Characteristics of the study participants
Of a total of 24 in-depth interviewees (Table 1), ten were pregnant women, five were postpartum women, four were mothers-in-law, and five were husbands. All pregnant women were housewives from 18 to 26 years of age. At the time of the interview, the mean gestational age was 23 weeks and four days (8–36 weeks). Among the ten pregnant women, four were pregnant for the first time. Seven pregnant women had less than 10 years of education, and the rest had more than10 years. All the postpartum women were housewives, and 22–32 years old. Three postpartum women had completed less than 10 years of education and two women, more than 10 years. The five husbands ranged from 25 to 41 years of age; four had less than 5 years of formal education, and one up to 10 years.
Table 1
Characteristics of study participants
| Participants | Mean age in years (range) | Education level (years) | Household type | Parity |
| Pregnant women | 22 (18–26) | Secondary (6–10): 7 Higher secondary (> 10):3 | Single family:3 Extended family:7 | Nullipara:4 Multiparous:6 |
| Postpartum women | 25 (18–32) | Secondary (6–10): 3 Higher secondary (> 10):2 | Single family:2 Extended family:3 | Parity = 1:1 Parity > 1:4 |
| Mothers-in-law | 55 (50–60) | Primary (0–5):3 Secondary (6–10):1 | | |
| Husbands | 35 (28–41) | Primary (0–5):4 Secondary (6–10): 1 | | |
| Perceived susceptibility and severity of pregnancy complications |
Knowledge of pregnancy-related complications
High blood pressure as a pregnancy complication was spontaneously mentioned by half of the postpartum women, but few pregnant women reported high blood pressure. Convulsions were mentioned as a common consequence of hypertension by most postpartum women spontaneously, but only one pregnant woman reported this. Anemia was rarely mentioned as a pregnancy-related complication by the pregnant and postpartum women without probing. Other complications reported by pregnant and postpartum women from their personal and family experiences included excess vomiting, less fetal movement, tetanus, breech presentation, white discharge, and fever. Women with children mentioned more complications compared to women who had never given birth. One pregnant woman said, “I have heard many women have problems. Some suffer a lot during delivery, a girl from the neighborhood delivered at eight months. This girl also had pressure. For pressure, she went to the doctor one week or two weeks ago.”(Pregnant woman, age 20, para 0)
Another pregnant woman stated, “Different types of complications could arise; there would be a pain in the lower abdomen if a pregnant woman does heavy work. Then if the pregnant woman doesn't take the proper amount of water, the baby doesn't move properly, or less, that is also a problem." (Pregnant woman, age 25, para 2)
Most of the mothers-in-law mentioned common pregnancy complications such as headache, abdominal pain, vaginal bleeding, anemia, convulsion, high blood pressure as well as other diseases that could complicate the pregnancy like jaundice, tuberculosis, and pneumonia. The majority of the husbands mentioned very few complications such as anemia, vomiting, reduced food intake, abdominal cramp or pain, weakness, and edema. Two husbands could not mention any complications related to pregnancy. When we asked about pregnancy complications, one husband stated that “we do not understand the feminine problem.” (Husband, age 40, CNG driver)
Perceived susceptibility to, and severity of, anemia, hypertension, and gestational diabetes
Women were prompted to discuss three specific pregnancy-related complications: anemia, hypertension, and diabetes. Spontaneous knowledge of anemia and diabetes was minimal among all respondents and, in particular, its association with pregnancy. Only one pregnant woman spontaneously reported that anemia was a pregnancy-related complication, but she was unaware of the consequences. One postpartum woman mentioned anemia from her personal experience. Another pregnant woman stated after prompting, “I have heard that anemia could happen. I have no idea. I can’t say what could happen to the mother and baby.” (Pregnant woman, age 22, para 1)
Few husbands knew about anemia and its consequences. Concerning diabetes, only one pregnant woman stated, after probing, “I have heard about diabetes. I know that it happens to people, but I also heard it might happen during pregnancy.” (Pregnant woman, age 22, para 1)
Knowledge of hypertension was quite different between pregnant and postpartum women, in that most postpartum women knew about hypertension in pregnancy and its consequences. Still, very few pregnant women, husbands, or mothers-in-law had the same level of knowledge. Only one pregnant woman could spontaneously mention hypertension since one of her relatives had suffered from it and developed convulsions later on.
