University of Groningen

Safe Motherhood: Maternity Waiting Homes in to Improve Women’s Access to Maternity Care Vermeiden, Catharina Johanna

IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record

Publication date: 2019

Link to publication in University of Groningen/UMCG research database

Citation for published version (APA): Vermeiden, C. J. (2019). Safe Motherhood: Maternity Waiting Homes in Ethiopia to Improve Women’s Access to Maternity Care. University of Groningen.

Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).

Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim.

Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum.

Download date: 27-09-2021 Chapter 1. General introduction BACKGROUND AND JUSTIFICATION

In 2013, the Gurage Zonal Health Department Maternity waiting homes offer in Southern Ethiopia requested that temporary accommodation General Hospital set up a Maternity Waiting near a health centre or hospital Home (MWH) (Textbox 1), to help bridge where women with high-risk the gap between its mostly rural population pregnancies and/or living far from a facility can await and the hospital. Until then, almost all birth during the final week(s) women (90%) gave birth at home without of pregnancy close to 24- a skilled birth attendant. Many women and hour emergency obstetric and babies were dying (676 maternal deaths newborn care. Once labour per 100,000 live births; 46 perinatal deaths starts or complications arise, per 1,000 live births), and most of these women can easily access deaths could have been prevented had they the facility to give birth. Some received timely care of sufficient quality (2, 3). MWHs also offer post-natal care (1).

This study was initiated to identify the Textbox 1 Definition maternity contextual factors that could affect waiting homes implementation of this MWH on hospital grounds. Our research plans followed a recommendation by the World Health Organization (WHO) to perform a needs assessment in the community before establishing an MWH, to identify the level of existing health services, whether women use these services and possible constraints to uptake (4). The 2012 Cochrane on MWHs reports that while some MWHs were successful, others remained empty, due to various factors inhibiting access (1).

The first MWH in Ethiopia was established as early as 1973, at Attat Our Lady of Lourdes Catholic Primary Hospital. The largest observational study on MWHs to date was conducted at this hospital, which revealed significantly fewer maternal deaths and stillbirths among MWH users compared to non- users (5). In 2012, Gaym et al. described services provided at the nine functioning MWHs throughout the country, eight of which were located at hospitals (6). In 2014, we learned that the MWH intervention would be rolled out nationwide, which changed the scope of this study. In addition to guiding local implementation, this study then acquired the potential to play a role in upscaling the intervention in Ethiopia and provide evidence-base to a range of stakeholders, from policy makers to health providers who intended to establish an MWH.

My personal motivation to contribute towards reducing maternal and perinatal mortality is related to our youngest child, Sara. She is Ethiopian. After a long journey, her biological mother was bleeding when she arrived at Butajira Hospital, where my husband Floris Braat and I were working through Voluntary Service Overseas (VSO). She gave birth to a premature baby girl of 900 grams. Sara’s chances of survival were slim, even more so when her

10 | Chapter 1 birth mother left her in the hospital after a few days for personal reasons. I still do not know how Sara’s birth mom managed to reach hospital in time. 1 But I know it saved Sara’s life. Through this research, I hope to make a contribution, however modest, towards realizing every human being’s right to timely, acceptable and affordable health care (7).

PROBLEM STATEMENT

Globally, the maternal mortality ratio fell by nearly 44% between 1990 and 2015, from approximately 385 to 216 per 100,000 live births (3). Despite this notable reduction, an immense challenge still lies ahead. In 2015, still 303,000 women died worldwide during pregnancy and following childbirth (8). Moreover, between 6 and 9 million women experienced acute or chronic morbidity, 2.6 million babies were stillborn, 2.7 million babies died in the first 7 days of life, and 30 million newborns required specialized/intensive care in a hospital. The vast majority of these tragedies (in total almost 13 million per year!) occurred in low- and middle-income countries, as a result of tremendous inequities between and within countries (9-12).

Ensuring that all women have timely access to skilled care during childbirth is an important strategy to reduce maternal and perinatal mortality and morbidity (13). Access to care is still a major challenge in low- and middle-income countries, with less than one-third of women with obstetric complications reaching an facility that provides emergency obstetric and newborn care (EmONC) (14).

