This evaluation includes program data from multiple implementation partners that addressed the second delay to care within the context of the SMGL initiative. In this section, we first present the overall statistics for the change in rate of facility delivery within the SMGL districts by country. We then provide a brief description of the interventions under each SMGL strategy (Table 1) and their results.
The facility delivery rate at all facilities providing delivery services increased by 47% in Uganda and 44% in Zambia during the evaluation period (2011–2016). The increase in the facility delivery rate in Uganda was due to increased use of both facilities that met the EmONC requirements (45% increase) and of non-EmONC delivery facilities (49% increase) (Table 2). By contrast, the change in Zambia was primarily driven by increased use of non-EmONC delivery facilities (67% increase). The proportion of births in EmONC facilities increased to a lesser degree (12% increase) (Table 3). Facilities that did not meet BEmONC requirements may have had some, but not all, of the 7 interventions defining BEmONC.2
The facility delivery rate at all facilities providing delivery services increased by 47% in Uganda and 44% in Zambia during the evaluation period.
Strategy 1: Decrease Distance to Skilled Birth Attendance by Increasing the Number of EmONC Facilities
Decreasing the distance to skilled birth attendance was addressed by upgrading a sufficient number of existing health facilities to meet BEmONC criteria in appropriate geographic positions (Table 1). One BEmONC criterion is to remain open 24 hours a day, 7 days a week with skilled staff present; this was a key element of the SMGL initiative to encourage and enable women to deliver in health facilities.27 Also critical for an EmONC facility is ensuring the availability of sufficient numbers of skilled birth attendants capable of managing complications (Table 1). During both Phase 1 and 2 of SMGL implementation, partners worked with ministries of health in both Uganda and Zambia to ensure facilities had staff capable of providing EmONC services.
To address a shortage of health centers adequately equipped to handle deliveries, an implementing partner worked with districts to identify facilities that would benefit from additional support to enable them to provide BEmONC services in geographic areas lacking these services. Facilities previously offering only outpatient services, but which had adequate space, were supported with the necessary equipment and supplies to conduct delivery services, and skilled midwives were redeployed to work there. To ensure the availability of a sufficient number of skilled staff, medical officers, anesthetists, midwives, and nurses were hired and retrained in EmONC.
During the period of implementation, 12 health center II facilities (which are generally outpatient facilities) in hard-to-reach areas were strengthened to provide delivery services capable of managing basic complications. The number of EmONC facilities increased between baseline and endline by more than double—from 10 (3 BEmONC and 7 CEmONC) to 26 (9 BEmONC and 17 CEmONC), with a 200% increase in the number of health facilities capable of providing BEmONC services (Table 2). Though not statistically significant, Uganda saw a 10% relative increase in the proportion of health facilities offering services 24 hours a day, 7 days a week. At baseline, all SMGL facilities had at least 1 doctor, nurse, or midwife on duty and this remained the same at endline (Table 2).
An analysis of the changes in estimated travel time to reach EmONC facilities across SMGL time points in Uganda found that geographic access to BEmONC and CEmONC increased significantly (P<.01) within the 4 SMGL study districts between 2012 and 2016.28
In Zambia, partners implemented a range of interventions including purchasing essential equipment, supplies, and medications necessary for EmONC, both basic and comprehensive; hiring additional midwives to fill existing vacancies; training doctors, midwives, and anesthetists in EmONC; and renovating health facility infrastructure, including making improvements to water source and provision of solar power when electricity was not available. Recently retired midwives were recruited to return to active service. In addition, implementing partners and district staff conducted monthly on-site mentorship of health facility staff using protocols, forms, and drills.
The number of EmONC facilities increased from 7 (3 BEmONC and 4 CEmONC) to 13 (8 BEmONC and 5 CEmONC). Zambia saw a 41% increase in the number of facilities offering services 24 hours a day, 7 days a week, and the proportion of health facilities reporting at least 1 doctor, nurse, or midwife on staff at the end of the project in 2016 improved significantly (P<.05) (Table 3). Specifics about health facility staff hires and trainings have been provided elsewhere.27
Zambia saw a 41% increase in the number of facilities offering services 24 hours a day, 7 days a week.
Strategy 2: Improve the Accessibility of EmONC Facilities
As illustrated by an excerpt from a verbal autopsy (Box 1), the challenges of distance and transportation are substantial.
