Integrating and scaling up mobile health (mHealth) interventions in antenatal care

programs in sub-Saharan Africa: Identifying the gaps and way forward

Tarisai Kudakwashe Manyati1 and Morgen Mutsau2

1
Research Associate, College of Economic and Management Sciences, University of South
Africa (UNISA). AJH 5-11, I Preller Street Muckleneuk Pretoria South Africa, 0003.
Corresponding email: tarysai1@gmail.com
2
Research Associate, Centre for Applied Social Sciences, University of Zimbabwe. 5
Aberdeen Road, Avondale, Harare, Zimbabwe.

Abstract

Background: The advances in digital technologies through the Fourth Industrial Revolution,
as well as the attendant behavioral changes in successive generation are paving the way for
rapid changes that are transforming healthcare services to become more integrated, efficient,
inclusive, democratized and affordable. However, the implementation of digital technologies
such as mHealth interventions has been faced with challenges. There is weak evidence on the
sustainability of mHealth interventions in antenatal care programs in sub-Saharan Africa
despite the high levels of cell phone penetration. This study reviews the factors that hinder
the scale up of mobile Health (mHealth) technologies in antenatal care programs in sub-
Saharan Africa.

Methods: Using PubMed, the Cochrane Library, Science Direct, a systematic review was
conducted during the period July–October 2019 of peer-reviewed literature on mHealth
innovations in antenatal care programs in sub-Saharan Africa. The inclusion criterion for the
reviewed studies were (1) studies that reported qualitative results studies (2) that reported
both qualitative and quantitative results of the barriers that hinder the scale-up of mHealth
interventions in antenatal care programs, (3) and studies that were conducted in sub-Saharan
Africa. The study excluded studies that were done outside sub-Saharan Africa that reported
quantitative findings only. This framework captures the current mHealth trends and
showcases the shortfalls and direction for future research. Two review authors independently
assessed all studies against the inclusion criteria. The synthesis of findings is described in line
with the guidelines for reporting qualitative studies —ENTREQ (enhancing transparency in
reporting the synthesis of qualitative research), as it provides evidence for health practice,
policy, and research in a range of settings.

Results: The searches identified a total of 1446 resources for screening, of which 30 articles
met the inclusion criteria.

Conclusions: The absence of robust data to support a scale up to sustainability has hindered a
transition beyond the pilot phase and for achieving economies of scale. The absence of data
to support sustainability or scale up mHealth interventions has also hindered a transition
beyond the pilot phase and the achievement of economies of scale. This research gaps is a
hindrance to scaling up. In countries such as Uganda most mHealth interventions were donor
funded, operated in silos, and lacked sustainability. Readiness assessment data for mHealth
interventions was missing. The absence of routine monitoring and evaluation data impact
analysis and cost-effectiveness data has raised the concerns of program funders,
implementers and policy makers about the efficacy of programs.

The absence of appropriate structures in health programs also limit the scaling up of mHealth
innovations in antenatal care programs. As mHealth innovations are a relatively a new
concept in some health centers there is an absence of laid-down procedures as to how they
can be integrated with existing antenatal care program. Moreover, the absence of such
procedures limits cooperation between the technical teams maintaining the mHealth system
and the medical staff in some cases where the mHealth system is integrated across many
health centers.

Moreover, there are legal and ethical ramifications of mHealth interventions on patients and
health-care providers. Some women in the rural areas have limited access to and ownership
of cell phones, which tend to be owned by their husbands or fathers, who are the gatekeepers
of this technology, and this may also have negative implications in terms of client privacy
when they receive updates and information through SMS.

In addition, standardized and easy-to-scale mobile applications or systems to identify and

monitor pregnant women, test them for HIV, and treat them and their children is still lacking.
Low literacy and proficiency in the use of mobile devices such as smartphones by women is
another factor that hinders the scale up of mHealth innovations in antenatal care programs.
This may be attributed to due to missed educational opportunities by women, especially in
rural areas, due to patriarchal values that do not prioritize women’s education.

In addition, poor internet connectivity and cell phone networks also interfere with the scale
up of mHealth innovations as it becomes difficult for community health workers, medical
professionals and clients of antenatal care to receive data and to synchronize information on
the central servers. Unreliable power supplies and frequent power outages make it difficult to
scale up mHealth in antenatal care, especially in rural areas, as mobile phones require on a
reliable supply of electricity for effective use.

Recommendations: To facilitate the transition beyond pilot phase and to achieve economies
of scale research, and for improved antenatal care outcomes, clearly laid down rules and
procedures for health care centers are required for the integration of services through
mHealth applications. Further, research into the cost effectiveness of mHealth innovations,
the impact of mHealth innovations on antenatal care outcomes, the feasibility and
acceptability of mHealth innovations might be central to policy makers and implementers.
There is a need to conduct more controlled-trials and quasi-experimental studies in order to
strengthen the literature in this field. Health-care providers and regulators need to consider
how patients use and manage their mobile phones when developing mHealth services and
regulations. There is need for standardized and easy-to-scale mobile applications to identify
and monitor pregnant women, test them for HIV, and treat them and their children is still
lacking.

Key Words: antenatal care, mHealth, technologies, sub-Saharan Africa, sustainability

Systematic review registration: This systematic review is registered with PROSPERO,

registration number CRD42018107354. The systematic review was registered on the 4 th of
September 2018. The study proposal for this protocol was also approved by the University of
South Africa ethics committee (2019_ CREC_008).