“If the pressure rises, that could create problems. If it’s high, some may have convulsions during pregnancy. I saw someone who had convulsions due to pressure. Then again, low pressure is also bad.” (Postpartum woman, age 27, para 4)
Another pregnant woman stated “I know that pressure increases. Increased pressure could create problems. But I don’t know what would be the problem or what harm could happen.” (Pregnant woman, age 18, para 0)
Misconceptions about anemia in pregnancy and gestational diabetes were common among pregnant and postpartum women. Some pregnant and postpartum women linked anemia only to blood loss during delivery. They thought that women were less likely to develop anemia during the first pregnancy, and that women with previous births could develop anemia due to blood loss at delivery. One pregnant woman stated “This is my first pregnancy; I should have plenty of blood in my body .” (Pregnant woman, age 18, para 0)
Women has no clear concept of gestational diabetes; one of them stated: "Many pregnant women develop diabetes after delivery…my elder brother’s wife didn't have any disease previously, but after delivery of her last child, diabetes was diagnosed.” (Postpartum woman, age 28, para 2)
Care for complications:
When we asked participants what they would do for pregnancy-related complications, all stated that they would visit a qualified doctor. One postpartum woman stated that pregnant women with anemia should take iron tablets and nutritious food. Another postpartum woman said that "If any problem arises, I will not understand whether I have any complication or not. I need to visit a doctor and take advice." (Postpartum woman, age 28, para 2)
Antenatal care practices
The perceived benefit of ANC attendance
Almost all pregnant and postpartum women mentioned that ANC is necessary to know the status of the baby and mother but could not mention the importance of timely ANC for appropriate screening and management as preventive care. ANC was mostly viewed as necessary during pregnancy only if complications developed. In addition women also thought that the health care provider needs to inform pregnant women about ANC utilization.
One pregnant woman with two children and in her fifth month of pregnancy stated “I am well now, it isn’t necessary to go to the healthcare provider now, and they haven’t even called me yet… if any healthcare provider calls me for ANC, I will go for an ANC visit, but if she doesn't come to me I will not go for it. It is her duty, not mine." (Pregnant woman, age 24, para 2)
Another postpartum woman stated "The benefits of check-ups are that I could get to know whether the baby is in the upper or lower abdomen or healthy. It is also possible to know the status of the baby as well." (Postpartum woman, age 28, para 2)
Mothers-in-law also stated that ANC is needed to know the status of the baby and the mother but could not mention the importance of timely ANC for appropriate screening and management as preventive care. Similar knowledge was found among husbands, although one of them stated that ANC is important to see the growth of the baby, and to identify problems. One husband stated that there is no need for ANC during pregnancy: “I don’t think that ANC is important, as my wife did not suffer from any problem, I didn’t give any importance to ANC. If she suffered from any complication, I would have gone to the doctor with my wife and ask about the problem” (Husband, age 28, cook)
First ANC attendance
Only half of the pregnant women had received their first ANC prior to the interview. Those that had not received ANC were less than five months of gestation. Their perceived need to attend ANC within five months was low. They believed that the chance of miscarriage within five months to be high, and they did not perceive that ANC played any role in preventing miscarriages.
