Saving Mothers, Giving Life: It Takes a System to Save a Mother.

BACKGROUND: Ending preventable maternal and newborn deaths remains a global health imperative under United Nations Sustainable Development Goal targets 3.1 and 3.2. Saving Mothers, Giving Life (SMGL) was designed in 2011 within the Global Health Initiative as a public-private partnership between the U.S. government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynecologists, the government of Norway, and Project C.U.R.E. SMGL's initial aim was to dramatically reduce maternal mortality in low-resource, high-burden sub-Saharan African countries. SMGL used a district health systems strengthening approach combining both supply- and demand-side interventions to address the 3 key delays to accessing effective maternity care in a timely manner: delays in seeking, reaching, and receiving quality obstetric services. IMPLEMENTATION: The SMGL approach was piloted from June 2012 to December 2013 in 8 rural districts (4 each) in Uganda and Zambia with high levels of maternal deaths. Over the next 4 years, SMGL expanded to a total of 13 districts in Uganda and 18 in Zambia. SMGL built on existing host government and private maternal and child health platforms, and was aligned with and guided by Ugandan and Zambian maternal and newborn health policies and programs. A 35% reduction in the maternal mortality ratio (MMR) was achieved in SMGL-designated facilities in both countries during the first 12 months of implementation. RESULTS: Maternal health outcomes achieved after 5 years of implementation in the SMGL-designated pilot districts were substantial: a 44% reduction in both facility and districtwide MMR in Uganda, and a 38% decrease in facility and a 41% decline in districtwide MMR in Zambia. Facility deliveries increased by 47% (from 46% to 67%) in Uganda and by 44% (from 62% to 90%) in Zambia. Cesarean delivery rates also increased: by 71% in Uganda (from 5.3% to 9.0%) and by 79% in Zambia (from 2.7% to 4.8%). The average annual rate of reduction for maternal deaths in the SMGL-supported districts exceeded that found countrywide: 11.5% versus 3.5% in Uganda and 10.5% versus 2.8% in Zambia. The changes in stillbirth rates were significant (-13% in Uganda and -36% in Zambia) but those for pre-discharge neonatal mortality rates were not significant in either Uganda or Zambia. CONCLUSION: A district health systems strengthening approach to addressing the 3 delays to accessing timely, appropriate, high-quality care for pregnant women can save women's lives from preventable causes and reduce stillbirths. The approach appears not to significantly impact pre-discharge neonatal mortality.

The Costs and Cost-Effectiveness of a District-Strengthening Strategy to Mitigate the 3 Delays to Quality Maternal Health Care: Results From Uganda and Zambia.

The primary objective of this study was to estimate the costs and the incremental cost-effectiveness of maternal and newborn care associated with the Saving Mothers, Giving Life (SMGL) initiative-a comprehensive district-strengthening approach addressing the 3 delays associated with maternal mortality-in Uganda and Zambia. To assess effectiveness, we used a before-after design comparing facility outcome data from 2012 (before) and 2016 (after). To estimate costs, we used unit costs collected from comparison districts in 2016 coupled with data on health services utilization from 2012 in SMGL-supported districts to estimate the costs before the start of SMGL. We collected data from health facilities, ministerial health offices, and implementing partners for the year 2016 in 2 SMGL-supported districts in each country and in 3 comparison non-SMGL districts (2 in Zambia, 1 in Uganda). Incremental costs for maternal and newborn health care per SMGL-supported district in 2016 was estimated to be US$845,000 in Uganda and $760,000 in Zambia. The incremental cost per delivery was estimated to be $38 in Uganda and $95 in Zambia. For the districts included in this study, SMGL maternal and newborn health activities were associated with approximately 164 deaths averted in Uganda and 121 deaths averted in Zambia in 2016 compared to 2012. In Uganda, the cost per death averted was $10,311, or $177 per life-year gained. In Zambia, the cost per death averted was $12,514, or $206 per life-year gained. The SMGL approach can be very cost-effective, with the cost per life-year gained as a percentage of the gross domestic product (GDP) being 25.6% and 16.4% in Uganda and Zambia, respectively. In terms of affordability, the SMGL approach could be paid for by increasing health spending from 7.3% to 7.5% of GDP in Uganda and from 5.4% to 5.8% in Zambia.

Sustainability and Scale of the Saving Mothers, Giving Life Approach in Uganda and Zambia.

