How scalable are maternity waiting homes?

ZIMBA, Zambia — The journey to the health facility to give birth was particularly arduous for 27-year-old Kellen Nyambili. It’s 93 miles from her house to the nearest hospital. She began her journey at 11 p.m. on an evening in mid-January, crammed in the back of a truck with about 40 other people. Eleven hours later, she reached the hospital.

But thankfully, her water hadn’t broken yet. During one of her antenatal visits, a health worker advised her to make this journey two weeks before her due date because she had high blood pressure, putting her at risk of complications. In the lead-up to delivery, she stayed in a dormitory near the hospital with other pregnant women.

On Jan. 27, she gave birth to a baby girl, and both she and the baby were healthy. She stayed for another four days before going home.

Many women in rural parts of Africa must embark on a long journey to get to a health facility when their water breaks — walking many miles, or taking a motorbike or a donkey cart. A river, mountain, or desert could stand in between a woman and the nearest facility.

This daunting journey leaves many women either opting to deliver from home or giving birth on the side of the road, when there is not enough time to reach a facility. This increases the risk of complications or death for both the mother and the child.

Globally, there is a rural-urban divide in access to skilled health professionals when women go into labor. About 67% of births among rural mothers are attended by skilled health personnel, compared with 89% of births among urban mothers, according to the United Nations Children’s Fund. In Zambia, 67% of deliveries take place in health facilities and there are an estimated 398 maternal deaths for every 100,000 live births.

Maternity waiting homes, like the one Nyambili stayed in, seek to improve maternal and child health outcomes by giving women a space to wait in the lead-up to delivering their children, with access to health workers who routinely check on them.

But there have been questions around their effectiveness, as well as what factors can encourage women to stay at these facilities. To better understand this, the Maternity Waiting Homes Alliance conducted a study in Zambia. This was the first large-scale study looking at the effectiveness of these homes for women living the farthest away from health facilities, according to Nancy Scott, assistant professor of global health at the Boston University School of Public Health.

Appealing to pregnant women, building evidence

The concept of women waiting at health facilities before giving birth is not new. In some cases, there are existing shelters for relatives of patients that pregnant women can use, or women sleep in wards, in corridors, or under trees, said Thandiwe Ngoma, monitoring and evaluation manager at Right to Care Zambia.

Starting in 2014, members of the Maternity Waiting Homes Alliance began to gather feedback from communities on how to improve waiting homes. The alliance includes Boston University, Right to Care Zambia, the University of Michigan, and Africare, with funding from MSD for Mothers, Bill & Melinda Gates Foundation, and The ELMA Foundation.

Complaints about existing setups included shelters being crowded and dirty, women not feeling safe, a lack of mattresses and locking doors, and minimal access to toilets and water, according to Ngoma.

Based on that feedback, the alliance developed model waiting homes furnished with beds, mattresses, mosquito nets, cooking utensils, bathrooms, and doors that locked, Ngoma said.

It also created community governance committees tasked with overseeing the homes and partnered with local governments. It linked the waiting homes to the health facilities so that staff would check on the women.

All homes have community gardens and were set up with a way to generate income, such as a mill for grinding maize or an agriculture supplies shop. People from the community are given a salary to manage these small businesses, and the rest of the profit goes into a bank account to fund the operation of the waiting homes, Ngoma said.

The alliance built the waiting homes next to hospitals capable of providing emergency care — such as blood transfusions and cesarean sections — or at clinics less than two hours away from these hospitals so that women can be transferred, Ngoma said.

As part of the study, the model waiting homes were built at 20 health facilities, while another 20 were control sites where nothing was changed. The trial ran from 2015 to 2018.

Improving access to health clinic deliveries

During pregnancy and when giving birth, women are at risk of complications such as hemorrhaging, preeclampsia, eclampsia, high blood pressure, infected vaginal tears, and fistulas. Newborn babies are also at risk of conditions such as neonatal sepsis, hypothermia, and asphyxia, according to health experts.

When a woman comes into the waiting home, she is assessed and either monitored at the waiting home or admitted to the antenatal ward, according to members of the alliance.

A key benefit to the homes is that health workers can better manage cases and keep an eye on women in the lead-up to their pregnancy, Ngoma said.

Tamala Zulu Lungu, maternal child health coordinator at the Pemba District Health Office, recalled the story of a mother who died in 2017.

“Where she was coming from was far, with two streams in between. She delivered at home and after delivery, she bled a lot. As they were bringing her to the facility, the streams were full, so they couldn't cross. By the time they reached the facility, the mother died,” Lungu said.