Vignette Illustrating Challenges Related to Delay in Reaching Care, From a Verbal Autopsy
Sylvia was a 23-year-old Ugandan woman who died giving birth to her third child, having had 2 previous births by cesarean delivery. Sylvia’s father was interviewed during a verbal autopsy. The interview was transcribed and is summarized below. Details have been added in brackets to clarify meaning; names of people, places, and dates have been changed to protect confidentiality.
At 5:00 a.m., Sylvia’s father was called and told that his daughter needed help; she was in labor, which had started some hours earlier. He found her in serious pain and went to look for a motorcycle [to take her to a health facility]. By the time he got a motorcycle, Sylvia could not manage to sit on it. It had already started raining heavily. Sylvia’s father contacted somebody who had a vehicle, but the driver told him he couldn’t manage the trip because the road was impassible. The father contacted a second person with a vehicle and was again told the trip was not possible because of the poor condition of the road. Their village was about 10.5 km from the main road. The rain continued and at 11:00 a.m. Sylvia’s brother came with a vehicle. By that time, the drug shop seller had put Sylvia on a drip [intravenous infusion] to stimulate contractions. While they were on the way to the health center number IV, or mini-hospital, the baby started bringing the head [crowning]. After they had been traveling for approximately 1 hour, Sylvia died before reaching the health center. They contacted the doctor to remove the fetus, but it had already died. The doctor told them that the uterus ruptured, which had caused Sylvia’s death.
In both Uganda and Zambia, a number of approaches were taken to improve access to EmONC services by establishing strong referral systems inclusive of communication and transportation. These approaches, detailed in the sections below, included strengthening maternity waiting homes, reinforcing communication and transportation systems, establishing community linkages to the health system, and facilitating better savings in preparation for delivery (Table 1).
Renovation and Construction of Maternity Waiting Homes
To increase access to EmONC services for women in need, partners renovated and constructed maternity waiting homes—residential lodging near facilities where women can stay while awaiting delivery—in both Uganda and Zambia. The temporary lodging spaces provided by maternity waiting homes enable health facilities with EmONC services to better accommodate mothers from hard-to-reach or distant communities who may otherwise experience transportation challenges at the time of delivery.
In one district, a partner renovated maternity waiting homes at CEmONC hospitals, creating a waiting space for women at sites that were capable of providing comprehensive care services without needing to be referred elsewhere. During SMGL Phase 1, 4 maternity waiting homes were refurbished at 1 district hospital and 3 at EmONC-capable health center IVs (health centers that function as mini-hospitals). Newly renovated maternity waiting homes in Uganda accommodated approximately 10% of all mothers who delivered at the associated health facilities during Phase 1 and Phase 2 of the initiative.
Newly renovated maternity waiting homes in Uganda accommodated approximately 10% of all mothers who delivered at the associated health facilities in Phase 1 and Phase 2 of the initiative.
In Zambia, some partners either constructed or renovated existing maternity waiting homes. As part of the Maternity Homes Alliance, other partners conducted formative research to design a community-informed maternity waiting home model during the end of SMGL Phase 1 and beginning of SMGL Phase 2 (2013–2014).9,29–31 During SMGL Phase 2 (July 2015), partners then refined the model with the government and constructed 24 maternity waiting homes in 7 SMGL districts across 3 provinces (Eastern, Luapula, and Southern) at sites where distance, physical geography, and terrain played a major role in determining access to EmONC services. Partners worked with health system staff, Safe Motherhood Action Group members, and traditional leaders to generate demand for maternity waiting homes. Beginning in SMGL Phase 2, partners began evaluating the impact of maternity waiting homes32 and assessing them for acceptability and sustainability.
During SMGL Phases 1 and 2, 211 maternity waiting home were either renovated (n=171) or newly constructed (n=40). Utilization data for all homes are not available, but in the 24 maternity waiting homes newly constructed by the Maternity Homes Alliance operating for the last 6 months of SMGL Phase 2, 1,123 women had used them before December 2016, approximately 49% of those delivering at the affiliated health facilities. Preliminary qualitative results from Zambia indicate that maternity waiting homes are acceptable to community members and that health facility staff perceive an increase in facility attendance for delivery and postnatal services (Box 2).
