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ORIGINAL ARTICLE
Open Access

Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner

Thandiwe Ngoma, Alice R. Asiimwe, Joseph Mukasa, Susanna Binzen, Florina Serbanescu, Elizabeth G. Henry, Davidson H. Hamer, Jody R. Lori, Michelle M. Schmitz, Lawrence Marum, Brenda Picho, Anne Naggayi, Gertrude Musonda, Claudia Morrissey Conlon, Patrick Komakech, Vincent Kamara and Nancy A. Scott on behalf of the Saving Mothers, Giving Life Working Group
Global Health: Science and Practice March 2019, 7(Supplement 1):S68-S84; https://doi.org/10.9745/GHSP-D-18-00367
Thandiwe Ngoma
aRight to Care-Zambia, Lusaka, Zambia.
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  • For correspondence: thandiwe.ngoma@equiphealth.org
Alice R. Asiimwe
bBaylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda.
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Joseph Mukasa
bBaylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda.
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Susanna Binzen
cDivision of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Florina Serbanescu
cDivision of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Elizabeth G. Henry
dHarvard T.H. Chan School of Public Health, Boston, MA, USA.
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Davidson H. Hamer
eDepartment of Global Health, Boston University School of Public Health, and Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA.
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Jody R. Lori
fSchool of Nursing, University of Michigan, Ann Arbor, MI, USA.
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Michelle M. Schmitz
cDivision of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Lawrence Marum
gU.S. Centers for Disease Control and Prevention, Lusaka, Zambia. Now retired.
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Brenda Picho
hInfectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
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Anne Naggayi
iAfricare, Washington, DC, USA.
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Gertrude Musonda
jAfricare, Lusaka, Zambia.
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Claudia Morrissey Conlon
kBureau for Global Health, U.S. Agency for International Development, Washington, DC, USA.
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Patrick Komakech
lDivision of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Kampala, Uganda.
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Vincent Kamara
bBaylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda.
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Nancy A. Scott
eDepartment of Global Health, Boston University School of Public Health, and Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA.
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Figures & Tables

Figures

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  • FIGURE 1
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    FIGURE 1

    Second Delay: Timely Access to Health Care

  • FIGURE 2
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    FIGURE 2

    SMGL Learning and Scale-Up Districts in Uganda

    Source: Adapted from Saving Mothers, Giving Life. Results of a Five-Year Partnership to Reduce Maternal and Newborn Mortality: Final Report 2018. http://www.savingmothersgivinglife.org/docs/smgl-final-report.pdf. Accessed December 18, 2018.

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    FIGURE 3

    SMGL Learning and Scale-Up Districts in Zambia

    Source: Adapted from Saving Mothers, Giving Life. Results of a Five-Year Partnership to Reduce Maternal and Newborn Mortality: Final Report 2018. http://www.savingmothersgivinglife.org/docs/smgl-final-report.pdf. Accessed December 18, 2018.

Tables

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    TABLE 1.

    Saving Mothers, Giving Life Strategies and Interventions to Reduce the Second Delay, 2011–2016

    SMGL Strategies and ApproachesCountry-Specific Interventions
    UgandaZambia
    Strategy 1. Decrease distance to skilled birth attendance by increasing the number of EmONC facilities
    Establish additional EmONC facilities and strengthen existing facilities to provide the following services 24 hours per day, 7 days a week, for all pregnant women in the district:
    • Clean and safe basic delivery services

    • Quality HIV testing

    • Counseling and treatment (for woman, partner, and baby as appropriate)

    • Essential newborn care

    • 24-hour availability of staff capable of managing delivery complications

    • When needed, timely facilitated referral to higher-level facility

    • Upgraded infrastructure to a sufficient number of public and private facilities in appropriate geographic locations and provided necessary equipment and commodities for EmONC service delivery

    • Hired midwives, medical officers, and anesthetists

    • Trained medical officers, anesthetists, midwives, and nurses in EmONC

    • Provided on-site mentorship of health facility teams using protocols

    • Upgraded infrastructure and provided necessary equipment to provide services for pregnant women in public and private facilities in appropriate geographic locations

