Stakeholders' perspectives on the acceptability and feasibility of maternity waiting homes: a qualitative synthesis.

BACKGROUND: Maternity waiting homes (MHWs) are recommended to help bridge the geographical gap to accessing maternity services. This study aimed to provide an analysis of stakeholders' perspectives (women, families, communities and health workers) on the acceptability and feasibility of MWHs. METHODS: A qualitative evidence synthesis was conducted. Studies that were published between January 1990 and July 2020, containing qualitative data on the perspectives of the stakeholder groups were included. A combination of inductive and deductive coding and thematic synthesis was used to capture the main perspectives in a thematic framework. RESULTS: Out of 4,532 papers that were found in the initial search, a total of 38 studies were included for the thematic analysis. Six themes emerged: (1) individual factors, such as perceived benefits, awareness and knowledge of the MWH; (2) interpersonal factors and domestic responsibilities, such as household and childcare responsibilities, decision-making processes and social support; (3) MWH characteristics, such as basic services and food provision, state of MWH infrastructure; (4) financial and geographical accessibility, such as transport availability, costs for MWH attendance and loss of income opportunity; (5) perceived quality of care in the MWH and the adjacent health facility, including regular check-ups by health workers and respectful care; and (6) Organization and advocacy, for example funding, community engagement, governmental involvement. The decision-making process of women and their families for using an MWH involves balancing out the gains and losses, associated with all six themes. CONCLUSION: This systematic synthesis of qualitative literature provides in-depth insights of interrelating factors that influence acceptability and feasibility of MWHs according to different stakeholders. The findings highlight the potential of MWHs as important links in the maternal and neonatal health (MNH) care delivery system. The complexity and scope of these determinants of utilization underlines the need for MWH implementation strategy to be guided by context. Better documentation of MWH implementation, is needed to understand which type of MWH is most effective in which setting, and to ensure that those who most need the MWH will use it and receive quality services. These results can be of interest for stakeholders, implementers of health interventions, and governmental parties that are responsible for MNH policy development to implement acceptable and feasible MWHs that provide the greatest benefits for its users. Trial registration Systematic review registration number: PROSPERO 2020, CRD42020192219.

Understanding maternity waiting home uptake and scale-up within low-income and middle-income countries: a programme theory from a realist review and synthesis.

INTRODUCTION: Maternity waiting homes (MWHs) link pregnant women to skilled birth attendance at health facilities. Research suggests that some MWH-facility birth interventions are more success at meeting the needs and expectations of their intended users than others. We aimed to develop theory regarding what resources work to support uptake and scale-up of MHW-facility birth interventions, how, for whom, in what contexts and why. METHODS: A four-step realist review was conducted which included development of an initial programme theory; searches for evidence; selection, appraisal and extraction of data; and analysis and data synthesis. RESULTS: A programme theory was developed from 106 secondary sources and 12 primary interviews with MWH implementers. The theory demonstrated that uptake and scale-up of the MWH-facility birth intervention depends on complex interactions between three adopter groups: health system stakeholders, community gatekeepers and pregnant women and their families. It describes relationships between 19 contexts, 11 mechanisms and 31 outcomes accross nine context-mechanism-outcome configurations (CMOCs) which were grouped into 3 themes: (1) Engaging stakeholders to develop, integrate, and sustain MWH-facility birth interventions, (2) Promoting and enabling MWH-facility birth utilisation and (3) Creating positive and memorable MWH-facility birth user experiences. Belief, trust, empowerment, health literacy and perceptions of safety, comfort and dignity were mechanisms that supported diffusion and adoption of the intervention within communities and health systems. Examples of resources provided by implementers to trigger mechanisms associated with each CMOC were identified. CONCLUSIONS: Implementers of MWHs cannot merely assume that communities will collectively value an MWH-facility birth experience over delivery at home. We posit that MWH-facility birth interventions become vulnerable to under-utilisation when implementers fail to: (1) remove barriers that hinder women's access to MWH and (2) ensure that conditions and interactions experienced within the MWH and its affiliated health facility support women to feel treated with compassion, dignity and respect. PROSPERO REGISTRATION NUMBER: CRD42020173595.

