Menu
Menu
Menu
Menu
Background: Difficulty in transportation to access skilled providers has been cited repeatedly as a major barrier to utilization of emergency obstetric care in Nigeria. Objective: The objective of this paper is to describe the design, implementation, and outcomes of a mobile phone technology aimed at rapidly reaching rural Nigerian women who experience pregnancy complications with emergency transportation and access to providers. Method: The project was implemented in 20 communities in two predominantly rural Local Government Areas (LGAs) of Edo State, in southern Nigeria, as part of a larger implementation project aimed at improving the access of rural women to skilled pregnancy care. The digital health innovation named Text4Life, allowed women to send a brief message from their mobile phone to a server linked to Primary Health Care (PHC) facilities and to access pre-registered transport owners. Pregnant women were registered and taught to text short messages to a server from their mobile phones or those of a friend or relative when they experience complications. Results: Over 18 months, 56 women out of 1620 registered women (3.5%) texted the server requesting emergency transportation. Of this number, 51 were successfully transported to the PHC facilities, 46 were successfully treated at the PHC, and five were referred to higher-level care facilities. No maternal deaths occurred during the period, while four perinatal deaths were recorded. Conclusion: We conclude that a rapid short message sent from a mobile phone to a central server and connected to transport providers and health facility managers is effective in increasing the access of pregnant women to skilled emergency obstetric services in rural Nigeria.
This paper is drawn from a larger separate sample pretest-posttest quasi-experimental research conducted in rural Edo State, Nigeria between July 2017 and March 2020, and the post-project activities. The general aim of the larger research was to increase rural women’s access to skilled pregnancy care in primary healthcare centres. The project was implemented in 20 randomly selected rural communities in two Local Government Areas (LGAs) of Edo State in Nigeria. Edo State is one of the 36 Federal states in Nigeria, with a population of over 4 million people, the majority of whom live in rural areas [16]. Edo State has 18 LGAs, each with at least 10 administrative wards, with 5000–10,000 people living in each ward. The study was set in Etsako East and Esan South East LGAs, two predominantly rural LGAs located in the northern part of Edo State, both bordering the southern part of the River Niger as it enters the Atlantic Ocean. We chose Okpekpe in Etsako EastLGA and Ewatto in Esan South East LGA, two wards comprising 31 villages and hamlets, from which 20 were randomly selected for the project. Both wards have two PHCs each for four PHCs covering the villages and hamlets. These communities were chosen because of their rural locations and the fact that PHCs are the only available sources of healthcare. There are no secondary or tertiary health care facilities in the immediate proximity although transfers can be made to secondary or tertiary facilities in other locations which are between 20 and 173 km. The sample size for the larger implementation research comprised 1408 ever married women at baseline and 1411 at endline who were randomly selected from households. The detailed description of the design, the selection of the study communities, sample size determination at the baseline and endline, and the intervention activities which included Rapidsms (Text4Life) have been described elsewhere [11, 15]. However, what is reported in this paper also includes pregnant women who registered in Text4Life after the larger project ended in March 2020. The formative research included qualitative needs assessment to identify gaps and challenges. Women reported that the major challenges related to care were transportation difficulties and access to skilled providers, among others [10]. We then worked closely with community leaders where the use of rapid short message service (SMS) to link pregnant women to health providers was proposed as a solution. The plan to use mobile phones was considered viable because of the wide mobile phone usage in Nigeria. About 85% of the population in rural Nigeria have mobile phones [7], while the remaining with no phones often have access to those owned by their spouses, children, relatives, or friends. Thus, along with information communication technology (ICT) experts, we designed a rapid SMS model named Text4Life to be managed by members of the Ward Development Committees (WDC) in the communities. Next, we worked with the local leaders to identify and appoint members of WDCs, with a chairperson for the two project sites and to develop and manage the application functions. The WDC is an initiative recommended by Nigeria’s Federal Ministry of Health to build community linkages and partnerships for the management of PHCs across the country [17]. Based on the formative research and subsequent brainstorming, we created Text4Life as a technology to establish real-time dual communication and alerts. The system was designed to run on an uninterrupted power supply, with a central database server located at the project office in Benin City, Nigeria. The system included a platform for the registration of new pregnancies with support to monitor pregnancies through the antenatal, delivery, and post-partum periods. Text4Life was built upon an open-source framework for basic short message services, data collection, and communication platforms written in Python and Django programming language [18]. It was developed to enable instant reporting of pregnancy-related complications and timely notification of health facilities. The provider system ran on a desktop computer which served as the central server where all patient information is stored using a web user interface called “Textit”. Textit receive messages from women and automatically sends dual replies to the phones of the WDC chairpersons and PHC workers. The device included a reversed billing method that triggers