Safe Delivery Program

Approximately 15% of births result in life threatening complications. Health care providers skilled in handling emergencies are essential to respond to these complications, but few have up-to-date, guideline-adherent, easy to understand job aids; and ineffective, infrequent or non-existent training means many do not get the education they need.

Part of the Safe Delivery Program, the Safe Delivery App provides skilled birth attendants with instant, evidence-based clinical guidelines on how to handle complications connected to pregnancy and childbirth – straight from phones or tablets. It contains simple, animated instruction videos, practical procedures, action cards, drug lists and interactive learning. The App is used as a job and in training. Content is designed for low-literacy, low-income settings and works offline once downloaded.

In addition, our remote training platform leverages adult learning principles, best practices from working on the ground in LMICs to further build the capacity of skilled birth attendants.

Every day, more than 800 women and 7,000 babies lose their lives during pregnancy and childbirth and 99 percent of them are in low- and middle-income countries, particularly in sub-Saharan Africa and South Asia. The majority of these deaths are preventable if the mother has access to skilled care during pregnancy and childbirth.

Health care providers skilled in handling emergencies are essential to respond to these complications, but few have up-to-date, guideline-adherent, easy to understand job aids; and ineffective, infrequent or non-existent training means many do not get the education they need.

In addition, the COVID-19 pandemic is having an unprecedented impact on the health of mothers, newborns and the health care workers who care for them. Recent modeling published in the Lancet estimates that reduced coverage of essential health services due to the pandemic could result in up to an additional 56,700 maternal deaths in the next six months alone.

With the Safe Delivery App skilled birth attendants have instant, evidence-based and up-to-date clinical guidelines on how to handle complications connected to pregnancy and childbirth. Developed in collaboration with Universities of Copenhagen and Southern Denmark, the App uses simple, animated instruction videos, procedures, drug lists and e-learning tools to guide skilled birth attendants in basic emergency obstetric and newborn care.

The App consists of 12 content modules addressing key interventions of childbirth emergencies and preventative procedures, all aligned primarily to WHO guidelines. Five basic features guide health workers in the App: animated instruction videos, action cards, drug lists, practical procedures, and an individualized e-learning component, MyLearning.

All content in the App is designed for low-literacy, low-income settings and works offline once downloaded, so healthcare workers in even the most remote settings can always refer to it – either on the job, in their spare time, or as part of their training.

Along with the Safe Delivery App, another part of the the Safe Delivery Program is the remote training platform consists of a set of interactive, engaging, blended learning modules to educate skilled birth attendants in the key skills and knowledge they need to handle emergencies.

Our solution serves most directly skilled birth attendants and those who train skilled birth attendants (ministries of health, NGOs, UN Agencies, professional organizations such as midwifery and nursing associations) in low-and-middle income countries, who in turn serve pregnant women, new mothers and newborns.

We created the Safe Delivery App because our team on the ground in Ethiopia noticed an important problem and unmet need in healthcare. It was after deeply understanding that problem that we then designed a technology uniquely suited to solve it. This was a need-driven approach. We subsequently achieved proof of concept through two RCTs, and many rounds of qualitative and quantitative feedback with end users. We continue to iterate on this human-centered, need-driven design and approach.

The Safe Delivery App has contributed to an estimated 2 million safer births in low- and middle-income countries, with 115,000+ health care workers with access to the Safe Delivery App and 130,000 downloads of the Safe Delivery App in more than 40 countries.

According to The Lancet, more people die due to poor care than due to lack of access to care and poor-quality care is responsible for an estimated 5 million deaths per year. Health care workers skilled in emergency obstetric and newborn care are essential to prevent maternal deaths, but the majority do not get the education and training they need and most lack access to up-to-date, easy-to-understand job aids.

Leveraging the growing ubiquity of mobile devices - Maternity Foundation developed the Safe Delivery App to ensure that all skilled birth attendants across LMICs are provided high quality care during labor.

While there are a plethora of health care apps in the international development space, very few have reached scale or have evidence behind them. The Safe Delivery App is the only digital tool with strong evidence behind it for training and equipping skilled birth attendants to handle emergencies during childbirth, rapidly scaling in low-and-middle-income countries.

