1Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
2Medecins Sans Frontiers, Japan
Received date: 30/07/2016; Accepted date: 24/08/2016; Published date: 31/08/2016
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Waiting home, Rural areas, Health facilities, Traditional birth.
A birth waiting home (BWH) is a shelter where pregnant women may spend the last few weeks of pregnancy close to a health facility where appropriate obstetric care is provided (World Health Organization [1,2]. It is a key element of a strategy to address the distance barrier to accessing skilled obstetric care services. Several studies have investigated the use and impact of BWHs. Findings demonstrated a decrease in maternal mortality and stillbirth and an increase in facility delivery in Ethiopia, Eritrea, Malawi and Cuba [3-6]. However, not all women who might benefit from staying at a BWH actually utilise the homes due to various reasons such as child care, family commitments, lack of understanding of the importance of the homes and cost of food during the women’s stay. In a previous examination of this phenomenon in Sierra Leone, we suggested the importance of strengthening community involvement in order to increase women’s use of BWH and sustain the BWH activities [7]. In Sierra Leone, especially in rural areas, deliveries often occur in communities rather than health facilities. Strategies, such as a BWH approach, to shift the traditional practice to facility deliveries should therefore involve the local community. This is especially true where there is a significant gap between communities and health facilities in the post Ebola phase.
In northern Sierra Leone, an international non-governmental organisation established the BWHs. For such an initiative, community participation is a key to sustain BWH activities even after the organisation’s programme ends. Community participation was identified in the previous study in the sense that the organisation consulted the community chiefs [7]. However, supervision and management roles of the BWH programme were taken by the organisation. This is probably because the programme was initiated by the organisation and local communities tend to rely on an aid organisation for financial or commodity support.
The definition of the word, ‘participation’ can be broad. There are different degrees of participation. It has to be noted that only informing or consulting the community is not real community participation [8]. The real participation means that power is delegated to the community and the community controls issues. In order for the BWH approach to succeed, WHO suggests that the community should seek the best solutions which fit to local circumstances. Financial matters also have to be dealt with and decided by the community [1]. This is the highest degree of community participation. Even in government-run BWHs, the communities play a key role in sustaining the activities. For example in Cuba and Mongolia, communities with greater local support were able to sustain the BWHs in spite of reduced government support [1]. Community participation has to be adapted to the local circumstances. Hence, the WHO’s recommendations may not be feasible in northern Sierra Leone. However, the community can take a step forward in terms of participation and the organisation can shift more responsibilities to the community which would lead to sustainability of the BWHs.
Even though WHO suggests that the community has to control all cost factors, the financing of BWHs have not been explored, as a very limited amount of literature is available [9]. In the previous research, we found difficult questions relating to the resources to run the BWHs: Who should take on the financial burden and who should contribute to the BWHs? The BWH hosts alone cannot take all the burdens. The community living in poverty cannot generate enough funds. The services need to be affordable for pregnant women to utilise the homes. Considering the time span of the organisation’s programme, depending on the organisation would not be a sustainable option. Answers to these questions have not been found. Thus, there is room for exploring financial and other resource dimensions of BWHs in a resource poor setting.
A BWH approach cannot be successful alone without other community interventions. For instance, many communities established a bylaw which bans a home delivery assisted by a traditional birth attendant. Community leadership is taken to reinforce facility deliveries. However, those who violate the law are usually forgiven without any punishment. Thus, people would not abide by the law and continue delivering at home. Proper implementation of such bylaw to make people abide by the law could play an important role to stop home deliveries in the community.
Another example of community involvement is health education by community members. Health promoters go to spread the latest knowledge and practice in maternal and child health, especially the importance of skilled birth attendance for all deliveries. Education on maternal and child health issues targeting women, men, traditional birth attendants and decision-makers in the community is critical. Establishing community groups, such as women’s groups, to discuss the relevant subjects would improve the participants’ understanding by interactions and discussions between them.
People are currently afraid of seeking obstetric care at health facilities which they associate with Ebola and many women most likely deliver at home with traditional birth attendants [10]. In the post Ebola phase, community engagement is the key to bring women back to obstetric care facilities. Already established community networks with BWHs can play a critical role to bridge the gap between communities and health facilities [11].
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