Continuum of Care Services for Maternal and Child Health using mobile technology - a health system strengthening strategy in low and middle income countries

Effectiveness and Implementation of a Text Messaging mHealth Intervention to Prevent Childhood Obesity in Mexico in the COVID-19 Context: Mixed Methods Study

BACKGROUND

Promoting physical activity (PA) and healthy feeding (HF) is crucial to address the alarming increase in obesity rates in developing countries. Leveraging mobile phones for behavior change communication to encourage infant PA and promote HF is particularly significant within the Mexican context.

OBJECTIVE

This study aims to explore the effectiveness and feasibility of mHealth interventions aimed at promoting PA and HF among primary caregivers (PCs) of Mexican children under the age of 5 years. Additionally, the study aims to disseminate insights gained from intervention implementation amidst the COVID-19 pandemic and assess the potential of behavior change mHealth interventions on a broader population scale.

METHODS

NUTRES, an mHealth intervention, underwent an effectiveness-implementation hybrid trial. Over 36 weeks, participants in the intervention group (IG), totaling 230 individuals, received approximately 108 SMS text messages tailored to their children's age. These messages covered topics such as PA and HF and emphasized the significance of proper child nutrition amidst the COVID-19 pandemic. NUTRES participants were recruited from both urban and rural health units across 2 states in Mexico. Given the COVID-19 context, both baseline and follow-up surveys were conducted via mobile or fixed telephone. The evaluation of effectiveness and implementation used a mixed methods approach. Qualitative analysis delved into participants' experiences with NUTRES and various implementation indicators, including acceptance, relevance, and coverage. Grounded theory was used for coding and analysis. Furthermore, difference-in-differences regression models were used to discern disparities between groups (comparison group [CG] versus IG) concerning knowledge and practices pertaining to infant PA and HF.

RESULTS

Of the total 494 PCs enrolled in NUTRES, 334 persisted until the end of the study, accounting for 67.6% (334/494) participation across both groups. A majority of PCs (43/141, 30.5%, always; and 97/141, 68.8%, sometimes) used the SMS text message information. Satisfaction and acceptability toward NUTRES were notably high, reaching 98% (96/98), with respondents expressing that NUTRES was "good," "useful," and "helpful" for enhancing child nutrition. Significant differences after the intervention were observed in PA knowledge, with social interaction favored (CG: 8/135, 5.9% vs IG: 20/137, 14.6%; P=.048), as well as in HF practice knowledge. Notably, sweetened beverage consumption, associated with the development of chronic diseases, showed divergence (CG: 92/157, 58.6% vs IG: 110/145, 75.9%; P=.003). In the difference-in-differences model, a notable increase of 0.03 in knowledge regarding the benefits of PA was observed (CG: mean 0.13, SD 0.10 vs IG: mean 0.16, SD 0.11; P=.02). PCs expressed feeling accompanied and supported, particularly amidst the disruption of routine health care services during the COVID-19 pandemic.

CONCLUSIONS

While NUTRES exhibited a restricted impact on targeted knowledge and behaviors, the SMS text messages functioned effectively as both a reminder and a source of new knowledge for PCs of Mexican children under 5 years of age. The key lessons learned were as follows: mHealth intervention strategies can effectively maintain communication with individuals during emergencies, such as the COVID-19 pandemic; methodological and implementation barriers can constrain the effectiveness of mHealth interventions; and using mixed methods approaches ensures the complementary nature of results. The findings contribute valuable evidence regarding the opportunities and constraints associated with using mobile phones to enhance knowledge and practices concerning PA and HF among PCs of children under 5 years old.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04250896; https://clinicaltrials.gov/ct2/show/NCT04250896.

Technologies for strengthening immunization coverage in India: a systematic review

Background

Immunization coverage varies across India in different settings, geographic areas and populations. Technologies for improving immunization access can reduce disparities in coverage. This systematic review, which follows PRISMA guidelines, aims to examine the technologies for strengthening immunization coverage in India.

Methods

Studies published between January 1, 2011 and July 31, 2021 were searched in Medline (through PubMed), Cochrane Library and Google Scholar. All observational and experimental studies, except qualitative studies, were included. Studies published in the English language and related to technologies for strengthening immunization, conducted on children, pregnant women, adults, elderly, healthcare personnel, caregivers and vulnerable populations across all Indian settings were included. Non-English articles, protocols, commentaries, letters, abstracts, correspondence, opinion articles, modelling, narrative and systematic reviews were excluded. Two reviewers screened studies independently, extracted data in a standardized sheet and appraised the study quality using the Mixed Methods Appraisal Tool. The primary outcome was technologies that improved immunization coverage. The protocol is registered with OSF (https://osf.io/r42gm).

Findings

6592 titles and abstracts were screened, and data extracted from 23 India-specific studies. Quality of 22/23 studies was average or above. Technologies identified included reminder systems, capacity building, community engagement and wearable technologies. Automated incentivised mobile phone reminders, immunization due-list, computerized data tracking, community mobilization and campaigns improved vaccine coverage, although effectiveness of some varied viz., reminder systems, and across states. Newer technologies included the Jyotigram Yojana, Digital Near-field Communication Pendants, "Reaching Every District" Programme and the "My Village My Home" tool.

Interpretation

Technologies for improving immunization systems, capacity building and community engagement were effective. Newer technologies on vaccine delivery, mapping and cold chain logistics were not evaluated in India or were ineffective. There were limited studies in populations other than children and pregnant women. Future work is needed to evaluate the effectiveness of identified technologies across diverse settings.

Funding

No funding was received for preparing this manuscript.

Utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa: A scoping review protocol

INTRODUCTION

There has been significant progress in maternal health outcomes in the sub-Saharan African region since the early 1990s, in part due to digital and mobile health interventions. However, critical gaps and disparities remain. Mobile phones in particular have potential to reach underserved, hard-to-reach populations with underdeveloped infrastructure. In spite of the opportunities for mobile phones to address maternal mortality in the region, there is no extensive mapping of the available literature on mobile phone interventions that aim to improve access of maternal care in sub-Saharan Africa. The proposed scoping review aims to map literature on the nature and extent of mobile phones interventions designed to improve maternal care health services in the region.

METHODS

Conduct of this scoping review will be guided by the Joanna Briggs Institute approach. Literature searches will be conducted in multiple electronic databases, including MEDLINE, Embase, CINAHL, APA PsycInfo, Cochrane Central Register of Controlled Trials, Global Health, African Index Medicus, Web of Science, and Applied Social Sciences Index & Abstracts. Grey literature will also be identified. Keyword searches will be used to identify articles. Two reviewers will independently screen eligible titles, abstracts and full articles with a third reviewer to help resolve any disputes. We will extract data on general study characteristics, population characteristics, concept, context, intervention details, study results, gaps and recommendations.

DISCUSSION

Understanding use of mobile phones among underserved, hard-to-reach populations with underdeveloped infrastructure to address maternal mortality in developing countries is very critical to informing health systems on potential effective strategies. This review will complement the evidence base on utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa.

Use of mHealth in promoting maternal and child health in "BIMARU" states of India "A health system strengthening strategy": Systematic literature review

Low-middle income countries like India bear a heavier burden of maternal, childcare, and child mortality rates when compared with high-income countries, which highlights the disparity in global health. Numerous societal, geopolitical, economic, and institutional issues have been linked to this inequality. mHealth has the potential to ameliorate these challenges by providing health services and health-related information with the assistance of frontline workers in the provision of prepartum, delivery, and postnatal care to improve maternal and child health outcomes in hard-to-reach areas in low- and middle-income countries (LMICs). However, there is limited evidence to support how mHealth can strengthen maternal and child health in India. The scoping review guideline in the Cochrane Handbook was used to retrieve studies from 4 international databases: CINAHL, Embase, Medline Ovid, and PubMed. This search strategy used combined keywords (MeSH terms) related to maternal and child healthcare, mHealth, and BIMARU in conjunction with database-controlled vocabulary. Out of 278 records, 8 publications were included in the review. The included articles used mHealth for data collection, eLearning, communication, patient monitoring, or tracking to deliver maternal and neonatal care. The results of these papers reflected a favourable effect of mHealth on the target population and found that it altered their attitudes and behaviours about healthcare. Higher job satisfaction and self-efficiency were reported by mHealth user care providers. Multiple barriers to the acceptance of mHealth exist, but the majority of the evidence points towards the feasibility of the intervention in a clinical setting. The mHealth has positive potential for improving maternal and child health outcomes in low-resource settings in India's BIMARU states by strengthening the healthcare system. The results of the study could be used in the tailoring of an effective mHealth intervention and implementation strategy in a similar context. However, there is a need for economic evaluation in the future to bridge the knowledge gap regarding the cost-effectiveness of mHealth interventions.

Mobile health technology in providing maternal health services - Awareness and challenges faced by pregnant women in upper West region of Ghana

Objectives

The study assessed awareness on Mobile Health (mhealth) Technology as well as challenges pregnant women encounter in the utilization of mhealth technology to improve maternal health in rural settings in the Upper West Region (UWR) of Ghana.

Study design

The study was an exploratory design that employed the qualitative method of data collection.

Methods

Semi-structured interview guide was used to conduct six (6) Focus Group Discussions (FGDs) and nine (9) Key Informant Interviews (KIIs) among pregnant women and health workers respectively from three (3) selected rural districts in the Upper West Region. Data was collected in August 2020. Thematic analysis was conducted and some statements from participants were presented verbatim to illustrate the themes realized.

Results

Participants were aware of the mhealth intervention that had been implemented by Savanna Signatures in their districts. Major sources of information on the mhealth services were from durbars, health education sessions and health care providers. Challenges faced by pregnant women, in the mhealth technology intervention were; financial challenges, lack of mobile network connectivity, lack of electricity in some rural areas, low female literacy rate at household level and cultural barriers.

Conclusion

The Savanna Signatures mhealth intervention is widely known but some challenges exist that impede the smooth implementation of the intervention. The mhealth technology intervention implementers should partner with other sectors and policy makers to address the challenges identified by the study.

