Improvement of maternal health services through the use of mobile phones

Abstract

To analyse, on the basis of the literature, the potential of mobile phones to improve maternal health services in Low and Middle Income Countries (LMIC).
Wide search for scientific and grey literature using various terms linked to: maternal health, mobile telecommunication and LMIC. Applications requiring an internet connection were excluded as this is not widely available in LMIC yet.
Few projects exist in this field and little evidence is available as yet on the impact of mobile phones on the quality of maternal health services. Projects focus mainly on the delay in receiving care--that is in recognizing the need and making the decision to seek care--and the delay in arriving at the health facility. This is achieved by connecting lesser trained health workers to specialists and coordination of referrals. Ongoing projects focus on empowering women to seek health care.
There is broad agreement that access to communication is one of several essential components to improve maternal health services and hence the use of mobile phones has much potential. However, there is a need for robust evidence on constraints and impacts, especially when financial and human resources will be invested. Concurrently, other ways in which mobile phones can be used to benefit maternal health services need to be further explored, taking into consideration privacy and confidentiality.

Full text

Improvement of maternal health services through the use
of mobile phones
A. Camielle Noordam
1
, Barbara M. Kuepper
1
, Jelle Stekelenburg
2
and Anneli Milen
3
1Royal Tropical Institute, Amsterdam, The Netherlands
2Medical Centre, Leeuwarden, The Netherlands
3National Institute for Health and Welfare, Helsinki, Finland
Summary objective To analyse, on the basis of the literature, the potential of mobile phones to improve
maternal health services in Low and Middle Income Countries (LMIC).
methods Wide search for scientific and grey literature using various terms linked to: maternal health,
mobile telecommunication and LMIC. Applications requiring an internet connection were excluded as
this is not widely available in LMIC yet.
results Few projects exist in this field and little evidence is available as yet on the impact of mobile
phones on the quality of maternal health services. Projects focus mainly on the delay in receiving care –
that is in recognizing the need and making the decision to seek care – and the delay in arriving at the
health facility. This is achieved by connecting lesser trained health workers to specialists and coordi-
nation of referrals. Ongoing projects focus on empowering women to seek health care.
discussion There is broad agreement that access to communication is one of several essential com-
ponents to improve maternal health services and hence the use of mobile phones has much potential.
However, there is a need for robust evidence on constraints and impacts, especially when financial and
human resources will be invested. Concurrently, other ways in which mobile phones can be used to
benefit maternal health services need to be further explored, taking into consideration privacy and
confidentiality.
keywords maternal health, mobile phones, mHealth eHealth, communication
Introduction
Progress in achieving Millennium Development Goal
(MDG) 5, to improve maternal health by reducing mater-
nal mortality and improving access to reproductive health,
is lagging behind the targets. New impulses are needed to
attain the goals. Two recent international initiatives
recommend mobile phones as a means to improve maternal
health services (ITU 2010; mHealth Alliance 2010).
Maternal health
Every 90 seconds a woman dies of complications related to
pregnancy and childbirth, resulting in more than 340 000
maternal deaths a year (Hogan et al. 2010). Millions of
women suffer from pregnancy-related illnesses or experi-
ence other severe consequences such as infertility, fistula
and incontinence (UNICEF 2009). Delay is considered the
key factor leading to women not accessing health services.
There are three phases of delay: (i) recognizing the need for
health care and in the decision-making process; (ii) arrival
at a health facility; and (iii) receiving appropriate and
adequate care at the health facility (Maine 1994). Under-
lying determinants that cause the delays are the position of
women in society, large geographical distances, weak
health systems, poverty and lack of education (Ronsmans
& Graham 2006; UNICEF 2009).
Mobile phones
MDG 8 addresses the need to make benefits of new
technologies available, especially those related to infor-
mation and communication. The fastest growing new
technology worldwide is the mobile phone. In Africa and
Asia, where the burden of maternal mortality is greatest
(WHO & UNICEF 2010), the expectations are that by
2012, 50% of the people will have access to a mobile
phone (ITU 2009). The uptake of mobile phones varies; it
is inversely proportional to poverty rates, but also influ-
enced by the competitiveness and thus the price levels of
the relevant markets (UNCTAD 2010). The use of mobile
phones in health systems is called mHealth. This article
Tropical Medicine and International Health doi:10.1111/j.1365-3156.2011.02747.x
volume 16 no 5 pp 622–626 may 2011
622 ª2011 Blackwell Publishing Ltd

discusses the potential of mobile phones to improve
maternal health services in LMIC by strengthening com-
munication throughout different levels of the health
system.
