Does short message service improve focused antenatal care visit and skilled birth attendance? A systematic review and meta-analysis of randomized clinical trials

Evaluating the Adoption of mHealth Technologies by Community Health Workers to Improve the Use of Maternal Health Services in Sub-Saharan Africa: Systematic Review

BACKGROUND

Limited information exists on the impact of mobile health (mHealth) use by community health workers (CHWs) on improving the use of maternal health services in sub-Saharan Africa (SSA).

OBJECTIVE

This systematic review addresses 2 objectives: evaluating the impact of mHealth use by CHWs on antenatal care (ANC) use, facility-based births, and postnatal care (PNC) use in SSA; and identifying facilitators and barriers to mHealth use by CHWs in programs designed to increase ANC use, facility-based births, and PNC use in SSA using a sociotechnical system approach.

METHODS

We searched for articles in 6 databases (MEDLINE, CINAHL, Web of Science, Embase, Scopus, and Africa Index Medicus) from inception up to September 2022, with additional articles identified from Google Scholar. After article selection, 2 independent reviewers performed title and abstract screening, full-text screening, and data extraction using Covidence software (Veritas Health Innovation Ltd). In addition, we manually screened the references lists of the included articles. Finally, we performed a narrative synthesis of the outcomes.

RESULTS

Among the 2594 records retrieved, 10 (0.39%) studies (n=22, 0.85% articles) met the inclusion criteria and underwent data extraction. The studies were published between 2012 and 2022 in 6 countries. Of the studies reporting on ANC outcomes, 43% (3/7) reported that mHealth use by CHWs increased ANC use. Similarly, of the studies reporting on facility-based births, 89% (8/9) demonstrated an increase due to mHealth use by CHWs. In addition, in the PNC studies, 75% (3/4) showed increased PNC use associated with mHealth use by CHWs. Many of the studies reported on the importance of addressing factors related to the social environment of mHealth-enabled CHWs, including the perception of CHWs by the community, trust, relationships, digital literacy, training, mentorship and supervision, skills, CHW program ownership, and the provision of incentives. Very few studies reported on how program goals and culture influenced mHealth use by CHWs. Providing free equipment, accessories, and internet connectivity while addressing ongoing challenges with connectivity, power, the ease of using mHealth software, and equipment maintenance support allowed mHealth-enabled CHW programs to thrive.

CONCLUSIONS

mHealth use by CHWs was associated with an increase in ANC use, facility-based births, and PNC use in SSA. Identifying and addressing social and technical barriers to the use of mHealth is essential to ensure the success of mHealth programs.

TRIAL REGISTRATION

PROSPERO CRD42022346364; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=346364.

The impact of antenatal telehealth services on maternal and neonatal outcomes, a comparison of results before and during the COVID-19 pandemic: A systematic review and meta-analysis (The impact of telehealth services on maternal and neonatal outcomes)

OBJECTIVE

This review was conducted to examine the effectiveness of antenatal follow-up using telehealth in the pre-COVID-19 and active pandemic periods.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

METHODS

Searches were conducted from inception to September 2023 through PubMed, the Cochrane Library, EBSCO, Embase, Web of Science, all via Ovid SP, the National Thesis Center, TR Index, Turkiye Clinics, and DergiPark Academic. Data were combined in the meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool and quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation guidelines.

RESULTS

The meta-analysis examining the effectiveness of antenatal telehealth services included 35 studies with a total sample size of 16 033. The combined results of the studies revealed that antenatal telehealth services were similar to face-to-face follow-ups for many maternal and newborn health outcomes. Maternal outcomes included abortion, preterm delivery, gestational diabetes, weight gain, hypertensive disorders, maternal hospitalization, number of antenatal follow-ups, use of induction, vaginal and instrumental delivery, planned and emergency cesarean section, shoulder dystocia, episiotomy, perineal laceration, childbirth under the supervision of qualified personnel, breastfeeding problems and postpartum depression. Neonatal outcomes included an APGAR score of <7, neonatal hypoglycemia, hyperbilirubinemia, admission into the neonatal intensive care unit, respiratory distress syndrome, neonatal death, birth weight, low birth weight and macrosomia. However, statistically significant reductions in excessive weight gain (p<0.001) and a 1.23-fold increase in vaccination administration (p=0.001) were observed with telehealth services. Additionally, the effects of telehealth services on preterm and cesarean delivery rates were similar in the pre-pandemic and pandemic periods.

CONCLUSION AND IMPLICATIONS FOR PRACTICE AND RESEARCH

This review reveals that while antenatal telehealth services are comparable to face-to-face care in terms of multiple pregnancy, delivery, and neonatal outcomes, they contribute to improvements in preventing extreme weight gain and vaccination hesitancy. These findings suggest that the telehealth method can be used as an alternative to face-to-face monitoring in antenatal follow-ups.

Effectiveness of mHealth Apps for Maternal Health Care Delivery: Systematic Review of Systematic Reviews

BACKGROUND

Globally, the use of mobile health (mHealth) apps or interventions has increased. Robust synthesis of existing systematic reviews on mHealth apps may offer useful insights to guide maternal health clinicians and policy makers.

OBJECTIVE

This systematic review aims to assess the effectiveness or impact of mHealth apps on maternal health care delivery globally.