The well-established Three Phases of Delay Model by Thaddeus and Maine helps to better understand the factors contributing to preventable maternal and perinatal mortality and morbidity (Textbox 2) (15). The “Three Delays” in relation to causes of maternal mortality

The First Delay Delays at community level in recognizing an emergency situation, and/or delays in the decision to seek care at a health facility The Second Delay Delays in reaching appropriate care due to lack of access to transport or lack of resources to pay for transport The Third Delay Delays in receiving appropriate care - including adequate quality of care - after arrival at a health facility

Textbox 2 The Three Delays Model by Thaddeus and Maine 1994)

MWHs are used to bring pregnant women closer to institutionalized care before labour starts, thereby potentially reducing first and second delays. MWHs were first introduced in the early 1900s in North America and Europe for young,

General Introduction | 11 single pregnant women (16, 17). From the 1950s, MWHs were established in amongst others Nigeria, Malawi and Colombia (18). By 2017, the intervention had been implemented in over 25 countries to increase women’s access to institutionalized maternity care. The intervention is primarily implemented in low- and middle-income countries, including Ethiopia, but the governments of Canada and Australia have also applied it to bring indigenous women from remote areas closer to institutionalized care (19, 20).

ETHIOPIA

At the time of our study, Ethiopia had one of the world’s highest maternal mortality ratios in the world (2). The government’s vast and increasing health expenditures and important humanitarian aid contributions from donors have resulted in substantial progress (Table 1), but still not enough to ensure good health for all (Table 2). In 2015, the WHO advised Ethiopia to prioritize expanding the health workforce, improve the quality of reproductive, maternal, newborn and child health, increase public health financing, and focus on (operational) research to examine what works in the Ethiopian context (21). Between 2008 and 2016, the number of health facilities increased by 375% (Table 1). The health workforce also increased immensely by rapid expansion of pre-service education of doctors, nurses and midwives, which appeared to be accompanied by a reduction in the quality of education (Table 1) (22, 23).

In the 2015-2020 Health Sector Transformation Plan, MWHs were included as part of community ownership projects by the Health Development Armies. Health Development Armies have the objective to mobilise the community to take control over their own health and the factors affecting it (24). A national MWH guideline was drawn up in 2015 (25). By December 2016, 2,001 maternity waiting homes/rooms were realized (at 53% of all health facilities), most of which at health centres (91% of all MWHs) (Table 1) (26).

Table 1. Indicators health infrastructure in Ethiopia Health infrastructure (6, 26, 27) 2000-2012 2014-2016 EmONC facilities 2008-2016 (including percentage of 797 (11%) 3,804 (40%) the UN recommended number) Ambulances (introduced in 2012) 2014-2016 840 1,417 (85% operational) MWHs 2012-2016 9 2,001 Doctors, nurses and midwives density per 1,000 0.25 0.80 population 2000-2015 (SDG threshold 4.45) EmONC: Emergency Obstetric and Newborn Care; MWH: maternity waiting home; SDG: Sustainable Development Goal; UN: United Nations

12 | Chapter 1 Table 2. Indicators maternal healthcare in Ethiopia 1 Maternal healthcare in Ethiopia (2, 28, 29) 2000 2016 SDG target by 2030 Maternal mortality ratio 871 412 199 (per 100,000 live births) Neonatal mortality rate 49 29 10 (per 1,000 live births) Perinatal mortality rate 52 33 Not included (stillbirths + deaths within first week of life, per 1,000 live births) Antenatal care attendance at least once 27% 62% Not included Antenatal care attendance four or more times 10% 32% Not included Facility births 5% 26% 90% Postnatal care 10% 17% Not included Problems in accessing healthcare 96% 70% Not included (in 2005)

The Federal Democratic Republic of Ethiopia is divided into nine regions: Afar, Amhara, Beneshangul-Gumuz, Gambella, Harari, Oromia, Southern Nations, Nationalities, and Peoples, Somali and Tigray (Figure 1) (30). With over 100 million people, Ethiopia is the most populous African country after Nigeria (31). In 2016, Ethiopia ranked 174 out of 188 countries on the Human Development Index, a summary measure based on (healthy) life expectancy, access to knowledge and standard of living. The Netherlands ranked 7th (32, 33). Likewise, Ethiopia ranks low on the Gender Inequality Index (121st of 189 countries) (34).

