Assessing the Effect of mHealth Interventions in Improving Maternal and Neonatal Care in Low- and Middle-Income Countries: A Systematic Review

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Abstract

Introduction

Maternal and neonatal mortality remains high in many low- and middle-income countries (LMIC). Availability and use of mobile phones is increasing rapidly with 90% of persons in developing countries having a mobile-cellular subscription. Mobile health (mHealth) interventions have been proposed as effective solutions to improve maternal and neonatal health. This systematic review assessed the effect of mHealth interventions that support pregnant women during the antenatal, birth and postnatal period in LMIC.

Methods

The review was registered with Prospero (CRD42014010292). Six databases were searched from June 2014–April 2015, accompanied by grey literature search using pre-defined search terms linked to pregnant women in LMIC and mHealth. Quality of articles was assessed with an adapted Cochrane Risk of Bias Tool. Because of heterogeneity in outcomes, settings and study designs a narrative synthesis of quantitative results of intervention studies on maternal outcomes, neonatal outcomes, service utilization, and healthy pregnancy education was conducted. Qualitative and quantitative results were synthesized with a strengths, weaknesses, opportunities, and threats analysis.

Results

In total, 3777 articles were found, of which 27 studies were included: twelve intervention studies and fifteen descriptive studies. mHealth interventions targeted at pregnant women increased maternal and neonatal service utilization shown through increased antenatal care attendance, facility-service utilization, skilled attendance at birth, and vaccination rates. Few articles assessed the effect on maternal or neonatal health outcomes, with inconsistent results.

Conclusion

mHealth interventions may be effective solutions to improve maternal and neonatal service utilization. Further studies assessing mHealth’s impact on maternal and neonatal outcomes are recommended. The emerging trend of strong experimental research designs with randomized controlled trials, combined with feasibility research, government involvement and integration of mHealth interventions into the healthcare system is encouraging and can pave the way to improved decision making on best practice implementation of mHealth interventions.

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Most cited references 23

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3.6 million neonatal deaths--what is progressing and what is not?

Joy E. Lawn, Kate Kerber, Christabel Enweronu-Laryea … (2010)

Each year 3.6 million infants are estimated to die in the first 4 weeks of life (neonatal period)--but the majority continue to die at home, uncounted. This article reviews progress for newborn health globally, with a focus on the countries in which most deaths occur--what data do we have to guide accelerated efforts? All regions are advancing, but the level of decrease in neonatal mortality differs by region, country, and within countries. Progress also differs by the main causes of neonatal death. Three major causes of neonatal deaths (infections, complications of preterm birth, and intrapartum-related neonatal deaths or "birth asphyxia") account for more than 80% of all neonatal deaths globally. The most rapid reductions have been made in reducing neonatal tetanus, and there has been apparent progress towards reducing neonatal infections. Limited, if any, reduction has been made in reducing global deaths from preterm birth and for intrapartum-related neonatal deaths. High-impact, feasible interventions to address these 3 causes are summarized in this article, along with estimates of potential for lives saved. A major gap is reaching mothers and babies at birth and in the early postnatal period. There are promising community-based service delivery models that have been tested mainly in research studies in Asia that are now being adapted and evaluated at scale and also being tested through a network of African implementation research trials. To meet Millennium Development Goal 4, more can and must be done to address neonatal deaths. A critical step is improving the quantity, quality and use of data to select and implement the most effective interventions and strengthen existing programs, especially at district level. Copyright © 2010 Elsevier Inc. All rights reserved.

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Mobile phones improve antenatal care attendance in Zanzibar: a cluster randomized controlled trial

Stine Lund, Birgitte B Nielsen, Maryam Hemed … (2014)

Background Applying mobile phones in healthcare is increasingly prioritized to strengthen healthcare systems. Antenatal care has the potential to reduce maternal morbidity and improve newborns’ survival but this benefit may not be realized in sub-Saharan Africa where the attendance and quality of care is declining. We evaluated the association between a mobile phone intervention and antenatal care in a resource-limited setting. We aimed to assess antenatal care in a comprehensive way taking into consideration utilisation of antenatal care as well as content and timing of interventions during pregnancy. Methods This study was an open label pragmatic cluster-randomised controlled trial with primary healthcare facilities in Zanzibar as the unit of randomisation. 2550 pregnant women (1311 interventions and 1239 controls) who attended antenatal care at selected primary healthcare facilities were included at their first antenatal care visit and followed until 42 days after delivery. 24 primary health care facilities in six districts were randomized to either mobile phone intervention or standard care. The intervention consisted of a mobile phone text-message and voucher component. Primary outcome measure was four or more antenatal care visits during pregnancy. Secondary outcome measures were tetanus vaccination, preventive treatment for malaria, gestational age at last antenatal care visit, and antepartum referral. Results The mobile phone intervention was associated with an increase in antenatal care attendance. In the intervention group 44% of the women received four or more antenatal care visits versus 31% in the control group (OR, 2.39; 95% CI, 1.03-5.55). There was a trend towards improved timing and quality of antenatal care services across all secondary outcome measures although not statistically significant. Conclusions The wired mothers’ mobile phone intervention significantly increased the proportion of women receiving the recommended four antenatal care visits during pregnancy and there was a trend towards improved quality of care with more women receiving preventive health services, more women attending antenatal care late in pregnancy and more women with antepartum complications identified and referred. Mobile phone applications may contribute towards improved maternal and newborn health and should be considered by policy makers in resource-limited settings. Trial registration ClinicalTrials.gov, NCT01821222.