Effectiveness of mHealth Interventions for Monitoring Antenatal Care among Pregnant Women in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Antenatal care (ANC) is essential in maternal and child health since it provides care to pregnant women from conception through to labour in order to ensure a safe pregnancy and childbirth. In recent years, mobile health (mHealth) interventions have emerged as a promising solution to improve maternal and child health outcomes in low- and middle-income countries (LMICs). The present study aimed to conduct a systematic review and meta-analysis of trials to evaluate the effectiveness of mHealth interventions to monitor prenatal care among pregnant women in LMICs. A systematic literature review was conducted using the databases CINHAL, Embase, MEDLINE, and PsycINFO on the effectiveness of mHealth interventions in monitoring the antenatal care of pregnant women. The study selection, data extraction of the included articles, and quality appraisal were assessed. Our study included six studies considering 7886 participants. All articles were from low- and middle-income countries (LMICs). Antenatal mothers who used a mobile health intervention were more likely (RR = 1.66, 95%CI = 1.07-2.58, I2 = 98%) to attend ANC check-ups when compared with the women who did not use any mobile health applications or did not receive any short message services. mHealth technologies are being utilised more and more to increase care accessibility and improve maternal and fetal health. Policymakers should prioritise the integration of mHealth interventions into maternal healthcare services in LMICs, ensuring that they are cost-effective, accessible, and sustainable and that healthcare workers are trained to deliver these interventions effectively.

Digital solutions to follow up on discharged new parents-A systematic literature review

New parents and their newborns are followed up after discharge either through home visits from midwives/nurses or using information and communication technology. This follow-up focuses on individual needs related to breastfeeding and infant feeding, practical advice on caring for babies, supporting and strengthening the new mother's knowledge and self-confidence concerning child development and parenting skills, and supporting the relationship between parents and baby. This systematic review aims to integrate available research results that describe new parents' experiences when health and care providers used telemedicine as a platform for follow-up after discharge from the childbirth department. This literature review was conducted following the PRISMA statement and was prospectively registered in PROSPERO CRD42021236912. The studies were identified through the following databases: AMED, Academic, EMBASE, Google Scholar, Ovid MEDLINE via PubMed, Cochrane database, and CINAHL. Results from these studies were compiled using thematic analysis. A total of 886 studies were identified. Screening resulted in eight studies that met the inclusion criteria. Thematic analysis produced the following themes: a) Flexibility and convenience of digital support, b) Digital literacy, c) Parents feeling safe with digital support, and d) Adequate substitute for physical meetings. New parents who live in a home environment with a relaxed atmosphere and around-the-clock digital support experience a sense of control, security, full attention, and encouragement. Digital follow up at home has proven effective because it can meet the support needs of new parents when necessary.

Scalability of mobile technology interventions in the prevention and management of HIV among adolescents in low-income and middle-income countries: protocol for a systematic review

INTRODUCTION

The rate of new infections with HIV remains high among adolescents globally. Adolescents in low-income and middle-income countries (LMICs), who are least likely to have access to quality healthcare, have the highest proportion of those living with HIV. Mobile technology has played an important role in providing access to information and services among adolescents in recent years. This review aims to synthesise and summarise information that will be useful in the planning, designing and implementing of future mHealth strategies.

METHODS AND ANALYSIS

Interventional studies, reported in English, on the prevention and management of HIV among adolescents that used mobile technology in LMICs will be included. MEDLINE (via PubMed), Embase, Web of Science, CINAHL, Clinicaltrials.gov, WHO International Clinical Trials Registry Platform (ICTRP), and the Cochrane Library are the information sources that have been identified as relevant to the area of study. These sources will be searched from inception to March 2023. The risk of bias will be assessed using the Cochrane Risk of Bias tool. The scalability of each study will be assessed using the Intervention Scalability Assessment Tool. Two independent reviewers will conduct the selection of studies, data extraction, and assessment of the risk of bias and scalability. A narrative synthesis of all the included studies will be done.

ETHICS AND DISSEMINATION

Ethical approval was not necessary for this study. This is a systematic review of publicly available information and therefore ethical approval was not deemed necessary. The results of this review will be published in a peer reviewed journal.

TRIAL REGISTRATION

This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42022362130.

Evaluating the Feasibility, Acceptability, and Preliminary Efficacy of SupportMoms-Uganda, an mHealth-Based Patient-Centered Social Support Intervention to Improve the Use of Maternity Services Among Pregnant Women in Rural Southwestern Uganda: Randomized Controlled Trial

BACKGROUND

SMS text messaging and other mobile health (mHealth) interventions may improve knowledge transfer, strengthen access to social support (SS), and promote positive health behaviors among women in the perinatal period. However, few mHealth apps have been taken to scale in sub-Saharan Africa.

OBJECTIVE

We evaluated the feasibility, acceptability, and preliminary efficacy of a novel, mHealth-based, and patient-centered messaging app designed using behavioral science frameworks to promote maternity service use among pregnant women in Uganda.

METHODS

We performed a pilot randomized controlled trial between August 2020 and May 2021 at a referral hospital in Southwestern Uganda. We included 120 adult pregnant women enrolled in a 1:1:1 ratio to receive routine antenatal care (ANC; control), scheduled SMS text or audio messages from a novel messaging prototype (scheduled messaging [SM]), and SM plus SMS text messaging reminders to 2 participant-identified social supporters (SS). Participants completed face-to-face surveys at enrollment and in the postpartum period. The primary outcomes were feasibility and acceptability of the messaging prototype. Other outcomes included ANC attendance, skilled delivery, and SS. We conducted qualitative exit interviews with 15 women from each intervention arm to explore the intervention mechanisms. Quantitative and qualitative data were analyzed using STATA and NVivo, respectively.

RESULTS

More than 85% and 75% of participants received ≥85% of the intended SMS text messages or voice calls, respectively. More than 85% of the intended messages were received within 1 hour of the expected time; 18% (7/40) of women experienced network issues for both intervention groups. Over 90% (36/40) of the intervention participants found this app useful, easy to use, engaging, and compatible and strongly recommended it to others; 70% (28/40), 78% (31/40), and 98% (39/40; P=.04) of women in the control, SM, and SS arms, respectively, had a skilled delivery. Half (20/40), 83% (33/40), and all (40/40; P=.001) of the women in the control, SM, and SS arms attended ≥4 ANC visits, respectively. Women in the SS arm reported the highest support (median 3.4, IQR 2.8-3.6; P=.02); <20% (8/40; P=.002) missed any scheduled ANC visit owing to lack of transportation. Qualitative data showed that women liked the app; they were able to comprehend ANC and skilled delivery benefits and easily share and discuss tailored information with their significant others, who in turn committed to providing them the needed support to prepare and seek help.

CONCLUSIONS

We demonstrated that developing a novel patient-centered and tailored messaging app that leverages SS networks and relationships is a feasible, acceptable, and useful approach to communicate important targeted health-related information and support pregnant women in rural Southwestern Uganda to use available maternity care services. Further evaluation of maternal-fetal outcomes and integration of this intervention into routine care is needed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04313348; https://clinicaltrials.gov/ct2/show/NCT04313348.

An evaluation of the introduction of telehealth for remote antenatal and postnatal contacts in Bangladesh and Lao People's Democratic Republic during the COVID-19 pandemic

From 2020, COVID-19 spread rapidly around the globe and continues to have a major impact on health system functioning, with a disproportionate impact on low- and middle-income countries (LMIC). Reduced service utilisation and coverage of essential childbirth interventions is likely impacting maternal and newborn morbidity and mortality. Telehealth has been identified as an important tool in the continued provision of essential healthcare services. The aim of this study was to explore the experience and impact of implementing telehealth services for the provision of remote antenatal (ANC) and postnatal (PNC) contacts in regions of Bangladesh and Lao People's Democratic Republic through 100 semi-structured interviews with health service leaders and providers, and childbearing women who organised, provided, or were the recipients of ANC and PNC telehealth during the COVID-19 pandemic response. The findings showed that a sudden pivot from face-to-face to telehealth services posed both health system and provision of care challenges. Health systems lacked funding to support telehealth and the infrastructure needed for service changes; however, some were able to work with key maternal child health departments within Ministries of Health to find the resources to implement the services. Health providers found telehealth beneficial during the pandemic response but identified a lack of training, guidance, and support as a barrier to changing practice. Childbearing women reported being fearful of accessing care at health services due to COVID-19, and whilst they appreciated the telehealth contacts, many continued to prefer face-to-face delivery of ANC and PNC care. Telehealth, however, was a good alternative in a time when face-to-face care was not possible. Considerations for post-pandemic broader implementation or scale-up of telehealth for routine antenatal and postnatal maternity care provision include the need for further research on issues such as accessibility, acceptability, quality of care, and sustainability of service provision.

Mapping national information and communication technology (ICT) infrastructure to the requirements of potential digital health interventions in low- and middle-income countries

Background

Digital health can support health care in low- and middle-income countries (LMICs) by overcoming problems of distance, poor infrastructure and the need to provide community practitioners with specialist support. We used five RESPIRE countries as exemplars (Bangladesh, India, Indonesia, Malaysia, Pakistan) to identify the digital health solutions that are valuable in their local setting, worked together with local clinicians and researchers to explore digital health policy, electricity/ICT infrastructure, and socio-cultural factors influencing users' ability to access, adopt and utilise digital health.

Methods

We adopted the Joanna Briggs Institute's scoping review protocol and followed the Cochrane Rapid Review method to accelerate the review process, using the Implementation and Operation of Mobile Health projects framework and The Extended Technology Acceptance Model of Mobile Telephony to categorise the results. We conducted the review in four stages: (1) establishing value, (2) identifying digital health policy, (3) searching for evidence of infrastructure, design, and end-user adoption, (4) local input to interpret relevance and adoption factors. We used open-source national/international statistics such as the World Health Organization, International Telecommunication Union, Groupe Speciale Mobile, and local news/articles/government statistics to scope the current status, and systematically searched five databases for locally relevant exemplars.

