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Impact of maternity waiting homes on facility delivery among remote households in Zambia: protocol for a quasiexperimental, mixed-methods study
  1. Nancy A Scott1,
  2. Jeanette L Kaiser1,
  3. Taryn Vian1,
  4. Rachael Bonawitz1,2,
  5. Rachel M Fong1,
  6. Thandiwe Ngoma3,
  7. Godfrey Biemba4,
  8. Carol J Boyd5,
  9. Jody R Lori6,
  10. Davidson H Hamer7,
  11. Peter C Rockers1
  1. 1 Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
  2. 2 Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, USA
  3. 3 Right to Care Zambia, Lusaka, Zambia
  4. 4 National Health Research Authority, Pediatric Centre of Excellence, Lusaka, Zambia
  5. 5 Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
  6. 6 Center for Global Affairs and PAHO/WHO Collaborating Center, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
  7. 7 Section of Infectious Diseases, Department of Medicine, Boston University, Boston, Massachusetts, USA
  1. Correspondence to Dr Nancy A Scott; nscott{at}


Introduction Maternity waiting homes (MWHs) aim to improve access to facility delivery in rural areas. However, there is limited rigorous evidence of their effectiveness. Using formative research, we developed an MWH intervention model with three components: infrastructure, management and linkage to services. This protocol describes a study to measure the impact of the MWH model on facility delivery among women living farthest (≥10 km) from their designated health facility in rural Zambia. This study will generate key new evidence to inform decision-making for MWH policy in Zambia and globally.

Methods and analysis We are conducting a mixed-methods quasiexperimental impact evaluation of the MWH model using a controlled before-and-after design in 40 health facility clusters. Clusters were assigned to the intervention or control group using two methods: 20 clusters were randomly assigned using a matched-pair design; the other 20 were assigned without randomisation due to local political constraints. Overall, 20 study clusters receive the MWH model intervention while 20 control clusters continue to implement the ‘standard of care’ for waiting mothers. We recruit a repeated cross section of 2400 randomly sampled recently delivered women at baseline (2016) and endline (2018); all participants are administered a household survey and a 10% subsample also participates in an in-depth interview. We will calculate descriptive statistics and adjusted ORs; qualitative data will be analysed using content analysis. The primary outcome is the probability of delivery at a health facility; secondary outcomes include utilisation of MWHs and maternal and neonatal health outcomes.

Ethics and dissemination Ethical approvals were obtained from the Boston University Institutional Review Board (IRB), University of Michigan IRB (deidentified data only) and the ERES Converge IRB in Zambia. Written informed consent is obtained prior to data collection. Results will be disseminated to key stakeholders in Zambia, then through open-access journals, websites and international conferences.

Trial registration number NCT02620436; Pre-results.

  • maternity waiting home
  • maternal health
  • skilled birth attendance
  • mixed methods
  • impact evaluation
  • Zambia

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  • Contributors NAS led the scientific design, implementation, and was primarily responsible for drafting this manuscript. JK contributed to the development of the protocol, led the development of the study sample, coordinated data collection and contributed to revisions of the manuscript. TV and RB contributed to the revisions and science of the protocol and data collection instruments. RF contributed to the development of the protocol, implemented the electronic data capture system and contributed to the revisions of this manuscript. TN, GB, CJB and JRL provided feedback on the protocol and reviewed and edited the final manuscript. DHH provided scientific support, technical input into the survey design, and critically reviewed and edited the final manuscript. PCR helped conceptualise the scientific design of the study, provided technical input into the survey design, sampling approach, and critically reviewed and edited the final manuscript. All authors read and approved the final version of the manuscript.

  • Funding This programme was developed and is being implemented in collaboration with MSD for Mothers, MSD’s 10-year, $500 million initiative to help create a world where no woman dies giving life. MSD for Mothers is an initiative of Merck & Co, Kenilworth, NJ, USA (MRK 1846-06500.COL). The development of this article was additionally supported in part by the Bill & Melinda Gates Foundation (OPP1130329) ( and The ELMA Foundation (ELMA-15-F0017) (

  • Disclaimer The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The content is solely the responsibility of the authors and does not reflect positions or policies of MSD, the Bill & Melinda Gates Foundation or The ELMA Foundation.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Boston University Institutional Review Board, University of Michigan Institutional Review Board, and ERES Converge Institutional Review Board in Zambia.

  • Provenance and peer review Not commissioned; externally peer reviewed.