journal homepage: www.elsevier.com/locate/hlpt
Available online at www.sciencedirect.com
Mobile health and maternal care: A winning
combination for healthcare in the developing
Marine Al Dahdah
, Annabel Desgrées Du Loû
, Cécile Méadel
Center for Population and Development, University Paris Descartes –Sorbonne Paris Cité-IRD-INED, Paris
Institute of Research for Development (France), Center for Population and Development, University Paris
Descartes –Sorbonne Paris Cité-IRD-INED, Paris
Researcher at Centre de sociologie de l'innovation, Mines Paritech-CNRS, Paris
Available online 16 April 2015
Worldwide, concerted efforts are made to stimulate the use of information and communication
technology (ICT) in health care. From online Personal Health Record (PHR), treatment and
appointment reminders by SMS, to the e-mailing of conﬁdential clinical data, healthcare
systems are increasingly using technologies to provide better services with less ﬁnancial and
human resources. Among ICTs for health, eHealth –i.e. health on the Internet –has been
extensively studied whereas the use of mobile technologies for health called “mhealth”or
mobile Health has been less documented so far. In 2013, almost 6.8 billion people were mobile
phone users, mobile-cellular penetration rates stand at 96% globally (89% in developing
countries). Access to the Internet, by comparison, is a reality for only 39% of the world
population (77% of the developed world population is online). During the last three years, many
health stakeholders and mobile technology providers have understood the high potential of
mHealth and launched more than 600 operational projects in developing countries. In this
article we are discussing this issue ﬁrst by assessing the current state of knowledge on mobile
health in developing countries, as well as the issues and challenges raised by mobile health. We
then focus our discussion on maternal health to discuss the potential applications of these new
techniques in this speciﬁcﬁeld. Finally we suggest several avenues for further analysis on the
implications of using mobile phones as a tool for women's health.
&2015 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.
2211-8837/&2015 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.
Corresponding author. Tel.: +33674336699.
E-mail address: firstname.lastname@example.org (M. Al Dahdah).
Health Policy and Technology (2015) 4, 225–231
Mobile health: a growing phenomenon in developing countries .................................. 226
Maternal health, a productive sector for mHealth applications .................................. 226
Challenges of mHealth ........................................................... 227
Research on mHealth is only beginning ................................................. 228
The lack of cross-national studies .................................................... 228
Shaping future research .......................................................... 228
Author statements .............................................................. 229
Conﬂict of interest ........................................................... 229
Ethical approval............................................................. 229
Funding .................................................................. 229
Competing interests .......................................................... 229
References .................................................................. 229
There are many potential applications of digital technologies
in the health sector. Whether online “patient records”,clinical
data digitalized and transmitted electronically, or appoint-
ment reminders by SMS, health systems around the world are
increasingly using these technologies in the context of reduced
health resources and expenditure but also of increased
involvement of patients and lay personnel. Substantial
research has been conducted on eHealth –health on the
Internet, mainly regarding the nature and the value of health
information on the web [1,17], the redeﬁnition of the roles of
lay and expert in health [2,83,84], the subsequent transforma-
tion of the patient–caregiver relationship [3,7]orthecon-
sequences of eHealth on work organisation. The use of mobile
phone and wireless technology within health programs, called
“mHealth”or mobile health, is more recent and has been less
studied. And yet mHealth is likely to change how health is
deﬁned, to modify the relationship between caregivers and
patients, to inﬂuence medical information, etc. These issues
are particularly acute in developing countries in the context of
increased access to mobile phones, which has been shown to
be associated with great invention in use and a certain number
of technological innovations (Chéneau-Loquay, ;Hahnet
Kibora, ). In this paper, we address these transformations
ﬁrst by assessing the current state of knowledge on mobile
health in developing countries, as well as the issues and
challenges raised by mobile health. We then focus our
discussion on maternal health to discuss the potential applica-
tions of these new techniques in this speciﬁcﬁeld. Finally we
suggest several avenues for further analysis on the implica-
tions of using mobile phones as a tool for women's health.
