The evaluation of mMitra took place from June 2015 to January 2017. Over 23,500 households were visited and 2,050 pregnant women were identified as eligible. A total of 2,016 pregnant women were enrolled in the study. Of those, 1,516 were allocated to the intervention group and 500 to the control group (Figure 1).
Enrollment and baseline surveys (Time 1) lasted from June-October 2015, ending when the requisite numbers of women had been enrolled in the intervention and control groups. The post-partum surveys (Time 2) started in November 2015 and ended in March 2016 when all women enrolled had delivered their babies.
Characteristics of the Study Population
There were 2,016 pregnant women enrolled in the study. At baseline (Time 1), the 1,516 women in the intervention group and 500 women in the control group were similar in age, parity, education, family type, and membership in a social community . However, women in the intervention group were more likely to be employed, own a mobile phone, listen to a radio, read the newspaper, and have literate and employed husbands . This changes at Time 2 when conducting per protocol analyses: women in the intervention group were more likely to be older (p=0.001) and watch TV (p=0.013) yet have no difference in employment status, newspaper reading, or their husband’s literacy or employment status as compared to controls (Table 1).
Of the women enrolled, 1,750 (87%) were reached at Time 2. There were 174 women (11.4%) lost to follow-up in the intervention group compared to 92 (18.4%) in the control group. The reasons for attrition included moving out of the area, addresses not locatable, mobile phones switched off or women refusing to be interviewed (Figure 1). Unfortunately, one woman in the control group died during delivery. Also, at Time 2, 16 (3.9%) of the 418 women in the control group reported receiving mMitra calls, and 229 (17%) of the 1,342 women in the intervention group reported never receiving mMitra phone calls. According to per protocol analyses, the data for these women were discarded, resulting in the data of 1,515 women being analyzed (intervention n=1,113, control n=392).
Women in both groups did equally well in retaining their MCH cards. There were 1,734 women (87.5% in the intervention group, 81.6% in the control group) who showed their MCH cards at Time 1. At that time, 12% of women in their first trimester reported that they were yet to receive their cards, and 19% had the cards but refused to show them to the investigators. More women in both groups at Time 2 showed their cards to investigators (93.4% in the intervention group, 94.8% in the control group). However, there was a small but significant difference in the recording of health information in the MCH cards, with women in the intervention group having more complete cards as compared to controls for the number of ANC visits completed, weight and blood pressure measurements during ANC visits, and receiving a tetanus shot.
There were also discrepancies found between women’s self-reports (via the surveys) and documentation in the MCH cards for both groups. For example, over 90% of women self-reported making at least 3 ANC visits but only 20% of cards had a record of three or more ANC visits. Similarly, 96% of women self-reported receiving a tetanus toxoid injection while only 25% of cards had recorded administration of a tetanus toxoid injection. None of the MCH cards showed women being provided or prescribed calcium tablets, though over 67% of women reported taking calcium tablets during pregnancy.
Impact on Maternal Health Practices
The impact of mMitra on maternal care practices was compared between intervention and control groups using data collected at Time 2 on 22 maternal practice indicators (Table 2). The intervention group performed significantly better on the following 4 practice indicators: receiving the tetanus toxoid injection (OR: 1.6, 95% Confidence Interval (CI): 1.05-2.4, p=0.028), consulting a doctor if spotting or bleeding (OR: 1.72, 95%CI: 1.07-2.75, p=0.025), saving money for delivery expenses (OR: 1.79, 95%CI: 1.38-2.33, p=0.0001), and delivering in hospital (OR: 2.5, 95%CI: 1.49-4.35, p=0.001). While not statistically significant (p=0.077), women in the intervention group had 28.5% increased odds of registering their pregnancy in the first trimester as compared to controls.
By contrast, the control group performed significantly better than the intervention group on 2 practices indicators: resting regularly during pregnancy (OR: 0.7, 95%CI: 0.54-0.88, p=0.002) and having at-home deliveries attended by a skilled birth attendant (OR: 0.46, 95%CI: 0.23-0.91, p=0.027).
The groups performed similarly for the remaining practices during pregnancy, especially those related to anemia control, such as consuming iron and folic acid supplements, eating more frequently, eating nutritious food during pregnancy, and consulting the doctor for symptoms like tiredness (when experienced).
Impact on Clinical Maternal Health Outcome of Anemia
Clinical data on hemoglobin levels were only available for 24.3% of women in the control group and 33.8% of women in the intervention group. Subsequently, anemia status at or near the time of delivery, based on hemoglobin levels, could not be assessed.
Impact on Maternal Care Knowledge
For 13 of the 15 knowledge indicators compared at Times 1 and 2, there were improvements within both groups. However, one knowledge indicator was significantly increased among women in the intervention group: women should see a doctor in the first trimester of pregnancy. When comparing knowledge at Time 2 in the intervention group versus controls, adjusted analyses indicated that women in the intervention group had 2.13 times increased odds of agreeing that medical support is required during pregnancy (95%CI: 1.17-3.86, p=0.013). There were no indications of differential knowledge on the other health topics including other reasons for medical support during pregnancy, nutrition and supplements, and birth spacing. Additionally, there was no discernable association between background demographic characteristics and knowledge levels.
Women’s Experience with mMitra Messages
Of the women in the intervention group at Time 2, 975 (88%) report receiving the mMitra calls. For the remaining 12%, system data on call logs indicate that calls were being sent to the designated number, but nearly 50% were not answered and the other half were answered by family members (not the woman).
Close to 43% of women reported listening to the calls by themselves. Roughly 79% of the women who reported receiving the calls said that they often to always listened to the entire message. Close to 91% of women were satisfied to very satisfied with the mMitra calls, and 92% found that the calls were useful. Only 28.7% knew about the “missed call” function, and 19.2% reported using it.
Approximately two thirds of respondents reported discussing information contained in messages with family members and friends (60% with other family members, 61% with mother-in-law, 65.2% with friends). Most women (86%) reported discussing the information with their husband. Over 60% of women reported that mMitra had improved their health awareness, and by sharing that information with family members they felt comfortable in seeking assistance in daily chores and in taking care of themselves. However, only one third of women said that they felt comfortable discussing pregnancy-related problems with the health staff.