Centralising maternity care in low- and middle-income countries: A worthy goal?

Maternity waiting homes

Maternity waiting homes (MWHs), consisting of residential accommodation for pregnant women to wait close to obstetric facilities for birth, are being widely implemented across low- and middle-income countries (LMICs). However, surveys consistently report that a significant proportion of women do not intend to use these facilities, or that using them is problematic (Gazimu et al., 2021; Endalew et al., 2017; Vermeiden et al., 2018). It is significant to note that First Nations’ communities in high-income countries have spent decades trying to undo the damaging effects of removing women from their culture and communities during the critical time of birth (Ireland et al., 2011; Lawford et al., 2019). In a recent discussion paper, Wild & Kurji (2020) critically examined the evidence for MWHs for women living in remote settings in LMICs.


According to Wild & Kurji (2020), the World Health Organization (WHO) has made a conditional recommendation for MWHs to be established close to a health facility with essential obstetric services. But WHO highlight that their recommendation is based on very low-quality evidence and that additional research is required (WHO, 2015). Indeed, the Cochrane systematic review concludes that there is “insufficient evidence to determine the effectiveness of maternity waiting facilities for improving maternal and neonatal outcomes.” (van Lonkhuijzen et al., 2012). While a high-quality MWH model in Zambia, with access to skilled midwives, increased antenatal and postnatal care attendance, family planning use and newborn vaccination; further research is required to assess the effect on maternal and newborn outcomes (Buser et al., 2021).


The MWH model requires women to be separated from their partner and other children, and be socially isolated, for weeks at a time (Wild & Kurji, 2020; Tiruneh et al., 2016). When interviewed about MWHs in an African setting, key stakeholders reported lack of access (distance, roads, transport), over-crowding, lack of amenities and infrastructure, safety concerns, lack of supplies and poor-quality care (Scott et al., 2018; Vermeiden et al., 2018). This may explain why MWHs are under-utilised by pregnant women, particularly those who are socially, economically, or culturally vulnerable (Wild & Kurji, 2020). The researchers argued that MWHs in preparation for institutionalised birth, is more likely to reflect the interests of governments and donors, rather than the needs and preferences of women (Wild et al., 2015). Indeed, MWHs are unlikely to meet the needs of most women and families; and are particularly problematic as a strategy during epidemics and other crisis situations (Wild & Kurji, 2020).


When researchers report that MWHs are largely unacceptable to women, some argue this can be addressed by awareness campaigns and education (Gazimu et al., 2021; Vermeiden et al., 2018; Kurji et al. 2019). Alternatively, maternity models could be co-designed from the outset to explicitly and comprehensively meet women’s needs. According to the International Confederation of Midwives, birth is primarily a social and emotional event in the life of a woman and her family (ICM, 2014). From this perspective, maternity care should be organised to enable women to birth safely close to home or at home, with the support of a known midwife and their family. Instead, MWHs remove women from their home and their support networks and limit the potential for midwifery continuity of carer.

Birthing close to home

The international movement, Birthing on Country, calls for action to return birthing services to First Nations’ community control as the primary mechanism to improve their health and well-being (Kildea et al., 2019). See more about Birthing on Country in our blog post here. This aligns with the concept of access to a home-like healthcare facility that is guided by a midwifery philosophy of care, centred on the woman’s experience, specialising in physiological birth, with access to basic emergency care, and fully integrated within the healthcare system (Stevens & Alonso, 2020). See more about midwifery centres in our blog post here.


There is ample evidence to invest in midwifery-led models of care (Edmonds et al., 2020). In high-income countries, midwifery-led care is as safe as or safer than other forms of maternity care; it is associated with fewer unnecessary medical interventions, higher care quality and cost-savings (Birthplace in England Collaborative Group, 2011; Scarf et al., 2021; Scarf et al., 2018; Sandall et al., 2016). Any model of care is likely to be more acceptable and sustainable when it is co-designed by the community who invest and have a sense of ownership (Fontanet et al., 2020). Therefore, it is critical that remote birthing women are at the forefront of co-designing maternity services. This will ensure services meet women’s social, cultural and access needs, while improving their safety and wellbeing.

Blog written by

Dr Jyai Allen & Dr Kayli Wild


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