Mobile phones as a health communication tool to improve ... - K4Health

Intrapartum care

DOI: 10.1111/j.1471-0528.2012.03413.x www.bjog.org

Mobile phones as a health communication tool to improve skilled attendance at delivery in Zanzibar: a cluster-randomised controlled trial S Lund,a M Hemed,b BB Nielsen,c A Said,b K Said,b MH Makungu,b V Rascha,d a Department of International Health, Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark b Ministry of Health, Revolutionary Government of Zanzibar, Zanzibar c Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark d Department of Obstetrics and Gynaecology, Odense University Hospital, Odense, Denmark Correspondence: Dr S Lund, Department of International Health, Immunology and Microbiology, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen N, Denmark. Email [email protected]

Accepted 9 May 2012. Published Online 17 July 2012.

Objective To examine the association between a mobile phone

intervention and skilled delivery attendance in a resource-limited setting. Design Pragmatic cluster-randomised controlled trial with primary healthcare facilities as the unit of randomisation. Setting Primary healthcare facilities in Zanzibar. Population Two thousand, five hundred and fifty pregnant

women (1311 interventions and 1239 controls) who attended antenatal care at one of the selected primary healthcare facilities were included at their first antenatal care visit and followed until 42 days after delivery. All pregnant women were eligible for study participation. Methods Twenty-four primary healthcare facilities in six districts

in Zanzibar were allocated by simple randomisation to either mobile phone intervention (n = 12) or standard care (n = 12). The intervention consisted of a short messaging service (SMS) and mobile phone voucher component.

Main outcome measures Skilled delivery attendance. Results The mobile phone intervention was associated with an increase in skilled delivery attendance: 60% of the women in the intervention group versus 47% in the control group delivered with skilled attendance. The intervention produced a significant increase in skilled delivery attendance amongst urban women (odds ratio, 5.73; 95% confidence interval, 1.51–21.81), but did not reach rural women. Conclusions The mobile phone intervention significantly

increased skilled delivery attendance amongst women of urban residence. Mobile phone solutions may contribute to the saving of lives of women and their newborns and the achievement of Millennium Development Goals 4 and 5, and should be considered by maternal and child health policy makers in developing countries. Keywords Maternal health, mHealth, mobile phones, skilled

delivery attendance, socioeconomic determinants, Zanzibar.

Please cite this paper as: Lund S, Hemed M, Nielsen B, Said A, Said K, Makungu M, Rasch V. Mobile phones as a health communication tool to improve skilled attendance at delivery in Zanzibar: a cluster-randomised controlled trial. BJOG 2012;119:1256–1264.

Introduction Reducing maternal and neonatal mortality remains a global challenge. Worldwide, around 350 000 women die annually during pregnancy and childbirth,1,2 and an estimated 4.4 million newborns die during the first 4 weeks of life.3 Internationally, despite the high priority given to maternal and child health, the prospect of achieving the related Millennium Development Goals (MDGs) by 2015 appears bleak, with several countries experiencing an increase rather than a decrease in maternal and child

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mortality.1,2 Most maternal deaths occur as a result of direct obstetric complications between the third trimester and the first week after delivery, with the majority of deaths being a result of avoidable causes.3–6 It is documented that newborn survival is closely related to maternal health.7 Because obstetric complications cannot be predicted, skilled attendance at the time of delivery and access to emergency obstetric care remain the most effective and widely recommended strategies to reduce maternal and perinatal mortality,8–13 and an important indicator to achieving MDGs 4 and 5.14

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

Mobile phones improve skilled attendance at delivery

‘Wired mothers’ is a pragmatic cluster-randomised controlled trial with the primary healthcare facility as the unit of randomisation. One group of primary healthcare facilities and women attending those facilities was randomised to receive a mobile phone intervention, whereas the control group received no intervention. The study included 2550 women distributed in 24 primary healthcare facilities. The terminology ‘wired mother’ was used to describe a woman

Study setting The study took place in 2009–10 on the island of Unguja in Zanzibar, a part of the United Republic of Tanzania. The island has six districts with 80 healthcare facilities, 95% of which are government owned.30 Of the six districts, two are urban (Urban and West) and four are rural (North A, North B, Central, South) (Figure S1).

Participants Twenty-four government-run primary healthcare facilities, four per district, were selected, based on two inclusion criteria: highest number of antenatal care clients in 2008 and the availability of at least one midwife in the facility. All included facilities had mobile phone network coverage. Women who attended antenatal care at one of the 24 selected healthcare facilities were included on their first antenatal care visit and followed until 42 days after delivery. Women were eligible for study participation irrespective of their mobile phone and literacy status. A total of 2637 women agreed to participate; 82 were excluded as they missed the end-of-study questionnaire. Of these, 15 were known to have travelled outside the study area and three were not pregnant. During the study period, five women died as a result of direct obstetric complications (Figure 1).

