Participant flow and attrition
The participant flow is reported according to the CONSORT statement [32]. Of the 91 eligible participants, fifty-two young mothers (57%) were enrolled in the study, out of whom 43 completed the follow-up and were analysed (attrition rate=17.3%). There was no protocol violation in the study. Recruitment, allocation, and sample attrition is shown in Figure 1.
Participant characteristics
There were no differences in characteristics at baseline between the two randomised groups (Table 1).
Table 1: Socio-demographic characteristics of the enrolled mothers by randomised group
|
Intervention
|
Control
|
Total
|
n(%)
|
n(%)
|
n(%)
|
Site MTRH
|
11 (47.8)
|
11(52.4)
|
22 (51.2)
|
KCGH
|
11 (52.2)
|
10(47.6)
|
21 (48.8)
|
Age group (years) 12-16
|
3 (13.6)
|
4(19.0)
|
7 (16.3)
|
17-19
|
19 (86.4)
|
17(81.0)
|
36 (83.7)
|
Education level Primary
|
10 (45.5)
|
7(33.3)
|
17 (39.5)
|
Secondary
|
11 (50.0)
|
14(66.7)
|
25 (58.1)
|
Tertiary
|
1 (4.5)
|
0(0.0)
|
1 (2.3)
|
Marital status Married
|
4 (18.2)
|
8(38.1)
|
12 (27.9)
|
Single
|
17 (77.3)
|
13(61.9)
|
30 (69.8)
|
Separated
|
1 (4.5)
|
0(0.0)
|
1 (2.3)
|
Occupation Self-employed
|
1 (4.5)
|
2(9.5)
|
3 (7.0)
|
Unemployed
|
11 (50.0)
|
12(57.1)
|
23 (53.5)
|
Student
|
10 (45.5)
|
7(33.3)
|
17 (39.5)
|
Religion Catholic
|
4 (18.2)
|
3(14.3)
|
7 (16.3)
|
Protestant
|
18 (81.8)
|
17(81.0)
|
35 (81.4)
|
Muslim
|
0 (0.0)
|
1(4.8)
|
1 (2.3)
|
No. ANC visits None
|
0 (0.0)
|
1 (4.8)
|
1 (2.3)
|
One
|
2 (9.1)
|
4 (19.0)
|
6 (14.0)
|
Two
|
2 (9.1)
|
0 (0.0)
|
2 (4.7)
|
Three
|
5 (22.7)
|
2 (9.5)
|
7 (16.3)
|
Four
|
11 (50.0)
|
9 (42.9)
|
20 (46.5)
|
>Four
|
2 (9.1)
|
5 (23.8)
|
7 (16.3)
|
Primary support person Parent
|
18 (81.8)
|
16 (76.2)
|
34 (79.1)
|
Partner
|
3 (13.6)
|
4 (19.0)
|
7 (16.3)
|
Friend
|
1 (4.5)
|
0 (0.0)
|
1(2.3)
|
None
|
0 (0.0)
|
1 (4.8)
|
1(2.3)
|
Baby sex Male
|
11(50.0)
|
9 (42.9)
|
20 (46.5)
|
Female
|
11 (50.0)
|
12 (57.1)
|
23 (53.5)
|
Distance to clinic <5km
|
11(50.0)
|
10 (47.6)
|
21(48.8)
|
>5km
|
11 (50.0)
|
11 (52.4)
|
22 (51.2)
|
KEY: MTRH – Moi Teaching and Referral Hospital; KCGH – Kakamega County General Hospital
Feasibility outcomes
i) Quantitative
Over three months, 91 young/teenage mothers were assessed for eligibility (recruitment rate=30/month), 52 agreed to participate and 43 were retained (overall attrition rate=17.3%; differential attrition=15.4% vs 19.2% for intervention and control groups respectively). Only seven mothers were recruited and enrolled in the 12-16 age group across both study centres, with the youngest mother being aged fourteen. During recruitment, most mothers (79%) singled out their parents as their primary support persons after birth.
ii) Qualitative
During recruitment, it was observed that several mothers, who were otherwise eligible for recruitment, did not have personal mobile phones and so were consequently excluded. This finding was also noted during the midwives’ interviews, who observed that many young/teenage mothers did not have mobile phones, as illustrated by the following excerpts:
‘Many young adolescents mothers do not have phones, you may call when some are in school, some parents may not want them to receive the phone calls, and some may have sim cards, without cell phones……’ [Midwife2, Site2]
‘………some did not have telephones……and some were using the phone calls of their parents of whom when you would pass information, they would not faithfully transmit it to the recipients …..’ [Midwife1, Site1]
Although the study initially set out to conduct FGDs concurrently after the questionnaire survey, this was not feasible as mothers came in at different times and thus it was not possible to constitute such FGDs. The FGDs were therefore planned and conducted on an agreed date and time with the mothers who were willing and consented to take part. Further, with the limited sample (n=7) recruited in the younger age group, individual interviews were only feasible for the younger mothers.