The Safe Delivery App unique in that it is:

• Evidence-based: both through multiple RCTs but also through continuous implementation research and through data from the App itself which is collected and analyzed through our dashboar
• Flexibility and adaptability: the Safe Delivery App is designed to be highly nimble, with a back end that makes creating new and adapted versions cost and time efficient for us and our partners.
•  Designed with end user in mind: highly visual and animated for low literacy and low tech literacy settings
• Partner developed & driven, which provides different and important perspectives & expertise, strong anchoring & reach
• Scaling rapidly across LMICs- with a large user base of our target end users

Maternity Foundation, together with key partners at the UN, WHO and ministries of health among others, is now leveraging the reach of the Safe Delivery App and lessons learned working with digital for training in low resource settings to develop a robust remote training approach to help build the capacity of skilled birth attendants during and after the covid-19 pandemic.

The Safe Delivery App is an application for smartphones and tablets, both Apple and Android. The platform is built in Azure SDK, and the mobile technology is primarily React-Native, written with JavaScript. This is an existing technology. 

The remote training platform uses Zoom, and pre-recorded videos.

In the digital health space, there are a multitude of pilot innovations, but very few are able to demonstrate impact. In this vein, the Safe Delivery App is a rarity. A one-year randomized controlled trial in Ethiopia was conducted to assess the impact on health workers’ life-saving skills and knowledge. Key results revealed a significant increase in the skills and knowledge level of the health workers using the App. For example, at 12 months health workers' ability to handle post-partum bleeding and to resuscitate a newborn more than doubled.                                                                         

In 2018, Dr. Nancy Bolan, a WHO consultant, published a study to determine the feasibility, acceptability, and potential effect of the App on health workers' practices in BEmONC in the Democratic Republic of the Congo. The results Dr. Bolan’s research further support the findings of the RCT in Ethiopia – that use of the Safe Delivery App supports increased health worker knowledge and self-confidence in the management of obstetric and newborn emergencies.

We routinely track user behavior, acceptability of the App and changes in knowledge, skills and confidence among health workers. Across all implementations, we have observed an average knowledge increase of 22% and an average confidence increase of 47%.

As anyone in the public health field knows, it is very difficult to influence how people think and behave. At Maternity Foundation we are working together with our partners to positively improve the skills, knowledge and confidence of skilled birth attendants to handle emergencies in childbirth.

To do this, we’ve learned that a key to achieving this difficult goal is finding the right mix of behavior change elements both within the technology itself – the Safe Delivery App -and but also the right combination of external factors.

Within the technology itself, we ensure first and foremost that the content provided for learning is easy to understand and access by ensuring its highly visual, concise and works for low-literacy and low-tech literacy audiences. Then within the App the primary behavior change element we use is called gamification- defined as “the use of game design elements in non-game contexts.” There is promising evidence which suggests that not only does gamification work, but that it shares elements with proven health behavior change approaches. Our MyLearning platform gamifies the experience for users by tailoring content, providing a progress dashboard, "rewards" as users advance through levels and a champion certificate. 

External factors that we use to bring about our desired behavior change primarily have come about from deep integration of the App (with partners) into with training and mentorship programs. These factors incentivizing health care workers to use the App have been a central part of our strategy in the design, roll-out and implementation of the App with partners.

In the past five years, we’ve learned that it is essential that both the digital content and full functionality of the Safe Delivery App is integrated into the pedagogy of the training– into the group exercises, classroom lectures, skills practices and drills. It is only when the App is deeply integrated into teaching, training and learning pedagogy together with the gamification elements of the App itself that we see suggested evidence of behavior change among our end users.

To date the Safe Delivery App has been downloaded over 135,000 times by health care workers in LMICs. We expect that in one year with will be 185,000 and in 5 years we will reach 1 million health care workers with either the App and/or our remote training. These are the numbers of the people we are most directly serving. 

Drawing on fifteen years of health worker capacity building, implementation of the Safe Delivery App across fifteen countries, and a team of international, multi-disciplinary experts Maternity Foundation is working to become a trailblazer in adult learning and training with digital for health care workers in LMICs. 

We will leverage the App’s momentum to help transform training programs and approaches in low-and-middle-income countries into stronger and digitally supported training programs that better cater to the needs of the target groups and transcend traditional barriers of reach and efficiency.

In order to do this, top priorities for the next five years include continuing to cement key partnerships with global governance actors, among others, and actualizing our sustainable business model. We have laid the groundwork for both of these areas but must continue to prioritize both highly. 

Collaboration and cooperation with WHO, UN Agencies, country governments and leading NGOs is paramount to ensuring that Maternity Foundation can address the most pressing challenges to health care worker capacity building.

Risk: The Safe Delivery App becomes an isolated tool.

Risk: Our work becomes unsustainable due to end of funding.

Risk: Political climate can impact partnerships with ministries.

Risk: Lack of hard-ware (smart-phones) and internet connection.

The Safe Delivery App becomes an isolated tool.

