s12916 024 03417 9

Knop et al.
BMC Medicine (2024) 22:196 BMC Medicine

https://doi.org/10.1186/s12916-024-03417-9
REVIEW Open Access
Impact of mHealth interventions

on maternal, newborn, and child health
from conception to 24 months postpartum
in low‑ and middle‑income countries:
a systematic review
Marianne Ravn Knop1†, Michiko Nagashima‑Hayashi1†, Ruixi Lin1, Chan Hang Saing1, Mengieng Ung1,
Sreymom Oy1, Esabelle Lo Yan Yam1, Marina Zahari1 and Siyan Yi1,2,3*
Abstract
Background Mobile health (mHealth) technologies have been harnessed in low- and middle-income countries
(LMICs) to address the intricate challenges confronting maternal, newborn, and child health (MNCH). This review
aspires to scrutinize the effectiveness of mHealth interventions on MNCH outcomes during the pivotal first 1000 days
of life, encompassing the period from conception through pregnancy, childbirth, and post-delivery, up to the age
of 2 years.
Methods A comprehensive search was systematically conducted in May 2022 across databases, including PubMed,
Cochrane Library, Embase, Cumulative Index to Nursing & Allied Health (CINAHL), Web of Science, Scopus, PsycINFO,
and Trip Pro, to unearth peer-reviewed articles published between 2000 and 2022. The inclusion criteria consisted
of (i) mHealth interventions directed at MNCH; (ii) study designs, including randomized controlled trials (RCTs), RCT
variations, quasi-experimental designs, controlled before-and-after studies, or interrupted time series studies); (iii)
reports of outcomes pertinent to the first 1000 days concept; and (iv) inclusion of participants from LMICs. Each
study was screened for quality in alignment with the Cochrane Handbook for Systematic Reviews of Interventions
and the Joanne Briggs Institute Critical Appraisal tools. The included articles were then analyzed and categorized
into 12 mHealth functions and outcome domain categories (antenatal, delivery, and postnatal care), followed by for‑
est plot comparisons of effect measures.
Results From the initial pool of 7119 articles, we included 131 in this review, comprising 56 RCTs, 38 cluster-RCTs,
and 37 quasi-experimental studies. Notably, 62% of these articles exhibited a moderate or high risk of bias. Promis‑
ingly, mHealth strategies, such as dispatching text message reminders to women and equipping healthcare pro‑
viders with digital planning and scheduling tools, exhibited the capacity to augment antenatal clinic attendance
†
Marianne Ravn Knop and Michiko Nagashima-Hayashi contributed equally
to this work.
*Correspondence:
Siyan Yi
[email protected]
Full list of author information is available at the end of the article
© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
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Knop et al. BMC Medicine (2024) 22:196 Page 2 of 19
and enhance the punctuality of child immunization. However, findings regarding facility-based delivery, child immu‑
nization attendance, and infant feeding practices were inconclusive.
Conclusions This review suggests that mHealth interventions can improve antenatal care attendance and child
immunization timeliness in LMICs. However, their impact on facility-based delivery and infant feeding practices varies.
Nevertheless, the potential of mHealth to enhance MNCH services in resource-limited settings is promising. More
context-specific implementation studies with rigorous evaluations are essential.
Keywords Maternal and child health, Digital health, mHealth, Healthcare access, Primary care, Low- and middle-
income countries
Background low broadband requirements [15]. However, the authors

Despite the significant progress in maternal and child suggested further studies be conducted with more robust
mortality globally, large inequities persist between and designs to confirm the efficacy of mHealth interventions
within countries [1, 2]. Over 4.5 million women and [15]. Studies in LMICs involving mHealth technologies
babies die annually during pregnancy, childbirth, or the have often needed more representativeness, as popula-
first weeks after birth. Most of these preventable deaths tions most likely to benefit from the interventions (i.e.,
are concentrated in low- and middle-income countries lower-income groups, women, older people, and rural
(LMICs), especially among some geographical regions populations) were excluded, owing to the lack of access to
and populations, such as socio-economically vulnerable digital technologies [11, 17, 18]. Other systematic reviews
women in Sub-Saharan Africa and South Asia [1–3]. To have assessed the effectiveness of diverse mHealth inter-
address the challenge, strategies to integrate the pro- ventions in LMICs targeting maternal, neonatal, and
grams across the maternal, newborn, and child health infant care individually or a combination thereof [8, 19–
(MNCH) continuum have been adopted to lower costs 23]. However, to the best of our knowledge, no systematic
while promoting greater efficiencies and reducing dupli- reviews have covered the MNCH spectrum, which cov-
cation of resources. The continuum of care strength- ers a period of 1000 days from the time of conception to
ens healthcare quality, coverage, and affordability [4, 5], 2 years postpartum.