Method
Our literature search limited to English publications
combined terms linked to: maternal health, mobile tele-
communication, and LMIC. Only publications considering
the basic use of mobile devices (without requiring internet
access) were included, as poor internet coverage, high
illiteracy rates and low levels of experience in using
technology make more advanced use of mobile technology
difficult in LMIC.
Searches initiated in PubMed, Embase, Cochrane Li-
brary, Scopus, Science Direct and African Journals Online
retrieved a large amount of mHealth-related publications,
of which only eight were relevant; these articles address
maternal health services in LMIC, the use of mobile devices
and reported preliminary results. The search was subse-
quently expanded to grey literature, and reference lists
were also screened for further relevant sources.
Literature findings
A recently published paper on mobile phone technology for
health care in LMIC (Mechael et al. 2010) reviewed
literature on mHealth, such as treatment compliance, data
collection and disease prevention. The authors see great
potential for mHealth; however, there is not much evidence
of actual and wide-scale impacts yet. We analysed
resources for the particular area of maternal mHealth and
confirmed a lack of evidence-based studies focusing on
the efficacy and effectiveness of interventions. Most
documentation referred to pilot studies and often lacked
baseline data, a control group and clear outcome
indicators.
Accessing emergency obstetric care
Before the wider use of mobile phones, several project
publications considered improved communication through
radio systems as one component among several aimed at
improving access to emergency obstetric care and referral
systems. These projects mainly focused on reducing the
second phase of delay. Traditional Birth Attendants (TBAs)
and ⁄or midwives were equipped with walkie-talkies,
enabling them to contact supervisors and ambulances when
facing difficult situations. Concurrently, other components
such as the overall quality of the health services were
improved through more reliable transport means, increased
capacity, medical equipment and reduction of financial
barriers.
Projects in Mali, Uganda, Malawi, Sierra Leone and
Ghana, which implemented the above mentioned com-
ponents, noted a significant reduction in maternal deaths
and an increase in supervised births when comparing the
situation before and after the interventions. Faster modes
of communication and transport were named as impor-
tant factors in improving access to emergency obstetric
care (Samai & Sengeh 1997; Musoke 1999, 2002;
Matthews & Walley 2005; Lungu & Ratsma 2007;
Fournier et al. 2009). The projects in Uganda and
Ghana additionally considered the first phase of delay
by connecting traditional health providers to the bio-
medical health system. As TBAs are frequently at the
homes of pregnant women, they can speed up the
process there.
Krasovec (2004) concluded that studies provided only
weak empirical evidence regarding the actual impact of
communication systems and that access to tools of com-
munication is not the solution for decreasing maternal
deaths in isolated areas. The tight timeframe in which a
woman requires emergency obstetric care (due to e.g.
severe bleeding) implies that quality services need to be
accessible at short notice and supported by effective
infrastructure management. In a more recent review, Lee
et al. (2009) confirm the need for more rigorous assess-
ments.
Information regarding plans for scaling-up projects that
use radio systems was only found for the pilot project in
Uganda. These plans were not realized due to high costs,
inability to maintain equipment and lack of integration
into the health system. However, in this project the radio
system was later replaced by mobile phones, which were
found to be a cheaper and a more practical solution
(UNFPA 2007).
Improving the capacity of lesser trained health workers
More recent projects introduced mobile phones to improve
the capacity of lesser trained health workers by connecting
them to better trained medical staff, thus aiming to reduce
the third phase of delay. In Indonesia, Chib et al. (2008)
selected 15 health facilities through random sampling;
midwives in eight of the facilities received a mobile phone.