A systematic review and meta-analysis of the effectiveness of maternity waiting homes in low- and middle-income countries.

Maternity waiting homes (MWHs) in low- and middle-income countries (LMICs) provide women with accommodation close to a health facility to enable timely access to skilled care at birth. We examined whether MWH use and availability compared with non-use/unavailability were associated with facility birth, birth with a skilled health professional, attendance at postnatal visit(s) and/or improved maternal and newborn health, in LMICs. We included (non-)randomized controlled, interrupted time series, controlled before-after, cohort and case-control studies published since 1990. Thirteen databases were searched with no language restrictions. Included studies (1991-2020) were assessed as either moderate (n = 9) or weak (n = 10) on individual quality using the Effective Public Health Practice Project tool. Quality was most frequently compromised by selection bias, confounding and blinding. Only moderate quality studies were analyzed; no studies examining maternal morbidity/mortality met this criterion. MWH users had less relative risk (RR) of perinatal mortality [RR 0.65, 95% confidence intervals (CIs): 0.48, 0.87] (3 studies) and low birthweight (RR 0.34, 95% CI: 0.20, 0.59) (2 studies) compared with non-users. There were no significant differences between MWH use and non-use for stillbirth (RR 0.75, 95% CI: 0.47, 1.18) (3 studies) or neonatal mortality (RR 0.51, 95% CI: 0.25, 1.02) (2 studies). Single study results demonstrated higher adjusted odds ratios (aOR) for facility birth (aOR 5.8, 95% CI: 2.6, 13.0) and attendance at all recommended postnatal visits within 6 weeks of birth (aOR 1.99, 95% CI: 1.30, 3.07) for MWH users vs. non-users. The presence vs. absence of an MWH was associated with a 19% increase in facility birth (aOR 1.19, 95% CI: 1.10, 1.29). The presence vs. absence of a hospital-affiliated MWH predicted a 47% lower perinatal mortality rate (P < 0.01), but at a healthcare centre-level a 13 higher perinatal mortality rate (P < 0.01). Currently, there remains a lack of robust evidence supporting MWH effectiveness. We outline a six-point strategy for strengthening the evidence base.

Understanding the implementation (including women's use) of maternity waiting homes in low-income and middle-income countries: a realist synthesis protocol.

INTRODUCTION: Maternity waiting homes in low-income and middle-income countries provide accommodation near health facilities for pregnant women close to the time of birth to promote facility-based birth and birth with a skilled professional and to enable timely access to emergency obstetric services when needed. To date, no studies have provided a systematic, comprehensive synthesis explaining facilitators and barriers to successful maternity waiting home implementation and whether and how implementation strategies and recommendations vary by context. This synthesis will systematically consolidate the evidence, answering the question, 'How, why, for whom, and in what context are maternity waiting homes successfully implemented in low-income and middle-income countries?'. METHODS AND ANALYSIS: Methods include standard steps for realist synthesis: determining the scope of the review, searching for evidence, appraising and extracting data, synthesising and analysing the data and developing recommendations for dissemination. Steps are iterative, repeating until theoretical saturation is achieved. Searching will be conducted in 13 electronic databases with results managed in Eppi-Reviewer V.4. There will be no language, study-type or document-type restrictions. Items documented prior to 1990 will be excluded. To ensure our initial and revised programme theories accurately reflect the experiences and knowledge of key stakeholders, most notably the beneficiaries, interviews will be conducted with maternity waiting home users/nonusers, healthcare staff, policymakers and programme designers. All data will be analysed using context-mechanism-outcome configurations, refined and synthesised to produce a final programme theory. ETHICS AND DISSEMINATION: Ethics approval for the project will be obtained from the Mozambican National Bioethical Commission, Jimma University College of Health Sciences Institutional Review Board and the University of Saskatchewan Bioethical Research Ethics Board. To ensure results of the evaluation are available for uptake by a wide range of stakeholders, dissemination will include peer-reviewed journal publication, a plain-language brief, and conference presentations to stakeholders' practice audiences. PROSPERO REGISTRATION NUMBER: CRD42020173595.

