Understanding the implementation of maternity waiting homes in low- and middle-income countries: a qualitative thematic synthesis

Background Maternity waiting homes (MWHs) are accommodations located near a health facility where women can stay towards the end of pregnancy and/or after birth to enable timely access to essential childbirth care or care for complications. Although MWHs have been implemented for over four decades, different operational models exist. This secondary thematic +analysis explores factors related to their implementation. Methods A qualitative thematic analysis was conducted using 29 studies across 17 countries. The papers were identified through an existing Cochrane review and a mapping of the maternal health literature. The Supporting the Use of Research Evidence framework (SURE) guided the thematic analysis to explore the perceptions of various stakeholders and barriers and facilitators for implementation. The influence of contextual factors, the design of the MWHs, and the conditions under which they operated were examined. Results Key problems of MWH implementation included challenges in MWH maintenance and utilization by pregnant women. Poor utilization was due to lack of knowledge and acceptance of the MWH among women and communities, long distances to reach the MWH, and culturally inappropriate care. Poor MWH structures were identified by almost all studies as a major barrier, and included poor toilets and kitchens, and a lack of space for family and companions. Facilitators included reduced or removal of costs associated with using a MWH, community involvement in the design and upkeep of the MWHs, activities to raise awareness and acceptance among family and community members, and integrating culturally-appropriate practices into the provision of maternal and newborn care at the MWHs and the health facilities to which they are linked. Conclusion MWHs should not be designed as an isolated intervention but using a health systems perspective, taking account of women and community perspectives, the quality of the MWH structure and the care provided at the health facility. Careful tailoring of the MWH to women’s accommodation, social and dietary needs; low direct and indirect costs; and a functioning health system are key considerations when implementing MWH. Improved and harmonized documentation of implementation experiences would provide a better understanding of the factors that impact on successful implementation.


Background
Ensuring births with a skilled attendant and births in health facilities has been the key focus of attempts to reduce maternal mortality in the last two decades [1,2]. Many women in developing countries live far away or across difficult terrain from facilities. Transport is not always available, or may be difficult or too slow, particularly for women in labour, or when complications have developed [2]. Strategies typically designed for inaccessible areas aim to facilitate the timely movement of women from home to health facility by diminishing barriers that inhibit access to care such as distance, geography, seasonal barriers or the time of day. The interventions relate to improving infrastructure or transport, addressing the cost of transport or enabling communication between referral points [3]. One intervention designed to address accessibility are maternity waiting homes (MWHs). Maternity waiting homes are defined as lodgings or accommodation close to a health facility where women can stay before and sometimes after they give birth. Women staying in MWHs are then able to easily access services for essential childbirth care or obstetric or newborn complications at the nearby facility [4].
MWHs have been advocated for and implemented for over four decades [5]. Current maternal health strategies embrace MWHs, including the Campaign on Accelerated Reduction of Maternal, Newborn & Child Mortality in Africa (CARMMA) programme in South Africa [6], Saving Mothers Giving Lives in Zambia and Uganda [7], Gates funded projects in Malawi [8]and the Plan of Action to Accelerate the Reduction of Maternal Morality and Severe Maternal Morbidity for the Americas [9]. Different operational models of MWHs exist. In the past, MWH programmes targeted women most at risk of developing obstetric complications [10][11][12][13][14]. More recently, the focus has expanded to all pregnant women who would otherwise have problems accessing facilities for birth [3,10,[15][16][17].
In 2015 the World Health Organization (WHO) published Recommendations on Health Promotion Interventions for Maternal and Newborn Health [4]. An intervention assessed within this guideline include MWHs. The Guideline Development Group reviewed the evidence collected and concluded that "MWHs are recommended to be established close to a health facility where essential childbirth care and/or care for obstetric and newborn complications is provided to increase access to skilled are at birth for populations living in remote areas or with limited access to services" p. 5.
In addition to commissioning a systematic review to determine the evidence of effectiveness of MWHs on key maternal health outcomes, the WHO also commissioned a background document to analyse the context and conditions and factors that affect implementation of MWHs. This article builds on that background document. The objective of this paper is to share with policy makers and implementers who are thinking about implementing MWHs key learnings from other implementation experiences, so that they can apply lessons to their own contexts.

