Working with the community can be challenging. Our people are set in their ways. While they may have the information they need, they often lack the deeper understanding needed to make the right decisions.
Asya, Nurse, Zanzibar

Asya has been a nurse in Zanzibar for 13 years, dedicated to mothers and children. But she’s frustrated. Women arrive late in pregnancy, miss critical checkups and struggle to follow medical advice.

At the clinic, Asya is overwhelmed.  Time constraints for each visit drive consultations short, making it difficult to take medical histories, which can impact the type of care provided. Supply shortages add to the challenge, eroding trust with the very community she’s determined to serve. Her struggle isn’t unique – it’s the daily reality for countless healthcare providers in Zanzibar and beyond.

Last year, D-tree set out to uncover how culture and behavior shape pregnant women’s access to healthcare in Zanzibar. Partnering with a creative design agency, Khanga Rue, we went deep – speaking to mothers, healthcare workers and community health providers – to expose barriers, gaps and opportunities. The insights are now shaping Jamii ni Afya, Zanzibar’s national digital community health program, and improving our people-centered care approach to better serve women from pregnancy through postpartum.

Insights from the study

Few women see a formal healthcare provider early in their pregnancy

Most women know it’s recommended to see a healthcare provider early in their pregnancy, but in Zanzibar, few do. Why? For many, the reasons to delay outweigh the motivation to initiate an early check-up. 

Women are told to visit a clinic in the first trimester, but are rarely told why it matters. Their role models – mothers, grandmothers, and mothers-in-law – gave birth at home, with little contact with health facilities. Without a clear understanding of early check-ups’ life-saving value, cultural and social norms take over, delaying care. By the time they seek help, it may be too late to catch complications or plan for a safe birth.

I keep my pregnancies secret because I don’t want anyone to harm me or my baby. I rely on my mother for advice as she is experienced, but I also seek medical care for I want to ensure well-being of my family
Rehema, Mother, Zanzibar

Fear of the “evil eye” keeps pregnancies secret, as people believe this will protect the mothers and babies from envy and harm. An early clinic visit risk exposure and overcrowded facilities offer little privacy. Women without visible pregnancies fear judgment, and some are even turned away due to staff shortages, told to come back later. There is an exception – women who have suffered previous pregnancy losses. Often driven by despair, their worry and grief push them to seek care earlier, hoping to protect their current pregnancy. Understanding these realities is key to supporting women and addressing the barriers that keep them from accessing care when it matters most.

After having had miscarriages, I attended all 8 antenatal care visits and have taken my baby to have all vaccines needed, with my community health worker providing counsel and also relying on my family members for support.
Salima, a mother of three with two prior miscarriages.

As for postpartum, we saw that even fewer women saw a healthcare provider, also because of a lack of understanding of the value and true understanding that a woman can still be at risk of maternal complications up to 42 days after she has given birth. Typically once a woman has delivered the focus and attention fully divert to the health and well-being of the baby.

Trust Matters

Trust is the foundation of early maternal care. Health systems earn trust in different ways: the presence of competent providers, the access to medical tests and medication, and adequate infrastructure are necessary but alone insufficient for high-quality care, and building trust.  Experience of care, including seeing providers with good interpersonal and communication skills will drive trust in the health system. This echoes what we saw from the study – where women get information on pregnancy and delivery from traditional healers (Mkunga wa jadi), family members, and friends who are often more accessible and more trusted as they already have the rapport and relationship with the client. 

While mkunga wa jadi are trusted and sometimes more accessible than formal healthcare providers, their treatments do not always follow precise dosage or accreditation which the formal health system applies. Healthcare providers express concern over the unregulated nature of the remedies, which lack scientific backing, clear dosing instructions or safety standards and many worry that some treatments may contribute to additional risks and at times even complications to clients.

But trust isn’t built on services alone – it’s about experience. Women need care that is competent and compassionate.

