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Background: Failure to attend maternal health services is an intractable challenge for the health-care system in low- and middle-income countries. The use of technology for reminding patients about their appointments has been demonstrated to be an effective (future) tool toward increased health care services utilization in developing countries, such as Ethiopia. Objective: We aimed to investigate the effect of enhanced reminders on postnatal care attendance versus usual care (notification of an appointment at discharge). Methods: The study was a cluster randomized controlled trial: out of eligible 86 health centers, 16 health centers in Addis Ababa (AA) were randomized to either the intervention (8) or the control (8) groups; with a total of 350 mothers equally randomized into each arm. Mothers in the intervention group received the SMS (short message service) or a voice call reminder at 48 and 24 hours before the due postnatal appointment, whereas the control group received only the usual notification of appointments provided by health professionals at discharge from the ward following delivery. We recruited participants on wards after delivery at discharge and followed them up to 6 weeks. This study’s primary outcome was postnatal visit compliance. Our assessment consisted of a two-level bivariate and a multivariate ordinal logistic regression analysis. Results: The majority (97.7%) of the participants completed the study; 173(98.9%) of women in the intervention group and 169 (96.5%) of women in the control group. There was a statistically significant difference in postnatal care (PNC) compliance among women who were in the intervention versus the control group (p-value = 0.005). Higher odds of postnatal compliance was observed among the intervention group (AOR:2.98, 95% CI 1.51–5.8). Conclusions: Mobile phone reminders were effective in terms of enhancing adherence to PNC appointments. This indicates integration of mobile phone reminders in postnatal care could improve postnatal appointment compliance.
This study was conducted in Addis Ababa, the capital city of Ethiopia. The city is divided into 10 administrative sub-cities and 116 kebeles (the smallest administration unit in Ethiopia). In 2016, the total population of Addis Ababa was estimated to be 4 million with a population annual growth rate of nearly 2.9% per year [34]. According to Addis Ababa Health Bureau (AAHB) report, there are 91 health centers in AA. These health centers are primarily responsible for the provision of primary health care (PHC) services including ANC, delivery and postnatal care services. In the Ethiopian health-care system, health centers have a specific catchment populations and area to serve. More than 90% of the mothers access delivery and postnatal services in the health center serving the catchment population, while the rest gets a referral to higher health facilities [35]. The mobile phone subscription rate in AA is more than 80% making it ideal for mobile health (mHealth) interventions [36]. A cluster randomized control trial was conducted in 16 (eight matched pairs) health centers (eight interventions; eight control) across Addis Ababa, Ethiopia between August and November, 2017. The study recruited participants at wards after delivery and followed them for 6 weeks at postnatal clinics. There were 10 sub-cities in AA and they were stratified into two strata (stratum 1 = 6 sub cities and stratum 2 = 4 sub cities) based on geographical location, the size of geographical areas, population density, and economic activities. Two sub-cities were selected from each stratum using simple random sampling. All health centers found in the selected sub-cities of Addis Ababa were eligible to be included in this study. Health centers were excluded if they do not give maternal care (ANC, delivery and postnatal care). All women who gave birth in selected public health centers in Addis Ababa within the study period were eligible for inclusion. Mothers were counseled for participation in the study and provided with all information required. They were recruited if they owned or had regular access to phones, and gave written informed consent for participation in the study. Mothers were excluded if they were having serious obstetrical and/or medical complications requiring hospitalization during the postnatal period or beyond the study period, and were unwilling to participate in the study. Women who indicated that they planned to receive postnatal care outside the intended health center and those who had provided incorrect contact information such that they could not be traced were excluded from this study. Before the randomization process began health centers in selected sub cities were assessed for eligibility (5 health centers were excluded because they don’t give the service). An independent intervention manager who was unaware of the objective of the study randomized the health centers (1:1) to the mobile reminder intervention or usual care using a computer-generated randomization sequence. The health centers were randomized in matched pairs and this was done based on the geographic non-adjacency which was extracted from health facilities distribution in AA. Within each matched pair, health centers were randomly assigned to either intervention or control groups there and after. The data collectors were not masked to the intervention but were asked not to inform assessors (research assistants responsible for the end line data collection). Figure 1 shows the enrollment and lost to follow-up according to the consort extension 2010 for cluster randomized trial. The number of women to be included from each health center was proportionately allocated based on three-month average delivery flow. All mothers who gave birth in the selected health centers and met the inclusion criteria were recruited consecutively into the study. The sample size was determined using two population proportion formula for cluster randomized trial [37,38]. The sample size calculation assumed α (level of significance) = 1.96); β (power) = 80% (0.845); the baseline rate of postnatal visit in Addis Ababa = 55% [39] and an increase of 21% expected based on a quasi-experimental study done in Nigeria comparing SMS reminder intervention with a historical control for postnatal care attendance [40]. The intervention to control ratio was 1:1; lost to follow-up of 10% and the design effect of 2 was used to estimate the minimum sample size of n = 175 in each group. We used open-sourcing software, frontline SMS version 2.6.5 (Occam Technologies Inc.) to manage the schedule and send short messages to participating mothers in the intervention group. The software works in combination with internet, a computer, and android phone. After installation, the SMS was managed using frontline sync. The scheduler and the open-sourcing SMS software were downloaded and refreshed daily, and connected to broadband internet by the intervention