“Saving Mothers, Giving Life has undeniably raised the bar in how we address maternal perinatal mortality,” said Dr. Florina Serbanescu, Team Lead of Global Reproductive Health Evidence for Action at the Centers for Disease Control and Prevention, for the launch of the Global Health: Science and Practice Supplement on Saving Mothers, Giving Life at a recent Wilson Center event. Saving Mothers, Giving Life (SMGL), is a public-private partnership created to reduce maternal and newborn mortality in sub-Saharan African countries. “The achievements show that what is often seen as an intractable problem,” said Serbanescu, “can be addressed with the right leadership, resources, and political will.”

The Need to Intervene

The Saving Mothers, Giving Life partnership employs a health systems approach to ensure that clean, safe childbirth services are available to every pregnant woman. It focuses its efforts in sub-Saharan Africa where 60 percent of global maternal deaths occur and 8 of the 10 most dangerous places to be born are located. Given these facts, the interventions discussed in this supplement were specifically targeted toward mostly rural, poor districts in Zambia and Uganda that had a large number of deliveries and maternal deaths, existing health systems, and compatible national priorities. Dr. Diane Morof, a Medical Epidemiologist at the Centers for Disease Control and Prevention, said, they did a lot of baseline assessments to see where gaps were. “We could see from the data collection that there were obvious areas where interventions were needed and that drove a lot of the political investment in making that change.”

Saving Mothers, Giving Life is designed to strengthen district health systems. Because the model addressed both demand-side and supply-side issues (the barriers that block women from life-saving care) and took a systems approach, it was ideal for the project, said Dr. Claudia Morrissey Conlon, the partnership’s U.S. Government Lead. The interventions were designed specifically to address the three delays that overwhelmingly contribute to maternal mortality.

Three Delays

SMGL tried to build off existing platforms, do it in a practical way, and make the intervention sustainable, said Dr. Diane Morof. This is reflected in strategies used to address the three delays. The first delay, in seeking care, was addressed with strategies like ensuring mothers had birth plans, implementing a voucher system to subsidize costs, and distributing “mama kits,” necessary supplies in the event that a mother could not make it to a nearby facility. To address the second delay, in reaching care, the program strengthened the existing referral and transport systems, improved communication tools, and established maternity waiting homes. To reduce the third delay, in receiving care, the program implemented national guidelines, trained and mentored medical staff, and ensured drugs were available for all.

The results of the SMGL approach were compelling. The baseline maternal mortality rate in Uganda was 452 deaths per 100,000 live births. This dropped by 44 percent to 255 deaths per 100,000 live births in facilities with SMGL interventions. In Zambia, the maternal mortality rate dropped from 480 deaths to 280 deaths per 100,000 live births in the select health facilities. It is well-known that when you save a mother’s life, you save the life of the family and the community, said Carrie Hessler-Radelet, President and Chief Executive Officer of Project Concern International. This unprecedented decline in maternal mortality was likely due to the increase in demand for, access to, and quality of health facilities. Facility deliveries increased by upwards of 40 percent, and C-section delivery rates, a quality indicator of emergency obstetric care, increased by more than 70 percent in both Uganda (5.3 percent to 9.0 percent) and Zambia (2.7 percent to 4.8 percent). Unfortunately, the mortality rate of newborns did not decrease through the SMGL approach. Overall, however, SMGL built infrastructure for real-time measurements of pregnancy outcomes and vital statistics that can address important causes of the burden of disease, said Dr. Serbanescu.  

The Factors of Success

This approach was groundbreaking, not only because of its successful results, but also because of the unique nature of the partnership, consisting of global health leaders from public, private, and NGO sectors. Much of the success was due to these particular partners who came together, their diverse expertise, their uniform commitment to the cause, and “their support for infrastructure development and careful monitoring and evaluation so that we could improve the process along the way,” said Anne Palaia, Senior Evaluation Advisor of Global Health at USAID. All of the partners, whether local or global, were committed to the sustainability of this project, said Robert Clay, Vice President, Global Health, of Save the Children. Ownership is essential for partnership if partners are to be successful, he said. The diversity of this partnership further contributed to the resiliency of the SMGL approach.

“Unlike progress, money is a finite resource and we have to make decisions around how to allocate it,” said Dr. Mary-Ann Etiebet, Executive Director of Merck for Mothers.  Cost-effectiveness was another factor driving the success of SMGL. The cost per life-year gained in Uganda was 25.6 percent of gross domestic product (GDP) per capita and in Zambia was 16.4 percent of GDP per capita. Both of these costs are less than 50 percent of GDP per capita, which is an indicator of cost-effectiveness. In terms of affordability, in Zambia the additional costs were about $4.85 per person per year. In Uganda they were about $1.36 per person per year. In order to do these activities on a national level, said Ben Johns, Senior Associate and Scientist at Abt Associates, Zambia would have to pay less than one half of one percent of its GDP, and Uganda would pay less than one quarter of one percent.

The problems Zambia and Uganda are facing are not exclusive to these countries – they are universal, said Dr. Barbara S. Levy, Vice President of Health Policy and Administers at The American College of Obstetricians and Gynecologists. “The central word I’d like us to leave with is trust,” said Levy, “trusting in our partners, trusting the communities, and earning their trust in us, so that we can be successful.” This trust as well as the knowledge that we are a global community will contribute to solving the serious problems pregnant women face around the world.