Maternity Waiting Homes

The Reproductive, Maternal and Neonatal Health Innovation Fund (RIF)

Policy brief June 2018

RIF (2013-2018) has been funded by the UK’s Department for International Development (DFID) and managed by Ethiopia’s Federal Ministry of Health (FMOH) with the assistance of a Technical Assistance Supplier (Pathfinder International).

Maternity Waiting Homes The Reproductive Maternal and Neonatal Health Innovation Fund (RIF) has aimed to improve the health outcomes of women, newborns and young people in the pastoralist areas of Ethiopia.

With RIF funding, FMOH has administered grants to both government and non-governmental implementing partners. They have been tasked with identifying innovative solutions to the barriers that prevent pastoralist populations (especially women and young people) from accessing reproductive, maternal and neonatal health (RMNH) services.

Why a focus on Maternity Waiting Homes?

A Maternity Waiting Home (MWH) is an accommodation near a health facility where pregnant women from remote areas or at high risk of obstetric complications can await their delivery. MWHs aim to help overcome barriers of distance and time when women go into labour.

MWHs have been endorsed by WHO as one component of a comprehensive strategy to reduce maternal morbidity and mortality.1 In Ethiopia, their use spans more than three decades.2 A UNICEF-supported study in 2010 reviewed data over 22 years from the Attat MHW in central Ethiopia: it concluded that MHWs are vital in providing emergency obstetric and neonatal care and recommended expansion nationally.3 Until recently MWH services were mainly hospital-based, but the current emphasis is on bringing them closer to women at the primary health facility level; to this end, FMOH developed a set of service standards in 2015 to ensure consistency in implementation (see Box).4

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Despite Ethiopia’s significant experience with MWHs in agrarian areas, there is little practical experience of establishing and maintaining MWHs in the pastoralist areas.

This policy brief describes the experience gained by RIF in introducing MWHs to the pastoralist zones of Afar, Somali, Oromia and SNNP, the lessons learnt and the policy implications.

Summary of FMOH Ethiopia’s Standards for Provision of Maternity Waiting Homes Construction standards •

There should be separate pre- and post-delivery spaces. Each space should be able to accommodate at least six mothers and one family member/companion. If possible, the design of the MWH should be consistent with indigenous designs and customs. There should be adequate air circulation and light.

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Each MWH should have access to a safe water supply, an equipped food preparation area, and a latrine and bathroom. MWHs should be fitted with appropriate flooring, bedding, equipment and utensils for each resident.

Services •

Pre-delivery, each mother should receive full ANC services, with laboratory support; in addition, facility staff should provide daily check-ups. Delivery services should be provided in the facility’s delivery unit by trained staff.

Postnatal services should be provided to the mother and newborn for at least 24 hours. An ambulance should be kept on standby for transfers to an emergency obstetric/neonatal unit if necessary.

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Health education and other appropriate entertainment should be provided at least three times a week.

Maintaining the MWH •

The MWH should be supported by an effective community and institutional referral system.

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As far as possible, running of the MWH should promote community participation.

Food and other subsistence needs should be met by mobilising resources from the community. Daily cleaning and maintenance of the MWH, as well as food preparation/consumption should be overseen and coordinated by facility staff.

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The Woreda health office is responsible for supervising and monitoring the MWH to ensure it complies with government standards and receives appropriate resource allocations.

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RIF’s experience in providing MHWs Over 22,000 pregnant women have attended MWHs in the pastoralist zones of Afar, Somali, Oromia and SNNP regions over the period June 2016-December 2017. Many of these have been constructed, partially constructed or supported by RIF implementing partners.

Evaluation research suggests that in most cases efforts have been made to adapt the design of MWHs to the local pastoralist context. However, this has required significant resource investments in design work and identification of materials that are consistent with traditional structures, yet durable and practical to maintain (taking into account the turnover of multiple residents). In some cases, this has taken considerable trial and error by implementing partners and has stretched available budgets. As a result, the design of RIF MWHs varies considerably in size, level of cultural adaption and quality.

Examples of RIF Maternity Waiting Home structures

In Afar, operational research by Mekelle University suggests that, given these challenges in pastoralist areas, there could be considerable value in constructing clusters of small self-contained diboras (wooden huts) for women and family members, rather than large single structures. These smaller structures are easier to erect, maintain and repair and can be tailored to demand.

MWH use and operational challenges in pastoralist areas Engaging pastoralist communities and households to meet the subsistence needs of women residing in MWHs has proved especially challenging. This is particularly the case in areas where pastoralist communities move frequently and where there is a dependence on livestock for daily subsistence needs. Where households are small or dispersed, there may also be concerns about care of other children and dependents and other vital subsistence activities when women are absent, sometimes for several weeks. Male partners can therefore be reluctant to allow their wives to stay at a MWH. In addition, many pastoralist households are situated at great distances from a health facility (sometimes 50-100 km), with only rough and dusty roads to travel on. In these conditions, it can be extremely challenging and costly for a pregnant woman and her

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family members to travel to a MWH. Over the course of the RIF programme, these challenges have been heightened by periods of protracted drought, outbreaks of acute watery diarrhoea and episodes of civil unrest. All of these factors have increased the risks and difficulties of travel and attendance of MWHs for pastoralist women and their families. These factors have also placed additional demands on facility staff who have considerable formal responsibilities towards residents of MWHs. Identification of a ‘community’ to support residents of a MWH can thus be complicated in a pastoralist area and may require considerable resourcefulness and coordination efforts on the part of facility, woreda and Regional Health Bureau staff.