Methods
This article is a secondary thematic analysis of studies identified in a systematic review of MWHs commissioned by WHO whose findings are summarized in the above-mentioned guidelines: [4] four existing systematic reviews [3,[18][19][20] and a systematic mapping of maternal health literature published from 2000 to 2012 were identified [21].
For this paper we included 29 studies identified through the above systematic reviews: 14 of these were included in the WHO-commissioned review and an additional 15 papers which were not included in the WHO-commissioned evidence review but included here as they described the implementation of MWHs, through qualitative or quantitative studies. The characteristics of the 29 studies included in this analysis are listed in Table 1.
We used the Supporting the Use of Research Evidence framework (SURE) framework [22] to identify different contextual and health system factors that affect implementation of MWHs and conducted data extraction on the key themes (See Table 2). The relevant information extracted on perspectives of women who used MWHs, community stakeholders, health care providers and other stakeholders; health service delivery factors; and social and political factors is presented in Table 3 and summarized below. Table 1 gives information on study design of the papers included. Fourteen of the papers included were impact studies, including 11 cohort studies, two cross-sectional studies and one review of records. The other fifteen papers were either qualitative or mixed method in research design. In two cases, no research design was reported. The dates of the studies ranged from 1978 to 2013, with the majority published between 2003 and 2013. Below we organize the analysis of implementation factors extracted from the different studies into five main categories.

Maternity waiting homes settings and target populations
The included studies on MWHs were from countries in Africa (nine countries -Eritrea, Ethiopia, Ghana, Kenya, Liberia, Malawi, South Africa, Zambia, Zimbabwe), Latin America (four countries -Cuba, Guatemala, Honduras,  Reported interventions were generally confined to a few districts involving one to five MWHs. However, articles from Cuba and Peru reported larger numbers of MWHs being built [16,23]. The majority of settings were rural. Some specifically targeted conflict areas, indigenous women, the socially excluded, or poor people. [17,24,25] Depending on the location of the MWH, women travelled from less than 5 km to 400 km to reach the closest MWH [10,15]. Along with large distances, several studies reported women having to cross difficult terrain to reach the facility. Most MWHs were situated next to a hospital facility, which provided essential childbirth care services and care for complications (comprehensive obstetric care services), although a few were placed near health centres that provided only essential childbirth care. Practices of referral to MWHs varied; women were referred by health professionals, from antenatal clinics or self-referred.

Administrative set up and maintenance of maternity waiting homes
There is diversity in the stakeholders who took responsibility to establish the MWHs in the different studies included. The programmes in Cuba and Peru were large scale and, at least initially, adequately funded and supported by their respective National Ministries of Health. These MWHs were implemented as part of a national programme to improve maternal health outcomes, alongside new protocols, staff training, and improved referral and support for women [16,23]. Aside from these examples, little information was found on policy support for MWHs at a national level.
The remainder of the MWHs consisted of isolated projects, supported by non-governmental and donor organisations. A number of articles reported community support and contribution to the setup and ongoing running of the MWH. The need for the community to be involved in the set up and maintenance of the MWH was identified in three studies, and six studies identified the absence of community involvement as a reason for low utilization of the MWH programme [13,17,[26][27][28][29].
Several studies reported on MWH residents incurring user fees for antenatal care or childbirth services [10,17,25,[29][30][31][32][33]. The removal or reduction of costs associated with using the MWH and subsequent institutional birth were noted as important strategies for increasing MHW use. In two studies, financial incentives were even offered for women, who were charged less for childbirth services if they stayed in the MWH [13,17]. The provision of free food by the MWH varied across settings. In Cuba, meals were provided and tailored to the nutritional needs of each woman in consultation with dieticians at the MWH [16], while in other MWHs, food or kitchen facilities were available for the women to arrange their own meals [10,16,18,31,33]. However, in instances where women and their families were required to provide their own meals, inequalities in terms of volume and quality of food emerged among the women [10,13,33,34].
A number of studies reported that simply building a MWH did not overcome barriers to accessing care as women still needed financial resources to get to the MWH [15,17,25,28,30]. The cost of public transportation to reach the MWH was a common barrier to its use and varied depending on the mode of transport distance and time of day [13]. Considerable costs were also reported for securing private transport. The comfort and speed of the transport, as well as the terrain covered were other elements considered by women [13,30]. In Laos PDR, women were refunded transport costs. In Nicaragua and Laos PDR, women and their families indicated that upfront support for transportation costs would be important [23,30].

