Maternal, child and reproductive health (51)

Two stark statistics from Nigeria are “Each day in Nigeria, 109 women lose their lives due to pregnancy-related issues and 660 newborns die from preventable causes.” MamaYe has a clear goal to improve it by making “Life-saving change for mothers and babies in Nigeria.” It’s one of six countries in the Evidence for Action (E4A) programme, E4A-MamaYe. The other five are Ethiopia, Ghana, Malawi, Sierra Leone and Tanzania. The initiative aims to use better information, advocacy and accountability to save lives. It’s financed by the Gates Foundation

Five project reports are published in the International Journal of Gynecology and Obstetrics. They describe accountability arrangements and publicise E4A-MamaYe experiences and achievements in Maternal and Neonatal Health (MNH) that are essential to achieve Sustainable Development Goal (SDG) 3

The first paper provides a review of the MNH accountability mechanisms in sub-Saharan Africa that have been implemented and assessed. It offers a conceptual framework to guide discussion.

The second paper discusses political accountability using a review of three global and regional mechanisms used to monitor and track MNH progress. It draws on how global and regional commitments have impacted national responses, as shown in the E4A countries.

The third paper deals with performance and accountability of Maternal Death Surveillance and Response (MDSR) systems, especially response and action components. It includes describe describes the E4A-MamaYe country experiences in implementing MDSR systems.

The fourth paper sets out a case study on a pilot for social accountability to improve MNH services in Ghana. The project uses scorecards and engaging stakeholders in districts.

The fifth paper provides another case study on how evidence supported a campaign on budget advocacy in Sierra Leone. It advocates financial and budget monitoring to ensure financial commitments for MNH are sustained.

MDSR Technical Guidance proposes several actions to increase effectiveness and sustainability. They include:

  1. A supportive institutional culture fostering a learning environment
  2. Multidisciplinary teams at different health system levels to review, communicate and act on findings
  3. Leadership and commitment of government and healthcare staff
  4. Aggregate data from facility and community to higher levels to provide a deeper understanding of gaps in care quality and system-wide challenges
  5. Recognising that local and less resource-intensive solutions can save lives.

These are relevant for Africa’s eHealth governance. An example is Nigeria’s Commission on Information and Accountability (COIA) tracking progress on maternal and child health. It reviews MNH features such as the latest MNH numbers, their variations between urban and rural areas, and impact of education on young women using contraception. There’s much more evidence on MamYe’s progress that provide benchmarks and lessons for all Africa.

As a solution for better health, eHealth may not always be straightforward. A team from Mexico and Colombia reviewed the evidence for eHealth and Sexual and Reproductive Health (SRH) and found clear progress for eHealth for SRH in Latin America and the Caribbean (LAC), many persistent institutional and technological challenges too, and the need for more studies should test eHealth’s beneficial effects on improving access to SRH services. It has an important value for Africa’s health systems and their strategies and plan for eHealth in SRH.

The team describes its study in an article in the Journal of Public Health Policy, Health information technologies for sexual and reproductive health: Mapping the evidence in Latin America and the Caribbean. It includes an evidence map of articles published between 2005 and 2015 about using eHealth to enhance SRH services in LAC countries. Most documents retrieved correspond to information provided by technology developers and primarily for sexually transmitted infection prevention and adolescent health.

Maternal mortality rates in LAC have dropped by 38% over the past 15 years. Despite this success, LAC faces many challenges in guaranteeing good quality and affordable SRH services, including controlling HIV infection in vulnerable groups, reducing adolescent pregnancies, and high caesarean section delivery rates. eHealth’s widely proposed as an element of a complementary strategy to strengthen health systems.

There’s a substantial number and type of eHealth and mHealth services available. The percentage distribution across eHealth from the 31 reports included in the study shows SMS and websites as the most used for SRH.

There were five main health categories in the review, but they’re not mutually exclusive because eHealth covers more than one. HIV is set apart as the main emphasis.

About two-thirds of the studies focused on free eHealth. Their distribution across SHR service access priority group focus was wide. The international priority was greatest, communities second.

The study provides a valuable eHealth status for SRH and a foundation to build from for the next stages of eHealth development. There’s more to do. The report shows that the LAC’s recent efforts to increase the use of eHealth for SRH isn’t derived from a general strategy to expand and evaluate eHealth’s use. Learning from successes in other developing countries should be part of the next steps. This’s good advice for Africa’s health systems too.

