Community Perspectives of a 3-Delays Model Intervention: A Qualitative Evaluation of Saving Mothers, Giving Life in Zambia

Background: Saving Mothers, Giving Life (SMGL), a health systems strengthening approach based on the 3-delays model, aimed to reduce maternal and perinatal mortality in 6 districts in Zambia between 2012 and 2017. By 2016, the maternal mortality ratio in SMGL-supported districts declined by 41% compared to its level at the beginning of SMGL—from 480 to 284 deaths per 100,000 live births. The 10.5% annual reduction between the baseline and 2016 was about 4.5 times higher than the annual reduction rate for sub-Saharan Africa and about 2.6 times higher than the annual reduction estimated for Zambia as a whole.

Objectives: While outcome measures demonstrate reductions in maternal and perinatal mortality, this qualitative endline evaluation assessed community perceptions of the SMGL intervention package, including (1) messaging about use of maternal health services, (2) access to maternal health services, and (3) quality improvement of maternal health services.

Methods: We used purposive sampling to conduct semistructured in-depth interviews with women who delivered at home (n=20), women who delivered in health facilities (n=20), community leaders (n=8), clinicians (n=15), and public health stakeholders (n=15). We also conducted 12 focus group discussions with a total of 93 men and women from the community and Safe Motherhood Action Group members. Data were coded and analyzed using NVivo version 10.

Results: Delay 1: Participants were receptive to SMGL's messages related to early antenatal care, health facility-based deliveries, and involving male partners in pregnancy and childbirth. However, top-down pressure to increase health facility deliveries led to unintended consequences, such as community-imposed penalty fees for home deliveries. Delay 2: Community members perceived some improvements, such as refurbished maternity waiting homes and dedicated maternity ambulances, but many still had difficulty reaching the health facilities in time to deliver. Delay 3: SMGL's clinician trainings were considered a strength, but the increased demand for health facility deliveries led to human resource challenges, which affected perceived quality of care.

Conclusion and Lessons Learned: While SMGL's health systems strengthening approach aimed to reduce challenges related to the 3 delays, participants still reported significant barriers accessing maternal and newborn health care. More research is needed to understand the necessary intervention package to affect system-wide change.