Saving Mothers, Giving Life Phase 1 Monitoring and Evaluation Findings:

8/12/2019 Saving Mothers, Giving Life Phase 1 Monitoring and Evaluation Findings:

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Saving Mothers, Giving LifeSMGL Phase I Monitoringand Evaluation Findings:

Executive Summary


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Suggested citation:Centers for Disease Control and Prevention. Saving Mothers, Giving Life Phase 1 Monitoring and Evaluation Findings: Executive

Summary. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2014.


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Acknowledgements This summary and the accompanying reports were prepared by staff of the Centers for Disease Controland Prevention (CDC) of the US Government, located both at CDC headquarters and in the Ugandaand Zambia CDC country offices.

Thousands of individuals participated in activities to monitor and evaluate Phase 1 of the Saving Moth-ers, Giving Life (SMGL) Initiative, including: staff affiliated with country SMGL teams and implementingorganizations; district and national-level Ministry of Health officials; village health teams and communityhealth workers; headquarters representatives of all US Government agencies involved; the Governmentof Norway; and private-sector SMGL partners. Because those involved in this momentous effort are toonumerous to name individually, the organizations they represent are acknowledged below:

UgandaGovernment of Uganda

Ministry of Health of Uganda

District Medical/ Health OfficersUganda Village Heath Teams

Centers for Disease Control andPrevention (CDC) Country Office

US Agency for International Development(USAID) Mission in Uganda

Baylor Childrens Foundation

Uganda Infectious Diseases Institute(Makerere University)

Marie Stopes Uganda (MSU)

STRIDES for Family Health

Health Care Improvement Project (HCI)

Uganda Health Marketing Group (UHMG)

Uganda Episcopal Conference (UEC)

Health Initiatives for the Private Sector (HIPS)

Capacity Project

Stop Malaria Project (SMP)

Johns Hopkins University

Strengthening Decentralizationfor Sustainability (SDS)

Uganda Blood Transfusion Services (UBTS)

Makerere University School of Public Health

Securing Ugandas Right toEssential Medicines (SURE)

Zambia

Government of ZambiaZambia Ministry of Community Development,Mother and Child Health (MCDMCH)

Zambia Central Statistics Office

District and Provincial Medical/ Health Officers

Community Health Workers and SafeMotherhood Action Groups (SMAGs)

Centers for Disease Control andPrevention (CDC) Country Office

US Agency for International Development(USAID) Mission in Zambia

Center for Infectious DiseaseResearch in Zambia (CIDRZ)

Zambia Center for Applied Health Research andDevelopment (Boston University) (ZCAHRD)

Maternal and Child HealthIntegrated Program (MCHIP)

Zambia Integrated SystemsStrengthening Program (ZISSP)

Communication Support for Health (CSH)

University of Zambia (UNZA)

Department of Population Studies

Global PartnersAmerican College of Obstetricians and Gynecologists

Every Mother Counts

Merck for Mothers

Government of Norway

Project CURE

US Government Agencies:Centers for Disease Control and Prevention (CDC)US Agency for International Development (USAID)Peace CorpsUS Department of Defense (DOD)US Global AIDS Coordinator (OGAC)


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4 SMGL Phase I Monitoring and Evaluation Findings: Executive Summary


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Table of Contents

Introduction .....................................................................................................................................................................................6

SMGL Monitoring and Evaluation ..............................................................................................................8

Results ........................................................................................................................................................................................................9

Maternal Deaths ............................................................................................................................................................................9

Access to and Availability of Obstetric Care ...............................................................................11

Emergency Obstetric and Newborn Care ..................................................................................16

HIV Prevention and Treatment for Women and Infants ..........................................19

Conclusion ......................................................................................................................................................................................................20

Summary of Key Findings from SMGL Phase 1 .......................................................................21


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IntroductionSaving Mothers, Giving Life (SMGL) is a 5-yearinitiative designed to rapidly reduce deathsrelated to pregnancy and childbirth througha coordinated approach that strengthensmaternal health services in high-mortality set-tings. These evidence-based interventionsare focused primarily on the critical periodof labor, delivery, and 48 hours postpar-tum, when most maternal deaths and abouthalf of newborn deaths occur. Coordinatedand funded by a public-private partnership, 1 SMGL strives to improve access to, demandfor, and the quality of Emergency Obstetricand Newborn Care (EmONC). 2 It also seeks tostrengthen links to other essential services for

women and children, including HIV preven-tion, care, and treatment, and family planning.SMGL began in June 2012 in eight districts,

four each in Uganda and Zambia. Phase 1 (thepilot phase) activities took place from June 2012through May 2013. Participating US Governmentagencies, along with partner governments andmultiple partner organizations, enhanced exist-ing district maternal and child health services tostrengthen evidence-based interventions. Alto-gether, 107 health facilities in Uganda and 113in Zambia that provided delivery care received

support through the SMGL initiative. SMGL activ-ities included routine monitoring during therst year of the project, including baseline andendline assessments before and after Phase 1.

SMGLs essential components andconcepts include the following:

A comprehensive approach. Womenslives cannot be saved by any one interven-tion alone. Reducing maternal mortalityrequires a solution that addresses multi-ple health system issues at multiple levels.SMGL uses evidence-based interventionsthat are designed to address three danger-ous delays that pregnant women face in

childbirth: delays in deciding to seek carefor an obstetric emergency, delays in reach-ing a health facility in time, and delays inreceiving quality care at health facilities.

An adequate number of high-qual-ity delivery facilities, including EmONC,that are accessible within 2 hours of theonset of labor or obstetric emergencies.