Community health workers can play a vital role in maternal health, improving access to care by marginalized communities and supporting to improve inequalities in health. Many go beyond duty – checking in outside schedules, rushing to emergencies and demanding priority care for mothers. Yet, cultural barriers and mistrust keep some women silent about their pregnancies. To address this, it is crucial to find ways to strengthen trust by continuing to educate the pregnant woman support network and the community as a whole on the importance of the importance of early check-ups during pregnancy. 

Also, governments play a role. They must formally recognize community health workers – pay them, equip them and integrate them into the health system. In places where health professionals are scarce, community health workers bridge the gap, reaching underserved communities and driving life-saving maternal care. They can restore trust in healthcare, but the higher levels of care must be there to provide quality care for the trust to be maintained.

Stronger referral systems are needed for better care

Referrals are a critical part of maternal health care but gaps in the system often lead to missed opportunities for follow-up and put women at risk after complications.

A major issue is the lack of a clear feedback loop. Once a referral is made, the referring provider, whether a community health worker or healthcare provider at a clinic, rarely receives updates on the patient’s care or outcomes. Similarly, referring providers can’t share information with new providers about the client, including relevant medical history, symptoms or concerns. This disconnect leaves critical information undocumented and unshared and creates additional work for providers, and clients having to answer questions repeatedly.

It’s hard to track referrals from community health workers because there’s no prompt with the Jamii ni Afya app that informs me about the referral. The community health worker has to call to inform me of the referral
Community health worker supervisor, Zanzibar

Currently, the referral process relies on informal communication and personal relationships. Community health workers make direct phone calls to formal healthcare providers, like nurses, (often their supervisors) in the clinics to refer high-risk clients. While this approach gets the job done in the moment, it’s not documented and important medical details can get lost along the way.

A well-coordinated referral system with clear documentation and communication could change this, and in 2024 we took important steps toward this as Jamii ni Afya for the first time became connected with higher levels of care. This will not only ensure better follow-up and care continuity but also alleviate the risks for mothers navigating during pregnancy and beyond.

Tailoring our programs with mothers, children and healthcare providers at the centre: Ideas on how we can improve

Two recommended improvements arose from the study: closing the referral loop and creating more engaging, client-centered content for maternal and child health. Here’s how we’re working to bring these ideas to life.

Closing the Referral Loop

We need to close the referral loop in Zanzibar to make sure women receive the care they need from conception to postpartum and beyond. We need to create a practical way for community health workers to know whether their clients attended the clinic they were referred to — and for health facility staff to stay informed about ongoing follow-up. At its simplest, this could mean a digital notification system that alerts the community health worker when a referred client visits a health facility. We’re currently designing a service prototype that integrates the Jamii ni Afya app used with the electronic medical digital system at selected health facilities. This integration would enable two-way communication between these two systems, ensuring that information flows seamlessly.

By formalizing this connection, community health workers will be better able to take on roles like counseling and follow-up, helping to reduce the burden on health facilities and creating a more connected system.

Creating Engaging, People-Centered Content

Another challenge that was clear in the study is the misconception among many women that early checkups in pregnancy aren’t necessary. This delay can result in missed opportunities to address potential health risks for both mothers and babies.

We believe that by improving the way community health workers communicate with women, we can encourage earlier disclosure of pregnancy and earlier care-seeking. It’s about building trust, sharing knowledge and creating a deeper connection between community health workers and the clients they serve.

We’re exploring ways to make communication more engaging and impactful by:

• Incorporating simple, memorable video content into the Jamii ni Afya app. These videos can serve as tools for community health workers to educate women about the importance of early visits and what services are available.
• Refreshing the educational content in the app to keep it up-to-date, engaging and user-friendly.

These ideas may seem simple, but we believe they can have a significant impact. By closing the referral loop, we can ensure that no client falls through the cracks and by equipping community health workers with better tools and content, we can address misinformation and barriers that prevent women from accessing timely care.

At the heart of all of this, is a commitment to listening to the community and tailoring our programs to meet their needs. Together, we can build a stronger, more connected system that puts people first and improves the health and well-being for both mothers and children.

The names have been changed to protect the privacy of those interviewed.