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Some useful strategies Some RIF implementing partners have had success in forging links with communities by mobilising women from the Women’s Development Army (WDA) in Oromia and SNNP Regions or trained Traditional Birth Attendants (TBAs) in Afar and Somali Regions. Each of these women are supported by Health Extension Workers and are responsible for RMNH oversight of five households. By conducting house to house visits and convening events, such as Monthly Pregnant Mothers Days and Mother to Mother Support Groups (Somali Region) and Celebrate Life events (SNNP), these community ‘focal points’ have been able to identify pregnant women, promote attendance of MWHs, engage key ‘gatekeepers’ such as religious/clan leaders and male partners, and act as birthing companions for pregnant women at health facilities. They also act as part of post-partum care and education, including information on family planning.

There has also been success from establishing women’s self-help groups (SHGs) and credit and savings cooperatives. These groups have helped women generate small incomes and savings to assist them (or other women in their households) to overcome the financial constraints that prevent travel and attendance of a MWH. In Afar, there has been some success in targeting support to the poorest pregnant women through referrals to the Productive Safety Net Programme – a social protection initiative that helps eligible women access food and cash transfers that can facilitate attendance of a MWH. Other initiatives have included community ‘creativity funds’, where community members make regular small contributions to a shared fund that can be accessed in times of need; farming donated land to cover subsistence costs for MWHs, and plans for longer-term sustainable support through promoting tourism at a nearby lake (Lake Abe, Afar). Some SHGs in SNNP are committed to providing food and firewood for MWH residents, even travelling over the regional border to respond to women in need.

Factors in success The RIF evaluation team used a triangulated methodology to identity the most successful interventions based on three main criteria: likely contribution to results; stakeholder and beneficiary endorsement; and potential for scalability/sustainability.

This evaluation research suggested that MWHs can be successful if some key factors are in place: •

The MWH is attractive and appealing. Pregnant women are reluctant to stay for any length of time at MWHs that are not designed to meet their needs. Popular MWHs are appropriately designed for the target group, are clean and wellmaintained and aim to meet FMOH standards.

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Service providers and health bureaus are committed. MWHs can only function effectively if there is full buy-in from regional and woreda health bureaus, facility staff, HEWs and community based TBAs or WDA members. At successful MWHs, providers and woreda/regional officers understand their additional responsibilities and the potential contribution of MWHs to improved outcomes. They also demonstrate commitment to creative problem solving, coordination and resource mobilisation efforts. The recognition of senior managers also appears to be a motivator.

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There is a sound sustainability strategy. Construction of a MWH needs to go handin-hand with a clear and feasible strategy for ensuring the subsistence needs of residents are consistently met. The best performing implementing partners have found that this needs to be flexible and responsive to changes in the pastoralist context and adjusted e.g. seasonally. In most cases, additional resources need to be mobilised to ensure the availability of emergency transport and safe return transportation for women and newborns to their homes.

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Policy recommendations •

Avoid designing MWHs as an isolated intervention. Aim to meet FMOH standards, but adopt a health systems perspective that takes into account women and community perspectives, the acceptability of the MWH structure and the care and support available at and around the health facility.

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Commission regional operational research studies to establish the best approach for each region. Ensure this includes testing of whether early successes can be cost-effectively sustained over the longer term.

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Expand operational research to identify a portfolio of effective MWH sustainability strategies for each region. This should include effective approaches for community engagement, referral and emergency transport in different pastoralist settings.

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Establish a viable quality assurance mechanism for woreda health bureaus. Ensure officers are fully aware of FMOH standards and are able to support (or enforce) full compliance. Engage community support in creative solutions to problems as they arise.

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For each pastoralist region, review the targeting strategy for MWHs, taking into consideration that the majority of pregnant women will face considerable distance barriers. Consider a focus on high risk cases and alternative strategies for women who face extreme geographical barriers.

References 1. World Health Organization (1996). Maternity waiting homes: a review of experiences.

2. Gaym A, Pearson L, & Soe KW (2012). Maternity waiting homes in Ethiopia: three decades experience. Ethiopian Medical Journal, 50(3), 209-219.

3. Kelly J et al. (2010). The role of a maternity waiting area (MWA) in reducing maternal mortality and stillbirths in high‐risk women in rural Ethiopia. BJOG: An International Journal of Obstetrics & Gynaecology, 117(11), 1377-1383.

4. Ethiopia FMOH (2015). Standards for provision of Maternity Waiting Home.

Photo credits Page 1: Creative commons licensed (CC BY-NC-ND 2.0) flicckr photo: UNICEF Ethiopia/2015/Tesfaye, www.flickr.com/photos/unicefethiopia/21679981264/ Page 3: RIF Programme Page 5: ©Jeanette Dietl /Adobe Stock

This Policy Brief was prepared by the RIF Evaluation Team.