METHODS

We systematically searched Scopus, Web of Science (Core Collection), MEDLINE or PubMed, CINAHL, and Cochrane Database of Systematic Reviews using a predeveloped search strategy. The quality of the reviews was independently assessed by 3 reviewers, while study selection was done by 2 independent raters. We presented a narrative synthesis of the findings, highlighting the specific mHealth apps, where they are implemented, and their effectiveness or outcomes toward various maternal conditions.

RESULTS

A total of 2527 documents were retrieved, out of which 16 documents were included in the review. Most mHealth apps were implemented by sending SMS text messages with mobile phones. mHealth interventions were most effective in 5 areas: maternal anxiety and depression, diabetes in pregnancy, gestational weight management, maternal health care use, behavioral modification toward smoking cessation, and controlling substance use during pregnancy. We noted that mHealth interventions for maternal health care are skewed toward high-income countries (13/16, 81%).

CONCLUSIONS

The effectiveness of mHealth apps for maternity health care has drawn attention in research and practice recently. The study showed that research on mHealth apps and their use dominate in high-income countries. As a result, it is imperative that low- and middle-income countries intensify their commitment to these apps for maternal health care, in terms of use and research.

TRIAL REGISTRATION

PROSPERO CRD42022365179; https://tinyurl.com/e5yxyx77.

Impact of mHealth interventions on maternal, newborn, and child health from conception to 24 months postpartum in low- and middle-income countries: a systematic review

BACKGROUND

Mobile health (mHealth) technologies have been harnessed in low- and middle-income countries (LMICs) to address the intricate challenges confronting maternal, newborn, and child health (MNCH). This review aspires to scrutinize the effectiveness of mHealth interventions on MNCH outcomes during the pivotal first 1000 days of life, encompassing the period from conception through pregnancy, childbirth, and post-delivery, up to the age of 2 years.

METHODS

A comprehensive search was systematically conducted in May 2022 across databases, including PubMed, Cochrane Library, Embase, Cumulative Index to Nursing & Allied Health (CINAHL), Web of Science, Scopus, PsycINFO, and Trip Pro, to unearth peer-reviewed articles published between 2000 and 2022. The inclusion criteria consisted of (i) mHealth interventions directed at MNCH; (ii) study designs, including randomized controlled trials (RCTs), RCT variations, quasi-experimental designs, controlled before-and-after studies, or interrupted time series studies); (iii) reports of outcomes pertinent to the first 1000 days concept; and (iv) inclusion of participants from LMICs. Each study was screened for quality in alignment with the Cochrane Handbook for Systematic Reviews of Interventions and the Joanne Briggs Institute Critical Appraisal tools. The included articles were then analyzed and categorized into 12 mHealth functions and outcome domain categories (antenatal, delivery, and postnatal care), followed by forest plot comparisons of effect measures.

RESULTS

From the initial pool of 7119 articles, we included 131 in this review, comprising 56 RCTs, 38 cluster-RCTs, and 37 quasi-experimental studies. Notably, 62% of these articles exhibited a moderate or high risk of bias. Promisingly, mHealth strategies, such as dispatching text message reminders to women and equipping healthcare providers with digital planning and scheduling tools, exhibited the capacity to augment antenatal clinic attendance and enhance the punctuality of child immunization. However, findings regarding facility-based delivery, child immunization attendance, and infant feeding practices were inconclusive.

CONCLUSIONS

This review suggests that mHealth interventions can improve antenatal care attendance and child immunization timeliness in LMICs. However, their impact on facility-based delivery and infant feeding practices varies. Nevertheless, the potential of mHealth to enhance MNCH services in resource-limited settings is promising. More context-specific implementation studies with rigorous evaluations are essential.

Magnitude, disparity, and predictors of poor-quality antenatal care service: A systematic review and meta-analysis

Background

Antenatal care is directed toward ensuring healthy pregnancy outcomes. Quality antenatal care increases the likelihood of receiving an effective intervention to maintain maternal, fetal, and neonatal well-being, while poor quality is linked to poor pregnancy outcomes. However, owing to the complex nature of quality, researchers have followed several approaches to systematically measure it. The evidence from these variable approaches appears inconsistence and poses challenges to programmers and policymakers. Hence, it is imperative to obtain a pooled estimate of the quality of antenatal care. Therefore, considering the scarcity of evidence on the quality of antenatal care, this study aimed to review, synthesize, and bring pooled estimates of accessible evidence.

Objective

This study aimed to estimate the pooled magnitude and predictors of quality of antenatal care services and compare regional disparity.

Method

We conducted a comprehensive systematic three-step approach search of published and unpublished sources from 2002 to 2022. The methodological quality of eligible studies was checked using Joanna Briggs Institute critical appraisal tool for cross-sectional studies. Meta-analysis was carried out using STATA version 16. Statistical heterogeneity was assessed using Cochran's Q test. In the presence of moderate heterogeneity (I2 more than 50%), sensitivity and subgroup analyses were conducted and presented in a forest plot. Effect size was reported using standardized mean difference and its 95% confidence interval. Funnel plots and Egger's regression test were used to measure publication bias at the 5% significance level. A trim-and-fill analysis was conducted to adjust for publication bias. Pooled estimates were computed using random-effects models and weighted using the inverse variance method in the presence of high heterogeneity among studies. A 95% CI and 5% significance level were considered to declare significance variables.