BACKGROUND: Saving Mothers, Giving Life (SMGL) significantly reduced maternal and perinatal mortality in Uganda and Zambia by using a district health systems strengthening approach to address the key delays women and newborns face in receiving quality, timely, and appropriate medical care. This article documents the transition of SMGL from pilot to scale in Uganda and Zambia and analyzes the sustainability of the approach, examining the likelihood of maintaining positive trends in maternal and newborn health in both countries. METHODS: We analyzed the potential sustainment of SMGL achievements using a tool adapted from the HIV-focused domains and elements of the U.S. President's Emergency Plan for AIDS Relief Sustainability Index and Dashboard for maternal and neonatal health pro-gramming adding a domain on community normative change. Information for each of the 5 resulting domains was drawn from SMGL and non-SMGL reports, individual stakeholder interviews, and group discussions. FINDINGS: In both Uganda and Zambia, the SMGL proof-of-concept phase catalyzed commitment to saving mothers and newborns and a renewed belief that significant change is possible. Increased leadership and accountability for maternal and newborn health, particularly at the district and facility levels, was bolstered by routine maternal death surveillance reviews that engaged a wide range of local leadership. The SMGL district-strengthening model was found to be cost-effective with cost of death averted estimated at US$177-206 per year of life gained. When further considering the ripple effect that saving a mother has on child survival and the household economy, the value of SMGL increases. Ministries of health and donor agencies have already demonstrated a willingness to pay this amount per year of life for other programs, such as HIV and AIDS. CONCLUSION: As SMGL scaled up in both Uganda and Zambia, the intentional integration of SMGL interventions into host country systems, alignment with other large-scale programs, and planned reductions in annual SMGL funding all contributed to increasing host government ownership of the interventions and set the SMGL approach on a path more likely to be sustained following the close of the initiative. Lessons from the learning districts resulted in increased efficiency in allocation of resources for maternal and newborn health, better use of strategic information, improved management capacities, and increased community engagement.

Saving Mothers, Giving Life: It Takes a System to Save a Mother (Republication).

BACKGROUND: Ending preventable maternal and newborn deaths remains a global health imperative under United Nations Sustainable Development Goal targets 3.1 and 3.2. Saving Mothers, Giving Life (SMGL) was designed in 2011 within the Global Health Initiative as a public-private partnership between the U.S. government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynecologists, the government of Norway, and Project C.U.R.E. SMGL's initial aim was to dramatically reduce maternal mortality in low-resource, high-burden sub-Saharan African countries. SMGL used a district health systems strengthening approach combining both supply- and demand-side interventions to address the 3 key delays to accessing effective maternity care in a timely manner: delays in seeking, reaching, and receiving quality obstetric services. IMPLEMENTATION: The SMGL approach was piloted from June 2012 to December 2013 in 8 rural districts (4 each) in Uganda and Zambia with high levels of maternal deaths. Over the next 4 years, SMGL expanded to a total of 13 districts in Uganda and 18 in Zambia. SMGL built on existing host government and private maternal and child health platforms, and was aligned with and guided by Ugandan and Zambian maternal and newborn health policies and programs. A 35% reduction in the maternal mortality ratio (MMR) was achieved in SMGL-designated facilities in both countries during the first 12 months of implementation. RESULTS: Maternal health outcomes achieved after 5 years of implementation in the SMGL-designated pilot districts were substantial: a 44% reduction in both facility and districtwide MMR in Uganda, and a 38% decrease in facility and a 41% decline in districtwide MMR in Zambia. Facility deliveries increased by 47% (from 46% to 67%) in Uganda and by 44% (from 62% to 90%) in Zambia. Cesarean delivery rates also increased: by 71% in Uganda (from 5.3% to 9.0%) and by 79% in Zambia (from 2.7% to 4.8%). The average annual rate of reduction for maternal deaths in the SMGL-supported districts exceeded that found countrywide: 11.5% versus 3.5% in Uganda and 10.5% versus 2.8% in Zambia. The changes in stillbirth rates were significant (-13% in Uganda and -36% in Zambia) but those for pre-discharge neonatal mortality rates were not significant in either Uganda or Zambia. CONCLUSION: A district health systems strengthening approach to addressing the 3 delays to accessing timely, appropriate, high-quality care for pregnant women can save women's lives from preventable causes and reduce stillbirths. The approach appears not to significantly impact pre-discharge neonatal mortality.