report of field survey for the e-health observatory in the ... · what midwives on the ground call...

FIELD REPORT PRODUCED BY STARTUPBRICS FOR ODESS 2017

Report of field survey for the e-health Observatory in

the Southern countries of the

THE SAFE DELIVERY APP, A SMARTPHONE

APPLICATION TO TRAIN MIDWIVES IN ETHIOPIAN

RURAL AREAS

Samir Abdelkrim, StartupBRICS April

2017, Gimbi, Ethiopia

The Actu Tech and Start Up of the Emerging Countries


The Safe Delivery App project field survey took place in Ethiopia, in the small, isolated town of Gimbi,

situated 600 kilometres from Addis Ababa. Founded in 2012 in Denmark, Safe Delivery App (SDA) is an

Android smartphone application which aims to train midwives to help give birth to pregnant women in rural

Ethiopia. Every day, 800 women die in the world giving birth, and a large proportion of these deaths occur

in Africa according to the WHO: according to the Geneva-based institution, only one in three pregnant

African women receive the four recommended medical visits during pregnancy.

Safe Delivery App provides midwives with direct access to up-to-date video, tutorials and audio and written

advice on obstetric emergency management, as well as neonatal first aid. The application first uses video

animations in local languages such as Amharic to convey simple, clear and digestible messages, even for

people who cannot read or write, through a series of small animated clips. Safe Delivery App also provides

detailed lists of drugs to know in neonatology, particularly injectable drugs for new-borns, anti-infectives,

etc. which midwives learn to recognise.


General social context

Ethiopia has 100 million inhabitants, making it in fact the second most populous country in

Africa ahead of Nigeria. But it is in vast rural Ethiopia that the immense majority of the Ethiopian

population is concentrated. If Ethiopia is an African landlocked country, many of its regions are also

cut off from the capital Addis Ababa in times of tension, such as the West Welega region and its

capital city Gimbi, where the Safe Delivery App project is currently being tried out.

Gimbi is located in the heart of the Oromo country, within which is nestled an old ethno-political

conflict between the Oromo majority, economically marginalised and neglected and the Tigrayan

minority, who hold most of the political, economic and military levers on the whole country.

This climate of uncivilised civil war - which peaked in 2016 with many violent clashes

between the population and the Ethiopian army - reinforces the sense of isolation one feels through

the deep Ethiopian country, starting with the lack of adequate health coverage: the infant mortality

rate in rural Ethiopia is 59 children per 1,000 births according to the WTO, one of the highest in the

world. This structural underinvestment in health facilities has an impact on life expectancy, which

does not exceed 57 years for men, while the population is regularly the victim of epidemics: the

country is one of the most vulnerable to outbreaks of Malaria (3 million infections between 2000

and 2005) and tuberculosis epidemics (Ethiopia is the 8th most affected country by this disease).

Electrification which is stuttering or even non-existent in thousands of villages (Gimbi city is

electrified) is also a major aggravating factor for the economic and social development of rural

areas of Ethiopia.


Performance of the field survey

The survey took place over three days in the small town of Gimbi, which has 40,000

inhabitants, as the county town of the West Welega department in the Oromia region about 600 km

from the capital Addis Ababa. Getting there can take a whole day: departure at 7:30 to arrive

around 20:30. If, during the day, the paths take us to the heart of the Ethiopian countryside, with its

breath-taking mountainous reliefs, the last part of our journey will be in absolute darkness, for more

than an hour, symbol of the under-electrification of the African continent.

We are greeted by the local Safe Delivery App (SDA) team, which has two offices in

Ethiopia: a main headquarters in Addis Ababa, as well as an operational team directly in Gimbi. I

am guided by Feyisa Daro, Ethiopian project manager of Safe Delivery App in Gimbi and Rose

Stevens, a British international volunteer, completing her graduation internship in tropical medicine

as part of the Safe Delivery App team.

During my stay, we will make several field trips, including a very remote health centre (an

hour and a half drive from Gimbi) and located in a small hamlet, Yubdo. We will also spend several

hours at the Gimbi General maternity hospital the next day. To reach Yubdo, you have to ride on

the red and battered earth under a crushing and implacable sun. It is better to stay in the shade

once past 10:00. At the turn of several trails, children, especially girls, carry bundles of wood on

their backs. If on the way, we meet some clusters of children in uniforms and notebooks in hand

leaving guessing the existence of schools, we see mostly children who are struggling all day long

to keep the herds of cows, or work in the field.

When we arrive at Yubdo, we come across an ambulance which comes to drop off an elderly

woman whose left foot which is bleeding is devoured by worms (!). First shock. Visibly abandoned

by her family, she is dressed in rags and a neighbour has warned the health centre. I inspect the

health centre, which lacks everything, starting with running water. It is the only health centre for 50

kilometres... Yet it is here that women come in number, every day, to give birth and sometimes a

dozen the same day. I start talking to Workina, the midwife of the Yubdo centre who makes me

understand that we arrive at the time of the death of a new-born. Workina tells me, however, that

new-born deaths have drastically decreased in the centre since midwives have been using the

Safe Delivery App, giving the example that staff are much better trained to deal with postpartum

bleeding-type complications, since they regularly follow the recommendations of the application.


Telling me that, she takes me to see a mother who just gave birth a few hours ago. Her

name is Keribe and gave birth to a baby boy, Diribe, in perfect health, all under the supervision of a

trained midwife on Safe Delivery App.

Keribe and her son, Diribe

On the second day, we visit Gimbi hospital, more modern, although obsolete and

overloaded. When we arrive, long queues reflect the fertility rate per woman, which is not

decreasing in this region of Africa. I talk at length with several midwives, who detail how

Safe Delivery App helps them day-to-day, as we will see later.