Perceived benefits reported were that: (i) mobile phones
made it easier to contact patients, midwives and supervi-
sors, (ii) time efficiency increased due to the ability to
coordinate visits, and (iii) if complications occurred assis-
tance was only a call away. Despite these advantages,
constraints included the costs, poor mobile phone network
infrastructure in rural areas, increased demand for
Tropical Medicine and International Health volume 16 no 5 pp 622–626 may 2011
A. C. Noordam et al. Better maternal health services through mobile phones
ª2011 Blackwell Publishing Ltd 623

consultation, difficulties in uptake of higher technology
programmes for data analysis, and hesitation in contacting
supervisors due to organizational hierarchy (Chib et al.
2008; Chib 2010).
A recently launched project in Rwanda went a step
further by using text messaging to facilitate and coordinate
the communication as well as data exchange between
community health workers, health centres and hospitals.
Preliminary data suggested a positive effect on access to
maternal health services and consequently lower death
rates (Holmes 2010).
An initiative in Tanzania designed a phone-based
application that contained forms and protocols meant to
support pregnant women before, during and after delivery
(Svoronos et al. 2010). The results of a pilot project
seemed positive; however, the authors mentioned the need
to further assess the impact of the project.
Empowering women to contact health services and
access information
To decrease the first phase of delay, several programmes
aimed to empower women to contact health services and
access information; however, data was still being processed
at the time this article was written. In Zanzibar, a study
following 2 500 women investigated the impact of both
voice and text messages on maternal health (Lund 2009,
2010a). Text messages were sent to pregnant women
containing basic health education and reminders for
routine health care appointments. Expectant mothers
received vouchers and phone numbers that they could use
to contact services for questions and emergencies. The
study assessed the impact on quality of services, health
seeking behaviour and maternal morbidity and mortality.
The data was being processed at the time of writing this
article; the study promised to yield useful information
(Lund 2010b).
MoTECH is an ongoing project in Ghana aiming to
determine how mobile phones can best be used to increase
the quantity and quality of antenatal care (Mechael 2009).
Results from randomized treatment and control groups
were not yet available (Mailman School of Public Health
2010).
Gender discrepancies in access to and use of the technology
The analysis of the potential of mobile phones for maternal
health requires examining how mobile phones may relate
to the root cause of poor maternal health, namely the
position of women in society (UNICEF 2009). Globally, a
woman is 21% less likely to own a mobile phone than a
man (GSMA et al. 2010). This discrepancy in the uptake of
mobile phones is highest in South Asia, followed by Sub-
Saharan Africa.
Women who do have access to a mobile phone often use
it for business, banking and employment opportunities
(GSMA et al. 2010; Hellstro
¨m 2010; Macueve et al. 2009)
and thus to make themselves more independent. Several
projects use mobile phones to improve access to basic
education for women, for example text message-based
literacy programmes (GSMA et al. 2010).
The main reason for not owning a mobile phone lies in
the associated costs, illiteracy and lack of electricity
(GSMA et al. 2010; Hellstro
¨m 2010). Being practical,
especially women in Africa are likely to borrow a phone if
they do not own one (Macueve et al. 2009). Other
discrepancies in the ownership of mobile phones exist
between countries and in rural areas versus urban areas,
mainly due to poor network coverage (Comfort & Dada
2009).
Discussion
Robust studies providing evidence on the impact of
introducing mobile phones to improve the quality or
increase the use of maternal health services are lacking.
However, there is broad agreement that access to com-
munication is an essential component of improving the use
and quality of maternal health services. The mobile phone
has a high potential as it is small, portable, widely used,
relatively cheap and the extending network coverage
increasingly enables communication with rural and iso-
lated areas.
The extremely quick uptake of mobile phones world-
wide can shorten delays in seeking and receiving health
care. The available literature suggests great potential in
connecting traditional and biomedical health care, as well
as connecting the different levels within a health care
system, provided that women are not restricted due to their
position in society, lack of finance or means of transport.
To fully realize the benefits of mobile communication,
research needs to generate the evidence-basis for scaling up
mHealth and enabling informed mHealth policy-making,
and to analyse its benefit in ensuring timely delivery of
medical equipment, provide health education and improve
access to reproductive health services, e.g. for family
planning.