    • Hired a sufficient number of skilled birth attendants and midwives

    • Trained doctors, midwives, and anesthetists in EmONC and the Electronic Logistic Management Information System

    • Provided on-site mentorship of health facility staff using protocols, forms, and drills

    Strategy 2. Improve accessibility of EmONC facilities
    Create a communication and transportation referral system that operates 24 hours per day, 7 day per week, and:
    • Is consultative, protocol-driven, quality-assured, and integrated (public and private)

    • Ensures that women with complications reach emergency services within 2 hours

    • Includes buying ambulances, motorcycles, motorbikes, and communication equipment like 2-way radios

    • Provides or renovates, where appropriate, temporary lodging in maternity waiting homes for women with high-risk pregnancies or who live more than 2 hours travel time to an EmONC facility

    • Provides service delivery vouchers and vouchers for transport to basic delivery care facilities and referral to higher-level facilities

    • Forms district-level transport committees to improve referral

    • Created district transportation committees to improve coordination of ambulances for referrals

    • Provided service and transportation vouchers to women for transportation to facilities nearest to them and access to antenatal care, delivery, and postnatal care services at the facilities

    • Trained village health teams to encourage birth preparedness and escort women to the facility

    • Procured ambulances to facilitate transportation for referral

    • Renovated maternity waiting homes

    • Repaired and procured 2-way radios where needed

    • Procured ambulances and motorcycle ambulances; strengthened district transportation committees; and ensured strategic placement of ambulances

    • Renovated and constructed maternity waiting homes

    • Strengthened district transportation committees to improve coordination of ambulance services

    • Trained Safe Motherhood Action Groups to encourage birth preparedness and escort women to the facility

    • Established village-level savings programs for pregnant women to encourage better planning for delivery

    • Abbreviations: EmONC, emergency obstetric and newborn care; SMGL, Saving Mothers, Giving Life.

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    TABLE 2.

    Changes in Outputs and Outcomes Related to Activities Conducted Under SMGL Strategies Addressing the Second Delay in SMGL-Supported Districts, Uganda

    Baseline
    June 2012
    (105 facilities)
    Endline
    Dec 2016
    (105 facilities)
    % Relative changeaSignificance levelb
    Service delivery outcomesc
    Deliveries in all facilities45.5%66.8%+47%P<.01
    Deliveries in EmONC facilities28.2%41.0%+45%P<.01
    Deliveries in non-EmONC facilities17.3%25.8%+49%P<.01
    Strategy 1: Decrease distance to skilled birth attendance by increasing the number of EmONC facilitiesd
    Facilities offering services 24 hours a day, 7 days a week80.0%87.6%+10%NS
    Facilities with electricity57.1%96.2%+69%P<.01
    Facilities with running water76.2%100.0%+31%P<.01
    Number of BEmONC facilities39+200%NA
    Number of CEmONC facilities717+143%NA
    Number of pregnant women who received antiretroviral therapy for the prevention of mother-to-child-transmission of HIV/AIDS1,2626,837+442%NA
    Number of HIV-exposed infants receiving HIV prophylaxis1,1173,245+191%NA
    Health facilities reporting that at least 1 doctor, nurse, or midwife is on staff100.0%100.0%0%NS
    Strategy 2: Improve the accessibility of EmONC facilitiesd
    Institutional deliveries supported by Baylor transportation voucherse0.9%23.8%+258%P<.01
    Health facilities that reported having available transportation (motor vehicle or motorcycle)61.0%59.0%−3%NS
    Health facilities that reported having communication equipment (including 2-way radio, landline, or cell phone with service)93.3%99.0%+6%P<.05
    • Abbreviations: BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care; EmONC, emergency obstetric and newborn care; NA, not applicable; NS, not significant; SMGL, Saving Mothers, Giving Life.

    • ↵a Percentage of change calculations are based on unrounded numbers.

    • ↵b To test for significance, z scores based on the normal approximation to the binomial distribution were used to calculate P values.

    • ↵c The number of facility deliveries was collected through the Pregnancy Outcome Monitoring data collection. The number of live births was estimated by applying crude birth rates (derived from the age-specific fertility rates among women of reproductive age enumerated in 2013 in the SMGL Uganda districts) to the baseline and endline district populations.

