May, 2011 - SUPPORT Summary of a systematic review | print this article |

Do maternity waiting homes improve maternal and neonatal outcomes in low-resource settings?

The poor utilisation of maternal health services and antenatal care by women living in rural areas has been associated with high maternal and neonatal mortality. Maternity waiting homes have been advocated as a way of overcoming geographical barriers in such settings and improving access to care and maternal and neonatal outcomes.

Key messages

No RCTs were found on the effects of maternity waiting homes on perinatal and maternal mortality and morbidity in low -resource settings
- No studies were found that met the inclusion criteria of this review
Good quality studies are required to evaluate the effectiveness of maternity waiting homes in low-resource settings
Maternity waiting homes may be a relevant option in rural populations with limited access to emergency obstetric care
Related literature suggests that the planning of maternity waiting homes should address barriers to access and levels of use. These include financial costs, lack of transport, lack of privacy, poor hygiene, a lack of basic necessities such as water and food, and the attitudes of staff

Who is this summary for?

People making decisions about obstetric care in low- and middle income countries

This summary includes:

Key findings from research based on a systematic review
Considerations about the relevance of this research for low income countries

Not included:

Recommendations
Additional evidence not included in the systematic review
Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

van Lonkhuijzen L, Stekelenburg J, van Roosmalen J. Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.:CD006759. See in Cochrane Library

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

A maternity waiting home is a facility within easy reach of a hospital or health centre offering antenatal and emergency obstetric care provided by skilled birth attendants.. Maternity waiting homes seek to overcome barriers to access to obstetric care, particularly in rural and remote areas. Women, particularly those with high risk pregnancies, are encouraged to stay in maternity waiting homes close to health care facilities towards the end of their pregnancies. The aim is to improve access to antenatal care during the late stages of pregnancy, and intranatal care in particular. This ensures that the delivery takes place in an equipped setting where skilled attendance is available.

Some studies have reported a favourable effect of maternity waiting homes on outcomes for women and their newborns. But others have found that utilisation levels are low due to access barriers.

This review assessed the evidence of the effects of waiting homes on maternal and neonatal outcomes in low-resource countries. The authors looked for randomised control trials, including quasi-randomised and cluster randomised trials in low-resource settings.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.

About the systematic review underlying this summary

/	What the review authors searched for	What the review authors found
Review Objectives: To assess the effects of maternity waiting facilities on maternal and perinatal health in low-resource settings.
Interventions	Randomised control trials of maternity waiting homes i.e. facilities within a 1 km or a 10 minute walk from a medical facility designated for the lodging of pregnant women awaiting labour	No randomised control trials of maternity waiting facilities in low-resource settings
Participants	All pregnant women	None
Settings	Low-resource countries	None
Outcomes	Indices of perinatal morbidity and mortality, maternal morbidity and mortality, obstetric intervention and maternal satisfaction	None
Date of most recent search: April 2009
Limitations: This is a good quality systematic review with only minor limitations

About the certainty of the  evidence (GRADE)

High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.

Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.

Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.

Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

No studies were identified that met the inclusion criteria of the review. Good quality studies are required to evaluate the effectiveness of waiting homes on maternal and perinatal outcomes in low-resource settings.

Although maternity waiting homes could potentially improve access to, and the utilisation of, obstetric care, related literature describes reasons why this may not always be the case. These include:

Women may elect not to use maternity waiting homes if, for example, the housing is crowded, poorly staffed, unsafe at night, or lacking necessities such as water or food
They may also elect not to use them if there is a lack of privacy or if they are not able to have their families with them
The costs of staying in a maternity waiting home may exceed the costs of home delivery
Lack of transportation
Lack of respect from staff
Locations may be some way from a hospital or may have inadequate access to emergency obstetric care

There is therefore a need to plan maternity waiting homes carefully to ensure that they are positively perceived, that uti-lisation levels are high, and to ensure that they provide access to good quality obstetric care.

Relevance of the review for low-income countries

Findings	Interpretation*
APPLICABILITY
No data were available from studies in low-resource settings	Maternity waiting homes are likely to be appropriate to rural settings in which there is limited access to emergency obstetric care, where there is sufficient capacity to ensure access to emergency obstetric care, and where it is possible to offer homes that are safe, affordable, and attractive to women
EQUITY
No data were available from studies in low-resource settings	Maternity waiting homes are likely to reduce inequalities between rural and urban populations but this will depend on the degree to which they function as intended. If there are financial barriers affecting the usage of such facilities, inequalities in access to care may increase amongst poorer women in rural areas
ECONOMIC CONSIDERATIONS
No data were available from studies in low-resource settings	The costs of maternity waiting homes include those related to transportation,staffing, food and supplies, and emergency obstetric care. Although user fees may cover some of these costs, user fees are also likely to reduce utilisation levels and, therefore, effectiveness
MONITORING & EVALUATION
No data were available from studies in low-resource settings	Retrospective cohort studies of the impacts of maternity waiting homes are available but these studies have a high risk of bias because the women who use these homes are not comparable to the women who do not. Thus there is a need for randomised trials to evaluate their impacts on maternal and neonatal outcomes and costs

Additional information

Related literature

Bulatao RA, Ross JA. Which health services reduce maternal mortality? Evidence from ratings of ma- ternal health services. Tropical Medicine and International Health 2003;8:720-1.

Lee A, Lawn J, Cousens S, et al. Linking families and facilities for care at birth: What works to avert intrapartum-related deaths? International Journal of Gynecology and Obstetrics 107 (2009) S65–S88

Bhutta Z, Darmstadt G, Haws R et al. Delivering interventions to reduce the global burden of stillbirths: improving service supply and community demand. BMC Pregnancy and Childbirth 2009, 9(Suppl 1):S7

This summary was prepared by

Dudley, LD, Faculty of Health Sciences, University of Stellenbosch, South Africa

Conflict of interest

None declared. For details, see:

Acknowledgements

This summary has been peer reviewed by: Luc van Lonkhuijzen, the Netherlands; Joseph Kasonde, Zambia

This summary should be cited as

Dudley LD. Do maternity waiting facilities improve maternal and perinatal outcomes in low resource settings? A SUPPORT Summary of a systematic review. May 2011.

About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

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