Maintaining confidentiality when de-identifying data’s important for healthcare’s credibility.  Integrating the Healthcare Enterprise (IHE) has released a white paper, Analysis of Optimal De-Identification Algorithms for Family Planning Data Elements, proposing a new technical framework for comment. It describes the rationale for selecting de-identification algorithms for each IHE Quality, Research and Public Health (QRPH) Family Planning data element. The Family Planning Annual Report (FPAR) de-identification analysis balanced two conflicting perspectives:

  1. Clinical subject matter expert who tends to want to keep as many data elements as possible at as high a level of fidelity as possible
  2. Security and privacy subject matter expert who aim to apply the most restrictive algorithm possible to safeguard the overall data set as much as possible.

To do this, IHE:

  1. Identified whether each data element is a direct identifier, indirect identifier, or data that does not need to be de-identified
  2. Discussed the purpose and need for each data element.

Simple so far, but it triggered 32 questions about de-Identification family planning spreadsheet data. After the first set of answers and revised method selected, the set of de-identification algorithms was reviewed to evaluate their effectiveness at reducing risk and identifying if any de-identification algorithms went too far and negatively impacted the performance measures relying on the data. Further passes through the data set and algorithm fine-tuning are set out in the white paper.

As HIV/AIDS policies and strategies are directly associated with family planning services, it’s important that Africa’s health systems informatics teams working in family planning contribute to IHE’s new technical framework. Participating offers considerable opportunities for learning and personal development, so double benefits.

South Africa’s mHealth service, MomConnect has used SMSs to provide pregnant women information with health advice for nearly a year and a half. The team has analysed its compliments and complaints and scrutinised the databases containing information on its operation. The result’s an improved service, showing the benefits of M&E.

In an article in of the Journal of Public Health Policy, The MomConnect mHealth initiative in South Africa: Early impact on the supply side of MCH services, the MomConnect review team from the School of Public Health, University of Witwatersrand, South Africa National Department of Health (NDoH) and South Africa MEASURE Evaluation Strategic Information for South Africa (SIFSA), says more than 580,000 pregnant women registered on MomConnect, less than half pregnant women booking their pregnancies in South Africa’s public health sector. About 4,170, 0.7%, provided compliments. There were 690 complaints, 0.1%, of which 74% were resolved, leading to better quality such as fewer drug stock-outs and improved behaviour of some health workers.

Once registered, women receive free SMSs linked to the stage of their pregnancy. They receive messages postnatally, linked to the age of their infant, up to one year. Pregnant women can also interact in three ways with a DoH health desk:

  1. A rating system the day after registration comprising ?ve basic questions about quality
  2. Women can ask for additional information on any topic about their pregnancy
  3. They can log a complaint or compliment about the service they’ve received.

These activities should be seen in the context of MomConnect’s aims to:

  1. Connect pregnant women to health services
  2. Enable these women to interact with the health system
  3. Improve service delivery
  4. Encourage pregnant women to attend antenatal clinics as early as possible, preferably before 20 weeks of pregnancy.

The review deals mainly with aims one to three. The findings lay down benchmarks for a subsequent review. Improvements should be expected in the ratio of compliments to complaints by exceeding the 6:1 rate, a general levelling of complaints across the nine provinces and fewer drug stock outs.

Equivalent benchmarks could be set on the socio-economic and health impact on mothers, babies, infant, families and communities of goal four. These are much more challenging to set and to measure, but provide important information.

eHNA reported on the MomConnect presentation at eHealth ALIVE in September. The audience was very responsive.

Mothers and babies are long-standing health priorities for Africa. South Africa’s MomConnect’s been a source of support for many of its mothers and babies in an effort to reduce their mortality rates, which, up to 2014 and 2015, had been higher than Africa’s average.

At this year’s eHealth ALIVE conference, Peter Barron, mHealth Advisor to South Africa’s National Ministry of Health set out MomConnect’s history and future. There are several themes to the concept:

  1. South Africa has significant avoidable maternal and child mortality
  2. It has not achieved its Millennium Development Goals (MDG) targets for Maternal Mortality Rates (MMR) and Under Five Mortality Rates (u5MR) and will need a big push to achieve its Sustainable Development Goal (SDG) targets
  3. Strong political leadership from the government and health minister has set in train several initiatives to improve progress towards MDGs and SDGs
  4. MomConnect’s one, aiming to strengthen health system in a number of ways
  5. MomConnect’s built on:
  • Very strong political support and leadership of the National Department of Health (NDoH)
  • mHealth programmes already in place in SA that harness support of a range of stakeholders including funders, technical experts, mobile network operators and training partners, so a true Public Private Partnership (PPP).

