Early-stage program saving mothers’ lives in Uganda and Zambia

Brenda Mweetwa was a janitor, not a nurse or a midwife. But she had heard her late husband, a doctor, talk about delivering babies. That was enough, in the understaffed health clinic where she worked in Mabombo, Zambia, to make her the most qualified candidate to help out when a pregnant 16-year-old showed up in labor.

Fortunately, she wasn’t on her own.

As part of a mentorship program administered by Boston University, a certified nurse midwife was standing by to talk Mweetwa through the two-hour delivery over the phone, said Donald Thea, the professor who heads up the effort. When, after producing a healthy, squawking set of twins, the mother started hemorrhaging, Mweetwa harkened back to a training session she’d attended just two days earlier. With a condom and a catheter, she cobbled together a device to stop the bleeding and saved the mother’s life. 

The Boston University mentorship program is one of a portfolio of interventions launched in eight districts in Uganda and Zambia in 2012 as part of Saving Mothers, Giving Life, a $200 million initiative propelled by former US Secretary of State Hillary Clinton. The project, which aims to halve maternal mortality in participating districts by 2017, leverages the resources and expertise of more than a dozen public and private organizations, including USAID, pharmaceutical giant Merck and the governments of Uganda and Zambia.

Approximately 800 women die from preventable causes related to pregnancy and childbirth each day, according to the World Health Organization. Ninety-nine percent of those deaths occur in developing countries, like Uganda and Zambia, where women are 77 to 100 times more likely to die from maternal causes than women in the United States. 

Saving Mothers, Giving Life’s first annual report, published last week, shows impressive improvements. In just one year, the maternal mortality rate in participating districts in Uganda has dropped 30 percent. In Zambia, health clinics, which often see the most high-risk pregnancies, reported 35 percent fewer childbirth related deaths. Still, challenges remain. Because of the project’s over-the-top budget, experts worry improvements will only last as long as the foreign aid.

“It’s exciting to see how much progress is possible,” Thea said. “But this was a very big effort with a lot of people and a lot of money. Next, we have to figure out how we can take the lessons we learned and apply them in a cost effective way so change is sustainable over a long period of time.”

A different approach to a difficult problem

Maternal mortality is a particularly difficult problem to address in the developing world because “there is no simple solution,” said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, at a conference examining the program held last week at Washington’s Center for Strategic and International Studies. Unlike other global health problems, such as measles or polio, which are being combatted with vaccination campaigns, there’s no way to predict or prevent complications arising from pregnancy and childbirth.

The most common reasons women die — hemorrhage, obstruction and infection — are best addressed through surgery, such as Caesarean section, Frieden said. But in Zambia and Uganda, health clinics with the necessary equipment and skilled personnel to perform life-saving surgery are few and far between. For many women, getting to a health clinic that offers even the most basic care means a two- to five-hour walk.

For many years, Frieden said, there has been consensus in the global health community that operative interventions to reduce maternal mortality are “necessary, but not practical” because success would require too many moving parts — more doctors, better clinics, an improved transportation system. So the modus operandi, he said, has been to “try a series of other things that we think might work because we know this thing that we know works is too hard.”

Saving Mothers, Giving Lives bucks convention by taking on the whole health system. Using more than two dozen interventions, the program attacks the three biggest obstacles that keep pregnant women from getting medical care: lack of education, lack of transportation and lack of adequate medical staff and facilities.

To get women to clinics, partners recruited and trained thousands of community health workers in Zambia and Uganda to go door-to-door, teaching women about the benefits of developing a birth plan and delivering under the care of a skilled attendant, according to the program’s annual report. Women were given vouchers to cover the cost of transportation. 

With the aim of improving the quality of care, partners outfitted 11 facilities in Uganda with operating theaters to perform C-sections and hired 147 new doctors. In Zambia, partners trained 199 health workers to perform emergency obstetric care and built maternity waiting homes, where women who live far from emergency services can stay ahead of their due date.

“In the past … whether it be training or transport or family planning, each part was tackled independently,” said Naveen Rao, head of Merck’s maternal mortality program, at the conference. “This is the first time that is seemed like instead of going at it with a silver bullet, we were going at it with silver buckshot.”

Progress and sticking points

When Boston University’s Thea first heard about Saving Mothers, Giving Life’s plan, his first thought was, “You’re nuts. This is crazy.”

“I’m a physician and I’ve been doing public health research for 28 years,” he said in a phone interview. “The idea that you could effect that kind of change on that kind of timeline — well, I was a skeptic.”

But now he — along with much of the global health community — is excited.

During Saving Mothers, Giving Life’s first year, the number of women in Uganda who gave birth at a facility jumped from 46 percent to 74 percent, according to the program’s annual report. Zambia saw similar improvements: by year’s end 84 percent of women were giving birth in a health clinic, up from 63 percent. 

Furthermore, the percent of facilities equipped to perform basic emergency obstetric care in Uganda increased from 3 to 9. Thanks to the upgrades, 72 percent of Ugandan women now live within two hours of a facility where doctor’s can manage childbirth complications. In Zambia, the proportion of women who had an obstetric complication and received life-saving care increased 23 percent.

Thea attributes the success, in part, to Saving Mothers, Giving Life’s innovative public-private partnership model.

Getting a health worker training program off the ground in Zambia with so many different players was “sort of a coordination nightmare at first,” Thea said. “But at the same time it was very gratifying to have so many players to access.”

Because Saving Mothers, Giving Life partnered with the Zambian government, for example, Thea and his team were able to side step red tape when they needed supplies from the national blood bank. When restrictions on US government money kept his team from building a much-needed building, he was able to appeal to Merck for funding.

Rajiv Shah, administrator of the US Agency for International Development, called the partnership worth “celebrating.”

“We’re not stopping here — not with these promising results,” he said, in a keynote speech delivered at the Center for Strategic and International Studies conference. “In the next five years, we plan to bring Saving Mothers, Giving Life to at least three more countries because we just what a difference this approach can make on the ground.”

But just how the program will be scaled up remains to be seen.

“It’s one thing to show you can get good results in a year with a huge infusion of cash,” said Margaret Kruk, an assistant professor of health policy and management at Columbia University, who headed up an independent evaluation of the program. “The question is, can you implement lasting change on a budget?”

The project is “definitely not sustainable without ongoing donor support,” Kruk said in a phone interview. The patient vouchers, the salaries of village health workers and doctors — it was all funded with aid dollars.

Lasting improvement to countries’ health systems require great country control and high level political will, Kruk said. But her external evaluation raised questions about the balance of power between partners.

“The governments of Zambia and Uganda were hosts, in a way, not full partners,” she said. “That has got to change.”

Global leaders say they recognize the project’s limitations and are taking steps to address them.

In Washington, Frieden called the first year a “proof of concept.”

“Not every dollar was spent perfectly,” he said. The plan going forward is to “optimize and expand.”

“This program is a neonate,” he said. “It needs good parents and a good family and … just like any child anywhere in the world, it could grow up to change the world.“

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