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 FIELD REPORT PRODUCED BY STARTUPBRICS FOR ODESS 2017 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. FIELD REPORT PRODUCED BY STARTUPBRICS FOR ODESS 2017 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. FIELD REPORT PRODUCED BY STARTUPBRICS FOR ODESS 2017 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. FIELD REPORT PRODUCED BY STARTUPBRICS FOR ODESS 2017 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. FIELD REPORT PRODUCED BY STARTUPBRICS FOR ODESS 2017 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. FIELD REPORT PRODUCED BY STARTUPBRICS FOR ODESS 2017 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.