Maternal and perinatal outcomes among maternity waiting home users and non-users in rural Rwanda

  • International Journal of Environmental Research and Public Health, Volume 18, No. 21, Year 2021

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Study Justification:
– Timely access to skilled birth attendants can prevent most maternal and perinatal deaths.
– Maternity waiting homes (MWHs) provide access to emergency obstetric care during labor.
– This study aimed to compare maternal and perinatal outcomes between MWH users and non-users in rural Rwanda.
Study Highlights:
– Data from 8144 deliveries between 2015 and 2019 were analyzed.
– 1305 women with high-risk pregnancies were included in the study.
– MWH users had more spontaneous vaginal deliveries (38.6% vs. 16.8%) and fewer cesarean sections (57.7% vs. 76.7%) compared to non-users.
– Maternal morbidities such as postpartum hemorrhage occurred less frequently among MWH users (2.13% vs. 5.64%).
– No deaths were reported among MWH users, while four deaths occurred among non-users.
– Non-users had more stillbirths than MWH users (7.68% vs. 0.91%).
– The MWH may have contributed to the observed differences in outcomes.
Recommendations for Lay Reader and Policy Maker:
– Scaling up the use of MWHs could improve maternal and perinatal outcomes in Rwanda.
– Efforts should be made to increase awareness and utilization of MWHs among women with high-risk pregnancies.
– Addressing barriers such as lack of awareness, perceived usefulness, and inability to stay at MWHs due to other responsibilities at home is crucial.
Key Role Players:
– Ministry of Health: Responsible for policy development and implementation.
– Health Facilities: Provide infrastructure and resources for MWHs.
– Community Health Workers: Educate and raise awareness about MWHs.
– Non-Governmental Organizations: Support the establishment and operation of MWHs.
– Research Institutions: Conduct further studies to evaluate the impact of MWHs on maternal and perinatal outcomes.
Cost Items for Planning Recommendations:
– Infrastructure: Construction or renovation of MWHs.
– Staffing: Hiring and training of healthcare professionals to provide care at MWHs.
– Supplies and Equipment: Provision of medical supplies, beds, and other necessary equipment.
– Education and Awareness: Development and implementation of educational programs for women and communities.
– Monitoring and Evaluation: Establishment of systems to track and assess the impact of MWHs on outcomes.
Please note that the provided cost items are general categories and not actual cost estimates. Actual costs may vary depending on the specific context and implementation strategies.

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Most maternal and perinatal deaths could be prevented through timely access to skilled birth attendants. Women should access appropriate obstetric care during pregnancy, labor, and puerperium. Maternity waiting homes (MWHs) permit access to emergency obstetric care when labor starts. This study compared maternal and perinatal outcomes among MWH users and nonusers through a retrospective cohort study. Data were collected through obstetric chart reviews and analyzed using STATA version 15. Of the 8144 deliveries reported between 2015 and 2019, 1305 women had high-risk pregnancies and were included in the study. MWH users had more spontaneous vaginal deliveries compared to non-users (38.6% versus 16.8%) and less cesarean sections (57.7% versus 76.7%). Maternal morbidities such as postpartum hemorrhage occurred less frequently among users than non-users (2.13% versus 5.64%). Four women died among non-users while there was no death among users. Non-users had more stillbirths than users (7.68% versus 0.91%). The MWH may have contributed to the observed differences in outcomes. However, many women with high risk pregnancies did not use the MWH, indicating a probable gap in awareness, usefulness, or their inability to stay due to other responsibilities at home. Use of MWHs at scale could improve maternal and perinatal outcomes in Rwanda.

