Safer Deliveries D-tree international

the problem

Despite high rates of antenatal care and relatively good access to health facilities, in Zanzibar over half of deliveries still occur in the home.

Health facility delivery however is known to be correlated with reduced maternal and neonatal mortality. Indeed, in Zanzibar, maternal and neonatal deaths remain high.

We are helping many women to have safer deliveries, as we explain in a bit more detail below. For the latest updates on the program that Safer Deliveries has grown into, please see our story on Zanzibar's nationwide digital community health program: Jamii ni Afya.

the innovation

D-tree's Safer Deliveries program empowers, informs and encourages women, with the support of their families, to deliver in health facilities.

It links pregnant women with community health workers (CHWs), community drivers, village savings groups and health facilities.

These connections are supported by the use of digital technology to facilitate better decision making and the co-ordination of resources and support.

digital antenatal & postnatal assistant

Our Community Health Workers are equipped with a dedicated app via which they register all pregnant women in their catchment areas. The app helps the health worker to schedule at least three visits to each client during pregnancy and three after delivery and helps systematise what happens during these visits.

With the support of this app, the CHW:

  • Engages husbands and family members in the birth planning process
  • Establishes, well in advance, family permissions for a facility delivery
  • Screens for danger signs and makes appropriate referrals to the relevant health facility
  • Counsels the woman and her family about healthy behaviors during pregnancy
  • Supports the woman and her family to save enough money for transportation and other delivery-related expenses
  • Links mothers with community drivers who are registered in the program and have agreed to pre-negotiated transport rates
  • Maintains contact information for transport options and savings groups in the locality

planning for a facility delivery

One of the main reasons why women deliver at home is a lack of preparedness to deliver in a facility.

The app first helps the CHW to clarify answers to important basic questions such as: what is the client's estimated date of delivery? And at which facility the client should give birth (given the client's location, obstetric history and health during current pregnancy)?

Mnazi Moja hospital, Zanzibar

The opportunity for a safer, facility, delivery can be lost if a woman's partner or family are not in agreement. The app raises this issue as a discussion point early on, so that when the time comes all parties have already signalled their understanding and consent, thus eliminating uncertainties and potential (and potentially dangerous) delays in getting to facility.

The app calculates the likely costs which the family will incur - for transport to facility, for example - and keeps a tally of what has been saved so far and shows the remainder needing to be saved. It explicitly encourages the client to communicate with local community savings groups which may help the woman to save the money needed.

community savings groups

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. Community savings groups have existed for decades throughout Zanzibar and much of the world.

Members meet on a weekly basis and contribute money to the group savings, which are then given out as loans to individual members and repaid over time. Community savings groups in Zanzibar also have a social fund which members also pay into on a weekly basis.

This money is used to help any member in the community in a time of need (for example, during a medical emergency, or to repair the village water pump). Money given out from the social fund is a gift which is not repaid by the recipient.

danger sign screening & referral follow-up

At every visit, both ante-natal and post-natal, the CHW is prompted to check the client for important danger signs (and the baby too) and, if guided by the app, to refer her to a facility for medical attention. The app auto-ensures a follow-up visit to the client at a set time after a referral has been made.

health counseling

The app contains ministry guidance. Some of it is conveyed in the form of recorded dialogues, a medium with which people are familiar with via radio, and which is a popular and accepted medium for such messages on Zanzibar.

The CHW clicks a button to play a dialogue and discusses the contents of the dialogue with the client afterwards

Here are the main topics covered:

citizen feedback & performance-based financing

Digital tools generate data, which yields potential for many new ways of working. One possibility which we have explored is using data generated by such a program in Performance-Based Financing schemes for facilities. To this end, we designed a "Citizen Feedback" questionnaire concerning client experiences when obtaining services from facilities. The content and structure of this questionnaire fits directly a current model of this kind of program. Aggregate data of this kind can be pulled from our system on a regular basis by a Performance-Based Financing system.

Kivunge Hospital

data for decision-making

D-tree starts with the determination to systemise health care at the point of care, but the data generated as a by-product of health-worker client interactions with a digital assistant yields data which provides innumerable insights for program managers seeking to make quality improvements.

We show here just one of our dashboards to indicate the kind of aggregate information we are able to make use of in developing our program.

Program Dashboard

Similarly, we use data analytics to monitor health worker capabilities with our tools, so that we can provide additional support where needed.

measuring impact

Since the introduction of the program in 2011, we have consistently found increases in facility deliveries by approximately 50% compared to baseline estimates. Postpartum visits have increased four-fold for women in the program compared to baseline estimates. The program is currently being implemented in 10 out of 11 districts in Zanzibar, supporting approximately 30,000 women per year, or 80% of all pregnant women in these areas. The program is expected to expand in 2018 to support children up to 5 years of age and expand to all 11 districts in Zanzibar with more than 1,200 Community Health Volunteers.

D-tree International


This program is made possible through the generous support of the Saving Lives at 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. It was prepared by D-tree International and does not necessarily reflect the views of the Saving Lives at Birth partners.