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AdaraNewborn Achieving the maternal and newborn survival targets in ten health facilities across Uganda (2020-2030) Overview Adara Development (Adara) is seeking long-term support from 2020 to 2030, to expand our high-impact model of maternal and newborn care to ten health facilities across Uganda serving populations with very high numbers of newborn deaths. This model, pioneered at Kiwoko Hospital in central Uganda over the past twenty years, has delivered strong results. More than 90% of sick and vulnerable newborns now survive and maternal deaths as a proportion of hospital births have fallen by 20%. The model also incorporates a “Hospital to Home” (H2H) program to further improve maternal and newborn health up to six months post- discharge and the ABAaNA Early Intervention Program to better support babies with moderate to severe developmental disabilities and their caregivers. Adara is seeking to demonstrate that introducing these three “arms” of the AdaraNewborn model - (1) Prenatal Care, (2) Delivery and Newborn Care, and (3) Community Care - can reduce health facility maternal and newborn deaths to the levels required by the Sustainable Development Goals (SDGs) in high-need settings across Uganda. The overarching goal of the program is to help Uganda “bend the curves” and reduce the national maternal mortality ratio to less than 70 maternal deaths per 100,000 live births and newborn deaths to less than 12 deaths per 1,000 live births by 2030. In addition, AdaraNewborn wants to show that 90% maternal and newborn vaccination rates, 90% exclusive breastmilk-feeding rates, and meeting 100% of the unmet need for modern contraception is achievable in Ugandan health facilities and the communities they serve, and will lay a strong foundation for the sustained low rates of maternal and newborn deaths required by the SDGs. Adara is also proposing an open- access, online “knowledge-sharing” platform to facilitate best practices among partners and encourage further replication of the model to other low resource settings. The AdaraNewborn program will measure success in the ten communities against five Key Performance Targets: 1. Facility Maternal Mortality Ratio of less than 70 per 100,000 live births 2. Facility Neonatal Mortality Rate of less than 12 per 1,000 live births 3. Maternal and Newborn Vaccination Rates of at least 90% upon discharge and six months after birth 4. Early Breastmilk Initiation Rate of at least 90% in the hour after birth and Exclusive Breastfeeding Rate of at least 90% upon discharge and six months after birth for babies delivered and cared for in the maternity ward 5. 100% of Unmet Need for Modern Contraception met at one and six months after birth The Challenge Uganda is not on track to achieve the SDGs for maternal and newborn mortality by 2030. In 2017, an estimated 375 women died in pregnancy or childbirth for every 100,000 live births and an estimated 20 newborns died for every 1,000 live births in 2018.1 In real numbers this means according to the latest available estimates, there are 6,000 maternal deaths and 32,000 1 WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division Trends in Maternal Mortality: 2000 to 2017 Geneva, World Health Organization, 2019 and UN Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, World Bank, UN DESA Population Division), Levels and Trends in Child Mortality, 2019. Page 1 of 10 newborn deaths in Uganda. Despite reductions in these deaths in recent years, at current rates of progress the Ugandan Maternal Mortality Ratio will be 325 per 100,000 live births and the Neonatal Mortality Rate will be 16 per 1,000 live births in 2030, above the SDG targets of 70 and 12 respectively. With Uganda’s rapid population growth, this means that in 2030 Uganda will still lose about 5,800 women in childbirth and pregnancy and 30,000 newborns every year, well above the SDG thresholds of 1,300 and 22,000 respectively. Over the next decade, Uganda needs to prevent the deaths of an additional 27,000 mothers and 60,000 newborns to achieve the SDGs.2 Bending the curves will require targeted action. This will be done Uganda needs to prevent the deaths of an in partnership with the Government of Uganda and the additional 27,000 mothers by 2030 communities where the largest numbers of women and newborns 7,000 face the greatest risk of death. The focus will be on childbirth and the week after as 82% of newborn deaths in Uganda occur during this critical window of time. With three- quarters of women in 5,375 Uganda now delivering their babies in hospitals,3 interventions to improve the quality of facility-based care around the time of birth and prior to discharge can have a major impact, especially when 3,750 they target the leading causes of maternal and newborn death in Maternal Deaths Uganda. According to the Global Burden of Disease (GBD), pre- SDG Target existing conditions, hypertension, hemorrhage, sepsis and 2,125 abortion/miscarriage caused three-quarters of all maternal deaths, while birth trauma, preterm birth complications, syphilis, sepsis and pneumonia caused three-quarters of newborn deaths in the six days after birth in Uganda in 2017. 