Physical infrastructure and facilities provided
A range of building types were used for MWHs, including unused wards of hospitals [29], traditional huts [12] and purpose-built structures. Some buildings had several separate rooms, each with a few beds [27], while others had large dormitories [17]. Total bed space ranged from 4 to to 83 [31]. In planning for the construction of a MWH in South Africa, Larsen et al. estimated that the size of a MWH should be based on 500 women per 1000 births in a district, with each stay averaging two weeks [35].  Articles that are highlighted in bold are those that were included in the systematic review of effectiveness of MWHs Living and social spaces, as well as utilities like electricity or water, kitchens, cooking utensils, toilets and bathrooms, lockers, bedding and firewood, were described in some papers. From the perspectives of women who used the facility, a lack of privacy, poor toilet and bathing facilities, poor or inadequate kitchen facilities, the non provision of food, and lack of space for women to stay post-partum were considerable barriers to MHW use. [10, 13, 15, 17, 25, 27-30, 36, 37] Overall, MWHs were better used and accepted by women and their families when they provided basic infrastructure and facilities such as those mentioned above [17,27,36,37]. In one MWH in Ethiopia the availability of a hot shower was very popular with women [13].
In some situations, accommodation was provided for relatives, including mother in laws [17,28]. Women cited companions not being allowedeither at the MWH or in the facilityas an additional factor undermining acceptability of MWHs [10,15,17,25,30]. Finally, in interviews with women and families, acceptability of MWH was noted as being higher if activities were available for women to do while awaiting childbirth, such as health education and income generation activities [14,16,17,33].

Health services and linkages with the facility
Various criteria were used to accept women into MWHs, from identified obstetric risk factors for complications, to open admission. Women were advised to stay for between one to four weeks before childbirth and, in some MWHs, for up to seven days after birth. Two studies suggested that sometimes uncertainty around a woman's due date meant that she did not know when it was appropriate to come to the MWH [30,32]. MWHs were sometimes also used as places for women to stay before and after undergoing postpartum tubal ligation at the hospital or other health facilities [10,33,38].
Studies suggest that strong referral and communication systems between the MWH and the facilities they are linked to are important, as well as a focus on providing high quality care in both the MWH and the facility linked to the MWH [14,16,17,25,26,32,34,37,39,40]. The type and quality of maternity care services received by women varied. Three studies noted that there were no regular visits by health care providers to the MWH and that referral from the MWH to the facility was not smooth [10,29,36]. In other sites, women regularly attended the nearby health facility, or were visited in the MWH by staff from the facility [14,26,31]. Standard guidelines for care processes, including criteria for admissions, diagnostic and clinical guidelines for identifying risk factors, and protocols for treatment in MWH settings, were reported in Cuba [16].

Community involvement and sensitivity to cultural norms
Linking with traditional birth attendants (TBAs) was seen as enabling the success of MWH programmes. Five studies identified this as critical to facilitating access to MWHs, specifically, through the training of TBAs and the integration of them into the preparation for birth and birthing process both at the MWH and at the facility [24][25][26][27]39].
In four studies, the integration of cultural norms around birthing and improved awareness that the MWH provided respectful and humanized care were key to getting women and their families to use both MWH and the nearby facility for birth [17,[23][24][25]. Finally, on the issue of cultural norms, concerns were expressed by women in Guatemala around health workers belonging to a different cultural group to those attending MWH, and the potential for this to pose linguistic challenges and also to undermine respect for a woman's cultural beliefs [17,31].
A number of studies identified outreach to the community, often using existing community health structures, as key to the success of a MWH project [25][26][27][28].
Community involvement was important to identify cultural factors that affected the use of the MHW; for example, family members, namely the husband or mother-in-law, would not "allow" women to use the MWH or to be away from the household for an extended length of time due to childcare and other household duties [17,27,31,36,37]. Awareness building efforts were especially important in places where community members had little knowledge of the MWH, which in itself constituted an important barrier to MWH use [17,28,36].
Overall, activities to increase community awareness of the MWH services were considered a vital facilitator of MWH uptake [10,13,15,25,26,31]. MWHs were embraced in those communities where family members and the larger community had been made aware of the importance of facility births [10,13,15,17,24,25,28,31].

