Safe Delivery+

Worldwide progress is stalling in advancing quality healthcare for mothers and newborns. Every other minute, a woman dies of causes related to pregnancy or birth (5), and every seventh second, a newborn suffers the same fate (6). With most of these deaths occurring in remote and fragile settings (7), we need to invest in overcoming barriers for reaching areas, where the needs maternal and newborn health are the largest.

The impact of maternal health extends beyond the alarming mortality figures. For every maternal death, 20-30 women suffer preventable morbidity, significantly affecting their quality of life (8). As advancements in health and quality of life of women benefits entire economies (9), ensuring safer births are not only a question of moral imperative – but also one of prosperity for some of the poorest regions in the world.

Asia, consisting of 48 countries grouped into sub-regions such as South, East, Southeast, West and Central Asia, faces ongoing challenges in maternal and neonatal health. South Asia accounts for 19% of global maternal deaths, with a maternal mortality ratio (MMR) of 163 per 100,000 live births (5). Low and lower-middle income countries in the Asia-Pacific region experience significantly higher rates of maternal mortality than upper-middle and high-income countries – more than 4 times and 14 times, respectively. According to WHO, the neonatal mortality rate in 2022 is 21 per 1000 live births in both Central Asia and South Asia. The leading cause of neonatal death remains premature birth, birth complications, infections and congenital anomalies (10).

Adolescents in the region face a considerable risk of complications and death due to pregnancy, with common causes of maternal deaths in low and middle income countries including severe bleeding, infections and unsafe abortions (11).

The Middle East and North Africa (MENA) is a geographic region which includes 20 countries. It is estimated to have a population of approximately 500 million people.

Despite many shared traits among the countries in the region, there is a noticeable diversity in humanitarian contexts, socioeconomic development, social and cultural norms, ethnicities, political systems, and national identities, with MENA region’s economies varying from oil-rich Gulf states to low-income countries, such as Syria and Yemen.

In the MENA region in 2020, 56 women died per 100,000 live births (5). The maternal mortality ratio in this region has seen a significant decline over the past 15 years and is better than the global figures, however, the improvement in these values is unequal. Countries such as Kuwait and Saudi Arabia, have made remarkable progress in reducing MMR in their countries, but countries such as Yemen and Syria have seen their progress stalled over the past decade (12).

The primary causes of maternal mortality in the MENA region have also remained largely unchanged since the 90s. Pregnancy and delivery-related complications, including haemorrhage, hypertensive disorders, maternal sepsis and infections and abortive outcomes, remain the leading causes of maternal mortality (13).

Most of the maternal mortality and morbidity is preventable when women have access to quality care provided by competent midwives (14). However, poor knowledge and skills and poor referral practices are critical barriers to maternity care (15). While the world needs an additional 900.000 midwives to ensure universal health coverage in 2030 (16), we must also focus on enabling the current generation of midwives with the necessary skills and knowledge to provide quality care now.

This requires personnel to be educated to the international standards of the midwife, and to be fully integrated into the health system.

Effective midwifery education is essential to the provision of quality maternal and newborn care that will save lives and improve health and well-being. This is particularly critical in remote and humanitarian settings where the institutional support for quality training and upskilling for midwives is most sparce. Efforts must therefore intensify in advancing the continuous professional development of existing midwives in a tangible, sustainable, eco-friendly, equitable, and cost-effective way.

Climate change is affecting millions of people. The consequences of climate change ruin livelihoods, exacerbate poverty and impacts families across the world. Climate change is expected to cause severe disruptions in sexual and reproductive healthcare services leaving vulnerable populations without access to life-saving care during pregnancy (18). Hence, the work of Maternity Foundation is more relevant than ever.

Maternity Foundation is committed to reducing carbon footprint through digital solutions and a climate-friendly training approach. Traditional in-person training for healthcare providers is often lengthy, expensive, logistically challenging, and removes providers from their critical work. It also has a significant environmental impact due to travel, printed materials, and resource use.Our training approach — centred on the use of the App, a combination of self-paced, online and on-site training sessions — addresses these challenges and helps reduce our carbon footprint. Instead of relying on printed guidelines or costly in-person sessions, a digital tool offers continuous updates based on the latest research; 24/7 accessibility from any location, especially in remote areas, and reduced need for travel and printed materials.