This study took place in the (Figure 1), a predominantly rural area in the Southern Nations, Nationalities, and Peoples’ Region, consisting of 13 woreda (districts) and two city administrations: and Butajira. The Gurage Zone is a semi-mountainous and semi-fertile area where most of the estimated 1.5 million people live in rural areas (85%) and of subsistence farming (35-37). Major religious denominations are Orthodox Christianity and Islam. In 2013/2014, the Gurage Zone had three hospitals (one government hospital and two faith-based hospitals) providing maternity care, plus 63 health centres and 400 health posts (personal communication). At the time of our study, the zone counted three paved roads, two from north to south ( - Welkite; Addis Ababa - Butajira - and beyond to ), and one from west to east (Welkite - Butajira - and beyond to Ziway in Oromia region).

The Gurage culture has been described as male-centred and greatly respecting the elderly ‘Baliqu’. Until the early 2000s, marriages arranged by the men of both families were the norm. Increasingly, women have some

General Introduction | 13 Figure 1 above: administrative regions of Ethiopia; below Gurage Zone

14 | Chapter 1 say in whom they want to marry, but still need their family’s approval and are expected to prioritise social obligations over personal preference (38). 1 Gender-based violence against women and girls is common in Ethiopia. A 2015 systematic review found a lifetime prevalence of domestic violence against women by their husband of 20 to 78%. Two of the ten included studies were done within the Gurage Zone, which reported levels of 45% and 72% for 2005 and 2009, respectively (39). No zonal data were found on educational levels, but nationally, 48% of women aged 15-49 years had no education, compared to 28% of men. Physical violence against women has a strong negative correlation with a woman’s educational level (28).

Data collection took place at various locations within the Gurage Zone:

1. Attat Our Lady of Lourdes Catholic Primary Hospital (hereafter referred to as “Attat Hospital” in the western Gurage Zone; 2. Butajira General Hospital (hereafter referred to as “Butajira Hospital”) in the eastern Gurage Zone; 3. All 20 health centres in the eastern Gurage Zone; 4. In each of the five Kebeles (neighbourhoods) in the Butajira city administration; 5. In the vicinity of 14 health centres in the districts , Meskan and within the eastern Gurage Zone.

CONCEPTUAL FRAMEWORK

Gabrysch and Campbell (2009) argue that the Three Delays Model implicitly looks at homebirths with complications, without bearing in mind women who opt for a “preventive” facility birth (40). Thus, they expanded the original framework by conceptually distinguishing between emergency care-seeking and preventive care-seeking for childbirth (Figure 1). As stated by Gabrysch and Campbell (2009):

‘While similar factors are involved, their relative importance may differ or they may act in different ways. Cost of transport, for instance, is likely to be a greater deterrent for preventive than for emergency care-seeking. Physical accessibility may exert its role on preventive care-seeking mainly through influencing the decision to seek care, while in the case of emergency care-seeking, reaching the facility in time may be the main problem.’ [(40), p3]

Since using an MWH is a preventive measure to ensure facility birth, this study used the determinants of the Adapted Three Delays Model (Figure 2) to design, analyse and describe factors affecting MWH utilisation in the Gurage Zone, Southern Ethiopia.

General Introduction | 15 Preventive care seeking Emergency care seeking

Development of Before delivery COMPLICATIONS Home delivery

Phase 1: Sociocultural factors Phase 1:

Deciding to seek Perceived benefit/need Deciding to seek preventive care preventive care for delivery for complication

Phase 2: Economic Phase 2: Accessibility Identifying and Identifying and reaching health Physical reaching health facility Accessibility facility

Quality of Phase 3: preventive care Receiving normal Referral Receiving delivery care at Development of health facility COMPLICATIONS adequate and appropriate Quality of treatment for emergency care complication perception

Preventing maternal death

Figure 2 Adapted Three Delays Model (38)

Textbox 3 lists the 20 determinants that Gabrysch and Campbell identified from their literature review. Factors affecting MWH utilisation were summarized in two systematic reviews, which included publications from 1979 to 2013 (1, 41). Most of 28 included studies used a qualitative design; two studies were done in Ethiopia (5, 6). An important sociocultural factor that affected MWH use was (the lack of) community involvement in the design, development and maintenance of an MWH. Providing culturally adapted services at an MWH and health facility, as well as involving traditional birth attendants were reported as enabling factors in some settings. Several studies reported that family members did not allow MWH use because women were needed at home. Factors relating to perceived benefit/need concerned the level of awareness about the presence and benefits of MWHs. Many studies reported that MWHs Textbox 3 Determinants and were not economically accessible, due to costs of amongst others transport, variables of the Adapted Three Delays Model food and medical services. Concerning physical accessibility, women reported not wanting to use an MWH that was located in an area that was considered unsafe or still too far from the health facility. Many studies described the negative effect of poor MWH facilities and services on their use, while some also related limited MWH use to perceived low quality of care at the health facility. Lonkhuijzen et al. (2012) stress the importance of careful planning for successful introduction of an MWH (1).

