The impact of mobile phone based health promotion services on maternal, neonatal and infant healthcare behaviour in resource-limited countries: lessons from a case study in Bangladesh
Creators: name: Alam, Mafruha
Publisher: name: The Australian National University
Year: 2020

description: As mobile phone technology has improved, health services provided via mobile phones (mHealth), have spread around the world including hard-to- reach areas. mHealth services have been popularized in developing countries to reduce maternal and under-5 child mortality. Although there is evidence that text messages make a significant improvement to maternal and new born health indicators, the effect of voice messages is under-researched. In this thesis I have investigated Bangladesh's first national mHealth service called 'Aponjon' that provides two messages (voice or text) per week to pregnant women and mothers of 0-11 month old babies. Bangladesh in South Asia has made praiseworthy improvements in maternal and child health indicators. However, the maternal mortality ratio stalled before reaching its millennium development goal. Furthermore, neonatal mortality which makes up two-thirds of under-5 child mortality did not drop significantly. The overall aim of my thesis is to evaluate the effectiveness of the Aponjon messaging and consultation service for Bangladeshi women around pregnancy, delivery, new born and infant healthcare. My analysis of a retrospective cross-sectional study of 476 new mothers who were enrolled in the Aponjon service before (n=210) or after childbirth (n=276) suggested that unidirectional messages during pregnancy had no or limited association with delivery by skilled birth attendants, initiation of breastfeeding right after birth, delayed bathing of new born baby and postnatal healthcare visits within 42 days of delivery. Facility based delivery was an independent factor for delayed bathing and post natal care visits. We conducted a mixed methods study to investigate the usability of Aponjon's 24/7 consultation service. Call log data analysis and interviews of 16 (8 women, 8 husbands) callers and 11 doctors suggested that the service was accessed almost equally by female subscribers and their husbands for enquiries and advice.The doctors graded patient symptoms according to the patient's description and advised treatment and referral as appropriate. Most emergency calls were reported between 8 p.m. to 8 a.m. when visit to local health facilities or a doctor was not possible. Doctors encouraged people to use medicines responsibly and often spelled the names of the medicine to local drugstore salesmen during purchase. The service lacked a referral service linked with local health facilities. A follow-up qualitative study with mothers (n=33) identified socio-cultural and technological barriers to adopting mHealth messages. Although women appreciated receiving information on new born and infant healthcare from the Aponjon service and followed advice, women's delivery decisions were guided by their socio-economic background, cultural influence, involvement of family members, fear of C-sections, trust in local birth attendants and previous history of miscarriages or complicated delivery. Finally, I analysed a retrospective cross-sectional study of pregnant women (n=459) enrolled in the Aponjon service for association between access to messages and satisfaction with the service. I found that women's singular access to messages was positively associated with their satisfaction with the service and better health practices compared to women who shared phone access with family members. Overall, my thesis shows that a mHealth service for maternal, neonatal and infant healthcare has been widely embraced by Bangladeshi women and their husbands. However, mHealth implementers should also address the socio-cultural barriers identified in this thesis that reduce adoption of mHealth services among low income households.This thesis makes recommendations about how mHealth could be enhanced while emphasising that this should occur in the context of broader improvements to existing services to collectively increase the quality of life for mother and children in resource limited settings like Bangladesh.