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ORIGINAL ARTICLE
Open Access

Addressing the Third Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Ensuring Adequate and Appropriate Facility-Based Maternal and Perinatal Health Care

Diane Morof, Florina Serbanescu, Mary M. Goodwin, Davidson H. Hamer, Alice R. Asiimwe, Leoda Hamomba, Masuka Musumali, Susanna Binzen, Adeodata Kekitiinwa, Brenda Picho, Frank Kaharuza, Phoebe Monalisa Namukanja, Dan Murokora, Vincent Kamara, Michelle Dynes, Curtis Blanton, Agnes Nalutaaya, Fredrick Luwaga, Michelle M. Schmitz, Jonathan LaBrecque, Claudia Morrissey Conlon, Brian McCarthy, Charlan Kroelinger and Thomas Clark on behalf of the Saving Mothers, Giving Life Working Group
Global Health: Science and Practice March 2019, 7(Supplement 1):S85-S103; https://doi.org/10.9745/GHSP-D-18-00272
Diane Morof
aDivision of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
bU.S. Public Health Service Commissioned Corps, Rockville, MD, USA.
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  • For correspondence: dmorof@cdc.gov
Florina Serbanescu
aDivision of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Mary M. Goodwin
aDivision of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Davidson H. Hamer
cDepartment of Global Health, Boston University School of Public Health, Boston, MA, USA.
dSection of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA.
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Alice R. Asiimwe
eBaylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda.
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Leoda Hamomba
fDivision of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia.
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Masuka Musumali
gFamily Health Division, U.S. Agency for International Development, Lusaka, Zambia.
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Susanna Binzen
aDivision of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Adeodata Kekitiinwa
eBaylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda.
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Brenda Picho
hInfectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
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Frank Kaharuza
iHIV Health Office, U.S. Agency for International Development, Kampala, Uganda.
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Phoebe Monalisa Namukanja
jDivision of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Kampala, Uganda.
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Dan Murokora
eBaylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda.
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Vincent Kamara
eBaylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda.
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Michelle Dynes
aDivision of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
bU.S. Public Health Service Commissioned Corps, Rockville, MD, USA.
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Curtis Blanton
aDivision of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Agnes Nalutaaya
hInfectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
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Fredrick Luwaga
eBaylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda.
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Michelle M. Schmitz
aDivision of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Jonathan LaBrecque
kBureau for Global Health, U.S. Agency for International Development, Washington DC. Now with Boston Children's Hospital, Boston, MA, USA.
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Claudia Morrissey Conlon
lBureau for Global Health, U.S. Agency for International Development, Washington, DC, USA.
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Brian McCarthy
mEck Institute for Global Health, University of Notre Dame, Notre Dame, IN, USA.
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Charlan Kroelinger
aDivision of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Thomas Clark
aDivision of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
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    Context of Quality of Health Services for the Third Delay

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    TABLE 1.

    SMGL Interventions to Reduce the Third Delay, 2011–2016

    Strategies and ApproachesCountry-Specific Interventionsa
    UgandaZambia
    Strategy 1. Ensure facilities have adequate infrastructure to provide EmONC
    Approach 1.1: Support expansion and renovation of operating theaters and facility enhancements to accommodate additional deliveries
    • Renovated and upgraded operating theaters

    • Increased the size of labor rooms

    • Provided additional delivery beds to allow more women to deliver in facilities and stay longer postpartum

    • Supported renovation of birthing centers, delivery rooms, and maternity annexes

    • Provided additional delivery beds to allow more women to deliver in facilities and stay longer postpartum

    Approach 1.2: Support facility enhancements to improve neonatal survival
    • Procured incubators, infant warmers, and phototherapy lamps

    • Renovated infrastructure to have designated space for KMC and to create NICUs

    • Refurbished dedicated KMC rooms at hospitals

    Approach 1.3: Support improved access to electricity and water
    • Provided safe water systems at health facilities

    • Provided solar panels at facilities to improve continuity of access to electricity and light

    • Improved lighting systems for delivery rooms

    • Improved piped water to maternity annexes

    Strategy 2. Ensure sufficient medical supplies, equipment, and medications
    Approach 2.1: Strengthen supply chains for essential supplies and medicines
    • Procured essential medication and backup supply of commodities for all sites on the SMGL project

