A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Maternal and perinatal mortality remains significantly high in low‐income countries with over 800 deaths per day of women around childbirth. Greater than 90% of such deaths occur in low‐income countries. The concept of maternity waiting homes (MWH) was reintroduced to aid in decreasing maternal and perinatal mortality. Since the previous Cochrane Review in 2012 on maternity waiting homes, there have not been any published randomized controlled studies. Do observational studies on MWHs demonstrate decreased maternal and perinatal mortality in low‐income countries when compared with the standard of care? We searched for primary articles that reported maternal and perinatal deaths as major outcomes in studies who compared MWHs to other methods such as direct hospital admits, we also investigated cesarean delivery rates. Search engines used were: Cochrane Review, Medline and CINAHL. Meta‐analyses and forests plots were formulated using MedCalc Software. Systematic review was drafted using MOOSE guidelines for meta‐analysis and systematic reviews of observation. Seven articles met criteria for this study. The maternal mortality rate for MWH was 105/100,000 and 1,066/100,000 for non‐MWH, Relative Risk (RR) 0.145 (95% Confidence Interval (CI) 0.062 to 0.204). Perinatal mortality rate was 60/1,000 in MWH compared to 65/1,000, RR 0.782 (CI 0.602 to 1.120) in non‐MWH. Stillbirth rate was 18/1,000 in MWH and 184/1,000 in non‐MWH, RR 0.204 (CI 63.88 to 94.08). Neonatal mortality rates were 16/1,000 in MWH and 15/1,000 in non‐MWH, RR 0.862 (CI 0.392 to 1.628). Cesarean deliveries rate was 24/100 for MWH and 18/100 in non‐MWH, RR 1.229 (CI 1.226‐1.555). MHWs statistically decreased maternal death, stillbirths and increased cesarean delivery rates. Overall, the observation nature of the study designs introduces selection biases that may have altered the results of the studies. No randomized trials have been done to date. We suggest cluster‐randomized studies to further evaluate the effect of MWHs.

The strong emphasis placed on improving equality and well-being for all in the Sustainable Development Goals underscores the importance of tackling persistent within-country disparities in maternal mortality and poor health outcomes. Addressing maternal healthcare access barriers is, thus, crucial, particularly in low-resource settings. Numerous studies investigating determinants of maternal healthcare service use in Ethiopia exist but are limited by their focus on individual and household factors, and by methodological weaknesses. A nuanced understanding of the role of socioeconomic and geographic context in influencing access to care is needed to respond effectively. Maternity waiting homes (MWHs) are a potential strategy to address geographical barriers that delay women’s access to obstetric care. However, in addition to concerns about service quality, there is limited evidence on their effectiveness and on what models meet women’s needs. My research goals were, therefore, to contribute to the understanding of what contextual factors influence maternal healthcare service use in general; and to determine whether or not upgraded MWHs operating in an enabling environment could improve delivery care use in rural Ethiopia. My primary data sources were household surveys conducted as part of a cluster-randomized controlled trial evaluating MWHs and local leader training in Jimma Zone, Ethiopia. Random effects multivariable logistic regression analysis of survey data brought to light the social and financial resources that facilitate MWH use, highlighting the need for complementary interventions to make access more equitable. Spatial analyses identified subnational variation in service use at a finer scale than routinely reported and unmasked local variation in the relevance and magnitude of associations between individual-, interpersonal-, and health system factors and maternal healthcare use. These findings have implications for relying upon homogenous national responses to improve equality in access to care and health outcomes. Finally, analysis of trial data found a non-significant effect of interventions on delivery care use likely due to implementation issues and extraneous factors. The need to generate strong evidence of effectiveness of MWHs in improving maternal healthcare service use using sustainable and equitable MWH models using methods appropriate for complex intervention evaluation remains.