Increasing facility delivery through maternity waiting homes for women living far from a health facility in rural Zambia: a quasi-experimental study

Objective: To report on the effectiveness of a standardised core Maternity Waiting Home (MWH) model to increase facility deliveries among women living >10 km from a health facility. Design: Quasi-experimental design with partial randomisation at the cluster level. Setting: Seven rural districts in Zambia. Population: Women delivering at 40 health facilities between June 2016 and August 2018. Methods: Twenty intervention and 20 comparison sites were used to test whether MWHs increased facility delivery for women living in rural Zambia. Difference-in-differences (DID) methodology was used to examine the effectiveness of the core MWH model on our identified outcomes. Main outcome measures: Differences in the change from baseline to study period in the percentage of women living >10 km from a health facility who: (1) delivered at the health facility, (2) attended a postnatal care (PNC) visit and (3) were referred to a higher-level health facility between intervention and comparison group. Results: We detected a significant difference in the percentage of deliveries at intervention facilities with the core MWH model for all women living >10 km away (DID 4.2%, 95% CI 0.6–7.6, P = 0.03), adolescent women (<18 years) living >10 km away (DID 18.1%, 95% CI 6.3–29.8, P = 0.002) and primigravida women living >10 km away (DID 9.3%, 95% CI 2.4–16.4, P = 0.01) and for women attending the first PNC visit (DID 17.8%, 95% CI 7.7–28, P < 0.001). Conclusion: The core MWH model was successful in increasing rates of facility delivery for women living >10 km from a healthcare facility, including adolescent women and primigravidas and attendance at the first PNC visit. Tweetable abstract: A core MWH model increased facility delivery for women living >10 km from a health facility including adolescents and primigravidas in Zambia. The core MWH model was developed by the Maternity Home Alliance (MHA) and is described in detail elsewhere. 18 Briefly, the core model was co‐created with communities based on formative research in response to community standards of acceptability related to: infrastructure, equipment and supplies; policies, management and finances; and linkages and services. Examples of core model components include lighting, lockable doors, concrete flooring, formalised management structure, mechanisms for community/women’s feedback, standard operating procedures, daily check‐in by facility staff, availability of emergency transport, and provision of health education. 18 The focus of the core model was to increase access to high‐quality obstetric services for the most vulnerable women living far from a health facility. As part of a quasi‐experimental study design with partial randomisation at the cluster level, 20 intervention sites received the core MWH model and 20 comparison sites provided the standard of care for waiting mothers. All intervention sites received newly constructed MWHs during implementation. Standard of care for waiting mothers at facilities without a MWH included informal short stays within the health facility; a simple community‐constructed shelter at the site, where women provide their own supplies such as bedding, cooking utensils, etc.; or no dedicated space at all to wait. 19 Two implementing partners used different methods to assign health facility sites to study arms: one used matched‐pair randomisation (10 intervention and 10 comparison) and the other a matched‐pair approach without random assignment (10 intervention and 10 comparison) due to political constraints at the district level (Figure S1). 18 Additionally, geographic information system (GIS) techniques were used to geo‐locate and map the distance between rural villages and health facility sites in each of the catchment areas. Distances from mothers’ home villages to health facilities were calculated using ArcGIS® Online (ESRI, Redlands, CA, USA). Recorded kilometer‐distances were determined as the most direct route along roads/paths between each village and their associated health facility. Seven districts (Chembe, Choma, Kalomo, Lundazi, Mansa, Nyimba and Pemba) in three provinces (Eastern, Luapula and Southern) were included in the study, with a total estimated population of 369 234 within‐catchment communities at all study sites. Baseline characteristics of study sites were primarily rural, with estimates of rural populations between 67% (Chembe) and 95% Lundazi. 20 Choma/Pemba and Mansa/Chembe were administratively combined in the 2010 census. Except for Chembe, each district had at least one district hospital providing Comprehensive Emergency Obstetric and Neonatal Care (CEmONC). The MWH intervention was examined at rural health facilities that serve women living in remote communities far from a health facility. The government of Zambia supports MWHs as one approach to increase facility delivery. 