Developing an mHealthintervention to improve maternal health in Sélingué Health District,

Mali

Peter Winch

pwinch@jhu.edu

Partners

JHSPH, International Health

University of Bamako/USTTB, Faculty of Medicine and Dentistry, Department of Public Health

– http://santepublique.fmpos.org/

– www.usttb.edu.ml/

ANTIM: Malian National Agency for Telemedicine and Medical Informatics

– www.antim.sante.gov.ml

Funding: NIH Fogarty International Center2

Mali, West Africa

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Major conflict in northern Mali in 2012-2013

On-going skirmishes and attacks in 2015

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Urban Rural TOTAL

Literacy in women 15-49

47.4% 11.8% 20.6%

Total Fertility Rate 5.0 6.5 6.1

Made at least one antenatal care visit

93.2% 69.3% 74.2%

Birth in health facility 91.4% 46.4% 55.0%

<5 Mortality Rate 64 113 95

Neonatal Mortality Rate 27 38 34

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Indicators from DHS 2012-2013

What is MMR in Mali?

Community Health Center in Kayes District, Mali

Population Density: 23/km2

Photo: Cecilia Flatley

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Sisterhood method: 4 questionsSource - http://en.wikipedia.org/wiki/Sisterhood_method

Question 1: How many sisters have you ever had, born to the same mother, who ever reached the age 15 (or who were ever married), including those who are now dead? (cutoff age used varies in different studies)

Question 2: How many of your sisters who reached the age of 15 are alive now?

Question 3: How many of these sisters are dead?

Question 4: How many of your sisters who are dead died during a pregnancy or during childbirth, or during the six weeks after the end of a pregnancy?

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What is maternal mortality ratio / MMR by Sisterhood method?

DHS 2012-2013: 368/100,000 live births - National

– 97,578 years of exposure

– 95% CI: 259-478

– 32% of deaths in women 15-49 years

Aa I et al. High maternal mortality estimated by the sisterhood method in a rural area of Mali. BMC Pregnancy Childbirth 2011, 11:56. – Kita District, Kayes Region

– 2,039 respondents reported 4,628 sisters

– MMR 3,131/100,000 live births (95% CI 2,967-

3,296), time reference around 1999, lifetime risk 20%

– Villages as far as 60km from nearest Health Center

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Factors contributing to high MMR

Low population densities, dispersed populations

Non-functional transport and referral systems

Low quality of care in health facilities

Shortage of skilled providers

Maternal anemia – DHS 2012-2013

– Pregnant = 59.3%

– Lactating = 51.3%

– Neither = 49.6%

High TFR, low contraceptive prevalence

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SEC*: Mali’s policy for community-level delivery of services

Two tier model of CHWs

– Upper tier: ASCs, one for every 3-4 villages

– Lower tier: RC, one per village

ASCs (Agents de Santé Communautaire-upper level CHW)

– Have more education, receive more training

– Can assess and treat sick children

– Supposed to supervise RCs

RCs (Relais Communautaires – lower level CHW)

– Minimal training

– Are to focus on promotion of preventive behaviors

Overall emphasis is on child health, not maternal health

* Soins Essentiels dans la Communauté 12

SEC: Mali’s policy for community-level delivery of services

In our current NIH R21, we started with equal emphasis on maternal and child health

After initial site visits and consultations with partners

– We are now looking to developing the maternal health components of the SEC

– Emphasis on antenatal care, birth planning and emergency transport

– mHealth playing a supportive role

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Study site: SélinguéHealth District

South-west of Bamako

On both sides of Lake Sélingué

One District Hospital where C-sections performed

Seven community health centers

"Lac Sélingué" by Olivier EPRON - Own work. Licensed under CC BY 2.5 via Wikimedia Commons -

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Sikasso Region

Lake Sélingué

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Vision for intervention

Focus on:

– Provision of services to women during antenatal and intrapartum periods

– Improving communication between different community-level providers

– Link community-level providers to health facilities

Key role for ASC in communication, this role currently undeveloped

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Role of ASC

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Assessment and treatment of sick children

Coordination and communication of health system at community level

ASC

RC RC RC RC

Auxiliary Nurse-

Midwives

Women and their families

Improved communication with community-based providers

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ASCCommunity leaders,

committees, transport system

Community Health Center

District Hospital

Strengthened referral and emergency transport systems

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ASC

RC RC RC RC

Auxiliary Nurse-

Midwives

Community leaders, committees,

transport system

Community Health Center

District Hospital

Women and their families20

Tracking of pregnant women (1) Build upon Mali’s SNISI platform for

mHealth interventions, operated by ANTIM

ASC and others to enter women into tracking system as early as possible in pregnancy

Receipt of key interventions tracked, e.g.

– Antenatal care attendance

– SP tablets*: 1/month starting Month 4

– Tetanus toxoid vaccination

– Blood pressure measurement* Sulfadoxine-Pyramethamine intermittent preventive treatment for malaria 21

Tracking of pregnant women (2)

If a pregnant woman misses or is late for a key intervention

– ASC is notified: ASC visits woman, or ASC calls RC to visit woman

ASC or RC call or visit women weekly late in pregnancy

– Remind woman and family of emergency transport system

– Advise early use of system22

Emergency transport system

Currently three (or more) types

– Community-based

– Health center-based

– District hospital-based / ambulance

No formal linkage or communication between the different systems

Many calls go directly to ambulance driver at District Hospital, who does triage

We are examining lessons learned from existing systems e.g. Diangounté Camara 23

Tracking of pregnant women (3)

Analysis of outcomes in monthly meetings at Health Centers and District Hospital

– Time from first contact with system to arrival at Health Center or District Hospital

– Antenatal care interventions: SP, tetanus toxoid, blood pressure monitoring etc.

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Next steps

Current:

– Develop intervention content

– Define mHealth platform & technology

June 2015: Baseline survey

July 2015-May 2016: Pilot test of intervention components for feasibility, acceptability

June 2016: Final survey

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