"I use the app every day, I look at the app at work when I'm on a break. I use it when faced with a

complicated situation and need information immediately, for example for uterine haemorrhage." A

midwife from the Yubdo Care Centre.


What is the operation of Safe Delivery App?

The Safe Delivery App contains 4 main features for midwives: 1- animated educational

videos; 2- "action cards" which identify a specific emergency situation; 3- a list of medicines; 4-

procedural guides to follow. Everything is designed in a simple and easily understandable

ergonomics, including for almost illiterate people.

The main advantage of the application is that it works in "offline" mode, since the contents

are downloaded to the phone. This is particularly convenient, given the very large internet breaks in

Ethiopia (not to mention its cost). The Safe Delivery App includes about 10 short films that train

what Midwives on the ground call "BEmONC", the Basic Emergency Obstetric and New-born Care

protocol. Several films are devoted to maternal-foetal infections, which can contaminate the new-

born (Escherichia coli, Listeria, Streptococcus A, mother-transmitted germs, etc.), and the

procedures to follow. Each video lasts about 6 minutes. In discussions with two midwives, I realise

that the Safe Delivery App is an excellent training tool for medical staff and that midwives are now

using the application on a daily basis to self-train, transfer their expertise to new recruits,

campaigning in campaigns to explain to pregnant women "what is happening in their womb" with

videos, etc.

"Safe Delivery App is a crucial tool to help us improve maternal health.

Its ease of use and its intuitiveness with simple videos to understand and interpret make it an ally

in my work. I learned with great confidence how to stop uterine haemorrhages and save lives in

this hospital. "

Nigatu Abebe, Gimbi Hospital midwife.


I ask about the use of the smartphone: how do midwives get it? Is it provided by Safe Delivery

App? And, knowing that the mobile penetration of smartphones (unlike the feature phone)

remains rather low in Ethiopia, how do midwives become familiar with the tool? Midwives explain

to me that smartphones are well supplied by the Safe Delivery App team, and that each midwife

has a full day of training dedicated to using the features of the smartphone. The other advantage

of the smartphone is that in the absence of internet, midwives can send the application and

videos between them directly via Bluetooth.

The paramedic at the Yubdo Fortune Health Centre.

What impact to date? What health benefits?

To date, the Safe Delivery App has already been downloaded to more than 30 countries

around the world. The application has a GPS feature which allows the Maternity Foundation,

developer of the Safe Delivery App, to geotag its users around the world accurately, to interact with

them, and also to conduct qualitative studies on the uses for better understand how to improve the

tool and its features.

The Safe Delivery App team in partnership with the University of Copenhagen conducted a

research in 2016, published in the American Medical Association, involving 3601 women by 176

midwives in 5 rural health centres located in Ethiopia. The study found that the infant mortality rate

was 14 per 1000 in health centres using the Safe Delivery App, compared to 23 per 1000 in health

centres which did not use the app. The study also showed that midwives' skills in resuscitating

new-borns in the birth room were much higher among midwives using the application.


What about financing and the business model?

The application does not pay. To date, the economic model is based on funding from the Bill and

Melinda Gates Foundation, the Obelske Family Foundation and the Merck for Mothers Foundation.

Small innovation, part of the running costs of the application were funded through a crowdfunding

campaign on Indiegogo.

What objectives for The Safe Delivery App?

At the global level, the Safe Delivery App team explained to me how to reach the millennium

goals detailed in the UN's "Every Woman Every Child" programme by training 20,000 midwives

with Safe Delivery App by the end 2018, all over the world, to facilitate the confinement of 2 million

women.

On the technical side, Safe Delivery App emphasised during our discussions in Gimbi

wanting to develop an online certification module in the application, to allow the ministries and

associations of midwives to put the recruitment tests directly on the application.


What partnerships and relevant supports?

The Safe Delivery App team wants to multiply partnerships in low income countries and

share its expertise in Ethiopia with other similar countries in Africa and Asia.

Locally, in Ethiopia, Safe Delivery App is looking for more support from the Ethiopian health

authorities: the National Association of Midwives of Ethiopia and the Safe Delivery App team are

currently carrying out a great deal of making aware and lobbying for the Ministry of Health of

Ethiopia to integrate the Safe Delivery App into the ministry's continuing education plan for

midwives. To date, this is not yet the case, even though the teams of the Ministry are very

receptive to the scientific arguments advanced.


Conclusion

This innovative application has rigorous scientific expertise, and its impact is

proven on the reduction of infant and maternal mortality, through awareness of the

intermediate level between care units and patients: midwives. The desire to improve the

tool in "lean start-up" mode is proving to be effective: the uses of the application by the

midwives are constantly monitored, both qualitatively (individual interviews of each of the

midwives every six months) and quantitatively, which constantly improves video content

and strengthens user retention.

The foundation, although based in Denmark, was keen to maintain a close

relationship with the field and Gimbi's health staff who use the Safe Delivery App. A

delegation travels from Denmark to Gimbi for scientific monitoring every six months. The

scientific strength of the Safe Delivery App (and thus its legitimacy) is the fact that the

Maternity Foundation has consistently collected inputs from experts, including the WTO

and UNFPA, for the semi-annual scientific assessments, as well as experts from the Red

Cross and AMREF.

A project to be supported and monitored in its desire to scale up in other

landlocked African countries, where people living in remote areas are the most vulnerable

and least covered in terms of obstetric medicine such as Burkina Faso, Niger or Mali, as

well as in Asia, particularly in Nepal.

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