Results

We found 118 studies (2015-2021) and 114 supplementary online news articles and national statistics. Digital health policy was available in all countries, but scarce skilled labour, lack of legislation/interoperability support, and interrupted electricity and internet services were limitations. Older patients, women and those living in rural areas were least likely to have access to ICT infrastructure. Renewable energy has potential in enabling digital health care. Low usage mobile data and voice service packages are relatively affordable options for mHealth in the five countries.

Conclusions

Effective implementation of digital health technologies requires a supportive policy, stable electricity infrastructures, affordable mobile internet service, and good understanding of the socio-economic context in order to tailor the intervention such that it functional, accessible, feasible, user-friendly and trusted by the target users. We suggest a checklist of contextual factors that developers of digital health initiatives in LMICs should consider at an early stage in the development process.

Cohort profile: CareConekta: a pilot study of a smartphone application to improve engagement in postpartum HIV care in South Africa

PURPOSE

Pregnant and postpartum women living with HIV in South Africa are at high risk of dropping out of care, particularly after delivery. Population mobility may contribute to disruptions in HIV care, and postpartum women are known to be especially mobile. To improve engagement in HIV care during the peripartum period, we developed CareConekta, a smartphone application (app) that uses GPS coordinates to characterise mobility and allow for real-time intervention. We conducted a randomised controlled pilot study to assess feasibility, acceptability and initial efficacy of the app intervention to improve engagement in HIV care. This cohort profile describes participant enrolment and follow-up, describes the data collected and provides participant characteristics.

PARTICIPANTS

We enrolled 200 pregnant women living with HIV attending routine antenatal care at the Gugulethu Midwife Obstetric Unit in Cape Town, South Africa. Eligible women must have owned smartphones that met the app's technical requirements. Seven participants were withdrawn near enrolment, leaving 193 in the cohort.

FINDINGS TO DATE

Data were collected from detailed participant questionnaires at enrolment and follow-up (6 months after delivery), as well as GPS data from the app, and medical records. Follow-up is complete; initial analyses have explored smartphone ownership, preferences and patterns of use among women screened for eligibility and those enrolled in the study.

FUTURE PLANS

Additional planned analyses will characterise mobility in the population using the phone GPS data and participant self-reported data. We will assess the impact of mobility on engagement in care for the mother and infant. We also will describe the acceptability and feasibility of the study, including operational lessons learnt. By linking this cohort to the National Health Laboratory Service National HIV Cohort in South Africa, we will continue to assess engagement in care and mobility outcomes for years to come. Collaborations are welcome.

TRIAL REGISTRATION NUMBER

NCT03836625.

Individual-level and community-level determinants of use of maternal health services in Northwest Ethiopia: a prospective follow-up study

OBJECTIVE

The use of maternal health services is an important indicator of maternal health and socioeconomic development. Evidence on individual-level and community-level determinants of use of maternal health services in Benishangul Gumuz Region was not well known so far. Hence, this study fills this gap.

DESIGN

A prospective follow-up study SETTING: This study was conducted from March 2020 to January 2021 in Northwest Ethiopia.

PARTICIPANTS

A total of 2198 pregnant women participated in the study.

MAIN OUTCOME MEASURES

A multistage random sampling technique was used to select study subjects. Data were collected via face-to-face interviews using pretested semistructured questionnaires. Collected data were coded, cleaned and analysed using Stata software. Multilevel regression models were applied to determine individual-level and community-level factors of use of maternal health services.

RESULTS

This study found that the proportions of women who visited recommended antenatal care (ANC), received skilled delivery care and postnatal care (PNC) were 66.1%, 58.3% and 58.6%, respectively. Being rural (adjusted OR (AOR)=3.82, 95% CI 1.35 to 10.78), having information on maternal health services (AOR=2.13, 95% CI 1.21 to 3.75), with a history of pregnancy-related problems (AOR=1.83, 95% CI 1.15 to 2.92) and women with decision-making power (AOR=1.74, 95% CI 1.14 to 2.68) were more likely to attend fourth ANC visits. Similarly, women who attended tertiary school (AOR=4.12, 95% CI 1.49 to 11.33) and who initiated the first ANC visit within 4-6 months of pregnancy (AOR=0.66, 95% CI 0.45 to 0.96) were determinants of skilled delivery care. Finally, women whose partners attended tertiary education (AOR=3.67, 95% CI 1.40 to 9.58), women with decision-making power (AOR=1.8, 95% CI 1.09 to 2.97), women who attended the fourth ANC visit (AOR=10.8, 95% CI 6.79 to 17.2), women received iron-folic acid during pregnancy (AOR=1.96, 95% CI 1.11 to 3.49) and women who received skilled delivery care (AOR=1.63, 95% CI 1.1 to 2.42) were more likely to get PNC services.

CONCLUSION

The proportion of women who attended ANC, received skilled delivery services and PNCs was low. Different individual-level and community-level factors that influenced the use of these services were discovered. Therefore, community-based interventions should target those identified factors to improve maternal health services.

Midwifery Continuity of Care in Indonesia: Initiation of Mobile Health Development Integrating Midwives' Competency and Service Needs

Midwives' competence in providing continuity of care using mobile health (mHealth) applications is limited in developing countries. This study identified and explored midwives' competency and service needs to develop mHealth in Midwifery Continuity of Care (MCOC) education and training. It used an explanatory sequential mixed method, and was conducted from August to December 2021. A cross-sectional approach was used to find the characteristics and competency scope of 373 midwives in West Java, and continued with a qualitative design through a Focus Group Discussion (FGD) of 13 midwives. Descriptive data analysis (frequency, mean, deviation standard) and qualitative data analysis (coding, sub-themes, and theme) were conducted. In terms of the midwives who participated in this study, more than half were aged ≤ 35 years (58.98%), with a working period > 10 years (56.30%), had diploma degrees (71.12%), and used smartphones on average 1-12 h/day (78.28%). Most midwives needed to develop competency in the MCOC scope, including its early detection of the risk factor of complications and treatment management. They were concerned about the purposes, benefits, and design of mHealth. In summary, midwives' competency indicators for early detection are more needed in MCOC using mHealth. Further research is required to evaluate midwives' competence in MCOC using mHealth.

Design, Development, and Testing of BEST4Baby, an mHealth Technology to Support Exclusive Breastfeeding in India: Pilot Study

Background

Exclusive breastfeeding (EBF) at 6 months of age in most low- and middle-income countries, including India, is surprisingly low. There is a relative lack of mobile health apps that specifically focus on leveraging the use of peer counselors (PCs) to support mothers as a means of increasing EBF practices in low- and middle-income countries.

Objective

This study aimed to design, develop, and test the usability of Breastfeeding Education Support Tool for Baby (BEST4Baby), a mobile health app specifically designed to support PCs in providing in-home breastfeeding counseling support to mothers in rural India on optimal breastfeeding practices.

Methods

A user-centered design process with an agile development methodology was used. The approach involved stakeholders and mothers who were trained to serve as PCs to guide BEST4Baby’s design and development, including the app’s content and features. PCs were engaged through focus groups with interactive wireframes. During the 24-month pilot study period, we conducted a feasibility test of the BEST4Baby app with 22 PCs who supported home visits with mothers residing in rural India. The intervention protocol required PCs to provide education and follow mothers using the BEST4Baby app, with 9 scheduled home visits from the late prenatal stage to 6 months post partum. BEST4Baby’s usability from the PCs’ perspective was assessed using the translated System Usability Scale (SUS).

Results

The findings of this study align with best practices in user-centered design (ie, understanding user experience, including context with iterative design with stakeholders) to address EBF barriers. This led to the cultural tailoring and contextual alignment of an evidence-based World Health Organization breastfeeding program with an iterative design and agile development of the BEST4Baby app. A total of 22 PCs tested and rated the BEST4Baby app as highly usable, with a mean SUS score of 85.3 (SD 9.1), placing it over the 95th percentile for SUS scores. The approach translated into a highly usable BEST4Baby app for use by PCs in breastfeeding counseling, which also statistically increased EBF practices.

Conclusions

The findings suggest that BEST4Baby was highly usable and accepted by mothers serving as PCs to support other mothers in their EBF practices and led to positive outcomes in the intervention group’s EBF rates. The pilot study demonstrated that using the specially designed BEST4Baby app was an important support tool for mothers to serve as PCs during the 9 home visits.

Trial Registration

Clinicaltrials.gov NCT03533725; https://clinicaltrials.gov/ct2/show/NCT03533725

Improved maternal-fetal outcomes among emergency obstetric referrals following phone call communication at a teaching hospital in south western Uganda: a quasi-experimental study

BACKGROUND

Emergency obstetric referrals develop adverse maternal-fetal outcomes partly due to delays in offering appropriate care at referral hospitals especially in resource limited settings. Referral hospitals do not get prior communication of incoming referrals leading to inadequate preparedness and delays of care. Phone based innovations may bridge such communication challenges. We investigated effect of a phone call communication prior to referral of mothers in labour as intervention to reduce preparation delays and improve maternal-fetal outcome at a referral hospital in a resource limited setting.

METHODS

This was a quasi-experimental study with non-equivalent control group conducted at Mbarara Regional Referral Hospital (MRRH) in South Western Uganda from September 2020 to March 2021. Adverse maternal-fetal outcomes included: early neonatal death, fresh still birth, obstructed labour, ruptured uterus, maternal sepsis, low Apgar score, admission to neonatal ICU and hysterectomy. Exposure variable for intervention group was a phone call prior maternal referral from a lower health facility. We compared distribution of clinical characteristics and adverse maternal-fetal outcomes between intervention and control groups using Chi square or Fisher's exact test. We performed logistic regression to assess association between independent variables and adverse maternal-fetal outcomes.

