In developing countries, women face a lifetime risk of maternal death of one in 160, as compared with 1 in 3700 for women living in developed countries(1). Pakistan has one of the highest maternal mortality ratios worldwide at 276/100,000 live births (2). One out of 140 Pakistani women faces a lifetime risk of maternal death (3). Most women die because of complications that occur during pregnancy, at delivery, and during the postnatal period (4). Evidence suggests that antenatal care (ANC) from a skilled provider is important to timely identify and manage preventable maternal morbidities such as preeclampsia, eclampsia, antepartum hemorrhage, obstructed labor, postpartum hemorrhage and puerperal sepsis, which are contributing to nearly 70% of all maternal deaths(2). ANC interventions have proven to be key health interventions to decrease maternal mortality in LMICs, such as Tanzania and Ethiopia (5, 6). Most importantly, there is need for reinforcement of prevailing evidence-based practices that include World Health Organization (WHO) recommended number of ANC visits (minimum of four ANC visits) to improve maternal health outcomes (7).
The Pakistan Demographic and Health survey (PDHS) 2017-18 shows that only 51% percent of women received four or more ANC visits (8). This means that there are missed opportunities for almost half of the women who were not able to seek the recommended antenatal visits. In Thatta district, the maternal mortality ratio is estimated at 313/100,000 live births. This estimate is based on a Maternal and Newborn Health Registry (MNHR), which is maintained by Global Network for Women’s and Children’s Health Research Network (GN). A recent trends analysis of ANC showed that the percentages of women receiving at least four ANC visits in Thatta is substantially lower (40%) (9). To meet the targets of the United Nations’ Sustainable Development Goal 3 by 2030 (maternal mortality ratio <70/100,000 live births) (10), novel and innovative strategies are required to decrease the rate of maternal mortality by improving the uptake of ANC services. An apparent and accessible strategy to meet this goal is to utilize the potential of simple mobile phones to increase the number of ANC visits (at least 4) among antenatal women.
Various studies reported that mHealth interventions, particularly those delivered through SMS and voice calls, are associated with improved utilization of preventive maternal healthcare services, including uptake of recommended ANC and PNC services. In Njoro Division, a randomized controlled trial evaluated the impact of mobile telephone support on antenatal attendance. A group of 191 pregnant women were regularly given advice and prompts regarding pregnancy care and scheduled antenatal visits through mobile phone; whereas the other groups of 206 pregnant women were provided usual care to continue antenatal visit. Positive association was found among women in intervention group and the number of ANC visits (96.4% in intervention group and 92.3% in the control group, P value: 0.002)(11). A pragmatic cluster randomized controlled trial was conducted in primary healthcare facilities of Zanzibar. The primary outcome measure of the trial was four or more ANC visits. The SMS intervention was related with an improvement in ANC visits in the intervention group. In the intervention group, 44% of women attained four or more ANC visits versus 31% in the comparison group (OR, 2.39; 95% CI 1.03–5.55)(12). In a rural area of Tamil Nadu, India, a pre-post study was conducted to evaluate whether mobile text messaging service is a feasible mode of raising knowledge level regarding Maternal and Child Health (MCH) services. Data was obtained using a questionnaire in three phases; a) baseline assessment, b) intervention: MCH related messages were sent, c) end line assessment. It was found out that 45 (37.5%) individuals knew about minimum number of antenatal visits during pregnancy after receiving text messages, as compared to 12 (10%) individuals before receiving text messages (P value <0.05, 95% CI: 0.16–0.38)(13). Three systematic reviews have been conducted on using mHealth applications for improving antenatal and postnatal care in low and middle income countries. All of reviews have reported that mHealth interventions have proven to be effective to improve antenatal care and postnatal care services, especially those that are aimed at changing behavior of pregnant women through SMS and voice messages (14-16).
However, the feasibility and effectiveness of mobile health interventions to increase uptake of preventive maternal healthcare services among pregnant women in different settings may be different due to differing patient demographics, cultural diversity, environmental and behavioral factors, availability and accessibility to mobile phones, and budgetary constraints. Prior to implementing a similar intervention in Thatta District, it is crucially important to assess the mobile phone access, usage and willingness among women to receive voice-message based mHealth intervention to improve antenatal care attendance.
Scope and objectives
- To assess the access and usage of mobile phone among MWRA in district Thatta, Karachi
- To determine the willingness of MWRA to receive voice-message based mHealth intervention to improve antenatal care attendance in district Thatta, Karachi
Operational definitions
- Mobile phone access: Access to basic mobile phone or smart phone, mobile phone ownership (self or shared)
- Mobile phone usage: quantifies the extent to which a person uses a phone, or categorizes the types of uses and situations in which use occurs
- Willingness for mHealth intervention: Women willing to receive voice message to improve ANC attendance. If yes, what are the preferences for language, time to receive voice message etc. If no, what are the barriers or reasons for poor willingness
Hypothesis
Married women of reproductive age in district thatta, who have access to simple mobile phones, would be willing to receive voice message to improve antenatal care attendance.