Impact of the Saving Mothers, Giving Life Approach on Decreasing Maternal and Perinatal Deaths in Uganda and Zambia

Florina Serbanescu; Thomas A. Clark; Mary M. Goodwin; Lisa J. Nelson; Mary Adetinuke Boyd; Adeodata R. Kekitiinwa; Frank Kaharuza; Brenda Picho; Diane Morof; Curtis Blanton; Maybin Mumba; Patrick Komakech; Fernando Carlosama; Michelle M. Schmitz; Claudia Morrissey Conlon

doi:10.9745/GHSP-D-18-00428

Figures & Tables

Tables

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TABLE 1.

SMGL Strategies and Interventions Implemented in Uganda and Zambia to Reduce the 3 Delays, 2012–2017

Strategy	Approach/Intervention	Primary DelayAddressed^a
Promote community engagement and empowerment for improved maternal and newborn health	Implement community-based communication and education messages on safe motherhood via mass media and community events, which includes displaying SMGL messages in public places to promote safe motherhood, broadcasting radio messages and programs, developing a documentary in Zambia, and supporting local drama groups in performing skits and traditional songs Build stronger partnerships between communities and facilities, which includes supervision and support provided by facility health workers to community volunteers Engage communities in monitoring and evaluation, which includes participation of VHTs in the SMGL baseline and endline evaluation of population maternal mortality ratio and MDSR (Uganda)	1
Increase birth preparedness, demand for facility delivery, and use of preventive health care services	Assist with community activities aimed to increase birth preparedness, knowledge of pregnancy danger signs, and use of antenatal care, facility-based delivery, and postnatal care services Extend the delivery system of preventive services by using mobile and community outreach clinics to provide antenatal care, HIV counseling and testing, immunization, and postpartum family planning; ensuring provision of postpartum home care for mothers and newborns; distributing commodities through Mama Ambassadors (Uganda); and distributing birth plans through community volunteers and change champions (Zambia)	1
Decrease financial and logistic barriers to accessing facility delivery care	Market and distribute clean delivery kits Market and distribute transport vouchers to subsidize access to facility delivery, antenatal, and postnatal care services Promote community-based loans to increase use of facility delivery care services	1 and 2
Decrease distance to facility-based delivery services by increasing the number of EmONC facilities	Establish additional EmONC facilities and strengthen existing ones to provide: clean and safe basic delivery services; quality HIV counseling and testing; management of routine and complicated deliveries; essential and specialized newborn care; and timely referrals Implement interventions to improve facility renovations, including building operation theaters and maternity waiting homes; expanding/upgrading maternity wards, neonatal special care units, and laboratories and pharmacies; purchasing equipment, supplies, and essential medicines; and hiring and training nurses, midwives, doctors, and anesthetists in EmONC	2 and 3
Improve the accessibility of EmONC facilities	Create a 24 hour a day/7 day a week communication/transportation system that is consultative, protocol-driven, quality-assured, and integrated (public and private) to ensure that women with complications reach emergency services within 2 hours Implement interventions such as purchasing ambulances and other motorized vehicles; supporting operating costs of transport, such as maintenance, insurance, and petrol; setting up district transportation committees to improve coordination of ambulances; and renovating and building maternity waiting homes	2
Ensure facilities providing delivery care have adequate infrastructure	Support uninterrupted access to electricity and water Implement interventions such as procuring solar panels and generators and ensuring safe water systems in maternity wards (water tanks and provision of piped water) Support expansions, renovations, and facility enhancements to accommodate additional deliveries (including renovating and building operation theaters, expanding labor rooms, and adding postpartum wards) Support facility enhancements to improve neonatal survival, including renovating infrastructure to provide space for KMC and neonatal special care units and procuring special equipment (incubators, infant warmers, and phototherapy lamps)	3
Ensure sufficient medical supplies, equipment, and essential medicines	Strengthen supply chains for essential supplies and medicines Strengthen availability of blood supplies and surgical equipment, including the opening of new blood banks	3
Ensure sufficient well-trained health care providers at facilities	Recruit new medical doctors and nurse-midwives through a joint hiring process with the districts Conduct trainings and refresher courses including: basic EmONC trainings, surgical skills course for medical officers, management of postpartum hemorrhage using uterine balloon tamponade, essential newborn care and neonatal resuscitation, and KMC Provide mentoring and supportive supervision to newly hired and existing personnel	3
Improve quality of care and ensure care is evidence-based	Implement quality effective interventions, such as partograph use, active management of the third stage of labor, KMC, improved infection control practices, and management of obstetric complications protocols to prevent and treat obstetric and newborn complications Ensure reliable delivery of quality essential and emergency maternal and newborn care, which includes interventions such as the training of midwives in respectful maternity care and the use of facility-generated data to review quality of care and implement practice changes Develop guidelines and policies, and ensure protocol adherence through activities such as the introduction of clinical guidelines and protocols for diagnosing and managing most common obstetric emergencies, delivery checklists, and a tool to prevent perinatal deaths by using data to guide actions (BABIES matrix)	3
Ensure referral capacity exists to support transfers to higher level of care	Improve referral communication systems through increased communication capacity and introduction of referral protocols and forms Ensure timely referrals through purchase of motorized vehicles, support of operating costs of transport, and promotion of district-level coordination	3
Strengthen health management information system and maternal and perinatal death surveillance	Set up pregnancy outcomes monitoring surveillance in health facilities and train health providers and health monitoring officers in data recording, data abstraction, data entry, and data file management Strengthen maternal and perinatal death surveillance in health facilities, including the development of national standards for MDSR Train medical doctors in assigning causes of maternal death using ICD-MM Train health personnel in conducting maternal and perinatal death reviews at facility and district levels Introduce a community MDSR system using the VHTs and other district personnel and develop protocols and tools, including an electronic data monitoring system	1,2,3

