JMIR Publications

ABSTRACT

Antenatal care (ANC) and skilled births are mainstays of preventing maternal and perinatal morbidity and mortality. Despite expanded availability of skilled birth attendants and referral health systems, Ugandan women have low ANC use and skilled births, resulting in one of the highest maternal mortality ratios and perinatal mortality rates in the world. Mobile health (mHealth) interventions can support individuals to internalize risks, need, and benefits of health services with high intervention delivery success. Provision of multiple messaging approaches—such as scheduled SMS, telephone voice messages and social support engagement—can empower individuals to seek and access care, and improve health outcomes. However, despite successes in pilot studies, there is little data on effectiveness, appropriateness, feasibility, fidelity and incremental costs needed to adopt, or scale up such strategies in sub–Saharan Africa, where the public health impact of such interventions is likely to be the greatest. In our previous studies, we used behavioral frameworks to develop a user-centered mHealth-based, audio-SMS messaging application to support pregnant individuals to use maternity care services in rural Uganda (Support-Moms app). The app shared health-related information and engaged social support networks via scheduled SMS/audio reminders and upcoming ANC appointment notifications. In a randomized 3-arm pilot study (n=120) comparing standard of care (SOC), scheduled messaging (SM), and scheduled messaging plus social supporter engagement (SS), we observed high intervention uptake, acceptability, and feasibility. All women whose social supporters were engaged on the app attended ≥4 ANC visits, compared to 83% and 50% of women receiving only messages and SOC, respectively. Nearly all women in the SS arm (98%) had a skilled delivery compared to 78% and 70% in SM and SOC groups, respectively. We now propose a type 1 hybrid implementation-effectiveness trial to evaluate and implement the Support-Moms intervention into routine care. We will test the effectiveness of the intervention in a randomized controlled trial (N=824); our primary outcome will be the proportion of healthcare provider-led skilled births (Aim 1). We will apply Proctor’s implementation outcomes framework to evaluate implementation, service and client outcomes, and conduct in-depth interviews with users and key stakeholders to contextualize/clarify these outcomes, and explore implementation strategies for future scale-up using the Consolidated Framework for Implementation Research (CFIR) (Aim 2). We will assess costs and cost-effectiveness of implementing Support-Moms into routine care (Aim 3). We hypothesize that Support-Moms will be an effective and cost-effective strategy to improve maternity service utilization.