Understanding the Adoption and Scale-up of Maternity Waiting Homes in Low- and Middle-Income Countries: A Program Theory from a Realistic Review and Synthesis – Global

Nadege Sandrine Uwamahoro, Daphne McRae, Zibrowski, Victor-Uadiale, Brynne Gilmore, Nicole Bergen, Nazeem Muhajarine
Correspondence to Dr. Nazeem Muhajarine; [email protected]


Introduction Maternity Waiting Homes (MWHs) connect pregnant women with skilled birth attendants in health facilities. Research suggests that some MWH facility birthing interventions are more successful in meeting the needs and expectations of their intended users than others. Our aim was to develop a theory about what resources work to support uptake and scale-up of MHW facility birth interventions, how, for whom, in what settings, and why.

Methods A realistic four-step review was conducted, including developing an initial program theory; search for evidence; selection, evaluation and extraction of data; and data analysis and synthesis.

Results A program theory was developed from 106 secondary sources and 12 primary interviews with MWH implementers. The theory demonstrated that adoption and scale-up of the MWH facility birth intervention depends on complex interactions between three groups of adopters: health system stakeholders, community gatekeepers and pregnant women and their families. It describes the relationships between 19 contexts, 11 mechanisms and 31 outcomes through nine context-mechanism-outcome configurations (CMOCs) that have been grouped into 3 themes: (1) Engaging stakeholders to develop, integrate and sustain birth interventions of MWH facilities, (2) Promote and enable the use of births at MWH facilities, and (3) Create positive and memorable experiences for users of births at MWH facilities. Belief, trust, empowerment, health literacy, and perceptions of safety, comfort, and dignity were mechanisms that supported dissemination and uptake of the intervention within communities and health systems. . Examples of implementer-provided resources to trigger the mechanisms associated with each CMOC have been identified.

conclusion MWH implementers cannot simply assume that communities will collectively value a birthing experience in a MWH over home birth. We posit that birthing interventions in MWH facilities become vulnerable to underutilization when implementers fail to: (1) remove barriers that impede women’s access to MWH and (2) ensure that the conditions and interactions experienced within MWH and its affiliated health facility support women to feel treated with compassion, dignity and respect.

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