An integrated communication-transpor-tation system that functions 24 hoursa day/7-days a week to encourage andenable pregnant women to use deliverycare facilities. This system should includecommunity outreach and interventionsthat increase awareness of these facilities.

An adequate number of skilled birth atten-dants who can provide quality care fornormal delivery and who are able to iden-tify and refer obstetric emergencies.

A functional supply chain system to ensurethat facilities have the equipment, sup-plies, commodities, and drugs they needto deliver high-quality obstetric care.

A system that accurately records everybirth and maternal and neonatal death.

Results from monitoring and evaluationindicate that SMGL interventions are effective.For example,

Maternal mortality fell sharply (by 30%) injust 1 year in Ugandas four SMGL districts.It also declined by 35% in health facili-ties that implemented SMGL interventionsin both Uganda and Zambia. (Population-based maternal mortality rates could not becalculated for the SMGL districts in Zam-bia.) These improvements appear to be due

to womens increased access to emergencyobstetric care and the effective care theyreceive once they arrive at health facilities.

1. Current partners are the American College of Obstetricians and Gynecologists, Every Mother Counts, Merck for Mothers, the Government of Norway,Project CURE, and the US Government [Centers for Disease Control and Prevention (CDC), US Agency for International Development (USAID),Corps, US Department of Defense, and US Office of the Global AIDS Coordinator (OGAC)]. The governments of Uganda and Zambia werecentral to the partnership and all activities.

2. Emergency Obstetric and Newborn Care includes a set of 9 life-saving interventions, known as signal functions that the World HealthOrganization has recommended to reduce maternal and neonatal mortality. Specic interventions are described later in this report.


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7SMGL Phase I Monitoring and Evaluation Findings: Executive Summary

The percentage of all births in SMGL dis-tricts that occurred at health facilitiesincreased during Phase 1 from 46% to74% in Uganda (a 62% increase) and from63% to 84% in Zambia (a 35% increase).

The percentage of all facilities performing

specic life-saving interventions increased. By the end of Phase 1, each country hadan adequate number of facilities (relative toeach districts population) to provide basicand comprehensive EmONC. In particu-lar, mid-level health clinics in both countriesmade substantial gains in their ability to per-form more life-saving interventions. Thepercentage of mid-level facilities that wereproviding four to ve of the recommendedseven signal functions increased from 28%at baseline to 44% by the end of Phase 1 inUganda, and from 24% to 37% in Zambia.SMGL districts showed improvement intreatment for HIV-positive mothers andprophylaxis for their infants betweenthe baseline and endline assessments. InUganda, 28% more HIV-positive womenreceived treatment and 27% more infantsreceived prophylaxis. Increases in Zam-bia were 18% and 29%, respectively.

These successes were likely due to acombination of the following factors:

Greater supply of services, includ-ing increased availability and improvedaccess to obstetric services.

Increased demand for obstetric and HIVservices, due to voucher programs andintensied activities to increase commu-nity awareness, as well as womens growingrecognition of the importance of facilitydelivery and skilled attendance at birth.

Improved quality of care at facilitiesthat hired more staff, trained and men-tored more staff in EmONC, and stockednecessary equipment and supplies, andhad reliable supplies of medicines.

The rst year of SMGL was designed toprovide proof of concept in the eight pilotdistricts to determine (1) if the SMGL inter-

ventions could improve health outcomes for women and their infants and (2) how theseinterventions could be scaled up as SMGLexpands. The declines in mortality achievedin both countries are impressive given thePhase 1s short timeframe (12 months).

This Executive Summary and the accom-panying reports were prepared by staff of theCenters for Disease Control and Prevention(CDC) of the United States at CDCs headquar-ters in Atlanta, Georgia, and in the Ugandaand Zambia CDC country ofces. CDC, in col-laboration with the USAID and OGAC, led themonitoring and evaluation efforts for the SMGLinitiative. These activities were conducted in

close collaboration with the governments ofUganda and Zambia and partner organizations.


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SMGL Monitoring and EvaluationExtensive monitoring and evaluation (M&E) ofSMGL during Phase 1 was essential to assesspotential changes in the key indicators closelyrelated to maternal and neonatal mortality.SMGL M&E efforts drew upon the experi-ence of existing global initiatives designed tostandardize data collection methods for mon-itoring interventions, making decisions, anddeveloping health policies related to mater-nal and neonatal outcomes and care.

The SMGL M&E Framework included arange of indicators designed to measure pro-gram achievements in Phase 1. They canbe grouped into four broad categories:

Impact such as changes in the num-

ber of maternal and newborn deaths Outcomes such as percent-

age of deliveries in health facilitiesand rates of Cesarean sections

Outputs such as the number ofEmONC signal functions performed,HIV tests conducted, and PMTCT (pre-

vention of mother-to-child HIVtransmission) services provided

Processes such as hiring and train-ing personnel, upgrading facilities, andstockpiling life-saving medicines

Several M&E methods were used to assess the various aspects of SMGL during Phase 1. Themost important of these processes were

Health Facility Assessments (HFAs): HFAs were conducted before and after Phase 1 atall facilities that provide delivery services inthe SMGL districts in both Uganda and Zam-bia. They gathered baseline and endline dataon maternity care infrastructure; EmONCavailability and use; human resources;

and drugs, equipment, and supplies.Routine Health Information Systems: Exist-ing Health Management Information Systems(HMIS), which collect monthly statistics fromhealth facilities, were used to monitor accessto and quality, efciency, and use of mater-nal and child health services. For example,one health information system supported

by the Presidents Emergency Plan for AIDSRelief (PEPFAR) monitors maternal and childhealth (MCH) and HIV-related indicators.

