Midwife Fareedah Tinorgah Yelgie uses the Safe Delivery App.
Picture this scenario. A woman in a rural area goes into labor in the middle of the night. When she arrives at the clinic, the on-call midwife is on duty alone. The delivery is quick, and both the baby and the mother seem to be doing well. Suddenly, the baby breaks into a fever, turns silent, and refuses to breastfeed.
Under normal circumstances, the midwife would refer the baby to the nearest hospital, but it is the middle of the night, there are no ambulances, and she doesn’t have much time. Instead, the midwife opens an app on her phone, follows a set of instructions to diagnose and treat the baby’s low glucose (blood sugar) level, and brings the baby’s temperature back to normal. After a few hours, the baby is fine – and the mother and her relatives can relax.
The above is not a hypothetical scenario. It is a story from midwife Fareedah Tinorgah Yelgie, who works at Tolon Health Centre in northern Ghana. There are just two midwives at the clinic, where they deliver around 80 babies every month.
Every year, around 300,000 women die from complications in pregnancy or childbirth, and 2.7 million babies die in the first 28 days of life. That is over 800 women and 7,000 babies losing their lives every day. 99 percent of these deaths happen in developing countries, particularly in sub-Saharan Africa and South Asia. The majority of these deaths (more than 80 percent according to the World Health Organization) could be prevented with access to skilled care during pregnancy and childbirth.
One critical component is ensuring that women give birth with a skilled birth attendant by their sides who has basic knowledge and skills to handle childbirth emergencies. The Safe Delivery App, a smartphone application developed by our organization, Maternity Foundation in Denmark, in partnership with the Universities of Copenhagen and Southern Denmark, aims to fill this gap. The app guides health workers through simple, animated instructional videos, drug lists, and quizzes. Midwives like Fareedah can get instant support right out of their pockets. All features are designed for low-literacy, low-income settings and work offline once downloaded.
The Safe Delivery App has been adapted into numerous languages and local clinical guidelines and is being used in countries including Ethiopia, Ghana, India, Laos, Myanmar, and Sierra Leone. For each new version we launch, Maternity Foundation and our partners make an effort to portray the reality of the women, newborns, family members, and health care workers in the specific local context.
Cultural, clinical and traditional norms and guidelines vary from country to country, so one of our biggest tasks – beyond adapting the clinical guidelines and languages – is to adapt the visuals and practices surrounding pregnancy and childbirth to the different settings we work in. For instance, in the Indian version of the app, the pregnant woman is assisted by her mother during labour, while in some of the other versions, she is assisted by her husband. The outfits of the women and the health care workers in the app also vary depending on the setting. To ensure that the app supports existing maternal and newborn health activities, Maternity Foundation works through partners such as ministries of health, UN organizations, and local and international NGOs (non-governmental organizations).
When our team met Fareedah in Ghana, she told us about the night where she saved the baby’s life, saying, “Because of the Safe Delivery App, I was able to manage the complications, and I observed the mother and baby until the next day. Both mother and baby were fine, the stress on me came down and I felt happy. Thanks to Safe Delivery App, I was the hero of that night.”
Fareedah is one of thousands of midwives for whom the app makes a difference in their daily work.
Evidence shows that health workers using the Safe Delivery App significantly improve skills, knowledge, and confidence in identifying and managing obstetric and newborn complications. In the case of Northern Ghana where Fareedah works, Maternity Foundation monitored 40 midwives using the app. After just 3 months, their average knowledge level had increased by 40 percent, and the midwives reported feeling more confident in their work. In a 2014 randomized control trial in rural Ethiopia, as well as a 2018 study in central Democratic Republic of Congo, the Safe Delivery App improved birth attendants’ scores on measures of confidence and in handling specific post-natal and newborn complications.
As another midwife, Nicola Zewge, put it when we met him at the maternity clinic in Nguenyyiel Refugee Camp in Gambella Regional State, Ethiopia, “Our work is risky – we have the lives of mothers and their babies in our hands every day. The Safe Delivery App makes it easier for us to manage. I think all midwives should use it.”
Lessons for Starting and Scaling Interventions
What we have we learned from developing, testing and then scaling the Safe Delivery App can be boiled down to four main points:
- Remember it is not about technology. An app will not make a difference on its own. It is easy to get carried away in terms of what technology can do. Often, what is needed is a simple and focused innovation that can easily be integrated into existing practices, programs, trainings or other activities. Technology can drive change – but cannot create change on its own.
- Move beyond the pilot. Getting strong evidence that your solution works is the first essential stepping stone for building credibility. But many solutions will never move beyond the pilot stage. Think about how to scale your solution from the very beginning.
- Make open collaboration your DNA. With a free tool – and a mission to reach as many health workers as possible – we are working with multiple partners at multiple levels at the same time. Even in the NGO world this is a very different business model than what we are used to. See collaboration and partnerships as a key to your success – not as a potential obstacle.
- Standardize 80 percent, customize 20 percent. It is critical that partners can feel a strong sense of ownership of the solution in their country and that it is adapted in terms of language, clinical standards, and visuals. But in order build a scalable platform in a cost-effective way, it must be built on a standardized core backbone. That is why we say 80 percent standardization, 20 percent customization.
To date, the Safe Delivery App has been downloaded more than 70,000 times and is being used in over 40 countries worldwide. The app is also increasingly being used as a tool to contribute to safer births in areas affected by humanitarian crisis and conflict, including in refugee camps in Ethiopia’s Gambella region. In the pipeline, we also have plans to launch Arabic and Swahili language versions, and a Russian version was recently launched in Kyrgyzstan.
The initial results of this work were shared as an abstract at the 2018 IHI Africa Forum on Quality and Safety in Healthcare. Reserve your spot now for the 2020 conference.
Anna Frellsen is the CEO of Maternity Foundation.