21 , 22 Briefly, facilities were chosen based on meeting the eligibility criteria of conducting at least 150 deliveries annually and situated ≤2 hours driving time from a facility providing CEmONC. Additionally, facilities were required to meet at least one of two sets of conditions: able to provide at least five of seven BEmONC signal functions or having at least one skilled birth attendant on staff, routinely providing active management of third stage of labour, and no stock‐outs of oxytocin or magnesium sulphate in the previous 12 months (Table S1). 18 The MHA partners harmonised instruments for data collection prior to the commencement of the study. Working with their local partners, the University of Michigan collected data on the MWH sites from Chembe, Lundazi and Mansa and Boston University collected data on the MWH sites from the remaining districts. Data were extracted from Ministry of Health (MOH) registers at each of the 40 health facility sites in the study for admission, delivery, PNC and referrals for complications to the next level of care (nearest CEmONC). Additionally, data were collected through an MWH register upon admission that captured demographic data, reason for MWH stay, travel time and means of travel to MWH. Time parameters for baseline data collection were set at 3 months prior to the opening of each individual MWH. The first MWHs opened in June 2016. Because MWHs were built and opened at various time points, time parameters for the study period included the first full month after the opening of the MWH through the end of data collection (August 2018); therefore, the study period reflects MWHs in operation between 12 and 24 months (Figure S2). Research assistants (RAs) extracted admission, discharge and transfer data from all health facility delivery registers at all 40 sites. They also extracted data on PNC attendance and referrals from facility registers. After obtaining informed consent, admission data were collected from each woman using a MWH survey that was administered verbally by a Zambian RA in the local language. Process and outcome indicators from the two implementing partners were agreed upon by partners a priori and data were combined at the end of the study. The MHA partners agreed on a small set of primary and secondary outcomes prior to the intervention to answer the overarching research question: ‘does a core MWH model increase access to facility delivery for women living far from the health facility (>10 km)’. By agreeing on a limited number of indicators easily retrieved from health facility registers to examine the research question, we decreased the burden of data collection on the health system. Descriptive analyses were performed comparing demographics across baseline and study period using Chi‐square tests for categorical variables and t‐tests for continuous variables. We used the difference‐in‐differences (DID) methodology to examine the effectiveness of the core MWH model on our primary and secondary outcomes. This approach adjusted for potential biases from underlying time trends and other unmeasured confounders between BEmONC facilities with MWHs (the intervention group) and BEmONC facilities without MWHs or unimproved MWHs (the comparison group). 23 Based on data from the Saving Mothers Giving Life (SMGL) initiative Phase I and district level MOH, intervention facilities experienced a common trend in attendance for maternal and newborn services to comparison facilities until the opening of MWHs. 24 For both groups, we calculated the proportions of women living >10 km from a health facility who came for deliveries at a BEmONC facility, attended a PNC visit at the recommended intervals (within 72 hours; 7–14 days; 6 weeks postpartum) 24 and were referred to a higher‐level health facility in baseline and the study period. We compared the differences in the change of percentages in the intervention group versus comparison group during the study period relative to baseline (3 months prior to MWH opening) to identify associations between MWHs and outcomes. Logistical regression was used to test the association between MWHs and the proportions of women who lived >10 km away from the facility for deliveries, PNC visits and referrals. In each model, we included two dummy variables: (1) equal to 1 for the intervention group and 0 for the comparison group and (2) equal to 1 for observations from the study period and 0 for those from baseline. We used an interaction term between these two dummy variables to perform a statistical test of the DID estimator. We then performed a risk‐adjusted model controlling for age, gravida and an indicator of whether randomisation was used in the facility assignment. We also conducted a sub‐analysis by facility assignment (randomised versus non‐randomised). All hypothesis tests were two‐sided with the level of statistical significance set to 0.05. Statistical analyses were conducted in STATA version 15.0 (StataCorp, College Station, TX, USA).