Four activities are:

  1. Strengthen information systems by registering electronically all pregnancies in the public health system as early as possible using unique ID number
  2. Strengthen the demand side of health system by sending targeted health promotion messages to these pregnant women to help them to improve their health and their infants’ health
  3. Provide pregnant women with an interactive mechanism to feedback on the service they’ve received
  4. Use NurseConnect to empower and support nurses with regular content, encourage study and peer support groups and provide feedback mechanism for nurses to make suggestions and improve their performance.

There are six steps in MomConnect. They’re:

  1. Nurses confirm pregnancies at clinics
  2. Nurses help expectant mothers to register on their mobiles using Unstructured Supplementary Service Data (USSD)
  3. Expectant mothers answer questions about their pregnancies
  4. MomConnect then registers them and links them to their clinic
  5. Their pregnancies are registered in the national database
  6. They receive weekly SMSs appropriate to the stages of their pregnancies about their health and their babies and infants health until their child’s one, and they can opt out at any time.

MomConnect’s voluntary. In its first two years, nearly 900,000 women registered on MomConnect. The MomConnect Helpdesk has received over 6,000 compliments and 1,000 complaints a ratio of 6:1 often seen as a health service benchmark. Complaints are fed back to relevant facility managers to ensure that problems are addressed. These are matched by answers to more than 200,000 routine questions that arrive at the Help Desk at a rate of about 1,000 a day.

A survey response of nearly 10,000, about 22%, in 2015 found that:

  1. Over 98% felt that MomConnect messages had helped them
  2. Over 80% shared SMSs with friends or partners, so extending MomConnect’s reach
  3. Over 75% said the SMSs helped them feel more prepared for childbirth and delivery
  4. Over 70% wanted more SMSs than the 100 plus messages they already receive during pregnancy and the first year of their child's life.

Alongside pregnant mothers, staff are positive about MomConnect. They think it’s a beneficial programme to mothers. Their views were reinforced in February 2016 when MomConnect was ranked as second prize in the African Association for Public Administration and Management Innovation Awards (AAPAM).

Many lessons have been learned since MomConnect started. They include:

  1. Ministerial and senior NDoH management vision and leadership
  2. Need for full time co-ordination
  3. Harness skills, resources and energy from numerous partners to achieve scale-up
  4. Manage many stakeholder agendas so everyone benefits
  5. Flexible funding for the start-up phase was critical
  6. Appropriate technical solution forms the basis but isn’t enough
  7. Links to the health system are critical
  8. Sharing data with the provincial and district staff important for their commitment.

Looking forward, MomConnect has several initiatives underway:

  1. An additional service for HIV positive pregnant women to ensure they have additional support, especially those who are at high risk
  2. An overall, formal, independent evaluation is due for completion by independent academic institutions, with results soon
  3. Network issues and time-outs are a barrier to MomConnect registrations, so need fixing
  4. Extending messaging to partners and children up to five years
  5. Other parties are interested in teenage pregnancy, early childhood development and adherence for TB and HIV
  6. Moving to data from SMS as smartphone coverage increases and testing Facebook Messenger and WhatsAPP for communications
  7. Improving the Help Desk to support women and enable the supply side to respond to complaints and address these
  8. Extend support and empowerment of nurses with a mobisite with materials and access to online support
  9. Ensuring sustainability by reducing operational costs of MNOs and setting a mainstream budget into routine NDoH financial management.

The future’s looking positive for MomConnect. It’s set to take its place with other initiatives as an integrated package to help to reduce maternal and child mortality.

Africa’s birth registrations have been a challenging undertaking for many years. Tigo, one of Africa’s leading innovative telecommunication companies, is supporting African governments with their under-five birth registration. Working with UNICEF Ghana and the country’s Births and Deaths Registry (BDR), they were recognised at the United Nations (UN) General Assembly 71st annual session for their innovative mHealth app to make children’s birth registration smart, quick and reliable. Tigo’s providing similar support in Tanzania too.

Tigo Tanzania supported the government birth registration initiative with a mobile app that’s accelerating provision of birth certificates for children under five. Tanzania’s Demographic Health Survey (DHS) 2010 found only 16% of children under the five have been registered by civil authorities, with the poorest performers coming from rural areas.  An article in BIZTECH Africa says the under-five birth registration initiative in Iringa and Njombe regions expects to benefit more than 200,000 children in both regions

The programme brings registration closer to communities by establishing registration points at health facilities and at community ward executive offices. They’ll enable parents to  access over 700 registration points, with more than 1,500 registration assistants equipped with 800 mobile phones donated by Tigo.

