How a simple travel voucher is saving the lives of pregnant African women

USAID is reporting 'extraordinary results' from a pilot program in Zambia and Uganda that gives pregnant women travel vouchers and spares them hours of walking to obtain health care.

Across much of Africa, a pregnant woman faces a long walk, sometimes up to several hours, to reach prenatal care – or a facility equipped to handle complications in birth.

The result is that few rural women have had access to the kind of maternal care that women in developed countries take for granted – and maternal mortality rates in many African countries has remained stubbornly high.

Enter a very simple idea – transport vouchers for pregnant women. Over the past year and a half of a new US-initiated program for addressing maternal mortality, Uganda provided more than 30,000 vouchers for women to be able to access pre-natal care and properly equipped birth facilities. [Editor's note: The original version of this story misidentified the country in which the travel vouchers were introduced. Corrections have been made throughout.]

The maternal health program, called Saving Mothers Giving Life, has a lot more to it than rides on the motorized cycles used in those rural areas. But the availability of transportation is one key reason the program has shown impressive results in a short time, experts say.

Uganda records about 4,700 maternal deaths every year and an estimated 1.5 million births, giving it a maternal mortality ratio of 310 per 100,000 live births. (In the US, the number is closer to 12 per 100,000, according to the Centers for Disease Control.) Worldwide, about 800 women die every day in labor as a result of complications in childbirth – 99 percent of them in developing countries.

But in the four Uganda districts participating in the Saving Mothers Giving Life (SMGL) program, the maternal mortality ratio fell by 30 percent, from 452 to 316, according to the SMGL annual report.

In four districts in Zambia participating in the program, the maternal mortality ratio for live births in health facilities dropped by 35 percent.

“We are seeing extraordinary results in the districts in Zambia and Uganda where this [SMGL] was implemented, and we know that will have significant impact,” says Rajiv Shah, administrator of the US Agency for International Development (USAID), the lead US partner in the program. “When maternal mortality goes down,” he adds, it sets off “ripples of change” that include greater community stability and rising prosperity. “Economies start to take off,” Dr. Shah says.

Shah spoke Thursday at Washington’s Center for Strategic and International Studies (CSIS) at a kind of review conference of the Saving Mothers’ pilot programs in Zambia and Uganda. The SMGL initiative, a triangular program among sponsoring governments (the US and Norway), the private sector (health NGOs and companies like Merck), and the host governments, recorded impressive results in both countries.

The Saving Mothers initial program cost $20 million – or about $7 per birth under the program in Zambia, and about $13 per birth in Uganda.

“We recorded a significant reduction” in maternal mortality in the four participating districts, says Jane Ruth Aceng, director general of Uganda’s Ministry of Health.

Dr. Aceng credits improved access to quality care – in part through an increase in maternal caregivers and midwives in rural areas, but also a rise in well-equipped facilities – plus a focus on communication with women and the innovative transport vouchers for the decrease.

“More women with major complications were able to be treated in facilities,” she says, “and that contributed significantly to the drop in fatalities.”

The SMGL pilot programs clearly demonstrate that maternal mortality is preventable, or at least that the high rates in some developing countries can be quickly and significantly reduced. So why aren’t they? After all, reducing maternal mortality by three-quarters by 2015 is one of the Millennium Development Goals set in 2000.   

One reason is that a focus on maternal health and reducing maternal mortality was not going to happen until emphasis was placed on the role and value of women in their communities. As understanding has grown in recent years of the importance of women, and in particular rural women, in economic prosperity and social stability, greater value has been placed on maternal health.

Of the key development challenges, reducing maternal mortality was long thought to be among the most challenging, some experts say. “People assumed it was too hard to do, and so it hasn’t got the attention of other goals, like child mortality, where we’ve seen some good progress, even if it’s not enough” says Tom Frieden, director of the Centers for Disease Control and Prevention.

But the SMGL program “is the first proof,” Dr. Frieden adds, “that we have the tools to make impressive progress in reducing” maternal mortality.

Others say the issue of maternal mortality didn’t become a priority on the global stage until it was taken up by an influential international leader – and for maternal health that “champion” was former Secretary of State Hillary Rodham Clinton, who joined Norway in establishing the SMGL program in 2012.

“About 25 years ago [USAID] started working on maternal health,” says Robert Clay, the agency’s deputy assistant administrator, “but I was always frustrated that we didn’t have a champion or a movement behind this initiative.”

But the issue got that “champion” in Secretary Clinton, Mr. Clay says, and SMGL became the initiative for focusing the agency’s efforts. When Clinton joined Norwegian officials, and representatives of NGOs and private companies in launching the program in Washington in 2012, she said, “Every life we save is a step towards a more peaceful and prosperous planet.”

A lot more will have to be done to significantly reduce the nearly 300,000 deaths of women each year from complications resulting from pregnancy or childbirth. But the SMGL program is one start. Both Uganda and Zambia plan to expand their programs into additional districts this year, and USAID will expand SMGL to three new countries.

The “ultimate goal,” says Janet Fleischman, a senior associate in the CSIS Global Health Policy Center, is for motherhood to constitute not a danger but a fulfillment for women across the developing world.

On a recent trip to Zambia, Ms. Fleischman recalls a woman telling her that the common response to a woman who has just delivered a child is, “Oh, you have survived.”

To change that, Fleischman says, more has to be done so that “maternity and childbirth are a joy and not a threat to women around the world.”

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