Abstract
In rural Zambia, pregnant mothers are referred from rural primary health facilities designed to provide Basic Emergency Obstetric and Newborn Care (BEmONC) to district hospitals where Comprehensive Emergency Obstetric and Newborn Care (CEmONC) can be provided when needed. Maternity waiting homes (MWH) are residential dwellings where mothers can await delivery and may offer a possible early referral source to CEmONC, ultimately serving as an intervention to improve maternal-newborn delivery outcomes. This case series study aimed to advance an understanding of maternal-newborn delivery outcomes for mothers referred from health facilities with and without MWHs to one district referral hospital. A retrospective medical record review of district-level data was performed to compare maternal-newborn delivery outcomes for cases referred from five BEmONC health facilities with and five without MWHs to a CEmONC district referral hospital. Information about MWH use was not recorded in the delivery register, and is unknown. Among all cases (n = 234) referred to a district hospital from facilities with and without MWHs, referrals were more likely to come from facilities with MWHs. Most were referred from facilities more than 12km from the district referral hospital. There were no statistically significant differences in newborn delivery outcomes for cases referred from MWH and non-MWH facilities. More cases with prolonged labor were referred from facilities associated with a MWH than without a MWH (37.3 vs. 23.9%). Access to a MWH may have brought mothers closer to a facility where prolonged labor was recognized and emergency referral was made for obstetric management. Key words: Newborn health, maternal health, pregnancy complications, delivery outcomes, Zambia.  
Highlights
In the Southern African country of Zambia, there are approximately 14,000 newborn deaths each year (38 babies each day) (WHO, 2018)
Among all cases referred to one district hospital from facilities with and without Maternity waiting homes (MWH), we found that referrals were more likely to come from facilities with MWHs (60.9% vs. 39.3%, P
By examining maternal-newborn delivery outcomes for cases referred from five facilities with MWHs and five without MWHs to one district hospital, this study found that, among all referrals across the ten facilities, more came from facilities with a MWH than from those without MWHs
Summary
In the Southern African country of Zambia, there are approximately 14,000 newborn deaths each year (38 babies each day) (WHO, 2018). Maternal mortality is a major cause of death among women in Zambia where 224 maternal deaths occur per 100,000 live births(UNICEF, 2017; Zambia National Public Health Institute, 2019). In 2017, maternal associated causes were the fourth leading cause of death in Zambian women of childbearing age (Zambia National Public Health Institute, 2019). Universal access to Emergency Obstetric and Newborn Care (EmONC) is considered essential to reduce maternal mortality and requires that all pregnant mothers and newborns with complications have rapid access to well-functioning facilities that include a broad range of service delivery types and settings (Otolorin et al, 2015; Campbell et al, 2006). Signal functions for EmONC are the major interventions for averting maternal and newborn mortalities (Roy et al, 2017) and help differentiate between levels of care provided at a facility.
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