So far, projects mainly focus on acute, life threatening
situations, but mobile phones can also be used to deliver
mass health messages to pregnant women, recalling women
with risk factors to present themselves at an antenatal
clinic or referring women who suffer from complications
such as fistula, incontinence and infertility. Possibilities
related to connecting them to specialized hospitals need to
Tropical Medicine and International Health volume 16 no 5 pp 622–626 may 2011
A. C. Noordam et al. Better maternal health services through mobile phones
624 ª2011 Blackwell Publishing Ltd

be integrated into research and project designs. In addition,
all the different applications, best practices, constraints and
lessons learned need to be documented.
The quick uptake of the mobile phone and its use in
health care requires policies and guidance of governments,
especially related to issues such as privacy and confiden-
tiality. An overuse of text messaging by the private and
public sector will soon be regarded as spam, making it lose
its effectiveness. In addition to privacy, governments need
to ensure confidentiality of sensitive information.
References
Chib A (2010) The Aceh Besar midwives with mobile phones
project: Design and evaluation perspective using the information
and communication technologies for healthcare development
model. Journal of Computer-Mediated Communication 15,
500–525.
Chib A, Lwin MO, Ang J, Lin H & Santoso F (2008) Midwives
and mobiles: using ICTs to improve healthcare in Aceh Besar,
Indonesia. Asian Journal of Communication 18, 348–364.
Comfort K & Dada J (2009) Rural women’s use of cell phones to
meet their communication needs: a study from northern Nigeria.
In: African Women & ICTs, 1st edn (eds Buskens I & Webb A)
Zed Books Ltd, London, pp. 44–55.
Fournier P, Dumont A, Tourigny C, Dunkley G & Drame
´S (2009)
Improved access to comprehensive emergency obstetric care and
its effect on institutional maternal mortality in rural Mali.
Bulletin of the World Health Organisation 87, 30–38.
GSMA Development Fund, Cherie Blair Foundation for Women &
Vital Wave Consulting (2010) Women & Mobile: A Global
Opportunity. A Study on the Mobile Phone Gender Gap in Low
and Middle-Income Countries. GSMA, London. Available at:
http://www.cherieblairfoundation.org/uploads/pdf/women_and_
mobile_a_global_opportunity.pdf.
mHealth Alliance (2010) Maternal and Newborn mHealth Ini-
tiative. Available at: http://www.mhealthalliance.org/ourwork/
maternal_and_newborn.
Hellstro
¨m J (2010) The innovative use of mobile applications in
East Africa. Sida Review 2010:12, Stockholm. Available at:
http://upgraid.files.wordpress.com/2010/06/sr2010-12_sida_hell
strom.pdf.
Hogan MC, Foreman KJ, Naghavi M et al. (2010) Maternal
mortality for 181 countries, 1980–2008: a systematic analysis of
progress towards Millennium Development Goal 5. Lancet 375,
1609–1623.
Holmes D (2010) Rwanda: an injection of hope. Lancet 376,
945–946.
International Telecommunication Union (ITU) (2009) Information
Society Statistical Profiles 2009. Africa. ITU, Gene
`ve. Available
at: http://www.itu.int/ITU-D/ict/material/ISSP09-AFR_final-
en.pdf.
ITU (2010) Committed to Connecting the World ITU is the UN
Agency for Information and Communication Technology.
Available at: http://www.itu.int/en/pages/default.aspx.
Krasovec K (2004) Auxiliary technologies related to transport and
communication for obstetric emergencies. International Journal
of Gynecology & Obstetrics 85(Suppl. 1), S14–S23.
Lee ACC, Lawn JE, Cousens S et al. (2009) Linking families and
facilities for care at birth: what works to avert intrapartum-
related births? International Journal of Gynecology and
Obstetrics 107(Suppl. 1), S65–S85.
Lund S (2009) Mobile Phones can Save Lives. Profile ⁄Global
Health, University of Copenhagen, Copenhagen, 18–19. Avail-
able at: http://www.e-pages.dk/ku/307/18.
Lund S (2010a) Wired Mothers – Use of Mobile Phones to
Improve Maternal and Neonatal Health in Zanzibar’. Enreca
Health. Available at: http://www.enrecahealth.dk/archive/
wiredmothers/.
Lund S (2010b) Personal communication via email, 10 June 2010.
