Impact of a multi-level intervention on facility-based births and skilled birth attendance in Kalomo District, Zambia: a mixed-methods evaluation
Henry, Elizabeth Gronewold
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Problem: Zambia has one of the highest maternal mortality ratios in the world. Risks of serious complications during childbirth and associated maternal morbidity and mortality can be mitigated by improving access to skilled birth attendants and emergency obstetric and newborn care (EmONC) in facilities when complications arise. In 2012, the Saving Mothers Giving Life (SMGL) initiative was launched in Kalomo District, Zambia, to reduce maternal deaths. Methods: This study assessed the impact of SMGL in Kalomo District on rates of facility delivery, delivery with a skilled birth attendant, and facility-level changes in the provision of maternity and newborn care during the first learning phase, 2012–2013. Changes in neonatal mortality were also assessed. A mixed-methods approach utilized a quasi-experimental pre-post nonequivalent comparison group design using household data (n=21,680 women) and health facility assessments (n=77) including EmONC signal functions. Data were collected from February 2011–October 2013, before and during SMGL program implementation, in the intervention district and a comparison area. A qualitative inquiry with key informants (n=26) was then conducted in September 2014. Results: There was a 49% relative increase in the odds of facility-based birth during SMGL in Kalomo relative to comparison districts (OR 1.49, 95% CI: 1.21–1.77), controlling for covariates. There was no significant change in delivery with a skilled birth attendant. Newborn mortality in Kalomo decreased significantly (4.3% to 2.6%, p<0.01), even when controlling for covariates, with no change in comparison. EmONC signal functions increased from a mean of 2.7 to 3.9 (p=0.003) per facility in Kalomo, with no change in the comparison area. Most facility-level changes related to newborn care. Informants attributed impacts primarily to community mobilization by Safe Motherhood Action Group volunteers and clinical mentorship. Conclusion: SMGL positively influenced demand for facility deliveries. Data indicate a limited measurable change in supply-side indicators of provision of intra-partum maternity care, while improving neonatal survival. Interviews suggested that mentoring existing staff might be responsible for improved care and referrals. Phase 2 should focus on strengthening human resources to increase access to skilled delivery and strategies to improve communication and transport to facilitate timely referral of emergency cases.