Maternity Foundation will ensure that the App is continually scaled in a sustainable and contextualized way by integrating it into other programs, trainings, and systems with the right partners. 

The App becomes unsustainable due to end of funding.

In-country partners are increasingly co-financing adaptation and implementation of the App in their setting. We are working to become technical experts in digital remote training and integrating digital tools for adult learning, diversifying what we offer to partners.

Political climate can impact partnerships with ministries.

In many cases we are dependent on ministry cooperation to ensure a sustainable scale-up, but are partnering with institutions that have lasting relationships despite regime turn-over e.g. UNFPA, midwifery associations, etc. We are monitoring elections and planning ahead, e.g. we do not tie programmatic plans to an initiative that is purely political.

Lack of hard-ware and internet connection.

When we look at expected mobile penetration rates, we have time on our side. As our target group is skilled birth attendants, a high number have been provided with a smartphone as part of the health facility supply.

The App can be downloaded to the phone and then used without internet connection. Regarding App updates and usage tracking, these will be stored on the phone until the user is again in a wireless zone - and will then be exchanged.

Our remote training concept is being tested and designed for varying levels of internet connectivity and hardware, e.g. pre-recording content.

About 30 full time and 3 part time staff across Denmark, Ethiopia, India and the United States.

We regularly work with Visikon, a Danish production company that develops new media solutions for the health care industry, as a contractor for development and iteration of/on our app.

Dr. Stine Lund from University of Copenhagen and Dr. Bjarke Lund Sørensen from University of Southern Denmark are our clinical advisors-- providing support in the development and validation of clinical content of the Safe Delivery App, related training concept, and research design together with Maternity Foundation's core staff.

Maternity Foundation is uniquely positioned to deliver our solutions- the Safe Delivery App and remote training concept for skilled birth attendants- because we have an inter-disciplinary team of experts that brings a wealth of experience working in the healthcare, development and innovation spaces across Ethiopia, Denmark, India and the United States. We have staff with backgrounds in business, public health, tech, academia, and health practitioners.

Our Ethiopia team draws on the networks and deep experience of staff who've worked with the midwifery association there for many years. In India, our staff have close relationships and deep understanding of the federal ministry of health-- resulting in full of the integration of the App into a national level quality of improvement program called LaQhshya. Experiences from working on the ground inform how we design digital solutions for these contexts, and also how we support implementing partners in countries where we do not have an on-the-ground presence. 

We combine our on-the-ground expertise with an entrepreneurial approach that focuses on developing evidence-based solutions that can be scaled up to benefit as many women and newborns as possible. Our rapid development and deployment of covid-19 content and training approaches demonstrates this clearly.

Finally, we are supported by a strong board of directors from the fields of medicine, global governance (WHO), business, law, NGO, and tech; and have Her Royal Highness Princess Mary and internationally acclaimed artist/social entrepreneur Olafur Eliasson amplifying the voice of our work at a global level.

Maternity Foundation works through a partnership-based model, which enables us to reach exponentially more skilled birth attendants. We work at various levels – from remotely supporting a small NGO on training a handful of midwives in Tanzania to working on-the-ground with the Ministry of Health in India for a national roll-out. Our support to partners creates a pipeline where projects grow into nationally supported scaled roll-outs, and lessons learned from both inform integration into global level training efforts. 

At the global level and across multiple countries we work with Danish Red Cross and International Red Cross, GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit GmbH/ German Development Agency), ICM (International Confederation of Midwives), Laerdal Global Health, Plan International, MSF, Save the Children, UNFPA (United Nations Fund for Family Planing Activities) and WHO.

In addition to various ministries of health, across 15 countries in Africa and Asia additional partners we support include: Amref Health Africa, ARC, Association of Danish Women Doctors, CARE India, CHAG (Christian Health Association of Ghana),East Central Southern African College of Nurses (ECSACON), Ethiopian Midwives Association, CPIRB, Ghana Health Service, IPE Global,Jhpiego, Kyrg Midwifery Association, OBGYN Society Laos, Tanzania Union of Government and Health Employees (TUGHE), UNICEF, and the World Bank.

The "Safe Delivery Program" is made up of the services and tools that build off and compliment the Safe Delivery App- technical support, expertise and resources to support partners in adapting, implementing, and conducting M&E related to the App, as well as the remote training concept. It was conceptualized based on the documented evidence of partners’ willingness to pay for these services. Please see more of our thinking below:

"Just download"

Small NGOs, health facility leaders, individual health workers.

·       Use the global or already available national versions of the App & remote training.

·       Can be entry point to deeper engagement with MF. 