Mobile health: a growing phenomenon in
Access to mobile phones is becoming increasingly common
in developing countries, and is increasing much faster than
access to the Internet: in 2013, there are almost 6.8 billion
mobile phone lines worldwide, with 128 lines per 100
inhabitants in developed countries and 89 lines per 100
inhabitants in developing countries, where only 37 out of
100 people have access to the Internet . Over the past
three years, many actors in the health (NGOs, pharmaceu-
tical companies, hospitals) and telecom sectors throughout
the world have understood the potential of mobile technol-
ogy in the ﬁeld of health and have launched hundreds of
health projects involving mobile phones. The GSM Associa-
tion (GSMA) of mobile operators and mobile technology
providers has estimated up to nearly 1000 the number of
such projects in 2013, 65% of which are taking place in
developing countries .
Aware of the growing deployments of mobile technology,
health policy makers aim to better characterize this phenom-
and analyzed the concept of mHealth in a report published in
2011 .Itisdeﬁned as the practice of medicine and public
health assisted by mobile technologies, such as mobile phones,
patient monitoring monitors, “personal digital assistants”
(PDAs) and other wireless technologies. mHealth capitalizes
on the core functions of mobile phones (voice and SMS) but
also on the more complex features and applications of new
generations of mobile phones. WHO segments mHealth
according to a typology of projects that include: communica-
tion from individuals to health services (call centres, helpline
or hotline), communication from health services to individuals
(appointment or treatment reminders, awareness and mobili-
zation campaigns on health issues) and communication
between health professionals (mobile telemedicine, manage-
ment of intersectoral emergencies, patient monitoring,
patient data collection and creation of patient records, aid
to diagnosis and decision-making).
Maternal health, a productive sector for
Half a million women die each year worldwide as a result of
pregnancy or childbirth, almost all (99%) in developing
countries. Millions of women experience pregnancy-related
morbidity, sometimes with severe consequences (infertility,
ﬁstula, incontinence) that could be avoided through better
information and better monitoring of pregnant women .
Clinicians report that postpartum hemorrhage is the main
nonattendance or late arrival in a health service [47,54].
Among the multiple reasons for this delayed care are:
M. Al Dahdah et al.226
services, poverty, lack of information or education, women's
social status . Large disparities remain worldwide in terms
of prenatal care coverage and skilled attendance during
likely to receive adequate care. This is especially true in areas
where the number of qualiﬁed health workers is low ,
especially in sub-Saharan Africa, Southeast Asia and Oceania.
Improving maternal health is one of the objectives of the
Millennium Development Goals set by the United Nations
by three quarters, between 1990 and 2015, is yet unattained
[38,49] and some actors are seeking new dynamics to reach
this goal. The private sector (telephone operators, pharma-
ceutical companies, foundations…) has been massively invest-
ing in mHealth projects involving women and several recent
international initiatives suggest using mobile phones to catch
up on improving maternal health .
The U.S. government launched in May 2011 a $10 million
partnership called “Mobile Alliance for Maternal Action”
(MAMA), devoted exclusively to providing health informa-
tion to future or young mothers using mobile phones. The 3-
year partnership is supported by USAID and the Johnson &
Johnson pharmaceutical company. Three pilot countries
were targeted to implement mHealth activities: India,
Bangladesh and South Africa. This public–private partner-
ship is an example of how mHealth projects tend to mix
general and commercial interests, especially in developing
countries. Maternal follow-up mobilizes most mHealth fund-
ing , representing near to one out of ﬁve mHealth
projects in developing countries.
The rapid development of mobile health projects addres-
sing maternal health can be explained in part by the wide-
spread access of women to mobile phones; gender
differences in accessing new technologies are much less for
mobile phone access. Several gender studies have shown that
access to ICT is (or has been for a long time in developed
countries) in general more difﬁcult for women, who are less
equipped –for example, the computer remains the property
of the spouse –and therefore less accustomed to ICT .
