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Factors Associated with Maternity Waiting Home Use Among Women in Jimma Zone, Ethiopia: a Multilevel Cross-Sectional Analysis

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Factors Associated with Maternity Waiting Home Use Among Women in Jimma Zone, Ethiopia: a Multilevel Cross-Sectional Analysis BMJ Open: first published as 10.1136/bmjopen-2018-028210 on 28 August 2019. Downloaded from Open access Research Factors associated with maternity waiting home use among women in Jimma Zone, Ethiopia: a multilevel cross-sectional analysis Jaameeta Kurji, 1 Lakew Abebe Gebretsadik,2 Muluemebet Abera Wordofa,3 Morankar Sudhakar,2 Yisalemush Asefa,4 Getachew Kiros,2 Abebe Mamo,2 Nicole Bergen,5 Shifera Asfaw,2 Kunuz Haji Bedru,6 Gebeyehu Bulcha,6 Ronald Labonte,1 Monica Taljaard,7 Manisha Kulkarni1 To cite: Kurji J, Gebretsadik LA, ABSTRACT Strengths and limitations of this study Wordofa MA, et al. Factors Objective To identify individual-, household- and associated with maternity community-level factors associated with maternity waiting ► A notable strength of the study was the simultane- waiting home use among home (MWH) use in Ethiopia. women in Jimma Zone, ous consideration of individual-level and contex- Design Cross-sectional analysis of baseline household Ethiopia: a multilevel cross- tual-level factors associated with actual maternity Library System. Protected by copyright. survey data from an ongoing cluster-randomised controlled sectional analysis. BMJ Open waiting home (MWH) use using a relatively large, trial using multilevel analyses. 2019;9:e028210. doi:10.1136/ community-based data set; several studies con- Setting Twenty-four rural primary care facility catchment bmjopen-2018-028210 ducted on MWH use have focused on the infuence areas in Jimma Zone, Ethiopia. Prepublication history for of service quality. ► Participants 3784 women who had a pregnancy outcome this paper is available online. ► We used statistical analyses which explicitly ac- (live birth, stillbirth, spontaneous/induced abortion) 12 To view these fles, please visit counted for the clustered nature of our data through months prior to September 2016. the journal online (http:// dx. doi. generalised linear mixed models. Outcome measure The primary outcome was self- org/ 10. 1136/ bmjopen- 2018- ► The cross-sectional nature of the analysis limits our reported MWH use for any pregnancy; hypothesised 028210). ability to make any conclusions about the causal re- factors associated with MWH use included woman’s lationship between hypothesised infuential factors http://bmjopen.bmj.com/ Received 27 November 2018 education, woman’s occupation, household wealth, and MWH use. Revised 02 August 2019 involvement in health-related decision-making, companion Accepted 05 August 2019 support, travel time to health facility and community-levels of institutional births. Results Overall, 7% of women reported past MWH use. per 100 000 live births by 2016.2 Making Housewives (OR: 1.74, 95% CI 1.20 to 2.52), women with motherhood safer is a priority for the Ethio- companions for facility visits (OR: 2.15, 95% CI 1.44 to pian government and various efforts, such as 3.23), wealthier households (fourth vs frst quintile OR: establishing the health extension programme 3.20, 95% CI 1.93 to 5.33) and those with no health (HEP),3 have been directed to reduce on October 15, 2019 at University of Ottawa (GST 123404113) facility nearby or living >30 min from a health facility (OR: maternal mortality. Also among these has 2.37, 95% CI 1.80 to 3.13) had signifcantly higher odds been the scale-up of maternity waiting homes of MWH use. Education, decision-making autonomy and (MWHs)4 which were initially concentrated community-level institutional births were not signifcantly 5 associated with MWH use. at the hospital level but have more recently Conclusions Utilisation inequities exist; women with been implemented at lower-level health less wealth and companion support experienced more centres. MWHs are temporary residential diffculties in accessing MWHs. Short duration of stay and spaces located within or close to health facil- failure to consider MWH as part of birth preparedness ities offering skilled obstetrical care. They © Author(s) (or their planning suggests local referral and promotion practices provide an opportunity for pregnant women employer(s)) 2019. Re-use need investigation to ensure that women who would who experience geographical barriers to be permitted under CC BY-NC. No beneft the most are linked to MWH services. commercial re-use. See rights near a health facility a few weeks before birth. and permissions. Published by MWHs have also been recommended for BMJ. housing pregnant women who may be at risk For numbered affliations see INTRODUCTION of delivery complications so that they can be end of article. Maternal mortality has declined significantly closely monitored by health workers.6 Correspondence to in Ethiopia over the last two decades. It was Utilisation levels of MWHs globally have Jaameeta Kurji; estimated to be 720 deaths per 100 000 live generally been reported to be low with their jkurj022@ uottawa. ca births in 20051 but dropped to 412 deaths conditions often regarded as unsatisfactory.7 8 Kurji J, et al. BMJ Open 