Limitations and research gaps
We identified several limitations in this review. The wide variations in the organization, functioning and operationalization of MWHs, and how women were screened for MWH residence means that the studies are difficult to compare.
Most papers did not specifically set out to either document the contextual factors or assess barriers and facilitators. A number of factors that may play a key role on the implementation of these programmes were not reported (see Table 1). Surprisingly, there was relatively little in the reviewed literature around health care workers attitudes towards MWHs and how these affected implementation. Issues such as community participation were stressed as important in many articles, but what was meant by community participation and how community participation was ensured was not expanded upon. Studies that did seek community input often obtained information from women who were already users of facilities, rather than non-users. Nonetheless the included studies provide rich findings.
The studies included were generally of small-scale projects, although examples of scaled-up MWHs were available from Peru and Cuba. We have only drawn from published literature, but we are aware that there may be other experiences of implementation of MWH programmes from which lessons could be drawn, as many programmes may not be implemented as part of research or with a research component. This is particularly true of programmes implemented by National Ministries of Health.
Publication bias cannot be ruled out although the collection of systematic reviews and extensive search strategy for the Mascot mapping aimed to minimise this [21].
When considering implementing MWHs, key factors to be addressed include: 1) Community engagement, ensuring input is obtained from women and other community members as to the design and running of the MWH, identification of barriers to the use of MWH's that need to be addressed and recommendations about how the community can be involved in maintaining the quality of the MWH's; 2) the quality of the MWH structure, including cleanliness, living conditions, and the safety of women staying there; 3) the quality of maternity care services provided at the corresponding health facility; and 4) the financial and operational sustainability of the MWH.. The literature suggests that there is not one model that fits the diversity of contexts but it is clear there are multiple issues that require discussion with key stakeholders in order to address the factors that will affect implementation and ensure integration in to the health system. Maternity Waiting Homes are not isolated interventions and one of the key challenges to its successful implementation is how well it can be embedded within the health system and integrated within community patterns, preferences, behaviours and other related services. Some interventions have presumed the following: women find birth in a health facility acceptable; the financial and indirect costs of residing away from home are affordable; and women's basic rights to comfort, companionship, tradition, information and quality of care are respected. However the studies in this review have shown that these elements are variable and heavily dependent on the local context. We also see that there are multiple factors that affect care seeking for childbirth services; distance is only one factor. The MWH needs to be imbedded in a programme that addresses the other factors including costs, household decision making, knowledge of services, women and community perceptions of quality of care, etc.
The community perspectives in the studies reviewed demonstrate there is general awareness of the benefits offered by MWH, particularly when the community is consulted and involved. Involvement can range from participation in a governing committee, to faith-based organizations spearheading the physical construction of MWH, to community volunteers supporting individuals or running programmes within the facility.
The literature also suggests that it is important that all those involved in promoting maternal and newborn health and providing maternity care services must know about MWHs. It is likely that provision of MWH should be included in community health workers training, birth and complication preparedness, voucher programmes and other efforts to improve the levels of birth with a skilled attendant in rural and remote areas.
The 'readiness' of the linked health facility is also crucial. The literature suggests that women will not use MWH even when they are available if they are not confident about the care they will receive in the linked health facility. The quality of care (both respectful and medical quality) provided in the health facility should be adequate to improve both acceptability and health outcomes of childbirth.

Conclusion
At policy level, there may be utility in development of guidelines and protocols on the physical infrastructure, utilities and services provided at the MWH, and community consultation. Additionally, clear identification of capital costs is required, along with a functioning management structure, regular flow of resources for maintenance and a defined relationship with the linked health facility and the health system. Improved and harmonized documentation of implementation experiences would provide a better understanding of the factors that impact on successful implementation. As is illustrated in Table 1 many of the articles did not record key information that would have been useful to enable implementation lessons to be learnt.