Randomisation and clusters Primary healthcare facilities were assigned by simple random allocation to the mobile phone intervention. To ensure comparability of the intervention and women with respect to socioeconomic baseline characteristics, two of

Allocation

24 eligible health facilities underwent randomisation

Follow up

Methods

linked to the health system by use of a mobile phone intervention throughout her pregnancy and postpartum period.

Analysis

Mobile phone use is expanding rapidly in Africa, amounting to more than 500 million users at present15 and it is estimated that one-half of all individuals in remote areas have a mobile phone.16 As a result of the obvious potential to reach large population groups and strengthen health systems, the use of mobile phones in health care, commonly referred to as mHealth, is emerging.16–19 Evidence of the effectiveness of mobile phone-based health applications is predominantly limited to developed countries, with a focus on the prevention and management of chronic diseases, including HIV and tuberculosis,20–23 and support to lifestyle changes.24–26 A recent review of mHealth for maternal health identified 34 articles and reports, only four of which had a quantitative design.27 Therefore, there is an urgent need for substantial evidence of mobile phone intervention benefits to maternal health services and its contribution to the achievement of MDGs 4 and 5.27,28 The maternal health situation in Zanzibar is similar to that in other sub-Saharan countries, with about 50% of all deliveries taking place at home with unskilled attendance. Women delivering in healthcare facilities typically spend less than a day in the facility and maternal mortality is dominated by preventable causes.29 Antenatal care coverage is high, with 98% of pregnant women making at least one visit during their pregnancy, but there is little knowledge of the quality of reproductive health services. Nationally, Zanzibar has the target to increase skilled delivery attendance to 80% by 2015.30 Mobile phone network coverage and ownership are widespread, also amongst women, although there are regional differences. With only 3 years to meet MDG 5, and a rapidly expanding number of mobile phone users in developing countries, it is time for the introduction of unconventional approaches, such as the use of mobile phones, to strengthen health systems and improve health outcomes in developing countries. This article presents results from a cluster-randomised controlled trial, named ‘wired mothers’, aimed to evaluate the use of mobile phones to bridge the communication gap between pregnant women and health providers, and increase skilled delivery attendance in a setting with scarce resources.

Allocated to mobile phone intervention: 12 health facilities 1351 women included at 1st antenatal care visit

Lost to follow up: 0 health facilities 36 women withdrew or were excluded 4 maternal deaths

Allocated to standard care: 12 health facilities 1286 women included at 1st antenatal care visit

Lost to follow up: 0 health facilities 46 women withdrew or were excluded 1 maternal death

Clusters: 12 health facilities, median size = 124, range 39–166

Clusters: 12 health facilities, median size = 101, range 31–153

Participants: 1311 women included in primary analysis postpartum

Participants: 1239 women included in primary analysis postpartum

Figure 1. Procedures for the selection of the study population.


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the four selected facilities in each district were randomly assigned to intervention (mobile phone intervention) and two to control (standard care). Neither study participants nor clinic staff were masked because of the nature of the intervention requiring overt participation. Analysis accounted for the within-cluster correlation of women cared for at the same facility. The average cluster size was 106 women: the lowest number was 26 and the highest 146.

Procedures In accordance with Zanzibar’s reproductive and child health guidelines, all enrolled women were offered the standard antenatal, delivery and postnatal services.30,31 These consisted of at least four antenatal care visits, skilled attendance at delivery and a postnatal visit within the first 48 hours for deliveries taking place outside healthcare facilities.30,31 The enrolled primary healthcare facility staff also functioned as research assistants recording an inclusion questionnaire, registering each contact with the women and completing an end-of-study questionnaire 6 weeks after delivery. Research assistants were assigned to the four hospitals providing emergency obstetric care and all contacts with enrolled women were similarly recorded. Optimal conditions for the provision of quality care in both intervention and control sites were ensured with the distribution of electronic blood pressure metres, weighing scales, haemocues for the measurement of haemoglobin and essential medicines. All research assistants received training on the use of the equipment and how to fill in the research forms. In addition, research assistants in intervention facilities received training on how to use the mobile phone intervention. Each district was assigned a supervisor who visited all facilities once a week during the study period for quality control. Supervisors reported any encountered problems to the research team.

Intervention The wired mothers’ intervention consisted of two components: an automated short messaging service (SMS) system providing wired mothers with registered phone numbers with unidirectional text messaging, and a mobile phone voucher system providing the possibility for direct two-way communication between wired mothers and their primary healthcare providers. Although only women with registered phone numbers received text messages, all women in the intervention group were given mobile phone vouchers to contact their local primary healthcare provider in the case of an emergency. The wired mothers were not provided with mobile phones or access to power supplies for mobile phone charging because researchers wished to study a realistic environment that could be replicable at scale and in other settings. To improve the communication and referral mechanisms between different levels of care, providers at primary healthcare facilities and hospitals were given mobile phones (Figure 2).

