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Background: Most maternal health programs in low-and middle-income countries estimate gestational age to provide appropriate antenatal care at the correct times throughout the pregnancy. Although various gestational dating methods have been validated in research studies, the performance of these methods has not been evaluated on a larger scale, such as within health systems. The objective of this research was to investigate the magnitude and impact of errors in estimated delivery dates on health facility delivery among women enrolled in a maternal health program in Zanzibar. Methods: This study included 4225 women who were enrolled in the Safer Deliveries program and delivered before May 31, 2017. The exposure of interest was error in estimated delivery date categorized as: severe overestimate, when estimated delivery date (EDD) was 36 days or more after the actual delivery date (ADD); moderate overestimate, when EDD was 15 to 35 days after ADD; accurate, when EDD was 6 days before to 14 days after ADD; and underestimate, when EDD was 7 days or more before ADD. We used Chi-squared tests to identify factors associated with errors in estimated delivery dates. We performed logistic regression to assess the impact of errors in estimated delivery dates on health facility delivery adjusting for age, district of residence, HIV status, and occurrence of past home delivery. Results: In our data, 28% of the estimated delivery dates were a severe overestimate, 23% moderate overestimate, 41% accurate, and 8% underestimate. Compared to women with an accurate delivery date, women with a moderate or severe overestimate were significantly less likely to deliver in a health facility (OR = 0.71, 95% CI: [0.59, 0.86]; OR = 0.74, 95% CI: [0.61, 0.91]). When adjusting for multiple confounders, women with moderate overestimates were significantly less likely to deliver in a health facility (AOR = 0.76, 95% CI: [0.61, 0.93]); the result moved slightly towards null for women with severe overestimates (AOR = 0.84, 95% CI: [0.69, 1.03]). Conclusions: The overestimation of women's EDDs reduces the likelihood of health facility delivery. To address this, maternal health programs should improve estimation of EDD or attempt to curb the effect of these errors within their programs.

The utilization of community health worker (CHW) programmes to improve maternal and neonatal health outcomes has become widely applied in low- and middle-income countries. While current research has focused on discerning the effect of these interventions, documenting the process of implementing, scaling and sustaining these programmes has been largely ignored. Here, we focused on the implementation of the Safer Deliveries CHW programme in Zanzibar, a programme designed to address high rates of maternal and neonatal mortality by increasing rates of health facility delivery and postnatal care visits. The programme was implemented and brought to scale in 10 of 11 districts in Zanzibar over the course of 3 years by D-tree International and the Zanzibar Ministry of Health. As the programme utilized a mobile app to support CHWs during their visits, a rich data resource comprised of 133 481 pregnancy and postpartum home visits from 41 653 women and 436 CHWs was collected, enabling the evaluation of numerous measures related to intervention fidelity and health outcomes. Utilizing the framework of Steckler et al., we completed a formal process evaluation of the primary intervention, CHW home visits to women during their pregnancy and postpartum period. Our in-depth analysis and discussion will serve as a model for process evaluations of similar CHW programmes and will hopefully encourage future implementers to report analogous measures of programme performance.

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