Too poor to give birth safely? Maternity waiting homes help bridge the gap for the most deprived

Abstract Maternal and neonatal deaths are largely preventable through improved access to care and skilled birth attendance. Maternity Waiting Homes (MWHs) facilitate access to essential obstetric services near health facilities. Socioeconomic vulnerability increases the risk of perinatal complications, particularly in Sub-Saharan Africa, where neonatal mortality remains unacceptably high, far from the target set by UN Sustainable Development Goal 3. Removing financial barriers to MWHs is crucial to enhance their use and promote institutional births. We conducted a multicentre nested case-control study (2023-2025) in three hospitals in Ethiopia, Tanzania, and Angola, supported by the NGO Doctors with Africa - CUAMM. All MWHs were free of charge. To assess socioeconomic barriers, we used an adapted version (D.L. Green et al.) of the internationally validated Multidimensional Poverty Index (global MPI), including seven binary indicators across three equally weighted domains: education, health, and living standards. MPI scores range from 0 (not deprived) to 1 (deprived in all indicators). A total of 921 women were enrolled in a 1:2 ratio. Women attending MWHs had a significantly higher MPI (mean 0.42, SD = 0.23) than non-users (mean 0.35, SD = 0.24; p < 0.001), with a mean difference of 0.069 (95% CI: 0.03-0.11). The proportion of deprived women (MPI>0.2) was higher among MWH users (75.7% vs. 66.5%; p = 0.003). Health contributed least to MPI (chronic condition/disability <3%), while educational deprivation (less than secondary education in 65%) and inadequate sanitation/water (>50%) were most prevalent. Free MWHs proved to be a powerful tool for reducing maternal and new-born negative outcomes, as poorer women were more likely to use MWHs before hospital delivery. Promoting MWHs near hospitals can help mitigate inequities in childbirth-related outcomes in Sub-Saharan Africa by improving access to advanced management of delivery complications, especially for the most disadvantaged women. Key messages • Maternity waiting homes effectively reach the most deprived women, improving access to safe delivery and bridging inequalities in maternal care in Sub-Saharan Africa. • Free-of-charge MWHs attract poorer women: 75.7% of users were deprived vs. 66.5% of non-users, showing their potential as a public health strategy to reduce perinatal risks.