Abbreviations: BABIES, birthweight group age-at-death boxes for an intervention and evaluation system; EmONC, emergency obstetric and newborn care; ICD-MM, International Classification of Diseases–Maternal Mortality; KMC, kangaroo mother care; MDSR, maternal death surveillance and response; SMGL, Saving Mothers, Giving Life; VHTs, village health teams.
Note: Detailed information about SMGL country-specific interventions targeting each of the 3 delays are included elsewhere in this supplement.
↵a Primary delay addressed refers to which of the 3 delays the interventions are assumed to primarily address, since some of the interventions may address more than one delay. 1=First Delay; 2=Second Delay; 3=Third Delay.

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TABLE 2.

Baseline SMGL-Supported District Characteristics

Characteristic	Uganda	Zambia
Area (sq. km)	10,851	49,468
Population (2011)^a	1,750,000	925,198
% of population in rural areas	84%	61%
Number of women of reproductive age (in 2011)^a	330,776	193,515
Number of expected live births (in 2011)^b	78,261	37,267
Number of health care facilities, by type (in 2011)
Health posts	19	16
Health centers without surgical care	72	91
Health centers with surgical care	8	0
District hospitals	7	5
Regional hospital^c	1	1
Number of facilities, by ownership (in 2011)
Government	65	106
Private for profit	11	0
Private not-for-profit	31	7
Number of EmONC facilities (in 2011)^d
Basic EmONC	3	3
Comprehensive EmONC	7	4

