Safe Mothers, Safe Babies: Incorporating community-based and facility-based approaches to improve maternal and perinatal health by reducing the three delays among rural populations in East Central Region, Uganda Open Access

Cutts, Jacqueline (2014)

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Background : Too little progress has been made in reducing maternal and perinatal mortality in Uganda since 2000, partly resulting from poor utilization of maternal healthcare services and poor facility infrastructure. Safe Mothers, Safe Babies (SAFE) addresses these deficiencies through an integrated intervention package targeting the three delays (Thaddeus and Maine), including: (1) increasing demand through participatory educational outreach with community groups; (2) improving access through motorcycle ambulances and personal savings programs; and (3) using innovative low-cost technology to improve quality of care through strengthening facility infrastructure, commodities, and medical training.

Objective: To evaluate whether Safe Mothers, Safe Babies' approach has improved utilization of delivery care in target health facilities.

Data and Methods : We conducted a cross-sectional quantitative and qualitative evaluation through: secondary health data from 4 intervention and 3 control facilities assessing change in the number of monthly health center deliveries and distribution of types of obstetric emergency and related maternal referrals; qualitative data from 49 key informant interviews assessing program quality; a photovoice project conducted by program beneficiaries assessing community views; and six months of field notes from observing obstetric care in 14 facilities.

Results: Key findings included: (1) Intervention facilities experienced a 40.63% average increase in health center deliveries 24 months after the intervention package, which three control facilities did not experience (t(5)=-2.8, p=0.038). This was confirmed by results from key informant interviews, which reported increased utilization of healthcare services in addition to satisfaction with all three delay projects. (2) Third delay projects have program deficiencies, primarily related to poor health facility capacity to provide emergency obstetric care, and community groups need more skills and resources to reach more people.

Discussion and Implications for Public Health: The intervention package has effectively improved the utilization of delivery care in target health facilities by addressing the three delays. This demonstrates a successful way that the three delays model can be united with community-based and facility-based approaches to improve maternal and child health, both in Uganda and potentially elsewhere. To improve the approach, SAFE must focus on increasing third delay projects and community group capacity.

Table of Contents

Chapter One: Introduction: 1

  • Objective: 2
  • Aims: 2
  • Research Question: 2
  • Background: 3
    • History of Safe Mothers, Safe Babies: 3
    • Current Status of Safe Mothers, Safe Babies: 6Context: East Central Region: 13

Chapter Two: Literature Review: 20

  • The Three Delays Model: 20
  • Engaging Communities: Community-Based Participatory Action Methods: 22
    • CBPAR in Maternal and Child Health: 24
  • The Gap: The Need for an Integrated Approach: 26

Chapter Three: Methods and Results: 32

  • Methods: Secondary Health Data: 32
  • Methods: Key Informant Interviews: 35
  • Methods: Photovoice Project: 36
  • Methods: Maternal Health Facility and Care Observations: 38
  • Results Aim 1: Utilization of Maternal Health Services for Delivery: 39
    • Theme: Utilization of health services is thought to have increased: 40
    • Theme: Utilization would improve further if groups expanded: 41
  • Results Aim 2: Evaluate SAFE's Impact on each of the Three Delays: 42
    • Theme: SAFE effectively targets the first delay: 43
    • Theme: SAFE second delay work is effective and well-received: 43
    • Theme: SAFE third delay interventions are biggest success and biggest challenge: 45
    • Observed impact and deficiencies in third delay interventions: 47
  • Results Aim 3: Strengths and Weaknesses of the Approach: 60
    • Theme: Maternal health is personal: 61
    • Theme: SAFE's approach is unique: 62
    • Theme: SAFE work empowers women: 63
    • Theme: Involving men is essential for SAFE's approach to work: 64
    • Theme: Definitions of maternal and child health vary widely: 65
    • Theme: Community perceptions of MCH problems vary widely: 66

Chapter Four: Discussion, Conclusion and Recommendations: 86

  • Discussion: 86
    • Facilitating Community-Led Change to Impact First Delay Barriers: 86
    • A Sustainable Way to Address Second Delay Barriers: 87
    • An Important and Underemphasized Priority: Third Delay Projects: 88
    • The Need for Increased Capacity of Community Groups: 90
  • Limitations:90
  • Conclusion and Recommendations: 91

References: 94

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