Facility-Based Pregnancy Outcome Monitor-ing: To track key facility indicators, Ugandaand Zambia intensied existing efforts todocument maternal and neonatal outcomesaccurately and completely. These outcomesincluded maternal complications, the use oflife-saving interventions such as Cesareansections, and more thorough identicationand investigation of maternal deaths. In Zam-bia, reductions in maternal mortality weremonitored through routine identicationand investigation of deaths that occurred infacilities before and during SMGL Phase 1.Community-Based Maternal MortalityIdentication: In Uganda, SMGL built onthe existing data collection infrastructureof Village Health Teams (VHTs) to con-duct a baseline and endline Reproductive

Age Mortality Study (RAMOS) in SMGL dis-tricts. A VHT member visited each householdin his or her village to ask if any womenhad died during a specied period of time,and to nd out if any of these women had

been pregnant at the time of death or in thepreceding 3 months. If so, trained health workers returned to the home to conducta verbal autopsy. Doctors then reviewedthe ndings of the verbal autopsies to cer-tify the death and used the InternationalClassication of Diseases, 10th Revisionto assign a code for the cause of death.

Findings and conclusions derived from theseM&E activities are summarized in this Execu-tive Summary, including data shown in Tables1 and 2. More in-depth data analysis from themajor components of SMGL M&E is provided infour CDC reports that cover the following topics:

Monitoring and Evaluation Overview

Maternal Mortality

Obstetric Care Services: Accessand Availability

Maternal and Perinatal Health Outcomes


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ResultsMaternal Deaths Declined inSMGL Districts and FacilitiesImproved access, emergency referrals, andhigh-quality, 24-hour emergency obstetric ser-

vices can increase the number of women thathave safe deliveries and quickly reduce the riskof women dying of pregnancy-related com-plications. SMGL interventions were designedto increase these services in both Ugandaand Zambia. As a result, sharp reductions inmaternal deaths and improvements in mater-nal and perinatal health outcomes werereported in the rst year of this initiative.

UgandaTo identify all maternal deaths, Uganda

Conducted a baseline and endline RAMOSto collect mortality data before andafter SMGL. Baseline deaths were thosethat occurred in the 12 months beforePhase 1 ( June 2011May 2012). Endlinedeaths were those that occurred dur-ing Phase 1 (June 2012May 2013).

Conducted verbal autopsies of eachdeath to learn the cause of death, placeof death, and contributing factors.Introduced community-based mater-nal mortality surveillance consisting ofmonthly identication and reporting ofsuspected maternal deaths by the VHTs dur-ing Phase 1 and continuing into Phase 2.

Reviewed medical records in SMGL facilitiesto identify the maternal deaths that occurredin facilities before and during the pilot year.

Maternal deaths from major direct obstet-ric causes declined by 39%, from an MMRof 382 per 100,000 live births to 234 per100,000. The largest reductions were forthe direct obstetric causes of obstructedlabor or uterine rupture (-54%), sepsisor infection (-50%), and obstetric hem-orrhage (-43%). All three of these causes

were addressed by components of theSMGL interventions, which focused onreducing maternal deaths in the periodaround and soon after labor and delivery.

The MMR for maternal deaths during thepostpartum period (142 days after deliv-ery) declined by 39%, from 223 per 100,000live births to 137 per 100,000. Both beforeand during Phase 1, the largest percentageof maternal deaths occurred after the rstday during the postpartum period, followedby deaths during pregnancy or delivery. Thereduction in postpartum deaths was alsolarger than declines in deaths during preg-nancy or delivery. Maternal deaths duringlabor, delivery, or less than 24 hours afterthe end of a pregnancy also declined (-28%).

A more modest decline was documentedfor maternal deaths during pregnancy(-5%). This smaller decline is not surpris-ing given the focus of SMGL on the periodof labor and delivery and early postpartum.

Maternal deaths in health facilities in theSMGL districts declined by 35%, from534 deaths per 100,000 live births to345 per 100,000. Declines in cause-spe-cic mortality were particularly striking forobstetric labor and postpartum sepsis.

The decrease in maternal deaths in healthfacilities is associated with a decrease incase fatality rates. In Uganda, the casefatality rate for deaths due to directobstetric complications declined by 25%in all facilities that performed deliver-ies (from 2.6% to 2.0%) and by 18% inEmONC facilities (from 2.9% to 2.4%).

During Phase 1 in Uganda, thematernal mortality ratio (MMR) forthe four SMGL districts (Kibaale,Kabarole, Kyenjojo and Kamwenge)declined from 452 maternal deathsper 100,000 live births at baselineto 316 per 100,000 at endline, a 30%decline in maternal mortality.


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These declines were accompanied by a42% increase in met need for EmONC (theproportion of all expected major directobstetric complications in a populationthat were attended in EmONC facilities).

ZambiaTo identify maternal deaths, 3 Zambia

Reviewed medical records in healthfacilities in the SMGL districts to iden-tify and investigate the maternal deathsthat occurred in facilities before and dur-ing Phase 1. Baseline facility deaths werethose that occurred during the 12 monthsbefore Phase 1 (June 2011May 2012). End-line facility deaths were those that occurredduring Phase 1 (June 2012May 2013).

Zambias mortality data for the SMGLdistricts represents only deaths thatoccurred in health facilities. Facility deathrates typically differ from those for thegeneral population because health facil-ities usually have a higher proportionof women with severe complications.

Maternal deaths in health facilities fromdirect obstetric causes declined by 36%,from 260 per 100,000 live births to 167 per100,000. The largest reductions were forobstructed labor (-78%) and obstetric hemor-rhage (-34%). These causes were addressedby components of the SMGL interventions.