Improving birth outcomes for women who are substance using or have mental illness: a Canadian cohort study comparing antenatal midwifery and physician models of care for women of low socioeconomic position.

BACKGROUND: Some observational studies have shown improved birth outcomes for women of low socioeconomic position (SEP) receiving antenatal midwifery versus physician care. To understand for whom and under what circumstances midwifery care is associated with better birth outcomes we examined whether psychosocial risk including substance use, mental illness, social assistance, residence in a neighbourhood of low/moderate SEP, and teen maternal age modified the association between model of care (midwifery versus physician) and small-for-gestational-age (SGA) or preterm birth (PTB) for women of low SEP. METHODS: For this retrospective cohort study, maternity data from the British Columbia Perinatal Data Registry were linked with Medical Services Plan billing data. We report adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for SGA birth (< the 10th percentile) and PTB (< 37 weeks' completed gestation). For tests of interaction between antenatal models of care and psychosocial risk, p-values < 0.10 were considered statistically significant. Women were eligible for inclusion if they were residents of British Columbia, Canada, carried a singleton fetus, had low to moderate medical/obstetric risk, birthed between April 1, 2008 and Dec. 31, 2012, and received a health insurance subsidy (n = 33,937). RESULTS: Midwifery versus obstetrician patients had lower odds of PTB. The difference was 31% larger among substance users (aOR 0.24, 95% CI: 0.11-0.54) compared to non-substance users (aOR 0.55, 95% CI: 0.45-0.68). Additionally, there was a 34% statistically significant absolute difference in odds of PTB for midwifery versus obstetrician patients with both mental illness and substance use (aOR 0.18, 95% CI: 0.06-0.55) compared to women with neither mental illness nor substance use (aOR 0.52, 95% CI: 0.41-.66). Results demonstrated a consistent association between midwifery versus physician care and lower odds of SGA, yet effects were not statistically significantly different for women with higher or lower psychosocial risk. CONCLUSION: Among low SEP women in British Columbia, Canada, antenatal midwifery compared to obstetrician care was associated with reduced odds of PTB. Odds were lower among women with substance use, and mental illness and substance use, than among women without these risk factors.

Aboriginal Status and Neighborhood Income Inequality Moderate the Relationship between School Absenteeism and Early Childhood Development.

The negative impact of school absenteeism on children's academic performance has been documented in the educational literature, yet few studies have used validated development indicators, or investigated individual and neighborhood characteristics to illuminate potential moderating factors. Using cross-sectional Early Development Instrument (EDI) panel data (2001-2005) we constructed multilevel linear and logistic regression models to examine the association between school absenteeism and early childhood development, moderated by Aboriginal status, length of school absence, neighborhood-level income inequality, and children's sex assigned at birth. Our study included 3572 children aged four to eight in 56 residential neighborhoods in Saskatoon, Canada. Results indicated that Aboriginal children missing an average number of school days (3.63 days) had significantly lower EDI scores compared to non-Aboriginal children, controlling for individual and neighborhood factors. As school absenteeism lengthened, the gap in EDI scores between Aboriginal and non-Aboriginal children narrowed, becoming non-significant for absences greater than two weeks. Children with long-term school absence (>4 weeks of school), living in neighborhoods of low income inequality, had significantly better physical and social development scores compared to children from medium or high income inequality neighborhoods. Across all EDI domains, girls living in neighborhoods with low income inequality had significantly better EDI scores than boys in similar neighborhoods; however, sex-differences in EDI scores were not apparent for children residing in high income inequality neighborhoods. Results add to the literature by demonstrating differences in the relationship between school absenteeism and early developmental outcomes moderated by Aboriginal status, length of school absence, neighborhood income inequality, and sex assigned at birth. These moderating factors show that differential approaches are necessary when implementing policies and programs aimed at improving school attendance.

Patient-led decision making: Measuring autonomy and respect in Canadian maternity care.

