In countries like Zambia with only one physician per 10,000 people, where a patient may realistically never see a physician, African countries have turned to novel methods to close clinician gaps. Many have responded with mid-level providers such as clinical officers (similar to a physician’s assistant in the United States (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3724708/)). Countries like Ethiopia go a level lower utilizing “health extension workers” with three months of training to handle up to 16 medical conditions(https://www.unicef.org/infobycountry/ethiopia_70372.html). And in a country where nearly 50% of women believe that husbands can be justified in beating their wives (https://tradingeconomics.com/zambia/physicians-per-1-000-people-wb-data.html), Zambia has employed another approach: Safe Motherhood Action Groups (SMAGs) who exist to help foster safer pregnancies to women in their villages, and go further in promoting women within communities.

“SMAGs are community-based volunteer groups that aim to reduce critical delays that occur at household level with regard to decision-making about seeking life-saving maternal care at health facilities.”

Zambia has 4,300 maternal deaths and over 20,000 infant mortalities from birth each year. According to USAID’s Saving Mothers, Giving Life program, these maternal and newborn deaths are largely preventable with access to health care facilities. Yet for geographic, economic, and religious reasons many women do not go to birthing facilities. Geographically, while most of Zambia’s rural population lives less than 8 km from a health center, the average distance to a safe delivery equipped health-care facility is more than 15 km, and some women need to travel 40 km over dirt roads. Economically, many of these women have direct or indirect fiduciary family responsibilities that prevent them from going to health centers for prenatal or ante natal checkups, or even for giving birth. Last, local religious leaders discourage women from going to health clinics, and instead encourage prayer or traditional medicine.

The SMAG program exists to help women and their families overcome these obstacles through identification, registration and referrals, and education. The SMAGs are elected at the community level, and the designation is seen as a sign of honor. Amazingly, while the SMAGs receive bicycles, rain coats and other rain equipment, a satchel, and cell phone, they receive no salary.

Their first task involves identifying those women in the community who are pregnant, and logging information in two registers: the pregnancy register and the birth register. The SMAGs will then refer pregnant women to health facilities for prenatal and ante natal checkups. Along the way, the SMAGs hold community education sessions where they educate not only the women in the community, but also men, who often use their power in the highly patriarchal Zambian culture to prevent women from seeking care that would lead to their and their children’s well being. At these education sessions, community members learn about implementing programs in HIV/AIDS prevention, family planning, emergency obstetric and neonatal care, and infection prevention. Those present are then tasked with education at least 10 other community members to sensitize the broader community on safe motherhood action plans.

While SMAG intervention has helped to reduce maternal mortality to 2,600 deaths per year, various challenges affect the SMAG program’s sustainability. The largest of these include lack of monitoring and evaluation, lack of consistent refresher training for SMAG members, and insufficient financial support. In response, action groups such as Safe Motherhood 360+ have stepped up.

The SMAG program has its own set of challenges, however, the institution has served as both an example to broader healthcare development utilizing low-level providers to increase utilization of facility-based skilled care and subsequently improve maternal and newborn health outcomes.