    • Redistributed supplies between health facilities to reduce stock-outs

    • Implemented SMS reminder system to ensure timely drug ordering

    • Equipped health centers with BEmONC equipment and supplies

    • Procured essential emergency medications and supplies with backup

    • Trained staff in eLMIS

    • Equipped health centers with BEmONC equipment and supplies

    • Assembled and distributed uterine balloon tamponade kits, and CPAP machines

    Approach 2.2: Strengthen availability of blood supplies and surgical equipment
    • Strengthened and maintained the blood supply system in CEmONC sites and supported new regional blood bank

    • Provided new blood refrigerators

    • Procured and distributed new surgical equipment to facilities

    • Procured and distributed centrifuges, refrigerators, and freezers to support blood bank

    • Procured and distributed new surgical equipment to facilities

    Strategy 3. Ensure sufficient trained health care providers at facilities
    Approach 3.1: Recruited staff
    • Recruited new medical doctors and nurse/midwives through a joint hiring process with the districts

    • Recruited new nurse/midwives

    Approach 3.2: Trained health professionals in emergency obstetric care, including obstetric surgeries
    • Trained medical officers, anesthetic officers, and midwives/nurses in CEmONC

    • Conducted surgical skills course for medical officers, including decision making and caesarean section

    • Trained providers on neonatal resuscitation/HBB and used drills to reinforce lessons

    • Trained doctors, nurses, midwives, and anesthetists in EmONC, clinical decision making, obstetric complications, hemorrhage management with uterine balloon tamponade, early HBB, and CPAP

    • Limited rotation of trained providers to different wards

    • Supported capacity building of laboratory staff for blood services

    Approach 3.3: Provided mentoring and supportive supervision to newly hired and existing personnel
    • Conducted individual clinical mentorship sessions

    • Provided selected nurses with intensive hands-on clinical skills placement to expand NICU skills

    • Trained district mentorship teams who then held monthly on site health facility staff training and mentorship visits on normal delivery and partograph use, EmONC, and HBB

    Strategy 4. Improve quality of care and ensure care is evidence-based
    Approach 4.1: Implemented quality, effective interventions to prevent and treat obstetric and newborn complications
    • Provided quality improvement practice to increase partograph use

    • Implemented KMC

    • Introduced emergency kits and logs/registers to facilitate quick access to emergency supplies

    • Implemented partograph use by facility staff

    • Enhanced infection prevention practices

    Approach 4.2: Introduced sound managerial practices using ‘short-loop' data feedback and response to ensure reliable delivery of quality essential and emergency maternal and newborn care
    • Incorporated concepts related to respectful maternity care into customer care training of midwives

    • Used facility-generated data to review quality of care and implement practice changes

    • Incorporated respectful maternity care into EmONC and early newborn care and supported it through mentorship

    Approach 4.3: Developed guidelines and policies, and ensured protocol adherence
    • Developed national standards for MDSR that were informed by SMGL processes

    • Implemented BABIES matrix to prevent perinatal deaths by using data to guide actions

    • Developed clinical guidelines and protocols for diagnosing and managing most common obstetric emergencies

    • Contributed to the development of the newborn health framework and guidelines

    • Created standardized clinical forms to guide providers in recognizing danger signs and diagnosing the most common obstetric emergencies

    • Introduced laminated checklists for quick reference in delivery rooms

    Strategy 5. Ensure referral capacity exists to support transfers to higher-level care
    Approach 5.1: Improved referral communication systems
    • Introduced ambulance referral forms to better track referrals

    • Set up and supported district ambulance committees to work on referral-related issues

    • Procured and maintained landline phones for facilities and mobile phones for village health workers

    • Used referral forms to improve communication between health centers and hospitals

    • Set up and supported district ambulance committees to work on referral-related issues.

    • Repaired and maintained 2-way radios at health facilities.

