Can traditional birth attendants (TBAs) use mobile technology to report vital maternal and newborn events at the community level in northern Nigeria? An evaluation of RapidSMS in Zaria, Nigeria
Andrew Karlyn
Dear all - I'd like to share with you a study of relevance to this list.
In 2010, the Population Council partnered with the Population and Reproductive Health Initiative (PRHI), a collaborative group between Ahmadu Bello University and the University of California, Berkeley, and eHealth Nigeria to conduct the mobile Community Based Surveillance (mCBS) study. The purpose of the study was to assess maternal and newborn health in Tsibiri, a rural community near the city of Zaria, Nigeria. The information gathered was intended to assist communities in developing interventions that will improve maternal and newborn health in a participatory way.
The project commenced in June 2010, with community-based
group ANC called Healthy Mothers Clubs (HMCs) and RapidSMS
mobile phone surveillance of maternal and newborn health events by
Traditional Birth Attendants (TBAs). The
participation of TBAs in surveillance is particularly relevant since we've come upon no
evidence to support the role of TBAs in health referral using mobile
phones.
The objectives of the RapidSMS evaluation were to:
1. To determine if automated data collection via SMS cellphone technology can improve vital event reporting quality as compared to hand-based tabulations
2. To determine if semi-literate
traditional birth attendants (TBAs) and community health extension workers
(CHEWs) can effectively use SMS cellphone technology to conduct systematic
surveillance of household vital events in their communities
Here’s a Youtube video of the RapidSMS activity.
The HMC activity was conducted fortnightly and facilitated by a 2-person team of researchers/ PRHI Fellows. eHealth Nigeria deployed OpenMRS to facilitate the HMC activity, including the digitization of all local surveillance forms, capture of the data gathered over a period of 1 year, and training of key personnel in the use of EMRS for case management. For the RapidSMS, 7 TBAs from Tsibiri were trained how to recognize and respond to vital maternal and child health events. On-call health personnel were alerted via SMS to respond in the event of a MNCH emergency.
The project developed training guides for TBAs and Community Health Extension Workers (CHEWs), and conducted trainings in the field for the TBAs which can be seen on eHealth Nigeria’s Youtube channel.
The project contributed to an essential toolkit necessary to stimulate both supply and demand for maternal and child health services in communities where public health resources are extremely scarce. The OMRS succeeded in registering over 87 women and infants while the vital event reporting system successfully engaged TBAs in the monitoring of mothers and babies at the household level. However, vital events were relatively rare over the reporting period with only 9 vital events occurring, 75% of which were reported but 25% of which were done so with a reporting error. As a result, 50% of events were reported correctly.
Although both activities proved to be a qualified success, particularly in a context where health outcomes are dire, a number of challenges hindered the project’s ability to accurately record the impact the interventions on maternal and newborn health. Two major challenges were 1) difficulties in ensuring complete and adequate records keeping, and 2) tracking and follow-up of patients and newborns into the community. Through the linking of the OMRS and RapidSMS household registration and reporting of expectant mothers and mother-baby pairs, it is hoped the system will improve loss to follow and continuum of care for mothers and infants at the community level as well as provide adequate linkages to facilities where primary and secondary care is administered.
I and the study team would be glad to respond to any questions or comments.
Many thanks.
Andrew.
neal lesh
Dear Andrew and the rest of the mCBS team,
Thanks for this great post and videos for an important and thoughtful project. I also don’t think we’ve seen many projects that directly serve TBAs, despite their obvious importance. I have a few questions, but as always no need to reply to them all.
Can you elaborate a little on the role of OpenMRS? Did inputs from RapidSMS create or extend electronic patient records? Was OpenMRS used in clinical workflows or was it used as a backend system to track the project?
Am I right that you taught the TBAs numeric codes to use to report events, such as to send in a 9 for post-partum hemorrhage? Had you also considered using codes such as “PPH”? Do you know if remembering the numeric codes (or even remembering to take the booklet or such that described) them was a challenge?
And I wonder if you could share any thoughts on what the incentives (in the broadest sense) were for the TBAs or CHEWs to do the reporting? Given that that there hasn’t been very much mHealth work with TBAs (though others on the list feel free to point us to examples), do you all have any further thoughts on the best way to support them with mHealth tools?
You mentioned that there were 9 vital events during the period. How did you know that outside of the electronic reporting system? This is just a question of how you did the research.
And finally, are there alerts or reminders in the system (or perhaps planned) that will help reduce loss to follow up?
