Dedicated to what works in global health programs GLOBAL HEALTH: SCIENCE AND PRACTICE 2019 Volume 7 Supplement 1 www.ghspjournal.org Saving Mothers, Giving Life A Systems Approach to Reducing Maternal and Perinatal Deaths in Uganda and Zambia Guest Editors: Marge Koblinsky, PhD; Claudia Morrissey Conlon, MD, MPH; Florina Serbanescu, MD, MPH EDITORS Editor-in-Chief Stephen Hodgins, MD, MSc, DrPH, Associate Professor, Global Health, School of Public Health, University of Alberta Editor-in-Chief Emeritus James D. Shelton, MD, MPH, Johns Hopkins Center for Communication Programs Associate Editors Matthew Barnhart, MD, MPH, Senior Science Advisor, Bureau for Global Health, USAID Cara J. Chrisman, PhD, Biomedical Research Advisor, Bureau for Global Health, USAID Elaine Menotti, MPH, Health Development Officer, Bureau for Global Health, USAID Jim Ricca, MD, MPH, Learning and Implementation Science Team Leader, Maternal and Child Survival Program, Jhpiego Madeleine Short Fabic, MHS, Public Health Advisor, Bureau for Global Health, USAID Digital Health: Alain Labrique, PhD, Professor, Department of International Health, Johns Hopkins Bloomberg School of Public Health Knowledge Management: Margaret D’Adamo, MLS, MS, Independent Consultant Malaria: Michael Macdonald, ScD, Consultant, Vector Control Unit, Global Malaria Programme, World Health Organization Maternal Health: France Donnay, MD, MPH, FRCOG, FACOG, Independent Consultant Maternal Health: Marge Koblinsky, PhD, Independent Consultant Nutrition: Bruce Cogill, PhD, MS, Independent Consultant Managing Editors Natalie Culbertson, Johns Hopkins Center for Communication Programs Ruwaida Salem, MPH, Johns Hopkins Center for Communication Programs Editorial Board Al Bartlett, Save the Children, USA Vinand Nantulya, Uganda AIDS Commission, Uganda Zulfiqar Bhutta, Aga Khan University, Pakistan Emmanuel (Dipo) Otolorin, Jhpiego, Nigeria Kathryn Church, London School of Hygiene and Tropical James Phillips, Columbia University, USA Medicine, UK Yogesh Rajkotia, Institute for Collaborative Development, USA Scott Dowell, Centers for Disease Control and Prevention, USA Suneeta Singh, Amaltas, India Marelize Görgens, World Bank, USA David Sleet, CDC, USA Lennie Kamwendo, White Ribbon Alliance for Safe John Stanback, FHI 360, USA Motherhood, Malawi Lesley Stone, USAID, USA Jemilah Mahmood, Malaysian Medical Relief Society, Douglas Storey, Johns Hopkins Center for Communication Malaysia Programs, USA Global Health: Science and Practice (ISSN: 2169-575X) is a no-fee, open-access, peer-reviewed journal published online at www.ghspjournal. org. It is published quarterly by the Johns Hopkins Center for Communication Programs, 111 Market Place, Suite 310, Baltimore, MD 21202. The jour- nal is made possible by the support of the American People through the United States Agency for International Development (USAID). The Knowledge for Health (K4Health) Project is supported by USAID's Office of Population and Reproductive Health, Bureau for Global Health, under Cooperative Agreement #AID-OAA-A-13-00068 with the Johns Hopkins University. GHSP is editorially independent and does not necessarily represent the views or positions of USAID, the United States Government, or the Johns Hopkins University. Global Health: Science and Practice is distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/. For further information, please contact the editors at [email protected]. Cover caption: A mother waits with her daughter at the Saving Mothers, Giving Life-supported Lundazi Urban Health Centre, Zambia. © 2017 Amy Fowler/USAID. Table of Contents 2019 | Volume 7 | Supplement 1 EDITORIALS Saving Mothers, Giving Life: A Systems Approach to Reducing Maternal and Perinatal Deaths in Uganda and Zambia The 5-year public-private partnership boldly addressed maternal mortality in Uganda and Zambia using a systems approach at the district level to avoid delays in women seeking, reaching, and receiving timely, quality services. This supplement provides details on the Saving Mothers, Giving Life partnership and approach, including the model, impact, costs, and sustainability. Lois Quam, Angeli Achrekar, Robert Clay Glob Health Sci Pract. 