Results

The global pooled poor-quality antenatal care was 64.28% (95% CI: 59.58%-68.98%) (I2 = 99.97%, p = 0.001). The identified pooled predictors of good-quality antenatal care service were: number of antenatal care visits (fourth and above antenatal care visit) (Adjusted odds ratio (AOR) = 2.6, 95% CI: 1.37-3.84), family wealth index (AOR = 2.72, 95% CI: 1.89-3.55), maternal education attainment (AOR = 3.03, 95% CI: 2.24-3.82), residence (urban dwellers) (AOR = 4.06, 95% CI: 0.95-7.17), and confidentiality antenatal care (AOR = 2.23, 95% CI: -0.36 to -4.82).

Conclusions

The study found regional and country-level disparities in the quality of antenatal care services for pregnant women, where poor-quality antenatal care services were provided for more than two-thirds to three-fourths of antenatal care attendants. Therefore, policymakers and health planners should put a great deal of emphasis on addressing the quality of antenatal care services.

Midwives' Voices on Early Initiation of Antenatal Care Following a Positive Gravindex Test: A Qualitative Study

Background

Early Antenatal Care (ANC) initiation is aimed at improving maternal and perinatal health outcomes through the identification of complications and determining the level of care needed. This study aimed to determine the voices of midwives on the provision of early initiation of ANC following positive gravindex.

Materials and Methods

The phenomenology approach underpinned the study. The participants included midwives providing ANC at health facilities under Tshino-Mutsha local area in May-December 2020. Nonprobability, purposive sampling was used to select four clinics and to sample 20 midwives. Semistructured face-to-face, in-depth interviews were conducted using an interview guide. Data saturation was reached at Participant 15; however, the researcher continued until Participant 20. Trustworthiness was ensured and ethical principles were adhered to. Data analysis was done using Tesch's open coding approach.

Results

Two themes and seven subthemes emerged, as challenges related to the provision of midwifery practice and to pregnant women. The seven subthemes were the shortage of resources, poor support of midwives, poor adherence to the available protocol for the provision of ANC, blaming of midwives by management and community, late ANC booking by pregnant women, denial of pregnancy by young women ignorance leading to a general resistance to ANC instructions, hence late booking.

Conclusions

It was concluded that shortage of human and material resources hindered the initiation of early ANC to detect, prevent, and manage the existing and potential causes of maternal and newborn mortality and morbidity.

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.

A Tailored mHealth Intervention for Improving Antenatal Care Seeking and Health Behavioral Determinants During Pregnancy Among Adolescent Girls and Young Women in South Africa: Development and Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

South Africa, a middle-income country, has an adolescent fertility rate far higher than that of high-income countries. Adolescent girls and young women have an increased risk of pregnancy-related complications and lower antenatal appointment attendance rates than older adult pregnant women. Mobile health (mHealth) interventions to improve health behaviors among pregnant adolescent girls and young women in low- and middle-income countries are scarce.

OBJECTIVE

This paper describes the development and components of an mHealth intervention to improve antenatal appointment attendance and health behavioral determinants among pregnant adolescent girls and young women in South Africa and details the protocol for a pilot randomized controlled trial that evaluated the intervention's efficacy and user acceptability.

METHODS

The intervention, Teen MomConnect, sent tailored motivational behavior change and behavioral reinforcement SMS text messages to participants about antenatal appointment keeping and pregnancy behaviors. The delivery methodology of the intervention was adapted from MomConnect, an mHealth education program for pregnant women in South Africa that has nationwide coverage. In addition, participants received a face-to-face motivational interviewing session delivered by a trained research assistant. Pregnant adolescent girls and young women aged 13 to 20 years were recruited from health facilities and community networks. Participants were randomized into the control group that received the standard MomConnect health SMS text messages or the experimental group that received the Teen MomConnect intervention. Participants completed a baseline questionnaire upon enrollment in the study and a follow-up questionnaire after the end of their pregnancy. The questionnaires assessed demographic characteristics, pregnancy behaviors, and the psychosocial determinants of antenatal appointment attendance (knowledge, attitudes, social support, risk perceptions, self-efficacy, intention, and action planning). Feasibility was assessed using descriptive analyses of acceptability, study implementation processes, and perceived satisfaction with the intervention. The number of appointments attended was obtained from the participants' clinic records. Appointment attendance was compared between the control and experimental groups, as were awareness of HIV status and the psychosocial determinants of antenatal appointment attendance.

RESULTS

Participant recruitment was conducted from May 2018 to December 2018, and the questionnaire-based data collection was completed by December 2019. Overall, 412 participants were enrolled.

CONCLUSIONS

This paper describes the Teen MomConnect intervention to improve antenatal appointment attendance and pregnancy health behaviors among adolescent girls and young women. The results on the intervention's preliminary efficacy and user acceptability will inform policy makers and health program officers on how tailored, age-appropriate, and motivational health behavior messages can be delivered via mobile phone to pregnant adolescent girls and young women.

TRIAL REGISTRATION

Pan African Clinical Trial Registry (PACTR) PACTR201912734889796; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9565.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43654.

Interventions to enhance healthcare utilisation among pregnant women to reduce maternal mortality in low- and middle-income countries: a review of systematic reviews

BACKGROUND

Maternal mortality in low- and middle-income countries (LMIC) has reduced considerably over the past three decades, but it remains high. Effective interventions are available, but their uptake and coverage remain low. We reviewed and synthesised evidence from systematic reviews on interventions to increase healthcare services utilisation to reduce maternal mortality in LMICs.