·       Standardized tools & support

"Project level"

Medium, large and international  NGOs, UN agencies, research institutions

·       All of the above

 +

·       More catered support with implementation design, training and M&E. 

New country/ language version

MoH + implementing partner (UN agency, large iNGO) 

·       All of the above

+

·       Adaptation of the App & remote training concept 

"Institutionalized national level"

Same as country level but at scale + often a professional agency

·       Same as above

+

·       Technical support with M&E, and integration with national level training curricula, systems and/or programs

·       Access to national level dashboard with catered analysis.

"Global level"

A collaborative group of INGOs/UN agencies

·       All of the above

+

·       Support to scale to multiple geographies, with support to fully integrate the App & remote training into the broader program design and structure.

The clear willingness of our partners to pay for the services of the Safe Delivery Program to date, coupled with a thorough assessment of the digital MNCH landscape make it clear that our expertise in these areas holds value worth paying for.

We have arrived at some clear conclusions about what it means for us to be sustainable- that as an organization we must be partner driven, focus on integration, be evidence driven, and stay nimble and adaptable. We have narrowed in on a funding model that has a cross-cutting backbone funded more traditionally by foundations, but that our in-country and project level work will be increasingly funded by partner organizations. 

We have identified roughly three funding models (or a mix of the three) for our work with these country and project level partners. These include: 1. Transactional funding whereby partners pay for our services “one by one”; 2. Joint Grant Seeking where we co-apply for joint funding together with the implementing partner (usually a project level partner) and finally 3. Tapping into larger programs- integrating the costs related to App into an already established and funded project. 

We must continually assess partners need and willingness to pay for the services of the Safe Delivery Program; while continuing to document and communicate the impact of those services. In doing so, we can iteratively refine and adjust what we offer as the needs of our partners shift and as our areas of expertise evolve. 

We are applying to Solve because while we have experienced success to date with the Safe Delivery App - in achieving proof of concept, piloting, beginning to scale and securing funding for those phases- the question for us is what is next? Who are we as as a foundation beyond "just the Safe Delivery App"? What are we uniquely positioned to do in the field of digital for maternal newborn health?

Thus far, we think the answer is that we are uniquely positioned to work in the digital learning and training space for the health providers, and are exploring creating a remote training platform for skilled birth attendants around childbirth. 

We would greatly appreciate the opportunity to draw from the deep pool of the Solver community's expertise to test this pivot of our work- to learn from others who have been there before, experts in this field who can help us hone our approach, and savvy social entrepreneurs who can ask the tough questions to draw out a polished and clear pitch to the next round of funders. We'd also like to share with the Solver community our experiences to date with the Safe Delivery App- our challenges, success and best practices.

Maternity Foundation is interested in partnering with others working in the field of digital for maternal, newborn health to expand our reach to our user base of skilled birth attendants and in partnering with those working in the solution technology space to explore ways to strengthen our underlying tech and learn more about alternate options.

In addition, we are seeking connections to funders who would be interested in supporting our remote learning platform for skilled birth attendants in low-and-middle income countries; and would greatly appreciate connections to mentors who can help us (as written in previous question) refine this concept/ pitch and related funding ask.

There are not any specific organizations, faculty or initiatives at this point in time that we would like to call out specifically. Rather, we would like as a Solver to have a mentor/ supporter help us figure out through collaborative discussion who we should connect with to further advance of solution.

The COVID-19 pandemic has had and will continue to have unprecedented direct and indirect consequences on the health and well-being of mothers, newborns and the health care workers who care for them. 

An investment in Maternity Foundation would allow us to further scale a powerful tool- the Safe Delivery App- which puts the latest guidelines on how to safely handle childbirth during the covid-19 pandemic while continuing to provide quality care, in the hands of skilled birth attendants who need them the most. 

Additionally, we would leverage the Health Workforce Innovation Prize to bring to fruition an digital approach to learning and training which overcomes existing gaps and barriers. Currently, there are many challenges to provide quality on-going training and on-site skills practice to birth attendants as well as pre-service students in settings with high maternal and new-born mortality and morbidity.  Remote training is more cost and time efficient for hosts/ organizers, trainers and trainees, and can facilitate methodologies that ensure knowledge retention and skill development.

Maternity Foundation has been working in the health workforce capacity space for fifteen years-- gathering experiences and best practices from Ethiopia, India and across LMICs; scaling the Safe Delivery App to over 100,000 users; and cementing the right partnerships with leading players including WHO, ICM, UNFPA and Laerdal Global Health. The time is now for us to answer the call to support all skilled birth attendants across LMICs with the remote training support they need to provide high quality care during birth.