The decrease in maternal deaths in healthfacilities is associated with a decrease incase fatality rates. In Zambia, the case fatal-ity rate for deaths due to direct obstetriccomplications declined by 34% in all facil-ities (from 3.1% to 2.0%) and by 35% inEmONC facilities (from 3.4% to 2.2%). These declines were accompanied by a57% increase in the number of facilitiesin SMGL districts that provided EmONC.

Data on maternal deaths that occurredoutside of facilities in the SMGL districtsduring Phase 1 were not available for Zam-bia. However, the high facility delivery ratein Zambia SMGL districts (84% at endline),coupled with a high percentage of deaths infacilities at baseline (70%) and sharp reduc-tions in the facility-based MMR with SMGL, suggest a probable decline in the population-based MMR across the four SMGL districts.During SMGL Phase 1 in Zambia,

the MMR in health facilities forthe four SMGL districts (Mansa,Lundazi, Nyimba, Kalomo) declinedfrom 310 maternal deaths per100,000 live births at baseline to203 per 100,000 at endline, a 35%decline in maternal mortality.

3. Zambia SMGL used two different approaches in gathering maternal mortality data. For the baseline, Zambia SMGL conducted a mortality assessmentof the four SMGL districts that identied possible maternal deaths during the 17 months before the SMGL initiative. The assessment included verbalautopsies of each death to learn the cause of death, place of death, and contributing factors. During Phase 1, Zambia switched to tracking deaths at thecommunity level; however, this approach identied only about one-third of the expected number of pregnancies. As a result, it was not possible toproduce a reliable population-based estimate of the endline MMR across the four SMGL districts.


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Improvement in Access to andAvailability of Obstetric Care

Most maternal deaths can be preventedby increasing access to skilled birth atten-dance (including delivery in health facilities)and improving the quality of care providedto women at delivery and during the earlypostpartum period. Improvements to facili-ties in SMGL districts were meant to ensureaccess to quality obstetric care within 2hours for all women, particularly those

with severe obstetric complications. Theyincluded improvements in the following:

Human resources

Facilities and equipment for emergencyobstetric care

Surgical capacity (medical skills andequipment)

Supply chains and blood banks

Communication and transportation networks

The SMGL initiative led to a sharp increase infacility delivery rates through interventionsthat addressed both supply and demand fac-tors. The percentage of births that took placein health facilities rose during Phase 1 from46% to 74% in Uganda (a 62% increase) andfrom 63% to 84% in Zambia (a 35% increase).

To allow hospitals and higher-levelhealth centers to focus more on complicatedcases, three strategies were used to encour-age women to seek delivery services atlower-level health centers and health posts:

A minimum level of high-quality obstetricservices in lower-level facilities.

Community outreach to inform families

about facility delivery services. Improved access to lower-level facilities.

P h

o t o gr a

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b y

R i c

a r r d

o G a n

g a l e

,2

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The overall proportion of deliveries taking place in facilities in both countries increasedsharply, by 62% in Uganda and by 35% in Zambia. Moreover, the proportion of births deliv-ered in EmONC facilities increased by 29% and 17%, in Uganda and Zambia, respectively.

Facility Delivery Ratesa by Type of Facility, SMGL Districts in Uganda

Facility Delivery Ratesa by Type of Facility, SMGL Districts in Zambia

0

20

40

60

80

100

Non-EmONC Delivery RateEmONCb Delivery Rate

Start of SMGLin June 2012

62%Increase

Endline(June 2012May 2013)

Baseline(June 2011May 2012)

Apr 2013Jun 2013

Jan 2013Mar 2013

Oct 2012Dec 2012

Jul 2012Sept 2012

Apr 2012Jun 2012

Jan 2012Mar 2012

Oct 2011Dec 2011

a Percentage of deliveries in health facilities per 100 live birthsb Emergency Obstetric and Newborn Care

P e r c e n t a g e

43 42

61

78 7869 70

46

74

0

20

40

60

80

100Non-EmONC Delivery RateEmONC

b

Delivery Rate

P e r c e n t a g e

61 6166

88 8982 79

63

84Start of SMGLin June 2012

35%Increase

Endline(June 2012May 2013)

Baseline(June 2011May 2012)

Apr 2013Jun 2013

Jan 2013Mar 2013

Oct 2012Dec 2012

Jul 2012Sept 2012

Apr 2012Jun 2012

Jan 2012Mar 2012

Oct 2011Dec 2011

a Percentage of deliveries in health facilities per 100 live birthsb Emergency Obstetric and Newborn Care


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N u m

b e r o

f R e

f e r r a l s

0

500

1000

1500

2000

AprJune 2013JanMar 2013OctDec 2012JulySep 2012AprJune 2012JanMar 2012

Referrals to facilities in Mid-Western districtsReferrals to facilities in SMGL districts

711678

1445

702

1776

659

1822

1413 1475

799693

886

Start of SMGLin June 2012

To increase demand for deliveries in health facili-ties, the SMGL initiative

Activated more than 4,000 Village HealthTeam (VHT) workers in 4 districts in Uganda.

Trained 1,500 Safe Motherhood ActionGroup (SMAG) members in 4 districts

in Zambia to conduct outreach, with an

emphasis on increasing deliveries, partic-ularly in mid-level and lower-level healthfacilities (health centers and health posts).

Improved communication, trans-portation, and voucher systems.

In Uganda, the number of referrals to obstetric care facilities in SMGL districts more than doubled compared with the number of referrals in contiguous Mid-Westerndistricts that did not participate in the SMGL initiative.