METHODS

We searched Medline PubMed and Cochrane Library databases for systematic reviews published between January 2014 and December 2021, investigating interventions to increase healthcare services uptake among pregnant women in LMICs. We used the AMSTAR tool (A Measurement Tool to Assess Systematic Reviews) to assess the methodological quality of the included reviews. We extracted data on the interventions and their effects and grouped them into broad groups based on the outcomes reported in each systematic review.

RESULTS

We retrieved 4,022 articles. After removing duplicates and screening, we included 14 systematic reviews. Male-partner interventions were effective in increasing skilled birth attendance (SBA) postnatal visits and maternal antiretroviral (ART) uptake for HIV-positive pregnant women. However, there was no evidence of their effectiveness on increased early ANC initiation or adequate ANC visits. Mobile health interventions were effective in increasing adequate ANC visits, SBA, facility-based service utilisation, early ANC initiation, and adherence to nutritional supplements. Incentive-based interventions, particularly financial incentives, were effective in increasing the number of ANC visits but not postnatal visits. Facility-based interventions were effective in increasing postnatal visits, maternal ART initiation and uptake, immunisation uptake and follow-up ANC visits. None of the reviews assessed their impact on SBA or adequate ANC visits. Community-based interventions were effective in increasing SBA, ANC service utilisation, ART initiation and uptake, and nutritional supplements and immunisation uptake.

CONCLUSION

Our findings show that the different interventions effectively improved different outcomes on the maternal healthcare continuum. Implementing these interventions in combination has the potential to enhance healthcare service uptake further.

A Cluster Randomised Control Trial of an SMS-Based Intervention to Promote Antenatal Health amongst Pregnant Women in a Remote, Highland Region of Vietnam

Although Vietnam has achieved significant improvements in maternal, newborn, and children's health, outcomes for ethnic minorities living in remote mountainous areas continue to lag. Interventions that leverage the extensive mobile networks in the country have been proposed as a way to overcome some of these challenges. A cluster randomised controlled trial (cRCT) was conducted to assess the effectiveness of an intervention comprising tailored SMS messages for promoting antenatal care knowledge and behaviours amongst ethnic minority (EM) pregnant women. The cRCT was implemented across eight intervention communes (640 women) and four control communes (315 women) in Northern Vietnam. Maternal health-related knowledge and behaviour outcomes and self-rated health status were assessed through questionnaires administered pre- and post-intervention. Difference-in-difference and logistic regression analysis found that the intervention group showed significant improvements in awareness about the danger signs of pregnancy and the importance of nutritional supplements. Significant improvements were seen in antenatal care-seeking behaviours and the intake of nutritional supplements. Mobile messaging-based behaviour change interventions can significantly improve maternal health-related knowledge and care-seeking amongst women residing in marginalised, hard-to-reach populations.

The effects of mHealth interventions on improving institutional delivery and uptake of postnatal care services in low-and lower-middle-income countries: a systematic review and meta-analysis

BACKGROUND

Maternal mortality due to pregnancy, childbirth and postpartum is a global challenge. Particularly, in low-and lower-income countries, the outcomes of these complications are quite substantial. In recent years, studies exploring the effect of mobile health on the improvement of maternal health are increasing. However, the effect of this intervention on the improvement of institutional delivery and postnatal care utilization was not well analyzed systematically, particularly in low and lower-middle-income countries.

OBJECTIVE

The main aim of this review was to assess the effect of mobile heath (mHealth) interventions on improving institutional delivery, postnatal care service uptake, knowledge of obstetric danger signs, and exclusive breastfeeding among women of low and lower-middle-income countries.

METHODS

Common electronic databases like PubMed, EMBASE, the Web of Science, Medline, CINAHL, Cochrane library, Google scholar, and gray literature search engines like Google were used to search relevant articles. Articles that used interventional study designs and were conducted in low and lower-middle-income countries were included. Sixteen articles were included in the final systematic review and meta-analysis. Cochrane's risk of bias tool was used to assess the quality of included articles.

RESULTS

The overall outcome of the systematic review and meta-analysis showed that MHealth intervention has a positive significant effect in improving the institutional delivery (OR = 2.21 (95%CI: 1.69-2.89), postnatal care utilization (OR = 4.13 (95%CI: 1.90-8.97), and exclusive breastfeeding (OR = 2.25, (95%CI: 1.46-3.46). The intervention has also shown a positive effect in increasing the knowledge of obstetric danger signs. The subgroup analysis based on the intervention characteristics showed that there was no significant difference between the intervention and control groups based on the intervention characteristics for institutional delivery (P = 0.18) and postnatal care utilizations (P = 0.73).

CONCLUSIONS

The study has found out that mHealth intervention has a significant effect on improving facility delivery, postnatal care utilization, rate of exclusive breastfeeding, and knowledge of danger signs. There were also findings that reported contrary to the overall outcome which necessitates conducting further studies to enhance the generalizability of the effect of mHealth interventions on these outcomes.

Mobile Phone-Based Nutrition Education Targeting Pregnant and Nursing Mothers in Sri Lanka

INTRODUCTION

A woman's nutrition during pregnancy and nursing affects the mother and the growing child. Similarly, the first two years of a child's life are critical to their growth and development and are facilitated by optimum nutrition. Women's nutrition-related knowledge, attitudes, and practices influence household food and nutrition security. Mobile health (mHealth) is a potentially effective health intervention in pandemic situations when physical gatherings are restricted.