Abbreviations: CEmONC, comprehensive emergency obstetric and newborn care; EmONC, emergency obstetric and newborn care; SMGL, Saving Mothers, Giving Life.
↵a Based on the 2013 4-district population census in Uganda and the Population and Housing Census 2010 in Zambia projected to 2011 for the 4 SMGL districts.
↵b In Uganda, expected births were estimated by multiplying the number of women of reproductive age from the 2013 4-district census by age-specific fertility rates from the 2011 Demographic and Health Survey; in Zambia, expected births were derived from the 2010 census crude birth rates.
↵c Fort Portal Regional Referral Hospital is a 351-bed level-3 referral hospital located in Kabarole district and serving 3 SMGL-supported districts (Kabarole, Kyenjojo, and Kamwenge) and 4 non-SMGL districts (Kasese, Ntoroko, Kyegegwa, and Bundibugyo); Mansa General Hospital is a 352-bed level-2 referral hospital providing care to Luapula province, which, in 2011, included 1 SMGL-supported district (Mansa) and 5 nonsupported districts.
↵d Facilities were classified based on whether they had, within the previous 3 months, performed the signal functions associated with each level of EmONC care. Because assisted vaginal delivery—using either forceps or vacuum extractor—is relatively uncommon in both Uganda and Zambia, some facilities were classified as fully providing EmONC care even if they did not perform assisted vaginal deliveries within the past 3 months (EmONC-1). In Uganda, district and regional hospitals and health centers with surgical capacity (health centers IV) are designated as CEmONC facilities, able to perform each of the 9 signal functions and serving about 100,000 population; in Zambia, only district and higher-level hospitals are designated to provide CEmONC care.

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TABLE 3.

SMGL Indicator Baseline and Endline Data Sources in Uganda and Zambia SMGL-Supported Districts

Period and Indicator	Uganda			Zambia
Period and Indicator	Community	Health Center IV and Hospitals	Health Centers III and II	Community	Health Centers and Hospitals
Baseline (June 2011–May 2012)
Routine and emergency obstetric care indicators	--	HFA	HFA	--	HFA
Institutional deliveries (vaginal and cesarean deliveries)	--	Individual outcome data and triangulation of facility registers (POMS)	Facility aggregate outcome data	--	HFA and facility aggregate outcome data
Direct obstetric complications prevalence rates	--	POMS and RAPID	Facility aggregate outcome data	--	HFA and facility aggregate outcome data
Stillbirth and predischarge neonatal mortality rates	--	POMS and RAPID	Facility aggregate outcome data	--	HFA and facility aggregate outcome data
Cause-specific maternal mortality and case fatality rates	--	POMS and RAPID triangulated with RAMOS	Facility aggregate outcome data	--	Facility aggregate outcome data triangulated with census-identified maternal deaths
Population maternal mortality ratios	RAMOS	--	--	4-district census^a	--
Endline (January–December 2016)
Routine and emergency obstetric care indicators	--	HFA	HFA	--	HFA
Institutional deliveries (vaginal and cesarean deliveries)	--	POMS	POMS	--	HFA and facility aggregate outcome data
Direct obstetric complications prevalence rates	--	POMS and RAPID	POMS and RAPID	--	HFA and facility aggregate outcome data
Stillbirth and predischarge neonatal mortality rates	--	POMS and RAPID	POMS and RAPID	--	HFA and facility aggregate outcome data
Cause-specific maternal mortality and case fatality rates in facilities	--	POMS and RAPID triangulated with RAMOS	POMS and RAPID triangulated with RAMOS	--	Facility MDSR; individual cases triangulated with census-identified maternal deaths
Population maternal mortality ratios	RAMOS	--	--	4-district census^a	--

Abbreviations: HFA, health facility assessment; MDSR, maternal death surveillance and response; POMS, Pregnancy Outcome Monitoring System; RAPID, Rapid Ascertainment Process for Institutional Deaths; RAMOS, Reproductive Age Mortality Studies.
↵a Conducted in 2012 and 2017 for the previous 18 months; 12-month pre-census population maternal mortality ratios were estimated after adjustments for underreporting of population and births.

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TABLE 4.