The alliance collected data at the end of the study in 2018 — disaggregating it by the distance a woman came to stay at the home. Early analysis shows that the waiting homes significantly improved access to facility delivery among women living more than 6 miles from a health center, according to Scott. The alliance expects to publish two papers on the study before the end of this year.

No food, overworked health workers

But these homes also have challenges. A key one is that they don’t provide food, according to women whom Devex spoke with. This means women are expected to bring their own — whatever they can carry. Some women run out or find it hard to come up with a supply that would last a few weeks, if resources are limited at home.

Vera Mweemba, a 20-year-old pregnant woman, came to the home with food but ran out. She didn’t eat for a full day as she waited for people from her village to deliver her food.

Sometimes, a pregnant woman or the person who accompanies her, such as her mother, looks for day labor in the surrounding community to afford food, said Dorothy Phiri Sitali, nursing officer at Zimba Mission Hospital. Maria Mwinga, a 15-year-old pregnant girl, for example, had to weed local fields to earn money.

The community gardens have not always been successful in filling in the food gaps at the home. It was a challenge to mobilize the pregnant women to tend to the gardens in the dry season, among other factors, Ngoma said.

Another issue is that health personnel can be overworked, Phiri Sitali said. Bringing new women to the waiting homes puts more burden on an already stretched workforce.

In Zambia, the levels of staffing in health facilities have largely remained the same for decades, despite population growth, said Dr. Angel Mwiche, assistant director of the department of reproductive, maternal, newborn, and child health and nutrition at Zambia’s Ministry of Health. In rural Zambia, there are an estimated 70 health care workers for every 100,000 people.

Despite this, a recent study found that while health workers complained they were overworked, they also said the maternity waiting homes allowed them to provide better and more timely care.

Still, there are challenges in getting the women to the homes — much of this having to do with resistant spouses and responsibilities at home, such as taking care of other children, health workers said.

“There are husbands that are not ready to release the women. They will say, ‘No, you will just be sleeping there instead of working,’” Phiri Sitali said. Because of this, there is a need to engage with men on the benefits of these homes, she said.

There are also signs that sometimes the income-generating activities and governance structures don’t run as planned. Lilian Muleya, who manages one of the homes, said she used to receive a monthly salary but hasn’t been paid since July.

“If she hasn't been paid and was paid in the past, I would guess that is either a breakdown of the governance committee or a breakdown of the income-generating activities. They may not necessarily be generating sufficient funds to continue paying her, or their governance committee has shifted their decision-making or priorities to something else,” Scott said.

Sustainability and scalability

With the positive news that the homes are effective in increasing the number of health facility deliveries for women living farthest away, there are now questions over the potential for long-term sustainability and scale-up.

“That's always the question after the funding is over, the NGO pulls out, and there's not that continued support,” said Jody Lori, professor and associate dean of global affairs at the University of Michigan School of Nursing.

The income-generating projects are intended to sustain existing homes, and the governance structure is aimed at creating a lasting sense of ownership in communities.

All of the waiting homes in the study continue to function after the project ended.

“It's been a year-plus now since we stopped working on this, but the facilities have continued to keep them operating. The communities have a sense of ownership,” Ngoma said.

There are also questions over whether governments will be willing to take on the financial burden of building more.

“The upfront cost of constructing a maternity waiting home and doing the sensitization is not cheap,” said Susana Oguntoye, former director of monitoring, evaluation, and knowledge learning at Africare.

Another costly element is the mentorship provided to governance committees in areas such as accountability and financial management, Scott said.

Whether the impact made with the homes is enough to justify them as an intervention to prioritize over other strategies is another lingering question.

"They are not a strategy on their own, and our experience is that factors such as the quality of care, complications in pregnancy, and, often, the cost of these facilities can diminish their effectiveness," said Dora Curry, deputy director of sexual and reproductive health and rights for CARE International.

But for many on the ground, it’s a strategy that is working — and is also comforting. This includes 73-year-old Rasina Haakuluma, who escorted her youngest daughter to a waiting home. The memory of Haakuluma’s own near-death experience is seared in her memory.

During Haakuluma’s last pregnancy, the baby’s hand came out first. The women from her village pushed the hand back, causing Haakuluma to bleed. By the time she reached the hospital, the baby died.

“It’s only by God’s grace that I’m alive,” she said.

A few years ago, one of Haakuluma’s other daughters delivered at home and the baby died. And last year, one of her neighbors delivered at home, but neither the women nor the baby lived.

“Right now, I’m concerned about my daughter giving birth, but I do feel much better that she is here because I know there are people to watch over her,” she said.

Editor’s note: The Maternity Waiting Homes Alliance facilitated Devex's travel and logistics for this reporting. Devex retains full editorial independence and control of the content.