Project Background

From the lack of life-saving medications and access to skilled birth attendants to the cost of transportation, the barriers to rural health-care facilities for antenatal care and delivery in Tanzania are numerous and well documented. For women living in Mara Region, the situation is no exception. About half of all births take place away from health facilities and post partum haemorrhaging (PPH) and infection (puerperal sepsis) account for 35 per cent and 15 per cent of the region’s total maternal deaths, respectively (TDHS-MIS). Shirati and its partners introduced the Saving Mothers project to pregnant women in 202 villages in Tarime and Bunda Districts, Mara Region. The project aimed for a 30 per cent reduction in the number of women who might otherwise die of PPH by distributing clean delivery kits containing misoprostol to prevent infection and stem heaving bleeding.

Project Description

The kits were distributed by trained community health volunteers (CHVs) and district nurses to women who were between 34 and 36 weeks pregnant. The women were instructed to seek a health facility for birth, but the kits could be used for home births, delivery en route, or at the facility where supplies were lacking. CHVs were given mobile phones equipped with an m-health app to register the women, send them reminders to attend antenatal clinic appointments, warn them about danger signs, and track their delivery outcomes. The app also provided information on staff workflows and stock levels.

Project Results

• 191 CHVs and 64 district nurses were trained to provide safe pregnancy education.
• CHVs and nurses distributed 14,000 clean birth kits with misoprostol to pregnant women in 191 villages.
• According to data from the District Medical Offices, the facility birth rate in Tarime District rose from 48.3 per cent in 2015 to 67 per cent in 2016 while in Bunda District, the facility birth rate increased from 70 per cent in 2015 to 84 per cent in 2016.
• Advisory team meetings and site visits were conducted, and policy dialogue sessions were initiated with the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) to share on the project model and to lobby for its adoption. ‘Women were so grateful for receiving the birth kits at the facility. Their happiness could not be hidden from their faces and that’s why they turned up in large numbers for the birth kits.’ (Nurse, Tarime District)

Key Lessons

• Use incentives to change health-seeking behaviours: The women and their families’ trust in the health-care system improved once the nurses stopped demanding money for supplies. This in turn led to a greater number of women returning to the health facilities for antenatal appointments and the delivery of their babies as well as for other health needs.
• Policymaker engagement needs time: The 18-month time frame was too short to allow for complete uptake of the kits into district budgets. More time was also needed to share the results at the national level, particularly with the MOH Reproductive Health Team, for a more lasting impact.
• Extend antenatal education beyond expectant mothers: Involving both men and traditional birth attendants (TBAs) was key to ensuring that expectant mothers received holistic support. The project provided men with health education on the importance of attending antenatal care while TBAs were shown how to use the birth kit in the event of a home birth.
• Understand the technological barriers to access: Poor connectivity and erroneous data entry were among other factors that led to difficulties in data collection through the m-health app. Ongoing training and support would help CHVs use the app more effectively and allow for regular feedback to help improve its functionality.

Gender Equity and Social Inclusion

Concern about the informal costs of care can sometimes lead to men’s reluctance to seek health[1]care services for their partners. Shirati was able to circumnavigate this issue by providing the birth kits for free. The project noted that the gender of the health worker may impact the provision of after-hours care. During one focus group discussion it came to light that some of the female health workers were reluctant to get up at night to deliver babies in the health facility where no security was provided.

Principles for digital development

Design with the user: The project was designed with the input of women from an earlier pilot who had described the cost of supplies and distance to the health facility as two significant factors that prevented women from accessing health-care services. In response, Shirati and its partners distributed free supplies to expectant mothers in the community as well as those attending the health facilities.

Next steps

Based on the evidence generated from this project, Shirati received funding to continue a related project in Rorya District, Mara Region. To ensure sustainability, the project will engage the government at the district, regional and national levels to raise the importance of incorporating misoprostol into birth kits.