2019;9:e028210. doi:10.1136/bmjopen-2018-028210 1 BMJ Open: first published as 10.1136/bmjopen-2018-028210 on 28 August 2019. Downloaded from Open access Formative work in Zambia revealed that perceptions about population sizes compared with other districts, had poorly discomfort experienced at MWH because of over- functioning MWHs according to Jimma Zone Health Office crowding, lack of beds and water shortages can influence (JZHO) data, and did not have ongoing maternal health use9; in Malawi, satisfaction with MWHs was associated interventions such as other research or development proj- with decent toilets and showers, accommodation for ects or maternal health campaigns to minimise potential companions, adequate sleeping areas and availability of co-interventions and to facilitate a more even distribution private storage spaces among other amenities.10 In Kenya, of interventions as requested by our JZHO partners. women were unhappy with health worker attitudes and Ethiopia’s three-tiered healthcare system consists of a felt that staff should check on them more often during district hospital and primary healthcare units (PHCUs) - their stay at the MWH.11 Ethiopian users wished for better made up of a health centre and community-based health quality meals and in many cases had to rely on family for posts - at the bottom. Levels 2 and 3 include general and food supplies.5 specialised hospitals respectively.3 In partnership with the Although, service quality plays an important role in District Health Offices, the JZHO oversees service delivery MWH use, other factors may do so and need to be consid- at the 26 health centres present in the study area. ered to optimise utilisation. A cross-sectional, facility All health centres have either temporary spaces or perma- based survey in Tanzania found that women’s socioeco- nent, standalone structures designated to provide MWH nomic status and distance from health facility was asso- services. According to the national guidelines, women who ciated with having stayed at an MWH prior to delivery.12 live far away from health centres, are inaccessible by ambu- In Ethiopia, intended MWH use was reported to be asso- lance, are 38 weeks or more pregnant and/or are at risk of ciated with history of obstetrical complications and not experiencing obstetrical complications during delivery are perceiving barriers to MWH use.13 A Zambian household eligible for MWH referral.4 MWHs are typically expected to survey reported marital status and distance being statis- consist of two rooms each accommodating six women and 14 tically associated with being an MWH user. As part of to have a suitable space equipped with utensils for women to Library System. Protected by copyright. the continuum of maternal healthcare services, it is also prepare food or offer meals to women who cannot afford to conceivable that factors shaping the usage of other services provide for themselves. MWHs should have access to clean may also influence MWH use, as the service largely func- water, latrines and a power source.4 Exit surveys conducted tions to link women to obstetrical care. Women’s educa- nationally in 2016 revealed only 50% of rural MWHs had tion level,15 16 household wealth,15 17 decision-making water available, 65% had an electricity supply and 73% had dynamics,15 social norms around service use18 and travel latrines although most were shared with other patients.24 As time to care facility19 have been reported to influence use part of the country’s strategy to reduce maternal mortality, of antenatal, obstetrical or postnatal care services in Ethi- the MWH policy was drafted in 2013 to standardise the opia and in a number of countries in sub-Saharan Africa. service provision of this joint community-health system, http://bmjopen.bmj.com/ Consideration of individual and contextual factors fee-free initiative. MWH operations are mainly sustained when examining women’s access to health services is key. through community cash or crop contributions while Service use, a proxy for access to care, is influenced by management is handled by health centre staff. Reliance availability of quality services but also by women’s ability on community contributions may result in some variation to obtain these services.20 Women’s ability in turn is between the districts in the quality and availability of MWH shaped by household and community level factors.21 To services. have equitable, gender-responsive health systems that Health extension workers (HEWs), based in health posts, cater to the specific needs of women facing a multitude link communities to the health system by tracking pregnant on October 15, 2019 at University of Ottawa (GST 123404113) of structural barriers, requires a holistic understanding of women in their catchment areas and referring them for the factors shaping use.22 services.25 Additionally, HEWs provide community-based The primary objective of this analysis, therefore, was to primary healthcare as prescribed in the 16 modules of the identify factors associated with maternity waiting home HEP; HEWs offer education and counselling, conduct phys- use at the individual, household and community levels ical exams of pregnant women, make referrals to health among women in Jimma Zone, Ethiopia.
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