Effect of Mobile Health Integrated Antenatal Care Intervention in Improving Maternity Continuum of Care, Obstetric Health Literacy, Maternal and Perinatal Outcomes in Public Hospitals, Ethiopia: A Randomized Control Trial

Background: Maintaining the best possible health for the mother and newborns is still a challenge in Sub-Saharan Africa (SSA), including Ethiopia (1). The high toll of maternal and child mortalities remains the single most important challenge to the health sector (2). In low-income countries, hypertensive disorders of pregnancy (HDP), obstetric hemorrhage (OH), and sepsis are the most common drivers of maternal morbidity and mortality (3). Preventive measures that are straightforward and evidence-based are likely to prevent catastrophic morbidity and mortality during pregnancy (4). ANC is crucial for ensuring positive maternal and perinatal outcomes (5).

The WHO recommends establishing a broader package of interventions to increase individual, family, and community capacity to contribute to maternal and newborn health improvements and to increase use of skilled care during pregnancy, for childbirth, and after birth (5,6). The Health for All application is developed by scholars from the University of Gondar and granted by the International Institute for Primary Health Care - Ethiopia and the Ethiopian Ministry of Health. The Health for All app contains detailed information on family planning packages, ANC packages (updated 8 contacts), birth preparedness and complication readiness, skilled delivery, maternal nutrition, danger signs during ANC, perinatal periods, post-partum family planning, and postnatal care, but has not yet been implemented in Ethiopia. Therefore, this study will implement integrated services during ANC that may contribute to changes in healthcare-seeking during the perinatal period, ensure ongoing maternity care, and provide a positive pregnancy experience.

Even though maternal and neonatal health has received significant attention during the present Sustainable Development Goal (SDG) period, maintaining the best possible health for both the mother and newborns is still a challenge in Sub-Saharan Africa (SSA) (7). Ethiopia is one of the sub-Saharan countries with the highest toll of maternal and child mortalities; it remains the single most important challenge to the health sector (i.e., 401 MMR per 100,000 live births,and the perinatal mortality rate is 33 deaths per 1000 (8). The continuum of maternal care completion rate was extremely low (2). According to the 2019 Ethiopian mini demographic health survey report, about 57% of pregnant women didn't get optimum antenatal care (14), 69.1% of women dropped out of the maternity continuum of care (9). To increase pregnant women's adherence to the continuum of care, thereby reducing morbidity and mortality, mobile Health (mHealth) Apps are essential tools accessible through smartphones, empowering women with the health information they need to take control of their well-being like never before (10). These innovations are essential to improve women's limited understanding of the need for maternal health services, and harmful cultural norms pose obstacles to women's healthcare service utilization (11). Moreover, mHealth innovative applications enable users to learn about their conditions, promote lifestyle modifications during pregnancy, treatment options, and preventive measures, promoting informed decision making, access health information, and seek care (7,12-15). However, there is limited integrated uptake of this digital health solution in the maternal and child healthcare service delivery processes due to a lack of adequate information about the presence of these updated and evidence-based mHealth Apps (i.e., Safe Delivery and Health for All). Moreover, the lack of practical implementation experience is limiting Ethiopia's ability to move toward maturing its digital healthcare. Hence, healthcare providers and women's engagement are key components of effective healthcare, and mHealth apps have emerged as a game-changer in this domain.

Evidence revealed that mHealth interventions have emerged as a promising solution to improve maternal and child health outcomes. Despite the acceptance and effectiveness of mHealth being widely documented in literature, little to no research has been done in Ethiopia.

Research question: Does implementation of the mHealth integrated antenatal care intervention have a significant effect on improving maternity continuum of care, obstetric health literacy, and maternal and perinatal outcomes? Research hypothesis: Implementation of the mHealth integrated antenatal care intervention will improve maternity continuum of care, obstetric health literacy, and maternal and perinatal outcomes.