Mobile-health tool to improve maternal and neonatal health care in Bangladesh: a cluster randomized controlled trial

Utilization of maternal healthcare services in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Maternal mortality is a critical public health issue, especially in low- and middle-income countries (LMICs). Maternal healthcare services (MHS), including antenatal care (ANC) visits, skilled birth attendants (SBA), institutional delivery (ID), and postnatal care (PNC), are crucial policy priorities to address maternal mortality and improve pregnancy outcomes. This systematic review and meta-analysis aimed to provide a comprehensive, quantitative analysis of MHS utilization among women in LMICs.

METHODS

We conducted a comprehensive search on PubMed, Scopus, Web of Science, CINAHL, and SocINDEX to gather relevant studies on the utilization of MHS in LMICs conducted between January 2015 and December 2024. These were then synthesized both quantitatively and qualitatively and random-effect models were employed to obtain pooled estimates.

RESULTS

A total of 145 studies included in this review. Coverage of at least one ANC visit (ANC1), at least four ANC visits (ANC4), SBA, ID and PNC were reported in 66, 108, 42, 63, and 37 studies respectively and for these studies pooled prevalences of ANC1, ANC4, SBA, ID, and PNC were found 85.0% (95% CI 81.2-88.1%), 50.8% (95% CI 46.4-55.2%), 65.6% (95% CI 58.7-71.9%), 66.9% (95% CI 60.3-72.9%), and 48.9% (95% CI 41.7-56.2%), respectively, with high heterogeneity among the studies (I2 > 99.0%). Results obtained from the sub-group analysis revealed that the prevalence of MHS indicators was higher in the South and Southeast Asia (SSEA) region compared to Sub-Saharan Africa (SSA), except for ID, e.g., SBA prevalence in SSEA was 70.1% (95% CI 60.4-78.3%) whereas for SSA it was 64.0% (95% CI 53.3-73.6%). The prevalence of all MHS indicators was higher for studies with primary data than those with secondary data, except for ANC4 and PNC. Overall, associations were reported between MHS utilization and women's age, education level, household socioeconomic status, place of residence, decision-making power, and exposure to mass media.

CONCLUSION

High heterogeneity among studies infer possible disparities in MHS utilization at both global and national levels. Hence, it is crucial for policies to prioritize enhancing effective coverage, narrowing disparities, and improving care quality in alignment with the Sustainable Development Goals.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023401745.

Development and testing of mobile phone text messages for improving maternal and newborn care practice in Jimma Zone, Ethiopia: a user-centered design approach

BACKGROUND

Mobile phone-based messaging for maternal education has indicated promising outcomes in promoting maternal and newborn care practices. However, most mobile phone-based messaging interventions are not tested before their implementation, and the evidence on the message content development process and methods is limited and underreported. The aim of this study was to develop and test text messages for interventions designed to improve maternal services utilization and newborn care practices.

METHODS

The development process has 4 phases: engaging pregnant mothers and experts in selected districts of the Jimma Zone, Ethiopia. During phase 1, the draft messages were developed based on the message framing concept, and the number of messages was reduced after review. In phase 2, 12 mothers participated in card sorting and the messages were refined. In phase 3, 8 experts evaluated the messages using 10 items with a 5-point Likert scale. In phase 4, a pilot study (n = 30) was conducted to evaluate the messages and their delivery when they were sent to individuals' mobile telephones. In this phase, a system usability scale was also used to assess the usability of the planned intervention.

RESULTS

An initial bank of 120 messages was developed, 42 of which were discarded during the development process. Of these, 32 were discarded by the research team at phase 1, and 10 were discarded during the card sorting at phase 2. Based on the experts' evaluations, 14 messages were reworded and refined in phase 3. During the pilot testing phase, the majority (80%) of the participants mentioned that the time they had been receiving the message was early, and 66.7% of the participants preferred the time to receive text messages about health. The mean SUS score was 72.26, which is acceptable for the usability of the mobile phone-based messaging intervention.

CONCLUSION

A final bank of 78 (39 for each framing type) messages was obtained after refinement according to feedback from participants. The SUS showed an acceptable score for the planned intervention. This message development process confirms that the messages are acceptable, and important for improving maternal and newborn health care practices.

TRIAL REGISTRATION

PACTR202201753436676.