16 | Chapter 1 RESEARCH AIM AND QUESTIONS 1

Sociocultural factors The aim of this PhD thesis was to explore factors affecting MWH utilisation in a rural • Maternal age setting in Southern Ethiopia. Applying a • Marital status convergent parallel design, we conducted • Ethnicity, religion, traditional five studies to answer our three research beliefs + • Family composition questions (see Table 3). The first research • Woman's education + question concerns the impact of MWH use • Husband’s education + on maternal and perinatal outcomes. Over • Woman’s autonomy + 25 countries are using the intervention, but evidence on their effectiveness is Perceived benefit/need limited and of low quality (1). The World • Information availability + Health Organization has therefore stated • Health knowledge + that research on the effectiveness of • Pregnancy wanted MWHs needs to be prioritized (42). The • ANC use rationale behind the second research • Previous facility birth • Birth order question was to identify contextual factors • Complications that could affect implementation of the MWH at Butajira Hospital. Insights into Economic accessibility these factors have the potential to appeal to a wider audience involved in maternal • Woman’s occupation Figure 2 Adapted Three Delays Model (38) • Husband’s occupation and newborn health in low- and middle- • Ability to pay + income countries. The third research Textbox 3 lists the 20 determinants that Gabrysch and Campbell identified question was added when we learned that from their literature review. Factors affecting MWH utilisation were summarized Physical accessibility most MWHs were established at health in two systematic reviews, which included publications from 1979 to 2013 (1, centres. If women await birth at an MWH • Region, urban/rural 41). Most of 28 included studies used a qualitative design; two studies were • Distance, transport, roads + in the final week(s) of pregnancy, it is done in Ethiopia (5, 6). An important sociocultural factor that affected MWH important to know whether health centres use was (the lack of) community involvement in the design, development and Quality of care are capable of providing the necessary maintenance of an MWH. Providing culturally adapted services at an MWH life-saving care in case of obstetric and health facility, as well as involving traditional birth attendants were reported • Perceived quality of care + complications. as enabling factors in some settings. Several studies reported that family +: variables included in studies on members did not allow MWH use because women were needed at home. MWHs. Factors relating to perceived benefit/need concerned the level of awareness OUTLINE OF THE THESIS about the presence and benefits of MWHs. Many studies reported that MWHs Textbox 3 Determinants and were not economically accessible, due to costs of amongst others transport, variables of the Adapted Three The second chapter of this thesis examines Delays Model food and medical services. Concerning physical accessibility, women reported the effect of MWH use on birth outcomes not wanting to use an MWH that was located in an area that was considered and mode of birth by comparing MWH users to non-users at hospitals with unsafe or still too far from the health facility. Many studies described the and without an MWH. The third chapter documents which determinants of negative effect of poor MWH facilities and services on their use, while some the Adapted Three Delays Model are associated with intended use of an also related limited MWH use to perceived low quality of care at the health MWH in the catchment area of Butajira Hospital. The fourth chapter describes facility. Lonkhuijzen et al. (2012) stress the importance of careful planning for a qualitative exploration of community members’ and frontline healthcare successful introduction of an MWH (1). workers’ perspectives on MWH use and facility births. Chapter five looks closely at the MWH intervention at Attat Hospital, which was established

General Introduction | 17 in 1973 and was used from the start. To learn from their experience, we explored which factors facilitated uptake. The sixth chapter examines basic emergency obstetric care provision at all 20 health centres in the catchment area of Butajira Hospital. Chapter seven is a commentary on MWHs that was published in the Journal of Midwifery and Women’s Health alongside two studies on MWHs in Zambia and Liberia. In the eighth and last chapter, the most important study findings are summarized and put into a broader perspective.