OBJECTIVE: The Changing Childbirth in British Columbia study explored women's preferences and experiences of maternity care, including women's role in decision-making. METHODS: Following content validation by community members, we administered a cross-sectional online survey exploring novel topics, including drivers for interventions, and experiences of autonomy, respect, or mistreatment during maternity care. Using the Mothers Autonomy in Decision-Making (MADM) scale as an outcome measure in a mixed-effects analysis, we examined differential experiences by socio-demographic and prenatal risk profile, type of care provider, interventions received, and nature of communication with care providers. RESULTS: A geographically representative sample of Canadian women (n = 2051) reported on 3400 pregnancies. Most women (95.2%) preferred to be the lead decision-maker during care. Patients of physicians had significantly lower autonomy (MADM) scores than midwifery clients as did women who felt pressured to accept interventions. Women who had a difference in opinion with their provider, and those who felt their provider seemed rushed reported the lowest MADM scores. CONCLUSION: Women's autonomy is significantly altered by model of maternity care, the nature of interactions with care providers, and women's ability for self-determination. PRACTICE IMPLICATIONS: If health professionals acquire skills in person-centred decision-making experience of autonomy among pregnant women may improve.

Reduced prevalence of small-for-gestational-age and preterm birth for women of low socioeconomic position: a population-based cohort study comparing antenatal midwifery and physician models of care.

OBJECTIVE: Our aim was to investigate if antenatal midwifery care was associated with lower odds of small-for-gestational-age (SGA) birth, preterm birth (PTB) or low birth weight (LBW) compared with general practitioner (GP) or obstetrician (OB) models of care for women of low socioeconomic position. SETTING: This population-level, retrospective cohort study used province-wide maternity, medical billing and demographic data from British Columbia, Canada. PARTICIPANTS: Our study included 57 872 pregnant women, with low socioeconomic position, who: were residents of British Columbia, Canada, carried a singleton fetus, had low to moderate medical/obstetric risk, delivered between 2005 and 2012 and received medical insurance premium assistance. PRIMARY AND SECONDARY OUTCOME MEASURES: We report rates, adjusted ORs (aOR), and 95% CIs for the primary outcome, SGA birth (

Corrigendum to "Is model of care associated with infant birth outcomes among vulnerable women? A scoping review of midwifery-led versus physician-led care" [SSM - Population Health 2 (2016) 182-193].

[This corrects the article DOI: 10.1016/j.ssmph.2016.01.007.].

Is model of care associated with infant birth outcomes among vulnerable women? A scoping review of midwifery-led versus physician-led care.

This scoping review investigates if, over the last 25 years in high resource countries, midwives' patients of low socioeconomic position (SEP) were at more or less risk of adverse infant birth outcomes compared to physicians' patients. Reviewers identified 917 records in a search of 12 databases, grey literature, and citation lists. Thirty-one full documents were assessed and nine studies met inclusion criteria. Eight studies were assessed as moderate in quality; one study was given a weak rating. Of the moderate quality studies, the majority found no statistical difference in outcomes according to model of care for preterm birth, low or very low birth weight, or NICU admission. No study reported a statistically significant difference for small for gestational age birth (2 studies), or mean or low Apgar score (4 studies). However, one study found a reduced risk of preterm birth (AOR=0.70, p<0.01), and heavier mean infant birth weight (3325 g vs. 3282 g, p<0.01) for midwifery patients. Another study reported lower risk of low (RR=0.59, 95% CI: 0.46, 0.73) and very low birthweight (RR=0.44, 95% CI: 0.23, 0.85) for midwifery care. And, a third study reported a decrease in stays (1-3 days) in NICU (Adjusted Risk Difference=-1.8, 95% CI: -3.9, 0.2) for midwifery patients, though no overall difference in NICU admission of any duration. Other studies reported significant differences favoring midwifery care for mean birth weight (3598 g vs. 3407.3 g, p<0.05; 3233 g vs. 3089 g, p<0.05; 2 studies) and very low birth weight (OR=0.35, 95% CI:0.1, 0.9), for sub-groups within the larger study populations. This scoping review documented heterogeneity in study designs and analytical methods, inconsistent findings, moderate methodological quality, and lack of currency. There is a need for new studies to definitively establish if and how a midwifery-led model of care influences birth outcomes for women of low SEP.