Tigo’s been partnering with the Registration, Insolvency and Trusteeship Agency (RITA) and UNICEF in scaling up this project in Njombe and Iringa following success in other regions. Since 2013, more than 400,000 under –fives have been registered and given birth certificates.

Tigo General Manager, Diego Gutierrez says “through innovative mobile technology application, which ensures that birth registration data is uploaded and sent to a central database at RITA in real-time, we have been able to demonstrate our strong commitment to building a societal ecosystem that brings the promise of technology to life in the communities where we operate”.

Better under-five birth registration marks a significant shift in accelerating birth registration in Tanzania. After years of stagnation. “We are transforming the system to make it easier for children and their families to access the entitlement of a birth certificate,” said Emmy Hudson, Acting Chief Executive Officer of RITA.

The initiative covers two regions Mbeya and Mwanza, and will cover ten more, including Iringa and Njombe. The aim’s to facilitate sustainable birth registration for 3.5 million under fives.

Among the most common causes of maternal mortality, severe bleeding, infections and pregnancy-associated high blood pressure account for over half of all maternal deaths worldwide. Medical Aid Films has produced two new films in English, Haitian Creole and Kannada to demonstrate the use of the CRADLE Vital Signs Alert (VSA), a device that detects heart rate and blood pressure and calculates shock index, the most consistent predictor of maternal morbidity in low-resource settings.

Developed by Kings College London, to meet the World Health Organisation criteria for use in a low-resource setting, the CRADLE VSA is a robust, low cost, portable device that uses a simple traffic light system to show when abnormalities in vital signs are detected. It can be easily charged using a standard micro USB, ubiquitous with the explosion of mobile phone use worldwide.

The films demonstrate how to use the device and how to interpret the results. Following a three-month pilot in Ethiopia, Zimbabwe and India, they are being used as part of the CRADLE 3 trial which aims to determine whether introducing the CRADLE VSA into maternity care reduces rates of maternal mortality and severe pregnancy complications in 10 low-income countries.

Click here to watch the films.

Your feedback is important to Medical Aid Films. If you use these films, please take five minutes to complete their short survey.

The development of these films are dependent on donations and has the ability to save countless lives. To find out more about supporting their work please click here.

Child and maternal health’s a healthcare priority for most African nations. Although many have made tremendous strides in reducing the mortality rates for moms and babies, thousands still die every year due to preventable conditions.

A new initiative’s underway in Ghana. Tigo, UNICEF Ghana and the country’s Births and Deaths Registry (BDR). They were recognised at the recent 71st annual session of the United Nations (UN) General Assembly for their innovative mHealth application to make birth registration of children smart, quick and reliable. An article in IT NEWS Africa says the app was featured in a video presented to the Every Woman Every Child event on the margins of the session.

Every Woman Every Child’s a global movement mobilising and intensifying international and national action by governments, the UN, multi-laterals, the private sector and civil society to address the main health challenges facing women, children and adolescents. It puts into action the Global Strategy for Women’s, Children’s and Adolescents’ Health, a roadmap on ending all preventable deaths of women, children and adolescents in a generation.

Ghana’s President, John Dramani Mahama, was there. He said “Lack of birth registration prevents us from knowing how many kids to register for school, vaccines, and quick dissemination of health information through mobile apps will reach more people in more areas, especially women. We can empower people widely by giving them access to education and resources, human development opportunities for all. We can do more to end hunger. Especially with mobile innovation that will push attainment of Sustainable Development Goals.”

Tigo’s Chief Executive Officer, Roshi Motman was there too. After the event, he said. “We are passionate about improving lives in communities in which we operate through the use of technology which is why we embraced the opportunity to collaborate with UNICEF on this initiative. We are excited about the impact this innovation will have in communities across Ghana especially in areas which are hard to reach.”

The automated birth registration system is an Android App customised for the Tigo Network. It operates offline and online, critical for rural communities where connectivity is challenging. Tablets use the app to collect data, such as children’s names, genders, dates of birth and other family details. They’re sent to the BDR’s central database.

Then, it’s stored and an automated response sent to the BD’'s local official, confirming that a certificate can be issued. Data collected though the paper-based system took up to six months to complete registrations in the central system. The mHealth app does it in less than two minutes.

At the end of the one year pilot, over 670,800 new births will be register on the new system. It’ll help to increase Ghana’s birth registration rate to 75%, up from 65%.  It’s a big step in the right direction. The data provides critical insights into healthcare in the country, allowing officials to track and support moms and babies better.