OBJECTIVES

To examine the effectiveness of a mobile phone-based nutrition education intervention targeting pregnant and nursing mothers in six Sri Lankan divisional secretariat areas.

METHOD

This intervention was evaluated using a before and after within-subjects design. The intervention included 19 messages over four weeks sent via mobile phone, covering nutrition themes such as pregnancy care, infant and young child-feeding, diet, family care for mother and child, and cash management. The intervention was evaluated based on a quantitative survey using a structured interviewer-administered questionnaire and qualitative interviews using a semi-structured questionnaire. The study population was pregnant and nursing mothers. The objective of the qualitative interviews was to identify how respondents used messages and how satisfied they were with the project. The outcome measures were awareness/knowledge, attitudes, social norms, self-efficacy, behaviour intentions, and practices of pregnant and nursing mothers. Trained enumerators collected data using a mobile phone.

RESULTS

A total of 996 pregnant and nursing mothers participated in the pre-assessment survey, of which 720 completed the post-assessment. Most were nursing mothers (84.2% pre- and 78.9% post-assessment). Participants provided positive feedback on the intervention. Knowledge/awareness (t = -18.70, p < 0.01) and attitudes (t = -2.00, p < 0.05) increased when exposed to the intervention. Favourable improvements in the practices were also observed. Mothers' practices related to breastfeeding and 24-h dietary diversity showed a statistically significant improvement. However, social norms and behaviour intentions did not significantly improve. The qualitative component also revealed favourable responses.

CONCLUSION AND RECOMMENDATIONS

The mobile intervention improved participants' knowledge, awareness, attitude, and practices, but not social norms or behaviour intentions. This approach is recommended to be used on a larger scale in community settings. In addition, mobile technology could drive intervention in pandemic-related situations.

A realist review of interventions targeting maternal health in low- and middle-income countries

Maternal mortality is disproportionately higher in low- and middle-income countries compared to other parts of the world. International research efforts are reflective of the urgency to improve global maternal outcomes. The existing literature of maternal health interventions in low- and middle-income countries targets a variety of populations and intervention types. However, there is a notable lack of systemic reviews that examine the wider contextual and mechanistic factors that have contributed to the outcomes produced by interventions. This article aims to use realist synthesis design to identify and examine the relationships between the contexts, mechanisms and outcomes of maternal health interventions conducted in low- and middle-income countries. This will inform evidence-based practice for future maternal health interventions. In May 2022, we searched four electronic databases for systematic reviews of maternal health interventions in low- and middle-income countries published in the last 5 years. We used open and axial coding of contexts, mechanisms and outcomes to develop an explanatory framework for intervention effectiveness. After eligibility screening and full-text analysis, 44 papers were included. The majority of effective interventions reported good healthcare system contexts, especially the importance of infrastructural capacity to implement and sustain the intervention. Most intervention designs used increasing knowledge and awareness at an individual and healthcare-provider level to produce intended outcomes. The majority of outcomes reported related to uptake of healthcare services by women. All mechanism themes had a relationship with this outcome. Health system infrastructure must be considered in interventions to ensure effective implementation and sustainability. Healthcare-seeking behaviours are embedded within social and cultural norms, environmental conditions, family influences and provider attitudes. Therefore, effective engagement with communities and families is important to create new norms surrounding pregnancy and delivery. Future research should explore community mobilization and involvement to enable tailored interventions with optimal contextual fit.

Technology-based innovative healthcare solutions for improving maternal and child health outcomes in low- and middle-income countries: A network meta-analysis protocol

AIM

The aims of the study were to synthesize the role of technology-based healthcare interventions (TBIs) and to identify the most effective interventions for the best functional maternal and child health (MCH) outcomes among low-risk pregnant women in low- and middle-income countries (LMICs).

DESIGN

A systematic review and network meta-analysis (NMA).

METHODS

We will perform a comprehensive search in electronic databases and other resources to identify relevant randomized controlled trials. Two reviewers will independently perform study selection, data extraction and quality assessment. Our primary outcomes include proportion of recommended antenatal care visits, skilled delivery care, postnatal care visits and exclusive breastfeeding practices. We will use pairwise random-effects meta-analysis and NMAs to estimate direct, indirect and relative effects using the relevant intervention classifications for each outcome separately. We plan to assess hierarchy of interventions, statistical inconsistency and certainty of evidence.

RESULTS

This review will compare the effectiveness of different form of TBIs on a comprehensive range of MCH outcomes and will provide the outcome-specific reliable evidence of the most effective interventions on improving MCH in LMICs. The review findings will guide researchers, stakeholders or policymakers on the potential use of TBIs in the given contexts that could achieve the best functional MCH outcomes in LMICs.

Effects of mHealth Interventions on Improving Antenatal Care Visits and Skilled Delivery Care in Low- and Middle-Income Countries: Systematic Review and Meta-analysis

BACKGROUND

The poor coverage of essential maternal services, such as antenatal care (ANC) and skilled delivery care utilization, accounts for higher maternal and infant mortality in low- and middle-income countries (LMICs). Although mobile health (mHealth) interventions could potentially improve the service utilization in resource-limited settings, their effectiveness remains unclear.