Maternal and child health handbook to improve continuum of maternal and child care in rural Bangladesh: Findings of a cluster randomized controlled trial

This study aimed to evaluate the effectiveness of maternal and child health handbook (MCH) enhanced by mobile tools and to generate evidence informing the adoption of the program in Bangladesh. A cluster randomized controlled trial (RCT) has been implemented in Lohagora of Narail District and Dhamrai of Dhaka District. Unions of the study settings were randomly allocated in either one of three groups: (1) Intervention 1 using both mobile platform and MCH, (2) Intervention 2 using MCH alone, or (3) the Control. A total of 3,002 participants were recruited. The interventions were designed to promote two-way communications between pregnant women/their families and community health workers by an empowering approach. A total of 3,002 pregnant women were recruited. As the results, the interventions both significantly improved the utilization of CoC, although the overall proportion of CoC was relevantly low: 2.79% in the Control (95% CI: 1.37-3.54%), 6.16% in Intervention 2 (95% CI: 4.67-7.86%), and 7.89% in Intervention 1 (95% CI: 6.29-9.90%). Neonatal mortality rate with and without CoC was 5.43 per 1,000 (95% CI: 3.63-9.57 per 1,000) and 34.8 per 1,000 (95% CI: 24.3-45.4 per 1,000), respectively. Our study indicated the effectiveness of the interventions by leveraging MCH and a mobile platform to promote uptake of CoC throughout prepartum, intrapartum and postpartum/neonatal periods, potentially bringing long-lasting benefits to mothers and their offspring. The explicit approach is expected to guide policy makers to adopt MCH interventions in primary healthcare strengthening at the community level. Trial registration: UMIN000025628 Registered June 13, 2016.

Mobile Phone App Use Among Pregnant Women in China and Associations Between App Use and Perinatal Outcomes: Retrospective Study

BACKGROUND

Maternal and child health (MCH)-related mobile apps are becoming increasingly popular among pregnant women; however, few apps have demonstrated that they lead to improvements in pregnancy outcomes.

OBJECTIVE

This study aims to investigate the use of MCH apps among pregnant women in China and explore associations with pregnancy outcomes.

METHODS

A retrospective study was conducted at 6 MCH hospitals in northern China. Women who delivered a singleton baby at >28 weeks' gestation at the study hospitals were sequentially recruited from postnatal wards from October 2017 to January 2018. Information was collected on the women's self-reported MCH app use during their pregnancy, along with clinical outcomes. Women were categorized as nonusers of MCH apps and users (further divided into intermittent users and continuous users). The primary outcome was a composite adverse pregnancy outcome (CAPO) comprising preterm birth, birth weight <2500 g, birth defects, stillbirth, and neonatal asphyxia. The association between app use and CAPO was explored using multivariable logistic analysis.

RESULTS

The 1850 participants reported using 127 different MCH apps during pregnancy. App use frequency was reported as never, 24.7% (457/1850); intermittent, 47.4% (876/1850); and continuous, 27.9% (517/1850). Among app users, the most common reasons for app use were health education (1393/1393, 100%), self-monitoring (755/1393, 54.2%), and antenatal appointment reminders (602/1393, 43.2%). Nonusers were older, with fewer years of education, lower incomes, and higher parity (P<.01). No association was found between any app use and CAPO (6.8% in nonusers compared with 6.3% in any app users; odds ratio 0.77, 95% CI 0.48-1.25).

CONCLUSIONS

Women in China access a large number of different MCH apps, with social disparities in access and frequency of use. Any app use was not found to be associated with improved pregnancy outcomes, highlighting the need for rigorous development and testing of apps before recommendation for use in clinical settings.

Determinants of a mobile phone-based Interactive Voice Response (mIVR) system for monitoring childhood illnesses in a rural district of Ghana: Empirical evidence from the UTAUT model

Background

The use of a mobile phone-based Interactive Voice Response (mIVR) System for real time monitoring of childhood illnesses provides an opportunity to improve childhood survival and health systems. However, little is known about the factors that facilitate its use. This study sought to identify key determinants and moderators of mIVR system use among caregivers in a rural district of Ghana using the Unified Theory of Acceptance and Use of Technology (UTAUT) model.

Methods

The mIVR system was designed to provide real-time data on common symptoms of childhood illnesses after answering several questions by caregivers with sick children. A structured questionnaire with closed questions was used to collect data from 354 caregivers of children under-five living in rural communities, four (4) months after introducing the system. Regression analysis was used to identify key determinants and moderating factors that facilitate the use of the system based on the UTAUT model.

