Date Published: June 27, 2018
Publisher: Public Library of Science
Author(s): Gershim Asiki, Robert Newton, Leonard Kibirige, Anatoli Kamali, Lena Marions, Lars Smedman, Cassandra Nichole Spracklen.
Homebirths are common in low and middle income countries and are associated with poor child survival. We assessed the feasibility of using smartphones by village health workers for pregnancy registration and the effectiveness of health text messages (SMS) sent to pregnant women through village health workers in reducing homebirths in rural Uganda.
A non-randomised intervention study was undertaken in 26 villages. In the intervention arm, village health workers registered pregnant women (n = 262) in 13 villages using a smartphone app (doForm) and paper forms and gestation age-timed SMS were sent through village health workers to the pregnant women. In 13 control villages, (n = 263) pregnant women were registered on paper forms only and no SMS was sent. The main outcome was place of birth measured through a self-report. Logistic regression with generalised estimating equations was used to explore the effect of the intervention.
Comparing 795 corresponding data fields on phone and paper revealed that numeric variable fields were 86%-95% similar while text fields were 38%-48% similar. Of the 525 pregnant women followed, 83 (15.8%) delivered at home. In the adjusted analysis, the intervention was associated with lower odds of homebirths [AOR = 0.38, 95%CI (0.15–0.97)]. Muslim religion [AOR = 4.0, 95%CI (1.72–9.34)], primary or no maternal education [AOR = 2.51, 95%CI (1.00–6.35)] and health facility distance ≥ 2 km [AOR = 2.26, 95%CI (0.95–5.40)] were independently associated with homebirths.
Village health workers can register pregnant women at home using phones and relay gestation age specific SMS to them to effectively reduce homebirths.
Although a substantial decline in child mortality has been observed over the past decades, the burden of neonatal mortality remains high. Sub Saharan Africa contributes half of under-five mortality globally and 44% of the deaths occur in the neonatal period . Increasing access to skilled birth attendance (SBA) is among key strategies recommended by the World Health Organization (WHO) to reduce maternal and neonatal mortality . Despite several efforts geared towards scaling up SBA, many women in low income countries deliver at home. A recent estimate showed that between 2011 and 2015, approximately 50% of births in sub Saharan Africa occurred at home . Among several barriers to health facility delivery, lack of consistent communication on the importance of delivering at a health facility has been cited .
Our study has shown that village health workers can be effectively engaged to register pregnant women and follow them with standardised text messages in their homes. Village health workers were able to deliver the messages to 60% of pregnant women registered in the study and this was associated with a substantial reduction in home births. A cluster randomized trial in Zanzibar showed approximately 20% increase in uptake of facility deliveries among pregnant mothers attending antenatal care when the messages were directly delivered to the mothers . Unlike in the Zanzibar trial, we recruited pregnant women from their homes and sent text messages through village health workers to reach women who do not own phones and are most vulnerable in rural communities. Our findings contribute to dearth of literature on mobile phone use for data collection and dissemination of specific health messages to improve maternal and child health. A recent systematic review on mHealth interventions for maternal, new-born and child health in low–and middle–income countries highlighted the scarcity of literature and lack of robust evidence . Strengthening community health systems within which homebirths occur through prospective village-based registration of pregnant women has been shown to reduce neonatal mortality in India  and Bangladesh . Pregnancy registration enables accurate estimate of population denominators that improves the targeting of services. In our study area, pregnancy registration was enhanced during the intervention and this directly contributed to the village health workers focusing their mobilisation activities to a targeted audience. The pregnant women most likely attached more value to gestation age-timed messages than general messages, thus the higher uptake of services. Although our study showed a lower infant mortality in the intervention arm, there was no difference in neonatal mortality on the first day of delivery possibly because of delayed care-seeking at the time of birth and the inability of health centres to handle new born resuscitation.