OBJECTIVE

This review aimed to summarize the effect of mHealth interventions on improving the uptake of ANC visits, skilled birth attendance at the time of delivery, and facility delivery among pregnant women in LMICs.

METHODS

We conducted a comprehensive search on 9 electronic databases and other resources from inception to October 2020. We included individual randomized controlled trials and cluster randomized controlled trials that assessed the effectiveness of mHealth interventions for improving perinatal health care utilization among healthy pregnant women in LMICs. We performed a random-effects meta-analysis and estimated the pooled effect size by using risk ratios (RRs) with 95% CIs. In addition, 2 reviewers independently assessed the risk of bias of the included studies by using the Cochrane risk of bias tool and the certainty of the evidence by using the Grading of Recommendation, Assessment, Development and Evaluation approach.

RESULTS

A total of 9 studies (10 articles) that randomized 10,348 pregnant women (n=6254, 60.44% in the intervention group; n=4094, 39.56% in the control group) were included in this synthesis. The pooled estimates showed a positive effect of mHealth interventions on improving 4 or more ANC visit utilizations among pregnant women in LMICs, irrespective of the direction of interventions (1-way communications: RR 2.14, 95% CI 1.76-2.60, I²=36%, 2 studies, moderate certainty; 2-way communications: RR 1.17, 95% CI 1.08-1.27, I²=59%, 3 studies, low certainty). Only 2-way mHealth interventions were effective in improving the use of skilled birth attendance during delivery (RR 1.23, 95% CI 1.14-1.33, I²=0%, 2 studies, moderate certainty), but the effects were unclear for 1-way mHealth interventions (RR 1.04, 95% CI 0.97-1.10, I²=73%, 3 studies, very low certainty) when compared with standard care. For facility delivery, the interventions were effective in settings where fewer pregnant women used facility delivery (RR 1.68, 95% CI 1.30-2.19, I²=36%, 2 studies, moderate certainty); however, the effects were unclear in settings where most pregnant women already used facility delivery (RR 1.01, 95% CI 0.97-1.04, I²=0%, 1 study, low certainty).

CONCLUSIONS

mHealth interventions may contribute to improving ANC and skilled delivery care utilization among pregnant women in LMICs. However, more studies are required to improve their reproducibility and efficiency or strengthen the evidence of different forms of mHealth interventions because of the considerable heterogeneity observed in the meta-analyses.

TRIAL REGISTRATION

PROSPERO CRD42020210813; https://tinyurl.com/2n7ny9a7.

Low utilisation of postnatal care among women with unwanted pregnancy: A challenge for Bangladesh to achieve Sustainable Development Goal targets to reduce maternal and newborn deaths

Pregnancy complications are the major cause of maternal and newborn deaths in low- and middle-income countries that are more frequently associated with unintended pregnancy. The World Health Organization (WHO) recommends postnatal care (PNC) for women and their newborns within 24 hr of birth to prevent pregnancy complications and associated adverse outcomes. We, therefore, examined the relationship between unintended pregnancy and PNC use in Bangladesh. Data from 4,493 women and newborn dyads were extracted from the 2014 Bangladesh Demographic and Health Survey and analysed. PNC was classified as: no PNC; some level of PNC (either the woman or her newborn missed PNC within 24 hr of birth but had at least one PNC visit within 42 days of birth); and WHO's recommended level of PNC (at least one PNC use for both the woman and her child within 24 hr of birth). Pregnancy intention at conception for the last live birth was categorised as wanted, mistimed or unwanted. Multilevel multinomial logistic regression modelling was used to assess the association between pregnancy intention and PNC use, adjusting for possible confounders. We found around 27% of participants had adhered to WHO's PNC use recommendations. Around 26% of pregnancies that resulted in live births were unintended at conception, including 15% of which were classified as mistimed and 11% as unwanted. Following adjustment of confounders, a 37% (OR = 0.63, 95% CI: 0.47-0.85) lower odds of using WHO's recommended level of PNC and a 33% (OR, 95% CI, 0.49-0.93) lower odds of some level of PNC were found for pregnancies that were unwanted relative to those that were wanted. No association was found between mistimed pregnancy and PNC use. Strengthening healthcare facilities and improving the linkage between women and existing healthcare facilities are important to ensure WHO's PNC recommendations are met for women experiencing an unwanted pregnancy.

mHealth Conceptual Model for Providing Quality Antenatal Care in Health Centers during the Coronavirus Disease 2019 Pandemic

BACKGROUND: In Indonesia, the maternal mortality rate is still high and far from the Sustainable Development Goals target of 305 compared to 70 per 100,000 live births. AIM: This study aims to design the mHealth concept to improve the quality of antenatal care (ANC) with features that support service workers during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: The method used was literature study and conceptual design of the mHealth model with Rapid Application Development approach. RESULTS: The result showed that several factors influence the quality of ANC and the potential for improvement with mHealth. There are nine features of pregnancy services designed to improve the quality of ANC, such as standard operating procedure compliance, maternal health records, clinical decision aids, referral links, teleconsultation, health promotion improvement, alerts, and reminders, real-time reports, and distribution maps for pregnant women. The depicted context diagram consists of four external entities such as pregnant women, midwives, maternal and child health coordinators at Health centers and Health offices in Indonesia as well as the flow of data or information to and from mHealth, and the interface design understands users’ role and is executed accordingly. CONCLUSION: The problems of pregnant women during the COVID-19 pandemic or the new normal were partially resolved with mHealth innovations, teleconsultation features, and improving health promotion. Therefore, all the mHealth features this helps in improving the quality of ANC.