Stakeholder Perceptions of Maternity Waiting Homes in Zambia
“It’s always good to go and wait in the [maternity waiting home]. The doctors are always available and in case you have a complication, they always know fast. So that’s why it’s good to go and wait in the [maternity waiting home].”
—Focus group discussion with recently delivered or pregnant women
“We are very happy because it used to be a problem for our children when they become pregnant; we would be very worried on where to take our children in case of delivery. But now that they have built a [maternity waiting home] which is very good and clean, we will be very free and happy to come and live here with our children.”
—Focus group discussion with community elders
“I think the appearance of the [maternity waiting home] is very good. The way I saw it … it really helps our women because everything is there. For a woman who is very pregnant, it’s a very good thing.”
—Focus group discussion with men
“The success is that we no longer have mothers delivering from outside the facility, giving reasons that they were unable to come because they are coming from very far. Most of the mothers coming from distant places usually are admitted in our [maternity waiting home]. We have reduced on people having the excuse of delivery at home because of distance.”
—In-depth interview with health facility staff
“From the time the [maternity waiting home] was opened, we have seen that the number of women who are coming for deliveries has risen and the standard of the [maternity waiting home], which has been built now, is of high quality than the one we used to have, which was just a simple house and some women would not even want to stay in it.”
—Focus group discussion with Safe Motherhood Action Group members
Communication and Transportation Services
A key element of the SMGL initiative was the creation of an integrated communication and transportation system that functions 24 hours a day, 7 days a week, to encourage and enable pregnant women to access delivery care facilities. Both Uganda and Zambia led several efforts to facilitate transportation to and between facilities.
In Uganda, partners collaborated with the Ministry of Health to establish guidelines and referral procedures, which did not exist before Phase 1. The referral system consisted of 5 critical components (Box 3). A transportation committee was established in each SMGL-supported district that comprised the district health officer, assistant district health officer for maternal and child health, hospital superintendents, health center IV in-charges, ambulance drivers, and a project mentor midwife. These committees met monthly to review referrals and quarterly to review maternal and child health outcomes. The ambulance and referral systems were jointly coordinated by SMGL project staff and the district health office. To facilitate coordination, fixed phones were procured, enabling facilities to better communicate referrals with the district health office. The district staff communicated with the ambulance driver closest to the health facility, with clear instructions of the name of the facility needing the service and the name of the facility where the client was being taken. By phone, the district health office staff also provided mentorship on how to handle the patient as they waited on the ambulance to reach them.
Details of the Ambulance Coordination Efforts in Uganda
Ambulance Coordination and Communication
Positioned tricycle and vehicle ambulances at strategic facilities for prompt referral
Trained drivers in first aid and emergency care and provided first aid kits containing gloves and plastic sheets, surgical blades, cotton, and ligatures
Availed contact lists for ambulance drivers at each health facility; these were networked with health facility and village health teams for toll-free calls (closed user group) to facilitate timely referral
Referral calls received by a district health officer or senior midwife, including from private hospitals
Monthly and quarterly committee meetings to review the number of referrals and outcomes, respectively, for quality improvement:
A total of 3,180 women in Phase 1 and 14,871 women in Phase 2 were transported by the ambulances for referral between facilities
When needed, senior midwives met with private and nonprofit hospitals to coordinate ambulances
Senior driver regularly checked fuel, tires, brakes, oxygen, and emergency supplies
Human and Financial Resources
Around-the-clock (24 hours a day, 7 days a week) duty schedule and on-call sleep room for drivers at district hospitals
Ambulance team included nurse-midwives, doctors, and emergency responders; picked up by drivers at night for emergency referrals
Drivers hired by the Saving Mothers, Giving Life initiative who performed well were transitioned to government positions, as available
Guidelines for Transport and Infection Control
Referral log book in triplicate: copy at referring site, copy at receiving site signed by attending midwife, and third copy in ambulance book
Key vital signs recorded in log book
Outcomes discussed in quarterly meetings
Secondly, partners in Uganda procured and distributed at least 1 ambulance to each SMGL district to supplement existing ambulances or fill a gap in districts with none. Large 4×4 vehicles were procured for areas with the most difficult terrain to navigate, smaller vehicles were procured for distant but easily navigable destinations, and motorized tricycle ambulances for areas that were nearer and had good terrain. The motorized tricycle ambulances were placed at the health sub-district or sub-county levels and the vehicles at the district level. This allowed the closest ambulance to the emergency to be assigned for timely referral of mothers and newborns with complications. SMGL partners supported existing ambulances within the districts with vehicle maintenance and repairs and by hiring and paying ambulance drivers’ salaries and allowances. Program-based data included individual-level data such as the status of the patient, diagnosis, time of arrival, and reason for referral. These data were collected through referral forms completed at the destination health facility.