Maternal mortality is a key indicator of health inequity – inequitable access to quality, skilled, respectful care is key driver of maternal and neonatal death. Therefore, the initiative contributes to addressing inequities in two ways:  1. address inequities among midwives in terms of access to training, tools and support; and 2. by addressing inequities in access to continuous professional development, it also contributes to addressing inequitable access to safe and respectful maternity services for pregnant women, newborns and their communities.

The following aspects help us to address inequity:

• As a free tool the SDA removes cost as a barrier
• By supporting an Alliance of several Midwifery Associations in both Asia and the Middle East, the initiative helps to address inequities in access to education and services between different geographical areas.

Our initiative will be implemented through partners and strengthen existing systems and therefore helps to promote equity by empowering local partners, which helps to ensure that activities are mutually beneficial and more likely to have a positive impact.

Background

Maternity Foundation’s Safe Delivery+ programme is an innovative and cost-effective digital platform, and a comprehensive learning universe aimed at enhancing the quality of care provided along the continuum of midwifery care. We focus on improving midwifery practices and increasing knowledge and skills through instant access to evidence-based clinical guidelines, descriptions of practices for routine and emergency care. The SDA covers contents on Basic Emergency Obstetric and Newborn Care (BEmONC), health promotion and disease prevention in women and their newborns (ANC and PNC) and addresses critical core competencies in maternal and newborn health care such as perinatal mental health, and modern contraception. Maternity Foundation offers a comprehensive range of training packages tailored to the specific needs of our partners and trainees. These include an introductory session on how to use the App, an in-depth deep dive into its features and content, in-service clinical training with simulation on one or more modules covered in the app, and Training of Trainers (ToT) programmes. The ToT packages also include sessions on adult learning principles and effective teaching methodologies. Our blended learning approach ensures cost-effectiveness and enhances learning outcomes. The App has been accredited in several countries as a digital Continuing Professional Development (CPD) course, supporting midwives in renewing their licenses.

The Midwives Alliance of Asia (MAA) brings together midwifery associations from across Asia and the Middle East. Founded in 2015, MAA works to advance professional midwifery practice, advocate for respectful, high-quality, accessible, and affordable reproductive health care, and support midwifery education and relicensing through CPD. MAA also empowers midwifery leaders by building their confidence and enhancing their professional practice. The mission of MAA aligns closely with that of Maternity Foundation, as both strive to strengthen midwifery practice and education while improving the quality of care midwives provide. Midwifery associations from the following eight countries across Asia and the Middle East are members of MAA: Pakistan, Afghanistan, Bangladesh, Nepal, Yemen, Iran, the UAE, and Bahrain. Since the launch of the Alliance there have been limited activities but in 2024, with the support of Aga Khan University and School of Nursing and Midwifery, they hosted its first-ever three-day strategic directions meeting in Islamabad (3, 4).

The App is actively used in 46 countries in Asia with more than 185.000 users to date. Furthermore, Nepal, Bangladesh, Afghanistan, and Cambodia have country-specific versions aligned to their national clinical guidelines. Those countries have – combined- more than 20.000 users and nearly 1.400 have obtained the Safe Delivery Champion certificate.

Since 2022, Maternity Foundation has been actively working in the Middle East and North Africa (MENA) region to improve maternal and newborn health outcomes through the Safe Delivery App. Maternity Foundation developed a global Arabic version of the App. We have introduced the App to key stakeholders, including midwifery associations, Ministries of Health, NGOs, and private healthcare providers in countries such as Jordan, Syria, Iraq, Lebanon, Yemen, Palestine, Saudi Arabia, Oman, Bahrain, and the UAE. The App’s Arabic and English versions are widely used in the region, with preferences varying by country based on professional and educational language norms.

Maternity Foundation’s past and present partnerships with many midwifery associations that are part of the MAA and the joint mission of Maternity Foundation, and the MAA is a strength for the initiative.

Objectives and activities

The project’s overall objective is to contribute to improved quality of midwifery care through capacitating the leaders of the midwifery associations in the different training sessions that we developed. With our support, the midwifery leaders will develop a plan to cascade the training sessions- online and in-person to key midwives in their country. The sessions can also be integrated into mentorship activities, through preceptorship trainings, during national events and existing training or workshops organised by a range of stakeholders.