RESULTS

We enrolled 177 participants: 75 in intervention group and 102 in control group. Participants had similar demographic characteristics. Three quarters (75.0%) of participants in control group delayed on admission waiting bench of MRRH compared to (40.0%) in intervention group [p =  < 0.001]. There were significantly more adverse maternal-fetal outcomes in control group than intervention group (obstructed labour [p = 0.026], low Apgar score [p = 0.013] and admission to neonatal high dependency unit [p =  < 0.001]). The phone call intervention was protective against adverse maternal-fetal outcome [aOR = 0.22; 95%CI: 0.09-0.44, p = 0.001].

CONCLUSION

The phone call intervention resulted in reduced delay to patient admission at a tertiary referral hospital in a resource limited setting, and is protective against adverse maternal-fetal outcomes. Incorporating the phone call communication intervention in the routine practice of emergency obstetric referrals from lower health facilities to regional referral hospitals may reduce both maternal and fetal morbidities.

TRIAL REGISTRATION

Pan African Clinical Trial Registry PACTR20200686885039.

Exploration of Telemidwifery: An Initiation of Application Menu in Indonesia

The midwifery continuity-of-care model improves the quality and safety of midwifery services and is highly dependent on the quality of communication and information. The service uses a semi-automated chatbot-based digital health media service defined with the new term "telemidwifery". This study aimed to explore the telemidwifery menu content for village midwives and pregnant women in the Purwakarta Regency, West Java, Indonesia. The qualitative research method was used to explore with focus group discussion (FGD). The data collection technique was purposive sampling. The research subjects were 15 village midwives and 6 multiparous pregnant women. The results of this study involved 15 characteristics of menu content: (1) Naming, (2) Digital Communication, (3) Digital Health Services, (4) Telemidwifery Features, (5) Digital Check Features, (6) Media Services, (7) Attractiveness, (8) Display, (9) Ease of Use, (10) Clarity of Instructions, (11) Use of Language, (12) Substances, (13) Benefits, (14) Appropriateness of Values, and (15) Supporting Components. The content characteristics of this telemidwifery menu were assigned to the ISO 9126 Model standards for usability, functionality, and efficiency. The conclusion is that the 15 themes constitute the characteristic menu content required within the initiation of telemidwifery.

Does Digitally Enabling Frontline Health Workers Improve Coverage and Quality of Maternal and Child Health Services? Findings From a Mixed Methods Evaluation of TECHO+ in Gujarat

Introduction

Technology Enabled Community Health Operations (TeCHO+) is a mobile and web-based application (app) for frontline health workers. It includes features such as real-time data entry, automated generation of the work plan, and a decision support system generating alerts for high-risk cases. Since 2019, the programme is implemented across all 33 districts of Gujarat, catering to a population of over 60 million. This study aims to compare changes in the coverage, quality of data reporting maternal and child health services, and time spent in the documentation before and after the introduction of the TeCHO+ app.

Methods

To address the study aim, a mixed-method design with a realist evaluation approach was adopted. The survey was conducted with randomly selected beneficiaries from 32 sub-centers across two districts of Gujarat State in India. We surveyed 215 postpartum women and mothers of 102 children at baseline (pre) and 246 postpartum women and mothers of 119 children post 1 year of the TeCHO+ programme intervention in 2020. For qualitative data, total 29 Auxiliary Nurse Midwives, 12 Data Entry Operators and 10 Primary Health Center Medical Officers were purposively selected from 32 PHCs and interviewed to understand the pathways leading to the programme outcome.

Results

Following introduction of TeCHO+, the coverage of full antenatal care (ANC; 75.6% vs. 67.9%, p-value < 0.0001), consumption of at least 180 iron-folic acid tablets (93% vs. 77%, p-value < 0.001), early initiation of breastfeeding (42.7% vs. 24.2%, p-value < 0.001), five home-visits by ANM during the first month after delivery (36.2% vs. 27.9%, p-value = 0.056), HBV0 vaccination (67.2% vs. 35.3%, p-value < 0.0001) and Pentavalent 2 (100% vs. 95.1%, p-value = 0.015) improved. The overall concordance rate for routine maternal health indicators (a measure of data quality) improved from 69.1 to 80.5%, while that for routine child health indicators improved from 86.6 to 92.1%. The programme resulted in 1.7 h saving a day of ANM's productive time and 1.5 h (a day) of data entry operator's time.

Conclusions

The TeCHO+ programme has improved access to care. It impacted both coverage of maternal and child health services and data reporting quality of various maternal and child high-risk conditions. Considering the programme's success, other disease services might be added to the scope of TeCHO+ software.

Predictors of the utilisation of continuum of maternal health care services in India

Background

Utilisation of continuum of maternal health care services is crucial for a healthy pregnancy and childbirth and plays an important role in attaining Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs) related to maternal and child health. This paper aims to assess the percentage of dropouts across various stages of utilization of continuum of maternal health services (CMHS) in India and also investigates the factors hindering the utilization of these services.

Methods

We used recent data from National Family Health Survey(NFHS) encompassing a total sample of 1,70,937 pregnant women for the period 2015–16. The percentage of women dropping out while seeking maternal health care is measured using descriptive statistics. While, the factors impeding the utilization of maternal health services is estimated using a Multinomial Logistic Regression Model, where dependent variable (CMHS) is defined as complete care, incomplete care and no care.

Results

Only17% of pregnant women availed the utilisation of complete care and 83% either did not seek any care or dropped after seeking one or two services. For instance, it is found that 79% of women who registered for antenatal care services (ANC) did not avail the same adequately. An empirical investigation of determinants of inadequate utilization of CMHS revealed that factors like individual characteristics, for instance- access to media (RRR: 2.06) and mother’s education play (RRR: 3.61) a vital role in the uptake of CMHS. It is also found that the interaction between wealth index and place of residence plays a pivotal role in seeking complete care. Lastly, the results revealed that male participation (RRR: 2.69) and contacting multi-purpose worker (MPW) (RRR: 2.33) are also at play.

Conclusion

The study suggests that the major determinants of utilisation of CMHS are access to media, mother’s education, affordability barriers and male participation. Hence, policy recommendations should be oriented towards strengthening these dimensions and the utilisation of adequate ANC has to be considered as the need of the hour.

Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice

Background

The deployment of Community Health Workers (CHWs) is widely promoted as a strategy for reducing health inequities in low- and middle-income countries (LMIC). Yet there is limited evidence on whether and how CHW programmes achieve this. This systematic review aimed to synthesise research findings on the following questions: (1) How effective are CHW interventions at reaching the most disadvantaged groups in LMIC contexts? and (2) What evidence exists on whether and how these programmes reduce health inequities in the populations they serve?

Methods

We searched six academic databases for recent (2014–2020) studies reporting on CHW programme access, utilisation, quality, and effects on health outcomes/behaviours in relation to potential stratifiers of health opportunities and outcomes (e.g., gender, socioeconomic status, place of residence). Quantitative data were extracted, tabulated, and subjected to meta-analysis where appropriate. Qualitative findings were synthesised using thematic analysis.

Results

One hundred sixty-seven studies met the search criteria, reporting on CHW interventions in 33 LMIC. Quantitative synthesis showed that CHW programmes successfully reach many (although not all) marginalized groups, but that health inequalities often persist in the populations they serve. Qualitative findings suggest that disadvantaged groups experienced barriers to taking up CHW health advice and referrals and point to a range of strategies for improving the reach and impact of CHW programmes in these groups. Ensuring fair working conditions for CHWs and expanding opportunities for advocacy were also revealed as being important for bridging health equity gaps.

Conclusion

In order to optimise the equity impacts of CHW programmes, we need to move beyond seeing CHWs as a temporary sticking plaster, and instead build meaningful partnerships between CHWs, communities and policy-makers to confront and address the underlying structures of inequity.

Trial registration

PROSPERO registration number CRD42020177333.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01615-y.

At the frontlines of digitisation: a qualitative study on the challenges and opportunities in maintaining accurate, complete and timely digital health records in India's government health system

OBJECTIVES

To understand factors underpinning the accuracy and timeliness of mobile phone numbers and other health information captured in India's government registry for pregnant and postpartum women. Accurate and timely registration of mobile phone numbers is necessary for beneficiaries to receive mobile health services.

SETTING

Madhya Pradesh and Rajasthan states in India at the community, clinical, and administrative levels of the health system.

PARTICIPANTS

Interviews (n=59) with frontline health workers (FLHWs), data entry operators, and higher level officials. Focus group discussions (n=12) with pregnant women to discuss experiences with sharing data in the health system. Observations (n=9) of the process of digitization and of interactions between stakeholders for data collection.

PRIMARY AND SECONDARY OUTCOME MEASURES

Thematic analysis identified how key actors experienced the data collection and digitisation process, reasons for late or inaccurate data, and mechanisms that can bolster timeliness and accuracy.

RESULTS

Pregnant women were comfortable sharing mobile numbers with health workers, but many were unaware that their data moved beyond their FLHW. FLHWs valued knowing up-to-date beneficiary mobile numbers, but felt little incentive to ensure accuracy in the digital record system. Delays in registering pregnant women in the online portal were attributed to slow movement of paper records into the digital system and difficulties in gathering required documents from beneficiaries. Data, including women's phone numbers, were handwritten and copied multiple times by beneficiaries and health workers with variable literacy. Supervision tended to focus on completeness rather than accuracy. Health system actors noted challenges with the digital system but valued the broader project of digitisation.

CONCLUSIONS

Increased focus on training, supportive supervision, and user-friendly data processes that prioritise accuracy and timeliness should be considered. These inputs can build on existing positive patient-provider relationships and health system actors' enthusiasm for digitisation.

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.

Effect of mobile health interventions in increasing utilization of Maternal and Child Health care services in developing countries: A scoping review

Background

Mobile health (mHealth) technology is being used predominantly in low- and middle-income countries. Developing countries with low level of investment in health infrastructure can augment existing capacity by adopting low-cost affordable technology. The aim of the review was to summarize the available evidence on mHealth interventions that aimed at increasing the utilization of Maternal and Child Health (MCH) care services. Further, this review investigated the barriers which prevent the use of mHealth among both health care workers as well as beneficiaries.