One pregnant woman at four months of gestational age said: "within five to six months, I have a plan to visit the facility for antenatal care." (Pregnant woman, age 18, para 0)
Another pregnant woman at the same gestational age said: "No, I don’t need to visit yet.” (Pregnant woman, age 18, para 1)
On the other hand, most of the postpartum women had received ANC, and the majority had attended ANC following complications during their pregnancy or due to previous pregnancy complications. Other pregnant and postpartum women who had not experienced problems earlier received their first ANC after five months of gestation. Most women felt that if any health problem arises during pregnancy, then they need to visit a doctor. One woman stated that “if I suffer from any problem, I should visit a doctor and follow doctor’s advice." (Pregnant woman, age 25, para 2)
When we interviewed husbands, they reported that their wives did attend ANC. Among the five, three visited a facility within four months. One husband mentioned "I have a child, if I didn’t have a child, I would not have known about the check-ups. After three months and up to delivery, we need to go monthly for check-ups. As we have the government hospital and don’t need to pay, we go for check-ups monthly." (Husband, age 40, CNG driver)Follow-up ANC visits
Health care providers shared information about follow-up visits with about half of the pregnant women who had ever attended ANC but did not provide specific dates for follow-up visits. Most of the women who received information on the timing of follow-up ANC visits actually attended those follow-up ANC visits, while the inverse was true for those who did not receive detailed information. More than half of the pregnant women and most of the postpartum women received at least one follow-up ANC, but it was not aligned with the recommended schedule of ANC visits. The women reported attending follow-up visits when they faced complications, and in this regard, one pregnant woman said, "I visited a doctor for vomiting, and she prescribed medicine. But the condition is the same, although I am taking medicine. I am at six months. Still, I am vomiting. During the first visit, I was told that it would subside gradually. If it happens more frequently, then I plan to visit a doctor. I vomited once, and then it stopped; therefore, I didn’t visit.” (Pregnant woman, age 24, para 2)
Perceived barriers to ANC attendance:
Pregnant women who did not attend care reported a wide range of reasons including lack of decision making power, distance to the facility, being too busy, not being satisfied with the treatment by health care providers, non-cooperation by their husband, and unavailability of any family member to help in the household. One woman mentioned “I did not panic. I cried a lot yesterday. I know a little bit about what I should do this time. But I am unable to do anything. If I can't go to the doctor now, what I know, what I am worried about is that, if I lost blood like this, it would be harmful to my baby. My baby would only be healthy if I have enough blood. Now, if I lost blood this way, this would be harmful to me. But I cannot do anything.” (Pregnant woman, age 25, para 2)
Self-care and family support
We further explored women’s general attitudes to taking care of their pregnancy through self-care and their families’ supportiveness of her pregnancy and care. The majority of women practiced healthy behaviors such as eating adequate nutritious diets, avoiding heavy work, and resting. Most of the mothers-in-law and husbands knew that pregnant women need to eat nutritious food, take proper rest, and avoid lifting heavy things. Only very few pregnant women, pregnant for the first time, mentioned dietary restrictions such as selected fishes and green coconut during pregnancy.
Most of the women living with extended families received household support from their family members, especially from mothers-in-law. “My mother-in-law brings me some water, or sweeps the room, and helps to cut the vegetables. I do all the cooking and other work. My husband doesn’t stay at home; he goes for work in the early morning and comes back at 10 or 11 at night. Within that time, I usually finish all household chores. ”(Pregnant woman, age 25, para 2)
In a few cases, husbands helped their wives with household work. “I have my mother-in-law, but she can’t work due to her excess weight and old age. She can’t help me; she is more disabled. My husband helps me a lot. Like if there are a lot of heavy clothes to wash, bed covers, or curtains, he washes those for me. And we also have cows; he looks after those, I don’t do any work related to cow ranching. He also fetches water for me if I need more water. I have to do the rest as I am the only one in this home.” (Pregnant woman, age 20, para 1)
Women living in single-family households generally did not get support for their household work.
