**Background:** Tanzania has a high maternal mortality ratio, with only 51% of pregnant women attending four or more antenatal care (ANC) visits, far below the WHO recommendation of at least eight visits. Previous research identified substandard ANC quality, including insufficient basic blood and urine tests, with 20% of severe maternal morbidities attributed to substandard care. The research team previously developed a paper-based antenatal education program using picture dramas that showed potential for increasing birth preparedness and reducing maternal complications. Given the rapid increase in smartphone use in Tanzania, particularly among professional groups, this study aimed to develop and pilot a smartphone app for midwifery education to expand the reach of the program.
**Methods:** This mixed-methods pilot study was conducted between October 2019 and March 2021 at two health facilities in Dar es Salaam (population approximately 4.3 million), randomly assigned to intervention or control groups. The intervention used the Goocus online education platform, which included video content with Kiswahili narrations, locally adapted illustrations, an "ANC by week guide," mini-quizzes, and social media functions for reciprocal communication. Content was based on WHO recommendations for antenatal and intrapartum care. Midwives (n=23) in the intervention group received one-day training on app use and were reimbursed 10,000 Tanzanian shillings (approximately 5 USD) for mobile data costs. App usage was monitored for two months post-intervention. Learning outcomes were measured using a 10-item mini-quiz and the 23-item Women-Centered Care Questionnaire (WCC23E, Cronbach's alpha 0.835). Focus group discussions (FGDs) were conducted with 21 midwives to assess usability. Pregnant women (n=207; 109 intervention, 98 control) completed the 34-item Birth Preparedness Questionnaire (BPQ) assessing knowledge (10 items) and birth preparedness (24 items across seven subscales). Statistical analyses included Wilcoxon signed-rank tests for midwife outcomes and ANCOVA (unadjusted and adjusted for parity) for pregnant women's outcomes, with multiple imputation for missing data.
**Key Results:** Among midwives, 87.5% continued using the app two months post-intervention, and 62.5% completed the study module. Mini-quiz scores significantly increased from a mean of 6.9 (SD 1.79) to 8.4 (SD 1.19) points (p=0.018). WCC23E scores increased from 98.6 (SD 12.05) to 102.2 (SD 5.53) points, but this was not statistically significant (p=0.39). FGDs revealed that midwives found the app provided useful knowledge, increased confidence and ability, was easy to understand and use, and had fun game elements. They requested more content (childcare, infectious diseases, vaccines), improved environment (free internet, integration with electronic medical records), and app improvements (voice recordings, more Kiswahili content, share function). For pregnant women, the intervention group had significantly higher knowledge scores (p=0.048 unadjusted, p=0.033 adjusted) and home-based value scores (p=0.033 unadjusted, p=0.016 adjusted) compared to controls. Total scores and other subscales (birth preparedness, family support, avoidance of medical intervention, provision of money and food, preference for skilled birth attendants, pregnant women's workload) showed no significant group differences. The intervention group had significantly older women (mean age 28.94 vs 25.80 years, p<0.001) and higher parity (mean 1.21 vs 0.65, p=0.001).
**Clinical Implications:** This pilot study demonstrates the feasibility and potential effectiveness of a smartphone-based educational app for midwives in urban Tanzania. The high continued usage rate (87.5%) and significant improvement in knowledge scores suggest that mHealth interventions can be acceptable and effective for continuing professional education in resource-limited settings. The significant improvement in pregnant women's knowledge and home-based values (preference for facility birth) indicates that improving midwife education may translate into better health education for patients. However, the limited impact on other BPQ subscales suggests that household-level factors (monetary preparation, nutrition, workload) may require family-inclusive interventions. Key challenges identified include the need for free internet access, integration into clinical workflows to avoid misinterpretation of smartphone use, and the need for offline functionality. The authors recommend future larger-scale studies using women-centered care as an outcome measure and developing a parallel app for pregnant women to reinforce health education at home.