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Conflict of interest disclosure (Potential) conflict of interest None Relationships with companies of Company names relevance for this meeting  Sponsoring or research funding   Consultancy fee or other (financial)  reimbursement   Shareholder   Other relationship, namely …

mHealth to improve maternal and neonatal care in LMICs Stephanie Sondaal & Alexander Borgstein Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands.

Early neonatal mortality Maternal mortality Births attended Physician workforce Lawn et al., 2010

Challenges of LMICs Shortage of health workers (Lawn et al., 2010) • Specific LMIC factors (Chen et al., 2004) : • – migration of qualified health workers to richer countries – inadequate investment in national health systems resulting in low capacity to health needs (people and resources) – double burden of disease (NCDs and communicable diseases)

Opportunities in LMICs High number of mobile phone subscriptions (ITU, 2014) • High mobile-cellular penetration, reaching 90% by the end • of 2014 (ITU, 2014)

Possible solution

mHealth “ medical and public health practice supported by mobile phones” (WHO) and tablets for the exchange of health related information in the form of coded data, text, images, audio, and video

Research question: to assess the potential of mHealth interventions focused on supporting (1) pregnant women during the antenatal, delivery and postnatal period and (2) health care providers bestowing maternal and neonatal care in LMICs in improving maternal and neonatal outcomes

Methods Systematic review • – The Cochrane Library (Cochrane Database of Systematic Reviews) – PubMed/MEDLINE – EMBASE – Global Health Library – Popline Two reviewers • Quality assessment •

Flow chart

Intervention studies included in qualitative synthesis: Pregnant women, n = 12 • Health care providers, n = 11 •

Observational studies on feasibility and usage Pregnant women, n = 11 • Health care providers, n = 6 •

Results - Overview of scope of research Form of mHealth targeting pregnant women 11,1 Unidirectional text (and voice) messaging 11,1 Direct two-way communication Both unidirectional and direct two-way communication 11,1 55,6 Multidirectional text messaging Unidirectional telephone counselling 11,1

Results - Overview of scope of research Form of mHealth targeting health care providers 9,1 Unidirectional text messaging 9,1 Unidirectional text messaging 36,4 & web-based technology Two-way text messaging Multidirectional text and voice 18,2 messages Smartphone health applications Smartphone recording 9,1 18,2

Results - Overview of scope of research Function of mHealth targeting pregnant women (%) 15,8 Educational Monitoring 15,8 47,4 Reminder Communication and support Emergency medical response system 15,8 5,3

Results - Overview of scope of research Function of mHealth targeting health care providers 9,1 9,1 Educational 9,1 Transmission of test results Appointment reminder 63,6 Communication and support Data collection 27,3

Key messages – mHealth interventions targeted at pregnant women Access to and experience of care improved • – ANC visits (Lund et al., 2014, Kaewkungwal et al., 2010) – Skilled attendance at birth (Lund et al., 2012) – Immunization services received (Kaewkungwal et al., 2010) – Facility utilization rate (Oyeyemi and Wynn, 2014) – Depressive symptoms amongst HIV+ pregnant women (Ross et al., 2013) – Confidence scores and anxiety levels (Jareethum et al., 2008) Pregnancy related outcomes • – Perinatal mortality (OR, 0.50; 95% CI, 0,27-0,90) (Lund et al., 2014) – Compliance to iron supplementation (Khorshid et al., 2014)

Key messages – mHealth interventions targeted at health care providers Data collection tool: • – Positive effect on reporting postpartum haemorrhage and recorded birth weights (Andretta et al., 2011; Gisore et al., 2012) Communication tool: • – Reduced communication gap between CHWs and higher health institutions (Lemay et al., 2012; Ngabo et al., 2012) Education: • – Positive outcome (Woods et al., 2012)

Key messages of observational studies Important to conduct prior to intervention, as they: • – Give insight into possible barriers • E.g. illiteracy, equity, costs for participants, technological issues, maintenance of mobile phones, privacy not always guaranteed ( Munro et al., 2014; Jennings et al., 2013; Ngabo et al., 2012; Woods et al., 2012) – Give insight into needs of the target population • Customized programs: SMS combined with phone calls (Jennings et al., 2013) and, timing and amount of SMS sent (Cormick et al., 2013)

Key messages of observational studies Important to conduct prior to intervention, as they: • – Give insight into possible barriers • E.g. illiteracy, equity, costs for participants, technological issues, maintenance of mobile phones, privacy not always guaranteed (Jennings et al., 2013) – Give insight into needs of the target population • Customized programs: SMS combined with phone calls (Jennings et al., 2013) and, timing and amount of SMS sent (Cormick et al., 2013) Important to conduct during and after intervention, as • they: – Give insight into areas of improvement • Private-public partnerships could play an important role in the expansion of mHealth interventions in LMICs (Ngabo et al., 2012) – Allow for a fuller interpretation of the data

Discussion/Limitations Study and outcome level • – Risk of bias increased as study design became less experimental – Only post-analysis of mHealth activities (no clear outcome) – Comparison between interventions not possible (differing outcomes) Review level • – Thorough systematic search (+) – Grey literature (i.e. NGO activities) (-) Domain • – Neonatal defined as newborn up to the age of 28 days (immunization, retinopathy of immaturity, feeding) – LMICs • Lessons learnt from high income countries lacking • Interesting group not included: low-income women in high-income countries

Discussion/Limitations Study and outcome level • – Risk of bias increased as study design became less experimental – Only post-analysis of mHealth activities (no clear outcome) – Comparison between interventions not possible (differing outcomes) Review level • – Thorough systematic search (+) – Grey literature (i.e. NGO activities) (-, but currently ongoing) Domain • – Neonatal defined as newborn up to the age of 28 days (immunization, retinopathy of immaturity, feeding) – LMICs • Lessons learnt from high income countries lacking • Interesting group not included: low-income women in high-income countries

Discussion/Limitations Study and outcome level • – Risk of bias increased as study design became less experimental – Only post-analysis of mHealth activities (no clear outcome) – Comparison between interventions not possible (differing outcomes) Review level • – Thorough systematic search (+) – Grey literature (i.e. NGO activities) (-) Domain • – Neonatal defined as newborn up to the age of 28 days (immunization, retinopathy of immaturity, feeding) – LMICs • Lessons learnt from high income countries lacking • Interesting group not included: low-income women in high-income countries

Key messages mHealth interventions can be effective solutions • – Improve access to and experience of maternal and neonatal care for pregnant women – Improve data collection by, communication between, and education of health care providers

Key messages mHealth interventions can be effective solutions • – Improve access to and experience of maternal and neonatal care for pregnant women – Improve data collection by, communication between, and education of health care providers mHealth programs featuring alongside investments in • infrastructure and human resources are needed to improve maternal and neonatal outcomes

Key messages mHealth interventions can be effective solutions • – Improve access to and experience of maternal and neonatal care for pregnant women – Improve data collection by, communication between, and education of health care providers mHealth programs featuring alongside investments in • infrastructure and human resources are needed to improve maternal and neonatal outcomes Important role for qualitative research alongside • experimental studies

Key messages mHealth interventions can be effective solutions • – Improve access to and experience of maternal and neonatal care for pregnant women – Improve data collection by, communication between, and education of health care providers mHealth programs featuring alongside investments in • infrastructure and human resources are needed to improve maternal and neonatal outcomes Important role for qualitative research alongside • experimental studies Strong experimental research was lacking, but more and • more examples are available – What is needed for it to become the standard method? • Research “know - how” • Improved collaboration between NGOs and academic institutions