Methodology

A scoping review of literature was undertaken using the five-stage framework developed by Arksey and O’Malley. The articles published between 1990 and 2021 were retrieved from three databases (PubMed, Cochrane Reviews, and Google Scholar) and grey literature for this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was followed to present the findings.

Result

A total of 573 studies were identified. After removing duplicates, studies not related to mHealth and MCH and publications of systematic reviews and protocols for studies, a total of 28 studies were selected for review. The study design of the research articles which appeared during the search process were mostly observational, cross-sectional, and randomized controlled trials (RCTs). We have classified the studies into four categories based on the outcomes for which the mHealth intervention was implemented: MCH care services, child immunization, nutrition services, and perceptions of stakeholders toward using technology for improving MCH outcomes.

Conclusion

This brief review concludes that mHealth interventions can improve access to MCH services. However, further studies based on large sample size and strong research design are recommended.

Investments for effective functionality of health systems towards Universal Health Coverage in Africa: A scoping review

The health challenges in Africa underscore the importance of effectively investing in health systems. Unfortunately, there is no information on systems investments adequate for an effective functional health system. We aimed to address this by conducting a scoping review of existing evidence following the Joanna Briggs Institute Manual for Evidence Synthesis and preregistered with the Open Science Framework (https://osf.io/bvg4z). We included any empirical research describing interventions that contributed to the functionality of health systems in Africa or any low-income or lower-middle-income regions. We searched Web of Science, MEDLINE, Embase, PsycINFO, Cochrane Library, CINAHL, and ERIC from their inception, and hand-searched other relevant sources. We summarized data using a narrative approach involving thematic syntheses and descriptive statistics. We identified 554 unique reports describing 575 interventions, of which 495 reported evidence of effectiveness. Most interventions were undertaken in Africa (80.9%), covered multiple elements of health systems (median: 3), and focused on service delivery (77.4%) and health workforce (65.6%). Effective interventions contributed to improving single (35.6%) or multiple (64.4%) capacities of health systems: access to essential services (75.6%), quality of care (70.5%), demand for essential services (38.6%), or health systems resilience (13.5%). For example, telemedicine models which covered software (technologies) and hardware (health workers) elements were used as a strategy to address issues of access to essential services. We inventoried these effective interventions for improving health systems functionality in Africa. Further analyses could deepen understanding of how such interventions differ in their incorporation of evidence for potential scale across African countries.

Mobile health technology to improve maternal health awareness in tribal populations: mobile for mothers

Mobile health (mHealth) applications have the potential to improve health awareness. This study reports a quasi-controlled intervention to augment maternal health awareness among tribal pregnant mothers through the mHealth application. Households from 2 independent villages with similar socio-demographics in tribal regions of India were selected as intervention (Village A) and control group (Village B). The control group received government mandated programs through traditional means (orally), whereas the intervention group received the same education through mHealth utilization. Postintervention, awareness about tetanus injections and consumption of iron tablets was significantly (P < .001) improved in the intervention group by 55% and 58%, respectively. Awareness about hygiene significantly (P < .001) increased by 57.1%. In addition, mothers in the intervention group who recognized vaginal bleeding, severe abdominal pain, severe blurring of vision, or convulsions as danger signs during pregnancy significantly (P < .001) increased by 18.30%, 23.2%, 20.0%, and 4.90%, respectively. Our study indicates that despite the low literacy of users, mHealth intervention can improve maternal health awareness among tribal communities.

Using mHealth to Improve Timeliness and Quality of Maternal and Newborn Health in the Primary Health Care System in Ethiopia

The use of mobile health (mHealth) in Ethiopia’s primary health care system offers a potential solution to improve timeliness and quality for maternal and newborn health care services. It is user-friendly and fosters communication between health care workers and health extension workers to provide quality services across the pregnancy continuum of care.

The Last Ten Kilometers 2020 Project (L10K 2020) designed a strategy for piloting, implementing, and scaling a mobile health (mHealth) digital solution to improve the quality of community-level maternal and child health service delivery in Ethiopia. L10K 2020 first conducted a landscape assessment to design a context-appropriate smartphone-based mHealth solution for the Health Extension Workers and tablets for their supervisors and the midwives managing the same clients at the health center level. These applications included multiple modules and packages including client registration and appointment management; follow-up and notifications; digital job aids for each of the maternal and child health program packages (for Health Extension Workers only); and referral and client tracking systems.

Findings from the process evaluation of the mHealth app usage and user experience indicated that the application was user-friendly and facilitated real-time information exchange, defaulter tracing, referral, and feedback systems. It improved the timely identification and registration of pregnant mothers. Adherence to treatment protocols also increased in all domains across the pregnancy continuum of care.

L10K 2020 has developed a user-friendly model for implementing mHealth solutions at the community level through stakeholder engagement across levels when developing, testing, and deploying the applications, which was critical to effectively cultivating ownership as well as skills and knowledge transfer at all levels. To replicate and scale this model, context-based scoping, resource analysis, and mapping are essential to determine the infrastructure, cost, time, risks, and key stakeholders involved throughout the implementation of the intervention. During implementation, vigilance in consistently mitigating the challenges related to mHealth infrastructure, such as mobile data capacity, electricity, smartphones and tablets, solar chargers, and internet connectivity, is critical for continued success.

Implementation of the new WHO antenatal care model for a positive pregnancy experience: a monitoring framework

Monitoring the implementation and impact of routine antenatal care (ANC), as described in the new World Health Organization (WHO) ANC model, requires indicators that go beyond the previously used global benchmark indicator of four or more ANC visits. To enable consistent monitoring of ANC content and care processes and to provide guidance to countries and health facilities, WHO developed an ANC monitoring framework. This framework builds on a conceptual framework for quality ANC and a scoping review of ANC indicators that mapped existing indicators related to recommendations in the new WHO ANC model. Based on the scoping review and following an iterative and consultative process, we developed a monitoring framework consisting of core indicators recommended for monitoring ANC recommendations in all settings, as well as a menu of additional measures. Finally, a research agenda highlights areas where ANC recommendations exist, but measures require further development. Nine core indicators can already be monitored globally and/or nationally, depending on the preferred data sources. Two core indicators (experience of care, ultrasound scan before 24 weeks) are included as placeholders requiring priority by the research agenda. Six context-specific indicators are appropriate for national and subnational monitoring in various settings based on specific guidance. Thirty-five additional indicators may be relevant and desirable for monitoring, depending on programme priorities. Monitoring implementation of the new WHO ANC model and the outcomes of routine ANC require greater attention to the measurement of ANC content and care processes as well as women’s experience of ANC.

How can human resources for health interventions contribute to sexual, reproductive, maternal, and newborn healthcare quality across the continuum in low- and lower-middle-income countries? A systematic review

BACKGROUND

Well-trained, competent, and motivated human resources for health (HRH) are crucial to delivering quality service provision across the sexual, reproductive, maternal, and newborn health (SRMNH) care continuum to achieve the 2030 Sustainable Development Goals (SDGs) maternal and neonatal health targets. This review aimed to identify HRH interventions to support lay and/or skilled personnel to improve SRMNH care quality along the continuum in low- and lower-middle-income countries (LLMICs).

METHODS

A structured search of CINAHL, Cochrane Library/trials, EMBASE, PubMed, SCOPUS, Web of Science, and HRH Global Resource Centre databases was undertaken, guided by the PRISMA framework. The inclusion criteria sought to identify papers with a focus on 1. HRH management, leadership, partnership, finance, education, and/or policy interventions; 2. HRH interventions' impact on two or more quality SRMNH care packages across the continuum from preconception to pregnancy, intrapartum and postnatal care; 3. Skilled and/or lay personnel; and 4. Reported primary research in English from LLMICs. A deductive qualitative content analysis was employed using the World Health Organization-HRH action framework.

RESULTS

Out of identified 2157 studies, 24 intervention studies were included in the review. Studies where ≥ 4 HRH interventions had been combined to target various healthcare system components, were more effective than those implementing ≤ 3 HRH interventions. In primary care, HRH interventions involving skilled and lay personnel were more productive than those involving either skilled or lay personnel alone. Results-based financing (RBF) and its policy improved the quality of targeted maternity services but had no impact on client satisfaction. Local budgeting, administration, and policy to deliver financial incentives to health workers and improve operational activities were more efficacious than donor-driven initiatives. Community-based recruitment, training, deployment, empowerment, supportive supervision, access to m-Health technology, and modest financial and non-financial incentives for community health workers (CHWs) improved the quality of care continuum. Skills-based, regular, short, focused, onsite, and clinical simulation, and/or mobile phone-assisted in-service training of skilled personnel were more productive than knowledge-based, irregular, and donor-funded training. Facility-based maternal and perinatal death reviews, coupled with training and certification of skilled personnel, positively affected SRMNH care quality across the continuum. Preconception care, an essential component of the SRMNH care continuum, lacks studies and services in LLMICs.

CONCLUSIONS

We recommend maternal and perinatal death audits in all health facilities; respectful, woman-centered care as a critical criterion of RBF initiatives; local administration of health worker allowances and incentives; and integration of CHWs into the healthcare system. There is an urgent need to include preconception care in the SRMNH care continuum and studies in LLMICs.

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.

Nonadherence to tuberculosis treatment and associated factors among patients using directly observed treatment short-course in north-west Nigeria: A cross-sectional study

INTRODUCTION

Tuberculosis is a public health problem in Nigeria. One of the most effective ways of controlling tuberculosis is the directly observed treatment short-course. However, some factors influence tuberculosis patients' treatment nonadherence via directly observed treatment short-course. The study objective was to assess medication nonadherence and associated factors among tuberculosis patients in north-west Nigeria.

METHODS

A cross-sectional study enrolled tuberculosis patients using directly observed treatment short-course in public health facilities in Kano and Kaduna States from January 2015 to June 2016. The sample selection was conducted via a multistage sampling procedure. Data were collected using tuberculosis patients' demographic and clinical characteristics forms, well-validated structured instruments, and medical records. SPSS version 20 was used for data analysis. Logistic and multivariable logistic regression analyses to determine factors of medication nonadherence (P < 0.05).