SMS text messages The aim of the SMS component was to provide simple health education and appointment reminders to encourage attendance to routine antenatal care, skilled delivery attendance and postnatal care. Specially designed software automatically generated and sent text messages according to the women’s gestational age throughout the pregnancy and until 6 weeks after delivery. The information required for the SMS software, e.g. gestational age, date and mobile phone number, was gathered during the first antenatal care visit and entered into the web-based system by the district supervisors. The registered phone numbers were either the women’s own phone or an access phone number of a husband/friend/mother who could relay the messages. If the women could not provide a phone number, they benefited only from the mobile phone voucher component. The frequency and content of the messages varied depending on the stage of the pregnancy. Early in the pregnancy, women

Figure 2. The wired mothers’ intervention.

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received two messages a month, but, after gestational week 36, the intensity increased to two a week. The content of the messages was developed by a team consisting of international researchers and local partners from the Ministry of Health in Zanzibar. Message content was standardised with neutral phrasing and provided as simple text in the local language of Swahili. Specialised systems, such as voicemails and pictograms, were not used.

Mobile phone vouchers The mobile phone vouchers allowed all wired mothers to communicate directly with primary healthcare providers and to access emergency obstetric care through improved communication and referral links from primary healthcare facilities to hospitals. Each wired mother was given a phone voucher with a modest credit of 500 Tanzanian Shillings and a card with the phone number of her local primary healthcare provider. This allowed the women to make a short call, after which the health provider would call them back. The 12 primary healthcare facilities randomised for intervention were provided with a mobile phone with sufficient credit and a phone directory for higher levels of care. Providers at referral hospitals, such as the medical doctor on call, the midwife and the ambulance driver, were also provided with phones. This allowed access to emergency obstetric care as the wired mothers could communicate with primary healthcare providers who, in turn, could access advice and the referral ambulance service from higher levels of care when needed.

Definitions and outcomes We aimed to compare the effectiveness of the mobile phone intervention for improving skilled delivery attendance amongst pregnant women in Zanzibar. We used the World Health Organization definition, whereby skilled delivery attendants are midwifes, doctors or nurses who have been educated and trained in the skills needed to manage pregnancies, childbirth and the immediate postnatal period, including the identification, management and referral of complications in women and newborns. We also included home deliveries assisted by skilled birth attendants, although international consensus has not been reached on this issue.8,32

Data collection Demographic and covariate information was recorded with structured questionnaires at inclusion and 6 weeks after delivery. In between, all contacts with the health system were recorded at antenatal care, delivery and postnatal care visits. All enrolled women received an individual identity number and card. Research assistants maintained a register for each patient at facility level, and all hospitals had registers for wired mothers who were identified by

the issued identity card. If the women did not return for the end-of-study interview, the research assistant contacted them either by phone or directly. Radio announcements were also used requesting women to provide the end-of-study interview. Double entry of data was performed in Epidata and transferred and validated in spss (Chicago, IL, USA).

Statistical analysis Analyses were performed according to the intention-totreat principle, and all available data were included in the analysis. The primary outcome was skilled delivery attendance (‘yes’ or ‘no’), and logistic analysis was performed to assess the impact of the intervention as well as the various socioeconomic variables. Because facilities rather than individual women were randomised, we used generalised estimating equations to account for within-cluster correlation in all logistic regression analyses.33,34 As a first model, we included all variables from Table 1 as explanatory variables (including two-factor interactions). The model was reduced and nonsignificant confounders were removed using backwards elimination, resulting in a model with the following significant variables: occupation, education, mobile phone status, parity, residence status and intervention. Furthermore, there was an interaction between intervention and residence (P < 0.01), indicating that the effect of intervention was different for urban and rural women. Therefore, a final logistic regression analysis included two separate effects of intervention: one for urban and one for rural women. Because mobile phone interventions for health care are relatively new, we were also interested in the intervention effect in various socioeconomic subgroups. No adjustments were carried out for multiple testing, but results were viewed in the light of mass significance issues. Results were expressed as odds ratios (ORs) for skilled delivery attendance, with 95% confidence intervals (95% CIs). For all models, the criterion for significance was set at P = 0.05 and all statistical analyses were conducted using spss (version 20).

Results Skilled delivery attendance and socioeconomic variables The majority of the women participating were housewives and farmers of rural residence, and 17% were totally illiterate. Thirty-seven per cent of the women included in the study owned a mobile phone. The remaining had various degrees of access to mobile phones. There were no significant differences between intervention and control groups with regard to baseline characteristics (Table 1). The analysis of the influence of socioeconomic variables on skilled delivery attendance revealed that, generally, levels


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Table 1. Baseline characteristics of the study population. Values are numbers (percentages) Variable Health facilities No Participants Number of women Age (years)*