Acceptability/views on intervention
The intervention was acceptable by midwives and young mothers. Most midwives welcomed the idea of TSI and described it as ‘a good idea or initiative’ and thought that it would be acceptable among their fellow midwives and other healthcare providers. In addition, most midwives thought their institutions had the capacity to implement such innovative interventions as telephone support. As noted in the midwives’ FGD, one of the midwives observed that as midwives, they always wanted to know the progress of their clients/patients after discharge, as illustrated by the following excerpt:
“……as a midwife, I strongly concur with it [TSI] because many times, you hear my colleagues say, ‘how is so and so, we took care of her, nursed her for three days and discharged her in a fairly stable condition’… this is prove that we are interested to know the progress of our patients” [Midwife1,FGD, Site1]
Interestingly, similar thoughts were also shared by another midwife at the second study centre, who stated:
‘….. my personal experience as a midwife, I have really enjoyed on doing follow up, therefore, I know my fellow midwives will embrace and even other health workers, because, honestly after handling, treating, nursing and discharging a patient, you will keep on asking questions, wanting to know the patients’ progress….’ [Midwife3, Site2]
Similarly, young/teenage mothers perceived TSI as beneficial particularly in helping them to (effectively) transit and assume motherhood responsibilities. In particular, those who received the TSI highlighted perceived benefits, ranging from critical aspects such as breastfeeding support to infant care practices such as bathing and changing the baby, and including being reminded on their clinical appointments. The following excerpt clearly illustrates the mothers’ views of the TSI:
‘The telephone support and the text messages were of greater importance to me and my baby because I learnt many things…. it was my first time to give birth and my first experience on breastfeeding and I needed guidance….’ [Young mother, 17 years, FGD1Site1- participant in focus group discussion1 in Site1]
The midwives and young/teenage mothers also perceived telephone support to be cheaper than travelling to the clinic/hospital. Midwives felt that there are some aspects of care that could easily be addressed through telephone support, thereby helping mothers to save on fare as well as travel time to the clinic/hospital, as illustrated by the following excerpts:
‘……and even it will be cheaper economically and less time consuming, as in, wasting time and fare travelling from the village to hospital to seek assistance….and yet it can be sorted out using a two minutes phone call or a mere text message’ [Midwife1, Site1].
‘I would really like the use of telephone support because some of us stay so far away from this hospital, so, it will be easier when we receive telephone support……’ [Young mother, 19 years, FGD2Site2 – participant in focus group discussion2 in study Site2]
Additionally, the potential benefits of TSI in maternal and infant care were elicited. Table 2 highlights the thematic areas of the qualitative findings regarding the perceptions of both midwives and young mothers of the intervention.
Table 2: Midwives’ and young mothers’ perceptions of telephone support intervention in maternal and infant care
Subthemes
|
Illustrative quotes
|
TSI as a means of knowledge dissemination to young mothers
|
‘It is [TSI] a good idea, because you will be passing forth knowledge, you know, you will be having one on one contact with them, so they will open up…….’ [Midwife2, Site1]
‘Sending text messages and making phone calls as midwives to these young mothers will be very important, informing on cord care and some of the danger signs…….’[Midwife1, Site2]
‘Yes, I would have gained a lot because I would have been educated on breastfeeding and general guidance on baby care like especially on cord care’ [Young mother, 19 years, FGD3 Site 1]
|
TSI as a means of bridging the gap in healthcare access
|
‘…..they need ….additional support through telephone support especially for those who can’t travel to hospital……’ [Midwife1, Site1]
‘……. it will help solving many issues, especially to the ignorant people in the society, hence will not be a must for a young adolescent mother to travel to hospital……’ [Midwife2, Site 2]
‘Sending text messages and making phone calls as midwives to these young mothers will be very important …….in fact for those who are not educated in those remote villages need more health support than others……..’ [Midwife1, Site2]
|
TSI as a means of providing continuity of care/follow up
|
‘……as a midwife, I strongly concur with it because many times, you hear my colleagues say, “how is so and so, we took care of her, nursed her for three days and discharged her in a fairly stable condition" this is prove …. that we’re interested to know the progress of our patients’ [Midwife1, FGD,Site1]
‘Yes, if health workers send us the text messages, we will benefit because it’s important for follow-up of our babies and our health too……’ [Young mother, 17 years , FGD3 Site1]
|
Perceived effect/influence of TSI in MIC/midwifery
|
‘I strongly suggest that we also do the same to in antenatal period’
[Midwife1, Site2]
‘……it [TSI] will greatly reduce both maternal and neonatal deaths because they will know how to handle the danger signs…..’[Midwife1, Site2]
‘In the recent past…… we have had neonatal and maternal deaths because of ignorance, so, if telephone support is implemented, it will help a great deal to curb these deaths...’ [Midwife 8, FGD, Site1]
|
Psychological outcomes
Although the study was not aimed at looking for statistical significance, the results offer some insight into the value of the tools used and may be incorporated in meta-analyses. There was no difference between groups in means for both postnatal depression (EPDS) (intervention group mean 8.5, control group mean 8.6, p=0.916) and maternity social support (MSSS) (intervention group mean 22.9, control group mean 22.5, p=0.763), with small effect sizes (Cohen’s d=-0.03 and 0.09 for EPDS and MSSS) respectively. Mothers in the intervention group appeared to have a very slightly higher self-esteem (mean=23.0, median=25) compared to the control group (mean=21.6, median=22); and appeared to have a slightly lower infant-focussed anxiety (mean=2.6, median=1.5) than the control group (mean=3.7, median=4.0). There was no statistically significant difference between groups in means for maternal self-esteem (SES), (p=0.087) and postpartum bonding factors (PBI-1, PBI-2 and PBI-3, all p>0.05), but there was a moderate effect size for SES (Cohen’s d=0.54). Table 3 and Table 4 summarise these statistics.
