Experiences with and expectations of maternity waiting homes in Luapula Province, Zambia: A mixed-methods, cross-sectional study with women, community groups and stakeholders

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Study Justification:
– Luapula Province in Zambia has the highest maternal mortality and low facility-based births, primarily due to the distance to healthcare facilities.
– Maternity homes were introduced in 2013 to increase facility-based births and reduce maternal mortality.
– This study aims to examine the experiences with maternity homes, assess women’s and community’s needs, use patterns, collaboration between maternity homes, facilities, and communities, and identify successful practices and models.
Study Highlights:
– Women who used maternity homes recognized the advantages of facility-based births.
– However, women and community groups requested improvements in infrastructure, services, food, security, privacy, and transportation.
– Safe Motherhood Action Groups (SMAGs) played a crucial role in the construction and advocacy of maternity homes.
– Successful maternity homes in other provinces relied on SMAGs for financial support, but sustainability was uncertain.
– Strengthening relationships between home managers and communities is essential to meet the needs and expectations of pregnant women.
– Quality standards and sustainability should be prioritized for maternity homes.
Study Recommendations:
– Interventions are needed to address women’s needs for better infrastructure, services, food, security, privacy, and transportation.
– Strengthen relationships between home managers and communities to ensure effective collaboration.
– Pay attention to quality standards and sustainability of maternity homes.
Key Role Players:
– Ministry of Health, Provincial and District Medical Office Managers
– Health workers
– Traditional leaders
– Couples
– Partner agency staff
– Safe Motherhood Action Groups (SMAGs)
– Chiefs or village headmen
– Neighbourhood Health Committees
– Traditional birth attendants
Cost Items for Planning Recommendations:
– Infrastructure improvements
– Service enhancements
– Food provisions
– Security measures
– Privacy enhancements
– Transportation services
– Training and capacity building for SMAGs and health workers
– Monitoring and evaluation systems
– Advocacy and awareness campaigns
– Sustainability planning and support

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a mixed-methods, cross-sectional study design, which provides a moderate level of evidence. The study collected qualitative data through focus group discussions and interviews, as well as quantitative data through facility assessments and service abstraction forms. The study also contextualized findings by drawing lessons from successful maternity homes in other provinces. However, the abstract does not provide information on the sample size or representativeness of the participants, which could affect the generalizability of the findings. To improve the strength of the evidence, the abstract should include more details on the sampling strategy, sample size, and participant demographics. Additionally, providing information on the validity and reliability of the data collection methods would enhance the credibility of the study.

Background: Luapula Province has the highest maternal mortality and one of the lowest facility-based births in Zambia. The distance to facilities limits facility-based births for women in rural areas. In 2013, the government incorporated maternity homes into the health system at the community level to increase facility-based births and reduce maternal mortality. To examine the experiences with maternity homes, formative research was undertaken in four districts of Luapula Province to assess women’s and community’s needs, use patterns, collaboration between maternity homes, facilities and communities, and promising practices and models in Central and Lusaka Provinces. Methods: A cross-sectional, mixed-methods design was used. In Luapula Province, qualitative data were collected through 21 focus group discussions with 210 pregnant women, mothers, elderly women, and Safe Motherhood Action Groups (SMAGs) and 79 interviews with health workers, traditional leaders, couples and partner agency staff. Health facility assessment tools, service abstraction forms and registers from 17 facilities supplied quantitative data. Additional qualitative data were collected from 26 SMAGs and 10 health workers in Central and Lusaka Provinces to contextualise findings. Qualitative transcripts were analysed thematically using Atlas-ti. Quantitative data were analysed descriptively using Stata. Results: Women who used maternity homes recognized the advantages of facility-based births. However, women and community groups requested better infrastructure, services, food, security, privacy, and transportation. SMAGs led the construction of maternity homes and advocated the benefits to women and communities in collaboration with health workers, but management responsibilities of the homes remained unassigned to SMAGs or staff. Community norms often influenced women’s decisions to use maternity homes. Successful maternity homes in Central Province also relied on SMAGs for financial support, but the sustainability of these models was not certain. Conclusions: Women and communities in the selected facilities accept and value maternity homes. However, interventions are needed to address women’s needs for better infrastructure, services, food, security, privacy and transportation. Strengthening relationships between the managers of the homes and their communities can serve as the foundation to meet the needs and expectations of pregnant women. Particular attention should be paid to ensuring that maternity homes meet quality standards and remain sustainable.