RESULTS

Complete responses from 390 patients out of the 460 patients recruited for the study were used for data analyses. The mean age was 51.5 (standard deviation = ±13.8) years. The mean tuberculosis medication adherence questionnaire score was 4.35 ± 1.12. The prevalence of nonadherence to tuberculosis medication was 30.5%. Multivariable logistic regression analysis showed that having a monthly income between #100,000 and #199, 000 (adjusted odds ratio = 0.01; 95% confidence interval: 0.00-0.13), being widowed (adjusted odds ratio = 26.74, 95% confidence interval: 2.92-232.9), being married (adjusted odds ratio = 120.49, 95% confidence interval: 5.38-271.1), having a distance <5 km to directly observed treatment short-course center from home (adjusted odds ratio = 0.06, 95% confidence interval: 0.00-0.01), having a tuberculosis/HIV co-infection (adjusted odds ratio = 0.01, 95% confidence interval: 0.12-0.35), use of antiretroviral treatment and cotrimoxazole prophylaxis therapy medications (adjusted odds ratio = 24.9, 95% confidence interval: 19.6-304.3) were associated with tuberculosis medication nonadherence.

CONCLUSION

Tuberculosis medication nonadherence was high among the patients. Thus, patient-specific adherence education, attenuation of potential factors for tuberculosis medication nonadherence, and continual resource support for tuberculosis patients are needed to improve treatment outcomes.

Towards deep phenotyping pregnancy: a systematic review on artificial intelligence and machine learning methods to improve pregnancy outcomes

Objective

Development of novel informatics methods focused on improving pregnancy outcomes remains an active area of research. The purpose of this study is to systematically review the ways that artificial intelligence (AI) and machine learning (ML), including deep learning (DL), methodologies can inform patient care during pregnancy and improve outcomes.

Materials and methods

We searched English articles on EMBASE, PubMed and SCOPUS. Search terms included ML, AI, pregnancy and informatics. We included research articles and book chapters, excluding conference papers, editorials and notes.

Results

We identified 127 distinct studies from our queries that were relevant to our topic and included in the review. We found that supervised learning methods were more popular (n = 69) than unsupervised methods (n = 9). Popular methods included support vector machines (n = 30), artificial neural networks (n = 22), regression analysis (n = 17) and random forests (n = 16). Methods such as DL are beginning to gain traction (n = 13). Common areas within the pregnancy domain where AI and ML methods were used the most include prenatal care (e.g. fetal anomalies, placental functioning) (n = 73); perinatal care, birth and delivery (n = 20); and preterm birth (n = 13). Efforts to translate AI into clinical care include clinical decision support systems (n = 24) and mobile health applications (n = 9).

Conclusions

Overall, we found that ML and AI methods are being employed to optimize pregnancy outcomes, including modern DL methods (n = 13). Future research should focus on less-studied pregnancy domain areas, including postnatal and postpartum care (n = 2). Also, more work on clinical adoption of AI methods and the ethical implications of such adoption is needed.

Bibliometric Analysis and Methodological Review of Mobile Health Services and Applications in India

PURPOSE

The purpose of this research is to analyze the literature published on mobile health (mHealth) in the Indian context. It also reviews the most important research works and presents various methodologies adopted by the researchers in this domain.

DESIGN/METHODOLOGY/APPROACH

The SciVerse SCOPUS database was used for extracting the literature on mobile health. The study used articles published between January 2008 to 28^th June 2019. The keyword used is 'mHealth' and journal articles with studies or interventions carried out in India were selected for bibliometric analysis and methodological review.

FINDINGS

For the keyword search, a total of 7,874 documents have been extracted, of which only 158 have been considered for the analysis. There is an exponential increase in the number of publications from the year 2015 to 2019. The keywords used for representing their articles have been grouped as mobile health devices, gender and age groups, system and software, health and disease condition, management, evidence-based practices (outcome), methods, and importance of the study. The journal PLOS One (87) has the highest number of citations, followed by The Lancet (63). The bibliometric analysis of the literature revealed seven clusters classified as individual's individual's mobile health applications adoption characteristics, need for mobile health and its governance, mobile phone application with the internet of things based framework for healthcare monitoring, mobile health for primary healthcare systems, authentication and security protocol for mobile healthcare, development and experimentation of mobile health application, and development and mobile health for adherence support intervention.

ORIGINALITY/VALUE

The study contributes in analyzing the bibliometrics and provides a methodological review for the journal articles published on mobile health. Previous articles considered systematic analysis of the bibliometric for mHealth, and mobile technology but less adequately discussed specifically towards Indian context which this study has embraced.

A Mobile App, KhunLook, to Support Thai Parents and Caregivers With Child Health Supervision: Development, Validation, and Acceptability Study

BACKGROUND

In Thailand, children born in government hospitals receive a maternal and child health handbook (MCHH). However, when a new MCHH edition is released, those with the previous editions do not have access to the updated information. A mobile app is an appealing platform to fill this gap. We developed a mobile app called "KhunLook" as an interactive electronic MCHH intended to assist parents in child health supervision.

OBJECTIVE

This study describes the user requirements and development of the KhunLook mobile app, validity of parents' growth assessments, and parents' evaluation of feasibility and acceptability of the app.

METHODS

Phase 1 was a qualitative study using individual interviews. The interview data were used to revise the prototype. In phase 2, parents were randomly assigned to assess their children's growth with the app or the MCHH. The outcomes were compared to those of the physician's assessment, and congruence was determined. In phase 3, parents evaluated the feasibility and acceptability of the app in comparison to the MCHH through a web-based survey.

RESULTS

Four health care providers and 8 parents participated in phase 1. Two themes were identified: (1) the mobile app potentially counters parents' infrequent use of the MCHH with accuracy, attractiveness, convenience, and simplicity, and (2) health supervision needs to be standard, up-to-date, and understandable. KhunLook was publicly launched with a family page and 7 key features: growth and nutrition, development, immunizations, oral health, reminders for the next appointment, memories, and health advice. In phase 2, 56 parents participated in the growth parameter assessments; 34 were in the App group and 22 in the MCHH group. The outcomes of the growth parameter assessments between parents and physicians in both the App and MCHH groups were not significantly different. The congruence proportions were higher in the App group for weight and head circumference, but the differences were not statistically significant. In phase 3, 356 parents from all over Thailand participated in a web-based survey. Parents rated the app feasibility as "very easy to easy" to use at higher proportions than the MCHH in all health assessment domains (growth, development, and immunizations) and ease-of-use domains with statistical significance (P<.001). The KhunLook app received a significantly higher mean score (8.59/10) than the MCHH (7.6/10) (P<.001). Most parents (317/356, 89.0%) preferred the app over MCHH. Further, 93.5% (333/356) of the parents stated that they would continue to use the app and 96.9% (345/356) would recommend others to use it.

CONCLUSIONS

KhunLook, a Thai mobile app for child health supervision, was developed, validated for growth assessments, and was well accepted for ease-of-use by parents. Further studies should be conducted with a large scale of users, and the impact of this app on health behaviors and health outcomes must be evaluated.

Evaluating the effect of maternal mHealth text messages on uptake of maternal and child health care services in South Africa: a multicentre cohort intervention study

Background

There are high expectations that mobile health (mHealth) strategies will increase uptake of health care services, especially in resource strained settings. Our study aimed to evaluate effects of an mHealth intervention on uptake of maternal health services.

Methods

This was an intervention cohort study conducted at six public antenatal and postnatal care clinics in inner-city Johannesburg, South Africa. The intervention consisted of twice-weekly informative and pregnancy stage-based maternal health information text messages sent to women during pregnancy until their child was one year of age. The intervention arm of 87 mother-infant pairs was compared to a control arm of 90 pairs. Univariate and multivariate analyses were used to compare the probability of the outcome between the two groups.

Results

Intervention participants had higher odds of attending all government-recommended antenatal and postnatal visits, all recommended first year vaccinations (OR: 3.2, 95% CI 1.63–6.31) and had higher odds of attending at least the recommended four antenatal visits (OR: 3.21, 95% CI 1.73–5.98).

Conclusion

We show an improvement in achieving complete maternal-infant continuum of care, providing evidence of a positive impact of informative maternal mHealth messages sent to pregnant women and new mothers.

Trial registration ISRCTN, ISRCTN41772986. Registered 13 February 2019—Retrospectively registered, https://www.isrctn.com/ISRCTN41772986

Use of mobile phones for behavior change communication to improve maternal, newborn and child health: a scoping review

Background

Behavior change communication (BCC) to improve health and caring practices is an integral component of efforts to improve maternal, newborn and child health (MNCH). Mobile phones are widely available in low- and middle-income countries (LMIC), presenting new opportunities for BCC delivery. There is need for delivery science to determine how best to leverage mobile phone technology for BCC to improve MNCH practices.

Methods

We conducted a scoping review of studies and project reports documenting the feasibility, implementation or effectiveness of using mobile phones for BCC delivery related to MNCH in LMIC. Data were extracted and synthesized from three sources: i) systematic search of three electronic databases (PubMed, MedLine, Scopus); ii) grey literature search, including mHealth databases and websites of organizations implementing mHealth projects; iii) consultation with researchers and programme implementers. Records were screened using pre-determined inclusion criteria and those selected were categorized according to their primary intervention delivery approaches. We then performed a descriptive analysis of the evidence related to both effectiveness and implementation for each delivery approach.

Results

The systematic literature search identified 1374 unique records, 64 of which met inclusion criteria. The grey literature search added 32 records for a total of 96 papers in the scoping review. Content analysis of the search results identified four BCC delivery approaches: direct messaging, voice counseling, job aid applications and interactive media. Evidence for the effectiveness of these approaches is growing but remains limited for many MNCH outcomes. The four approaches differ in key implementation elements, including frequency, length and complexity of communication, and potential for personalization. These elements influence resource allocation and are likely to impact effectiveness for BCC targeting complex, habitual MNCH practices.

