Pregnant women’s experiences with an integrated diagnostic and decision support device for antenatal care in Ghana

Background: Quality antenatal care (ANC) is recognised as an opportunity for screening and early identification of pregnancy-related complications. In rural Ghana, challenges with access to diagnostic services demotivate women from ANC attendance and referral compliance, leading to absent or late identification and management of high-risk women. In 2016, an integrated diagnostic and clinical decision support system tagged ‘Bliss4Midwives’ (B4M), was piloted in Northern Ghana. The device facilitated non-invasive screening of pre-eclampsia, gestational diabetes and anaemia at the point-of-care. This study aimed to explore the experiences of pregnant women with B4M, and its influence on service utilisation (“pull effect”) and woman-provider relationships (“woman engagement”). Methods: Through an embedded study design, qualitative methods including individual semi-structured interviews and non-participant observation were employed. Interviews were conducted with 20 pregnant women and 10 health workers, supplemented by ANC observations in intervention facilities. Secondary data on ANC registrations over a one-year period were extracted from health facility records to support findings on the perceived influence of B4M on service utilisation. Results: Women’s first impressions of the device were mostly emotive (excitement, fear), but sometimes neutral. Although it is inconclusive whether B4M increased ANC registration, pregnant women generally valued the availability of diagnostic services at the point-of-care. Additionally, by fostering some level of engagement, the intervention made women feel listened to and cared for. Process outcomes of the B4M encounter also showed that it was perceived as improving the skills and knowledge of the health worker, which facilitated trust in diagnostic recommendations and was therefore believed to motivate referral compliance. Conclusions: This study suggests that mHealth diagnostic and decision support devices enhance woman engagement and trust in health workers skills. There is need for further inquiry into how these interventions influence maternal health service utilization and women’s expectations of pregnancy care. Qualitative methods including individual semi-structured interviews and non-participant observation were employed. Data collection was embedded into a broader realist evaluation of midwives’ adoption and utilization of the B4M device. The Upper East region (UER) is one of the 10 administrative regions in Ghana and is further sub-divided into districts and municipalities. The B4M project was piloted in Bawku municipal (one health facility- identified as Facility A) and Binduri district (three health facilities- identified as B, C and D) in the UER. Both Bawku municipal and Binduri district are predominantly rural and about half of their population is illiterate [23, 24]. Three B4M devices were placed in health facilities on a fixed (permanently stationed in facilities A and D) or rotational basis (one device shared by facilities B and C) and used to screen women attending ANC. Exit interviews following ANC screening were conducted using a semi-structured interview guide. Questions explored women’s initial reactions to the device, its perceived benefits, their views on its (potential) effect on ANC uptake behaviour (i.e. pull effect), quality of service delivery and their desire for continued use of the device. Interview guides for pregnant women were developed in English language and translated to the local language- Kusaal (see Additional file 1). These were discussed with local program managers before piloting and subsequent modification (ambiguous words identified and refined, exclusion of questions perceived to be culturally inappropriate). The first author and a trained female Research Assistant (RA) who is fluent in both English and Kusaal conducted 20 interviews with pregnant women in June 2017. Sixteen exit interviews were conducted in the four health facilities immediately after ANC visits with B4M use. Using disaggregated data from the project database and with the help of health facility staff, additional women who had been exposed to the device during past ANC visits were traced at community level and invited to the health facility for retrospective interviews (n = 4). Respondents were selected by convenience sampling based on their attending ANC at the health facility during data collection, or based on previous ANC screening with the device and availability for interview. Women were interviewed irrespective of gestation and type of ANC visit (i.e. first or follow-up). Interviews were conducted in locations close to health facilities, but not in the immediate vicinity of ANC consultations. Based on the level of education and preference of the respondent, interviews with pregnant women were conducted in English or Kusaal. Depending on the nature and unique circumstances related to timing and respondents’ convenience, the RA was sometimes the main interviewer while the principal researcher observed or functioned as the main interviewer, with the RA translating. In addition, 10 semi-structured interviews in English were conducted with health workers (midwives and community health nurses) who operated the B4M device in intervention facilities and thereby were engaged in the B4M-ANC care process (see Additional file 2). This was done to understand the experience of use and nature of the mHealth-mediated consultation from different actors. Health workers were asked to share their perceptions of the influence of B4M on women’s behaviour, compliance to referral or clinical recommendations, and on women’s attitudes to the use of mHealth for ANC. As part of the realist evaluation in which this study was embedded, workers were asked to respond to a colour-guided Likert five-point scale (ranging from ‘strongly disagree’ to ‘strongly agree’) in response to specific questions about B4M use. The questionnaire section of the interview explored perceptions of how women responded to the device. Specifically: “I think more pregnant women are coming for ANC now that we use B4M in the Health Facility” and “I think that pregnant women follow my advice more now that I use B4M for consultation.” Responses to these questions were therefore included in the analysis for this paper. We aimed to interview all health workers who had been trained in B4M use, had used the device at least once post-training and were available at the time of data collection. Due to staff rotations, not all midwives who were initially trained were available to be interviewed and not all health workers in each facility were trained on the use of B4M. A summary of the number and category of interviews is presented in Table 1. Categories of respondents per health facility aFacility A is a district hospital in Bawku Municipality and is the first level referral point for facilities B, C and D which are health centers in Binduri district All interviews were audio recorded and later transcribed and translated where necessary to English language. Two independent individuals transcribed a random number of interviews done in Kusaal to assure the quality of transcription and translation. Duration of interviews with pregnant women was between 11 and 34 min (median 21.36 min). Because interviews with health workers were part of a broader evaluation objective, these lasted longer- from 35 to 91 min (median 52.29 min). In order to triangulate and validate findings from interviews, one researcher using a semi-structured checklist and observation guide conducted non-participant observations of ANC consultations in three intervention sites (facilities A, B and D). These were documented using handwritten notes. Non-participant observation is stated here to mean that the researcher is not an active participant in the facility, but interacts occasionally with the people in a non-intrusive way through questions and active listening, if the opportunity presents itself [25]. Secondary data on first ANC visits (i.e. registrations) over a one-year period- from December 2015 to December 2016 (i.e. 6 months before and 6 months after the pilot commenced in June 2016) were extracted from health facility records to supplement findings on the perceived pull effect of B4M. All transcripts were read and a preliminary codebook was developed guided by the main themes explored in the interviews. Two researchers developed codes inductively. One researcher coded all transcripts while another coded a random number of six transcripts to test consistency of codes and support data analysis. Codes were clustered into themes based on similar or recurring patterns. Qualitative data analysis was supported using NVivo qualitative data analysis Software; QSR International Pty Ltd. Version 11, 2014. Approval for this study was granted by the Navrongo Health Research Centre Institutional Review Board (Approval ID: NHRCIRB18) and the EMGO+ Scientific Committee of the Amsterdam Public Health Institute (Reference Number: WC2017–026). Verbal and or written consent was secured from all respondents. Consent was secured prior to all interviews, and respondents signed or appended their thumbprints to an informed consent form. Respondents for exit interviews received transport reimbursement (equivalent value of USD$1 – $2). Health workers were not reimbursed since interviews were conducted at their work place.