A cluster-randomized trial of an mHealth integrated model of hypertension, diabetes and antenatal care in primary care settings in India and Nepal (2018-2021)

Meeting at the PHFI for mIRA

The project aims to improve antenatal care in Nepal and India via mHealth to help frontline health workers provide antenatal care (ANC) and increase the detection and management of pregnancy induced hypertension (PIH) and gestational diabetes (GDM). Pregnancy-related deaths and complications are common in both Nepal and India. The South East Asia region has the highest prevalence of GFM and PIH worldwide. With the decrease in some direct causes of maternal mortality such as haemorrhage since the 1990s, the share of maternal deaths associated with PIH and GDM has grown.  ANC can play an important role in reducing maternal deaths, but the focus needs to be on content of care, and not just contact with ANC services

The research project will answer the following questions:

  • Does an mHealth, tablet-based electronic decision support system (EDSS), provided to frontline health workers (FHWs), enhance ANC by improving adherence to national ANC guidelines, and improve the screening, detection, referral and management of GDM and PIH, compared with usual care in primary healthcare settings?
  • What are the socio-economic, health-system and political factors affecting the implementation of the enhanced ANC?
  • What is the cost of the enhanced ANC intervention, the change in resource use, and the costs of the intervention relative to the value of the improved health outcomes achieved?

The project will use mHealth to provide better ANC at primary health centres, sub-centres and at a village level. The project plans to work with Auxilary Nurse Midwifes, who form the majority of FHWs in both India and Nepal. They will be trained to follow AND guidelines on content of ANC, and to screen and detect both PIH and GDM.  The intervention should also lead to better record keeping and continuity of care. Pregnant women living in rural areas using public sector health services will be the main beneficiaries.

Institutions working on this project are the Public Health Foundation of India, Kathmandu University in Nepal, and the University of Glasgow and the London School of Hygiene & Tropical Medicine, in the UK. The London School of Hygiene & Tropical Medicine team is led by Professor Oona Campbell working closely with Dr Clara Calvert,Prof Pablo Perel, Prof John Cairns, Emma Radovich, Loveday Penn-Kekana. The country PIs Prof Doiraj Prabahkaran and Dr Biraj Karmacharya

A cluster randomized controlled trial will evaluate the effectiveness of the intervention at the various levels of health care (primary health centres, their associated sub centres (in Telangana and Kathmandu). It will be carried out in a total of 88 PHCs. All women using services will be enrolled, and 20 women per centre will be follow-up postpartum to look at health outcomes

In addition, we conduct formative research and a process evaluation.  The latter will focus on the context in which intervention occurred as well as potential issues faced by the FHWs. Moreover, this particular component of the project will allow for a greater understanding of how the FHWs view mHealth as a form of data collection

Finally, there will be an economic evaluation will estimate the cost of intervention relative to the value of improved health care that it provides.

Our project’s vision is to improve data collection and interpretation, leading to action that will enhance ANC services. Because of this project, India and Nepal will gain insight into the feasibility and cost of implementing an EDDS, and its effectiveness, informing potential national scale-up. We will use our advisory committee, including MoH partners, to see how best to implement findings or effect change in existing plans. We will engage with stakeholders in a number of ongoing workshops, and use our other partnerships to build political commitment. Results are likely to be generalizable to other under-resourced settings. Better data will benefit health care providers, data managers, programme managers, policymakers, and global funders, by giving them the information they need to do their jobs. An efficient EDSS has the potential to save FHWs time, alleviate some of their work burden, and reduce costs. Ultimately, we hope to achieve better care for women and babies.

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