Saving Mothers, Giving Life: overcoming maternal mortality in Zambia

The initiative

Saving Mothers, Giving Life (SMGL) is a public-private partnership (PPP) that aims for a dramatic reduction in newborn mortality in sub-Saharan African countries. The initiative was launched by Secretary of State Hillary Clinton in 2012 as part of the Global Health Initiative (GHI) and to support achievement of the UN's Millennium Development Goals (MDGs).

It aimed to test an integrated health systems approach that addresses the ‘three delays' associated with maternal and newborn deaths:

• Delays in seeking appropriate care.
• Delays in reaching care in a timely manner.
• Delays in receiving high-quality care at a health facility.

“In Zambia, SMGL is putting in place key interventions to improve maternal and newborn health across 16 districts. Working hand-in-hand with the Zambian government, the initiative has set out to make high-quality, safe childbirth services available and accessible to women and their newborns, focusing on the critical period of labour, delivery and the first 48 hours postpartum.”

The specific objectives of SMGL's five-year initiative included accelerating reductions in maternal and newborn mortality: to reduce maternal deaths by 50% within 12 months - by June 2013.

The challenge

The public impact

The current figures in Zambia relating to the launch of SMGL are as follows:

• “Decrease in Institutional Maternal Mortality Ratio - 53 percent. [2]
• Women in Target Districts Giving Birth in a Facility - 90 percent.
• Increase in Rate of Cesarean Sections in Target Districts - 32 percent.”

The perinatal mortality rate has decreased by 29 percent the total stillbirth rate by 37 percent. The number of women who received antiretroviral drugs (for the prevention of mother-to-child transmission of HIV) increased by 81 percent.

Stakeholder engagement

The SMGL project is led by the US government, through USAID, as a PPP which includes “the Norwegian Government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynaecologists and eventually Project C.U.R.E. to amplify its on-the-ground efforts”. [3]

SMGL also engages the Government of Zambia, through its Ministry of Health (MOH) and its Ministry of Community Development, Mother and Child Health (MCDMCH).

Political commitment

The US government, in particular Secretary of State Clinton, were profoundly committed to SMGL, and worked hard to assemble the government and NGO participants.

Although the project was not an initiative of the Government of Zambia, it supported the initiative and helped in building a programming model to accelerate the prevention of maternal and newborn mortality.

Public confidence

Clarity of objectives

Strength of evidence

The SMGL programme in Zambia was designed to build on programmes already in place. “Building on the GHI whole-of-government approach, the US created an interagency headquarters and country support team comprised of senior maternal health and PEPFAR experts from USAID, the Office of the US Global AIDS Coordinator (OGAC), the Department of Health and Human Services (HHS), the Centers for Disease Control and Prevention (CDC), the Peace Corps and the Department of Defense (DOD).”

Moreover, there was a “pilot project in Zambia ... focused on four districts: Kalomo, Lundazi, Mansa and Nyimba”. [5] The results were used to modify the eventual nationwide implementation. One area in which SMGL was unsuccessful during its pilot phase was in reducing neonatal mortality. As a result, the initiative redoubled its efforts to train providers on newborn resuscitation and essential newborn care as it was expanded to cover more districts.

Feasibility

The project was financially supported by the US and Norwegian governments and a number of NGOs. Secretary of State Hillary Clinton pledged US$75 million in US support to the SMGL initiative. The Norwegian Foreign Minister said Norway would commit about US$80 million to the effort.

However, “one implementing partner called it ‘an unrealistic set of expectations' ... Another official thought the programme worth the risks: “Is it feasible? Is it the right thing to do? Do we have the courage and the will to make it happen? There is an element of risk, but we can do nothing or we can do something… This is a bellwether issue — if we can't save mothers at birth, how can we move up the chain of progress? We have to break the cycle.” [6]

Management

SMGL's management approach focused on the needs of host country governments, “building the programme around existing national MNH plans, and seeking to strengthen local partners and institutions to manage programme activities.” [7]

It also addresses the delay in providing quality care by “training, deploying, equipping and motivating health providers to provide quality, respectful care during the most dangerous period for mothers and newborns - labour, delivery and the first 48 hours postpartum... hiring and training additional doctors, midwives and nurses”. [8]

Measurement

The CDC leads the monitoring and evaluation efforts for SMGL. The project impact is monitored consistently and the indicators capture the outcomes of the programme and publish them prominently on its website. “During Phase 1, the initiative was monitored and evaluated by the CDC to inform programmatic scale-up and expansion plans, including:

• Enumeration of maternal and newborn outcomes.
• Health facility assessments.
• Health information system strengthening.
• Support for maternal death reviews and verbal autopsies.
• “An external evaluation by Columbia University's Mailman School of Public Health assessed the partnership's functioning and identified best practices and barriers to reducing maternal mortality.” [9]

Alignment

There is a strong sense of alignment between the actors required to make the change happen:

• Financial support was provided by the governments of Norway and the US, which also drove the SMGL initiative.
• USAID works with implementing partners to support the government, private sector, local institutions and communities.
• Merck for Mothers is guiding the strategic direction of the initiative.
• The American College of Obstetricians and Gynecologists is providing healthcare for women and will provide technical and clinical leadership.
• Every Mother Counts is raising public awareness, advocating for global maternal health, and initiating fundraising efforts.
• The government of Zambia is also playing its role in supporting the project, through the MOH and MCDMCH.

Bibliography

Zambia: our Progress, Savings Mothers Giving Life

Saving Mothers, Giving Life: Attainable or Simply Aspirational? Janet Fleischman, June 2012, Center for Strategic & International Studies

Primer, May 2014, Saving Mothers, Giving Life

Project: Saving Mothers Giving Life (SMGL), fhi360

Hillary Clinton pledges US support for global maternal health initiative, 2 June 2012, GlobeMed