Abstract
Background/objectiveGuatemala’s indigenous Maya population has one of the highest perinatal and maternal mortality rates in Latin America. In this population most births are delivered at home by traditional birth attendants (TBAs), who have limited support and linkages to public hospitals. The goal of this study was to characterize the detection of maternal and perinatal complications and rates of facility-level referral by TBAs, and to evaluate the impact of a mHealth decision support system on these rates.MethodsA pragmatic one-year feasibility trial of an mHealth decisions support system was conducted in rural Maya communities in collaboration with TBAs. TBAs were individually randomized in an unblinded fashion to either early-access or later-access to the mHealth system. TBAs in the early-access arm used the mHealth system throughout the study. TBAs in the later-access arm provided usual care until crossing over uni-directionally to the mHealth system at the study midpoint. The primary study outcome was the monthly rate of referral to facility-level care, adjusted for birth volume.ResultsForty-four TBAs were randomized, 23 to the early-access arm and 21 to the later-access arm. Outcomes were analyzed for 799 pregnancies (early-access 425, later-access 374). Monthly referral rates to facility-level care were significantly higher among the early-access arm (median 33 referrals per 100 births, IQR 22–58) compared to the later-access arm (median 20 per 100, IQR 0–30) (p = 0.03). At the study midpoint, the later-access arm began using the mHealth platform and its referral rates increased (median 34 referrals per 100 births, IQR 5–50) with no significant difference from the early-access arm (p = 0.58). Rates of complications were similar in both arms, except for hypertensive disorders of pregnancy, which were significantly higher among TBAs in the early-access arm (RR 3.3, 95% CI 1.10–9.86).ConclusionsReferral rates were higher when TBAs had access to the mHealth platform. The introduction of mHealth supportive technologies for TBAs is feasible and can improve detection of complications and timely referral to facility-care within challenging healthcare delivery contexts.Trial registrationClinicaltrials.gov NCT02348840.
Highlights
Improving maternal and neonatal health in resource-limited settings is a key priority in global health [1]
We hypothesized that the system would improve maternal and perinatal complication detection and referral rates to facility-level care. Study design This was a pragmatic, randomized controlled trial assessing the effectiveness of a Mobile Health (mHealth) decision support system to improve maternal and perinatal complication detection and referral rates to facility-level care by Traditional birth attendant (TBA)
Ten neonatal deaths were reported, with two thirds occurring in the first two days of life (6/10), and with no significant difference in occurrence between the study arms. This pragmatic, randomized-controlled feasibility trial showed that the introduction of a mHealth decision support technology into the routine community-based practice of a group of TBAs in rural Guatemala resulted in a significant increase in the rate of emergency referrals to facility-care for maternal and perinatal complications
Summary
Improving maternal and neonatal health in resource-limited settings is a key priority in global health [1]. The most populous country in Central America, has one of the highest perinatal and maternal mortality rates in Latin America [4, 5] These poor outcomes impact Guatemala’s rural indigenous Maya population, where both perinatal and maternal mortality rates are markedly higher than for Guatemala’s non-indigenous population [6, 7]. Contributing factors to these disparities include lack of rural infrastructure for early detection and referral of maternal and neonatal complications and systemic discrimination against Maya women in healthcare facilities, leading to a strong cultural preference for home births [8,9,10]. At least 50% of births in rural Maya communities in Guatemala occur in the home under the care of Traditional Birth Attendants (TBAs) [7, 11]
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