2000 2010 2017 2030 It is also important that interventions target the leading risk Sources: WHO, UNICEF, UNFPA, World Bank Group, and the United factors for maternal and newborn death around the time of birth. Nations Population Division, 2018 and UN World Population Prospects, 2017 In Uganda, prematurity, low birth weight, household air pollution, lack of access to handwashing facilities and unsafe water are the leading risk factors for newborn death in the first week, and iron deficiency is the leading risk factor for maternal death, according to the GBD. In this context, prenatal care that prioritizes maternal nutrition as well as access to clean cooking fuels and technologies, safe water and handwashing during pregnancy is critical. From day seven to 27 after birth, the leading causes of newborn death in Uganda are sepsis, malaria, syphilis, birth trauma and preterm birth complications, according to the GBD. Post-natal care that targets infection control (including malaria) in the home, exclusive breastmilk feeding and the proper care of sick and vulnerable newborns can have a major impact on reducing newborns death in the community. It will be important to implement programs that ensure a link between health facility and home, allowing for the quick referral of mothers and newborns who experience complications after discharge. In Uganda, 18% of newborn deaths occur between days seven and 27 after birth. 2 All calculations based on latest UN data. 3 Uganda, Demographic and Health Survey, 2016. Page 2 of 10 Further, integrating modern contraceptive access into every stage of the maternal and newborn care continuum will save many Ugandan lives due to the current high fertility rate (5 children per woman),4 and the very low level of modern contraception coverage among Ugandan women (29%).5 As each one percentage point increase in the modern contraceptive coverage rate prevents an estimated 200 maternal deaths in Uganda, increasing coverage to 33% could prevent an additional 1,000 maternal deaths.6 Increases in modern contraception coverage also reduce newborn deaths, as babies spaced too closely together are at greater risk of death.7 Together, these interventions can lay a solid foundation for sustained low rates of maternal and newborn deaths in Uganda and may even trigger the “demographic dividend” - the rise in economic growth that occurs when the share of the working-age population (ages 15 to 64) is larger than the non-working- age population (ages 14 and younger, and 65 and older). The Solution To help Uganda “bend the curves” and contribute to the prevention of an additional 27,000 maternal and 60,000 newborn deaths over the next decade, Adara is proposing to expand the high-impact maternal and newborn care model that we have pioneered at Kiwoko Hospital in central Uganda to ten other Ugandan health facilities. This model has shown that improvements in the quality of care provided at the time of childbirth, especially to sick and vulnerable newborns and their mothers, coupled with facility-linked but community-based pre- and postnatal care can dramatically improve maternal and newborn survival in the next decade. In 1999, Adara began working with Kiwoko Hospital, a 204-bed non-profit community hospital in the Nakaseke District of Uganda which also acts as a referral hospital for the area.8 In the years following, with Adara support, the hospital introduced and significantly improved newborn care, integrating new components at appropriate times. In 2010, the NICU was remodeled to accommodate an increase in patients. In the eight years following, maternity ward admissions rose by 44% to 3,901 women and NICU admissions rose by 150% to 1,223 babies. This rise in NICU admissions included many babies born outside of the hospital who are at greater risk of death due to higher rates of preterm birth and/or low birth weight and delays in seeking care. Despite this rapid growth, maternal deaths as a proportion of births fell by 20% to 0.2% and NICU survival rates remained above 90% over the period. By 2018, babies born weighing less than 2.5kg had a 91% survival rate in the Kiwoko NICU. Over the same period, the hospital increased the number of antenatal appointments by 146%, the number of pregnant women immunised with the tetanus toxoid vaccine by 17%, and the number of infant BCG vaccinations by 94%.9 By 2018, 32% of women admitted to the maternity ward were discharged with contraception - a massive increase of 275% - and 91% of maternity ward babies were exclusively breastmilk-fed.

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