One pregnant woman living in a single-family household (i.e., without extended family) reported most components of appropriate self-care as defined in the national ANC guidelines, but could not avoid doing heavy household work and mentioned “I am the only female in the household. I have two small children. While cooking, I may need to do some heavy work, need to bring water, and wash clothes.” (Pregnant woman, age 26, para 2)
One postpartum woman stated “In this pregnancy, I did a lot of work. In addition to my household works, I had to take care of 4 cattle and need to collect grass from the field to feed them. On the last day, my pain started, just after finishing grass cutting.” (Postpartum woman, age 27, para 4)
Decision making for maternal and child care service utilization
When the pregnant and postpartum women were asked about the decision-maker regarding their healthcare service utilization, most of them mentioned that their husbands were the main decision-makers in the family. But nulliparous women reported that their mothers-in-law played a vital role in the decision making along with their husbands. “I became pregnant for the first time. I don’t know much about pregnancy. So, most of the decisions are taken by my mother-in-law and husband.” (Pregnant woman, age 18, para 1)
All mothers-in-law with currently pregnant daughters-in-law mentioned that she and her son jointly made critical decisions about the pregnancy-related care in the family. Most husbands said that he was the main decision-maker in the family. One husband cited, “I will have to make the decision. I can’t depend on anybody. Now I am here; I will make the decision.” (Husband, age 35, migrant worker)
Targeted client communication strategy
Modes of contact and reminders
Pregnant women were asked about communication strategies that could increase ANC attendance. Almost everyone preferred direct communication to remind them of ANC dates and give them health information. One woman stated "Through a phone call, I would be able to talk directly. In the case of messages, I would have to read the message to understand… I read, sometimes not, if I am doing any work. That's why phone calls would be good." (Pregnant woman, age 20, primipara)
One woman stated "If there is an emergency and the phone rings, I would pick it up and listen to that. After that, the phone remains somewhere idle; the message would only make a small sound, nothing after that." (Postpartum woman, age 32, para 3) They also mentioned that text messages could work as a reminder. However, they didn’t know anything about voice messages as an option.
Contact person and time for communication
Given that husbands and mothers-in-law were the decision-makers, we asked to whom and when to send the text messages related to ANC attendance and pregnancy complications. Most suggested that it was preferred to communicate directly with the pregnant woman. Although some said the information could be sent at any time, a similar number suggested that evenings would be better.
Development of SMS messages for TCC:
The most important findings from our study guided the development of SMS messages for TCC. First, women and families only perceive the need for early ANC when women are sick. Perceived susceptibility to common pregnancy complications, and the knowledge that they may occur without symptoms, was low among study participants. Second, women did not recognize that common pregnancy complications could necessitate care during pregnancy. Third, they didn’t know that attending ANC could result in fewer complications or earlier detection of complications. Fourth, they were unaware of the appropriate number and timing of ANC visits. Finally, most of the women who received detailed information on when and where to attend follow-up ANC during their first ANC visit did attend those follow-up visits, suggesting that lack of information is a key factor leading to inadequate utilization of ANC and that basic information served as cues-to-action. The evidence did not suggest any specific modifiable factor which could address a majority of women’s self-efficacy and ability to attend ANC.
Given this evidence, and the planned integration of automated data-driven SMS messages into a health information system (the eRegistry), we designed a series of text messages for women to act as cues-to-action and target women’s knowledge about ANC, specifically on 1) the benefits of attending ANC; 2) women’s susceptibility to complications; and 3) the severity of complications. The messages were designed to match the timing of critical screenings for common conditions including for anemia, hypertension, and gestational diabetes. We used clinical data from the eRegistry to further tailor these messages, based on women’s gestational age and common risk factors for the medical conditions targeted (Table 2), in order to make the text messages more individualized and provide added value to the individual woman.
