Utilization of a Targeted Mobile Phone Intervention in Antenatal Care and its Effects on Postnatal Outcomes Among Pregnant Women in a Pastoralist Community in Narok County in Kenya

Abstract

Introduction Worldwide, complications that occur in pregnancy, at childbirth, and in the immediate postnatal period (puerperium) are the leading causes of mortality and morbidity among Women of Reproductive Age (WRA). Most women die because of complications occurring during and following pregnancy. The majority of these mortalities and morbidity are due to preventable causes and almost all of them (99%) occur in low and middle-income countries (LMICs). Antenatal care (ANC) is one of the key high-impact strategies to improve maternal and child health globally. WHO recommends eight visits. In LMICs, only about half of pregnant women receive the WHO-recommended minimum ANC visits. Good quality ANC care can reduce maternal morbidity and mortality and perinatal morbidity. Using technology in maternal health (mHealth) improves outcomes. Methods This study was conducted in four busy public hospitals in Narok County. A Randomized Controlled Trial (RCT) was conducted to determine the effect of a targeted mobile phone intervention on antenatal and postnatal clinic attendance, level of skilled attendant delivery, and also the resultant postnatal outcomes. The study population comprised WRA who were expectant recruited early in pregnancy. Two hundred and eighty mothers (280) were recruited. Recruitment began in June 2018 and the study closed in March 2021. The intervention was bi-component, consisting of a standardized Short-message Service (SMS) sent fortnightly and a phone call reminder made one week (7 days) before the date the study mother had been booked to attend the ANC clinic. All study mothers were followed up from recruitment to 42 days post-delivery. Data were analyzed with Stata v14 using descriptive and inferential statistics. Ethical approval was obtained from SERU at KEMRI. Results Two hundred and sixty-two mothers completed the study giving a 93.6% completion rate. The mean age at enrolment of the study participants was 23.87 years (SD 5.22, 95% CI 23.23-24.50) with the youngest study participant being 14 years old and the oldest mother being 44 years old. Eighty-six percent (86.26% (n=226)) of the study participants were married. ANC Attendance The mean number of antenatal visits done by each study participant was 3.48 visits (SD 1.06, 95% CI 3.35-3.61). The intervention was associated with improved antenatal care clinic attendance amongst the study population with the mean number of antenatal visits being 4.099 visits for the 131 study participants in the intervention group while it was 2.843 visits for the 128 study participants in the non-intervention study arm giving a difference in means of 1.256 visits (95% CI 1.044-1.467, p-value < 0.0001) Skilled Care deliveries The intervention was associated with improvement in skilled care deliveries. In the intervention group with 130 study participants, 90% (n=117) of them were assisted by a healthcare worker to deliver. Five percent (5.38%, n=7) of the study mothers were assisted by a relative to deliver while 4.62% (n=6) were assisted by a traditional birth attendant. In the non-intervention study arm with 128 study participants, 69.53% (n=89) were assisted by a healthcare worker to deliver while 15.63% (n=20) were assisted by a relative to deliver with 14.84% (n=19) being assisted by a traditional birth attendant. The null hypothesis of there being no difference in the likelihood of a study mother being assisted to deliver by a healthcare worker by the study group, was rejected (X2 16.810, p-value < 0.0001) indicating that the study mothers in the intervention study arm were more likely to be assisted by a healthcare worker to deliver than those in the nonintervention study arm. The intervention was also associated with improved health facility-based deliveries. Of the 130 study mothers in the intervention study arm, 90% (n=117) delivered in a health facility while 10% (n=13) delivered at home. Of the 128 study mothers in the non-intervention study arm, 69.53% (n=89) delivered in a health facility while 30.47% (n=39) delivered at home. The difference of proportions for the health facility-based deliveries between the intervention and non-intervention study arms was 20.47% (95% CI 10.97-29.96, p-value < 0.0001), which was statistically significant. Postnatal Clinic (PNC) Attendance The intervention was also associated with improved postnatal care clinic attendance. Of the 60 study participants who were in the intervention study arm, 41.67% (n=25) attended the PNC while 58.33% (n=35) did not attend. Of the 76 study participants who were in the nonintervention study arm, 21.05% (n=16) attended the PNC while 78.95% (n=60) did not attend. The null hypothesis that there was no difference in the likelihood of a study mother attending postnatal clinic by study group was rejected (X2 6.766, p-value 0.009). Maternal Postnatal Outcomes The intervention was associated with fewer maternal complications during and after delivery. The likelihood of a study participant having any complication at birth was 33.33% (n=86) while that of a study mother having no complication was 66.67% (n=172). The difference in proportion between the study participants who had a complication at birth was 17.23% (95% CI 6.51-27.94, p-value = 0.002) between the intervention (19.70%) and the non-intervention (36.92%) study arm which was statistically significant. Neonatal Outcomes The intervention was also associated with fewer neonatal complications. The median APGAR score at 5 seconds for the 121 study mothers in the intervention study arm was 10 while it was nine for the 99 study mothers in the non-intervention study arm. Mann Whitney U test of significance was used to test the null hypothesis that there was no difference between the median APGAR score at 5 seconds of the two study groups. The difference between the medians was found to be statistically significant at a 95% confidence level (Z statistic of 4.698, p-value < 0.0001). A targeted mobile phone intervention was associated with fewer neonatal mortalities. The difference in proportion between the study participants who had neonatal mortality at birth was 9.32% (95% CI 1.91-16.74, p-value = 0.015) between the intervention (6.06%) and the nonintervention (15.38%) study arm which was statistically significant. In conclusion, a targeted mobile phone intervention used in antenatal care was associated with improved ANC and PNC attendance and better maternal and neonatal postnatal outcomes.