Conclusions

This scoping review contributes to the evidence-base on the opportunities and limitations of using mobile phones for BCC delivery aiming to improve MNCH practices. The incorporation of mobile phone technology in BCC interventions should be guided by formative research to match both the content and delivery approach to the local context. We recommend five areas for further research, including both effectiveness and implementation studies on specific delivery approaches.

Cardiometabolic Risk Factors in Pregnancy and Implications for Long-Term Health: Identifying the Research Priorities for Low-Resource Settings

Cardiometabolic disorders (CMDs), including ischemic heart disease, stroke and type 2 diabetes are the leading causes of mortality and morbidity in women worldwide. The burden of CMDs falls disproportionately on low and middle-income countries (LMICs), placing substantial demands on already pressured health systems. Cardiometabolic disorders may present up to a decade earlier in some LMIC settings, and are associated with high-case fatality rates. Early identification and ongoing postpartum follow-up of women with pregnancy complications such as hypertensive disorders of pregnancy (HDPs), and gestational diabetes mellitus (GDM) may offer opportunities for prevention, or help delay onset of CMDs. This mini-review paper presents an overview of the key challenges faced in the early identification, referral and management of pregnant women at increased risk of CMDs, in low-resource settings worldwide. Evidence-based strategies, including novel diagnostics, technology and innovations for early detection, screening and management for pregnant women at high-risk of CMDs are presented. The review highlights the key research priorities for addressing cardiometabolic risk in pregnancy in low-resource settings.

Use of mobile technology by frontline health workers to promote reproductive, maternal, newborn and child health and nutrition: a cluster randomized controlled Trial in Bihar, India

Background

mHealth technology holds promise for improving the effectiveness of frontline health workers (FLWs), who provide most health-related primary care services, especially reproductive, maternal, newborn, child health and nutrition services (RMNCHN), in low-resource – especially hard-to-reach – settings. Data are lacking, however, from rigorous evaluations of mHealth interventions on delivery of health services or on health-related behaviors and outcomes.

Methods

The Information Communication Technology-Continuum of Care Service (ICT-CCS) tool was designed for use by community-based FLWs to increase the coverage, quality and coordination of services they provide in Bihar, India. It consisted of numerous mobile phone-based job aids aimed to improve key RMNCHN-related behaviors and outcomes. ICT-CCS was implemented in Saharsa district, with cluster randomization at the health sub-center level. In total, evaluation surveys were conducted with approximately 1100 FLWs and 3000 beneficiaries who had delivered an infant in the previous year in the catchment areas of intervention and control health sub-centers, about half before implementation (mid-2012) and half two years afterward (mid-2014). Analyses included bivariate and difference-in-difference analyses across study groups.

Results

The ICT-CCS intervention was associated with more frequent coordination of AWWs with ASHAs on home visits and greater job confidence among ASHAs. The intervention resulted in an 11 percentage point increase in FLW antenatal home visits during the third trimester (P = 0.04). In the post-implementation period, postnatal home visits during the first week were increased in the intervention (72%) vs the control (60%) group (P < 0.01). The intervention also resulted in 13, 12, and 21 percentage point increases in skin-to-skin care (P < 0.01), breastfeeding immediately after delivery (P < 0.01), and age-appropriate complementary feeding (P < 0.01). FLW supervision and other RMNCHN behaviors were not significantly impacted.

Conclusions

Important improvements in FLW home visits and RMNCHN behaviors were achieved. The ICT-CCS tool shows promise for facilitating FLW effectiveness in improving RMNCHN behaviors.

Connecting mothers to care: Effectiveness and scale-up of an mHealth program in Timor-Leste

Background

Health Alliance International (HAI) with the Ministry of Health (MoH) of Timor-Leste and Catalpa International implemented a mobile phone-based mHealth program in 2013 known as Liga Inan ("Connecting Mothers"). Liga Inan was designed as a sustainable and scalable effort that would support MoH efforts to improve maternal and newborn health care-seeking and home practices. Key aims were to use mobile phone technology to improve communication between pregnant women and their MoH health providers and to increase optimal maternal health behaviors. MoH health staff registered pregnant women into Liga Inan at their first antenatal care (ANC) visit and followed them through pregnancy, delivery and six months postpartum. A web-based platform sent text messages twice weekly to promote safe pregnancy/delivery and facilitated phone communication between pregnant women and their MoH care providers.

Methods

For the program's final evaluation, baseline (2012) and final (2015) surveys interviewed women in one intervention district and one adjacent control district who had given birth in the preceding two years. Primary outcomes were receiving four or more ANC visits, using skilled birth attendants, delivery in health facilities, and timely postnatal care.

Results

Multivariate analysis compared endline maternal health behaviors for women in the intervention district compared to baseline and to women in the control district. Controlling for other factors, women in the intervention district had nearly twice the odds of having a skilled birth attendant and a facility delivery, nearly five times the odds of receiving a postpartum care visit within two days of delivery, and over five times the odds of having their newborn's health checked within two days of birth. There was no significant association between Liga Inan exposure and receipt of four or more ANC visits.

Conclusions

Liga Inan was associated with substantial increases in MoH health provider-assisted and facility-based births and timely postnatal care in Timor-Leste. These positive results led the MoH to incorporate Liga Inan into the national maternal and child health program. To date the program has expanded to cover all 13 districts in the country, with gradual assumption of management and financial responsibility by the MoH under way.

Barriers to the Use of Mobile Health in Improving Health Outcomes in Developing Countries: Systematic Review

Background

The use of mobile health (mHealth) technologies to improve population-level health outcomes around the world has surged in the last decade. Research supports the use of mHealth apps to improve health outcomes such as maternal and infant mortality, treatment adherence, immunization rates, and prevention of communicable diseases. However, developing countries face significant barriers to successfully implement, sustain, and expand mHealth initiatives to improve the health of vulnerable populations.

Objective

We aimed to identify and synthesize barriers to the use of mHealth technologies such as text messaging (short message service [SMS]), calls, and apps to change and, where possible, improve the health behaviors and health outcomes of populations in developing countries.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Deriving search criteria from the review’s primary objective, we searched PubMed and CINAHL using an exhaustive terms search (eg, mHealth, text messaging, and developing countries, with their respective Medical Subject Headings) limited by publication date, English language, and full text. At least two authors thoroughly reviewed each article’s abstract to verify the articles were germane to our objective. We then applied filters and conducted consensus meetings to confirm that the articles met the study criteria.

Results

Review of 2224 studies resulted in a final group of 30 articles for analysis. mHealth initiatives were used extensively worldwide for applications such as maternal health, prenatal care, infant care, HIV/AIDS prevention, treatment adherence, cardiovascular disease, diabetes, and health education. Studies were conducted in several developing countries in Africa, Asia, and Latin America. From each article, we recorded the specific health outcome that was improved, mHealth technology used, and barriers to the successful implementation of the intervention in a developing country. The most prominent health outcomes improved with mHealth were infectious diseases and maternal health, accounting for a combined 20/30 (67%) of the total studies in the analysis. The most frequent mHealth technology used was SMS, accounting for 18/30 (60%) of the studies. We identified 73 individual barriers and grouped them into 14 main categories. The top 3 barrier categories were infrastructure, lack of equipment, and technology gap, which together accounted for 28 individual barriers.

Conclusions

This systematic review shed light on the most prominent health outcomes that can be improved using mHealth technology interventions in developing countries. The barriers identified will provide leaders of future intervention projects a solid foundation for their design, thus increasing the chances for long-term success. We suggest that, to overcome the top three barriers, project leaders who wish to implement mHealth interventions must establish partnerships with local governments and nongovernmental organizations to secure funding, leadership, and the required infrastructure.

Contribuições dos aplicativos móveis para a prática do aleitamento materno: revisão integrativa

Resumo Objetivo Identificar as contribuições dos aplicativos móveis para a prática do aleitamento materno. Métodos Revisão integrativa da literatura, realizada nas bases de dados CINAHL, BDENF, Medline/PubMed, Scopus, LILACS, Web of Science e nas bibliotecas virtuais Cocharane e Scielo, para responder a questão norteadora: Quais as contribuições dos aplicativos móveis para a prática do aleitamento materno?. As buscas ocorreram entre setembro a novembro de 2017, utilizando os descritores “aplicativos móveis”, “aleitamento materno”, “período pós-parto”, “gestante” e “apoio social”. Após os cruzamentos desses descritores, identificou-se 530 artigos, que ao aplicar os critérios de elegibilidade, restaram nove estudos, avaliados quanto ao rigor metodológico e nível de evidência. Na extração dos dados empregou-se um instrumento validado e adaptado. Resultados Os aplicativos móveis que contribuíram para prática do aleitamento materno foram informacionais. Ofertaram orientações sobre promoção do aleitamento materno, alimentação infantil, uso de álcool na amamentação e posições para amamentar. Vários foram utilizados na coleta de dados referentes aos problemas, experiências e barreiras na amamentação; frequência da mamada; início do uso de fórmulas ou da alimentação complementar. Os aplicativos que continham a rede social de apoio na amamentação e os submetidos aos processos avaliativos tiveram pouca expressividade. Conclusão Os aplicativos foram direcionados apenas com objetivo de apoio informativo as nutrizes e sua rede social, na amamentação. Porém, apresentam lacunas quanto à qualidade de informações, usabilidade, aceitabilidade e eficácia desses aplicativos, como também não ficou evidenciado se a construção dos mesmos foi alicerçados na literatura científica.

