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Important, Yet Overlooked: Maternity Waiting Homes

By Dr. Fikrejesus Amahazion

Eritrea is one of the few countries that entered the United Nations Sustainable Development Goals (UN SDGs) period having achieved most of the United Nations Millennium Development Goals related to health. Since the onset of the UN SDGs period close to a decade ago, the country has continued to make considerable progress in a number of areas, including within neonatal, child, and maternal health. In particular, the country’s maternal mortality ratio dropped from 998 per 100,000 live births in 1990 to 228 in 2015, and 184 in 2019 – an overall reduction of approximately 82 percent during the period running from 1990 to 2019. In addition, between 1990 and 2020, the neonatal mortality rate in Eritrea was reduced by about 49 percent, dropping from 35 deaths per 1,000 live births to 18, while the country’s under-five mortality rate was reduced by approximately 75 percent, falling from 153 to 39. Of note, the average annual rate of reduction (AARR) for under-five mortality in Eritrea between 1990 and 2020 is estimated at about 4.5 percent, which is not only considerably ahead of the AARR for the entire Sub-Saharan Africa region (approximately 3.0 percent), but also among the fastest anywhere in the world.

As one considers these various health-related improvements that have unfolded in Eritrea, it is well worth recalling that they were achieved despite an array of daunting challenges and myriad significant obstacles for the country, including many years of illegal, unjust sanctions, tough general climate and environmental conditions, and an extremely difficult regional geopolitical context. Another issue that merits further consideration is how these particular improvements have actually been brought about. To be brief, there is no single cause or element that accounts for the country’s success in reducing neonatal, child, and maternal mortality. Instead, the substantial improvements have been the result of a comprehensive approach and a mix of factors that cut across several sectors.

Although I (in addition to a number of other authors) have explored and discussed many of these various factors at length in past articles, the following few paragraphs will briefly shed light on one increasingly important, yet relatively underdiscussed, contributing factor: maternity waiting homes (MWHs).

MWHs are not a new development within global or public health. They have a relatively long, extensive history. Sometimes also referred to as maternity waiting areas, mother’s shelters, or antenatal villages, they may be most simply defined as standalone, safe residential facilities where pregnant women and girls can stay for an extended period prior to the onset of labor or before being transferred to other health facilities for delivery.

Eritrea – Births in Health Facilities (HF) and Maternity Waiting Homes (MWH), 2017-2019

A number of empirical studies conducted in an array of settings around the world have demonstrated that MWHs can be a relatively cost-effective, successful strategy to help reduce the risk of adverse birth outcomes and child or maternal mortality, especially within low- and middle-income countries or resource limited settings. Timely, high-quality care during and around the period of delivery is crucial as serious complications and maternal and newborn deaths are heavily concentrated around this time. (In fact, research shows that the majority of maternal and newborn deaths are caused by preventable or treatable complications that take place during labor, delivery and the immediate 24 hours after giving birth.)

MWHs help ensure more high-risk pregnancies can be detected, with these pregnant women subsequently being provided specialized services, further examination, and appropriate care or treatment. As well, MWHs can mean that more pregnant women are delivering with the assistance of skilled birth attendants. In addition to the important role that they perform throughout pregnancy, the academic literature is replete with evidence showing the significant, vital role performed by skilled birth attendants during childbirth and postpartum. During delivery, for instance, skilled birth attendants closely monitor progress of labor, facilitate physiological processes, and help address complications (e.g., obstructed labor, birth asphyxia, and trauma), while in the period shortly following birth, when the risk of mortality for newborns and mothers can be quite high, they help with feeding, managing complications (e.g., postpartum bleeding, infection, or depression), and counseling (e.g., providing information or advice about family planning and birth spacing), along with offering other vital forms of support.

In terms of Eritrea, MWHs were first introduced into the national health system in 2007, primarily in order to better serve women in remote and hard-to-reach areas. Steadily, the role and position of MWHs has expanded to where they now represent an integral link within the continuum of care for maternal and newborn health in the country.

At present, there are a total of 43 MWHs distributed around the country. In addition to offering a much-needed setting where women can be comfortable, safely accommodated, and receive timely, high-quality health

services during their pregnancy, the nationwide network of MWHs reduces the need for difficult or long distance travel, provides women with critical education, such as learning about healthy behaviors and how to best care for the baby or themselves, offers much-needed social, cultural, emotional, and psychological support or the opportunity to build mutual support networks, and helps to promote births in facilities and assisted by skilled birth attendants. In areas of the country where malaria is endemic, local health personnel also provide pregnant women with medications and insecticide-treated mosquito nets, while MWHs additionally provide greater opportunities for new mothers to rest, recover, and receive follow-up care following delivery.

Over the years, there has been an increase in the use of MWHs in Eritrea, with more babies being delivered in these facilities. In 2017 there were 7,699 deliveries in MWHs, while in 2018 and 2019 there were 8,670 and 9,173 deliveries, respectively. This, in combination with a variety of other factors, has played a role in positive maternal, newborn, and child health outcomes.

As a final point, since they significantly improve access to maternal and child care in remote, hard-to-reach areas within Eritrea, as well as among historically marginalized communities or groups in the country (which have historically borne the greatest burden of childbirth-related complications and deaths), MWHs are promoting social justice and dignity, reducing inequalities, and a genuine reflection of the principle of leaving no one behind.

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