The study was conducted at Ruli Hospital (RH) in Gakenke District, Rwanda. Geographically, Gakenke District has a mountainous landscape with an average altitude of 1788 m above sea level. According to the Rwanda Health Management Information System, the district’s maternal mortality ratio and skilled birth attendance were 325 per 100,000 live births and 96.7%, respectively by December 2019. About 50% of households walk for more than 1 h to reach a nearby health facility. Ruli Hospital serves a population of about 110,548 inhabitants (projections from the 2012 census) and also receives patients from neighboring districts. The hospital has a bed capacity of 179 and provides a wide range of services including comprehensive emergency obstetric and newborn care for eight health centers and eight health posts within their catchment area. During the study period, the medical staff in the maternity ward consisted of one medical officer, five nurses, and nine midwives. There was no obstetrician. Furthermore, the hospital has an operating theatre, a laboratory, a medical imaging unit, and blood transfusion services. In 2011, Matres Mundi, an international non-governmental organization, supported RH to set up a MWH within the hospital premises, which by the end of 2019 had received over 700 pregnant women. It is the only MWH in Rwanda. While staying in the MWH, pregnant women received obstetric care; psycho-social care; peer support; and education on proper nutrition, breastfeeding, and birth preparedness. Additionally, they were taught hands-on skills such as gardening, cooking, making handcrafts, and knitting baby items. All medical services offered are paid for by the community-based health insurance scheme (commonly known as “mutuelle de sante”) and pregnant women contributed 10% of the cost. A facility-based retrospective cohort study was conducted. Over a period of 5 years (January 2015 to December 2019), 8144 women gave birth in RH. Among those, 1305 women were eligible for staying in the MWH while 6839 women were not eligible. Eligibility for admission to the MWH was determined by a medical officer on duty based on predefined criteria that consisted of the following: a problem related to the pregnancy e.g., history of an abortion; a caesarian section (CS); prolonged labor, as well as problems during the current pregnancy, including preterm premature rupture of membranes, antepartum hemorrhage, reduced fetal movement, pre-eclampsia, etc. and one of the following conditions: at least 36 weeks of amenorrhea, place of residence that was far from the hospital (more than 3 h of walking), having no one to take care of the woman at home, victim of gender-based violence, being in social economic category 1 or 2, as well as clinician decision. Among the 1305 eligible women, 329 MWH-users (women who delivered after having stayed at the MWH) and 976 non-users (women who delivered but had not stayed at the MWH) were compared on maternal and perinatal outcomes. Non-users were identified based on the assumption that they met the same admission criteria as users (see Table 1). We identified MWH users and non-users by following the elimination process as shown in Figure 1. Inclusion and exclusion of users and non-users. Indications for admission to the MWH. * preterm premature rupture of membranes, ** cephalopelvic disproportion, *** intrauterine fetal death. Data were collected from hard copy medical records by two trained research assistants using a pre-designed data collection form (see Supplementary File, Figure S1) that was designed using Kobo Toolbox (version 2018) and installed on Android tablets under the supervision of the principal investigator (ET). Information from files included sociodemographic characteristics, ANC, indication of MWH and non-MWH admissions, obstetric history, mode of delivery, complications during delivery, outcome of delivery (maternal and perinatal), etc., which were abstracted from obstetric charts. Data were exported from Kobo Toolbox to MS Excel 2016 and then to STATA 15 for cleaning and analysis. Demographic characteristics were compared between MWH users and non-users using chi-square statistic. Univariable logistic analysis was conducted to determine associations between dependent and independent variables. Crude Odds Ratios (cOR) and their 95% confidence intervals (CI) were calculated, and significant outcomes with p value < 0.05 were considered for multivariable logistic regression. Adjusted Odds Ratios (aOR) and their 95% CI were calculated to take care of potential confounding and identify variables that showed statistically significant differences in the two groups. The ORs were adjusted for age, parity, occupation, and ownership of health insurance. Ethical clearance was obtained from the Rwanda National Ethics Committee (protocol code 335/RNEC/2020).

The study titled “Maternal and perinatal outcomes among maternity waiting home users and non-users in rural Rwanda” recommends scaling up the use of maternity waiting homes (MWHs) in Rwanda to improve access to maternal health. MWHs provide pregnant women with a safe place to stay near a health facility when they are close to giving birth, allowing them to access emergency obstetric care promptly. The study found that MWH users had better maternal and perinatal outcomes compared to non-users, including higher rates of spontaneous vaginal deliveries, lower rates of cesarean sections, and fewer maternal morbidities such as postpartum hemorrhage. MWH users also experienced no maternal deaths, while non-users had four deaths. Additionally, MWH users had lower rates of stillbirths compared to non-users.

