This month, GBCHealth is featuring a partnership between Jacaranda Health and Johnson & Johnson, which utilized mobile technology to provide Kenyan mothers with important maternal health information and resources.

Introduction

Surveys indicate that women in Kenya do not seek maternity care as often as they should because of poor and disrespectful experiences with providers. Only 47% of expectant mothers complete all four antenatal visits recommended by the World Health Organization, and just 15% receive antenatal care in the first trimester. During childbirth, public clinics in Kenya are often overcrowded and lack appropriate systems for infection control and hygiene. Wait times are long, care is rushed, and emergencies often go unnoticed.

These problems are exacerbated among poor women in urban and peri-urban areas. To reach these at-risk Kenyan mothers, Jacaranda Health leverages mobile technology. As three out of four Kenyans have a mobile phone, the program primarily uses two-way SMS messaging to provide vital information and resources to women and their partners at critical periods before and after childbirth. Clients are able to text back questions and a nurse or customer service representative responds with a follow-up call.

About Jacaranda Health

Jacaranda Health is a social enterprise that is changing the way maternity care is provided in East Africa. Its staff of business and healthcare professionals work to expand the line of Jacaranda Maternity Hospitals and through partnerships build a network of maternity hospitals in the public and private sector that delivers high quality, respectful maternal healthcare.

About the Project: 
Jacaranda Health: M-Health Technology for High-Quality, Patient-Centered Care
From January to September of 2015, Jacaranda Health and Johnson & Johnson piloted a personalized m-health program to improve the maternal health of low-income women in Nairobi, Kenya. At a woman’s first antenatal care visit at a Jacaranda Maternity or partner hospital, they are enrolled in a no-cost SMS program. Specifically staged text alerts are sent to these clients and their partners or husbands, reminding them to set money aside to pay for high quality delivery, to pay attention to nutrition and specific signs of labor and to give tips on breastfeeding and timely vaccination. In this way, health care is more patient-centered instead of transactional.

Each stage of maternal care is paired with its own customized text messages, catering to the specific needs of the mother and child during that stage. In the antenatal stage, patients receive a series of six messages about nutrition, danger signs, signs of labor and options for financial planning in preparation for childbirth. Patients could “reply” to these messages, and a Jacaranda nurse or Customer Service Representative would follow up with a phone call. After childbirth, two messages were sent out, one five days after birth regarding warning signs and to reinforce postnatal care behaviors like breastfeeding, and another at six weeks for tips on family planning activities and important dates to start childhood vaccinations.

For family planning support, patients receive a total of six messages, each designed to enhance knowledge and address misconceptions about the specific family planning method that they chose. In this stage, Jacaranda also offers a targeted messaging service to husbands and partners: six messages at one-week intervals that provided basic information about family planning during the postpartum period. Partners could “reply” to these texts for follow-up by a Jacaranda nurse.

Outcomes from the project include:

• A 45 percent increase in follow-up care after antenatal appointment reminders
• An increase in the total number of antenatal care appointments per client, from 2.4 to 3.2 visits after SMS reminders
• Increased family planning uptake when both partners were messaged about postpartum care, from 42 percent to 51 percent

A patient who used the SMS services said, “I like how personal the messages are and how you feel welcomed to the program. The messages were also so helpful in reminding me how to use injectables the right way so that I don’t become pregnant.”

The M-Health Technology for High-Quality, Patient-Centered care project is an initiative of Jacaranda Health funded by Johnson & Johnson and supported by research from a number of research institutions and universities, including the Harvard University T.H. Chan School of Public Health.

Critical Success Factors

• Targeted Outreach. Specificities of the population in Nairobi, Kenya, fueled the program. Since many of the participants used mobile phones as their primary form of getting information, SMS messages were sent to provide assistance and support before and after childbirth.

• Pilot tested. Different phases of gathering information were used effectively to scale up the program. Before the main thrust of the initiative, a pilot program was developed using SMS messaging content from the Mobile Alliance for Maternal Action (MAMA) which were created by BabyCenter, the #1 pregnancy and parenting digital destination worldwide. Focus group discussions honed the content for clients in Nairobi specifically, and when the pilot program saw an increase in return antenatal follow up visits, the program was expanded to include postnatal care as well.

• Strategic Partnerships. Partnerships with Johnson & Johnson and the Harvard T.H. Chan School of Public Health enabled Jacaranda to implement the program with the most benefit to patients. Specifically, researchers at HSPH have played a key role in helping Jacaranda Health develop and run three randomized control trials to learn more about women’s decision-making for maternal health care. Johnson and Johnson enabled Jacaranda to take these proven innovations to public health facilities and scale the interventions that are found to have significant impact.

Lessons Learned

• Walking the talk. Evidence continues to show that low-quality facility-based care and an unskilled workforce are major barriers to improving health outcomes for women and newborns in this part of the world, yet little resources are invested in creating change. Jacaranda used its hospital centers to demonstrate how updating systems and processes within current low-resource facilities can be cost-effective and replicable in generating powerful results, such as increased uptake of postnatal visits and postpartum family planning.

• Use clear and familiar messaging terms. The language in the text messages needed to be revised (and re-revised) in light of the sensitivity of maternal care. For example, initially the focus groups advised against using the words “family planning” in postpartum messages, stating that the term could alienate husbands and partners. However, talking around the words “family planning” rather than using the term made text messages unnecessarily confusing.  After further focus groups and piloting, it was discovered that using those words was not only appropriate, but also made messages clearer.

Learn more

• On Facebook: Jacaranda Health
• On Twitter: @jacarandakenya
• On the Web: http://jacarandahealth.org/