Thanks again!
take care,
neal
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Evelyn Castle
Thanks for the nice comments! I'll take the first stab at answering
your questions and then Andrew can elaborate on anything I missed.
Role of OpenMRS: OpenMRS was an add-on to the project towards the end.
While working with the community NGO, it became apparently that one of
the problems they were having was with managing their patient records
and doing analysis on the data. OpenMRS was introduced to gather
information on maternal and child health (ANC, delivery, and child
immunizations). OpenMRS is running independently on 2 laptops that the
service providers bring out into the community, data is entered, and
when they return to their office, they synchronize the systems with a
server located at our office in Kano and between themselves. RapidSMS
currently does not transfer information into OpenMRS.
TBAs: We taught the TBAs numeric codes for a few reasons. The first is
that they had never used a cell phone before and typing was difficult.
The second was because they were illiterate but some could recognize
numbers. So the first thing we had to do was a review on numbers. Then
we had to train them how to use the cell phone, and how to text
message. Another issue was that many of them had poor eye sight. So it
was difficult for them to see the numbers on the buttons, and
impossible for them to see any letters. I am pretty sure that none of
the TBAs memorized the numbers, they just used the cards given to them
to identify the vital event. I visited them quite a few times during
the project and when I would see them, they all had their cards. I
also was asked by one TBA to replace her card because the lamination
had come off and she didn't want it to get ruined. So my assumption is
they were using them.
Incentives: In this specific community, the local NGO is very involved
and does a lot of work with the TBAs. Because of this, they didn't
need much incentive to do the reporting. They also got a cell phone
which was a pretty good incentive for them. The CHEW was receiving
payment for her work in the village. Because the TBAs that we worked
with were illiterate, their use of mHealth tools is limited. However,
we feel that training them on the most simple of mHealth tools and
linking them with a CHEW who can do more reporting and follow-up is a
good solution that involves the TBAs and allows for better response
and data collection.
Vital events: Previous to the RapidSMS system, th CHEW had weekly
meetings with the TBAs to find out what events they had witnessed. We
continued this so that we could compare the text-messages the TBAs
were sending vs. what the CHEW was reporting (which we assumed to be
accurate). In this way, we could catch any vital events that were not
reported or reported incorrectly.
Loss to follow-up: We are currently working on expanding this system
to include PMTCT. For this reason, the loss to follow-up aspect is
really important. We will be building in text-message reminders that
will automatically be sent at specific times after delivery to alert
the CHEW to check up on the woman and send in a report.
Thanks and please let me know if you have more questions.
Evelyn
> ership-northern-nigeria/> , a collaborative group between Ahmadu Bello
> Surveillance (mCBS) study
> <http://ehealthnigeria.org/wp-content/uploads/2011/08/project_descript...
> workplan.pdf> . The purpose of the study was to assess maternal and newborn
> information gathered was intended to assist communities in developing
> interventions that will improve maternal and newborn health in a
> participatory way.
>
> The project commenced in June 2010, with community-based group ANC called
> Healthy Mothers Clubs (HMCs) and RapidSMS mobile phone surveillance
> df> of maternal and newborn health events by Traditional Birth Attendants
> since we've come upon no evidence to support the role of TBAs in health
> referral using mobile phones.
>
> The objectives of the RapidSMS evaluation were to:
>
> 1. To determine if automated data collection via SMS cellphone technology
> can improve vital event reporting quality as compared to hand-based
> tabulations
>
> 2. To determine if semi-literate traditional birth attendants (TBAs) and
> community health extension workers (CHEWs) can effectively use SMS cellphone
> technology to conduct systematic surveillance of household vital events in
> their communities
>
> Here's a Youtube video
>
> The HMC activity was conducted fortnightly and facilitated by a 2-person
> team of researchers/ PRHI Fellows. eHealth Nigeria deployed OpenMRS
> ect-description> to facilitate the HMC activity, including the digitization
> of 1 year, and training of key personnel in the use of EMRS for case
> management. For the RapidSMS, 7 TBAs from Tsibiri were trained how to
> recognize and respond to vital maternal and child health events. On-call
> health personnel were alerted via SMS to respond in the event of a MNCH
> emergency.
>
> The project developed training guides for TBAs
> al_V2.pdf> and Community Health Extension Workers
> <http://ehealthnigeria.org/wp-content/uploads/2011/08/RSMS_CHEW_Traini...
> df> (CHEWs), and conducted trainings in the field for the TBAs which can be
> lter=0> .