as represented in the “first 1000 days” concept [6, 7]. In A qualitative content analysis of users’ perspectives of
LMICs, however, the degree of availability and quality of 75 applications for pregnant mothers and new parents
MNCH services varies considerably, and barriers, such as revealed that women increasingly used mobile tech-
limited resources and poor information and communica- nology to improve their health literacy, monitoring,
tion infrastructures, compromise access to services [8]. self-management, decision-making, and searching for
With rapidly growing digital connectivity, the roles credible information, such as how to establish breastfeed-
of mobile health technologies (mHealth) in addressing ing and common infant health issues [24, 25]. Women
MNCH outcomes in LMICs have been recognized [9– reported using the applications for multiple pregnancies
11]. Expectations towards mHealth, in general, include its [24], implying that such interventions offer a high poten-
potential to improve the quality and coverage of health- tial for improving MNCH outcomes. Given the crucial
care, increase access to health information, services and need for such an integrated approach in LMICs, this sys-
skills, and promote positive changes in health behaviors tematic review will provide a comprehensive overview of
to prevent the onset of acute and chronic diseases and available evidence and understanding of research gaps in
improve treatment adherence and outcomes [10–14]. In mHealth for improving the continuum of MNCH care
LMICs, mHealth systems can potentially fill the critical in LMICs by synthesizing the mHealth evidence encom-
gaps in human resources and information and communi- passing the 1000 days. This study’s findings will support
cation infrastructures, reaching remote and marginalized the policy decision and resource allocation for future
populations and enhancing a range of low-cost life-saving interventions and research planning in resource-con-
interventions at the community level [11, 12, 15, 16]. strained settings.
Studies of the efficacy of mHealth interventions vary in
their design and focus, such as types of health outcomes
and domains and mHealth functions. In their systematic Methods
review of systematic reviews on mHealth interventions, This systematic review followed the Preferred Report-
Marcolino et al. revealed that the most popular and suc- ing Items for Systematic Reviews and Meta-Analyses
cessful mHealth interventions were behavior change (PRISMA) statement [26]. A detailed protocol has been
approaches using text messaging due to the low cost and registered with the International Prospective Register for
Systematic Reviews (PROSPERO registration number: snowballing effect by (i) reviewing relevant study pro-
CRD42022354586). tocols to identify publications reporting relevant inter-
vention outcomes, (ii) reviewing previously published
Eligibility criteria systematic reviews, and (iii) screening the reference lists
Articles were included in this review if they (i) primar- of all articles included in this review.
ily evaluated an mHealth intervention targeting MNCH We removed duplicate articles using Endnote (ver-
outcomes; (ii) were designed as a randomized controlled sion 20.3). Two primary reviewers (MRK and RL) inde-
trial (RCT), variations of RCT, quasi-experimental study, pendently screened titles, abstracts, and full-text articles
controlled before-and-after study, and interrupted time of potentially eligible articles against the inclusion and
series study; (iii) reported outcomes relevant to the exclusion criteria. MRK extracted the data, and RL
first 1000 days concept; (iv) involved participants from reviewed them to identify the following information:
LMICs, according to the World Bank index [27] as of study design, research methods, location and settings,
May 2022; and (v) were published in a peer-reviewed target population and size, mHealth function and forms,
journal between 01 January 2000 and 31 May 2022. We and research findings. We resolved discrepancies in the
excluded studies published before the year 2000 as we data selection and extraction by consensus or consulting
focused on more contemporary forms of mHealth that a third reviewer within the study team.