To address the gap in awareness, usefulness, or the ability to stay in MWHs among women with high-risk pregnancies, the study recommends increasing awareness about the benefits of MWHs and ensuring that women with high-risk pregnancies are informed about the option to stay in MWHs. Efforts should also be made to address any barriers that prevent women from staying in MWHs, such as their responsibilities at home.

Scaling up the use of MWHs at a national level could significantly improve maternal and perinatal outcomes in Rwanda, particularly in rural areas where access to health facilities is limited. This recommendation is based on the positive impact observed in the study and the potential for MWHs to provide timely and appropriate obstetric care to pregnant women.
AI Innovations Description
Based on the study titled “Maternal and perinatal outcomes among maternity waiting home users and non-users in rural Rwanda,” the recommendation to improve access to maternal health is to scale up the use of maternity waiting homes (MWHs) in Rwanda.

Maternity waiting homes provide pregnant women with a safe place to stay near a health facility when they are close to giving birth. This allows them to access emergency obstetric care promptly when labor starts. The study found that MWH users had better maternal and perinatal outcomes compared to non-users. MWH users had a higher rate of spontaneous vaginal deliveries, lower rates of cesarean sections, and fewer maternal morbidities such as postpartum hemorrhage. Additionally, there were no maternal deaths among MWH users, while non-users experienced four deaths. MWH users also had lower rates of stillbirths compared to non-users.

However, the study identified a gap in awareness, usefulness, or the ability to stay in MWHs among women with high-risk pregnancies. To address this, it is recommended to increase awareness about the benefits of MWHs and ensure that women with high-risk pregnancies are informed about the option to stay in MWHs. Additionally, efforts should be made to address any barriers that prevent women from staying in MWHs, such as their responsibilities at home.

Scaling up the use of MWHs at a national level could significantly improve maternal and perinatal outcomes in Rwanda, particularly in rural areas where access to health facilities is limited. This recommendation is based on the positive impact observed in the study and the potential for MWHs to provide timely and appropriate obstetric care to pregnant women.
AI Innovations Methodology
To simulate the impact of the main recommendations of this abstract on improving access to maternal health, the following methodology can be used:

1. Identify the target population: Determine the population that will be affected by the scaling up of maternity waiting homes (MWHs). This could include pregnant women in rural areas of Rwanda who have limited access to health facilities.

2. Define the intervention: Specify the details of the intervention, including the number of MWHs to be established, their locations, and the services they will provide. Consider factors such as proximity to health facilities, capacity, and availability of skilled birth attendants.

3. Collect baseline data: Gather data on the current maternal and perinatal outcomes in the target population. This can include information on maternal mortality rates, rates of cesarean sections, stillbirths, and other relevant indicators.

4. Estimate the impact: Use statistical modeling techniques to estimate the potential impact of scaling up MWHs on maternal and perinatal outcomes. This can involve comparing the baseline data with projected outcomes based on the increased utilization of MWHs.

5. Consider potential barriers: Identify potential barriers that may prevent women from utilizing MWHs, such as lack of awareness or other responsibilities at home. Develop strategies to address these barriers, such as community education campaigns or support systems for women with caregiving responsibilities.

6. Monitor and evaluate: Implement the intervention and closely monitor its implementation and impact. Collect data on key indicators such as the number of women utilizing MWHs, changes in maternal and perinatal outcomes, and any challenges or successes encountered during the implementation process.

7. Analyze the results: Analyze the data collected during the monitoring and evaluation phase to assess the effectiveness of scaling up MWHs in improving access to maternal health. Compare the outcomes with the baseline data to determine the impact of the intervention.

8. Adjust and refine: Based on the results and lessons learned from the implementation and evaluation, make any necessary adjustments or refinements to the intervention. This may involve modifying the MWH model, addressing additional barriers, or expanding the intervention to other areas.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of scaling up MWHs on improving access to maternal health in Rwanda. This information can guide decision-making and resource allocation to prioritize interventions that have the greatest potential for positive outcomes.

Statistics:
Authors: 8
Identifiers:
DOI: 10.3390/ijerph182111211
ISSN: 16617827
Research Areas:
Community Interventions, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce
Study Countries:
Rwanda
Study Design:
Cohort Study, Cross Sectional Study, Grounded Theory
Study Approach:
Quantitative
Participants Gender:
Female
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