Last month, we explored how policymakers can channel empathy in policymaking, using as an example our work with UNICEF to identify diverse needs and challenges of children in Nicaragua’s North Atlantic Autonomous Region (RAAN). Our community-based approach highlighted success stories as well as services in need of redesign. Today, we’ll go to a casa materna, a “maternity waiting home”,  in Puerto Cabezas to see how this important resource for women can better serve as a source of medical and emotional care.

The women of the Puerto Cabezas casa materna have come from near and far. They’ve made journeys of up to multiple hours over rough roads, by foot and in designated ambulances. They’ve come to get the care they need as soon-to-be mothers.

There are 88 casas maternas spread throughout Nicaragua, and seven in RAAN. The government has invested in them in recent years in an effort to reduce maternal mortality. Funded by the Ministry of Health, they are a critical bridge linking rural women to modern facilities in Puerto Cabezas and other cities.

Casas maternas are part of a wider model of healthcare present throughout Latin America. The casas are intended to provide a supportive environment for women who are in the final stages of pregnancy, and especially for women with at-risk pregnancies. Women in earlier stages of pregnancy may also stay at these homes to attend prenatal exams when these services are not available in their own communities. While some casas provide significant medical services, their main purpose is to serve as a refuge and link to other sources of care.

The women at the Puerto Cabezas casa materna arrived at a brand new building: walls painted in bright shades of red, teal, and yellow, beds and mattresses for 16 women, a full kitchen, and a small medical exam room. At the time of our research, three nurses rotated to staff the facility 24 hours-a-day, and at least one doctor attended to the women staying here daily. Women are transported to checkups at the local public clinic—right next door—and then to the hospital to deliver their babies.

Contrary to what the new building may have implied, the physical upgrade of the casa materna was not emblematic of a higher standard of care offered. Many of the women reported disappointment with the attention they get from caretakers and doctors. They find themselves on the receiving end of harsh treatment and obligations to contribute to the daily operations of the facility when late in their pregnancy. When the facility’s water tank broke, women were made to haul heavy water buckets from the backyard well. One woman said she was even forced to mop floors just a few days before her delivery date.

Casas maternas are supposed to be places of support, but regulations meant to maintain an orderly experience at the facility end up regimenting the experience, limiting the diversity and quality of personal supportive care women receive.

Many women report feeling bored and confined because they’re not allowed to leave the grounds to run errands or even take a walk without special permission. Some women went so far as to refer to themselves akin to prisoners. Little socializing among residents reduces potential for camaraderie beyond nurse-led “chats” about important maternal and infant health-related topics.

Perhaps most damaging is the restriction on visitors. According to the casa materna model, it is common to allow expectant women to bring along family members and friends to accompany them throughout their stay. But the casa  in Puerto Cabezas appears to follow a less inclusive model, running counter to many women’s expectations.

One pregnant teenager was told by a nurse at her local health post that her friend could accompany her to the casa. When the two girls arrived, the nurse on duty said the friend was not authorized to stay and would have to leave. The friend had no way to return to her community, and knew no one in Puerto Cabezas to turn to for help. Fortunately, the night nurse later overruled the previous decision and allowed the friend to stay, but the situation could have easily ended far worse.

When women face experiences like these, they share them with others in their home communities, advising others to not go to casas maternas. A casa materna can be a life-saver and a foundational resource for women. But asking a woman to voluntarily separate herself from her children, mother, and partner during pregnancy is hard enough. How can this woman then be expected to stay somewhere where the care she receives—even if technically high quality—isn’t delivered with compassion?

A service as critical as the casa materna should be built for the women it attempts to serve, with women’s health—both physical and emotional—at its core. Making women feel welcome, happy, and safe is the only way to encourage them to reach out for the service in the future.