Impact of a Smartphone Intervention on Tanzanian Women's Childbirth Location (SUSTAIN1)

Evaluation of an mHealth Intervention to Improve Women's Access to Maternal Health Services in Rural Tanzania

This study investigates whether training Community Health Workers (CHW) to use a smartphone-based prenatal counseling application as a "job aid" instead of the existing paper based standard is associated with increased women's use of maternal health services in Singida region, Tanzania.

In low-income countries, frontline community health workers (CHWs) have potential to improve women's access to maternal health services through prenatal counseling and referral. However, CHW performance can often be enhanced with sufficient training, incentives, supportive supervision and job aids. Smartphone-based applications designed to assist CHWs with referrals, health education and client counseling may improve the quality of care delivered during household visits. There is a need for rigorous scientific studies on the impact of such interventions. This study investigates whether CHWs' use of a smartphone-based application increases women's use of maternal health services in Singida region, Tanzania. It is hypothesized that smartphone-assisted counselling by CHWs can increase use of health facility-based delivery services compared to a control group of CHWs using standard paper-based protocols. This study is conducted within the context of larger project - SUSTAIN-MNCH Project (Supporting Systems to Improve Nutrition, Maternal, Newborn and Child Health), implemented by World Vision through multiple partners.

Maternal Death Affecting Fetus or Newborn, Delivery Complication, Obstetric Complication, Birth Injuries, Delivery; Injury, Maternal, Delivery Problem for Fetus

Women received prenatal household visits from CHWs who were trained on the Tanzania Ministry of Health and Social Welfare's National integrated Maternal, Newborn and Child Health (i-MNCH) paper-based protocols, i.e. received intervention "SUSTAIN Paperbased training of CHW (SOC)"

Women received prenatal household visits from CHWs trained on the following: A) National i-MNCH programme; and B) Smartphone-assisted counseling protocol: a smartphone application designed to assist with identification of danger signs during pregnancy, referral to health facilities, and MNCH counseling , i.e. received intervention "SUSTAIN Smartphone training of CHW (SP+)"

Intervention (Smart phone assisted): During prenatal household visits, the smart phone based application guides CHW through electronic "decision tree" protocols, directing them to specific health/nutrition counseling topics and messages based on each woman's gestational age, and her answers to a specific series of diagnostic questions. Based on the client's gestational age, the tool directs CHW to lessons in an accompanying photo book, and reminds them to counsel on the importance of accessing timed and targeted maternal health services at health facilities. The application also assists CHW to identify danger signs during pregnancy, flags clients who require immediate referral to health facilities, and reminds CHW to follow-up with clients who were previously referred to clinics.

SUSTAIN Paperbased training of CHW (SOC): During prenatal household visits, the CHW asks a specific series of diagnostic questions based on the client's gestational age, offers counsel on the importance of accessing appropriate maternal health services at health facilities and uses lessons in an accompanying photo book to deliver messages on a variety of maternal and newborn health and nutrition topics. CHW are trained to identify danger signs during pregnancy, flag clients who require immediate referral to health facilities, and follow-up with clients who were previously referred to clinics.

Participant delivered at or on the way to a health facility, measured by retrospective report at time of interview, after delivery

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Whether the participant reported during interview taking any listed de-worming medication during pregnancy

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Time between the participant's first prenatal visit by a trained CHW and the date of the postnatal household interview (up to 10 months)

Inclusion Criteria: client of one of the CHWs enrolled in the mHealth study visited at least once by a CHW following intervention (baseline training for CHWs) and during their most recent pregnancy most recent delivery was a live birth and the child is still living Exclusion Criteria: None

Sharing raw data is inconsistent with what was stated in the ethics application form and participant informed consent materials.

Hackett K, Lafleur C, Nyella P, Ginsburg O, Lou W, Sellen D. Impact of smartphone-assisted prenatal home visits on women's use of facility delivery: Results from a cluster-randomized trial in rural Tanzania. PLoS One. 2018 Jun 18;13(6):e0199400. doi: 10.1371/journal.pone.0199400. eCollection 2018.