Selected Facility Characteristics and Interventions at Baseline and Endline in Uganda and Zambia SMGL-Supported Districts

Facility Characteristic/Intervention	Uganda (n=105 facilities)				Zambia (n=110 facilities)
Facility Characteristic/Intervention	Baseline^a^,^b	Endline^a^,^b	% Change^c	Sig. Level^d	Baseline^a^,^b	Endline^a^,^b	% Change^c	Sig. Level^d
Facility infrastructure
Availability of delivery services 24 hours a day/7 days a week	80.0	87.6	+10	NS	68.2	96.4	+41	***
Uninterrupted electricity available	57.1	96.2	+69	***	55.5	92.7	+67	***
Running water available	76.2	100.0	+31	N/A	90.0	97.3	+8	**
Functional communications available^e	93.3	99.0	+6	**	44.6	100.0	+124	N/A
Transportation available^f	61.0	59.0	−3	NS	55.5	72.7	+31	***
Sufficient number of obstetric beds	35.2	91.4	+160	***	62.7	73.6	+17	NS
Women do not deliver on the floor	85.7	91.4	+7	NS	71.3	83.8	+18	NS
Mother shelter present	0	3.9	NA	N/A	28.8	48.8	+69	***
Availability of medications and supplies
No stock-out in last 12 months: magnesium sulfate^g	47.6	63.8	+34	***	20.0	43.0	+115	***
No stock-out in last 12 months: oxytocin^g	56.2	81.9	+46	***	75.3	75.0	−0.4	NS
HIV rapid test kits currently available^g^,^h	70.5	79.0	+12	NS	82.5	93.8	+14	**
At least 1 long-acting reversible family planning method currently available	41.0	55.2	+35	***	20.0	71.3	+257	***
EmONC functions and labor management
Number of functioning CEmONC facilities	7	17	+143	N/A	4	5	+25	N/A
Number of functioning BEmONC facilities	3	9	+200	N/A	3	8	+167	N/A
Number of facilities with partial BEmONCⁱ	19	34	+79	N/A	22	29	+32	N/A
Use of partograph to monitor labor	33.3	92.4	+178	***	NA	92.7	NA	NA
Active management of third stage of labor	75.2	96.2	+28	***	71.8	95.5	+33	***
Use of parenteral antibiotics in last 3 months	85.7	92.4	+8	NS	79.1	73.6	−7	NS
Use of parenteral oxytocin in last 3 months	69.5	98.1	+41	***	90.9	95.5	+5	NS
Use of parenteral anticonvulsants in last 3 months	48.6	34.3	−29	**	44.6	40.0	−10	NS
Perform newborn resuscitation in last 3 months	34.3	87.6	+155	***	27.3	74.6	+173	***
Perform manual removal of placenta in last 3 months	28.6	54.3	+90	***	39.1	30.0	-23	NS
Remove retained products in last 3 months	19.0	61.9	+226	***	17.3	49.1	+184	***
Perform assisted vaginal delivery in last 3 months	4.8	10.5	+119	NS	10.0	15.5	+55	NS
Perform surgery (cesarean delivery) (HC IV or higher) in last 3 months	7.6	16.2	+113	***	3.6	4.6	+28	NS
Perform blood transfusion (HC IV or higher) in last 3 months	8.6	16.2	+88	***	5.5	4.6	−16	NS
Perform maternal death reviewsⁱ	6.7	32.4	+384	***	42.5	75.0	+76	**
Health facility has associated community volunteers	18.3	91.5	+400	***	63.8	96.3	+51	***

Abbreviations: BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care; EmONC, emergency obstetric and newborn care; HC, health center; Sig., significance.
Note: All data reported as percentages unless otherwise noted.
↵a Baseline period is June 2011–May 2012; endline period is January–December 2016.
↵b Baseline and endline results are percentages of all facilities, unless otherwise noted.
↵c Percent change calculations based on unrounded numbers.
↵d Asterisks indicate significance level of the difference between baseline and endline outcomes using McNemar's exact test, as follows: ***P<.01, **P<.05, NS = not significant. NA = data not available. N/A = not applicable.
↵e Uganda: facility-owned landline, cell, two-way radio, or individual had cell phone; Zambia: two-way radio, landline, or cell phone with service.
↵f Uganda: available and functional motorized vehicle with fuel today and funds generally available; Zambia: motor vehicle, motorcycle, or bicycle.
↵g Zambia: Kalomo facilities did not collect the information and were excluded from the analysis.
↵h Uganda: Rapid HIV test was used in maternity ward in the last 3 months (does not indicate current availability).
↵i Percentage of health centers that performed 4 to 5 basic emergency obstetric care interventions in the past 3 months.

