower odds of delivery complications.

This study strengthens the evidence of MWH utilization as a helpful strategy to overcome geographic barriers and lower delivery complications.

Geographic barriers influenced the utilization of MWH. The women who used MWH had lower delivery complications.

19

Vermeiden et al. (2019) (preprint) [38]

To explore perspectives on MWH (MWH) utilization and facility births from the perspectives of community members and healthcare workers

N = 74 33 in-depth interviews and five focus group discussions

A qualitative study

Framework analysis

Gurage zone

Facility births were considered more common, yet uncomplicated births preferably took place at home. Ambulance services were highly appreciated in case of complications, while MWHs were unknown to most community members, and husbands were likely to object to their wives staying at MWHs.

Many community members reported negative experiences at health facilities, especially hospitals. In contrast, MWH users recounted a positive experience and recommended it to others.

Community networks have facilitated MWH stays and facility births through saving schemes and household support.

HCWs were also optimistic about the quality of care, but examination areas needed improvement. In addition, being overworked, underpaid, and undertrained undermined the quality of care.

Providing high-quality, compassionate care at health facilities was crucial to MWH use and facility births. In addition, community networks and health education may potentially overcome existing barriers to MWH use and facility births.

20

Kurji et al. (2020) [39]

to identify individual-, household- and community-level factors associated with MWH use in Ethiopia

N = 3784 women

Cross-sectional analysis of baseline household survey data

multi- variable generalized linear mixed-effects regression

Jimma zone

7% of women reported past MWH use. Housewives, women with companions for facility visits, wealthier households, and those with no health facility nearby or living > 30 min from a health facility had significantly higher odds of MWH use.

Education, decision-making autonomy, and community-level institutional births were not significantly associated with MWH use.

The short duration of stay and failure to consider MWH as part of birth preparedness planning suggests that local referral and promotion practices need investigation to ensure that women who would benefit the most are linked to MWH services.

21

Getachew et al. (2019) [40]

To compare the health care expenditures between MWH (MWH) users and nonusers in Ethiopia

N = 812 postpartum women

Cross-sectional study, face-to-face interviews

quantile regression to explore associated factors

Gurage Zone of Ethiopia

There were significantly higher out-of-pocket payments (OOP), women’s costs, total costs, and overall costs among MWH users compared with nonusers, regardless of the duration of their MWH stay.

The MWH users were more likely to have higher OOP payments than MWH nonusers in linear and quantile regressions for both unadjusted and adjusted analyses.

Higher OOP payments were observed for longer distance traveled and cesarean section (CS) delivery women. In addition, using public transportation was significantly associated with higher OOP payment in all quantile levels.

The utilization of MWH was associated with higher OOP payments. Higher OOP payments for delivery care among MWH users were observed in all quantile of expenditure.

22

Kebede et al. (2019) [41]

to assess women’s MWH satisfaction

N = 362 women

Cross-sectioal study, face-to-face interviews

Multiple linear regressions

Jimma Zone

A 68.8% level of MWH satisfaction was reported. Higher mothers’ satisfaction was from social support aspects: one to five women’s network (89.5%), cleaner/servant in MWH (88.9%), and husband (87.3%).

Lower satisfaction was from the ambulance (24%), recreational (38.5%), and food (49.4%) services and utensils in MWH (56.2%). Nearly 2/5th of users claim they do not come again and recommend MWH to others.

Women’s overall satisfaction with MWH was predicted by length of stay in MWH (≤ 14 days), utensils in MWH, services (prenatal, food, sanitation, recreational), social supports (family, women’s 1–5 networks, and servants) and interpersonal communication with HCWs.

23

Bergen et al. (2019) [16]

To explore the barriers and enablers that Health Extension Workers (HEWs) encounter when engaging with communities about MWHs.

36 HEW

Across sectional study, Qualitative, in-depth interview

thematic content analysis

Jimma zone

HEWs reported various factors that determined MWA use, including the number of children at home, previous childbirth experiences, community support networks, family decision-making practices, the availability and acceptability of health services, geographical access, and health beliefs.

HEWs worked to increase the use of MWAs by engaging with husbands and communities, raising awareness in target groups of women, and managing community participation.

At the individual level, HEWs reported that some women did not see the importance of using an MWA, while others were compelled to prioritize remaining at home to care for their families. Within families and communities, male partners and support networks appear instrumental in enabling or deterring MWA use. Prominent factors associated with intermediate and structural determinants of health included functionality and acceptability of the MWA and adjacent health facility, geographical access, and cultural/social norms

Though MWHs, by design, aim to address geographical barriers to facility birth, access to MWH itself frequently emerges as a barrier. For example, while ambulances, if available and functioning, may be a viable transportation option for women during labor, this service is not available for women to attend MWHs.

Compared with decisions about place of birth, decisions about MWA use entail additional considerations, as women spend a greater amount of time away from home and adapt to different living conditions at an MWA.

24

Vermeiden et al. (2018) [42]

To describe facilitators for MWH utilization from the perspectives of MWH users and health staff

FGD = 28 participants

IDI = 7 participants

N = 244 respondents MWH users

mixed-methods design, review of the record, FGD, in-depth interview, and observation

content analysis, descriptive statistics, and data triangulation

Gurage zone

Perceived high quality of care at the health facility, awareness of their high-risk status, support in overcoming barriers (supportive husbands), and women’s groups were facilitators of MWH utilization. In addition, community and facility-level integrated health services were also facilitators for using MWH.