Maternal Referrals to Facilities in SMGL Districts in Uganda Compared withReferrals in Mid-Western Districts


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In Zambia, the percentage of mid-level and lower-level facilities with an active SMAGincreased sharply in only 12 months.

Percentage of Mid-Level and Lower Level Facilities with anAssociated Safe Motherhood Action Group, SMGL Districtsa in Zambia

Facility infrastructure in Uganda andZambia improved. The SMGL Initiative

Increased the availability of electricityand water.

Improved communication systems to makeemergency referrals easier. By the end ofPhase 1, about 90% of health facilities ineach country had one or more functioningmeans of communication in place.

Increased access to transportation forwomen who seek delivery care in facilities, including using innovations such as transpor-tation vouchers (Uganda).

Improved service availability so that morefacilities offered delivery services 24 hours aday, 7 days a week.

Provided more beds for delivery care.

Built mothers shelters outsidehospitals where rural women can

wait for delivery (Zambia).These improvements built on and ampliedother health system improvements, includingearlier PEPFAR-funded improvements in the8 SMGL districts.

0

20

40

60

80

100

Endline (Jun 2013)Baseline (Dec 2011)

HealthPosts

HealthCenters

P e r c e n t a g e

aExcludes Kalomo district where data were not available

66

89

56

88


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Percentage of Health Facilities with Selected Infrastructure, SMGL Districts in Uganda

Percentage of Health Facilities with Selected Infrastructure, SMGL Districts in Zambia

In Uganda, improvements were made in four of ve infrastructure indicators. In Zambia,improvements were made in all ve indicators.

0

20

40

60

80

100Endline (Jun 2013)Baseline (Feb 2012)

Open 24/7 Transpor-tation

CommunicationWaterElectricity

P e r c e n t a g e 58

94

77

94 94 93

6065

80

95

0

20

40

60

80

100

Endline (Jun 2013)Baseline (Feb 2012)

Open 24/7 Transporta-tion

CommunicationWaterElectricity

P e r c e n t a g e 57

76

9099

45

89

5561

68

95


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In Uganda and Zambia, SMGL part-ners and the Ministries of Health (MOHs)committed to increase the number ofskilled medical staff and their training inSMGL districts. By the end of Phase 1--

Uganda had achieved its MOH targets

for obstetrician-gynecologists, regis-tered nurses, and registered midwives.

Zambia had increased the number ofmidwives to meet the governmentsstafng goals.

The SMGL initiative provided training inEmONC to more than 500 health careproviders in the eight pilot districts.

SMGL increased access to life-saving medi-cations through improved management andsupply chains. In Zambia, the percentageof facilities that reported no recent stock-outs of magnesium sulfate (an anticonvulsantthat reduces deaths from eclampsia) at theend of Phase 1 quadrupled (from 22% to87%). In Uganda, the percentage increasedby 32% (from 47% to 62%). Oxytocin, themain component of the Active Managementof the Third Stage of Labor, also becamemore widely available in both countries.Out-of-stock reports for this drug were virtu-ally eliminated in Zambia, and only 18% ofhealth facilities in Uganda reported a recentstock-out of oxytocin at the end of Phase 1.The availability of the equipmentnecessary to provide life-saving inter-ventions increased. In Uganda, thepercentage of facilities that had new-born ventilation equipment increasedfrom 19% to 63%. The percentage that hadfunctional autoclaves to sterilize deliveryinstruments increased from 18% to 44%.

Emergency Obstetricand Newborn CareCoverage Increased

About 15% of women develop complicationsin childbirth that are potentially life-threaten-ing and require immediate access to emergencyobstetric care. A central pillar of the SMGL strat-egy is to ensure adequate coverage of EmONC,

which is a package of life-saving interventionsdesigned to manage the direct obstetric compli-cations that cause the majority of maternal deaths.

During Phase 1, SMGL districts increasedthe met need for basic and comprehen-sive EmONC by 42% in Uganda and 31%in Zambia. (Met need for EmONC isthe estimated proportion of all women

with major obstetric complications whoare treated in EmONC facilities.)

Availability of basic and comprehensiveEmONC facilities improved substantiallybecause of SMGL. Health facilities in SMGLdistricts were classied as Basic (BEmONC)or Comprehensive (CEmONC) care facil-ities4 (or neither) on the basis of whetherthey had recently performed specic medi-cal interventions (aka signal functions) thatthe World Health Organization (WHO) hasdetermined should be available to save thelives of mothers and newborns. The num-ber of CEmONC facilities (those havingthe ability to perform Cesarean sectionsand blood transfusions, in addition to theseven basic life-saving interventions thatshould be available in BEmONC facili-ties) increased from 7 to 16 in Uganda, andfrom 4 to 5 in Zambia. The number ofBEmONC facilities also increased from 3 to9 in Uganda, and from 3 to 6 in Zambia.

4. Emergency Obstetric and Newborn Care includes a set of 9 life-saving interventions, known as signal functions that the World Health Organizationhas recommended to reduce maternal and neonatal mortality. Basic Emergency Obstetric and Newborn Care (BEmONC) facilities are those thatperformed at least 6 of 7 functions in the 3 preceding months (administer parenteral antibiotics, parenteral oxytocic drugs, parenteral anticonvulsantsfor pre-eclampsia and eclampsia; perform manual removal of placenta, removal of retained products, and assisted vaginal delivery). ComprehensiveEmergency Obstetric and Newborn Care (CEmONC) facilities are those that per formed BEmONC signal functions and two additional functions:Cesarean sections and blood transfusions.