To facilitate transportation for women from the community to health facilities, Uganda implemented a “boda-for-mother” voucher program in 3 districts. This was guided by results from a health systems needs assessment conducted in April 2012, which indicated that boda-bodas (local motorcycles) were acceptable for transportation and could improve access to skilled birth attendance. Boda-bodas were engaged to facilitate the transportation of pregnant women from their villages to the nearest health facility providing EmONC as part of the voucher program. Transportation vouchers were distributed within the communities by village health team members to ensure women’s access to health facilities and to reach upper-level referral facilities in the event of a delivery-related emergency. Village health teams are community volunteers affiliated with health facilities and engage during health promotion activities at the community level.33 The transportation vouchers were expanded during Phase 2 to provide transportation not only for delivery but also for 4 antenatal care visits and 1 postnatal care visit. Thirty percent of transportation vouchers were redeemed, resulting in a 258% increase (P<.0001) in the proportion of deliveries supported by boda-for-mother transportation vouchers (Table 2).
Although the percentage of facilities reporting the availability of motor vehicle transportation was stable in Uganda (61% at baseline and 59% at endline), there was a 6% increase (P<.05) in the percentage of health facilities that reported having communications equipment (Table 2).
Zambia had existing referral guidelines and procedures before Phase 1, consisting of triplicate Ministry of Health referral forms or books that logged the time the transportation was called, time of patient pickup, time of arrival to hospital, outcome of mother and baby, and feedback to the referring facility. SMGL partners strengthened the use of existing referral procedure guidelines and supported printing of the triplicate referral forms and log books. Over time, support for the printing of log books was withdrawn and districts took on the printing of referral logs for their facilities. Technical committees met monthly to review transportation coordination, patient referrals, partner coordination, and other maternal health issues. Program-based data included referral forms and logs in each facility and at the district level. A pilot program in Kalomo District conducted in 2012–2013 used a transportation checklist to help stabilize pregnant women before moving them to a higher-level facility for emergency procedures or surgery; this strategy was not scaled up beyond Kalomo and was not rigorously evaluated.
Similar to Uganda, ambulances were procured in Zambia to supplement existing ambulances in SMGL districts. The need for ambulances was identified through updates at provincial and district-level monthly meetings, and districts (through SMGL partner organizations) procured ambulances to fill the identified gaps. The strategic placement of ambulances within the districts was dependent on availability and the most efficient distribution. Ambulances were coordinated by district transportation committees. In Lundazi District, for example, where travel time from facilities to the district hospital is about 6 hours during the rainy season, the district positioned ambulances at strategic health facilities, so they would need to go only in one direction when referral to the hospital was needed. In Mansa District, on the other hand, the placement of ambulances was zonal. Mansa District is divided into 5 zones and each zone has a central “zonal” health facility (with higher-level services) that serves all health centers within that zone. The 3 ambulances procured under the SMGL initiative were placed in 3 of the 5 zones that did not already have an ambulance. The district transportation committees (a subset of the district technical committee) were responsible for the coordination of ambulance services. To request an ambulance, health facilities communicated with committee members by phone or radio messaging.
Bicycle ambulances (Zambulances) and motorcycle ambulances were procured in Zambia to provide transportation for pregnant women from the community to the health facilities. In some instances, the motorcycle ambulances were used for transportation of referral cases from health facilities to higher-level facilities or hospitals, filling the gap of unavailable motor vehicle ambulances. Safe Motherhood Action Group members were trained as motorcycle riders and worked as volunteers.
Lastly, to facilitate transportation between facilities, radios were repaired, and, where needed, cell phones or talk time were provided to enable communication between facilities and districts to improve coordination of ambulance services.
The availability of motor vehicle transportation improved significantly (P<.01) in Zambia, and there was a 124% increase in facilities that reported having communication equipment (Table 3). SMGL partners procured and distributed 1,500 bicycle ambulances; however, partner reports indicate this intervention was not successful because the bicycle-drawn carriage was an uncomfortable mode of transportation for pregnant women.