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TABLE 5.

Maternal Health Outcomes in Facilities at Baseline and Endline in Uganda and Zambia SMGL-Supported Districts

Maternal Health Outcomes	Uganda				Zambia
Maternal Health Outcomes	Baseline	Endline	% Change	Sig. Level^a	Baseline	Endline	% Change	Sig.Level^a
Number of live births – all facilities	33,492	57,355	+71	N/A	21,914	38,174	+74	N/A
Institutional delivery rate – all facilities (%)	45.5	66.8	+47	***	62.6	90.2	+44	***
Institutional delivery rate – EmONC facilities (%)	28.2	41.0	+45	***	26.0	29.1	+12	***
Number of obstetric complications treated^b	5,256	8,458	+61	N/A	1,844	1,979	+7	N/A
Cesarean delivery rate as a proportion of all births (%)	5.3	9.0	+71	***	2.7	4.8	+79	***
Met need for emergency obstetric care – all facilities (%)	46.3	64.7	+40	***	34.1	30.6	−10	***
Met need for emergency obstetric care – EmONC facilities (%)	39.2	62.1	+58	***	25.8	23.1	−11	***
Direct obstetric case fatality rate – all facilities (%)	2.6	1.7	−37	***	3.7	3.2	−12	NS
Direct obstetric case fatality rate – EmONC facilities (%)	2.9	1.6	−45	***	2.9	3.8	+31	NS
Facility MMR, overall (per 100,000 live births)	534	300	−44	***	370	231	−38	***
Direct obstetric causes MMR	415	244	−41	***	310	168	−46	***
Obstetric hemorrhage MMR^c	131	77	−42	***	119	42	−65	***
Puerperal infection/sepsis MMR^d	75	47	−37	NS	NA	NA	N/A	N/A
Obstructed labor MMR^e	72	56	−22	NS	59	31	−47	NS
Abortion-related MMR^f	63	23	−64	***	NA	NA	N/A	N/A
Preeclampsia/eclampsia MMR	45	26	−42	NS	NA	NA	N/A	N/A
Other major direct obstetric causes MMR^g	30	16	−47	NS	132	94	−29	NS
Indirect obstetric causes MMR^h	119	56	−53	***	59	63	+6	NS
Facility perinatal mortality (per 1,000 births)	39.3	34.4	−13	***	37.9	28.2	−26	***
Total stillbirth rate (per 1,000 births)	31.2	27.0	−13	***	30.5	19.6	−36	***
Intrapartum stillbirth rate (per 1,000 births)	22.4	14.3	−36	***	NA	NA	N/A	N/A
Predischarge neonatal mortality rate (per 1,000 live births)	8.4	7.6	−10	NS	7.7	8.7	+14	NS

Abbreviations: EmONC, emergency obstetric and newborn care; MMR, maternal mortality ratio; Sig., signficance.
↵a Asterisks indicate significance level of the difference between baseline and endline outcomes for all facilities combined, using a z statistic to calculate the P value of the difference, as follows: ***P<.01, **P<.05, NS = not significant. NA = data not available. N/A = not applicable.
↵b Excludes early pregnancy complications (e.g., abortion-related complications and ectopic pregnancy).
↵c Includes antepartum, intrapartum, and postpartum hemorrhage.
↵d Infection of the genital tract occurring at any time between the onset of the rupture of membranes or labor and the day of death in facility; in Zambia, these maternal deaths were classified as deaths due to “other major direct complication.”
↵e Obstructed and prolonged labor including rupture of the uterus.
↵f Deaths after induced and spontaneous abortions.
↵g In Uganda, it includes deaths due to embolism, anesthesia, and ruptured ectopic pregnancy; in Zambia, it includes these conditions plus deaths due to puerperal infections, eclampsia/preeclampsia, and abortion.
↵h Includes HIV-, TB-, and malaria-related maternal deaths and those due to other medical conditions aggravated by pregnancy or postpartum.

