Despite comparatively good access to health facilities and high rates of antenatal care, over half of deliveries in Zanzibar occur at home. Safer Deliveries, a programme designed and implemented by D-tree International in collaboration with Zanzibar’s Ministry of Health, aims to reduce the state’s high rates of maternal and neonatal mortality by increasing the number of pregnant women who deliver in a health care facility and attend pre-natal and post-natal check-ups.
As part of the programme, D-tree has established a cadre of trained community health volunteers (CHV), equipped with smartphone-based decision support and registration tools contained in a mobile app. The app helps CHVs systematically schedule home visits to pregnant women in their communities during the prenatal and postpartum period. The objective is to increase the quality of maternal health care in key areas such as counselling, risk screening, referrals, the birth planning process and financial planning for delivery. Each small community has one or two CHVs, supervised by health facility nurses.
All data collected by the CHVs on the mobile app are synchronized in quasi-real time to the Safer Deliveries server. This real time data collection has revolutionized routine monitoring of both specific community health indicators and the performance of CHVs. The data have also helped to inform policy dialogue and planning within the Ministry of Health. For example, information collected by the CHVs on the reasons why women choose to give birth at home have contributed to a policy change that allows pregnant woman, during labor and delivery, to be accompanied by a birth companion in one of the state’s large hospitals.
The strength and versatility of this platform – a network of CHVs with digital work tools and an integrated monitoring system – could also be leveraged for the recruitment and maintenance of a birth cohort. This will likely be far more cost effective than a de novo cohort, since the necessary structures have already been established.
With a dense network of CHVs and modern digital technology at their disposal, it is possible for the Safe Deliveries team to follow a cohort longitudinally. The system should allow for the transfer of participants between CHVs, when participants move from one community to another, leading to a reduced attrition rate. Tracking participants is often one of the main challenges of maintaining a birth cohort in low-income countries due to inconsistently spelt names, undefined physical addresses, and the lack of unique national personal identification numbers. In addition, using CHVs and recruiting at the community level, instead of at health facilities, is an ideal way of involving fathers who are often not interested in or enrolled in these studies.
Currently the majority of birth cohorts are located in high-income countries. These fail to represent the conditions of low-income countries, and the contribution of absolute poverty to the development of disease in later life. The Safer Deliveries programme is an innovative maternal and child health intervention. Widening its scope of use could create opportunities to support research on a wide range of social and environmental exposures and health outcomes which are unique to low-income settings, whilst simultaneously sustaining the success of the programme.