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SAFER TRANSPORT, SAFER DELIVERIES D-tree International Connects Women and Babies to Lifesaving Maternal Healthcare in Tanzania

Seif Nzwala knows every inch of Usanda's cratered roads: Heading west toward the dispensary, just around the bend in the red clay path, tips of buried granite boulders are ready to break the axles of unsuspecting speeders. Just beyond them, jagged bits of metabasalt, stoic survivors of two billion years of geologic drama, wait to puncture tires that stray too far to the left. But Seif's mind is not on the road; he is rapt by the woman in labor in the back seat of his Toyota Noah minivan. He hopes he can make it to the hospital in time.

Seif is a driver for an emergency transport system that dispatches vehicles to some of Tanzania’s most remote villages. The transport system is part of Vodafone Foundation's m-mama program, led by the Touch Foundation in collaboration with the Government of Tanzania, D-tree International, and Pathfinder International.

Since it was introduced in July 2015, m-mama has supported more than 11,000 life-saving referrals, averaging six emergencies per day. Seif recalls the first time he transported a woman in labor. "The first time, I was so scared," says Seif. "So, when she delivered the baby in my car, I was shocked. I was truly shocked. I didn't know what to do. But we had a nurse in the car, and the nurse comforted me and told me not to worry. The baby was big, but the bounciness of the roads helped, so she gave birth. We went to the health facility and she got good services. So, we do thank God. The woman was fine, and the baby was fine."

"Transporting patients, I come across a lot of things. There are situations that are easier than others. Most times, you save the woman, and they get good service. But there are places that you go, and you come across many challenges." —Seif Nzwala

In the first few years of the program, Seif transported over 100 women via m-mama.

The Usanda Dispensary, one of 153 public dispensaries in the Shinyaga region, has a five-bed ward, a small labor room, and an outpatient clinic. Electricity is available intermittently.

Here's how m-mama's emergency referral system works: First, a pregnant or postpartum woman, her family, or a primary health care facility (if a woman has already traveled to one of Tanzania's primary health care facilities) calls a toll-free number. The call is answered by a dispatcher who uses a mobile decision-support app to triage calls, arranging emergency transportation to the nearest facility for basic emergency care or to the district/regional referral hospital for management of more severe conditions.

The mobile app prompts the dispatcher to organize a government ambulance as the first point of care. But ambulances are not always available because they're already out on call, lack fuel, or are simply broken down. In those cases, dispatchers call community drivers, like Seif, who have already been screened, registered in a database, and who have agreed to fixed rates for specified routes. Once the dispatcher confirms that the patient arrived at the destination, the drivers are paid through Vodacom’s M-Pesa mobile money system, which sends money via an SMS on the phone that can be withdrawn from community agents.

Two community health workers and a district health officer, left, get trapped for two hours on the road from Lyabukande Dispensary to Lyagiti village, 6 kilometers away. Although the roads appear dry in July, a hard crust sometimes conceals thick mud. In the rainy seasons, from March to May and again in November, the roads are sometimes impassable in motor vehicles.
Deborah James Mwakatefu, a "nurse medical attendant," serves as an emergency dispatcher at the maternity waiting home across the street from Shinyanga Regional Referral Hospital. She became a dispatcher in February 2016.

"If not for this program, many women would die," says Janeth Kibona, an emergency dispatcher stationed in the waiting home for expectant mothers across the street from Shinyanga Regional Referral Hospital. Janeth receives four or five emergency calls every day. "So many women are poor and living in rural areas away from the health centers. That means they have no way of getting here otherwise. But because of this program, if a facility does not have an ambulance or it does not work, we have the community taxis. The community taxis do a lot, and the mortality rate has decreased because of them." In fact, an analysis found that, within just one year, the maternal mortality ratio reduced by 27 percent throughout one district of implementation.

Using D-tree's web-based dashboards like this one, district health managers can optimize the number and distribution of emergency transport cases across participating facilities. The dashboards, as shown here, are also used to track family planning efforts.

Regina Thomas was among those helped by the referral system. When she was eight months pregnant with her first child, she began having labor pains. She had been registered in the program and received antenatal care since the end of her first trimester. Regina was not yet ready to give birth, but her family was growing concerned. With the roads impassable—cars and even mikokoteni, large carts pulled on foot, were getting stuck in the mud—Regina's mother and brother decided to hoist her on a bicycle and, standing abreast, pushed her six kilometers to the Lyabukande Dispensary.

(Clockwise from top, left): Leonard Daudi, a community health worker previously engaged with the m-mama program, checks his mobile phone for updates; autoclaves, needed to sterilize medical equipment, await use in the labor room; the dispensary at Lyabukande advertises its hours; and the five-bed maternity ward.

Because her cervix was not adequately dilated, Regina was moved from the labor room to the maternity ward. That was in the early afternoon. By six o'clock the next morning, attendants "exercised her," that is, walked her around the room, hoping to induce birth. By 11 a.m., she was no closer. By 4 p.m., nothing had changed. That’s when she was referred to Nindo Health Centre, a larger facility 50 kilometers away by a local driver who was registered with m-mama's emergency transport system. They arrived at the facility at 9 p.m., and Samson Daudi—5.5 kilograms, or 12.1 pounds—was delivered by C-section.

Using the m-mama emergency transport system, Regina Thomas was transported more than 50 kilometers from Lyabukande Dispensary to Nindo Health Centre after labor couldn't be induced. At Nindo, she gave birth by Cesarean section to Samson Daudi, who weighed in at over 12 pounds (5.5 kilograms).

The system is currently being used in the entire Shinyanga Region, supporting a population of nearly 2 million people including more than 90,000 pregnant women and their newborns. In 2020, the m-mama team began transitioning the program’s operations and management to the district government. Now, not only does the government manage the dispatch centers and community drivers but has taken full responsibility of driver payments for trips that originate from the health facilities. These are great achievements and promising steps towards sustainability and full government ownership.

Through the m-mama system, the lives of many women and children have been saved, demonstrating the crucial role of health systems strengthening, especially of referral coordination systems, in ensuring timely access to high quality care.

Credits:

Kevin Ferguson for D-Tree International