Impact Evaluation of a Digital Health Platform for Kenyan Women

Background

Accelerating improvements in maternal and newborn health (MNH) care is a major public health priority in Kenya, where the maternal mortality rate remains high.

While the use of formal maternity care has increased (90% of pregnant women receive antenatal care (ANC) and over 80% of births occur at health facilities), many women do not receive the recommended number of maternal care visits (40% do not receive the minimum of 4 ANC visits, and just over 50% receive any postpartum care).

Even when visits occur, they are often short, and providers may not offer important elements of evaluation and counseling, leaving gaps in women’s knowledge and preparedness.

Digital health tools, such as PROMPTS (Promoting Mothers in Pregnancy and Postpartum Through SMS), have been proposed as a complement to care provided by maternity care facilities. PROMPTS consists of informational messages, appointment reminders, and a two-way clinical helpdesk.

Methods

A cluster randomized controlled trial was conducted in 40 health facilities (clusters) across 8 counties in Kenya.

A total of 6,139 pregnant individuals were consented at baseline and followed through pregnancy and postpartum.

Individuals recruited from treatment facilities were invited to enroll in the PROMPTS platform, with roughly 85% (1,453/1,700) reporting take-up.

Outcomes were derived from phone surveys conducted with participants at 36 to 42 weeks of gestation and 7 to 8 weeks post-childbirth.

Outcomes were organized into 6 domains: knowledge, birth preparedness, routine care seeking, danger sign care seeking, newborn care, and postpartum care content.

Intention-to-treat analyses were conducted for all outcomes at the individual level, with standard errors clustered by facility.

Results

Participants recruited from treatment facilities had a:

• 0.08 standard deviation (SD) (95% CI [0.03, 0.12]; p = 0.002) higher knowledge index

• 0.08 SD (95% CI [0.02, 0.13]; p = 0.018) higher birth preparedness index

• 0.07 SD (95% CI [0.03, 0.11]; p = 0.003) higher routine care seeking index

• 0.09 SD (95% CI [0.07, 0.12]; p < 0.001) higher newborn care index

• 0.06 SD (95% CI [0.01, 0.12]; p = 0.043) higher postpartum care content index than those recruited from control facilities

No significant effect on the danger sign care seeking index was found (95% CI [−0.01, 0.08]; p = 0.096).

Specific Findings Detailed

Knowledge

Treatment arm participants demonstrated improvements in knowledge, particularly during the antenatal period:

• 3. 6 ppt higher antenatal danger sign knowledge score (p < 0.001)

• Listed 0.24 more signs of labor (p < 0.001)

Birth Preparedness

• The birth preparedness index was higher in the treatment arm (p = 0.018).

• Participants completed 0.13 more items in preparation for childbirth (p = 0.003).

• There was a 2.8 ppt decrease in late arrival at the facility for childbirth (p = 0.036).

Routine Care Seeking

• The routine care seeking index was higher in the treatment arm (p = 0.003).

• Share of women receiving at least the guideline-recommended number of 4 ANC visits was higher (3.1 ppt, p = 0.023).

• A 4.8 ppt increase in women attending at least 1 PNC visit within 6 weeks (p = 0.023) along with a 7.4 ppt increase in the share of women receiving at least the guideline-recommended number of PNC visits (p < 0.001).

Newborn Care

• The newborn care index was higher in the treatment arm (p < 0.001).

• The share of mothers always putting newborns to sleep on their back was 1.9 ppt higher (p < 0.001).

• Share of mothers frequently engaging newborns was 5.2 ppt higher (p < 0.001).

Postpartum Care Content

• The postpartum care content index was higher in the treatment arm (p = 0.043).

• There were improvements in discussions of mother’s health, family planning, and receipt of physical examinations.

Discussion and Conclusions

Digital health tools indicate promise in addressing shortcomings in pregnant and postpartum women’s health care, amidst systems that do not reliably deliver a minimally adequate standard of care.

PROMPTS led to improvements across the pregnancy-postpartum care continuum, especially in the postpartum setting for both mothers and newborns.

The study leverages self-reported outcomes and was not designed to detect effects on health outcomes; findings should be interpreted with these limitations in mind.

Future work is needed to ascertain the impact of at-scale digital platforms like PROMPTS on health outcomes.