    • Improved communications through the SMS and Remind-mi mHealth program (local communication programs)

    Approach 5.2: Support increased transportation between facilities with motor vehicles or ambulances
    • Procured ambulances (vehicle and tricycle)

    • Procured ambulances (vehicle and motorcycle)

    Strategy 6. Support effective maternal and perinatal health surveillance
    Approach 6.1: Strengthen maternal and perinatal mortality surveillance in facilities and communities
    • Trained providers on MPDSR

    • Set up MPDSR system, including committees to identify and understand maternal and newborn mortality at facilities and in communities

    • Strengthened prospective health facility surveillance through the MOH DHIS2

    • Set up POMS and RAPID to understand facility maternal and perinatal mortality

    • Developed national standards for MDSR that were informed by SMGL processes

    • Established MDSR including verbal autopsies at facilities with a community component

    • Conducted MDR trainings for the district medical officer and health facility staff

    • Supported MDR at facilities

    Approach 6.2: Promote a government-owned HMIS data-gathering system to accurately record every birth outcome, obstetric and newborn complication, and treatment at facilities
    • Trained providers and implemented BABIES matrix

    • Strengthened prospective health facility surveillance through the MOH DHIS2

    • Set up POMS

    • Supported national MDSR processes and expansion of MDSR to SMGL districts

    • ↵a This list is not exhaustive and activities noted may apply to more than one approach.

    • Abbreviations: BABIES, birth weight and age-at-death boxes for an intervention and evaluation system; BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care; CPAP, continuous positive airway pressure; DHIS2, District Health Information System 2; eLMIS, Electronic Logistic Management Information System; EmONC, emergency obstetric and newborn care; HBB, Helping Babies Breathe; HMIS, Health Management Information System; KMC, kangaroo mother care; MDR, maternal death review; MDSR, maternal death surveillance and response; MOH, ministry of health; MPDSR, maternal and perinatal death surveillance and response; NICU, neonatal intensive care unit; NSCU, neonatal special care units; POMS, pregnancy outcome monitoring surveillance; RAPID, Rapid Ascertainment Process for Institutional Deaths; SMGL, Saving Mothers, Giving Life; SMS, short message service.

    • View popup
    BOX 1.

    Definitions and Descriptions of Indicators of Interest for SMGL Monitoring and Evaluation

    IndicatorDescription
    Performance of EmONC signal functionsBasic Services:
    • Administer parenteral antibiotics

    • Administer uterotonic drugs (e.g., parenteral oxytocin)

    • Administer parenteral anticonvulsants for pre-eclampsia and eclampsia (e.g., magnesium sulfate)

    • Manual removal of placenta

    • Remove retained products (e.g., manual vacuum aspiration, dilation and curettage)

    • Perform assisted vaginal delivery (e.g., vacuum extraction, forceps delivery)

    • Perform basic neonatal resuscitation (e.g., bag and mask)

    Comprehensive Services:
    • Perform surgery (e.g., caesarean section)

    • Perform blood transfusion

    Basic facility infrastructure
    • Electricity

    • Regular water supply

    • Functional communications systems

    • Motorized vehicles available

    • Services available 24 hours a day

    Promotion of protocols and guidelinesFacilities with protocols available and displayed on the following topics:
    • Obstetric and newborn complications

    • Postpartum hemorrhage

    • Active management of the third stage of labor

    • Helping Babies Breathe or kangaroo mother care

    • Early newborn care

    Availability of essential drugs
    • Oxytocin, magnesium sulfate, gentamycin

    • Abbreviation: EmONC, emergency obstetric and newborn care.

    • View popup
    TABLE 2.

    Monitoring and Evaluation Outcomes Associated With Strategies to Reduce the Third Delay in Uganda, 2011–2016 (N=105 facilities)