an alert message at no cost. We worked with the WDCs to identify reliable taxi owners in the communities who agreed to participate in the fully explained project. The technology included a web-user interface created for the project by Textit. This interface is a visual platform for interactive messaging. The account gives access to aggregated and disaggregated data for the team and enables the tracking of individual history of patients and reports. The password-protected web interface provides an overview of the system’s outputs, including individual messages sent out, reports, statistics, and administrative data. The automated messages were designed to reply with customized messages (i.e., chatbots) that are then relayed to the sender, healthcare providers, and a WDC Chairman. This conversation workflow ran on an electronic communication device, looking out for SMS keywords and sending appropriate responses. Additionally, it can act on data from messages using Textit integrations and an application programming interface (API). It sends bulk SMS messages, managing them in an email-like inbox, sending automated messages, building bots for social networks, and keeping track of users in a simple customer relationship management (CRM) software. In addition, each Textit® interaction is defined by a systematic workflow, which defines how the user of the application will progress through the flow. Textit® creates a logic flow routine to route users based on their responses. At any point in the flow, one can trigger an action, such as sending personalized short messages, emails, or calling through an external software intermediary such as the API, which can speed response time. Group messages are sent to pregnant women, the health workers, and WDC chairmen on a regular basis to provide health information and platform updates. Each interaction creates a record associated with each user. The records are transferred into MS Excel representing data for all registered pregnant women. The user interface connects data across user groups for each project site, thereby serving as a tracker for the number of women registered and the inputs and outputs over the system. The system was designed to provide access to PHCs for pregnant women in case of an emergency. Text4life is accessed by pregnant women through registration with the WDC and the payment of a small fee – Naira 4000 (equivalent to less than $10) which could be paid in instalments. It enables the use of all facilities including antenatal, delivery, and postnatal care as well as the transportation at no cost. This was a part of a community health fund created as one of the intervention activities for the larger project [15]. Women were recruited and registered, with records of contact details including their telephone numbers and those of their next of kin and neighbours. If a pregnant woman were in distress, she would trigger an alert system by sending a keyword to a dedicated registered phone number configured to the central server. The pregnant woman receives automated feedback from the server for her to wait while an action is being taken. Simultaneously, a dual SMS is relayed through a web-designed interface to the phone number of the WDC Chairman in the ward, and the health care provider at the PHC. Additionally, the pregnant woman’s information is displayed on the message relayed to the WDC and PHC, which prompts them to take immediate action. The WDC then calls the transport owner to pick up the woman in distress, while the healthcare providers prepare to receive the woman in the PHC (see Fig. 1). Summary of Text4life design and implementation The WDC Chairs oversee the project in their communities and report directly to the community leaders for timely decisions. The WDC educates community members about the need for antenatal clinics through village meetings. They also arrange the transport system, including referrals and transport to higher-level health facilities as needed. The WDC managed the community health fund, from which the cost of transportation and delivery care were paid. To build capacity among community stakeholders to manage the system, a series of capacity-building workshops were organised. This consisted of four two-day workshops for the WDCs, PHC providers, and pregnant women (and their spouses or caregivers) in the two project sites (two per site) and two workshops for the health providers in the PHCs. During the workshops, trainers described the system and demonstrated the use of the Text4Life app. The education included explanation of the possible complications of pregnancy for which women would require immediate transfer. They were also taught the specific ways to send messages in English and interpret replies from the central server. Health providers were taught to prepare to receive women and the specific actions to be taken to respond to emergencies, including referrals to specific secondary care hospitals within the vicinity of the PHCs (with contact details) to which women with severe complications could be referred. On completion of the training, mobile phones were distributed to the healthcare workers in the PHCs and the WDC members. Each phone number was registered with all network providers in the communities. The second training series was training of female volunteers in each community. These volunteers were selected based on literacy and ability to triage emergencies using the SMS system. Further trainings were conducted at each PHC. Each participant and interaction are automatically uploaded to the server and transformed into variables. Additional variables were added to each record to denote outcomes of interactions and the pregnancy. Records were checked against WDC and PHC records to track the number of referrals to higher-level health facilities and the outcomes of treatment in the referral facilities. Data were exported to Microsoft excel and analysed to review descriptive information about the number of women who registered in the project, number who reported complications using Text4Life, used the transport, treated in the PHCs or referred. The number of maternal and perinatal deaths was calculated.
N/A
