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.