Table 3: Descriptive statistics by randomised group
Outcomes
|
Intervention (n=22)
|
Control (n=21)
|
Mean (SD)
|
Median
|
95%CI
|
Mean (SD)
|
Median
|
95%CI
|
Postnatal depression index (EPDS)
|
8.5 (5.1)
|
8
|
6.2 to 10.8ⱡ
|
8.6 (4.9)
|
9
|
6.4 to 10.9ⱡ
|
Maternity social support (MSSS)
|
22.9 (4.5)
|
22
|
20.9 to 24.9 ⱡ
|
22.5 (3.8)
|
22
|
20.7 to 24.2 ⱡ
|
Maternal self-esteem (SES)
|
23.0 (4.5)
|
25
|
21 to 26 ⱡ ⱡ
|
21.6 (3.2)
|
22
|
20.0 to 24.0 ⱡ ⱡ
|
Postpartum bonding-Factor 1 (General)
|
6.8 (5.8)
|
6
|
4 to 8 ⱡ ⱡ
|
6.7 (3.8)
|
7
|
4.0 to 10.0 ⱡ ⱡ
|
Postpartum bonding-Factor 2 (Rejection & Pathological anger)
|
3.0 (3.4)
|
2
|
0.001 to 5 ⱡ ⱡ
|
2.9 (2.8)
|
2
|
0.001 to 5.0 ⱡ ⱡ
|
Postpartum bonding-Factor 3 (Infant-focussed anxiety)
|
2.6 (2.5)
|
1.5
|
1 to 5 ⱡ ⱡ
|
3.7 (3.0)
|
4
|
0.001 to 6.0 ⱡ ⱡ
|
ⱡ95%CI for means; ⱡ ⱡ95%CI for median
Table 4: Differences between randomised groups with effect sizes
Outcomes
|
Test statistic
|
p-value
|
95%CI for difference in means or medians
|
Effect size (Cohen’s d)
|
Postnatal depression index (EPDS)
|
t=-1.07
|
0.916
|
-3.28 to 2.95 ⱡ
|
-0.03
|
Maternity social support (MSSS)
|
t=0.304
|
0.763
|
-2.19 to 2.97 ⱡ
|
0.09
|
Maternal self-esteem (SES)
|
MW Z=-1.709
|
0.087
|
0.001 to 4.00 ⱡ ⱡ
|
0.54
|
Postpartum bonding-Factor 1 (General)
|
MW Z=-0.416
|
0.678
|
-3.00 to 1.00 ⱡ ⱡ
|
0.13
|
Postpartum bonding-Factor 2 (Rejection & Pathological anger)
|
MW Z=-0.250
|
0.803
|
-2.00 to 2.00 ⱡ ⱡ
|
0.07
|
Postpartum bonding-Factor 3 (Infant-focussed anxiety)
|
MW Z=-0.911
|
0.362
|
-3.00 to 1.00 ⱡ ⱡ
|
0.28
|
ⱡ95%CI for difference in means; ⱡ ⱡ95%CI for difference in median; MW=Mann Whitney test
Additionally, mothers who received telephone-support were less likely to report being ill (22.7% vs 71.4%; % difference=48.7%; 95 % CI for % difference=18.9% to 68.1%); experiencing difficulty in breastfeeding (9.1% vs 38.1%; %difference=29.0%; 95%CI for % difference=3.5% to 51.0%); and initiating early-weaning (22.7% vs 52.4%; % difference=29.7%; 95%CI for % difference=0.9% to 52.7%).