Results

A total of 101 (28.5%) caregivers had used the system and 328 (92.7%) had intention to use the mIVR system. Caregivers’ level of education and household wealth were associated with use of the mIVR systems (p<0.001). Behavioural intention (BI) to use mIVR system was positively influenced by performance expectancy (PE) (β = 0.278, 95% CI: 0.207, 0.349), effort expectancy (EE) (β = 0.242, 95% CI: 0.159, 0.326) and social influence (SI) (β = 0.081, 95% CI: 0.044, 0.120). Facilitating conditions (FC) (β = 0.609, 95% CI: 0.502, 0.715) and behavioural intention (β = 0.426, 95% CI: 0.255, 0.597) had a positive influence on user behaviour (UB). Mobile phone experience and household wealth significantly moderated the effect of PE, EE, SI, and FC on behavioural intention and usage of mIVR systems.

Conclusion

The perceived usefulness of the mIVR system, ease of use, social influences, and facilitating conditions are key determinants of users’ attitude and use of mIVR system. These relationships are significantly moderated by users’ phone experience and wealth status.

Explaining the impact of mHealth on maternal and child health care in low- and middle-income countries: a realist synthesis

Background

Despite the growing global application of mobile health (mHealth) technology in maternal and child health, contextual factors, and mechanisms by which interventional outcomes are generated, have not been subjected to a systematic examination. In this study, we sought to uncover context, mechanisms, and outcome elements of various mHealth interventions based on implementation and evaluation studies to formulate theories or models explicating how mHealth interventions work (or not) both for health care providers and for pregnant women and mothers.

Method

We undertook a realist synthesis. An electronic search of five online databases (PubMed/Medline, Google Scholar, Scopus, Academic Search Premier and Health Systems Evidence) was performed. Using appropriate Boolean phrases terms and selection procedures, 32 articles were identified. A theory-driven approach, narrative synthesis, was applied to synthesize the data. Thematic content analysis was used to delineate elements of the intervention, including its context, actors, mechanisms, and outcomes. Abduction and retroduction were applied using a realist evaluation heuristic tool to formulate generative theories.

Results

We formulated two configurational models illustrating how and why mHealth impacts implementation and uptake of maternal and child health care. Implementation-related mechanisms include buy-in from health care providers, perceived support of health care providers’ motivation and perceived ease of use and usefulness. These mechanisms are influenced by adaptive health system conditions including organization, resource availability, policy implementation dynamics, experience with technology, network infrastructure and connectivity. For pregnant women and mothers, mechanisms that trigger mHealth use and consequently uptake of maternal and child health care include perceived satisfaction, motivation and positive psychological support. Information overload was identified as a potential negative mechanism impacting the uptake of maternal and child health care. These mechanisms are influenced by health system conditions, socio-cultural characteristics, socio-economic and demographics characteristics, network infrastructure and connectivity and awareness.

Conclusion

Models developed in this study provide a detailed understanding of implementation and uptake of mHealth interventions and how and why they impact maternal and child health care in low- and middle-income countries. These models provide a foundation for the ‘white box’ of theory-driven evaluation of mHealth interventions and can improve rollout and implementation where required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03684-x.

Mobile health applications for disease screening and treatment support in low-and middle-income countries: A narrative review

The advances in mobile technologies and applications are driving the transformation in health services delivery globally. Mobile phone penetration is increasing exponentially in low-and middle-income countries, hence using mobile phones for healthcare services could reach more people in resource-limited settings than the traditional forms of healthcare provision. The review presents recent literature on facilitators and barriers of implementing mHealth for disease screening and treatment support in low-and middle-income countries. We searched for relevant literature from the following electronic databases: MEDLINE; CINAHL with full text via EBSCOhost; Science Direct; PubMed; Google Scholar and Web of Science using the keywords for relevant studies. We searched for published studies from 2015 to August 2020 with no language limitations. A total of 721 articles identified, 125 articles met the inclusion criteria and were included in the qualitative synthesis. The review demonstrates relevant facilitators for the implementation of mHealth, which includes knowledge, attitudes, and perceptions of stakeholders on the use of mHealth and the performance of mHealth for disease diagnosis in low and-middle-income countries. Barriers and challenges hindering the implementation of mHealth applications were also identified. We proposed a framework for improving the implementation of mHealth for disease screening and treatment support in low-and middle-income countries.

Targeted client communication via mobile devices for improving maternal, neonatal, and child health

BACKGROUND

The global burden of poor maternal, neonatal, and child health (MNCH) accounts for more than a quarter of healthy years of life lost worldwide. Targeted client communication (TCC) via mobile devices (MD) (TCCMD) may be a useful strategy to improve MNCH.

OBJECTIVES

To assess the effects of TCC via MD on health behaviour, service use, health, and well-being for MNCH.

