Assessing implementation modalities of mhealth intervention on pregnant women in Dschang health district, West region of Cameroon

Introduction Every 90 seconds, a woman dies of complications related to pregnancy and childbirth, resulting in more than 340,000 maternal deaths a year. Antenatal care (ANC) and postnatal care (PNC) are significant determinants of maternal health and, particularly, safe motherhood. Antenatal care is an important predictor of safe delivery and provides health information and services that can improve the health of women and infants. mHealth broadly encompasses the use of mobile telecommunication and multimedia technologies as they are integrated within increasingly mobile and wireless health care delivery systems. This study aimed at assessing the acceptable implementation modalities of mHealth intervention on pregnant Women in Dschang health district, West Region of Cameroon.ng ba. Methods This was a cross sectional descriptive study in the Dschang health district, West region of Cameroon. Key informants were all pregnant women from 18 years and above and a total of 372 pregnant women were included. This study was carried out from March to July 2017. Results Majority of the women, that is, 252(67.74%) were married, 117(31.45%) declaredtheir status as being single, while 3(0.81%) were devorced. Out of the 335 women that declared wanting an mHealth intervention, 41.79% of this number preferred SMS texts in the afternoon, 111(33.13%) in the evening, 46(13.73%) anytime and 38(11.34%) in the morning hours. A total of 83.33% women confirmed using telephone services. Conclusion This study reveals that cell phones would be the acceptable medium of providing pregnancy and postpartum support to women in the Dschang health district. This is justified by the fact that a vast majority of women interviewed had access to a cell phone and referred to it as their desired and accepted means of communication.

Introduction mHealth broadly encompasses the use of mobile telecommunication and multimedia technologies as they are integrated within increasingly mobile and wireless health care delivery systems [1]. The field broadly incorporates the use of mobile telecommunication and multimedia technologies in health care delivery [2]. The term mHealth was coined by Robert Istepanian as use of "emerging mobile communications and network technologies for healthcare." A definition used at the 2010 mHealth Summit of the Foundation for the National Institutes of Health (FNIH) was "the delivery of healthcare services via mobile communication devices," [3]. mHealth broadly encompasses the use of mobile telecommunication and multimedia technologies as they are integrated within increasingly mobile and wireless health care delivery systems [4]. The field broadly encompasses the use of mobile telecommunication and multimedia technologies in health care delivery [5]. The term mHealth was coined by Robert Istepanian as use of "emerging mobile communications and network technologies for healthcare". A definition used at the 2010 mHealth Summit of the Foundation for the National Institutes of Health (FNIH) was "the delivery of healthcare services via mobile communication devices" [1]. While there are some projects that are considered solely within the field of mHealth, the linkage between mHealth and eHealth is unquestionable [1]. For example, a mHealth project that uses mobile phones to access data on HIV/AIDS rates would require an eHealth system in order to manage, store, and assess the data. Thus, eHealth projects operate many times as the backbone of mHealth projects [6]. Antenatal care (ANC) and postnatal care (PNC) are significant determinants of maternal health and, particularly, safe motherhood. Antenatal care is an important predictor of safe delivery and provides health information and services that can improve the health of women and infants [2]. In addition, ANC has a positive impact on the utilization of postnatal healthcare services, while PNC and intrapartum (the period from the onset of labour to the end of the third stage of labour) care significantly reduces maternal mortality given that most maternal deaths occur in the first week after delivery [2].
Every 90 seconds, a woman dies of complications related to pregnancy and childbirth, resulting in more than 340,000 maternal deaths a year. Millions of women suffer from pregnancy-related illnesses or experience other severe consequences such as infertility, fistula and incontinence [1]. Delay is considered the key factor responsible for women not accessing health services. There are three phases of delay: (i) recognizing the need for health care and in the decision making process; (ii) arrival at a health facility; and (iii) receiving appropriate and adequate care at the health facility [7].
Underlying determinants that cause the delays are the position of women in society, long geographical distances, weak health systems, poverty and lack of education [1,6]. There is an extensive agreement care significantly reduces maternal mortality given that most maternal deaths occur in the first week after delivery [2]. The mobile phone has a high potential as it is small, portable, widely used, relatively cheap and its extended network coverage increasingly enables communication with rural and isolated areas [8]. This technology enhances components like: accessing emergency obstetric care, improving capacity of lesser trained health staff, and empowering women to contact health services and access information [8]. This study aims at assessing the acceptable implementation modalities of mHealth intervention on pregnant Women in the Dschang Health district, West Region of Cameroon.