2019;7(suppl 1):S1–S5 https://doi.org/10.9745/GHSP-D-19-00037 SYNTHESIS Saving Mothers, Giving Life: It Takes a System to Save a Mother A multi-partner effort in Uganda and Zambia employed a districtwide health systems strengthening approach, with supply- and demand- side interventions, to address timely use of appropriate, quality maternity care. Between 2012 and 2016, maternal mortality declined by approximately 40% in both partnership-supported facilities and districts in each country. This experience has useful lessons for other low- resource settings. Claudia Morrissey Conlon, Florina Serbanescu, Lawrence Marum, Jessica Healey, Jonathan LaBrecque, Reeti Hobson, Marta Levitt, Adeodata Kekitiinwa, Brenda Picho, Fatma Soud, Lauren Spigel, Mona Steffen, Jorge Velasco, Robert Cohen, William Weiss, on behalf of the Saving Mothers, Giving Life Working Group Glob Health Sci Pract. 2019;7(suppl 1):S6–S26 https://doi.org/10.9745/GHSP-D-18-00427 Global Health: Science and Practice 2019 | Volume 7 | Supplement 1 Table of Contents www.ghspjournal.org ORIGINAL ARTICLES Impact of the Saving Mothers, Giving Life Approach on Decreasing Maternal and Perinatal Deaths in Uganda and Zambia Through district system strengthening, integrated services, and community engagement interventions, the Saving Mothers, Giving Life initiative increased emergency obstetric care coverage and access to, and demand for, improved quality of care that led to rapid declines in district maternal and perinatal mortality. Significant reductions in intrapartum stillbirth rate and maternal mortality ratios around the time of birth attest to the success of the initiative. Florina Serbanescu, Thomas A. Clark, Mary M. Goodwin, Lisa J. Nelson, Mary Adetinuke Boyd, Adeodata R. Kekitiinwa, Frank Kaharuza, Brenda Picho, Diane Morof, Curtis Blanton, Maybin Mumba, Patrick Komakech, Fernando Carlosama, Michelle M. Schmitz, Claudia Morrissey Conlon, on behalf of the Saving Mothers, Giving Life Working Group Glob Health Sci Pract. 2019;7(suppl 1):S27–S47 https://doi.org/10.9745/GHSP-D-18-00428 Addressing the First Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Approaches and Results for Increasing Demand for Facility Delivery Services The Saving Mothers, Giving Life initiative used 3 coordinated approaches to reduce maternal deaths resulting from a delay in deciding to seek health care, known as the “first delay”: (1) promoting safe motherhood messages and facility delivery using radio, theater, and community engagement; (2) encouraging birth preparedness and increasing demand for facility delivery through community outreach worker visits; and (3) providing clean delivery kits and transportation vouchers to reduce financial barriers for facility delivery. These approaches can be adapted in other low-resource settings to reduce maternal and perinatal mortality. Florina Serbanescu, Mary M. Goodwin, Susanna Binzen, Diane Morof, Alice R. Asiimwe, Laura Kelly, Christina Wakefield, Brenda Picho, Jessica Healey, Agnes Nalutaaya, Leoda Hamomba, Vincent Kamara, Gregory Opio, Frank Kaharuza, Curtis Blanton, Fredrick Luwaga, Mona Steffen, Claudia Morrissey Conlon, on behalf of the Saving Mothers, Giving Life Working Group Glob Health Sci Pract. 2019;7(suppl 1):S48–S67 https://doi.org/10.9745/GHSP-D-18-00343 Addressing the Second Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching Appropriate Maternal Care in a Timely Manner The Saving Mothers, Giving Life initiative employed 2 key strategies to improve the ability of pregnant women to reach maternal care: (1) increase the number of emergency obstetric and newborn care facilities, including upgrading existing health facilities, and (2) improve accessibility to such facilities by renovating and constructing maternity waiting homes, improving communication and transportation systems, and supporting community-based savings groups. These interventions can be adapted in low-resource settings to improve access to maternity care services. Thandiwe Ngoma, Alice R. Asiimwe, Joseph Mukasa, Susanna Binzen, Florina Serbanescu, Elizabeth G. Henry, Davidson H. Hamer, Jody R. Lori, Michelle M. Schmitz, Lawrence Marum, Brenda Picho, Anne Naggayi, Gertrude Musonda, Claudia Morrissey Conlon, Patrick Komakech, Vincent Kamara, Nancy A. Scott, on behalf of the Saving Mothers, Giving Life Working Group Glob Health Sci Pract. 2019;7(suppl 1):S68–S84 https://doi.org/10.9745/GHSP-D-18-00367 Global Health: Science and Practice 2019 | Volume 7 | Supplement 1 Table of Contents www.ghspjournal.org Addressing the Third Delay in Saving Mothers,Giving Life Districts in Uganda and Zambia: Ensuring Adequate and Appropriate Facility-Based Maternal and Perinatal Health Care Saving Mothers, Giving Life used 6 strategies to address the third delay—receiving adequate health care after reaching a facility–in maternal and newborn health care. The intervention approaches can be adapted in low-resource settings to improve facility-based care and reduce maternal and perinatal mortality. Diane Morof, Florina Serbanescu, Mary