Short message service (SMS) reminders for childhood immunisation in low-income and middle-income countries: a systematic review and meta-analysis

Introduction

Childhood vaccine delivery services in the low- and middle-income countries (LMIC) are struggling to reach every child with lifesaving vaccines. Short message service (SMS) reminders have demonstrated positive impact on a number of attrition-prone healthcare delivery services. We aimed to evaluate the effectiveness of SMS reminders in improving immunisation coverage and timeliness in LMICs.

Methods

PubMed, Embase, Scopus, Cochrane CENTRAL, CINAHL, CNKI, PsycINFO and Web of Science including grey literatures and Google Scholar were systematically searched for randomised controlled trials (RCTs) and non-RCTs that evaluated the effect of SMS reminders on childhood immunisation and timeliness in LMICs. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 assessment tool for RCTs and Cochrane Risk of Bias in Non-randomised Studies of Interventions tool for non-RCTs. Meta-analysis was conducted using random-effects models to generate pooled estimates of risk ratio (RR).

Results

18 studies, 13 RCTs and 5 non-RCTs involving 32 712 infants (17 135 in intervention groups and 15 577 in control groups) from 11 LMICs met inclusion criteria. Pooled estimates showed that SMS reminders significantly improved childhood immunisation coverage (RR=1.16; 95% CI: 1.10 to 1.21; I²=90.4%). Meta-analysis of 12 included studies involving 25 257 infants showed that SMS reminders significantly improved timely receipt of childhood vaccines (RR=1.21; 95% CI: 1.12 to 1.30; I²=87.3%). Subgroup analysis showed that SMS reminders are significantly more effective in raising childhood immunisation coverage in lower middle-income and low-income countries than in upper middle-income countries (p<0.001) and sending more than two SMS reminders significantly improves timely receipt of childhood vaccines than one or two SMS reminders (p=0.040).

Conclusion

Current evidence from LMICs, although with significant heterogeneity, suggests that SMS reminders can contribute to achieving high and timely childhood immunisation coverage.

PROSPERO registration number

CRD42021225843.

The Study on Public-Interest Short Message Service (SMS) in China during the COVID-19 Pandemic: Mobile User Survey and Content Analysis

The outbreak of coronavirus disease 2019 (COVID-19) has greatly threatened the global health system and triggered the public health emergency. In order to manage the COVID-19 pandemic, healthcare and prevention information have been delivered through omni-media channels (e.g., television, radio, social platform, etc.). As a traditional outlet, the short message service (SMS) can timely provide abundant anti-epidemic alerts to mobile users. In this paper, we aim to investigate mobile users' attitudes toward COVID-19 public-interest SMS sent from government authorities and then explore the insight from messaging texts collected between January and April 2020 in China. In general, respondents show a positive attitude towards content and the necessity of public-interest SMS during the pandemic. However, we find that gender and age differences not only affect content evaluation, but also influence reading and forwarding behaviors. For the necessity of SMS, it shows significant difference between the 18-25-year-old and over 40-year-old group, with the middle and elder group showing serious attitudes and giving higher remarks than the youth due to the habits of media usage. However no significant difference is presented between females and males. In terms of content, the category of topics and releasing institutions are analyzed, respectively. Due to the centralized responses and coordination of prevention and control in China, the messages from COVID-19 disposal organizations (e.g., municipal steering group and provincial CDC) account for more than 70% among four cities.

Mobile Device Usage by Gender Among High-Risk HIV Individuals in a Rural, Resource-Limited Setting

Background: Mobile health (mHealth) is a promising tool to deliver healthcare interventions to underserved populations. We characterized the use of mobile devices in rural KwaZulu-Natal, South Africa to tailor mHealth interventions for people living with HIV and at risk for acquiring HIV in the middle-income country. Methods: We surveyed participants in community settings and offered free HIV counseling and testing. Participants self-reported their gender, age, relationship, and employment status, receipt of monthly grant, condomless sex frequency, and circumcision status (if male). Outcomes included cell phone and smartphone ownership, private data access, health information seeking, and willingness to receive healthcare messages. We performed multivariable logistic regression to assess the relationship between demographic factors and outcomes. Results: Although only 10% of the 788 individuals surveyed used the phone to seek health information, 93% of cell phone owners were willing to receive healthcare messages. Being young, female, employed, and in a relationship were associated with cell phone ownership. Smartphone owners were more likely to be young, female, and employed. Participants reporting condomless sex or lack of circumcision were significantly less likely to have private data access or to purchase data. Conclusions: mHealth interventions should be feasible in rural KwaZulu-Natal, though differ by gender. As women are more likely to own smartphones, smartphone-based mHealth interventions specifically geared to prevent the acquisition of or to support the care of HIV in young women in KwaZulu-Natal may be feasible. mHealth interventions encouraging condom use and medical male circumcision should consider the use of nonsmartphone short message service and be attuned to mobile data limitations-especially when targeting men.