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In Uganda, the percentage of mid-level health centers performing BEmONC signalfunctions increased for ve of the seven functions. Zambia reported an increase infour of the seven functions in mid-level health centers.

Percentage of Mid-Level Health Centers (HC III) that Performed BEmONC Signal Functionsin the Past 3 Months, SMGL Districts in Uganda

Percentage of Health Centers that Performed BEmONC Signal Functionsin the Past 3 Months, SMGL Districts in Zambia

0

20

40

60

80

100

8175

89 93

39

28 26

65

3429

14

33

611

Endline (Jun 2013)Baseline (Dec 2011)

AssistedVaginalDelivery

Removal ofRetainedProducts

ManualRemoval of

Placenta

NewbornResuscitation

Anti-convulsants

OxytocinAntibiotics

BEmONC Signal Functions

P e r c e n t a g e

0

20

40

60

80

100

Endline (Jun 2013)Baseline (Feb 2012)

AssistedVaginalDelivery

Removal ofRetainedProducts

ManualRemoval of

Placenta

NewbornResuscitation

Anti-convulsants

OxytocinAntibiotics

BEmONC Signal Functions

P e r c e n t a g e

83

94

65

96

49

32 29

71

24

43

13

43

1 0


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In both countries, the largest gains in per-formance of the EmONC signal functionsoccurred in mid-level facilities. In particu-lar, mid-level health clinics in both countriesmade substantial gains in their ability to per-form signal functions. The percentage ofmid-level facilities that were performing 45signal functions increased from 28% to 44%in Uganda, and from 24% to 37% in Zambia

Cesarean sections as a percentage of allbirths increased in EmONC facilities in bothcountries. This increase was most evidentin Uganda, where the percentage increasedfrom 5.3% to 6.5% (a 23% increase), furtherexceeding the 5% minimum recommendedby WHO. In Zambia, the percentageincreased from 2.7% to 3.1% (a 15% increase).

Institutional perinatal mortal-ity (PMR) 5 rates declined. Ugandareported an 17% decrease in PMR,

while Zambia reported a 14% decreasebetween the baseline and endline. Declines in the PMR were due to declines

in the institutional stillbirth rate. Both

countries showed comparable and signi-cant declines in institutional stillbirth rates(20% in Uganda, 19% in Zambia), sug-gesting important improvements in thequality of delivery care in health facilities.

The pre-discharge institutional neona-

tal mortality rate (NMR), however, did notchange signicantly between the baselineand endline assessments in either coun-try.6 This lack of improvement in theNMR could have been because of a shiftin mortality from the intrapartum period(i.e., fewer deaths occurred during laborand delivery because of improved qualityand timeliness of care) to the postpar-tum period (more infants were born alivedue to skilled care, but were too sick tosurvive). Training on neonatal resuscita-

tion may also have led to improvementsin the classication of neonatal deaths.Deaths that would have been classied asstillbirths in the baseline may have beenclassied as neonatal in the endline.

5. The institutional perinatal mortality rate is the number of stillbirths and predischarge neonatal deaths, divided by the number of total births in the samefacilities, during the same period, per 1,000.

6. Erratum An advance copy of this executive summary indicated the pre-discharge institutional neonatal mortality rate (NMR) increased signicantlyin Uganda during SMGL Phase 1. Further investigation found and corrected erroneously recorded data in one facility, leading to a downward revisionof the endline NMR and PMR in Uganda.

Facility Perinatal Mortality Rate Before and After SMGL,SMGL Districts in Uganda and Zambia

0

10

20

30

40

50

Uganda Endline

Uganda Baseline

Zambia Endline

Zambia Baseline

ZambiaUganda

P

e r i n a t a

l D e a t h s p e r

1 , 0

0 0 F a c

i l i t y

B i r t h s

39

3338

33


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Number of HIV-Positive Pregnant Women and Their Infants WhoReceived Testing and Treatment, SMGL Districts in Zambia

HIV Prevention andTreatment for Womenand Infants ImprovedBecause the SMGL initiative was built on andintegrated with existing PEPFAR and MCH effortsand platforms, it was expected that SMGL wouldcontribute to mutually benecial results in areas

where initiatives overlapped, especially for careand treatment of HIV-positive pregnant womenand their infants. Evaluation of activities con-ducted during Phase I found the following:

In CEmONC facilities in Uganda, the num-ber of HIV-positive mothers treated andinfants who received prophylaxis hadbeen on the rise before SMGL, due to thePrevention of Maternal to Child Transmis-

sion (PMTCT) acceleration supported byPEPFAR. These gains continued and wereamplied during Phase 1 of the SMGL ini-tiative. As a result, the number of womendelivering in CEmONC facilities whose

HIV status was known at the time of thebirth increased from 16,941 at the base-line to 20,564 at the end of Phase 1 (21%increase). The number of HIV-positivemothers delivering in these facilities whoreceived antiretroviral drugs increasedfrom 1,262 to 1,620 (a 28% increase). Thenumber of infants born in these facili-ties who received prophylaxis increasedfrom 1,117 to 1,415 (a 27% increase).

In Zambia, routine data collected by PEP-FAR also showed a clear improvement intreatment for HIV-positive mothers andprophylaxis for their infants. Between thebaseline and endline assessments, the num-ber of pregnant women with known HIVstatus (including women who were tested forHIV and received test results) increased from

23,986 to 33,176 (a 38% increase); the num-ber of HIV-positive women treated increasedfrom 930 to 1,095 (an 18% increase), whilethe number of infants receiving prophylaxisincreased from 523 to 674 (a 29% increase).