managers. According to the Ethiopian national guideline for the postnatal care at least three visits on the 3rd, 7th and between 8th and 42nd days are recommended. Women who came to health centers in the intervention arm received a sequential reminder (SMS or Voice) 48 and 24 hours before their next appointment. The content of reminders was prepared based on literature search and consultations with communication expert. A SMS reminder content of less than 164 characters was designed validated and pretested to check whether the message was consistently understood by the receivers. The message was prepared in English and translated to local language (Amharic) version; thereafter back translation to English was done to verify accuracy of the translation by an expert in both English and the local language. After recruitment of the study participants the data collectors sent the details of the mother including contact number, preferred mode of reminder, date of delivery and details of the health facility to the intervention manager. The intervention manager was a nurse trained by the principal investigator on how to make a voice call, update and refresh the database. The intervention manager was in charge of making calls and ensuring that the SMS were sent according to the schedules. We used the confirmatory mode to verify whether the messages were sent or delivered to study participants. If the messages were not delivered multiple SMS and voice calls were tried. However, the level of exposure (delivery and read of messages) was not considered in this study. Aggregate 840 SMS and 420 minutes’ voice call were done to reach the intervention group. The following SMS or Voice call was sent out to the study participants SMS Dear [first name] [middle name], this is a reminder for you to go to [name of the health center] for your (# of postnatal visit) postnatal checkup on date [date of the checkup date/month/year] please remember to visit the health center by (date of the week). Thank you! Voice Call “Hello, May I speak to [full name]. Hi [first name] I am calling you from [name of the health center] to remind you to attend your [# of postnatal visit] postnatal checkup on [date of the checkup date/month/year]. Please remember to visit the health center by (date of the week). Thank you! Individuals in the control group received the usual care: appointment given by health professionals at discharge from the ward after delivery. In the Ethiopian health-care system, the health professionals working in the maternity ward are responsible for giving appointments to the mothers and no subsequent reminders were given. The primary outcome of this study was postnatal care visit compliance categorized on a three-level ordinal scale. The classifications were (1) no compliers, for mothers who never attended PNC, (2) partial compliers, for women who visited 1 or 2 times for their PNC and (3) full compliers, for women who attended the health facility 3 or more times during their PNC. Selected demographic characteristics of the mother; age, maternal educational-level categorized into (no formal education, primary, secondary and higher education), marital status, husband’s education level and occupation status were included independent variables. Maternal service utilization during the index pregnancy and the last child was assessed. The adequacy of ANC service was described as compliance to the recommended routine ANC services. Four or more ANC services attendance during the index pregnancy were considered as optimal ANC attendance, otherwise the participants were considered as having suboptimal ANC attendance. The past PNC experience was measured based on whether the mother had previously sought postnatal care for the senior siblings of the current baby, where mother was considered as a full compliant if she attended 3 or more postnatal visits, partially compliant, if the mother sought service 1 or 2 times and not compliant, if the mother never got PNC service for the last child. Parity was defined as the number of children ever delivered by a mother. The baseline data collected from the study participants were entered into Epi Data version 4.2.0 and the data were cleaned and exported to STATA version 13 (Stata Corp, College Station, TX) for analysis. Comparisons between the groups were made using Chi square test. The primary outcome, postnatal visit compliance, was assessed for all assigned health centers. Outcome was fitted using a two-level bivariate and multivariate ordinal logistic regression model allowing for health centers clustering. The model was adjusted for study groups, selected sociodemographic characteristics (highest level of maternal educational attainment, husband educational status), level of compliance with PNC visit for the last child, ANC visits for the index pregnancy, parity and pregnancy desirability, decision making for medical care and perceived distance from health facility. Variables found to be significant during the two-level bivariate analysis were further analyzed using the two-level multivariate ordinal regression model. The model was built under the assumption of individuals (Level I) were nested within health centers (Level II). The first model, null model (intercept only model), was fitted without independent variables. The empty model was used to determine the overall difference between the health centers and individuals in PNC compliance. The second model assessed the fixed effect and random effect of the model where individuals and the clustering level health center fitted in to the ordinal multilevel regression model. In multilevel models, fixed effects referred to the average relation of individual variables on postnatal compliance and were expressed as adjusted odds ratio (AOR) and 95% confidence intervals. The random effects were the measure of variation in PNC visit compliance across the assigned health centers. We used the variance and intracluster correlational coefficient (ICC) to explain the variation. The ICC was calculated to see whether the variation in postnatal clinic visit compliance was primarily within or between the health centers. Ethical clearances for the study were obtained from the University of Ibadan/University College Hospital Institutional Review Board (UI/UCH/17/0050) and Ethiopian Public Health Institute Scientific and Ethical Review Committee (EPHI-IRB-034–2017). The permission to conduct the study was given by Addis Ababa health bureau. Written informed consent was obtained from mothers participating in the study after counseling. Parental or guardian informed assent was obtained for study participants less than 18 years of age. Women who refused to give consent to participate in the study were excluded without prejudice to their hospital care. Information gathered from the participants was stored in a secured cabinet by the first author and the contacts provided were confidentially kept by the research team.
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