This study focuses on Luapula Province in northern Zambia. Luapula Province is a sparsely populated (19.6 persons per square kilometre), primarily rural province with poor roads and expansive swamps [22]. It has the highest maternal mortality ratio in Zambia at 573 per 100,000 live births, compared to 483 per 100,000 live births nationally [22]. In 2013–2014, 68.4% of live births occurred in health facilities in Luapula Province [3]. The study also draws lessons from successful maternity homes in the Central and Lusaka Provinces. All study districts are similar in terms of population, road access, livelihood, [22] and poverty level [23]. At the time of this study, the health system comprised 68 health facilities, 21 of which had maternity homes in Luapula Province. There were 204 health facilities in Central Province and 294 health facilities in Lusaka Province [24]. In addition, in rural areas community groups, including chiefs or village headmen, Safe Motherhood Action Groups (SMAGs), Neighbourhood Health Committees, and traditional birth attendants promote reproductive, maternal, neonatal and child health (RMNCH), and HIV services [5]. This study employed a mixed–methods, cross-sectional research design [25, 26]. Data were collected between September and December 2013. Three data extraction tools described below were used to collect quantitative data. Qualitative data were collected through focus group discussions and key informant interviews in the four districts in Luapula Province. Additional qualitative data were collected in Serenje and Mkushi Districts in Central Province and Rufunsa District in Lusaka Province to contextualize findings from Luapula Province. Luapula Province was selected to be the focus of this study by the Ministry of Health, Provincial and District Medical Office Managers because it reported the highest maternal mortality ratio in Zambia [22]. In Luapula Province, only these four districts had maternity homes in 2013 [24]. The three districts in Central and Lusaka Provinces were selected because they had well-integrated and functioning maternity homes. Purposeful sampling was used to select the sites and recruit focus group discussion and key informant interview participants in all provinces [26]. In Luapula Province, qualitative data were collected from 17 of 21 facilities with maternity homes in 2013. The four maternity homes not included were incomplete at the time of data collection. In Central and Lusaka Provinces, qualitative data were collected from three CRHCs and a mission hospital that had maternity homes [26]. In the four districts of Luapula Province, 21 focus group discussions were conducted with 210 participants who attended antenatal care, postnatal care, family planning and children’s clinics in CRHCs and mission hospitals and members of the SMAGs. The participants were maternity home users, non-maternity home users, women who were pregnant for the first time, women who had delivered at home in 2012, elderly women and SMAG/Neighbourhood Health Committees members (Table 1). Each focus group discussion included eight to 12 participants. Interviews were conducted with 21 health facility in-charges, 10 couples from antenatal care clinics, 17 chiefs (four chiefs were unable to participate due to unforeseen circumstances), 12 village headmen, four District Community Health Officers, two District Community Nursing Officers and three staff members from partner agencies (Table 2). Number of focus group discussions and participants in Luapula, Central and Lusaka Provinces Number of key informant interview participants in Luapula, Central and Lusaka Provinces In the Central Province districts, four focus group discussions with six to 12 participants were conducted with 26 SMAG members responsible for mobilizing communities and organizing activities to support maternity waiting homes [26]. Rufunsa District had no SMAGs. In the three districts of Central and Lusaka Provinces, interviews were conducted with three District Community Medical officers, two District Nursing Officers and five health facility in-charges who supervised health staff and had developed systems to work with community groups on maternity homes [26]. Field guides were used by interviewers to guide focus group discussions and key informant interviews (Additional file 1). Focus group discussions focused on maternity home use, food availability, customs and traditions related to facility-based deliveries, maternity homes’ cost and length of stay, willingness to pay, transportation services for pregnant women, and general impressions of maternity homes. Key informant interviews investigated support for maternity waiting homes, mechanisms to sustain maternity homes and their operations. Focus group discussions and interviews lasted approximately 30 to 45, and 20 to 30 min, respectively. In Luapula Province, quantitative data was collected using three assessment tools. The Maternity Home Assessment Tool containing 42 items was used to collect data through direct observation and clinic staff interviews about the structures and amenities available in maternity homes (Additional file 2). In particular, this tool was created by the research team to collect data on maternity home ownership, funding, and building materials, as well as availability of water and electricity, rooms, beds, mattresses and cooking amenities. A Service Abstraction Form containing 23 items was used to extract annual deliveries from maternity registers accessed through facility in-charges (Additional file 3). A separate assessment tool created by Integrated Rural Development Initiative and Jhpiego was used to collect water sources and sanitation data. Nine trained research assistants collected all data in Mansa, Chembe, Samfya and Lunga districts. They received training on research ethics, the study’s protocol and data collection tools, and empirical content on collection and quality of qualitative and quantitative data through didactic and hands-on sessions. The first author supervised this team and collected data in Serenje, Mkushi and Rufunsa districts. Focus group discussions and key informant interviews were conducted in the local language, Bemba, until saturation was reached [27]. The data collection tools were piloted with 20 midwives at Levy Mwanawasa General Hospital and Bauleni, Chilenje and Kabwata Health Centres in Lusaka Province and revised before the study started. Qualitative data were transcribed from audio recordings in Bemba, translated into English, and back-translated into Bemba to ensure accuracy of the translation. The data were coded in Atlas-ti using codes derived from the field guide questions and emergent themes [28]. Working matrices were used to organize passages and themes by participant type and analysed each district’s responses in a framework [27]. The data coders, three based at Jhpiego in Baltimore and three based in Lusaka, refined the themes, found commonalities, wrote up findings, and returned iteratively to the raw data to find relationships between themes. Quantitative variables were entered into a Microsoft Access database and analysed with descriptive statistics by district using Stata [29]. Results were shared with stakeholders at a dissemination meeting in Lusaka. The study was approved by the Johns Hopkins University Institutional Review Board in Baltimore and the University of Zambia Research Ethics Committee. All focus group and interview participants were consented verbally prior to their participation in the study. A waiver of written consent was obtained as the study posed no more than minimal risk of harm.

