Study setting
This study was carried out at Dodoma Municipal for both the intervention group and control group from January to November, 2018. Dodoma Municipality is found in Dodoma Urban. The region is one of Tanzania’s 30 administrative regions as well as a Capital city of the country. It lies centrally in the eastern-central part of the country; it is about 300 miles (480 km) of the coast. Dodoma Urban District is one of the seven districts of the Dodoma region of Tanzania. It is bordered to the west by the Bahi district, and to the east by Chamwino district. According to the 2012 Tanzania national census, the population of Dodoma urban district was 410,956 and the area of 2,576 square kilometers (11). Dodoma is one of the regions with the highest maternal mortality rates in Tanzania as in 2012, Dodoma ranked the ninth high burdened region with a maternal mortality rate of 512/100,000 live births (12) .
Within the municipal, there are two major public hospitals; the Makole health center which serves as the main antenatal care facility and the Dodoma regional referral hospital which caters for all deliveries for high-risk mothers. In this study, the interactive mobile health was developed and pregnant mothers Attending Antenatal care Services at Makole Health center and Chamwino Dispensary were followed and receive text messages regarding their pregnancy. Control group were taken from other facilities offering RCH and delivery services in Dodoma Municipal which were not selected for the intervention and included Hombolo Health center, mkonze health centre and St.Gemma hospital.
Study Design
The study was a Quasi-experimental study with control group. The intervention group was enrolled in the Interactive system and received Health education messages pertaining to their pregnancy, whereas control group went on with the normal Standard ANC service being offered in our ANC local clinics.
Study Population
All pregnant women who started their first antenatal visit below the first twenty weeks .Controls were pregnant who used the current antenatal care assessment modality as per Tanzania guideline that also started their first visit below the first 20 weeks. Controls were matched to the intervention group by age group, education level, gravidity Parity and gestation age.
Sampling Technique
A purposive sampling method was used to select healthcare facilities offering ANC and delivery care services in Dodoma Municipal. Purposeful sampling was employed to ensure that data came from all levels of the maternal services referral system in the region. Systematic random sampling method was used to select participants for both the intervention and control groups. Every third pregnant woman among those who met the criteria in a given day and agreed to participate in the study was selected until the required number of sample was obtained.
Sample Size
The sample size for the Intervention and Control group was obtained by using the formula for comparing two independent samples(Intervention group against control group), and using proportion women attending Four visit or more at baseline was 51% and after intervention it was 63% as per (Ekirapa, Muhumuza, Tetui, & George, 2017), A Quasi-experiment that was done in Rural Uganda on Maternal Health Service utilization and Newborn care. Standard normal deviation of 1.96 at 95% confidence interval (CI) with 5% attrition rate. So, the minimum sample size was 142 plus 5% Attrition = 150.The ratio of the Intervention group to control was 1:2, so controls were 300. The total sample size in this study was 450 pregnant women.
Inclusion and exclusion criteria
All pregnant women who started their ANC first visit below 20 weeks, attending ANC and planning to deliver in Dodoma Municipal and who owned phones and consented to participate were considered for the study. Pregnant women who were receiving pregnancy-related health text SMS from other sources through their mobile phones and those who meet the inclusion criteria and refused to participate were excluded from the study.
Measurements Of Variables
Antenatal care service utilization:
Adequate antenatal care service utilization was measured by:
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ANC care provided by skilled health personnel (a nurse or a doctor)
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Sufficient number of ANC visits (4 or more visits during pregnancy),
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Appropriate ANC content provided (Included at least 13 out of 15 of the recommended basic care procedures or contents).The sample was divided into two outcome categories: Received adequate antenatal care (delivered by skilled health personnel, Sufficient and with appropriate content).received inadequate antenatal care (services which did not fully comply with the above criteria). Adequate ANC care corresponded to receiving thirteen out of fifteen basic ANC This method of scoring has been previously used in Mexico to measure the adequacy of antenatal health It was adopted and modified to fit the Tanzania content (8).
Components of antenatal care offered in Tanzania include
Blood test for hemoglobin level, urine test for protein and sugar, obstetric exam, blood pressure measurement, maternal weight/height, rapid syphilis test, blood type and Rh factor testing, tetanus toxoid vaccine, iron/folic acid supplementation, antimalaria prophylaxis and client health education and counseling as well as HIV/AIDS testing, one ultrasound scan in the first 24 weeks of pregnancy. Currently, all the information are being recorded on the antenatal card (RCH4).
Research Instrument/tool
Semi-structured questionnaire (with both closed and open-ended questions) was developed to be interviewer-administered. This ensured that those unable to read and write could fully participate and also to ensure optimal capturing of all the needed information. The questionnaire included questions on socio-demographic characteristics, utilization of antenatal care services. The questionnaire was first developed in English and then translated later to Kiswahili which is the national language of Tanzania and the language used by the study population. The questionnaire was adopted and modified from Jhpiego and modified to fit the Tanzanian context (14) also from Tanzania Demographic and Health Survey 2015/2016 and from Nepal Demographic and Health Survey (15).
Overview Of The System
Interactive mobile health system is a computerized system that ensures the provision of reproductive health and communication between pregnant woman and the medical practitioners. The system started working in January, 2018 whereby pregnant women who started their first antenatal visit below 20 weeks were recruited and enrolled at Makole Health Centre and Chamwino Dispensary. The participants were followed until delivery. The system tracks every visit diagnosis and assembles them to give the general health overview of a woman in each trimester of the visit. The system also included an SMS Module where pregnant mothers were notified with SMS texts about when to come for the next visit and were also given health tips and were also able to call and text back for clarification when need arises .See the diagram below
Data Processing And Analysis
In this study, data was analyzed by using the Statistical Product for Service Solutions (SPSS) software program version 21. Before conducting the analysis, the error checking (data cleaning) was performed by using Frequency distribution tables to see if all the data were entered correctly. Each variable was manually cross-checked to ensure validity and reliability of the findings. Scores that were out of range were corrected to avoid distortion of the statistical analysis.
Descriptive analysis was used to analyze participant’s characteristics to determine the frequencies and percentages of their distributions between the two groups. Chi-square test was employed to analyze all categorical data to see their distributions between the two groups and to establish the relationship between the categorical variables and the outcome variables. Independent two-sample T-test was used to compare the mean scores and establish any effect of the intervention between the two groups. Logistic regression analysis was also used to establish the association between the interactive mobile health system and ANC service utilization. A confidence interval of 95% with the margin of error 5% (0.05) were used as statistical measure of significance (< 0.05 was regarded as significant while > 0.05 not significant).