Why Women Choose Maternity Waiting Homes: Enhancing Maternal Health Outcomes in Rural Ethiopia

Highlights

• Less than half of pregnant women in rural Ethiopia plan to use maternity waiting homes (MWH).
• The main factors that influence their decision are attitudes, social norms, their sense of control, and their use of antenatal care.
• We need comprehensive interventions that address these factors to increase the use of maternity waiting homes

Background

Maternal mortality is a major public health issue in Ethiopia, with 267 deaths per 100,000 live births in 2020, far above the Sustainable Development Goal target of 70 by 2030. Rural areas are particularly affected as women face significant barriers to accessing skilled care during childbirth, such as the long distances many rural women have to travel to reach health facilities. MWHs are facilities near health centres where pregnant women can stay before delivery, they are aimed at reducing delays in reaching care and ensuring skilled birth attendance. MWHs were introduced in Ethiopia as part of efforts to reduce maternal mortality by increasing access to skilled birth attendance. These homes are typically simple facilities located near health centers where pregnant women can stay in the weeks leading up to their delivery date. They are staffed by health workers who provide basic care and monitor the women’s health. Local communities often contribute to their operation, providing food and other necessities. Research shows that MWHs significantly reduce the risk of perinatal mortality. Despite their benefits, only 7% of women used MWHs during their most recent pregnancy, according to a 2016 study. This underutilisation represents a missed opportunity to improve maternal and neonatal outcomes in Ethiopia.

Utilisation of MWH remains low due to barriers such as lack of awareness, cultural norms favouring home births, and concerns about the quality of MWH services. Understanding these barriers is crucial to unlocking the potential benefits of MWHs and improving maternal and neonatal health outcomes.

Methods:

This study used the Theory of Planned Behaviour to understand the factors influencing the use of MWHs in Bench Maji Zone (rural), Southwest Ethiopia by interviewing 829 pregnant women.

Key findings:

Only about 4 out of 10 women (42.6%) said they planned to use a MWH. The key factors influencing women’s decisions to use MWHs include their attitudes towards the facilities, social norms and expectations, perceived control over using the facilities, and engagement with antenatal care.

Four main factors influence whether women decide to use MWHs:

1. Women’s feelings about MWHs play a big role. If they believe MWHs can help them have a safer birth with fewer complications, they are more likely to use them.
2. What family, community leaders, and healthcare workers think matters a lot. Women are more inclined to use MWHs if they feel that important people in their lives support this choice.
3. If they think they can overcome challenges like finding transportation, managing home duties, or getting family permission, they are more likely to stay in an MWH.
4. Women who go for regular pregnancy check-ups (antenatal care) are more likely to use MWHs. These visits allow healthcare workers to inform and encourage women about the benefits of staying in MWHs.

Together, these four factors – attitudes, social norms, perceived control, and antenatal care visits – explain 81% of whether a woman plans to use a MWH. Surprisingly, a woman’s age, education level, or past childbirth experiences do not significantly affect this decision

Conclusion

The study shows that increasing the use of MWHs requires more than just building more facilities. It requires changing mindsets and addressing practical barriers. Women’s personal beliefs, social pressures, perceived ability to overcome obstacles, and engagement with antenatal care all play crucial roles. To make real progress, a comprehensive approach addressing all these areas is needed.

Policy Implications

• Current efforts to promote MWHs are insufficient. New, more comprehensive strategies are required.
• Providing information alone is not enough. Active shaping of attitudes and social norms around using these facilities is necessary.
• Community involvement is crucial. Family members and local leaders can significantly influence women’s decisions.
• Improving antenatal care services could have a positive effect on MWH use.
• Practical barriers that make women feel they can’t use these facilities, such as transportation and childcare, need to be addressed.

Recommendations

1. Community Campaigns: Launch widespread community campaigns to improve knowledge and attitudes about MWHs. These should target pregnant women, their families, and community leaders.
2. Community Leaders: Engage community leaders, religious figures, and respected elders to promote MWHs as a socially acceptable and beneficial option.
3. Practical Barriers: Identify and address practical barriers to using MWHs. This could include providing transportation, assisting with childcare arrangements, or offering income support for women who need to be away from home.
4. Antenatal Care: Integrate MWH promotion as a key component of antenatal care visits. Train healthcare workers to discuss this option with all pregnant women.
5. Facility Improvement: Improve the quality and comfort of MWHs. Ensure they meet women’s basic needs and cultural expectations.
6. Monitoring and Evaluation: Develop a monitoring and evaluation system to track progress and identify areas for improvement in MWH services.
7. Further Research: Conduct further research to test different intervention strategies and identify the most effective ways to increase MWH use in various contexts.

The above article is based on this publication:

Nigussie, T., et al. (2020). Predictors of Intention to Use Maternity Waiting Home Among Pregnant Women in Bench Maji Zone, Southwest Ethiopia Using the Theory of Planned Behavior. International Journal of Women’s Health, 12, 901-910.  https://pubmed.ncbi.nlm.nih.gov/33149701/

Other references

Dadi TL, Bekele BB, Kasaye HK, Nigussie T. Role of maternity waiting homes in the reduction of maternal death and stillbirth in developing countries and its contribution for maternal death reduction in Ethiopia: a systematic review and meta-analysis 11 medical and health sciences 1117 Public Health. BMC Health Serv Res. 2018;18 (1):1–10. doi:10.1186/s12913-018-3559-y

Gurara, MK., Jacquemyn, Y., Ukke, GG. 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

Kurji J, Gebretsadik LA, Wordofa MA, et al. Factors associated with maternity waiting home use among women in Jimma Zone, Ethiopia: a multilevel cross-sectional analysis. BMJ Open. 2019;9(8):e028210. doi:10.1136/bmjopen-2018-02821014.