Table 2
Common Risk Factors for Anemia, Hypertension, and GDM
| Risk factors for anemia | Risk factors for hypertension | Risk factors for GDM |
| Age < 20 | Age ≥ 35 [38] | Age > 25 [39] |
| Low Body Mass Index [40, 41] | High body weight/high Body Mass Index[38] | High Body Mass Index [39, 42] |
| Grand multiparity [43, 44] | Nulliparity [45, 46] | Grand multiparity [47] |
| Multiple pregnancies [44] | Previous hypertension [46] | Multiple pregnancies [39] |
| | Previous Small for Gestational Age[48, 49] | Previous hypertension [39] |
| | Previous prenatal mortality [50, 51] | Previous GDM [39] |
| | Family history of hypertension[38, 46] | Previous perinatal mortality [50] |
| | | Family history of DM[39] |
| GDM = Gestational Diabetes Mellitus; DM = Diabetes Mellitus |
The Bangladeshi government recommends a schedule of four antenatal care visits for low-risk pregnant women. Reminder messages were designed to be sent both one week and one day prior to the scheduled ANC date, and we selected one topic to be highlighted in each of the reminder messages (Table 3). In addition, we created a welcome message to be sent upon enrolment, referral facilitation messages, and facility delivery reminders. The referral facilitation messages were reminders to women that their provider had recorded danger signs or created a referral in the eRegistry.
Table 3
National ANC schedule and linked health topic for messages
| ANC schedule | Health topic for Messages | Recommended by |
| Within 16 wks | Anemia | National guideline [5, 52, 53] |
| 24–28 wks | Gestational Diabetes | [54, 55] |
| 32 wks | Gestational Hypertension | National guideline |
| 36 wks | Malpresentation | National guideline |
Given that the messages would be automatically generated within the eRegistry, we were able to additionally tailor each message based on clinical characteristics. Specifically, if data were entered into the eRegistry indicating anemia, hypertension, or gestational diabetes, an algorithm was developed which would take that into consideration and appropriately modify the messages. And, if the risk factors for these conditions were documented in the eRegistry (as shown in Table 2), the text messages would be tailored further.
Once the general topic for each message was agreed by the research team, the format of that message was designed based upon our review of effective behavior change techniques (BCT) recommended by Abraham and Michie [34]. The messages covered five theoretical frameworks and six BCTs. Behavior change techniques included the provision of general information about behavioral risk, information on benefits and consequences of action or inaction of the behavior, encouraging the person to decide to perform, rewarding the effort toward achieving the behavior change, how to perform the desired health behavior, and planning the desired health behavior with a planned outline to perform (Table 4). The theories linked with the techniques used are the information-motivation-behavioral skills model (IMB), a theory of reasoned action (TRA), theory of planned behavior (TPB), social-cognitive theory (SCogT) and control theory (CT).
Table 4
Behavior change techniques and HBM used to create TCC messages for ANC utilization
| Behavior change technique [34] | Description | HBM domain | Example text message phrase |
| Provide information about behavior health link (IMB) | General information about health outcomes concerning behavior | Perceived benefit | Come to our health center, and we will check you and your baby (ies')'s health throughout your pregnancy. |
| Provide information on consequences (TRA, TPB, IMB, SCogT) | Information about the advantages and disadvantages of action | Perceived susceptibility and severity | High blood pressure may develop during this time and lead to a serious problem for the mother. The baby might be born early or very small. |
| Prompt intention formation (IMB, SCogT) | Encourage the person to decide to act | Other | Come to our health center, and we will check your and your baby's health throughout your pregnancy. |
| Provide general encouragement (SCogT) | Outcome of performance | Perceived benefits | Anemia will be treated accordingly, and you will be better prepared for delivery. |
| Prompt specific goal setting (CT) | Involves detailed planning of ANC visits | Cues to action | Please remember to attend your ANC visit next week. Excess blood pressure in pregnancy may cause serious problems for the mother and the baby. Come to the health centre, and we will reassess your blood pressure. |
| Provide instruction (SCogT) | Tell the person how to perform the desired behavior and how to prepare for it. | Cues to action | Please remember to attend your ANC visit next week. Come to our health center. |
| Personalization (nudge theory) | Insertion of the recipient's name and signing with the name of the clinic as a “trusted source” | Other | Salam (name) apa. Name of health facility |
| Note: IMB = Information-motivation-behavioural skills model; TRA = Theory of reasoned action; TPA = Theory of planned behaviour; SCogT = Social –cognitive theory; CT = Control Theory |
Table 4: Behavior change techniques and HBM used to create TCC messages for ANC utilization (Page 36–37)
The initial draft of the TCC messages, based on the HBM and the ANC schedule and tailored with the behavior change techniques, were translated into Bengali from English and shared with pregnant women in focus group discussions (data not shown). Participants reported that the content of messages was adequate, but some modifications of terminology were needed for ease of understanding. We then reviewed each message and finalized the wording of the TCC messages. Each message was then adapted to the typical SMS character limits (knowing that for some messages up to three SMS could be sent). In the end, a library of a total of 43 TCC messages was developed based on the individual woman’s presence or absence of anemia, hypertension, GDM, and associated risk factors in the eRegistry. Examples of the messages are included in Table 5.