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Analysis of human immune responses in quasi-experimental settings: tutorial in biostatistics

Rajiv Sarkar, Sitara S. R. Ajjampur, Honorine D. Ward … (2012)

Background Human immunology is a growing field of research in which experimental, clinical, and analytical methods of many life science disciplines are utilized. Classic epidemiological study designs, including observational longitudinal birth cohort studies, offer strong potential for gaining new knowledge and insights into immune response to pathogens in humans. However, rigorous discussion of methodological issues related to designs and statistical analysis that are appropriate for longitudinal studies is lacking. Methods In this communication we address key questions of quality and validity of traditional and recently developed statistical tools applied to measures of immune responses. For this purpose we use data on humoral immune response (IR) associated with the first cryptosporidial diarrhea in a birth cohort of children residing in an urban slum in south India. The main objective is to detect the difference and derive inferences for a change in IR measured at two time points, before (pre) and after (post) an event of interest. We illustrate the use and interpretation of analytical and data visualization techniques including generalized linear and additive models, data-driven smoothing, and combinations of box-, scatter-, and needle-plots. Results We provide step-by-step instructions for conducting a thorough and relatively simple analytical investigation, describe the challenges and pitfalls, and offer practical solutions for comprehensive examination of data. We illustrate how the assumption of time irrelevance can be handled in a study with a pre-post design. We demonstrate how one can study the dynamics of IR in humans by considering the timing of response following an event of interest and seasonal fluctuation of exposure by proper alignment of time of measurements. This alignment of calendar time of measurements and a child's age at the event of interest allows us to explore interactions between IR, seasonal exposures and age at first infection. Conclusions The use of traditional statistical techniques to analyze immunological data derived from observational human studies can result in loss of important information. Detailed analysis using well-tailored techniques allows the depiction of new features of immune response to a pathogen in longitudinal studies in humans. The proposed staged approach has prominent implications for future study designs and analyses.

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Author and article information

Contributors

Dongmei Li: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 4 May 2016

Publication date Collection: 2016

Volume: 11

Issue: 5

Electronic Location Identifier: e0154664

Affiliations

[1 ]Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht, The Netherlands

[2 ]School of Public Health, University of Ghana, Legon, Accra, Ghana

[3 ]Department of Community Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway

[4 ]Afya Connect(4)Change, Change Lake Zone, Mwanza, Tanzania

[5 ]International Institute for Communication and Development, The Hague, The Netherlands

[6 ]Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

University of Rochester, UNITED STATES

Author notes

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: SFVS JLB AB KKG. Performed the experiments: SFVS AB ASM MV. Analyzed the data: SFVS. Wrote the paper: SFVS. Critically reviewed and approved the final version of the manuscript: SFVS JLB AB KKG MAC ASM MV.

* E-mail: stephanie.sondaal@ 123456gmail.com

Article

Publisher ID: PONE-D-15-28893

DOI: 10.1371/journal.pone.0154664

PMC ID: 4856298

PubMed ID: 27144393

SO-VID: 73f8e529-261e-4bf2-a5fa-a8234fb7c183

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 1 July 2015

Date accepted : 5 April 2016

Page count

Figures: 3, Tables: 5, Pages: 26

Funding

The authors received no specific funding for this work.

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Data Availability All relevant data are within the paper and its Supporting Information files.

Assessing the Effect of mHealth Interventions in Improving Maternal and Neonatal Care in Low- and Middle-Income Countries: A Systematic Review

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Most cited references 23

3.6 million neonatal deaths--what is progressing and what is not?

Mobile phones improve antenatal care attendance in Zanzibar: a cluster randomized controlled trial

Analysis of human immune responses in quasi-experimental settings: tutorial in biostatistics

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