employed mobile technologies to ensure the relevance
of this review. Outcomes were not pre-specified, given Risk of bias assessment
our interest in all outcomes related to MNCH from con- MRK performed the quality assessment independently,
ception to 2 years postpartum. Therefore, we reported while other team members (RL, MU, SC, SO) performed
outcomes related to pregnant women, mothers and new- the second assessment. A third team member conducted
borns, and children under the age of 2 years. Consider- an additional check to resolve discrepancies. We assessed
ing the extensive literature we identified, we included intervention studies using the criteria of the Cochrane
only articles published in peer-reviewed journals. Peer- Handbook for Systematic Reviews of Interventions
reviewed articles are generally regarded as providing [29] and quasi-experimental studies using the Joanne
more trusted and reliable scientific information due to Briggs Institute Critical Appraisal (JBI) tools [30, 31].
their adherence to rigorous methodological standards, as We assessed the quality of studies using baseline-online-
opposed to non-peer-reviewed sources. comparison designs with a control group using the JBI
We excluded studies (i) that did not have a control tool for quasi-experimental studies regardless of whether
group, (ii) without accessible full-texts, and (iii) that were a randomization process was described.
observational, such as cohort, case–control, cross-sec- We graded the risk of bias for RCTs into three levels
tional and qualitative studies, expert opinions, reviews, (low, moderate, or high). Quasi-experimental studies
project/program reports, discussion papers, or case received a grade according to the scale they were evalu-
reports. Initially, we did not restrict the publication lan- ated against. We considered the risk of bias in determin-
guage; however, we eventually excluded one article where ing the strength of the conclusion [29].
translation from Thai to English was unavailable. We
excluded studies that evaluated the willingness of partici- Analysis and synthesis
pants to receive a mHealth intervention or the mHealth We conducted systematic narrative and descriptive
tool itself, as those outcomes are not directly relevant to analyses of the 131 included articles [32–162] to capture
MNCH outcomes. the main characteristics of each study by mapping out
the study designs, settings, population groups and sizes,
Search strategy and information sources intervention and control groups, outcome measures and
We developed a systematic search strategy and qual- results, outcome domains, and mHealth forms and func-
ity assessment of the literature. We searched PubMed, tions (Additional file 2: Table A2). For each study, at least
Cochrane Library, Embase, Cumulative Index to Nurs- two other authors further reviewed the analyzed charac-
ing & Allied Health (CINAHL), Web of Science, Sco- teristics and assigned categories to ensure consistency
pus, PsycINFO, and Trip Pro in May 2022. Search and rigor.
terms included Medical Subject Headings (MeSH), title,
abstract, and text words. The detailed search syntax can mHealth functions
be found in Additional file 1: Table A1. We used an online We categorized the mHealth strategies adopted in each
Polyglot Search Translator for database platforms [28]. study into 12 mHealth functions described by Labrique
Trip Pro required a different search approach, as speci- et al. [163]. The 12 functions are (1) client education and
fied in Table A1. We further searched literature via the behavior change communication (BCC), (2) sensors and
point-of-care diagnostics, (3) registries and vital events compare the effects across articles. After attempting mul-
tracking, (4) data collection and reporting, (5) electronic tiple meta-analyses and sensitivity analyses, we found the
health records, (6) electronic decision support, (7) pro- heterogeneity too high (I2 > 90) for a meaningful meta-
vider-to-provider communication, (8) provider work analysis. We, therefore, refrained from synthesizing any
planning and scheduling, (9) provider training and edu- pooled effect measures from these studies.
