Table 1 SMGL Interventions Implemented in Uganda and Zambia to reduce the Three Delays

Increase Awareness and Seeking Care for Safe Delivery (to reduce the First Delay)

• Training of Village Health Teams to encourage birth preparedness and increase demand for facility-based delivery care

• Community outreach activities to counsel women, families, local leaders, and community organizations on the importance of birth planning, recognition of danger signs of pregnancy complications, attending at least 4 antenatal care visits, facility delivery care, HIV testing and treatment, post-partum homecare for mother/newborn and postpartum family planning.

• Distribution of Mama Kits to incentivize facility-based births

• Community mobilization messages (radio, billboards, newspaper articles) and drama skits

• Promotion of demand- and supply-side financial incentives to facilitate women seeking, accessing and utilizing quality care services (eg. transport and delivery care vouchers, user-fee reductions, and conditional cash transfers).

Increase access to quality health care services (to reduce the Second Delay)

• Upgrade a sufficient number of public and private facilities with appropriate geographical positioning to provide—24 h per day/7 days a week—clean and safe basic delivery services, quality HIV testing, counseling and treatment (for woman, partner, and baby as appropriate), and essential newborn care for all pregnant women in the district.

• Ensure that a minimum of five emergency obstetric and newborn care (EmONC) facilities (public and private), including at least one facility that can provide comprehensive EmONC per 500,000 population are providing the recommended life-saving obstetric interventions 24 h per day/7 days a week.

• Hire a sufficient number^a of skilled birth attendants to provide, on a consistent basis, quality respectful basic delivery care, diagnosis and stabilization of complications, and if needed, timely facilitated referral for EmONC. Performance-based EmONC-trained personnel in facilities that provide basic and comprehensive EmONC.

• Create a 24-h/7 day per week, consultative, protocol-driven, quality-assured, integrated (public and private) communication/transportation referral system that ensures women with complications reach emergency services within 2 h. This includes providing, where appropriate, temporary lodging in maternity waiting homes for women with high-risk pregnancies or who live greater than 2-h travel time to an EmONC facility.

Improve quality, appropriate and respectful care (to reduce the Third Delay)

• Train health professionals in emergency obstetric care, including obstetric surgeries

• Ensure mentoring of newly hired personnel and supported supervision

• Strengthen supply chains for essential supplies and medicines

• Ensure implementation of quality, effective interventions to prevent and treat obstetric complications (MgSO4, infection prevention practices, assisted vaginal delivery, Active Management of the Third Stage of Labor [AMSTL], C-section and other obstetric surgeries (e.g., laparotomy, hysterectomy, repairs following obstetric complications), safe blood supplies, prevention of HIV maternal to child transmission, etc.)

• Introduce sound managerial practices utilizing ‘short-loop’ data feedback and response, to ensure reliable delivery of quality essential and emergency maternal and newborn care.

• Strengthen maternal mortality surveillance in communities and facilities, including timely, no-fault, medical death reviews performed in follow-up to every institutional maternal death with cause of death information used for ongoing monitoring and quality improvement.

• Promote a government-owned HMIS data-gathering system that accurately records every birth, obstetric and newborn complication and treatment provided, and birth outcomes at public and private facilities in the district. Where appropriate, m-health approaches to facilitate the monitoring activities.