Methods
Study design: this was a cross sectional descriptive study.
Study area: the Dschang health district, West region of Cameroon.

Selection criteria
Inclusion criterion: pregnant women, with the minimum 18 years old who gave their consent to participate in the study.
Exclusion criteria: pregnant women with less than 18 years and pregnant women who did not give consent to participate in the study; Page number not for citation purposes 3 pregnant women who refuse to continue participating in the study after consent (inconvenient questions).

Results
Socio demographic characteristics: the average age of women used in this study was 26.9(min 18, max 40). A total of 175(47%) of the women had the secondary school as their highest level of education, while 3(0.81%) women declared that they didn't go to school. Also, while 124 (33.33%) women were students (level undifferentiated), and were the highest represented, they were followed by business women with 108(29.03%). The least represented were farmers with 15(4.03%). Majority of the women, that is 252 (67.74%) were married, 117(31.45%) of the women asserted being single, while 3(0.81%) were divorced. In addition, while 336(90.32%) of the women were Christians, 28(7.53%) were Muslim and 8(2.15%) admitted being pagans. week. The distribution of these frequencies is better illustrated in Figure 3.

Interest of pregnant women in
Network operators: a total of 310(83.33%) women affirmed using MTN, followed by Orange with 250(67.2%), and last by NEXTTEL with 105(28.23%) women.

Discussion
Majority of the women (90.05%) were willing to receive SMS messages and phone calls during and after their pregnancy, which is less than the 96% obtained by Cormick et al. in 2012 [9], but still very close. We can also observe that the age group that holds the majority of positive responses to wanting a possible mHealth intervention is the 25-29 years old age group. Most of the women wished to receive their SMS messages in the afternoon (41.7%) and evening (33.13%) meaning that in an eventuality of a mHealth program, these are the times the women will be more receptive to receiving information. This again differs from the results obtained by [9] stating that majority (36.3%) of the women wished to receive this information anytime. To say more, 52.23% of the pregnant women interviewed wished to receive 3 messages per week, which is different from the results obtained by [9], stating that a majority (52.7%) of women wished to receive one SMS per day. All of this only goes to prove how different communities could be and that operational research should be done before, during and after any program implementation in every community. A potential drawback to implementing a text-messaging program is that it requires the recipient to have an adequate level of literacy, and marginalizing groups who could potentially benefit from the intervention. In our study population, this could affect around 0.81% of women having no or incomplete primary schooling, against the 17% obtained by [9].
That is why these researchers thought of an SMS and voice call program. In case the woman is uneducated, the voice call option using a hotline could be used to propagate the health information needed accordingly. The high level of literacy observed in this study just comes to confirm, the regional level of literacy of girls (99%), and at the national level (87%) [10].

Conclusion
This study reveals that cell phones would be an acceptable approach to providing pregnancy and postpartum support to women in the Dschang health district, since the vast majority of women interviewed had access to a cell phone and referred to it as their desired and accepted means of communication. In this cell phone approach, free SMS messages and voice calls will be privileged over internet based interventions.
What is known about this topic Page number not for citation purposes 5 What this study adds  Cell phones would be an acceptable approach to providing pregnancy and postpartum support to women, since the vast majority of women interviewed had access to a cell phone and referred to it as their desired and accepted means of communication.

Competing interests
The authors declare no competing interests.

Acknowledgements
We are grateful to all the pregnant women who participated in this research. Figure 1: distribution of participants willing to accept mhealth intervention per age group