The University of Edinburgh Medical School (Lee, Nurmatov, Nwaru, Mukherjee, Pagliari, Grant); Edinburgh Health Services Research Unit (Mukherjee)
"mHealth research projects are typically under-theorised, poorly specified and vaguely described. This creates challenges for effective evidence synthesis, risks unintended consequences that cannot be explained, makes replication and scaling difficult and hinders the effective translation of research to practice."
This study, sponsored by the World Health Organization (eHealth Unit, Geneva), sought to assess the effectiveness of mHealth interventions for maternal, newborn, and child health (MNCH) in low- and middle-income countries (LMICs). Overall, the available evidence is weak, and the results, in most cases, are too inconsistent to enable robust conclusions to be drawn about impacts on patient health outcomes.
The systematic review analyses both health and health care utilisation indicators, includes all legitimate mHealth technologies, covers the full spectrum of maternal and infant health, and was not restricted by language. It sought to capture the body of quantitative comparative studies on mHealth for MNCH through analysing a very large initial corpus of studies. Sixteen online international databases were searched to identify studies evaluating the impact of mHealth interventions on MNCH outcomes in LMICs, between January 1990 and May 2014. Comparable studies were included in a random-effects meta-analysis.
The majority of included studies took place in Sub–Saharan Africa and East Asia, while a few were undertaken in South Asia and the Middle East. Included studies encompassed interventions designed for health information delivery (n=6); reminders (n=3); communication (n=2); data collection (n=2); test result turnaround (n=2); peer group support (n=2) and psychological intervention (n=1). The delivery modes used were mobile phones with text messaging via short message service, or SMS (n=11), SMS and voice messaging (n=1), and voice calls (n=2). Two studies used mobile applications to collect data, and one study used MP3 players to deliver audio recordings.
The primary outcomes were estimates of maternal, newborn, and child mortality and morbidity. Secondary outcomes included: number of planned antenatal and postnatal visits; number of unscheduled care visits and emergency care; quality of life; quality of care (delivery by skilled birth attendants, appropriate use of evidence-based medical and obstetric interventions); self–efficacy; cost–effectiveness; immunisation coverage; child developmental milestones; and other process indicators.
The researchers discovered that most studies of mHealth for MNCH in LMICs are of poor methodological quality, and few have evaluated impacts on patient outcomes. Fifteen research articles and 2 conference abstracts met inclusion criteria, including 12 intervention and 3 observational studies. Only 2 studies were graded at low risk of bias. Only one study demonstrated an improvement in morbidity or mortality - specifically, decreased risk of perinatal death in children of mothers who received SMS support during pregnancy, compared with routine prenatal care. Meta-analysis of 3 studies on infant feeding showed that prenatal interventions using SMS/cell phone (vs. routine care) improved rates of breastfeeding (BF) within one hour after birth (odds ratio (OR) 2.01, 95% confidence interval (CI) 1.27-2.75, I2=80.9%) and exclusive BF for 3-4 months (OR 1.88, 95% CI 1.26-2.50, I2=52.8%) and for 6 months (OR 2.57, 95% CI 1.46-3.68, I2=0.0%). Some studies showed that mHealth interventions, particularly those delivered using SMS, were associated with increased utilisation of health care, including uptake of recommended prenatal and postnatal care consultation, skilled birth attendance, and vaccination.
Reflecting on these findings, the researchers suggest that further research, using rigorous methodologies, is needed to better establish the effectiveness of mHealth interventions in MNCH initiatives in LMICs. In particular, they say, trials with quantifiable economic, clinical, and long-term patient-centred health outcomes are warranted. As low-cost smartphones begin to penetrate in these regions, a new generation of mobile apps is now emerging, which will also require evidence-based methods to establish their safety, efficacy, and societal impacts. Methods of integrating real-time evaluation into these deployments will be essential. The researchers also recommend that mHealth researchers, sponsors, and publishers prioritise the transparent reporting of interventions in terms of their aims, contexts, modes of delivery, and presumed mechanisms of impact. Without this level of specification, it will be difficult to develop robust evidence-based recommendations for policymakers and planners wishing to make informed choices about mHealth investments in LMICs.
Journal of Global Health. 2016 Jun; 6(1): 010401; and email from Claudia Pagliari to The Communication Initiative on September 12 2017. Image credit: Medscape