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Saving Mothers, Giving Life initiative: lessons learned from a maternal death surveillance and response system in Uganda

Uganda was selected for a pilot project — Saving Mothers, Giving Life – to rapidly reduce maternal deaths through community and facility-based interventions. The model employs a comprehensive approach that builds upon existing district health systems, including strengthening the evidence base for improving maternal and perinatal survival. Read how investing in village health teams has resulted in a 30% reduction in population-based maternal mortality as well as stimulating advocacy efforts and community mobilisation. 

Although Uganda’s Ministry of Health has made great strides in recent years to improve maternal health and reduce the number of maternal deaths, the maternal mortality ratio remains high (estimated at 438 deaths per 100,000 live births by 2011 UDHS) [1].

Uganda was one of two countries selected for a pilot project — Saving Mothers, Giving Life (SMGL) — to rapidly reduce maternal deaths through community and facility-based interventions. The SMGL model employs a comprehensive approach that builds upon existing district health systems and implements evidence-based practices to improve maternal and perinatal survival.

Through the SMGL initiative, over 4,000 village health teams (VHTs) were trained, one for each 100-300 households, to identify any deaths of women of reproductive age (WRA) through routine monthly monitoring visits. Currently, about 3,800 VHTs continue to report monthly the number of deaths among WRA identified in the previous 30 days. Their reports are compiled and submitted to the sub-district health coordinators. Approximately 6-8 weeks after a death, the household is visited by a team trained in verbal autopsy procedures.  If the death occurred during pregnancy or delivery or within 2 months of a delivery, the team collects information about the circumstances of death and contributing factors, using the WHO Maternal Death Surveillance and Response (MDSR) verbal autopsy tool. Complete verbal autopsies are used to identify causes of death and contributing factors—obtaining information critical to designing interventions to prevent the next death.

Improving the system: lessons

In establishing a district level maternal death surveillance system in Uganda, it was learned that:

  • Identification of all deaths of WRA was important in improving the efforts to detect all maternal deaths. MDSR monthly reports revealed that WRA deaths declined at a faster pace than the number of maternal deaths, suggesting that village health teams and others in the data-collection process were focusing increasingly on identifying pregnancy-associated deaths and neglecting surveillance of all deaths of WRA.
  • Continuous supervision and quality assurance of the SMGL maternal mortality surveillance system needs to be carefully planned, implemented, and maintained. This includes clear case definitions, periodic reminders on both the importance of and  the process for reporting, accountability, monitoring results, information sharing, and linkages with action.
  • Real-time data on maternal mortality in communities is an important tool that can be used to advocate for increasing prevention and community mobilization activities. Following presentation of these data in village health team meetings, the leadership of Kibaale district allocated resources for building a bridge that helped connect several communities with high mortality rates to the main road and increased access to emergency obstetric care.

The study found that during its first year of implementation, SMGL activities were associated with a reduction of 30% in the population-based maternal mortality in four districts in Uganda (Kibaale, Kabarole, Kyenjojo and Kamwenge); from 452 to 316 deaths per 100,000 live births.

The Ministry of Health is planning to scale up the MDSR to other non-SMGL districts.  The Uganda adaptation of the WHO MDSR Guidance was launched in September 2015. It is based on the country experience in the SMGL-supported districts and includes the tools, standard operation procedures, and monitoring processes developed and refined by the project.

With an established network of trained community health workers, the SMGL districts added perinatal surveillance activities in 2015.

The MDSR system in Uganda can be further improved by communicating its results and the actions that were taken to prevent maternal deaths to all stakeholders, including the communities where these deaths occur.

Acknowledgements:

This case study was written by Florina Serbanescu, Susanna Binzen, and Diane Morof, from the U.S. Centers for Disease Control and Prevention/Division (CDC) of Reproductive Health, and Frank Kaharuza on behalf of SMGL Uganda. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC.

Thousands of individuals participated in activities to monitor and evaluate Phase 1 of the Saving Mothers, Giving Life (SMGL) initiative, including staff affiliated with country SMGL team and implementing organisations; district and national-level Ministry of Health officials; Village Health Teams, with support from the M&E technical team of the CDC and the USAID M&E technical team.

This is an updated version of a case study originally published in our December 2014 issue of the MDSR Action Network newsletter.

Reference:

[1] Uganda Bureau of Statistics and ICF International Inc. Uganda Demographic and Health Survey 2011. Preliminary Report. Kampala, Uganda: Uganda Bureau of Statistics and Calverton, MD: ICF International Inc.; 2012.