Assessment of the quality of antenatal care services provided by health workers using a mobile phone decision support application in northern Nigeria: a pre/post-intervention study.

According to the most recent estimates Nigeria’s maternal mortality ratio is the tenth highest in the world with an estimated 630 maternal deaths per 100000 live births and 40000 maternal deaths annually. Routinely available good quality antenatal care (ANC) services allow the provision of preventive services and counseling that can contribute to the reduction of adverse health outcomes. One of the main barriers to the delivery of high quality ANC services in Nigeria is the lack of skilled providers available at primary health centers (PHC); community health extension workers (CHEWs) not originally intended to serve as primary ANC care givers are now filling that gap and need additional support and training to deliver ANC services. Evidence suggests that mobile phone case management applications have the potential to improve adherence to clinical protocols and improve care. We conducted a pre / post intervention study to assess the effect of introducing a mobile case management and decision support application for ANC on the quality of ANC services provided in 10 PHCs in Abuja and Nasawara northern Nigeria. In 2012 Pathfinder Nigeria built a mobile application (app) for ANC using the CommCare mobile platform. The app dynamically guides health workers through ANC protocols and collects client data in real time. Thirteen health education audio clips were also embedded in the app for improving standardized client counseling. Ten facilities were equipped with phones or tablets and 150 CHEWs were trained to use the app. Prior to the intervention clients over age of 18 attending their first ANC visit were interviewed about the services they received at facilities to obtain baseline data. Endline client exit interviews were conducted one year after the start of the intervention. A quality score consisting of 25 indicators covering technical and counseling elements of ANC was developed. Client exit interview data was analyzed to assess change in overall quality score as well as change in the provision of key elements of ANC. A total of 266 ANC clients were interviewed directly after their first ANC visit for that pregnancy. Overall the quality score increased from 13.3 at baseline to 17.2 at the endline (p<0.0001) out of a total possible score of 25 with the most significant improvements related to health counseling. In terms of technical elements the quality score increased from 7.77 at baseline to 8.44 (p<0.0001). The health education domain of the quality score had the highest increase from 5.45 to 8.67 points (p<0.001). Introducing a decision support ANC mobile application had a significant positive impact on the quality of ANC care offered by CHEWs / HCWs in Nigeria. Though the research design does not infer causality it does show that introducing a mobile app had an impact on technical and counseling aspects of ANC care. Integrating a health counseling component to the app is a low cost intervention that can impact behavior change and birth planning for delivery with a skilled birth attendant. This study found positive results of integrating the application on the quality of ANC care. Further research using a more rigorous experimental design will allow determination of the impacts of introducing the application on health outcomes.