A systematic review of targeted client communication via mobile devices for maternal health

Problem

The global burden of poor maternal health remains substantial and disproportionately affects women in low income countries, and marginalised populations worldwide. In 2015, over 300,000 women died during and following pregnancy and childbirth. Estimates suggest that for every maternal death, 20 to 30 women suffer maternal morbidity. Targeted client communication (TCC) is the transmission of targeted health content to individuals within a predefined health or demographic group. TCC has the potential to improve maternal health through targeting knowledge, motivation, and behaviour change, to increase client demand and utilization of essential interventions detailed in WHO Guidelines (PMNCH, 2011). Mobile phones may an effective way of delivering TCC, given their low-cost and potential for widespread delivery. Our systematic review aims to synthesise the evidence relating to the effectiveness of mobile phone-delivered TCC targeting maternal health.

Approach

We searched Medline, EMBASE, CENTRAL, Popline, and WHO Global Health Library for randomised control trials of mobile phone-delivered TCC targeting maternal health (published between 1990 and August 2017). Two reviewers conducted data extraction and risk of bias assessments. Meta-analysis was conducted to pool data for outcomes where appropriate. We applied GRADE criteria to assess quality of the evidence.

Findings

11 studies met the inclusion criteria - four were conducted in high income countries. One study was categorised as at low risk of bias for all quality criteria outlined by the Cochrane Collaboration. There was at best moderate quality evidence that TCC via mobile phone improved health behaviours (specifically, taking supplements during pregnancy (RR: 1.71, 95% CI: 1.49 to 1.96), and receiving help with breastfeeding (RR: 2.15, 95% CI: 1.78 to 2.58). There was no change in post-partum contraceptive use, smoking cessation, or ceasing alcohol intake during pregnancy. Evidence for whether TCC via mobiles increased service utilisation was mixed; there was low to moderate quality evidence of an increase in having a skilled attendant at birth (RR: 1.29, 95% CI: 1.20 to 1.40) (high risk setting only), and attendance at antenatal appointments (RR: 1.21, 95% CI: 1.00 to 1.48), however no effect was demonstrated for antenatal influenza vaccination uptake. The quality of the evidence relating to health status and wellbeing was low, and no evidence of benefit was observed for maternal mortality and morbidity, neonatal mortality and morbidity, or pre term birth.

Consequences

There was limited evidence that TCC via mobile phones may be beneficial to health behaviour and service utilisation, but no evidence of benefit for outcomes relating to health status and wellbeing. Due to heterogeneity in outcomes measured, few trials could be pooled together in meta-analyses. There was no evidence to suggest that such interventions result in harm. Further adequately powered high quality trials are required to establish whether TCC delivered by mobile phones improves maternal health.