Access to skilled maternity care is crucial for reducing maternal mortality and morbidity and meeting the Sustainable Development Goals, but barriers to access remain in many contexts, including rural communities in Nigeria. In this blog post, the author of a new paper in BMC Pregnancy and Childbirth discusses the development and outcomes of Text4Life, a mobile-phone based intervention to increase pregnant women’s access to skilled maternity care in rural Nigeria.
Text4Life design and operation
Across sub-Saharan Africa, maternal and child health initiatives are embracing the use of electronic or mobile technology to improve access to and utilization of skilled obstetric care, especially among marginalized and vulnerable populations. These initiatives have been shown to be successful in increasing the use of health facilities by pregnant women, improving two-way communication between healthcare workers and pregnant women, and increasing women’s self-efficacy through the dissemination of pertinent health information.
The research team at the Women’s Health and Action Research Centre (WHARC) in Nigeria, led by Professor Friday Okonofua in collaboration with national and international partners and with funding from the International Development Research Centre (IDRC) and the West African Health Organization, began formative, intervention, and implementation research in 2017 to identify innovations and evidence for improving women’s access to skilled pregnancy care in rural Primary Health Centers (PHCs). During the formative study, we identified transportation as a significant barrier for pregnant women to access existing PHCs.
Multiple qualitative studies with women, men, and community leaders revealed that women resorted to traditional methods of pregnancy care due to a lack of transportation to reach health facilities, especially when labor or complications began at night. This was one of the most important reasons that pregnant women preferred to use unskilled traditional birth attendants (TBAs) who are nearest to them.
The Text4Life intervention was carried out for nearly 24 months, yielding impressive results with no documented maternal deaths.
In response to this challenge, the team designed a set of interventions to address this barrier, in collaboration with women, community leaders, and policymakers, using community-based participatory research techniques. Text4Life, a RapidSMS system, was developed to respond to the difficulty faced by women in reaching PHCs when they experience pregnancy complications.
How it works
Text4Life was designed to enable two-way communication between women, PHC providers, and transport owners. When a pregnant woman experiences complications such as bleeding, normal or abnormal labor, severe abdominal pain, etc. and she has no means of transportation, she activates an alert system by texting a code from her preregistered phone number to a central server that is linked to all Nigerian telecommunication networks. She initiates the alert herself, or she is assisted by someone else.
When the alert is activated, the Chairman of the Ward Development Committee (WDC) that had been established to register the pregnant women in the community where the woman resides receives the alert and identifies her location. The WDC is an initiative of the Nigerian Federal Ministry of Health to strengthen community ties and partnerships for the management of PHCs. At the same time, the provider at the closest to the PHC also receives the alert and starts preparations to receive the woman. The WDC chair will then contact one of the authorized and pre-registered transporters (taxi-owners) in the community, who would go to the woman’s home and drive her to the health center. Text4Life includes a reversed billing technique that sends a free alert message.
Text4Life operates on a continuous power source, with a central server connected to the internet and a website. The system includes a platform for registering new pregnancies as well as assistance in monitoring pregnancies throughout the antenatal, birth, and post-partum phases.
A number of capacity-building workshops were organized in the project sites for WDCs, PHC providers, pregnant women (and their spouses or caregivers), and female volunteers to develop capacity among community stakeholders to manage the system. The training included an explanation of the potential pregnancy complications for which women would require urgent transfer. They were also shown how to transmit messages and interpret responses from the central server.
This intervention holds a strong promise for improving access to skilled pregnancy care, reducing delays due to lack of transportation, and decreasing the rate of maternal mortality.
Health providers were instructed on ways to prepare to receive women as well as the specific actions to take in response to emergencies, such as primary treatment, triaging, and referrals to secondary care hospitals should the need arise. Following the completion of the training, mobile phones were given to PHC healthcare providers and the WDC chairmen. During antenatal care visits, the PHC providers also showed the women how to use the Text4Life app.
Outcomes and other applications of Text4Life
As reported in our new paper, the Text4Life intervention was carried out for nearly 24 months, yielding impressive results with no documented maternal deaths in the rural communities. The United Nations Fund for Population Activities (UNFPA) Nigeria office is presently utilizing the Text4Life approach to carry out an intervention in 320 communities across nine Nigerian states and the Federal Capital Territory, Abuja for women to report cases of gender-based violence (GBV), COVID-19, family planning needs, and unwanted pregnancies.
Women experiencing GBV and other complications can text a code to a central server via their mobile phones. The messages are then relayed to trained nearby health providers and civic society officials, who are expected to provide health care and social management to the distressed callers. The findings show that over a 22-month period, the server received a total of 3,200 reports, with the data currently being analyzed to determine the outcomes of management.
The development of the Text4Life app shows the potential of a quick short message sent from a mobile phone to a central server and linked to community managers, transport providers, and health providers to increase pregnant women’s access to skilled emergency obstetric services in rural Nigeria. The findings suggest that the intervention is feasible and sustainable, particularly when implemented with the active involvement and ownership by community members. We believe that this intervention holds a strong promise for improving access to skilled pregnancy care, reducing delays due to lack of transportation, and decreasing the rate of maternal mortality in rural Nigeria and other sub-Saharan African countries.