SEARCH METHODS

In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials that assessed TCC via MD to improve MNCH behaviour, service use, health, and well-being. Eligible comparators were usual care/no intervention, non-digital TCC, and digital non-targeted client communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second.

MAIN RESULTS

We included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low-, middle- or high-income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle-income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Pregnant and postpartum women TCCMD versus standard care For behaviours, TCCMD may increase exclusive breastfeeding in settings where rates of exclusive breastfeeding are less common (risk ratio (RR) 1.30, 95% confidence intervals (CI) 1.06 to 1.59; low-certainty evidence), but have little or no effect in settings where almost all women breastfeed (low-certainty evidence). For use of health services, TCCMD may increase antenatal appointment attendance (odds ratio (OR) 1.54, 95% CI 0.80 to 2.96; low-certainty evidence); however, the CI encompasses both benefit and harm. The intervention may increase skilled attendants at birth in settings where a lack of skilled attendants at birth is common (though this differed by urban/rural residence), but may make no difference in settings where almost all women already have a skilled attendant at birth (OR 1.00, 95% CI 0.34 to 2.94; low-certainty evidence). There were uncertain effects on maternal and neonatal mortality and morbidity because the certainty of the evidence was assessed as very low. TCCMD versus non-digital TCC (e.g. pamphlets) TCCMD may have little or no effect on exclusive breastfeeding (RR 0.92, 95% CI 0.79 to 1.07; low-certainty evidence). TCCMD may reduce 'any maternal health problem' (RR 0.19, 95% CI 0.04 to 0.79) and 'any newborn health problem' (RR 0.52, 95% CI 0.25 to 1.06) reported up to 10 days postpartum (low-certainty evidence), though the CI for the latter includes benefit and harm. The effect on health service use is unknown due to a lack of studies. TCCMD versus digital non-targeted communication No studies reported behavioural, health, or well-being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low-certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low-certainty evidence). Pregnant and postpartum women living with HIV TCCMD versus standard care For behaviours, TCCMD may make little or no difference to maternal and infant adherence to antiretroviral (ARV) therapy (low-certainty evidence). For health service use, TCC mobile telephone reminders may increase use of antenatal care slightly (mean difference (MD) 1.5, 95% CI -0.36 to 3.36; low-certainty evidence). The effect on the proportion of births occurring in a health facility is uncertain due to very low-certainty evidence. For health and well-being outcomes, there was an uncertain intervention effect on neonatal death or stillbirth, and infant HIV due to very low-certainty evidence. No studies reported on maternal mortality or morbidity. TCCMD versus non-digital TCC The effect is unknown due to lack of studies reporting this comparison. TCCMD versus digital non-targeted communication TCCMD may increase infant ARV/prevention of mother-to-child transmission treatment adherence (RR 1.26, 95% CI 1.07 to 1.48; low-certainty evidence). The effect on other outcomes is unknown due to lack of studies. Parents of children aged less than five years No studies reported on correct treatment, nutritional, or health outcomes. TCCMD versus standard care Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low-certainty evidence); however, the effect estimates varied widely between studies. TCCMD versus non-digital TCC TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low-certainty evidence), and may make little or no difference to oral hygiene practices (low-certainty evidence). TCCMD versus digital non-targeted communication TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low-certainty evidence). No trials in any population reported data on unintended consequences.

AUTHORS' CONCLUSIONS

The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High-quality, adequately powered trials and cost-effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality.

Study on the Status of Health Service Utilization among 3⁻5 Years Old Left-Behind Children in Poor Rural Areas of Hunan Province, China: A Cross-Sectional Survey

The left-behind children (LBC) in China generally refer to children who remain in rural regions under the care of kin members while their parents migrate to urban areas. Due to some reasons, e.g., poverty, poor transportation conditions, lack of health resources, and preschool child care, it is hard for preschool-aged rural LBC to obtain essential health services. Random cluster sampling was used to recruit the caregivers and all the 3⁻5-year-old LBC in two rural counties in Hunan Province. A questionnaire was used to collect data on LBC demographics via face-to-face interviews with the caregivers. Health service needs were evaluated by the two-week prevalence rate, while health service utilization was measured by the two-week physician visit rate. Of the 559 respondents in the study, the two-week prevalence rate was 44.2% and the two-week physician visits rate was 48.6%. Nearly half of the sick children did not go to a hospital, 45.7% self-treated, and 5.3% did not take any treatment. The utilization rates of "health check," "eye exam," and "hearing screening for 3-year-olds" were extremely low (57.3%, 29.3%, 18.7%). The utilization rate of health services for preschool LBC in poor rural areas was extremely low, which can affect the normal growth and development of children.