cation, (10) human resource management, (11) supply Most articles reflected an odds ratio (OR) as the pri-
chain management, and (12) financial transactions and mary effect, and others reported risk ratios (RR). We cal-
incentives. We further categorized the studies accord- culated a crude risk ratio (cRR) when the primary effect
ing to the outcomes measured under each health domain size was not reported, while data on the outcomes in the
(antenatal care [ANC], delivery care, and postnatal care intervention and control groups were available. We calcu-
[PNC]). lated those studies’ crude OR (cOR) for comparison and
found less than a 7% difference between OR and RR. Only
Outcome domain categories cRR was included in the review, which has an advantage,
We categorized the intervention outcomes into three cat- especially in the cases of small numbers, that our final
egories according to the relevant care period within the estimate would tend to be more conservative. RCTs or
1000-day timeframe (i.e., ANC, delivery care, and PNC). cluster RCTs reporting pre- and post-effect measures for
ANC included the outcomes such as the number of ANC intervention and control groups were assumed to be bal-
visits, maternal micronutrient supplementation, medi- anced at baseline, given that all the reviewed publications
cal treatment encompassing tetanus toxoid injection, were peer-reviewed. Hence, only post-intervention effect
and compliance to any prescribed procedures and tests methods were taken into account. When a difference
(e.g., ultrasound examination, oral glucose tolerance test, coefficient was reported, we converted it to an OR using
urine tests, blood pressure measurement, and anemia an exponential function.
assessment). The category “other ANC” encompassed
outcomes such as depression, anxiety and stress, physical
activity, and general health knowledge. Results
The “delivery care” category covered outcomes such as Included studies
child delivery at health facilities and emergency obstet- We identified 7119 articles—6999 through database
ric care. The category “other delivery care” covered searches and 120 through published systematic reviews
pregnancy outcomes, such as miscarriage, stillbirth, neo- [8, 19–23, 164] and reference lists. Figure 1 illustrates
natal mortality, birth weight, birth preparation, child- the screening and complete study assessment processes,
birth complications, maternal and neonatal malnutrition indicating the number of articles excluded for a given
screening, and neonatal asphyxia. criterion. We included 131 articles based on 121 stud-
PNC outcomes included the number of postnatal vis- ies (55 RCTs, 39 cluster RCTs, and 37 quasi-experi-
its, childhood immunization, breastfeeding practices, mental study articles). Geographically, 33 articles were
and prevention of mother-to-child HIV transmission from studies in East Africa (Ethiopia, Kenya, Malawi,
(PMTCT). The category “other postnatal care” encom- Mozambique, Rwanda, Tanzania, Uganda, and Zim-
passed service utilization during the postnatal period for babwe), 16 from North and West Africa (Côte d`Ivoire,
infectious diseases, neonatal and infant death, postna- Egypt, Ghana, Guinea, Mali, and Nigeria), seven from
tal depression, contraception use, diet, physical activity, Central and Southern Africa (Botswana, Cameroon, and
nutritional status monitoring, and family planning. Types South Africa), 25 from South Asia (Bangladesh, India,
of outcomes assessed by each study are listed in Addi- Nepal, and Pakistan), 15 articles from East Asia (China
tional file 3: Table A3. In this article, we report the results and Hong Kong), 11 from Southeast Asia (Cambodia,
of selected outcomes most frequently measured and Indonesia, Malaysia, the Philippines, Thailand, and Viet-
reported in the reviewed studies, i.e., the number of ANC nam), 16 from the Middle East (Iran, Palestine, and Tur-
visits, the delivery rate at health facilities, child immuni- key), and seven from South America and South Pacific
zation rates, and child feeding practices. (Brazil, Ecuador, Guatemala, and Samoa). One multi-
country study reported combined findings from India,
Effect measures Mozambique, and Pakistan [153]. The study population
The included studies varied on essential aspects, such as comprised pregnant women and children between 0 and
study design, quality, duration, and settings, as well as 2 years of age and their mothers. For cases of potential
mHealth function and outcome specifications, such as data overlap when studies were carried out in the exact
the number and place of ANC/PNC visits and the num- geographical location or when publications were derived
ber and type of vaccinations. We used forest plots to from the same interventions, all available articles were
Fig. 1 Flow diagram of the study selection process
included as long as the outcomes of interest were rel- in randomization, 78 (83%) low risk in performance, 71
evant to our study objectives. (76%) low risk of data completeness, 81 (86%) low risk in
outcome measurements, and 90 (96%) low risk in report-
Synthesis of results ing. Twenty-six RCT (47%) and 15 cluster-RCT (38%)
Additional file 4: Table A4 summarizes the study charac- articles displayed an overall low risk of bias, while eight
teristics, outcomes, mHealth functions and forms, and (15%) RCT and four (10%) cluster-RCT articles displayed
quality assessment results. Further details of the study an overall high risk of bias. The quality of non-rand-
intervention designs and resulting outcome effects can be omized experimental studies was generally compromised
found in Additional file 1: Table A1. due to dissimilarities between comparison groups and
the magnitude of missing data.
