Benefits, barriers and enablers of maternity waiting homes utilization in Ethiopia: an integrative review of national implementation experience to date

Background: Though Ethiopia has expanded Maternity Waiting Homes (MWHs) to reduce maternal and perinatal mortality, the utilization rate is low. To maximize the use of MWH, policymakers must be aware of the barriers and benefits of using MWH. This review aimed to describe the evidence on the barriers and benefits to access and use of MWHs in Ethiopia. Methods: Data were sourced from PubMed, Google Scholars and Dimensions. Thirty-one studies were identified as the best evidence for inclusion in this review. We adopted an integrative review process based on the five-stage process proposed by Whittemore and Knafl. Results: The key themes identified were the benefits, barriers and enablers of MWH utilization with 10 sub-themes. The themes about benefits of MWHs were lower incidence rate of perinatal death and complications, the low incidence rate of maternal complications and death, and good access to maternal health care. The themes associated with barriers to staying at MWH were distance, transportation, financial costs (higher out-of-pocket payments), the physical aspects of MWHs, cultural constraints and lack of awareness regarding MWHs, women’s perceptions of the quality of care at MWHs, and poor provider interaction to women staying at MWH. Enablers to pregnant women to stay at MWHs were availability of MWHs which are attached with obstetric services with quality and compassionate care. Conclusion: This study synthesized research evidence on MWH implementation, aiming to identify benefits, barriers, and enablers for MWH implementation in Ethiopia. Despite the limited and variable evidence, the implementation of the MWH strategy is an appropriate strategy to improve access to skilled birth attendance in rural Ethiopia. We adopted an integrative review to summarize literature to provide a more comprehensive understanding of MWHs implementation in Ethiopia. The study protocol was registered with the International Prospective Register of Systematic Reviews under the registration number CRD42019125308. Systematic reviews, while important to evidence-based practice, tend to focus on experimental studies, specifically randomized clinical trials, usually used to determine to evaluate the effectiveness of an intervention. However, the primary literature in the MWH aspect was diverse in methodology including descriptive, observational, and qualitative research. Therefore, an integrative literature review was chosen because it allows for a greater breadth of research to be analyzed and plays an important role in evidence-based practice in healthcare [20]. We adopted an integrative review process based on the five-stage process proposed by Whittemore and Knafl: Developing the review question, searching the literature, Data evaluation, Data analysis, and presentation of integrated findings [20]. We conducted a systematic literature search across the three electronic databases: PubMed, Google Scholars and Dimensions, which encompass a wide range of research relevant to the healthcare domain. Boolean connectors AND, OR and NOT were used to combine search terms and the keywords used were Health Services Accessibility“[MeSH Terms] OR “maternity waiting home*“[Text Word] OR “maternity waiting area*“[Text Word] OR “maternity waiting*“[Text Word]) AND (“Ethiopia“[MeSH Terms] OR “Ethiopia“[Text Word]). We have presented the detailed search strategies of PubMed in Additional file 1. We also manually searched the reference lists of potentially relevant studies to find out studies that had not been identified during the search of electronic databases. We have contacted the corresponding authors for studies through the Research gate platform for the research we do have limited access due to a pay-wall restriction. We tried to employ a variety of search methods to ensure a broad representation of evidence from peer-reviewed journals and grey literature related to the subject matter. The inclusion criteria for the type of document included (1) published in the English language, (2) from Ethiopia, (3) experimental, quasi-experimental or non-experimental design, (4) investigated maternity waiting homes benefit, barriers and enablers. Studies were excluded if they were reviews, protocols, commentaries, conference proceedings, and editorials. The database search generated 1234 records. Searches were imported into the Mendeley Desktop, an external citation manager, for further screening. After removing duplicates, 991 potential studies were identified and preliminary screening was done by checking the titles and abstracts of the remaining studies. Two authors independently screened the titles and abstracts against the inclusion criteria and identified 42 studies. In the case of disparities, a consensus was achieved by examining the full-text and collaborative discussion. After scanning reference lists of included and review papers, three studies were identified. Lastly, full-text reviews were conducted, and articles were removed if they did not meet the inclusion criteria. The final 31 articles were then, systematically reviewed; the screening and selection process is outlined in a PRISMA flow chart in Fig. 1. Information was pulled together in a summary matrix table (Tables 1 and ​and2)2) to highlight similarities and differences between studies. The extraction form included the following items: authors (publication year), the title of the study, purpose/aim, sample size and study population, research design and data collection, method of analysis, and key MWHs outcomes (barriers, benefits, and enablers). Article search and selection process using PRISMA flowchart Summary of MWH studies included in the review in Ethiopia,2022 FGD = 28 participants IDI = 7 participants N = 244 respondents MWH users Concept matrix mapping on benefits and barriers to stay at MWHs in Ethiopia from the included studies, 2022 While it is agreed that potential studies for inclusion in the review should be evaluated for quality and bias, the best approach for assessing research quality in an integrated review is still up for debate. To evaluate the various forms of the methodology employed in the studies, various sorts of quality criterion tools can be applied. To assess the quality of the research included, Joanna Briggs Institute Critical Appraisal tools for qualitative and quantitative study [48]. Studies with statistically insignificant or negative outcomes, or study topics that may not be relevant to the journals’ scope, are less likely to be published than studies with significant or positive results. As a result, many completed studies are never published. To make the evaluation more comprehensive, we have also included unpublished studies (dissertations, theses, conference papers, and preprints after they were evaluated against the inclusion criteria [48]. Data analysis in research reviews requires that the data from primary sources are ordered, coded, categorized, and summarized into a unified and integrated conclusion about the research problem [20]. A constant comparison method: extracted data are compared item by item so that similar data are categorized and grouped. The method consists of data reduction (qualitative, quantitative, and mixed), data display, data comparison, conclusion drawing, and verification were also made [20]. Given the diversity of quantitative studies in terms of research questions, methods, samples, study settings, outcomes and outcome measures used, we undertook a narrative synthesis. The findings from the narrative synthesis of quantitative findings and the thematic analysis of the qualitative findings were then synthesized to identify common themes. A summary table was generated synthesizing the data from included studies (Table ​(Table11).