Even as she sat amid the tranquil thickets of bright green pigeon peas and clusters of broad-leafed ensete trees, Sumni Ali Haji had no doubt how difficult and perilous life was in her remote corner of Zanzibar—especially for mothers and their children.

In early 2017, Sumni's son Hassan Faki nearly bled to death when he wasn’t yet 24 hours old. Born at home in Kachongwe, a small village on Zanzibar's Unguja island, Hassan’s umbilical cord had bled so profusely that his face had gone pale and his skin, cool to the touch. Her last child—her sixth birth at home—had died for unknown reasons soon after birth. She was desperate not to lose another child.

Sumni Ali Haji nurses her son Hassan Faki, 18 months, at a neighbor's house in the village of Matemwe, Zanzibar.

Sumni’s ordeal was not uncommon. Despite high rates of antenatal care and relatively good geographical access to health facilities, nearly half of deliveries in Zanzibar occur at home, and occurrence of preventable maternal and neonatal deaths remain unacceptably high. One in 18 children will not live to their fifth birthday.

Getting Hassan to the hospital was not going to be easy, Sumni knew. There were no ambulances available, and with the onset of the rainy season, the dirt roads—not easily navigable even during the dry months—had become a soupy mix of mud and jagged rocks. Taxi drivers often refuse to come under such conditions. To make matters worse, Sumni’s husband, she said, had shown little concern for her well-being during her pregnancy and, anyway, was nowhere to be found the night of the birth.

That’s when Sumni called Amina Rashid Bakar, a Community Health Worker (CHW) trained on D-tree International’s Safer Deliveries program. From 2015-2019, the CHWs and the Safer Deliveries program served as a crucial link connecting even Zanzibar’s remotest communities to the national health system. Delivering in a health facility is an important step in reducing maternal and neonatal mortality, and by 2019 the Safer Deliveries program succeeded in supporting 77 percent of the women registered in its program to deliver in health facilities, compared to a baseline of 53 percent in the 2015 population-based survey.

Here's how it worked.

Equipped with a decision-support app on their mobile phones, Amina and other CHWs visited clients three times during pregnancy and three times after delivery. During their visits, CHWs screened for danger signs, referring patients to health facilities as appropriate depending on the severity of the danger sign. CHWs also counseled women about healthy behaviors, noted pregnancy outcomes, and facilitated postpartum check-ups in health facilities. Beyond the specific services offered by CHWs during home visits, the Safer Deliveries app also facilitated:

  • Engagement of CHWs with husbands and family members in the birth planning process
  • Discussion around financial techniques to support women and families to save enough money for transportation and other delivery-related expenses
  • Linkage of mothers with community drivers who were registered in the program and had agreed to pre-negotiated transport rates
Community Health Volunteers used a mobile app to register all pregnant women in their catchment areas. The app helped the health workers to schedule at least three visits to each client during pregnancy and three after delivery.

The connections didn’t end there. The data CHWs collected using the D-tree mobile app were synchronized with a cloud-based server, where they could be aggregated or parsed to highlight healthcare trends, such as the number of home deliveries per village and perinatal deaths. Those trends were then regularly reviewed through online dashboards by Zanzibar’s District Health Management Teams to inform their decisions and follow-up actions.

The data generated as a by-product of interactions between health workers and clients provided innumerable insights for program managers seeking to make quality improvements.

Although CHWs do their best to promote facility deliveries, the system doesn’t solve every challenge a mother faces. In the case of Sumni, the CHW had registered her months earlier in the Safer Deliveries program, but Sumni’s family remained leery. And when it came time for Sumni to give birth, her family summoned a traditional birth attendant to Sumni's home. The umbilical hemorrhage wasn't noticed until after she left.

Still, the Safer Deliveries system saved lives. When Amina heard Sumni had given birth at home, she headed to Sumni’s home in Kachongwe. “I came four hours after the baby was born. I knew the danger signs, and I saw the baby was bleeding very severely from the cord,” said Amina. “I asked the mother, ‘How long has the baby been bleeding?’ ‘All night. He has lost his color, and his eyes are yellow.’”

Only one day old, Hassan was brought to the Matemwe health facility, designated as a Primary Health Care Unit Plus. As a PHCU+, the facility provides basic health facilities for adults and children; antenatal care; breastfeeding counseling; delivery; the diagnosis and treatment of HIV, malaria, and tuberculosis; and some dental care.

Amina called a driver registered with the Safer Deliveries program, who responded immediately and rushed the child to the Matemwe health facility, about five kilometers away. Matemwe is designated as a Primary Health Care Plus-level facility that is capable of providing basic health services, including delivery services, and the staff there were able to care for Sumni and her baby. "I'm very happy with Amina," said Sumni. "As you can see my baby is alive today and very happy."

So, too, are thousands of other children, thanks to D-tree, the Zanzibar Ministry of Health, and its partners. Together, they succeeded in scaling up the Safer Deliveries program in 10 of Zanzibar’s 11 districts. Working with 404 CHWs and 67 supervisors, the program served over 54,000 pregnant women, almost 43,000 of whom delivered while part of the program.

They included Sumni's neighbor Patma Mcha, who also credits Amina and the Safer Deliveries program for saving her baby, Hajra. Amina had registered Patma in the program and encouraged her to receive antenatal screenings at the closest health facility. Patma did so and was told on her last visit that her baby was in a breech position. She was advised to give birth at Kivunge Hospital—a facility about 6 kilometers in the opposite direction—because Kivunge is a higher-level facility better equipped to handle complicated births. “When Patma was in labor she called me to help find transport…because she tried to find other means of transport without succeeding,” recalled Amina. “I called the driver and he came immediately, the driver picked me on the way going to the client’s home. We picked the client immediately and she was even not able to walk.”

With Amina’s assistance, Kivunge Hospital admitted Patma and safely delivered Hajra, Patma's fourth child. “This service was really good as they received me well and I had peace,” recalled Patma six months later. “We are poor. There is no transport to our village and the road is very bad. My husband is not working and while I make a little money selling bread. Business is not good.” Patma said that with Amina's intervention, the driver agreed to take her to the hospital and be repaid later.

The driver’s offer was a sign of trust, certainly. But it was much more than that. It was a sign that by linking pregnant women and their newborns to critical healthcare, as the Safer Deliveries program did, lives can be saved.

Given the promising results of the Safer Deliveries program, the Zanzibar Ministry of Health recognized the benefits of technology in the pursuit of its vision for a healthy population and chose to formally adopt and expand the digital community health system in a program now called "Jamii ni Afya." With D-tree's support, this government-owned, national digital health program was launched in early 2020 as part of the government's revised National Community Health Strategy (2019-2025). Learn more in our updated Jamii ni Afya story.

This story and all photos were contributed by Kevin Ferguson, a freelance writer and photographer based in Boston.


Kevin Ferguson for D-Tree International