As health challenges go, Africa’s HIV/AIDS is big. At 12%, it’s the biggest cause of deaths. Prevention of Mother-To-Child Transmission (PMTCT) is one initiative aiming to help. Peter Benjamin for HealthEnabled explained MomConnect’s role to eHealth ALIVE.

Messages about HIV supplement the main MomConnect content. They’re for HIV positive pregnant women and mothers to try to keep their babies HIV negative. Its aim’s to strengthen the National Department of Health’s (NDOH) strategy on PMTCT by supporting adherence to approved protocols and greater linkage of women to healthcare. There are 95 messages, covering pregnancy, delivery, up to the baby’s first birthday and a final reminder for 18 month tests. Pregnant women or mothers of infants living with HIV in South Africa, and caregivers for HIV positive infants benefit by opting into the system.

Patients know about MomConnect’s PMTCT service from their health workers advise HIV positive pregnant women and mothers of infants to up on their own mobile phones. They can do this at any stage, first stage Anti-Natal Care (ANC), late diagnosis or after delivery. Health workers can give women business cards as reminders. Posters also provide information, such as “Are you HIV positive and Pregnant? Ask the health worker.”

Signing in’s easy, with simple questions, steps and guides, and using keys 1 and 2 for responses. Opting out’s simple too.

The PMTCT helpdesk coordinator at NDOH Pretoria can answer SMS questions on HIV, pregnancy, PMTCT and related issues. It’s in parallel to calls out to HIV positive pregnant women and mothers. High-risk patients are a special priority for this service. These include women under 18 years old and the first ANC’s after 20 weeks. The helpdesk asks if they’re ‘Stable on Antiretroviral (ARV) drugs?’ and ‘Disclosed status?’ in research. They’re supported by links with local PMTCT services such as Mother2mothers. Western Cape offers follow-ups by Community Health Workers (CHW) for high-risk patients during pregnancy. There’s a National MomConnect link to local care too.

The initial pilot in five districts ends in December 2016. They’re Gauteng: Johannesburg and City of Ekurhuleni, KwaZulu-Natal (KZN): Ethekwini and Umgungundlovu and Western Cape: Cape Town, Khayelitsha, Mitchells Plain and Southern. It’s already decided to retain the pilot in these five districts until September 2017. Research with Wits Reproductive Health Institute (WRHI) will determine implementation in all districts as a national rollout, so more news to come.

Between 1990 and 2010, globally the under-five mortality rate fell by 28% instead of 67% target. Neonatal mortality accounts for 41% of the under-five mortality rate and has a drag on its slow reduction.

Improving Africa’s mother and baby mortality remain high priorities. Many programmes to reduce rates from Africa’s averages of about 430 per 100,000 and 70 per 1,000 respectively, often see mHealth as part of the solution. A review of the impact of 19 mHealth services in Low and Middle-Income Countries (LMICs)  published in the Journal of Medical Internet Research (JMIR) by a team from the Ghana, Tanzania, The Netherlands and Norway identified potential, and also “A gap in the knowledge whether mHealth interventions directly affect maternal and neonatal outcomes.” It seems these mHealth interventions are not yet proven.

Ten mHealth interventions and nine descriptive studies comprised the review. mHealth interventions were used as communication, data collection, or educational tool by healthcare providers, mainly at in community services for antenatal, delivery, and postnatal care. Interventions were used to track pregnant women to improve antenatal and delivery care and facilitate referrals. None of the studies directly assessed the effect of mHealth on maternal and neonatal mortality. The lack of evidence points to the need for more research with experimental designs with relevant outcome measures that plug the gap.

Several technical problems were included in the individual reviews. They include limited connectivity and electricity supplies and mobile phone maintenance services.

mHealth was found to be much more efficient when it’s used for communication compared to traditional methods. It also improves community health services’ effectiveness in logistics, reporting events and responding to emergencies. It also enables integration of health workers to expedite emergency referrals and communicate with skilled providers like midwives.

Limitations included over-simplified SMSs, so needing more detailed information. Educational information on web-sites is often limited due to remoteness and either no or poor Internet access.

mHealth interventions that depend on existing information systems are not interoperable, and can’t link to other settings and data structures.

The findings don’t mean that Africa’s health systems should stop or abandon their mHealth services for mothers and babies. It does mean that they should scrutinise them rigorously to focus them to their planned health outcomes and develop rigorous business cases for new mHealth projects.