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

1996 2002 2007 20150

100

200

300

400

500

600

700

800

649

729

591

162

MMR

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.

47%

25%

23%

5%

skilled health worker

Relative

Traditional birth attendant

No one

48%52% Health Faciliy Delivery

Home delivery

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 Personnelby 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 User’s interface

Real time data visualization, report generation and progress monitoring

SMGL-SMS

SMGL-SMS workflow

Web user interfaceSMGL-SMS Server

Pregnancy registration and follow-up

SMGL-SMS Server

Pregnancy is registered in the SMS system

Mother’s 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 Level of operation System functions Responsible

Facility Level

Registration o Pregnancyo Follow-up visitso Birth o Death

Data Clerk

Referral o Emergent /non-Emergent referral

o Notification of referral centero Dissemination of outcome

Data ClerkFacility Staff

Community Level Registration o Birth o Deatho Reminders

- Follow-up visit- Expected delivery date- Non-Emergent referral

CBA

District Level Monitoring And support

Monthly reports District mHealth Supervisor

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 3.1Web 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 24th 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