Perinatal mHealth Intervention in Guatemala

Study Overview
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Brief Summary
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The purpose of the study is to explore ways to improve maternal and child outcomes in the ethnic Maya speaking the Kaqchikel language population, which experiences wide disparities in health care access and outcomes when compared to other inhabitants of Guatemala who are not ethnically Maya and live in other parts of the country.

Detailed Description
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While advances in medical care have reduced mortality rates across the globe, the same cannot be said for perinatal mortality. This is particularly true of Low and Middle Income Countries (LMICs), which contribute by far the largest proportion of the estimated 5.4 million perinatal deaths annually. Key reasons for this include lack of systematic screening, lack of early health advice-seeking, lack of training for the healthcare workers involved in the healthcare delivery chain and a lack of robust referral. To address these issues, the investigators will introduce and evaluate a scalable mobile health (mHealth) referral system in Guatemala, one of the poorest countries in Latin America with one of the highest perinatal mortality rates. The system combines several key innovations which have been developed over the last 10 years. First, the investigators will introduce a low cost (under $30) ultrasound screening tool, with a blood pressure cuff and pulse oximeter, from which data is fed directly to a smartphone to produce an on-the-spot assessment of the health of the fetus and mother, using a step-by-step pictorial guide (also on the phone). Second, the investigators will implement a mobile phone-mediated medical record and referral system that allows users of both smartphones and basic mobile phones to upload data into a standardized medical record system already in operation in Guatemala. The data will allow healthcare workers to identify or enroll patients, review their histories, and schedule future screenings or follow-up visits, as well as equip the healthcare providers with the necessary information to assess needs, resource allocation and efficacy of treatment or personnel. Thirdly, the investigators will introduce a training protocol for lay midwives to provide routine screening with the system for risk factors such as high blood pressure, fetal growth restriction and fetal distress, and to promote postnatal care coordination. Importantly, this shared system will facilitate communication between the obstetrical care team and the postnatal child care team, which currently represents one of the most pressing care coordination challenges in rural Guatemala. By bringing together engineers, physicians, public health workers, anthropologists, and local nongovernmental organizations to co-design the system around the needs of the existing healthcare infrastructure and the local population, the investigators will create an intuitive system which relieves the burden of data collection, improves diagnostic capabilities, and assists with rapid and accurate referral. The system will also facilitate inter-facility research by introducing a standard medical record protocol.

Official Title
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Mobile Health Intervention to Improve Perinatal Continuum of Care in Guatemala

Conditions
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Pregnancy, Prenatal Care

Intervention / Treatment
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* Device: mHealth


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria for Midwives: Wuqu' Kawoq's catchment area Bilingual speakers of Spanish and Kaqchikel Maya Willing to give consent and be trained on the mHealth technology Must be under the age of 65 Must be 18 years-old or older Exclusion Criteria for Midwives: Outside Wuqu' Kawoq's catchment area Not a bilingual speaker of Spanish and Kaqchikel Maya Over the age of 65 Under the age of 18 Unable to give consent and be trained on the mHealth technology Inclusion Criteria for Pregnant Women: Must be 18 years-old or older Must be pregnant Must have a midwife that has been recruited for the study Bilingual speakers of Spanish and Kaqchikel Maya Willing to give consent Exclusion criteria for pregnant women Under 18 years of age Not pregnant Does not have a midwife in the study Is not bilingual in Spanish and Kaqchikel Maya Unable to consent

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Screening
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: mHealth midwives<br>Midwives will receive access to mHealth technology immediately and use it for 12 months | Device: mHealth<br>* A cell phone that can capture data measurements from devices on blood pressure, oxygen level, the heart rate of pregnant women, and the heart rate of the baby.<br>|
| Active Comparator: mHealth midwives - control<br>Midwives will not have access to mHealth technology for the first six months, and then will receive the technology for the remaining six months. | Device: mHealth<br>* A cell phone that can capture data measurements from devices on blood pressure, oxygen level, the heart rate of pregnant women, and the heart rate of the baby.<br>|
| Active Comparator: Pregnant Women<br>Pregnant women may or may not receive mHealth technology, based on the collaborating midwife they are assigned. | Device: mHealth<br>* A cell phone that can capture data measurements from devices on blood pressure, oxygen level, the heart rate of pregnant women, and the heart rate of the baby.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Referral Rates to Local Hospitals | TBAs refer pregnant women to local hospitals for further evaluation or treatment when a pregnancy complications are detected. The median adjusted monthly emergency referral rates (referrals/births) per 100 births for each time period are presented here. | Month 7, Month 12 | 
| Number of Neonatal Deaths | The number of neonatal deaths during the entire study period are presented. Baseline complication rates were unknown for this study population and the study was not powered to detect a difference in the rate of any complication (including neonatal deaths), thus only the total deaths during the entire 12 month period are included. | Month 12 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Successful Referrals | Referrals to hospitals for further evaluation of possible pregnancy complications were considered to be successful if the pregnant participant went to the hospital after being referred by her TBA. Non-successful referrals were due to the pregnant participant's refusal to go to the hospital (due to lack of permission from a family member, fear, or not recognizing the complication as an emergency) or due to logistical difficulties. | Month 7, Month 12 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Midwives, Pregnant Women