Barriers to utilization existed (no cooking utensils at the MWH; attendant being away from work), but users considered these necessary to overcome for the perceived benefit: a healthy mother and baby.

If providing high-quality EmONC and integrating health services are prioritized, MWHs have the potential to become an accepted intervention in (rural) communities. Only then can MWHs improve access to EmONC

It was suggested that health education is crucial to facilitate MWH utilization, including clear communication to women and their families about the indications for an MWH stay.

25

Vermeiden et al. (2018) [43]

To describe factors and perceived barriers associated with the potential utilization of an MWH

428 recently delivered and pregnant women

A community-based cross-sectional study, interview

Logistic regression

Gurage zone, southern Ethiopia

7.0% had heard of MWH. In addition, 55.1% of the women showed a positive intention to stay at MWHs after explaining the concept to them.

Last childbirth complications and envisioning fewer barriers to staying at MWH were associated with the positive intention to stay at MWH.

Unless community awareness of preventive maternity care increases and barriers for women to stay at MWHs are overcome, these facilities will continue to be underutilized, especially among marginalized women.

26

Gebremeskel et al. (2018) [44] (Thesis)

To assess the effect of MWH utilization on maternal and perinatal health outcomes

MWH user (330) and non-user (343)

Retrospective Cohort Study

Life table and Cox proportional hazard regression

Tigray region

The incidence rates of maternal complications, perinatal death, and complications were significantly lower among the MWH users than non-users.

Users and mothers who gave birth to twins were the independent predictors of the maternal complication.

Newborns born from the user, born from mother who had experienced an obstetric complication, rural residents and newborns weighted < 2500 gm were the independent predictors of perinatal death and complications.

27

Braat et al. (2018) [14]

To examine the impact of a MWH by comparing pregnancy outcomes between users and non-users at hospitals with and without an MWH

N = 550 (244 MWH users and 306 non-MWH)

A retrospective cohort study

χ2 and OR

Gurage zone, southern Ethiopia

MWH users were less educated, poorer, and had to travel longer to reach a hospital compared with non-users

While poverty and inequity are factors known to negatively impact the survival of women and neonates, the more vulnerable group of women had better birth outcomes than women with higher socioeconomic status who did not use an MWH.

Between 2011 and 2014, all maternal deaths and nearly all stillbirths and uterine ruptures occurred among women who did not use the MWH

High-risk pregnant women that used an MWH in rural Ethiopia had less favorable sociodemographic characteristics but better birth outcomes than women who gave birth at the same hospital but did not use the MWH and women who gave birth at a hospital without an MWH.

The use of an MWH appears to improve birth outcomes.

28

Meshesha et al. (2017) [45]

The Role of MWH in improving Obstetric Outcomes

N = 516 mothers

Hospital-based record review

χ2, independent samples t-test

Jinka Zonal

16.7% had stayed at MWH, and the rest were directly admitted to the hospital (516 mothers).

Most mothers who came to the labor ward via the MWA were pregnant women living in rural areas.

The prevalence of bad obstetric outcomes was 61.2% among direct admission and 33.7% after they stay at MWH.

Descriptive results showed that limited women’s ability to access facility-based obstetric care and attributing the percentage change to the utilization of MWH is unscientific.

29

Gaym et al. (2012) [46]

To describe the current status of MWH services in Ethiopia.

9 MWH 74 mothers

Cross-sectional: site visits and documentation review using a checklist

Thematic analysis

Nationwide

Seven MWHs required the clients to cater for their food, firewood, and clothing supplies, providing only kitchen space and a few kitchen utensils.

The client admitted to the MWH was as far from 400 Km away to obtain services, and major indications for admission were previous cesarean Sect. 34%; previous fistula repair 12%; multiple pregnancies, 12% and mal-presentations 8%.

Lacks standardization and institutionalization across all the facilities

Selection bias, sample size adequacy, and group comparability are all uncertain.

30

Kelly et al. (2010) [13]

To describe maternal mortality and stillbirth rates among MWH users and non-MWH over 22 years.

N = 24 148 deliveries (6805 admitted via MWA and 17 343 admitted directly)

Retrospective cohort study, Data abstracted from routine hospital records.

Descriptive

Gurage zone

Maternal mortality and stillbirth rates were substantially lower in women admitted via MWA. At least part of this difference is likely accounted for by the timely and appropriate obstetric management of women using this MWH facility.

The need for coordination between the community and appropriate secondary care facilities in operating an effective MWA was recommended.

A descriptive comparison of perinatal outcomes and uncertainty around the comparability of groups might be the limitation of the study.

31

Poovan et al. (1990) [47]

To examine the impact of MWH on maternal health

No information

retrospective, record review

Descriptive

Gurage zone

A retrospective hospital-based study of pregnancy outcomes among MWH users versus those who went directly to the hospital

There were no maternal deaths among the 142 MWH users, but there were 13 maternal deaths among the 635 MWH nonusers, with no statistically significant difference in the proportion of operative deliveries between the two groups