Exploring the Use of Mobile Health to Improve Community-Based Health and Nutrition Service Utilization in the Hills of Nepal: Qualitative Study

BACKGROUND

With mobile phone coverage and ownership expanding globally, mobile health (mHealth) interventions are increasingly being used to improve coverage and quality of health and nutrition services. However, evidence on mHealth intervention feasibility and factors to consider during program design is limited in low- and middle-income countries like Nepal.

OBJECTIVE

This study aimed to examine the potential of using text messages to improve health and nutrition services by exploring mobile phone ownership and sharing; mobile phone use and skills; and interest, preferences, and limitations regarding mHealth interventions.

METHODS

We conducted 35 in-depth interviews with 1000-day women (the period from conception to a child's second birthday), health facility staff, and female community health volunteers (FCHVs), as well as eight focus group discussions with health facility staff, FCHVs, and 1000-day household decision-makers (ie, husbands, mothers-in-law, and fathers-in-law). We also conducted a mobile phone skills test. We employed thematic analysis using framework matrices and analytical memos.

RESULTS

The study included 70 study participants, of whom 68 (97%) had a mobile phone, and phone sharing was uncommon. Use of text messages was most commonly reported by 1000-day women and health facility staff than household decision-makers and FCHVs. More than 8 in 10 participants (54/64, 84%) could dial numbers, and the majority (28/34, 82%) of 1000-day women, health facility staff, and male decision-makers could also read and write text messages. We found that 1000-day women preferred educational and reminder messages, whereas health facility staff and FCHVs desired educational and motivational messages. Participants suggested different types of texts for 1000-day women, families, FCHVs, and health facility staff, and reported less value for texts received from unknown phone numbers.

CONCLUSIONS

A text message-based mHealth intervention is acceptable in the hills of Nepal and has the potential to improve community health and nutrition service utilization, particularly by sending meeting reminders and by providing information. Our findings contribute to text message-based mHealth intervention design in under-resourced settings.

Accelerating progress towards the elimination of mother-to-child transmission of HIV: a narrative review

INTRODUCTION

Findings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother-to-child HIV transmission (PMTCT).

METHODS

We summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services.

RESULTS AND DISCUSSION

From May to November 2019, we identified numerous promising, evidence-based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility-based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT.

CONCLUSIONS

A wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.

Mobile phone-based Multimedia Application Could improve Maternal Health in Rural Southwestern Uganda: Mixed Methods Study

Background: Reducing maternal and infant mortality rates remains challenging. Illiteracy, lack of reliable information, long distances to health centers continue to limit access to quality maternal healthcare in Uganda. Mobile health technologies could be promising affordable strategies for enhancing access to maternal health services. However, there is lack of studies assessing the experiences of illiterate rural pregnant women regarding these technologies. Objective: To explore how illiterate pregnant women perceive a maternal health mobile application composed of tailored video and audio messages, appointment reminders and calling function. Methods: We purposively sampled illiterate pregnant women initiating antenatal care at Mbarara Regional Referral Hospital. We carried out three focus group discussions with 14 women to elicit information on perceptions of the proposed mobile phone based multimedia application. We used STATA 13 to describe study participants and their preferences. Results: Pregnant women anticipated that intervention would enhance maternal health by reminding them to attend antenatal appointments, enabling transport cost and time saving, providing tailored information that is easy to understand, and recall. However, financial constraints and phone sharing would limit the functionality. Conclusion: Mhealth application may provide acceptable and affordable alternative approaches to providing maternal health services, especially in settings where face-to-face approaches are challenging.

Promoting Antenatal Care Attendance Through a Text Messaging Intervention in Samoa: Quasi-Experimental Study

Background

Antenatal care (ANC) has the potential to improve maternal health, but it remains underutilized and unevenly implemented in many low- and middle-income countries. Increasingly, text messaging programs for pregnant women show evidence that they can improve the utilization of ANC during pregnancy; however, gaps remain regarding how implementation affects outcomes.

Objective

This study aimed to assess facilitators and barriers to implementation of an SMS text messaging intervention for pregnant women in Samoa and to assess its impact on ANC attendance.

Methods

This study took place in Upolu, Samoa, from March to August 2014 and employed a quasi-experimental design. Half (n=3) of the public antenatal clinics on the island offered adult pregnant women the SMS text messaging intervention, with 552 women registering for the messages. At the comparison clinics (n=3), 255 women registered and received usual care. The intervention consisted of unidirectional text messages containing health tips and appointment reminders. The outcome of interest was the number of attended antenatal visits. Implementation data were also collected through a survey of the participating midwives (n=7) and implementation notes. Data analysis included a comparison of women’s baseline characteristics between the two groups, followed by the use of negative binomial regressions to test for associations between participation in the intervention and increased ANC attendance, controlling for individual characteristics and accounting for the clustering of women within clinics.

Results

The comparison of ANC attendance rates found that women receiving the SMS text messaging intervention attended 15% fewer ANC visits than the comparison group (P=.004), controlling for individual characteristics and clustering. Data analysis of the implementation process suggests that barriers to successful implementation include women registering very late in pregnancy, sharing their phone with others, and inconsistent explanation of the intervention to women.

Conclusions

These results suggest that unidirectional text messages do not encourage, and might even discourage, ANC attendance in Samoa. Interpreted with other evidence in the literature, these results suggest that SMS text messaging interventions are more effective when they facilitate better communication between patients and health workers. This study is an important contribution to our understanding of when SMS text messaging interventions are and are not effective in improving maternal health care utilization.