Additionally, in collaboration with MAA and its members we aim to explore the feasibility of introducing the App as a tool for continuous professional development for midwives for their relicensing.

Specific objectives of the project are as follows:

1. Enhance the knowledge of midwifery leaders from 8 countries on the various topics covered in the Safe Delivery App (SDA).
2. Provide midwifery leaders with the essential skills and competencies to effectively conduct training sessions for midwives in their respective countries.
3. Strengthen the confidence, knowledge, and skills of midwives in the region to deliver high-quality maternal and neonatal care by widely implementing the SDA, offering in-depth sessions on the app’s features, and facilitating clinical training where feasible.

Activity 1. Training

The training sessions will be conducted in two phases using different methodologies and number of participants:

Phase 1: remote and self-paced training sessions for 40 midwifery leaders

• Online SDA introduction and deep dive session:

A 3 hour deep-dive and  9 hours (over 3 days) online training sessions that will enable the participants to gain an overview of the SDA and its features and receive guidance on the installation of the App with enrollment in the App’s MyLearning platform. Participants will be guided through a series of exercises using the App, helping them become familiar with its features and enabling them to use it effortlessly.

• A self-paced learning with the SDA to become an SDA champion:

Once participants have been oriented to the SDA, they can learn from the App at their own pace, become experts in all the SDA modules, complete the championship exam and become SDA Champions.

Phase 2: in-person training for 14 midwifery leaders

• A 3-day Training of Trainers (ToT) programme will be held in Karachi, Pakistan, for at least 14 midwifery leaders who will cascade the SDA training courses. This programme is designed to prepare midwifery leaders to become trainers, integrating the SDA into both pre-service and in-service areas. The ToT equips them with the necessary skills to effectively guide their learners in using the app. Training local healthcare professionals as trainers creates an opportunity to reach a larger number of healthcare professionals, who will benefit from the SDA. Additionally, conducting the training in the national language makes it more accessible. The ToT programme will be facilitated by SDA Master Trainers from the Maternity Foundation.
• As part of the ToT, the midwifery leaders will also receive a one-day clinical training themselves, to become familiar with the different training methodologies the App offers.

The midwifery leaders will be equipped to conduct the SDA clinical training sessions. A comprehensive training package will be developed and shared with the in-country trainers for cascading.

The different training packages and tools that MF has developed will be customised in partnership with the MAA based on needs analysis of the different midwifery associations’ leaders. Experience, expertise, and confidence of the participants of the ToT will be considered to adapt the training content and methodologies.

Activity 2:

After certification of the participants, Maternity Foundation will support the midwifery associations to develop an implementation plan to roll out the SDA and training sessions in their respective countries. They will have been skilled in providing training sessions with different methodologies so that the cascading is adapted to the context.

Activity 3:

An analysis of the feasibility of using the SDA as an accredited online training course for CPD to obtain credits/points for the renewal of the license will be done with each association, involving important stakeholders in-country such as the Ministry of Health, the nursing and midwifery councils amongst others.

Activity 4:

Communities of practice (CoPs) will be set up to facilitate peer-to-peer learning, the adoption of best practices, and support ongoing dialogue with the trainees to keep them motivated and engaged.

Activity 5:

The project’s monitoring & evaluation (M&E) system will build on the evaluation toolkit that MF has developed for assessing confidence, knowledge and skills of the participants of the ToT as well as the clinical trainings. The App contains the MyLearning feature, and Maternity Foundation collects data on the number of MyLearners, experts and champions over time, by country and region. A project specific M&E protocol will be developed to monitor, track, and evaluate activities to provide an ongoing feedback loop to the project implementation team and partners. Standard tools deployed as part of the M&E system include Project activity tracker; Confidence assessment; Knowledge assessment; Skills assessment, SDA usage data.

This initiative will contribute to the consolidating Maternity Foundation’s on-the-ground evidence and learnings into replicable and proven implementation models and roadmaps that showcase how to effectively roll out and institutionalise capacity-building activities of midwives in the most underserved areas.

Beneficiaries and Expected Outcomes

Direct Beneficiaries: Members of the Midwives Alliance for Asia, specifically the midwifery associations of eight countries in Asia and the Middle East.

Indirect Beneficiaries: Midwives in Pakistan, Afghanistan, Bangladesh, Nepal, Yemen, Iran, the UAE, and Bahrain, who will receive cascaded training from the Midwifery Associations through the project’s activities.

