Saving Mothers Giving Life (SMGL) SMGL-SMS : applying mobile phone-based system to reduce maternal mortality in Kalomo District, Zambia

Outline Background SMGL and aims mHealth in Maternal Health SMGL-SMS + Methodology Achievements Challenges Lessons learned Next step

Background Zambia is the first country to launch Saving Mothers Giving Life, through the Global Health Initiative (GHI), funded by US Government and aiming at reducing maternal mortality (by 50% at the end of year one) in the four chosen districts (Lundazi and Nyimba, Mansa, Kalomo)

Maternal Mortality ratio in Zambia since 1996 MGD Target

Rationale barriers associated to the 3 delays leading to most pregnancy-related mortality to health care prevent women to benefit from life-saving interventions Delayed decision to seek medical care Delay of getting to the health center Delay of receiving adequate care when a facility is reached Lack of proper Post-partum follow-up

Place of delivery and Assistance during delivery (ZDHS 2007) More than 90% of Zambian women receive some antenatal care Only 48% of women deliver in health facilities 47% have assistance of a skilled health provider.

Maternal health inequalities ZDHS did not disaggregate MMR data below national level But MMR is worse in rural areas where access to health services is much poorer 83% of women giving birth in urban areas were assisted by skilled people, compared to 31.3% in rural areas (ZDHS 2007) Figure: Births Attended by Skilled Personnel by Province, Zambia (ZDHS 2007)

Making pregnancy and childbirth safer Key Operational Strategies: – Access to a continuum of care, including appropriate management of pregnancy, – Enable access to life-saving emergency obstetric care (EmONC) when complications arise – Improving referral system – Delivery in health facility by skilled birth attendant – Monitoring during post partum period

SMGL 5-year effort intends to help mothers during labor, delivery, and postpartum SMGL has begun with select districts in Uganda and Zambia, (among the countries with the highest maternal mortality ratios in the world) In Zambia, the initiative will focus on the Lundazi, Nyimba, Mansa, and Kalomo districts. SMGL-SMS : Sub-project applying mHealth to maternal health care delivery

What is SMGL-SMS? A mobile phone SMS-based system Using RapidSMS open-sourced platform Designed and developed by mHealth team at ZCAHRD Lusaka Office Enable dynamic data collection and sharing Currently being piloted in 9 health facilities in Kalomo district, Zambia

SMGL-SMS Aims To contribute to the reduction of delays (1) associated with transport to the referral facility; (2) associated with timely intervention when the mother reaches the referral facility. To provide real-time information regarding maternal health in Kalomo District through routine SMS-based data collection methods. To increase the number of women who attend the WHO recommended four antenatal care (ANC) visits and the number of facility deliveries through SMS reminders

Rationale for using mobile phones The number of mobile phone subscribers in Zambia rose from just 464,000(2004) to over 5 million (2011) following market liberalization Continued growth in coverage of mobile networks Mobile phone penetration rate in Zambia is expected to reach 51% by end of 2012

Why mHealth? Mobile phones have the potential to reduce delays that often result in maternal death: Delayed decision-making added to delayed transport Mitigate information-sharing problems between Health centers and Hospitals Improve transportation and referral for maternal health Mobile phone can promote continuity of care: follow-up at community level and information sharing for effective referral

SMGL-SMS system Health facility Routine MCH data collection Community Registered Pregnant women are followed in the community by CBAs Reminders, Postpartum Referral System - Automated notification of referral center during emergency - Ambulance Notification Web Based Users interface Real time data visualization, report generation and progress monitoring SMGL-SMS

SMGL-SMS workflow Web user interface SMGL-SMS Server

Pregnancy registration and follow-up SMGL-SMS Server Pregnancy is registered in the SMS system Mothers details are recorded into Safe motherhood register CBA is notified of a new mother being registered in her zone of operation CBA keeps a record of the pregnant woman in a logbook

System features

Overall SMGL Result chain *Output that will be obtained through mHealth system. The three above outputs (1.1, 2.1 and 5.1) will constitute outcomes for SMGL-SMS in result chain below.

SMGL-SMS result Chain SMGL-SMS Goal: Applying mHealth technology to contribute to the reduction of Maternal mortality by 50% in targeted facilities in Kalomo District, Zambia by 2013 Outcome 1: Improved referrals communication Output 1.1: Functional SMS-based system application customized for SMGL Output 1.2 : Facility and community staff are trained and have the capacity to effectively use the SMS system Outcome 2: Improved antenatal, postnatal care and record keeping Output 2.1: Increased number of ANC visits and Facility deliveries output 2.2: Better management of postpartum care Outcome 3: Evidence generated through mHealth system Output 3.1 Web User interface showing selected maternal health indicators

Methodology System design and development Functional SMS-based system application customized for SMGL - Phase I - Phase II Implementation in 9 facilities in Kalomo Recruitment and training of data entry clerks, Community Based Agent Training of Health care worker Monitoring and evaluation Ongoing system Monitoring Evidence generation Evaluation

Achievements SMGL-SMS launched July 24 th 2012 Phase I system developed and fully operational in 9 health centers in Kalomo Recruitment and training of - 9 Data entry Clerks - 78 Community Based Agents Training of 33 Health workers Registration and follow-up of over 1500 pregnant women over a 2-month period

Challenges Non availability of baseline data necessary measure change over time Limited mobile network coverage in certain areas Limited availability of emergency vehicle in Kalomo Inhospitable terrain leading to poor transportation

Lessons learned A thorough facility and community assessment is required to build mHealth system that meet the needs of intended beneficiaries Involvement of trained Safe Motherhood Action Groups (SMAGs) or Traditional Birth Attendants (TBAs) in community based interventions/activities A bigger impact on maternal health will be achieve if communication and transport is improved at community level

Next Step Phase II: Development of web user interface and System enhancement Undertaking community based assessment of communication and transportation system Documenting lessons learned Generating evidences and evaluating the impact of the SMGL-SMS system

Conclusion mHealth applied to maternal health has the potential to: Enable monitoring, follow-up and referrals of pregnant women along a continuum of care from the start of the pregnancy all the way through her post-partum period The use of mobile phones will reduce delayed decision-making and transportation during childbirth