    • ↵d The number of health facilities performing deliveries varied over the 5-year initiative. Health facility assessments results for Uganda were compiled from only the 105 facilities that maintained delivery capacity from baseline to endline.

    • ↵e Transportation vouchers were introduced in April 2012 in the 3 Baylor districts; the system was rapidly scaled up with SMGL support.

    • View popup
    TABLE 3.

    Changes in Outputs and Outcomes Related to Activities Conducted Under SMGL Strategies Addressing the Second Delay in SMGL-Supported Districts, Zambia

    Baseline
    June 2012
    (110 facilities)
    Endline
    Dec 2016
    (110 facilities)
    % Relative changeaSignificance levelb
    Service delivery outcomesc
    Deliveries in all facilities62.6%90.2%+44%P<.01
    Deliveries in EmONC facilities26.0%29.1%+12%P<.01
    Deliveries in non-EmONC facilities36.7%61.1%+67%P<.01
    Strategy 1: Decrease distance to skilled birth attendance by increasing the number of EmONC facilitiesd
    Facilities offering services 24 hours a day, 7 days a week68.2%96.4%+41%P<.01
    Facilities with electricity55.5%92.7%+67%P<.01
    Facilities with running water90.0%97.3%+8%P<.05
    Number of BEmONC facilities38+167%NA
    Number of CEmONC facilities45+25%NA
    Number of pregnant women who received antiretroviral therapy for the prevention of mother-to-child transmission of HIV/AIDS9301,036+11%NA
    Number of HIV-exposed infant receiving HIV prophylaxis5231,030+97%NA
    Number of health providers hired—89—NA
    Health facilities reporting that at least 1 doctor, nurse, or midwife is on staff90.0%98.8%+10%P<.05
    Strategy 2: Improve the accessibility of EmONC facilitiesd
    Health facilities that reported having available transportation (motor vehicle or motorcycle)55.5%72.7%+31%P<.01
    Health facilities that reported having communications equipment (including 2-way radio, landline, or cell phone with service)44.6%100.0%+124%NA
    Health facilities that reported having an associated maternity waiting home28.8%48.8%+69%P<.01
    Health facilities that reported having an associated Safe Motherhood Action Group63.8%96.3%+51%P<.01
    • Abbreviations: BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care; EmONC, emergency obstetric and newborn care; NA, not applicable; NS, not significant; SMGL, Saving Mothers, Giving Life.

    • ↵a Percentage of change calculations are based on unrounded numbers.

    • ↵b To test for significance, z scores based on the normal approximation to the binomial distribution were used to calculate P values.

    • ↵c The number of facility deliveries was collected through the Pregnancy Outcome Monitoring data collection. The number of live births was estimated by applying crude birth rates (derived from 2010 national census in Zambia) to the baseline and endline district populations.

    • ↵d The number of health facilities performing deliveries varied over the 5-year initiative. Health facility assessments results for Zambia were compiled from only the 110 facilities that maintained delivery capacity from baseline to endline.

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Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner
Thandiwe Ngoma, Alice R. Asiimwe, Joseph Mukasa, Susanna Binzen, Florina Serbanescu, Elizabeth G. Henry, Davidson H. Hamer, Jody R. Lori, Michelle M. Schmitz, Lawrence Marum, Brenda Picho, Anne Naggayi, Gertrude Musonda, Claudia Morrissey Conlon, Patrick Komakech, Vincent Kamara, Nancy A. Scott
Global Health: Science and Practice Mar 2019, 7 (Supplement 1) S68-S84; DOI: 10.9745/GHSP-D-18-00367

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Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner
Thandiwe Ngoma, Alice R. Asiimwe, Joseph Mukasa, Susanna Binzen, Florina Serbanescu, Elizabeth G. Henry, Davidson H. Hamer, Jody R. Lori, Michelle M. Schmitz, Lawrence Marum, Brenda Picho, Anne Naggayi, Gertrude Musonda, Claudia Morrissey Conlon, Patrick Komakech, Vincent Kamara, Nancy A. Scott
Global Health: Science and Practice Mar 2019, 7 (Supplement 1) S68-S84; DOI: 10.9745/GHSP-D-18-00367
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