Table 3. Research questions and methodologies Research questions Studies & methodologies Chapter A. What is the impact 1. A retrospective cohort study using hospital 2 of MWH use on records comparing three groups of women birth outcomes? who gave birth: a) MWH users at Attat Hospital, b) non-users at Attat Hospital, c) women who gave birth at Butajira Hospital without an MWH. B. What are 2. A community-based cross-sectional study 3 facilitators and design using a structured questionnaire barriers to MWH among recently delivered and pregnant use in the Gurage women in the eastern Gurage Zone. Zone, Southern 3. A qualitative study using in-depth 4 Ethiopia? interviews and five focus group discussions with community members and frontline healthcare workers in the eastern Gurage Zone. 4. An exploratory sequential mixed methods 5 study design at Attat Hospital in the western Gurage Zone consisting of in- depth interviews with staff and MWH users, focus group discussions with users and attendants, a structured questionnaire among users, an observation period and review of annual facility reports. C. What is the 5. A facility-based survey at all health centres 6 capacity of health in the eastern Gurage Zone, using an centres to provide abbreviated version of the Averting Maternal basic emergency Death and Disability needs assessment tool obstetric and for emergency obstetric and neonatal care. newborn care in the eastern Gurage Zone, Ethiopia?

18 | Chapter 1 REFERENCES 1 1. van Lonkhuijzen L, Stekelenburg J, van Roosmalen J. Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries. Cochrane Database Syst Rev. 2012;10:CD006759. 2. Central Statistical Agency [Ethiopia] and ICF International. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF International; 2012. 3. World Health Organization. Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division; 2015. 4. World Health Organization. Maternity Waiting Homes: A review of experiences. Geneva: Maternal and Newborn Health/ Safe Motherhood Unit, Division of Reproductive Health; 1996. Contract No.: WHO/RHT/MSM/96.21. 5. Kelly J, Kohls E, Poovan P, Schiffer R, Redito A, Winter H, et al. The role of a maternity waiting area (MWA) in reducing maternal mortality and stillbirths in high-risk women in rural Ethiopia. BJOG. 2010;117(11):1377-83. 6. Gaym A, Pearson L, Soe KWW. Maternity waiting homes in Ethiopia -three decades experience. Ethiop Med J. 2012;50(3):209-19. 7. World Health Organization. Human rights and health 2017 [cited 2018 December 14]. Available from: https://www.who.int/news-room/fact-sheets/detail/ human-rights-and-health. 8. World Health Organization. Maternal mortality 2018 [cited 2019 January 26]. Available from: https://www.who.int/news-room/fact-sheets/detail/maternal- mortality. 9. Firoz T, Chou D, von Dadelszen P, Argawal P, Vanderkruik R, Tunçalp O, et al. Measuring maternal health: focus on maternal morbidity 2013 [cited 2018 December 14]. Available from: https://www.who.int/bulletin/volumes/91/10/13-117564/ en/. 10. de Bernis L, Kinney MV, Stones W, ten Hoope-Bender P, Vivio D, Leisher SH, et al. Stillbirths: ending preventable deaths by 2030. Lancet. 2016;387(10019):703- 16. 11. World Health Organization. Survive and thrive: transforming care for every small and sick newborn. Key findings. . Geneva; 2018. Contract No.: WHO/FWC/ MCA/18.11. 12. World Health Organization. Maternal, newborn, child and adolescent health [cited 2018 14 December]. Available from: https://www.who.int/maternal_child_ adolescent/en/. 13. World Health Organization. Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. Geneva: Department of Reproductive Health and Research, World Health Organization; ; 2004. 14. Holmer H, Oyerinde K, Meara JG, Gillies R, Liljestrand J, Hagander L. The global met need for emergency obstetric care: a systematic review. BJOG. 2015;122(2):183-9.

