WHO mHealth D-Tree eNUT program to prevent early childhood malnutrition

North A district, Unguja, Zanzibar
Matemwe Primary Health Care Unit

D-Tree's Juila Ruben:

This project - called "mhealth for Safer Deliveries" --primarily aims to facilitate deliveries and is being scaled up all over Zanzibar. The project is based on the use of a cell phone based algorithm that assists community health workers to quickly and accurately identify complications and provide targeted counseling during pregnancy, labor/delivery, and the early postnatal period. Health workers then
refer (mother and/or baby) without delay to the appropriate health facility, paying for transport using mobile money.

In Zanzibar, despite high rates of antenatal care and relatively good access to health facilities, over half of deliveries occur at home and maternal and neonatal deaths remain unacceptably high. Delivering in a health facility is an important step in reducing maternal and neonatal mortality.

The Safer Deliveries program employs a comprehensive approach to empower women, with the support of their families, to deliver in health facilities. This is achieved through an integrated approach which includes linkages between the pregnant women and community health workers, community drivers, village savings groups and health facilities. These systems are supported by the use of mobile technology to facilitate better decision making, sending of mobile money and remote supervision.

The program has a strong partnership with the Zanzibar Ministry of Health and other key stakeholders working to improve maternal and child health in Zanzibar. One main goal of this program is to fully integrate within the Ministry of Health system, and the Ministry is involved in all aspects of program implementation and planning. The program also has strong partnerships with Zantel, the leading mobile network operator in Zanzibar which has developed custom packages for data bundles and airtime which are sent monthly to CHW phones. In addition, there is close collaboration with UNICEF, UNFPA, Save the Children and the Health Improvement Project Zanzibar to ensure programs are coordinated and support each other to have the maximum impact.

The program is currently piloting and refining the integrated model in one district in Zanzibar with 45 community health workers. In July 2016, this intervention will be scaled up to 10 out of 11 districts in Zanzibar, working with approximately 400 community health workers and reaching 30,000 women per year (60% of all pregnant women in Zanzibar).

Helping Pregnant Women Deliver Safely

The program provides pregnant women with:

1. Home visits to pregnant women by trained community health workers, equipped with mobile decision support tools, at least 3 times during pregnancy and 3 times after delivery to:

  • Engage husbands and family members in the birth planning process, and record permission in advance for a facility delivery
  • Develop a birth plan with the woman and her family based on medical and obstetric history
  • Support the woman and her family to save enough money for transportation and other delivery-related expenses
  • Screen for danger signs and make appropriate referrals to the relevant health facility
  • Counsel the woman and her family about healthy behaviors

2. Access to short term loans, which can be used to pay for transportation and other delivery-related expenses, through participating village savings groups

3. A network of registered community drivers who transport women to health facilities during delivery

Safer Deliveries program framework
Community Health Workers Provide Counseling & Support

The community health workers, who were selected to participate in the program based on their respectability and standing in their communities, work with community leaders and staff at nearby health facilities to identify and register pregnant women into the program. At registration, the community health worker meets with the woman, her husband and/or other influential members of the family to discuss the program and record permission from the family for the woman to participate in the program and deliver in a health facility. Afterwards, the community health workers visit the woman in her home throughout her pregnancy and one week after delivery to provide education, counseling and support to help the woman prepare for a facility delivery.

Saving Up for a Safe Delivery

One key aspect of this program is community engagement and empowerment of women and their families to take responsibility for saving money in advance to pay for transport and other delivery-related expenses at the health facility. To support this, the program works closely with already-existing community savings groups. The Safer Deliveries program collaborates with community savings groups to ensure that all women have access to small, short-term loans.

At registration, each woman is given the opportunity to attend a nearby savings group. The woman is then invited to become a temporary member with the ability to access short term loans. To access a loan, women:

  • Attend weekly group meetings
  • Contribute money to the group
  • Receive a loan up to three times the amount contribution

The community health worker helps women to estimate their total expenses through the mobile application based on transport prices to the recommended delivery facility and historical averages of other expenses once at the health facility. Women then work directly with the savings groups to repay loans over time.

Integrated Mobile Technology & Mobile Money Systems

In addition to supporting women to save money, the Safer Deliveries program links pregnant women with reliable drivers within their communities. The community health workers screen and register drivers using the mobile app, then help women to contact drivers in advance and pre-negotiate prices to the health facility during labor and delivery.

The innovative use of integrated mobile health and mobile money systems allows the Safer Deliveries program to:

  • Monitor community health worker activity
  • Send and track mobile money payments to savings groups
  • Track overall program performance in real time

Data from the community health worker mobile phone automatically synchronizes with the program server. Community health workers are paid based on the work achieved through a pay for performance system which is viewable on the program dashboard and also on the community health worker phone.

This project is made possible through the generous support of the Saving Lives at Birth partners: the United States Agency for International Development (USAID), the Government of Norway, the Bill & Melinda Gates Foundation, Grand Challenges Canada, and the UK Government. This program overview was prepared by D-tree International, and does not necessarily reflect the views of the Saving Lives at Birth partners.