Project Goals:

• Up-skilling Midwifery Leaders: Enhance the skills of midwifery leaders from eight midwifery associations in Asia and the Middle East in providing training using the App and blended training approaches.
• Cascading Training Sessions: Reach at least 5,000 new users of the SDA by the end of 2026 through the cascading of training sessions and the rollout of the App in the eight countries.

Expected Outcomes:

• Midwifery leaders from eight countries will gain in-depth knowledge of the Safe Delivery App (SDA) and essential skills to conduct training sessions effectively.
• Midwives in the region will improve their confidence, knowledge, and skills in delivering high-quality maternal and neonatal care through the widespread implementation of the SDA.
• Training packages and tools will be tailored to the needs of midwifery associations’ leaders, considering their experience, expertise, and confidence.
• Training will be conducted in phases, including remote and self-paced sessions for 40 midwifery leaders and in-person Training of Trainers (ToT) for 14 midwifery leaders in Karachi, Pakistan.
• Certified midwifery leaders will receive support to develop and implement plans to roll out the SDA and training sessions in their respective countries.
• The feasibility of using the SDA as an accredited online training course for continuous professional development (CPD) will be analysed, involving key stakeholders.
• Communities of Practice (CoPs) will be established to facilitate peer-to-peer learning, adoption of best practices, and ongoing dialogue to keep trainees motivated and engaged.
• A comprehensive Monitoring and Evaluation (M&E) system will be developed to track and evaluate the project’s activities, including confidence, knowledge, and skills assessments, and SDA usage data.

The initiative will contribute to creating replicable and proven implementation models and roadmaps for capacity-building activities of midwives in underserved areas.

Proposed Indicators:

• Quality of Care
  • Indicator: Percentage of participants in the clinical training and ToT who report increased confidence and successfully complete the knowledge and skills assessments.
  • Target: 85% of midwives report improved confidence and successfully completed the knowledge and skills assessments.
• Retention of Knowledge and Skills
  • Indicator: Percentage of midwives who retain knowledge and skills three months after completing the SDA training.
  • Target: 70% of midwives retain key knowledge at three-month follow-up.
• Digital Tool Adoption
  • Indicator: Number of midwives obtaining the Champion certificate.
  • Target: 20% increase in champions in the target countries.
• Sustainability and Scale
  • Indicator: Number of midwifery leaders and educators continuing to deliver SDA-based training beyond the project period.
  • Target: Continued uptake of the SDA post-project, measured by proxy.
• Policy Integration
  • Indicator: Number of countries adopting the SDA as an official tool for CPD and relicensing.
  • Target: SDA integrated into CPD frameworks in at least one country.
• Environmental Impact
  • Indicator: Reduction in carbon footprint using hybrid SDA training instead of traditional in-person training.
  • Target: 20% reduction in travel-related emissions per participant due to increased use of digital training platforms.

As Maternity Foundation, we have successfully produced and provided readily available, evidence-based in-service training through the Safe Delivery+ programme. In the past decade, twenty SDA training modules have been developed spanning from prevention to intervention. The App has proven to be easily scalable as an accessible learning universe – particularly in low- and middle-income countries as well as humanitarian settings. Through refined micro-learning, users can access gamified content and WHO-aligned guidelines whenever needed. Designed to work in both online and offline mode, the App can reach users working in remote areas where connectivity is a challenge, and all content can be adapted to local culture and national guidelines. It therefore complements existing guidelines, training curricula and teaching methodologies.

Maternal and Newborn Health guidelines are evolving based on new evidence, new drugs and equipment, and policies. The clinical experts at Maternity Foundation stay up to date to ensure the content of the modules are adapted based on the latest WHO guidance. They also adapt the training content if there are any changes in protocols. Users of the App get notified when an updated version is available, or a new module has been released.

Maternity Foundation is improving the App with AI capabilities that services the on-the-job needs of midwives. The platform facilitates the continued growth of our work as well as responding to the needs of both our partners and our end-users by developing new clinical content such as climate-wise midwifery or suturing.

Our training concepts support long-lasting continued professional development (CPD) of midwives and offer the possibility to have digital training – such as the SDA – accredited for relicensing. Communities of practice complement and support existing forms of communication and empowerment of our target group, they promote peer-to-peer learning and increase motivation to life-long learning.