0

200

400

600

800

1000

1200

Infants born to HIV-positive women who startedCTX prophylaxis within 2 months of birth

Infants born to HIV-positive women whowere tested within 12 months of birth

HIV-positive pregnant womenwho received treatment

Oct 2012Mar 2013(During SMGL)

Oct 2011Mar 2012(Pre-SMGL)

Source: PEPFAR Semi-Annual Performance Reporting 2012/2013

N u m

b e r o

f C a s e s

930

600523

674

10951062


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ConclusionThere is much to celebrate about recent improve-ments in access to, utilization of, and qualityof maternity care for women and infants in the

countries that participated in the rst year ofthe SMGL initiative. Improvements in the avail-ability of and access to EmONC have saved thelives of many women who experienced obstet-ric hemorrhage, obstructed labor, eclampsia,preeclampsia, sepsis, and other major obstet-ric complications. The SMGL improvementshave also saved the lives of many infantsborn to women with these complications.

During Phase 1, the intensive and wide-ranging interventions of the SMGL initiativeresulted in sharp declines in maternal mortal-

ity in SMGL districts in Uganda and in facilitiesin SMGL districts in Zambia. These declines sug-gest that the SMGL approach could be expandedand used in other locations to reduce the tollof maternal deaths in resource-limited settings.

In Phase 2, SMGL will seek to further reducethe maternal and neonatal mortality, and applythese life-saving interventions in additional dis-tricts and countries. In order to sustain and buildon the progress made in Phase 1, SMGL needs to

Maintain the increased availability, use, andquality of EmONC in the pilot districts.

Work with lower-level facilities to continueto improve their obstetric services by ensur-ing routine use of Active Management ofthe Third Stage of Labor, immediate man-agement of postpartum hemorrhage andother severe maternal complications (includ-ing shock), and neonatal resuscitation.

Provide emergency transfer for com-plications that cannot be managed at

lower-level facilities by strengtheningand clarifying protocols, procedures, andagreements with higher-level facilities.

Focus on improvements in neonatal sur- vival through improved newborn care.

Maternal mortality can be further reducedthrough continued implementation of SMGL.Recommended activities include the following:

Earlier, more timely access to health facilitiesbecause many women who died in healthfacilities arrived in a critical state.

Sustained increases in the proportion of women who deliver in health facilities.

Measurable improvements in the quality ofobstetric and newborn care.

P h

o t o gr a

ph

b y

R i c

a r r d

o G a n

g a l e

,2

0 1

3


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Summary of Key Findingsfrom SMGL Phase 1

The numbers of obstetrician-gyne-cologists and registered midwivesincreased in the four SMGL districts inUganda to meet the Ministry of Healthstargets. In Zambia, the number of mid-

wives in the SMGL districts increased tomeet the governments stafng goals.

The availability of basic and comprehen-sive emergency obstetric and neonatalcare facilities (EmONC) increased sharplybecause of the SMGL initiative. The abil-ity of facilities to meet the need for

EmONC increased from 46% to 66% inUganda (a 42% increase) and from 34%to 45% in Zambia (a 31% increase).

Rates of Cesarean section increased.The percentage of all births deliveredby Cesarean section increased by 23%in Uganda and by 11% in Zambia.

Perinatal mortality rates (PMRs) and still-birth rates declined in both countries.The PMR in Uganda dropped 17%, whilethe rate in Zambia dropped 14%. Still-

born rates dropped 20% in Ugandaand 19% in Zambia, suggesting impor-tant improvements in the timeliness andquality of delivery care in facilities.

In Uganda, the maternal mortality ratio(MMR) for the four SMGL districts declined30%, from 452 maternal deaths per 100,000live births at the baseline assessment to316 per 100,000 at the endline assessment.

In Zambia, the MMR for health facil-ities in the four SMGL districtsdeclined by 35%, from 310 maternaldeaths per 100,000 live births at base-line to 203 per 100,000 at endline.

Major direct obstetric causes of mater-nal death declined in both Uganda andZambia. In the four SMGL districts inUganda, the MMR decreased by 43% forobstetric hemorrhage and by 54% forobstructed labor. In health facilities inthe SMGL districts in Zambia, the MMRdecreased by 78% for obstructed laborand by 34% for obstetric hemorrhage.

Rates of delivery in health facilitiesincreased sharply in both countries. Thepercentage of births that took placein facilities rose from 46% to 74% in

Uganda (a 62% increase) and from 63%to 84% in Zambia (a 35% increase).


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Table 1. SMGL Districts inUganda: Summary of Phase 1 Changes in SMGL IndicatorsBaseline 1 Endline % Change 2 Sig. Level 3

District-wide Maternal MortalityMaternal Mortality Ratio4 (per 100,000 live births) 452 316 -30% ***

Obstetric hemorrhage 128 73 -43% ***Obstructed labor and uterine rupture 71 33 -54% ***Eclampsia / Pre-Eclampsia 58 45

Cause-specic Postpartum sepsis 33 17Maternal Mortality Ratio

5

Complications of abortion 42 36

-23%-50%-15%

NS**NS

Other direct causes 49 31 -37% *Indirect causes 70 82 17% NS

Maternal and Perinatal Outcomes in FacilitiesMaternal Mortality Ratio in Facilities6 (per 100,000 live births in facilities) 534 345 -35% ***

Obstetric hemorrhage 131 94 -29% NSObstructed labor and uterine rupture 72 30 -58% **Eclampsia / Pre-Eclampsia 45 46Cause-specic

Maternal Mortality Postpartum sepsis 75 32Ratio in Facilities7 Complications of abortion 63 35