Effectiveness of programmes and interventions to support optimal breastfeeding among children 0-23 months, South Asia: A scoping review

Most children in South Asia are breastfed at some point in their lives; however, many are not breastfed optimally, including the early initiation of breastfeeding (EIBF) within 1 hr of birth, avoidance of prelacteal feeds (APF), exclusive breastfeeding (EBF) for 6 months, and continued breastfeeding (CBF) up to 2 years of age or beyond. This review identifies and collates evidence on the effectiveness of interventions to support optimal breastfeeding in five countries in South Asia: Afghanistan, Bangladesh, India, Nepal, and Pakistan. A scoping review was conducted of peer‐reviewed and grey literature. The 31 eligible studies included randomized trials and quasi‐experimental designs that were conducted between 1990 and 2015. Data were collated regarding intervention design, characteristics, and effectiveness to support EIBF, APF, EBF, and CBF. Most studies reported a positive impact on breastfeeding outcomes, including 21/25 studies that examined EIBF, 15/19 studies that examined EBF, and 10/10 studies that examined APF. The only study that examined CBF reported no effect. Education, counselling, and maternal, newborn, and child health initiatives were common intervention types with positive effects on breastfeeding outcomes. Interventions were delivered in health facility, community, and home/family environments. Programmes and interventions that reached women and their families with repeated exposure and beginning during pregnancy were more likely to improve EIBF and EBF outcomes. Interventions with no impact on breastfeeding were characterized by short duration, irregular frequency, inappropriate timing, poor coverage, and targeting.

Effectiveness of programme approaches to improve the coverage of maternal nutrition interventions in South Asia

The nutritional status of women before pregnancy, during pregnancy, and after delivery has far reaching consequences for maternal health and child survival, growth, and development. In South Asia, the high prevalence of short stature, thinness, and anaemia among women of reproductive age underlie the high prevalence of child undernutrition in the region, whereas overweight and obesity are rising concerns. A systematic review of evidence (2000-2017) was conducted to identify barriers and programme approaches to improving the coverage of maternal nutrition interventions in the region. The search strategy used 13 electronic bibliographic databases and 14 websites of development and technical agencies and identified 2,247 citations. Nine studies conducted in Bangladesh (n = 2), India (n = 5), Nepal (n = 1), and Pakistan (n = 1) were selected for the review, and outcomes included the receipt and consumption of iron and folic acid and calcium supplements and the receipt of information on dietary intake during pregnancy. The studies indicate that a range of barriers acting at the individual (maternal), household, and health service delivery levels affects intervention coverage during pregnancy. Programme approaches that were effective in improving intervention coverage addressed barriers at multiple levels and had several common features: use of formative research and client assessments to inform the design of programme approaches and actions; community-based delivery platforms to increase access to services; engagement of family members, as well as pregnant women, in influencing behavioural change; actions to improve the capacity, supervision, monitoring, and motivation of front-line service providers to provide information and counselling; and access to free supplements.

Developing measures for WHO recommendations on antenatal care for a positive pregnancy experience: a conceptual framework and scoping review

OBJECTIVES

In response to the newest WHO recommendations on routine antenatal care (ANC) for pregnant women and adolescent girls, this paper identifies the literature on existing ANC measures, presents a conceptual framework for quality ANC, maps existing measures to specific WHO recommendations, identifies gaps where new measures are needed to monitor the implementation and impact of routine ANC and prioritises measures for capture.

METHODS

We conducted searches in four databases and five websites. Searches and application of inclusion/exclusion criteria followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow approach for scoping reviews. Data were extracted on measure information, methodology, methodological work and implementation. We adapted and refined a conceptual framework for routine ANC based on these measures.

RESULTS

This scoping review uncovered 58 resources describing 46 existing measures that align with WHO recommendations and good clinical practices for ANC. Of the 42 WHO-recommended ANC interventions and four good clinical practices included in this scoping review, only 14 WHO-recommended interventions and three established good clinical practices could potentially be measured immediately using existing measures. Recommendations addressing the integration of ANC with allied fields are likelier to have existing measures than recommendations that focus on maternal health. When mapped to our conceptual framework, existing measures prioritise content of care and health systems; measures for girls' and women's experiences of care are notably lacking. Available data sources for non-existent measures are currently limited.

CONCLUSION

Our research updates prior efforts to develop comprehensive measures of quality ANC and raises awareness of the need to better assess experiences of ANC. Given the inadequate number and distribution of existing ANC measures across the quality of care conceptual framework domains, new standardised measures are required to assess quality of routine ANC. Girls' and women's voices deserve greater acknowledgement when measuring the quality and delivery of ANC.

Use of monitoring data to improve implementation of a home fortification program in Bihar, India

This paper describes the use of program‐monitoring data to track program performance and inform activities. Monitoring data were collected as part of an effectiveness trial of multiple micronutrient powders (MNPs) for children 6–18 months in Bihar, India. Communities (n = 70; reaching over 10,000 children) were randomized to receive either counselling on infant and young child feeding or both counselling and MNPs. Government frontline health workers (FLWs) implemented and monitored program activities with support from CARE India and university partners. Monitoring data were collected over the duration of the entire program to assess program impact pathways using various checklists, which captured information about (a) attendance and training of FLWs at health subcentre meetings, (b) distribution of MNPs, (c) receipt and use of MNPs at the household level, and (d) midline mixed methods survey. At the beginning of the program, 72% of households reported receiving and 53% reported currently consuming MNPs. These numbers fell to 40% and 43% at midline, respectively. The main barrier to use by household was a lack of MNPs, due in part to infrequent FLW distribution. However, FLWs rarely reported MNP shortages at Anganwadi centres. Side effects also emerged as a barrier and were addressed through revised recommendations for MNP use. Qualitative data indicated high community acceptance of MNPs and a good understanding of the program by FLWs. The use of real‐time program data allowed for recognition of key program issues and decision‐making to enhance program implementation.

The role of an mHealth intervention in improving knowledge and skills of accredited social health activists in tribal areas of Gujarat, India: a nested study within an implementation research trial

AIM

To evaluate the effectiveness of an mHealth intervention in improving knowledge and skills of accredited social health activists in improving maternal, newborn and child health care in India.

METHODS

This was a nested cross-sectional study within a cluster randomised controlled trial. The intervention was a mobile phone application which has inbuilt health education videos, algorithms to diagnose complications and training tools to educate accredited social health activists. A total of 124 were randomly selected from the control (n = 61) and intervention (n = 63) arms of the larger study after six months of training in Bharuch and Narmada districts of Gujarat.

RESULTS

The knowledge of accredited social health activists regarding pregnancy (OR: 2.51, CI: 1.12-5.64) and newborn complications (OR: 2.57, CI: 1.12-5.92) was significantly higher in the intervention arm compared to the control arm. The knowledge of complications during delivery (OR: 1.36, CI: 0.62-2.98) and the postpartum (OR: 1.06, CI: 0.48-2.33) period was similar in both groups. The activists from the intervention arm demonstrated better skills for measuring temperature (OR: 4.25, CI: 1.66-10.89) of newborns compared to the control group.

CONCLUSION

The results suggest potential benefits of this mHealth intervention for improving knowledge and skills of accredited social health activists.

A Missing Link: HIV-/AIDS-Related mHealth Interventions for Health Workers in Low- and Middle-Income Countries

PURPOSE OF REVIEW

Through a review of the peer-reviewed and gray literature on HIV mobile health (mHealth) tools for health workers and in-depth interviews with mHealth leaders in the field, we provide a synthesis of current work and propose mHealth research priorities for HIV prevention, care, and treatment.

RECENT FINDINGS

Significant investment in implementation research and bringing together researchers capable of identifying drivers of successful implementation and industry leaders capable of bringing efficacious tools to scale are needed to move this area forward. Effective and appropriate technologies to support health systems in the prevention and treatment of HIV/AIDS in low- and middle-income countries are needed to improve the efficiency and quality of health service delivery and ultimately improve health outcomes. Although a growing number of HIV mHealth tools have been developed to support health workers, few of these tools have been rigorously evaluated and even fewer have been brought to scale.

Current Status and Future Directions of mHealth Interventions for Health System Strengthening in India: Systematic Review

Background

With the exponential increase in mobile phone users in India, a large number of public health initiatives are leveraging information technology and mobile devices for health care delivery. Given the considerable financial and human resources being invested in these initiatives, it is important to ascertain their role in strengthening health care systems.

Objective

We undertook this review to identify the published mobile health (mHealth) or telemedicine initiatives in India in terms of their current role in health systems strengthening. The review classifies these initiatives based on the disease areas, geographical distribution, and target users and assesses the quality of the available literature.

Methods

A search of the literature was done to identify mHealth or telemedicine articles published between January 1997 and June 2017 from India. The electronic bibliographic databases and registries searched included MEDLINE, EMBASE, Joanna Briggs Institute Database, and Clinical Trial Registry of India. The World Health Organization health system building block framework was used to categorize the published initiatives as per their role in the health system. Quality assessment of the selected articles was done using the Cochrane risk of bias assessment and National Institutes of Health, US tools.

Results

The combined search strategies yielded 2150 citations out of which 318 articles were included (primary research articles=125; reviews and system architectural, case studies, and opinion articles=193). A sharp increase was seen after 2012, driven primarily by noncommunicable disease–focused articles. Majority of the primary studies had their sites in the south Indian states, with no published articles from Jammu and Kashmir and north-eastern parts of India. Service delivery was the primary focus of 57.6% (72/125) of the selected articles. A majority of these articles had their focus on 1 (36.0%, 45/125) or 2 (45.6%, 57/125) domains of health system, most frequently service delivery and health workforce. Initiatives commonly used client education as a tool for improving the health system. More than 91.2% (114/125) of the studies, which lacked a sample size justification, had used convenience sampling. Methodological rigor of the selected trials (n=11) was assessed to be poor as majority of the studies had a high risk for bias in at least 2 categories.

Conclusions

In conclusion, mHealth initiatives are being increasingly tested to improve health care delivery in India. Our review highlights the poor quality of the current evidence base and an urgent need for focused research aimed at generating high-quality evidence on the efficacy, user acceptability, and cost-effectiveness of mHealth interventions aimed toward health systems strengthening. A pragmatic approach would be to include an implementation research component into the existing and proposed digital health initiatives to support the generation of evidence for health systems strengthening on strategically important outcomes.