Table 5
Selected examples of the final targeted TCC messages
| Message type | Message Timing | Message Content |
| Welcome message | same day as pregnancy identification/enrolment | Welcome [xxx] apa. We will provide four routine ANC visits. Come to our health centre and we will check you and your baby (ies')'s health throughout your pregnancy. [yyy] |
| Visit 1 | 1 week prior to the first scheduled ANC visit | Salam [xxx] apa. Please remember to attend your ANC visit next week. 1 in 3 women is anaemic in pregnancy. Anemia can cause dizziness and weakness. Come to our health centre and we will check for your anemia and will treat accordingly so that you will be better prepared for delivery. [yyy] |
| Visit 2 reminder - for women with no risk | 1 week prior to second scheduled ANC visit | Salam [xxx] apa. Please remember to attend your ANC visit next week. We will check for sugar in blood or urine for signs of diabetes. Diabetes in pregnancy has to be followed-up carefully throughout pregnancy to ensure that both mother and baby stay healthy. [yyy] |
| Visit 2 reminder – for women with mild or moderate anemia | 1 week prior to second scheduled ANC visit | Salam [xxx] apa. Please remember to attend your ANC visit next week. Aaemia in pregnancy may cause problems for the mother and the baby, if not treated. Come to the health centre and we will reassess for anemia and check for diabetes. [yyy] |
| Visit 3 reminder - for women with no risk | 1 week prior to third scheduled ANC visit | Salam [xxx] apa. Please remember to come to ANC this week as agreed. High blood pressure may develop during this time and lead to serious problems for the mother. The baby might be born early or very small. Come to ANC and we will measure your blood pressure and manage it appropriately. [yyy] |
| Visit 3 reminder - for women with severe hypertension | 1 week prior to third scheduled ANC visit | Salam [xxx] apa. Please remember to attend your ANC visit next week. Excess blood pressure in pregnancy may cause serious problems for the mother and the baby. Come to the health centre, and we will reassess your blood pressure. [yyy] |
| Visit 4 reminder - for women with no risk | 1 week prior to fourth scheduled ANC visit | Salam [xxx] apa. Please remember to attend you ANC visit this week. Knowing your baby's presentation at this time can help you plan a safe delivery. Come to the health centre and we will check your baby's position. [yyy] |
| Visit 4 reminder - for women with anemia and GDM | 1 week prior to fourth scheduled ANC visit | Salam [xxx] apa. Please remember to attend your ANC visit next week. Knowing the baby's current position helps you to plan for safe delivery. Come to the health centre, and we will check your baby's position and reassess your diabetes and anemia. [yyy] |
| 1-day reminder | 1 day before each routinely scheduled ANC visit | Salam [xxx] apa. Remember to attend your ANC visit tomorrow. It is very important to know your present health status. [yyy] |
| Facility Delivery | 1 wk after last 36-week message | Salam [xxx] apa. Your health history puts you at greater risk of problems. You are advised to give birth in a facility for a safer delivery. [yyy] |
| Danger Sign | 1 day after being diagnosed | Salam [xxx] apa. You were referred to a higher level facility for improved care yesterday. Please attend care immediately if you have not already done so. [yyy] |
| [xxx]: woman’s name; [yyy]: name of health facility; GDM: gestational diabetes |
Table 5: Selected examples of the final targeted TCC messages (Page 38–39)