General Introduction | 19 15. Thaddeus S, Maine D. Too Far to Walk: Maternal Mortality in Context. Soc Sci Med. 1994;38(8):1091-110. 16. Boulbès Y. Histoire des maisons maternelles: entre secours et redressement. Paris: L’Harmattan; 2005. 17. Liebmann G. Back to the maternity home. American Enterprise. 1995;6(1):49. 7p.2. 18. Poovan P, Kifle F, Kwast BE. A maternity waiting home reduces obstetric catastrophes. World Health Forum. 1990;11(4):440-5. 19. Kruske S, Kildea S, Barclay L. Cultural safety and maternity care for Aboriginal and Torres Strait Islander Australians. Women Birth. 2006;19(3):73-7. 20. Van Wagner V, Epoo B, Nastapoka J, Harney E. Reclaiming birth, health, and community: midwifery in the Inuit villages of Nunavik, Canada. J Midwifery Womens Health. 2007;52(4):384-91. 21. World Health Organization & Ethiopia. Ministry of Health. Success factors for women’s and children’s health: Ethiopia.: World Health Organization,; 2015. 22. Kibwana S, Haws R, Kols A, Ayalew F, Kim YM, van Roosmalen J, et al. Trainers’ perception of the learning environment and student competency: A qualitative investigation of midwifery and anesthesia training programs in Ethiopia. Nurse Educ Today. 2017;55:5-10. 23. Yigzaw T, Ayalew F, Kim YM, Gelagay M, Dejene D, Gibson H, et al. How well does pre-service education prepare midwives for practice: competence assessment of midwifery students at the point of graduation in Ethiopia. BMC Med Educ. 2015;15:130. 24. Federal Democratic Republic of Ethiopia Ministry of Health. Health Sector Transformation Plan: 2015/16-2019/20. Addis Ababa: Federal Democratic Republic of Ethiopia Ministry of Health; 2015. 25. Federal Democratic Republic of Ethiopia Ministry of Health. Guideline for the establishment of Standardized Maternity Waiting Homes at Health Centres/ Facilities. Addis Ababa: Federal Democratic Republic of Ethiopia Ministry of Health; 2015. 26. Ethiopian Public Health Institute; Federal Ministry of Health; and Averting Maternal Death and Disability (AMDD) Columbia University. ETHIOPIAN Emergency Obstetric and Newborn Care (EmONC) Assessment 2016 - Final Report. Addis Ababa, Ethiopia and New York, USA: FMOH and AMDD; 2017. 27. Jackson R. Does the introduction of ambulances improve access to maternal health services in rural Ethiopia? : ANU College of Asia and the Pacific at The Australian National University; 2014 [cited 2018 December 14]. 28. Central Statistical Agency (CSA) [Ethiopia] and ICF. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia and Rockville, Maryland, USA: CSA and ICF; 2016. 29. National Planning Commision. Ethiopia 2017 Voluntary National Review on SDGs Government Commitments, National Ownership and Performance Trends. Addis Ababa: National Planning Commission; 2017. 30. Federal Democratic Republic of Ethiopia. Regional States [cited 2018 December 14]. Available from: http://www.ethiopia.gov.et/regional-states1.

20 | Chapter 1 31. World Population Review. Ethiopia Population 2018 [cited 2018 December 14]. Available from: http://worldpopulationreview.com/countries/ethiopia- 1 population/. 32. United Nations Development Programme. Human Development Indices and Indicators: 2018 Statistical Update - Briefing note for countries on the 2018 Statistical Update - Ethiopia: UNDP,; 2018 [cited 2019 January 26]. Available from: http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/ETH.pdf. 33. United Nations Development Programme. Human Development Reports: Netherlands 2018 [cited 2019 January 26]. Available from: http://hdr.undp.org/ en/countries/profiles/NLD. 34. United Nations Development Programme. Gender Inequality Index (GII): United Nations Development Programme; 2018 [updated 2018; cited 2019 January 26]. Available from: http://hdr.undp.org/en/content/gender-inequality-index- gii. 35. Central Statistical Agency (CSA) Ethiopia. Population Projection of Ethiopia for All Regions At Wereda Level from 2014 - 2017. Addis Ababa, Ethiopia: CSA; 2014. 36. Sinaga M, Mohammed A, Teklu N, Stelljes K, Belachew T. Effectiveness of the population health and environment approach in improving family planning outcomes in the Gurage, Zone South Ethiopia. BMC Public Health. 2015;15:1123. 37. Adugna A. Ethiopian Demography and Health - SNNPR 2018 [cited 2018 December 14]. Available from: http://www.ethiodemographyandhealth.org/ SNNPR.html. 38. Hussen TS. “War in the home’’ marriage and mediation among the Gurage in Ethiopia. South Africa: University of the Western Cape; 2011. 39. Semahegn A, Mengistie B. Domestic violence against women and associated factors in Ethiopia; systematic review. Reprod Health. 2015;12:78. 40. Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9:34. 41. Penn-Kekana L, Pereira S, Hussein J, Bontogon H, Chersich M, Munjanja S, et al. Understanding the implementation of maternity waiting homes in low- and middle-income countries: a qualitative thematic synthesis. BMC Pregnancy Childbirth. 2017;17(1):269. 42. Souza JP, Widmer M, Gülmezoglu AM, Lawrie TA, Adejuyigbe EA, Carroli G, et al. Maternal and perinatal health research priorities beyond 2015: an international survey and prioritization exercise. Reprod Health. 2014;11(61).

General Introduction | 21