The male presence and dominant position in the construction
of ICT technologies may also explain why women hardly ﬁnd
their place in those same technologies [32,36]. Mobile phones
however hold a special place in the world of ICT: women are
21% less likely than men to own a mobile phone, so gender
difference do exist, but mobile phones are a more “egalitar-
ian technology”than the computer or Internet access
because its cost is lower and its handling requires little
training. Sociology, particularly feminist, has provided ample
work to understand the distribution of social roles within ICT,
gender inequalities in professional practices, the impact of
ICT on socialization (or on the contrary on the dissolution of
the social bond), or the dominance effects, etc ([9,35];
Gardey, ). Certain studies have focused speciﬁcally on
Internet applications [74,79]. This research has contributed
to understand gender relations in the context of mobile tools
developed speciﬁcally for women's health. This, in order to
study both how mobile technologies shape “gendered”
relationships and how gender relationships have an impact
on the actual construction of technological projects.
The ﬁeld of maternal health is therefore particularly
relevant to explore the development of mHealth and the
associated public health transformations (institutional over-
haul, transnationalization, increasing role of communica-
tion technologies, gender relationships and expertise), but
has been little researched so far. The available articles on
the subject consist in literature reviews of existing projects
[57,76], or reports on the use of mobile phones by a group of
midwives in Northern Indonesia  and on Thai border
areas  or the use of persuasive messages addressed to
women in rural India .
Challenges of mHealth
The use of this “mobile”technology in the ﬁeld of health
raises a number of issues that should not be hidden by the
apparent simplicity of the “mobile phone”tool.
mHealth indeed redeﬁnes the roles of different public
health actors, may contribute to give them new roles and
redistribute powers and responsibilities. We see for example
pharmaceutical companies channeling public health infor-
mation through SMS.
mhealth contributes to the emergence of new actors that
have been little involved in the ﬁeld of public health so far,
such as mobile phone operators in charge of mobile phone
networks and connectivity (Orange, Telenor…)ortechnical
private operators in charge of development platforms,
mobile applications and interfaces as well as data storage
(Intel, Voxiva…). These ﬁrms act in their best commercial
interests and marketing developments, without necessarily
feeling obliged to endorse the objectives of equality and
access to health for all . In addition, mobile health can
reshape health ﬁnancing; on the one hand, because it
contributes to the emergence of new funders such as private
foundations born from Information and Communication Tech-
nology (ICT) companies (Vodafone Foundation or Bill and
Melinda Gates Foundation…), who embrace the notion of
“philanthrocapitalism” deﬁned as the combination of
generosity and commercial interests, or as the development
of new markets justiﬁed by a good cause. On the other hand,
because some health projects' funders (governments, foun-
dations, mutual funds, insurance companies, NGOs, etc.)
may reallocate funds previously devoted to building care
infrastructure towards innovative technologies such as those
involving mobile phones, to the detriment of more “tradi-
tional”healthcare services .
Mobile health raises major issues in terms of data security
and anonymity. In most countries, laws on conﬁdentiality of
health data and their transmission are very strict, however
they only partially apply to the new uses and new systems
implemented via mobile phones. These issues are all the
more problematic that mobile phones facilitate the transfer
and storage of data. Some doctors are questioning the
safety of the platforms used by mHealth projects, that do
not seem to protect the anonymity and conﬁdentiality of
patient health data . Questioning the access and use of
health data collected by mobile applications as well as the
medical credibility and intentions of the different stake-
holders involved in mHealth projects, seems all the more
essential that the main mHealth project partners are from
the private sector and have clear business imperatives.