The study mentioned focuses on improving access to maternal health in Luapula Province, Zambia. Based on the findings, here are some recommendations that can be developed into innovations to improve access to maternal health:

1. Improve infrastructure and services: Develop innovative solutions to address the needs for better infrastructure, services, food, security, privacy, and transportation in maternity homes. This could include designing modular maternity homes that can be easily constructed and renovated, incorporating technology to improve services and communication, and implementing sustainable solutions for food, security, and transportation.

2. Strengthen community engagement: Develop innovative approaches to strengthen collaboration between maternity homes, health workers, and community groups such as Safe Motherhood Action Groups (SMAGs). This could involve using mobile technology to facilitate communication and coordination, implementing community-based financing models to ensure financial support for maternity homes, and leveraging social media and other platforms to raise awareness and mobilize communities.

3. Address cultural norms and beliefs: Develop innovative strategies to address cultural barriers and promote the acceptance and utilization of maternity homes. This could involve using storytelling and media campaigns to challenge harmful cultural norms, engaging with influential community leaders and traditional birth attendants to change perceptions, and implementing culturally sensitive practices within maternity homes.

4. Ensure quality standards and sustainability: Develop innovative approaches to ensure that maternity homes meet quality standards and remain sustainable. This could include implementing digital monitoring and evaluation systems to track the effectiveness and sustainability of maternity homes, establishing partnerships with private sector organizations to support infrastructure and services, and exploring innovative financing models such as social impact bonds or public-private partnerships.

By developing and implementing these innovations, it is expected that access to maternal health will be improved, leading to increased facility-based births and a reduction in maternal mortality rates in Luapula Province, Zambia.
AI Innovations Description
Based on the study mentioned, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Improve infrastructure and services: Address the needs for better infrastructure, services, food, security, privacy, and transportation in maternity homes. This can be done by investing in the construction and renovation of maternity homes, ensuring they have adequate facilities and amenities to provide a safe and comfortable environment for pregnant women.

2. Strengthen community engagement: Strengthen the collaboration between maternity homes, health workers, and community groups such as Safe Motherhood Action Groups (SMAGs). SMAGs can play a crucial role in advocating for the benefits of facility-based births and mobilizing communities to support maternity homes. They can also provide financial support and help ensure the sustainability of the homes.

3. Address cultural norms and beliefs: Recognize that community norms often influence women’s decisions to use maternity homes. It is important to engage with community leaders, traditional birth attendants, and other influential individuals to address any cultural barriers and promote the acceptance and utilization of maternity homes.

4. Ensure quality standards and sustainability: Pay particular attention to ensuring that maternity homes meet quality standards and remain sustainable. This can be achieved by establishing clear management responsibilities for the homes, involving both SMAGs and staff in the management process. Regular monitoring and evaluation should be conducted to assess the effectiveness and sustainability of the maternity homes.

By implementing these recommendations, it is expected that access to maternal health will be improved, leading to increased facility-based births and a reduction in maternal mortality rates.
AI Innovations Methodology
The methodology used in the study mentioned is a mixed-methods, cross-sectional research design. The study collected both qualitative and quantitative data to assess the experiences and expectations of maternity waiting homes in Luapula Province, Zambia.

Qualitative data was collected through 21 focus group discussions with 210 pregnant women, mothers, elderly women, and Safe Motherhood Action Groups (SMAGs), as well as 79 interviews with health workers, traditional leaders, couples, and partner agency staff. The qualitative data was analyzed thematically using Atlas-ti software.

Quantitative data was collected through health facility assessment tools, service abstraction forms, and registers from 17 facilities in Luapula Province. Descriptive analysis was conducted using Stata software to analyze the quantitative data.

Additional qualitative data was collected from SMAGs and health workers in Central and Lusaka Provinces to contextualize the findings from Luapula Province.

The study employed purposeful sampling to select the sites and recruit participants. The selection of Luapula Province as the focus of the study was based on its high maternal mortality ratio in Zambia. The Central and Lusaka Provinces were selected because they had well-integrated and functioning maternity homes.

The data collection tools included field guides for focus group discussions and key informant interviews. The focus group discussions and interviews covered topics such as maternity home use, food availability, customs and traditions related to facility-based deliveries, cost and length of stay in maternity homes, transportation services for pregnant women, and general impressions of maternity homes.

The study also collected quantitative data on the structures and amenities available in maternity homes using assessment tools. Water sources and sanitation data were collected using a separate assessment tool.

The data collection was conducted by trained research assistants who received training on research ethics, the study’s protocol, and data collection tools.

The qualitative data was transcribed, translated into English, and coded using Atlas-ti software. The quantitative data was entered into a database and analyzed using descriptive statistics.

The study was approved by the Johns Hopkins University Institutional Review Board and the University of Zambia Research Ethics Committee. Verbal consent was obtained from all focus group and interview participants.

The results of the study were shared with stakeholders at a dissemination meeting in Lusaka.

The study was published in BMC Pregnancy and Childbirth in 2018.

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