Integration of a patient-centered mobile health intervention (Support-Moms) into routine antenatal care to improve maternal health in Uganda

PROJECT SUMMARY/Abstract
Antenatal care (ANC) and skilled births are mainstays of preventing maternal and perinatal morbidity
and mortality. Despite expanded availability of skilled birth attendants and referral health systems, Ugandan
women have low ANC use and skilled births, resulting in one of the highest maternal mortality ratios and
perinatal mortality rates in the world. Mobile health (mHealth) interventions can support individuals to
internalize risks, need, and benefits of health services with high intervention delivery success. Provision of
multiple messaging approaches—such as scheduled SMS, telephone voice messages and social support
engagement—can empower individuals to seek and access care, and improve health outcomes. However,
despite successes in pilot studies, there is little data on effectiveness, appropriateness, feasibility, fidelity
and incremental costs needed to adopt, or scale up such strategies in sub–Saharan Africa, where the public
health impact of such interventions is likely to be the greatest.
As part of a K43 career development award (PI Atukunda), we used behavioral frameworks to develop
a user-centered mHealth-based, audio-SMS messaging application to support pregnant women to use
maternity care services in rural Uganda (Support-Moms app). The app shared health-related information
and engaged social support networks via scheduled SMS/audio reminders and upcoming ANC appointment
notifications. In a randomized 3-arm pilot study (n=120) comparing standard of care (SOC), scheduled
messaging (SM), and scheduled messaging plus social supporter engagement (SS), we observed high
intervention uptake, acceptability, and feasibility. All women whose social supporters were engaged on the
app attended ≥4 ANC visits, compared to 83% and 50% of women receiving only messages and SOC,
respectively. Nearly all women in the SS arm (98%) had a skilled delivery compared to 78% and 70% in SM
and SOC groups, respectively. We now propose a type 2 hybrid implementation-effectiveness trial to
evaluate and implement the Support-Moms intervention into routine care. We will test the effectiveness of
the intervention in a randomized controlled trial (N=824); our primary outcome will be the proportion of
healthcare provider-led skilled births (Aim 1). We will apply Proctor’s implementation outcomes framework
to evaluate acceptability, feasibility, appropriateness, and fidelity, and conduct in-depth interviews with
users and key stakeholders informed by the Consolidated Framework for Implementation Research (CFIR)
to refine implementation strategies for future scale-up (Aim 2). We will assess costs and cost-effectiveness
of implementing Support-Moms into routine care (Aim 3). We hypothesize that Support-Moms will be an
effective and cost-effective strategy to improve maternity service utilization. This proposal directly responds
to NIH and NICHD priorities described in PAR-22-105 and PAR-22-132 to reduce preventable causes of
maternal deaths and improve health for women during and after pregnancy.

Grant Number: 5R01HD111692-03
NIH Institute/Center: NIH
Principal Investigator: Esther Atukunda