Qualitative application of the diffusion of innovation theory to maternity waiting homes in rural Zambia.

Abstract

Background: Understanding factors affecting adoption of an innovation is critical to its long-term success. Maternity waiting homes (MWHs) increase access to facility-based delivery in low-resourced settings; yet, quality issues deter utilization of this innovative approach. We sought to understand how attributes that are thought to promote diffusion of innovations (e.g., relative advantage, compatibility, observability, complexity, etc.) affected MWH use after implementation of an improved quality MWH model in rural Zambia compared to standard of care.

Methods: We conducted 158 in-depth interviews (IDIs) with randomly selected rural-living women who had delivered a baby in the prior 12 months. Half lived in catchment areas where new quality MWHs were constructed, half in catchment areas with standard of care (ranging from low quality community structures to no MWH). We applied content analysis to identify themes.

Results: Utilization of MWHs was higher among intervention (65.4%) than control women (42.5%). Respondents in both study arms perceived relative advantages to pregnant women staying at MWHs compared to going directly to health facilities when labor begins. MWH stays allowed for clinical staff to routinely check on and educate women, and address complications immediately. Compatibility of the homes with cultural values and needs depended on implementation. While some women from intervention sites complained about overcrowding, women in control sites more often perceived the lack of cleanliness, amenities, and safety as deterrents to utilization. Women at intervention sites received sensitization about MWHs from a wider range of sources, including traditional leaders. Required preparations needed to stay at MWHs (e.g. delivery supplies, food, and childcare) made adoption complex and may have deterred utilization.

Conclusions: The improved MWH model addressed most community concerns around quality. Having opinion leaders who communicate the relative advantage of MWHs to pregnant women and their social networks may facilitate MWH utilization. The complexity of decisions and resources needed to stay at MWHs remains a critical barrier to use. To facilitate equitable adoption of MWHs among the most vulnerable women, planners should explore how to support women during their delivery preparations and MWH stays, particularly regarding food security and lack of social support for childcare.

Trial registration: clinicaltrials.gov, NCT02620436, Registered 02 December 2015, https://clinicaltrials.gov/study/NCT02620436?term=NCT02620436&rank=1.