    IndicatorsBaselinea
    Value
    Endlinea
    Value
    % Relative ChangebSig. Levelc
    Strategy 1: Ensure facilities have adequate infrastructure to provide EmONC
    Total number of EMONC facilities1025150.0N/A
    Number of CEmONC facilities717142.9N/A
    Number of BEmONC facilities38166.7N/A
    Deliveries in EmONC facilities28.2%41.0%45.4***
    Hospitals/health center IVs that perform blood transfusionsd56.3%100.0%77.6N/A
    Hospitals/health center IVs that have capacity to perform surgery (caesarean-section)d50.0%100.0%100.0N/A
    Facilities with electricity57.1%96.2%68.5***
    Facilities with water76.2%100.0%31.2N/A
    Strategy 2: Ensure sufficient medical supplies and medications
    Facilities experiencing no stock-out of oxytocin in the past 12 months56.2%81.9%45.7***
    Facilities experiencing no stock-out of magnesium sulfate in the past 12 months47.6%63.8%34.0***
    Facilities reporting gentamycin antibiotic currently available90.5%88.6%−2.1NS
    Strategy 3: Ensure sufficient trained health care providers at facilities
    Facilities reporting at least 1 doctor, nurse, or midwife is on staff100.0%100.0%0.0NS
    Health center IIIs that are open 24/7e74.6%82.9%11.1NS
    Facilities reporting EmONC lifesaving interventions performed in the past 3 monthsf
        Parenteral antibiotics85.7%92.4%7.8NS
        Parenteral oxytocin69.5%98.1%41.2***
        Parenteral anticonvulsants48.6%34.3%−29.4**
        Manual removal of placenta28.6%54.3%89.9***
        Remove retained products19.0%61.9%225.8***
        Assisted vaginal delivery4.8%10.5%118.8NS
        Newborn resuscitation34.3%87.6%155.4***
    Strategy 4: Improve quality of care and ensure care is evidence-based
    Facilities with protocols and guidelines available and displayed on EmONC lifesaving interventions
        AMTSL39.0%58.1%49.0***
        Postpartum hemorrhage15.2%85.7%463.8***
        Eclampsia or magnesium sulfate use8.6%74.3%764.0***
        Obstetric and newborn complications26.7%61.0%128.5***
        Immediate newborn care30.5%79.0%159.0***
    Facilities that report routine practice of partograph33.3%92.4%177.5***
    Facilities that report routine practice of AMTSL75.2%96.2%27.9***
    Facilities reporting that obstetric patients never share beds35.2%91.4%159.7***
    Facilities reporting that women never deliver on the floor85.7%91.4%6.7NS
    Strategy 5: Ensure referral capacity to support transfers to higher-level care
    Facilities with at least 1 method of communication for referralsg93.3%99.0%6.1**
    Facilities that reported having available transportation (motor vehicle or motorcycle)h61.0%59.0%−3.3NS
    Strategy 6: Support effective maternal and perinatal health surveillance
    Facilities with maternal death reviews performed6.7%32.4%383.6***
    Hospital and health center IVs that performed maternal death reviewsd31.3%94.1%200.6***
    • ↵a Baseline period was June 2011 to May 2012; endline period was January to December 2016.

    • ↵b Percentage change calculations are based on unrounded numbers.

    • ↵c Asterisks indicate significance levels calculated with a z-statistic using McNemar's as follows: *** = P<.01, ** = P<.05, NS = not significant. In cases where significance testing is not warranted, this is denoted as N/A.

    • ↵d Hospital and health center IV was n=16 at baseline and n=17 at endline of HFA.

    • ↵e Health center III was n=71 at baseline and n=70 at endline of HFA.

    • ↵f Performance during the previous 3 months preceding the assessment.

    • ↵g Includes facility owned landline, mobile phone, 2-way radio, or individual had a mobile phone.

    • ↵h Includes available and functional motorized vehicle with fuel today and funds generally available.

    • Abbreviations: AMSTL, active management of the third stage of labor; BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care; EmONC, emergency obstetric and newborn care; HFA, health facility assessments; N/A, not applicable; NS, not significant; Sig, significance.

    • View popup
    TABLE 3.

    Monitoring and Evaluation Outcomes Associated With Strategies to Reduce the Third Delay in Zambia, 2011–2016 (N=110 facilities)