Finally, the development of mobile health projects raises
the issue of equity in partnerships, when projects are
227Mobile health and maternal care
implemented in developing countries and technology is
controlled by developed countries. Within the MOTECH
project for maternal follow-up in Ghana for example, project
stakeholders are numerous: the Bill and Melinda Gates
Foundation, the U.S. Agency for International Development
(USAID), the Johnson & Johnson laboratory, the Grameen
Foundation and the Norwegian government fund the project;
the Public Health Department of Columbia University in New
York and the Department of Computer Sciences of the
University of Southern Maine in Portland are responsible for
the scientiﬁc coordination of the project; the U.S. companies
Dimagi, Thoughtworks, Instedd and Reach Village are respon-
sible for developing the platform and for its local use; and
ﬁnally the Ministry of Health of Ghana collaborates to the
project and contributes to its implementation country-wide
. The American technical operators and funders are
largely dominant within this “African”project, and this is
facilitated by the ability to remotely develop, manage and
maintain these technical tools.
This new wave of mobile technology applied to health
thus raises complex issues in terms of economic organiza-
tion, governance, distribution of power and control. It calls
for anthropological and geopolitical questioning on the
implementation in developing countries of studies that are
sometimes entirely designed and funded by developed
countries, studies within which the types of collaboration
of developing countries, that is more or less voluntary, more
or less committed, deserve to be further studied. These
mobile technologies point out important issues in terms of
data safety, conﬁdentiality and “privacy”in the context of
collection and analysis of health data that is globalized and
deterritorialized. They also highlight the dynamics of how
foreign ethical and ﬁnancial practices adapt to local eco-
nomic and political contexts, customs and traditions, health
organizations and health professionals. mHealth thus parti-
cipates to the economic and technological reconﬁgurations
of transnational public health. It raises major issues at the
intersection of research on ICT, sociology of health and
research on science and technology.
Research on mHealth is only beginning
The ﬁrst academic studies focused on mHealth were con-
ducted within the past six years. Several papers have pre-
sented the results of pilot projects on: aid or emergency lines
[14,41,66], appointment reminders by SMS [18,15,28,55],
reminders to take anti-malarial  or antiretroviral medica-
tion , support to stop smoking or improve physical activity
[39,46], prevention of risk behaviors among youth [45,53,75],
follow-up of diabetic [12,23,34,65] or asthmatic patients
[37,72], or mobile telemedicine and mobile phone support in
collecting health data [4,6,52,61]. Most of these results
consist in descriptive analyses of mHealth pilot projects.
Unlike studies on eHealth, the overall consequences of these
technologies on care practices and on patient–practitioner
relationships, as their overall impact on health, are still poorly
The ﬁrst scientiﬁc papers analyzing the impact of
mHealth are very recent. These papers have focused on
reviewing the local mHealth trials and their consequences
on health care professionals and care practices on the one
hand  and on patient beneﬁciaries on the other hand
. Very few papers provide impact data. Free et al. have
identiﬁed just about forty articles reporting on mHealth
projects dedicated to health professionals and 75 articles on
mHealth projects with patients. Almost all of these papers
relate to projects conducted in developed countries only,
while more than 650 mHealth projects are currently under-
way in developing countries . The very construction of
these projects remains poorly documented: Who pays? What
technical infrastructure is deployed? Who produces the
information? What is the involvement of public and private
actors? Even though these essential questions remain unan-
swered, millions of dollars are being invested in mHealth
projects, particularly in developing countries where poor
health systems are failing to meet the needs of the
population and where the absence of legal framework may
leave the door open to experiments [62,70].
The lack of cross-national studies
The studies on mHealth mentioned above are implemented
within single observation geographical spaces and relate to
single applications of mHealth. Yet multi-or transnational
research on this issue would be relevant for several reasons.
Multi-site analysis, that encouraged ﬁeld research in multi-
ple and heterogeneous spaces –championed by anthropol-
ogist GE Marcus  and adopted by many researchers such
as Fischer , Jasanoff , Fassin  and Rajan  –is
particularly suitable for the study of ICT in a global context.