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TABLE 6.

Changes in District-Wide Numbers of Maternal Deaths and Maternal Mortality Ratios (per 100,000 Live Births) in Uganda and Zambia SMGL-Supported Districts, by Cause and Timing of Death

	Uganda				Zambia
	Baseline	Endline	% Change	Sig. Level^a	Baseline	Endline	% Change	Sig. Level^a
Number of maternal deaths	342	222	N/A	N/A	200	135	N/A	N/A
Total MMR^b^,^c	452	255	−44	***	480	284	−41	***
Cause of death (MMRs)^d
Direct obstetric causes	382	195	−49	***	364	220	−40	***
Obstetric hemorrhage	128	70	−45	***	131	45	−66	***
Obstructed labor (including uterine rupture)	71	46	−36	**	44	6	−87	**
Preeclampsia/eclampsia	58	29	−51	***	36	22	−39	NS
Puerperal infection/sepsis	33	21	−37	NS	29	42	+44	NS
Abortion-related	42	14	−67	***	66	64	−2	NS
Other direct obstetric causes	49	16	−67	***	58	42	−28	NS
Indirect obstetric causes	70	60	−15	NS	116	64	−45	NS
Timing of death (MMRs)^e
Antepartum	66	53	−20	NS	109	59	−46	NS
Intrapartum and immediate postpartum (up to 24 hours)	224	62	−72	***	196	106	−46	**
>24 hours–42 days postpartum	161	140	−13	NS	175	120	−31	NS

Abbreviations: MMR, maternal mortality ratio; P/F, parity/fertility; Sig., significance.
↵a Asterisks indicate significance level of the difference between baseline and 2016 MMRs, using a z statistic to calculate the P value of the difference, as follows: ***P<.01, **P<.05, NS = not significant. N/A = not applicable.
↵b Uganda MMRs are direct estimates for the baseline (June 2011–May 2012) and endline (2016): baseline MMR=342 maternal deaths/75,675 live births*100,000; 2016 MMR=222 maternal deaths/87,094 live births*100,000.
↵c Zambia MMRs are adjusted estimates using General Growth Balance method for compensating underreporting of all deaths to WRA in the previous 12 months and applying the proportion of deaths among WRA that are due to maternal causes to derive maternal deaths; population live births were adjusted using P/F ratios estimated from the lifetime fertility of women of reproductive age. Adjusted baseline MMR=200 maternal deaths/41,665 live births; adjusted endline MMR=135/47,509 live births.
↵d Uganda cause-specific MMRs are direct estimates using population maternal deaths of a specific cause divided by total number of population live births. Zambia cause-specific MMRs are adjusted estimates using General Growth Balance method for adjusting all deaths to WRA and applying the proportion of deaths among WRA that are due to maternal causes to derive maternal deaths; crude percent distribution by cause is applied to the adjusted maternal deaths to derive adjusted cause-specific MMRs.
↵e Uganda time-of-death MMRs are direct estimates using population maternal deaths while pregnant (antepartum), during delivery or first 24 hours postpartum, and up to 42 days postpartum divided by total number of population live births. Zambia MMRs are adjusted estimates using General Growth Balance method for adjusting all deaths to WRA and applying the proportion of deaths among WRA that are due to maternal causes to derive maternal death; crude percent distribution by timing of death is applied to the adjusted maternal deaths to derive adjusted cause-specific MMRs.