    IndicatorsBaselinea
    Value
    Endlinea
    Value
    %Relative ChangebSig. Levelc
    Strategy 1: Ensure facilities have adequate infrastructure to provide EmONC
    Total number of EMONC facilities71385.7N/A
    Number of CEmONC facilities4525.0N/A
    Number of BEmONC facilities38166.7N/A
    Deliveries in EmONC facilities26.0%29.1%12.2***
    Hospitals that perform blood transfusionsd100.0%83.3%−16.7N/A
    Hospitals that have capacity to perform surgery (caesarean section)d83.3%83.3%0.0NS
    Facilities with electricity55.5%92.7%67.0***
    Facilities with water90.0%97.3%8.1**
    Strategy 2: Ensure sufficient medical supplies and medications
    Facilities experiencing no stock out of oxytocin in the past 12 monthse75.3%75.0%−0.4NS
    Facilities experiencing no stock out of magnesium sulfate in the past 12 monthse20.0%43.0%115.0***
    Facilities reporting gentamycin antibiotic currently availablee67.3%48.2%−28.4***
    Strategy 3: Ensure sufficient trained health care providers at facilities
    Facilities reporting that at least one doctor, nurse, or midwife is on staff90.0%98.8%9.8**
    Health centers that are open 24/7f64.8%95.5%47.4***
    Facilities reporting EmONC lifesaving interventions performed in the past 3 monthsg
        Parenteral antibiotics79.1%73.6%−7.0NS
        Parenteral oxytocin90.9%95.5%5.1NS
        Parenteral anticonvulsants44.6%40.0%−10.3NS
        Manual removal of placenta39.1%30.0%−23.3NS
        Remove retained products17.3%49.1%183.8***
        Assisted vaginal delivery10.0%15.5%55.0NS
        Newborn resuscitation27.3%74.6%173.3***
    Strategy 4: Improve quality of care and ensure care is evidence-based
    Facilities that report routine practice of AMTSL71.8%95.5%33.0***
    Facilities reporting that obstetric patients never share beds62.7%73.6%17.4NS
    Facilities reporting that women never deliver on the floor71.3%83.8%17.5NS
    Strategy 5: Ensure referral capacity to support transfers to higher-level care
    Facilities with at least 1 method of communication for referralsh44.6%100.0%124.2N/A
    Facilities that reported having available transportation (motor vehicle or motorcycle)i55.5%72.7%31.0***
    Strategy 6: Support effective maternal and perinatal health surveillance
    Facilities with maternal death reviews performed42.5%75.0%76.5**
    Hospitals that performed maternal death reviewsd50.0%100.0%100.0N/A
    • ↵a Baseline period was June 2011 to May 2012; endline period was January to December 2016.

    • ↵b Percentage change calculations are based on unrounded numbers.

    • ↵c Asterisks indicate significance levels calculated with a z-statistic using McNemar's as follows: *** = P<.01, ** = P<.05, NS = not significant. In cases where significance testing is not warranted, this is denoted with N/A.

    • ↵d Hospitals (n=6) included in the HFA.

    • ↵e Data were not collected in Kalomo facilities so they were excluded from the analysis.

    • ↵f Health centers (n=88) included in the HFA.

    • ↵g Performance during the previous 3 months preceding the assessment.

    • ↵h Includes two-way radio or mobile phone with service.

    • ↵i Includes motor vehicle, motorcycle, or bicycle.

    • Abbreviations: AMSTL, active management of the third stage of labor; BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care; EmONC, emergency obstetric and newborn care; HFA, health facility assessments; N/A, not applicable; NS, not significant; Sig, significance.

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Global Health: Science and Practice: 7 (Supplement 1)
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Addressing the Third Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Ensuring Adequate and Appropriate Facility-Based Maternal and Perinatal Health Care
Diane Morof, Florina Serbanescu, Mary M. Goodwin, Davidson H. Hamer, Alice R. Asiimwe, Leoda Hamomba, Masuka Musumali, Susanna Binzen, Adeodata Kekitiinwa, Brenda Picho, Frank Kaharuza, Phoebe Monalisa Namukanja, Dan Murokora, Vincent Kamara, Michelle Dynes, Curtis Blanton, Agnes Nalutaaya, Fredrick Luwaga, Michelle M. Schmitz, Jonathan LaBrecque, Claudia Morrissey Conlon, Brian McCarthy, Charlan Kroelinger, Thomas Clark
Global Health: Science and Practice Mar 2019, 7 (Supplement 1) S85-S103; DOI: 10.9745/GHSP-D-18-00272

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Addressing the Third Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Ensuring Adequate and Appropriate Facility-Based Maternal and Perinatal Health Care
Diane Morof, Florina Serbanescu, Mary M. Goodwin, Davidson H. Hamer, Alice R. Asiimwe, Leoda Hamomba, Masuka Musumali, Susanna Binzen, Adeodata Kekitiinwa, Brenda Picho, Frank Kaharuza, Phoebe Monalisa Namukanja, Dan Murokora, Vincent Kamara, Michelle Dynes, Curtis Blanton, Agnes Nalutaaya, Fredrick Luwaga, Michelle M. Schmitz, Jonathan LaBrecque, Claudia Morrissey Conlon, Brian McCarthy, Charlan Kroelinger, Thomas Clark
Global Health: Science and Practice Mar 2019, 7 (Supplement 1) S85-S103; DOI: 10.9745/GHSP-D-18-00272
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Subjects

  • Health Topics
    • Maternal, Newborn, and Child Health
US AIDJohns Hopkins Center for Communication ProgramsUniversity of Alberta

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