It meets the new methodological requirements of research
on contemporary social reconﬁgurations since, by deﬁni-
tion, this type of study focuses on moving objects such as
mobile phones, symbol of mobility. The idea is not to simply
compare two similar research objects but to draw links,
juxtapositions, connections between different places and
objects. The aim is also to study the people, objects, ideas,
symbols, signs, tensions and conﬂicts embedded in these
projects and this is only possible by diversifying the ﬁelds of
research. mHealth raises international issues because its
ﬁnancing, its technical implementation, infrastructure and
areas of implementation are supported by different actors
across the world. The transnational mechanisms underlying
these various applications can only be highlighted through
studies involving different cultural areas, different socio-
economic contexts, different situations in terms of maternal
care and public/private healthcare sectors articulations.
Shaping future research
The recent multiplication of mHealth projects worldwide
illustrates the overall trend towards the globalization and
technologization of biomedicine. The idea that ICT contri-
butes to improving care, reducing health disparities and
optimizing health systems has taken shape in recent years in
a diverse set of technical devices: eHealth,mHealth,
telemedicine, big data, etc. mHealth or mobile Health is
a particular vector of this global movement, which goes
beyond the use of mobile phones, and shows how technol-
ogies contribute to the emergence of new powers, to the
reorganization of roles and the globalization of devices in
M. Al Dahdah et al.228
the ﬁeld of health. In order to move away from the sterile
opposition between euphoric technophiles who see ICT, and
among them mobiles phones, as sources of empowerment
and reduction of health inequalities, and technophobes who
emphasize the risks of market domination and increasing
inequalities, space needs to be made for research without
prejudice, capable of analyzing the modalities and issues
raised by the development of mHealth activities in the
context of an evolving public health sector, especially in
Three research areas seem particularly interesting.
–The reorganization of roles and the emergence of new
actors in the public health sector
The implementation of a socio-technical system such as
mHealth is giving way to a new approach to public
health. Mobile health is multidisciplinary and multisec-
toral, and is building speciﬁc issues that were once
outside the ﬁeld of health. Research on the reorganiza-
tion and redistribution of powers between private and
public actors, on the changes in balance between
historical (health facilities, clinics, governments, phar-
maceutical companies, etc) and emerging actors (mobile
networks operators, technology developers, donors and
ICT philanthropists) involved in mHealth projects has
been poorly explored so far. Questioning the notion of
Global Health [8,21] with regard to “Mobile Health”
issues also seems to be an interesting research issue to
–Processing techniques for administering health and care
While in developed countries, research has been con-
ducted on the impact of PDAs and smartphones on care
practices [19,58,71], in developing countries, in spite of
a multiplication in the number of mobile health projects,
the issues and consequences of mobile technologies on
health care and management practices are still poorly
documented . Issues of conﬁdentiality and security of
health data collected via mobile, the technical condi-
tions of storage and dissemination, and the evaluation of
these speciﬁc health programmes also remain to be
–The transformation of health uses and practices for
The observation of mobile phone uses, that is, what
people actually do with these objects and technical
devices, should be carefully studied. The impact of
objects on society was formalized by Coneinet al. ,
Proulx  or Jouët , among others, and investigated
regarding patient care and health in developed countries
[24,48,73]. The analysis of the individualized approach
allowed by mHealth and the mobility of health practices
associated with these projects are still to be further
explored in developing countries .
StudiesoninnovativeusesofmHealth (smart phones, PDAs
and tablets) apply to a limited group of professionals and
patients, mainly in developed countries, or to a very fortunate
population in developing countries. The identiﬁcation of the
barriers to these technologies  should also be explored in
parallel with those uses.
Maternal health programmes using mobile phones are
particularly relevant to explore thanks to these three areas
of analysis: they grow rapidly due to the emergency of the
situation around maternal health, and they will provide the
basis for questioning how gender roles are articulated
within the roles of the actors and beneﬁciaries of health
programmes, and possibly can be reshaped by the use of
Conﬂict of interest
The author assures that all data, models, or methodology
used in the research are proprietary.
The author certiﬁes that there is no conﬂict of interest
with any ﬁnancial organization regarding the material
discussed in the manuscript.
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