3%-57%-44%

NS**NS

Other direct causes 30 32 7% NSIndirect causes 119 76 -36% *All Facilities 46% 74%

Institutional Delivery Rate8 EmONC9 Facilities 28% 36%

62%28%

******

% Institutional deliveries supported by transport vouchers (3 districts) 10 6% 39% 550% ***Active Management of Third Stage of Labor Rate (%) 42% 85%in Comprehensive EmONC Facilities 100% ***

Cesarean Sections as a Proportion of All Births (%) 5.3% 6.5% 23% ***All Facilities 46% 66%

Met Need for EmONC11 (%)EmONC Facilities 39% 49%

42%25%

******

All Facilities 2.6% 2.0%Direct Obstetric Case Fatality Rate

12

(%) EmONC Facilities 2.9% 2.4%-25%-18%

**NS

Institutional Perinatal Mortality Rate13 (per 1,000 births) 39.3 32.7 -17% ***Institutional Stillbirth Rate14 (per 1,000 births) 31.2 24.8 -20% ***Pre-discharge Neonatal Mortality Rate 15 (per 1,000 live births) 8.4 8.1 -4% NSHIV Prevention in FacilitiesNumber of women who received prophylaxis or treatment 1262 1620 28%Number of infants born to HIV-positive pregnant women who received prophylaxis 1117 1415 27%Service DeliveryNumber of Basic EmONC facilities 3 9 200%Number of Comprehensive EmONC facilities 7 16 129%

% of Lower-level health facilities with Partial Basic EmONC16 28% 44% 57%Power availability 58% 94% 62%Water availability 77% 94% 22%Delivery care available 24 hours / 7 days a week (all facilities) 80% 95% 19%Number of Bir ths, June 2012 May 2013District-Wide Births 75675 78261 3%Births in Facilities 33492 56571 69%


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References for Table 11. Baseline deaths occurred in the 12 months before Phase 1 (June 2011May 2012); endline deaths occurred during Phase 1 (June 2012May 2013). Baseline facility outcom

occurred during the 12 months before Phase 1 (June 2011May 2012); endline facility outcomes occurred during Phase 1 (June 2012May 2013). Baseline Health FacilityAssessments were conducted in December 2011 (Zambia) and February 2012 (Uganda); endline Health Facility Assessments were conducted in June 2013.

2. Percent change calculations based on unrounded numbers.3. Asterisks indicate signicance level using the z-statistic as follows: ***p


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Baseline 1 Endline % Change 2 Sig. Level 3

District-wide Maternal Mortality

Maternal Mortality Ratio4 (per 100,000 live births) 310 202 -35% **Obstetric hemorrhage 110 72 -34% NS

Cause-specicMaternal Mortality Ratio5

Obstructed labor and uterine rupture -78% **Other direct causes 91 82 -11% NSIndirect causes 50 36 -28% NSAll Facilities

Institutional Delivery Rate6 (%)EmONC7 Facilities

63%26%

84%30%

35%17%

******

Cesarean Sections as a Proportion of All Births (%) 2.7% 3.1% 15% ***All Facilities

Met Need for EmONC8 (%)EmONC Facilities

34%26%

45%32%

31%23%

******

All FacilitiesDirect Obstetric Case Fatality Rate9 (%)

EmONC Facilities3.1%3.4%

2.0%2.2%

-34%-35%

****

Institutional Perinatal Mortality Rate10 (per 1,000 births) 37.9 32.8 -14% ***Institutional Stillbirth Rate11 (per 1,000 births) 30.5 24.8 -19% ***Pre-discharge Neonatal Mortality Rate 12 (per 1,000 live births) 7.7 8.2 7% NS

HIV Prevention in FacilitiesNumber of women who received prophylaxis or treatment 930 1095 18%Number of infants born to HIV-positive pregnant womenwho received prophylaxis during the rst 2 months 523 674 29%

Service Delivery

Number of Basic EmONC facilities 3 6 100%Number of Comprehensive EmONC facilities 4 5 25%% of Lower-level health facilities with Partial Basic EmONC13 28% 44% 57%Power availability 57% 76% 33%Water availability 90% 99% 10%Delivery care available 24 hours/7 days a week (all facilities) 68% 95% 40%Mothers shelter availability (% of health centers) 30% 36% 20%Number of Births, June 2012 May 2013

District-Wide Births 35879 37379 4%Births in Facilities 21914 30619 40%

Table 2. SMGL Districts inZambia: Summary of Phase 1 Changes in SMGL Indicators

59 13

1. Baseline facility deaths occurred in the 12 months before Phase 1 (June 2011May 2012); endline deaths occurred during Phase 1 (June 2012May 2013). Baseline facilityoutcomes occurred during the 12 months before Phase 1 (June 2011May 2012); endline facility outcomes occurred during Phase 1 (June 2012May 2013). Baseline HealtFacility Assessments were conducted in December 2011 (Zambia) and February 2012 (Uganda); endline Health Facility Assessments were conducted in June 2013.

2. Percent change calculations based on unrounded numbers.3. Asterisks indicate signicance level using the z-statistic as follows: ***p


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Notes:


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For more information please contact:

Centers for Disease Control and Prevention

Division of Reproductive Health, Mailstop F-741600 Clifton Road NE, Atlanta, GA 30333

Telephone: 1-800-CDC-INFO (232-4636) / TTY: 1-888-232-6348E-mail:[email protected]

Web: www.cdc.gov
mailto:[email protected]://www.cdc.gov/http://www.cdc.gov/mailto:[email protected]

Documents

Saving Mothers, Giving Life Phase 1 Monitoring and Evaluation Findings: