mHealth intervention to improve the continuum of maternal and perinatal care in rural Guatemala: a pragmatic, randomized controlled feasibility trial.
BACKGROUND/OBJECTIVE
Guatemala'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.


METHODS
A 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.


RESULTS
Forty-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).


CONCLUSIONS
Referral 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 REGISTRATION
Clinicaltrials.gov NCT02348840 .
['Martinez|Boris|B|', 'Ixen|Enma Coyote|EC|', 'Hall-Clifford|Rachel|R|', 'Juarez|Michel|M|', 'Miller|Ann C|AC|', 'Francis|Aaron|A|', 'Valderrama|Camilo E|CE|', 'Stroux|Lisa|L|', 'Clifford|Gari D|GD|', 'Rohloff|Peter|P|http://orcid.org/0000-0001-7274-8315']
D000293:Adolescent D000328:Adult D000368:Aged D002648:Child D003266:Continuity of Patient Care D003661:Decision Support Techniques D005240:Feasibility Studies D005260:Female D006166:Guatemala D006700:Home Childbirth D006801:Humans D007231:Infant, Newborn D008428:Maternal Mortality D008875:Middle Aged D008880:Midwifery D010043:Outcome and Process Assessment, Health Care D018743:Perinatal Care D011247:Pregnancy D019035:Rural Health Services D012424:Rural Population D017216:Telemedicine D055815:Young Adult
mHealth Guatemala Indigenous Traditional birth attendants Barriers to care Lay midwives Perinatal monitoring Referral system Resource-constrained healthcare