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Phase 5 (2012 Deadline)
Saving Maternal and Infant Lives with Affordable Technology Richard Rothenberg and Musharraf Cyan, Georgia State University
Hamid Hussain, Khyber Medical University, Peshawar
Project Overview Pakistan continues to suffer from a large number of preventable maternal and neonatal deaths. An overwhelming number of these deaths can be prevented by adopting appropriate hygiene, nutrition and antenatal care regimens and seeking skilled birth attendance during delivery. The research seeks to provide access to healthcare information and maternal and infant care services to rural women. Using android phones, telemessaging and follow up surveys, a system of well-timed health messages will be provided to pregnant mothers and their households to access antenatal care, skilled birth attendance, postnatal care and neonatal and infant care. In addition, dial in services will be provided to women. The recorded messages in local language are designed to circumvent low literacy barriers. The project will examine the affordability of the technological applications and suitability to adoption in the public health systems. Progress Reports 2014: Affordable Technology for Saving Maternal and Infant Lives seeks to create, implement and evaluate a cost effective method for behavior change communication in marginalized communities. Its primary beneficiaries are rural women and infants. The work area has been identified and local teams have been trained on ethical research to ensure respect for human subjects. A technology team has been identified and initial design of the technology to deliver recorded health messages in local languages have been consulted and brought on board. During the next year, 3210 rural women will be enrolled in the study and according to the research design, they will get health messages in different forms and at varying frequencies. The results will be used to lay out a cost effective method for behavior change communication which can work in under resources and low literacy environments.
2015: Affordable Technology for Saving Maternal and Infant Lives seeks to create, implement and evaluate a cost effective method for behavior change communication in marginalized communities. Its primary beneficiaries are rural women and infants. In a cluster randomized controlled trial, the study is being carried out in 326 villages in two districts of Pakistan. During the study, around 1500 rural women have been enrolled in the study and according to the research design, they will get health messages in different forms and at varying frequencies. The results will be used to lay out a cost effective method for behavior change communication which can work in under resources and low literacy environments.
2016: Affordable Technology for Saving Maternal and Infant Lives seeks to create, implement and evaluate a cost effective method for behavior change communication in marginalized communities. Its primary beneficiaries are rural women and infants. In a cluster randomized controlled trial, the study is being carried out in 411 villages in two districts of Pakistan. During the study, around 1556 rural women have been enrolled in the study and according to the research design, they will get health messages in different forms and at varying frequencies. The results will be used to lay out a cost effective method for behavior change communication which can work in under resources and low literacy environments.
2017: Skilled birth attendance (SBA) is a necessary lifesaving condition. It could be the most important factor in risky pregnancy. In rural areas of the developing world, public health systems may be thinly present, failing to identify pregnancy risks and referrals to facility equipped to provide lifesaving services. This is typified by the rural healthcare in Pakistan.
The study was implemented in Chakwal and Swabi districts of Punjab and Khyber-Pukhtunkhwa Province. Potohari and Pushto are the local languages in the two districts respectively. Each district represents a different social environment from the tapestry of cultures in Pakistan. The villages were identified from the district records. The villages were selected in the interior of districts away from the urban areas.
At baseline, from May to June 2015, 1684 women were contacted who were in their first trimester of pregnancy. Out of these, 1661 accorded consent to participate in the study. Later 105 subjects dropped out due to difficulties in accessing phone messages or disinterest in continuing. The attrition rate comes to 6.32 percent. A total of 1,556 subjects in 389 villages continued in the study (mean: 3.88; min: 1; max: 16).
Health messages were implemented as treatment, superimposed by call-in-referrals. The mothers in Arm A were designated to receive 2 messages per week, timed to gestation age, the messages informing them about conditions and care options at each stage; those in arm 2 received one message per week, timed to gestation age, half the frequency of Arm A but otherwise similar; while mothers in Arm C were relayed as many messages as in Arm B but in random order, not timed with progression in gestation age; and mothers in Arm D were designated to receive messages as in Arm B but 20 messages provided the option to access additional information by pressing ‘1’ on the cellphone and if they accessed this additional information, it would give them a phone balance transfer of Rs.20 (~USD0.20). Arm A in this manner was the main treatment where messages were timed with gestation age and Arm B was similar but the messages were relayed at half frequency. Arm C was designed to replicate the general public health messaging that is by definition not timed with pregnancy at individual level. Arm D was to test the effect of financial incentives on accessing health information.
According to the designated frequency and order, recorded calls in local languages were made between 11th June 2015 and 27th March 2016 for Arms A to D. A total of 58,457 calls were made using a specifically designed software program. The calls were timed according to the treatments by week (as described above) and within the week according to the subject’s preferred time. In case the call was not attended, the software was programmed to repeat the calls up to 10 times on average or till it was attended. Out of these 47,244 calls were heard by 1,220 subjects, giving a success rate 80.82 percent.
The adoption of SBA increased with health messages. Arm A depicts 66 percent SBA adoption (difference in mean test shows that it is statistically significant from the control arm at 5 percent level); Arm B is 59 percent (difference in means test shows that it is statistically significant at 10 percent level), Arm C is 58 and Arm D shows 58 percent while in the control arm, Arm E, it is 57 percent. The effect size in Arm A is 15 percent while for Arm B is 4 percent, showing that twice weekly messages significantly increased take up of SBA.
2018: Affordable Technology for Saving Maternal and Infant Lives seeks to create, implement and evaluate a cost effective method for behavior change communication in marginalized communities. Its primary beneficiaries are rural women and infants. In a cluster randomized controlled trial, the study is carried out in 411 villages in Swabi and Chakwal districts in Pakistan. During the study, around 1556 rural women have been enrolled and they receive health messages in different forms and at varying frequencies.
The results of the study shows that for women who received recorded health messages the probability of going to a skilled birth attendant is 2.4 times higher than women in control group who didn’t. Women were motivated to go to hospitals and they were facilitated in approaching hospitals in critical conditions. Furthermore, we find that call-in-referrals increases the probability of going to primary care hospital by 2.2 times and the probability of going to secondary or tertiary care hospital by 3.5 times compared to women in control group. The results will be used to lay out a cost effective approach for behavior change in communication which can work in low-resource environment and low-literacy population
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