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In Kenya, early coronavirus disease (COVID-19) modeling studies predicted that disruptions in antenatal care and hospital services could increase indirect maternal and neonatal deaths and stillbirths. As the Kenyan government enforced lockdowns and a curfew, many mothers-to-be were unable to safely reach hospital facilities, especially at night. Fear of contracting COVID-19, increasing costs of accessing care, stigma, and falling incomes forced many expectant mothers to give birth at home. MomCare, which primarily serves communities in remote areas and urban slums, links mothers-to-be with payers and health care providers, following a standardized pregnancy program based on World Health Organization guidelines at a predetermined cost and quality. Expectant mothers gain access to care through a mobile wallet on their feature phone (voice, text, and basic internet), and providers are paid after appropriate care is given. Within the first 3 weeks of the pandemic in Kenya, the following services were added to the MomCare bundle: emergency ambulance services during curfew hours, extended bed allowances to encourage early care, phone calls to check on mothers approaching their delivery dates and to promote the generation of a birth plan, SMS messages to inform mothers of open facilities and COVID-19 protocols, and training for clinic staff in managing COVID-19 patients and infection prevention. We compare data collected through the MomCare platform during the 6 months before the first confirmed COVID-19 case in Kenya (September 2019–February 2020) with data collected during the 6 months that followed. This study shows that care-seeking behaviors (enrollment, antenatal/postnatal care, skilled deliveries) increased for mothers-to-be enrolled in MomCare during the COVID-19 lockdowns, while quality of care and outcomes were maintained. Public health practitioners can promote interactive, patient-driven technology like MomCare to augment traditional responses, quickly linking payments with patients and providers in times of crisis.
The theory of action14 underlying our intervention (Figure 1) relies on MomCare’s flexible implementation of the value-based health care framework,15 which centers on patients’ needs. It encompasses the full cycle of care rather than single inputs, processes, and outputs—aiming to address comprehensive outcomes (both clinic and patient-reported) and to incentivize providers through appropriate reimbursement systems and smart contracts to create maximum value, defined as outcomes that matter to patients relative to the total costs of care. Examples of the value-based health care framework in MomCare16 include the detailed outcome measurements at the patient level, bundled payments to providers, and the adaptive digital platform in support there of (represented in the iterative Activities cycle in Figure 1). Central to the intervention is the ability to add features into the MomCare bundle, such as emergency ambulance services or extended bed allowance, that are reflected immediately and transparently across all the stakeholders. This enabled us to assess the efficacy of the newly added features; continued adherence to maternal, neonatal, and child health care services; and sustained quality of the care provided. MomCare Theory of Action Abbreviations: ANC, antenatal care; COVID-19, coronavirus disease; IT, information technology; SMS, short message service. Central to the MomCare intervention is the ability to add features to the care bundle that are reflected immediately across all stakeholders. The MomCare bundle first rolled out in November 2017 and serves 5 counties in Kenya and Tanzania. We focused this study on the 26 MomCare clinics with the highest pre-pandemic enrollment, concentrated in 3 Kenyan counties: Nairobi (10), Kisumu (13), and Kakamega (3). The majority of MomCare clinics are privately run (54% are faith-based organizations, 38% are privately owned facilities, and the remaining 8% are public) and located in remote rural areas or urban slums. To monitor and systematically improve quality, all clinics that run the MomCare platform are backed by SafeCare, a standards-based stepwise certification methodology that rates quality of care, identifies gaps, and helps develop quality improvement plans for health care facilities in resource-constrained settings.17 To assess the effect that COVID-19 had on the care journey, we looked at longitudinal data from 13,443 expectant mothers enrolled in MomCare. We compared care-seeking behaviors and quality measures 6 months before the COVID-19 outbreak (September 2019–February 2020) with those seen in the study period, the first 6 months after the first case of COVID was identified in Kenya (March 2020–August 2020). In Nairobi, Kisumu, and Kakamega counties, the 2015–2016 poverty headcount reported 17%, 34%, and 36% of the population, respectively.18 The MomCare program enrolls expectant mothers from these and other low-income populations by selecting clinics in catchment areas that mainly serve low-income women (e.g., urban slums and low-income rural areas). Baseline survey data collected from expectant mothers upon enrollment in MomCare confirm their low socioeconomic status. This sample is slightly smaller than the total number of 13,443 women included in the study period as not all survey data questions could be linked for all mothers. Of the 9,980 women linked to baseline survey data, 43% reached secondary-level education and 32% reached only primary education; 46% (of 9,840 women) cooked using wood; and 18% (of 9,946 women) reported that they or someone in their household went hungry in the past 12 months due to a lack of money for food. At the first MomCare visit (after the mother-to-be enrolls in the program), the care team reviews the consent form with the expectant mother, which includes a description of the bundle and how data are collected, limitations of liability, consent, and contact details. MomCare enrollment criteria include gestation less than 26 weeks since at this stage most of the risk of fatal outcomes can be mitigated with adequate care. However, teenagers may enroll at any time during their pregnancy, and providers have the discretion to enroll mothers-to-be identified as in high need. Expectant mothers and care providers then plot their journeys—ANC, transportation, complication risk, skilled delivery, PNC, and immunizations—and digitally-enabled smart contracts are created (Figure 