The availability of motor vehicle transportation improved significantly in Zambia, and there was a 124% increase in facilities that reported having communication equipment.
Community-Based Linkages to the Health Facility
In addition to the transportation schemes, some programs facilitated community health facility linkages in both Uganda and Zambia.
In Uganda, using the Ministry of Health CHW training manual, village health team members were trained on maternal and newborn health issues. Within the communities, the village health teams distributed transportation vouchers and facilitated communication with the ambulance coordination team to transport women who had complicated pregnancies to health facilities. In addition, during Phase 2 only, in response to requests from the community, portable stretchers were procured and distributed to communities with terrain inaccessible by both vehicles and motorcycles. These were used to transport pregnant women or sick people to pickup points (by either the boda or ambulance vehicles) or health facilities.
In Zambia, a cadre of non-clinical, community-based Safe Motherhood Action Group volunteers was expanded and trained extensively in safe motherhood strategies. This group had been supported initially on a pilot basis by a few nongovernmental organizations to help facilitate access to skilled deliveries. Safe Motherhood Action Group members were trained to educate women and their families about the risks associated with giving birth at home and with labor complications, and encourage them to develop birth plans, attend antenatal care, and give birth in a facility. In addition to the role they served addressing the first delay, the members also escorted women to the facility for delivery and in some instances called facilities to facilitate transportation of women from the community to the facility.34 Working in the community with direct links to the health facility, Safe Motherhood Action Group members were provided with mobile phone minutes or “airtime” to call the facility or call for transportation in an emergency. The proportion of health facilities that reported having an associated Safe Motherhood Action Group increased by 51% (P<.01) in Zambia (Table 3).33
Savings for Delivery as Part of Birth Preparedness
To address costs associated with access to delivery service, even when the delivery service itself is free of charge, different models of saving for birth preparedness were implemented at the community level in Zambia during the latter part of SMGL Phase 2. One partner tested a variety of savings groups approaches across villages in Choma and Kalomo districts, to assess the most effective model of community savings using a training-of-trainers approach. Safe Motherhood Action Groups were trained on the savings models and they in turn worked with the community savings groups to guide selection of a savings model and provide oversight for the groups. Another partner working in Mansa, Chembe (Chembe District was part of Mansa District during Phase 1), and Lundazi districts worked with Savings and Internal Lending Community (SILC) groups, which were developed as a strategy to provide low-income people, especially women, access to resources for income-generation opportunities through loans from self-managed savings.35 With a membership of 15 to 20 people, each person saved an equivalent of US$5 in a general pool, from which members borrowed loans at an interest rate of 10% to 25% per loan or per month, depending on what was set out in the group constitution. Members also contributed to a social fund from which women drew money for costs associated with access to delivery services such as transportation to the health facility, baby clothes, and supplies needed for delivery. Women of reproductive age were mobilized into the SILC groups as a mode of saving for delivery.
Preliminary results show that through the training-of-trainers model, savings have been integrated into home-based counseling for birth preparedness, and village savings groups have incorporated new mechanisms into their savings group constitution to enable women to save for the costs associated with delivery, such as transportation to a health facility, delivery supplies, and baby clothes.9 Nearly all (96%) of the savings groups are offering loans to pregnant women at reduced interest rates (median 5% for pregnant women and 20% for other group members), 10% are offering 0% interest loans for pregnant women, 87% have a provision to offer a bonus (median US$2) to pregnant women who demonstrate preparedness for delivery, 50% have a maternity fund focusing specifically on maternal services, and 100% have a provision for pregnant women to store their money in the group’s lockbox.
Saving for delivery has been integrated into home-based counseling for birth preparedness in Zambia, and village savings groups have helped enable women to save for costs associated with delivery.
The 319 SILC groups supported in Mansa, Chembe, and Lundazi had a total of 6,862 members. Of group members, 74% were women of reproductive age. Members of the SILC groups feel more prepared for delivery, as explained by a member of the group:
Through SILC I managed to buy all necessities for my baby and myself. I went and delivered a bouncing baby girl at the health center. Through SILC, I was able to prepare for transport to take me to the health facility on time.
—SILC member, recently delivered woman