Lungu K & Ratsma YEC (2007) Does the upgrading of the radio
communications network in health facilities reduce the delay
in the referral of obstetric emergencies in Southern Malawi?
Malawi Medical Journal 19, 1–8.
Macueve G, Mandlate J, Ginger L, Gaster P & Macome E (2009)
Women’s use of information and communication technologies
in Mozambique: a tool for empowerment?. In: African Women
& ICTs, 1st edn (eds Buskens I & Webb A) Zed Books Ltd,
London, pp. 21–32.
Mailman School of Public Health (2010) MoTeCH: A Compre-
hensive Overview. Colombia University, New York. Available
at: http://www.mailman.columbia.edu/sites/default/files/
Motech-ComprehensiveOverview_0.pdf
Maine D (1994) Too far to walk: maternal mortality in context.
Social Science & Medicine 38, 1091–1110.
Matthews MK & Walley RL (2005) Working with midwives to
improve maternal health in rural Ghana. Canadian Journal of
Midwifery Research and Practice 3, 24–33.
Mechael PN (2009) MoTECH: mHealth Ethnography Report.
Dodowa Health Research Center for The Grameen Founda-
tion, Washington DC. Available at: http://www.grameen-
foundation.
applab.org/uploads/Grameen_Foundation_FinalReport_3_.pdf
Mechael PN, Batavia H, Kaonga N et al. (2010) Barriers and
Gaps Affecting mHealth in Low and Middle Income Coun-
tries: Policy White Paper. Center for Global Health and
Economic Development Earth Institute, Columbia University,
New York.
Musoke MGN (1999) Some Information and Communication
Technologies and Their Effect on Maternal Health in Rural
Uganda. A summary of research findings prepared for the
African Development Forum 1999, Addis Abeba.
Musoke MGN (2002) Maternal Health Care in Rural Uganda:
Leveraging Traditional and Modern Knowledge Systems.IK
Notes No.40, World Bank, Washington DC.
Ronsmans C & Graham WJ (2006) Maternal mortality: who,
when, where, and why. Lancet 368, 1189–1200.
Samai O & Sengeh P (1997) Facilitating emergency obstetric care
through transportation and communication, Bo, Sierra Leone.
International Journal of Gynecology & Obstetrics 59,
S157–S164.
Tropical Medicine and International Health volume 16 no 5 pp 622–626 may 2011
A. C. Noordam et al. Better maternal health services through mobile phones
ª2011 Blackwell Publishing Ltd 625

Svoronos T, Mjungu D, Dhadialla P et al. (2010) CommCare:
Automated Quality Improvement To Strengthen Community-
Based Health. Available at: http://d-tree.org/wp-content/
uploads/2010/05/Svoronos-Medinfo-CommCare-safe-
pregnancy1.pdf.
UNFPA (2007) Report on the regional conference on obstetric
fistula and maternal health. UNFPA regional conference on
obstetric fistula and maternal health, 10–13 December 2007,
Nouakchott. Available at: http://www.fistulanetwork.org/
FistulaNetwork/user/ReportNKKT_Final-Version.pdf.
United Nations Children’s Fund (UNICEF) (2009) The state of the
world’s children 2009. UNICEF. Available at: http://www.
unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf.
United Nations Conference on Trade and Development (UNC-
TAD) (2010) Information Economy Report 2010 – ICTs,
enterprises and poverty alleviation. United Nations, New York
and Geneva. Available at: http://www.unctad.org/en/docs/
ier2010_embargo2010_en.pdf.
World Health Organization & UNICEF (2010) Countdown to
2015 Decade Report (2000–2010): Taking Stock of Maternal,
Newborn and Child Survival. Countdown to 2015 Coordination
Committee, Geneva & New York. Available at: http://www.
countdown2015mnch.org/documents/2010report/Countdown
ReportOnly.pdf.
Corresponding Author A. Camielle Noordam, Royal Tropical Institute, Mauritskade 63, 1092 AD Amsterdam, The Netherlands.
E-mail: acnoordam@hotmail.com
Tropical Medicine and International Health volume 16 no 5 pp 622–626 may 2011
A. C. Noordam et al. Better maternal health services through mobile phones
626 ª2011 Blackwell Publishing Ltd