2, top half). These contracts are monitored by the M-TIBA health-exchange platform. They include a digital wallet that serves as a dedicated method of payment for mothers-to-be, making sure funds are available to cover the pregnancy journey. Upon arrival at a MomCare clinic, expectant mothers use their feature phones to check in. After care is received, payment is transferred instantly using mobile technology. Payers can then see transactions in real time (while the mother’s personal information is protected), fostering transparency and accountability. The patient data are also available on the MomCare app to help medical staff uncover disparities in the health journey, improve adherence to clinical guidelines, and manage high-risk patients. The MomCare Mother Journey, Bundle Composition, and 5 COVID-19 Support Interventions Abbreviations: ANC, antenatal care; COVID-19, coronavirus disease; IMM, immunizations; MNCH, maternal, neonatal, and child health; PNC, postnatal care; SMS, short message service. On March 13, 2020, the first COVID-19-positive patient was diagnosed in Kenya,19 and within 3 weeks, the MomCare platform adapted to serve the changing needs of MomCare users. When governments restricted movement due to COVID-19, MomCare followed an agile cycle20 to adapt the platform and develop critical interventions (Figure 1). First, representatives of MomCare providers were contacted to assess their needs. Based on their responses, interventions were designed and piloted with a subset of expectant mothers and providers. Upon rapid analysis of the results, interventions were optimized before rolling them out to the full network. New features of the program included emergency ambulances during curfew hours, extended bed allowance, calls and SMS messages that reached out to mothers with fast-approaching delivery dates, and enhanced facility preparedness for COVID-19 (Figure 2, bottom half). After the first curfew went into effect on March 27, 2020, movement was limited from dusk until dawn,19 causing transportation problems for expectant mothers who needed care after hours, sometimes with devastating consequences.2,21 While medical emergencies were meant to be exempt from curfew,22 the reality was different. People who violated curfew faced fines, jail, fear of altercations, and unsanctioned police brutality (especially in urban slums).22–25 Therefore, in addition to a daytime taxi service, MomCare provided emergency ambulance services for mothers-to-be who needed after-hours care. If mothers-to-be could arrive at the hospital during the day, this would eliminate the stress of traveling at night. To facilitate this MomCare extended the bed allowance from 2 to 5 days, empowering expectant mothers to seek care at the first sign that delivery was imminent. For each facility, the MomCare platform generated a list of expectant mothers, between weeks 34 and 42 of gestation. The list was sorted by risk of complications and week of gestation. Midwives called mothers-to-be to check on their progress, support the generation of a birth plan, and encourage skilled delivery in a clinic staffed by a trained birth attendant. In general, facilities did not receive compensation for the airtime required to make the phone calls but rather received a payment in the form of a bonus conditional on women completing their full pregnancy journeys. To assure MomCare-enrolled women (who were either pregnant or who had recently delivered) that it was safe to seek care, MomCare sent them SMS messages, informing them of government call centers and COVID-19 protocols, and directing them to dedicated MomCare interventions. Expectant mothers in their delivery period received additional information on signs of labor, danger signs, and contact details for the closest care facility. SafeCare provided personal protective equipment and prepared health care workers at all MomCare-connected facilities. The SafeCare4Covid mobile assessment tool was used to determine the pandemic readiness of care facilities. Links were provided to digital tools and resources (e.g., guidelines, checklists, webinars, posters, patient information) in several languages, so facilities could fill gaps in knowledge.26 Tents dedicated to maternal, newborn, and child health services were then set up outside facilities. Each of the newly developed support interventions aimed to mitigate the effects of the pandemic outbreak: (1) the emergency ambulance during curfew hours aimed to avoid fatal outcomes deriving from the lack of skilled support during labor; (2) the extended bed allowance aimed to avoid delivery complications arisen from delayed access to care during labor; (3) the mothers-to-be calls and birth plan aimed to increase the likelihood of medium- and high-risk mothers to attend a skilled delivery at a MomCare facility; (4) the SMS campaign intended to educate expectant mothers about the complication signs, the labor signs, and the availability of COVID-19 safe environments to access care; finally, (5) the SafeCare COVID-19 readiness and safe environment for maternal, neonatal, and child health services aimed to support the care providers in activating safe practices and environments for the expectant mothers. First, we determined the uptake of the support interventions. Then we compared outcomes pre- and post-COVID (i.e., the control and study period, respectively) to investigate changes in care-seeking behavior and quality of care. To determine whether users of the MomCare bundle continued to seek and receive quality care during the pandemic, we examined data related to use of services, risk for complications, and outcomes (Table). Maternal and Child Health Care Outcomes in Kenya Before and During COVID-19a Abbreviation: ANC, antenatal care; COVID-19, coronavirus disease; SD, standard deviation; VDRL, venereal disease research laboratory. We used Chi-squared tests to compare data collected during the 6 months before COVID-19 (the control period, September 2019–February 2020) to the data collected during the first 6 months of the pandemic (the study period, March 2020–August 2020). All data collected during the care journey were anonymized. The analysis is performed on percentages calculated on a monthly basis to correct for the effect of birth seasonality. The ethical clearance to analyze MomCare data was obtained from the Amref Health Africa Ethics and Scientific Review Committee on August 8, 2019 (approval number P679-2019).
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