Risk of bias
The detailed quality assessment results are available in mHealth form and functions
Additional file 5: Table A5a for RCTs and cluster RCTs Figure 2 shows the number of studies by mHealth func-
and Additional file 5: Table A5b for quasi-experimental tions. Out of 121 studies reviewed, 105 (86.8%) used
studies. Of the 94 articles on RCTs and cluster RCTs, 43 mHealth Function 1 (client education and BCC), 17
were at low, 39 at moderate, and 12 at high risk of bias. (14.0%) used mHealth Function 4 (data collection and
The high risk of bias was primarily due to inappropriate reporting), 13 (10.7%) used mHealth Function 6 (elec-
randomization and incomplete data. As for the articles tronic decision support), 11 (9.1%) used mHealth Func-
from quasi-experimental studies, out of the nine ques- tion 5 (electronic health records), and 10 (8.3%) used
tions stipulated in the JBI checklist [31], nine scored mHealth Function 3 (registries and vital events tracking).
9/9, one scored 8/9, and the remaining 27 scored 7/9 or There was a high expectation of mHealth Function 1, typ-
below. We used these scores to categorize the level of risk ically used to deliver reminders or information (BCC) for
into three levels: high (9/9), moderate (8/9), and low (7/9 pregnant women and mothers.
or below). RCT and cluster-RCT articles generally per- Studies used various delivery modes (voice calls, text
formed well, with 75 (80%) exhibiting a low risk of bias messaging, transfer of still-moving images, multimedia
Fig. 2 Number of included studies by 12 mHealth functions
message services, videos, or audio) of mHealth. Hence, Functions 3 and 4). Appointment reminders were sent to
we categorized mHealth forms as either unidirectional, the HEWs (mHealth Function 8), who could call health
bidirectional, or multi-directional communication between centers for emergency referrals (mHealth Function 7)
senders and receivers. Most mHealth innovations were [40]. The third type of intervention used mHealth com-
designed as unidirectional communication using “push” ponents simultaneously at several levels within the health
technology to deliver information or reminders to sub- system, combined with other inter-sectoral improve-
scribers’ phones. Messages were often tailored to per- ments, such as infrastructure and capacity of human
sonal needs, such as information according to gestational resources. A study by Modi et al. is an example of the lat-
age or censored according to HIV status disclosure. ter, where Accredited Social Health Activists (ASHAs)
Bidirectional communication occurred as short mes- were trained to use Innovative Mobile-phone Technology
sage chats or phone calls between senders and receivers for Community Health Operations (ImTeCHO), a mobile
(e.g., nurses and clients) and was commonly employed phone application, to improve the case management of
with unidirectional communication. Data collection and pregnant women within their communities [104]. The lat-
reporting through tablets, phones, and other devices ter intervention used nine of the 12 mHealth functions.
were done using unidirectional or bidirectional com-
munication systems. For example, the two-way com- Effects on antenatal care (ANC)
munication approach using RapidSMS [130] provided ANC attendance
community health workers (CHWs) with a dynamic The effect of mHealth interventions on ANC attend-
tool for field data collection and clients’ access to sup- ance was assessed in 26 studies, including nine RCTs,
portive healthcare workers, leading to decentralized eight cluster RCTs, and nine quasi-experimental studies.
decision-making. Table 1 shows the individual effect estimates obtained in
We identified three types of interventions with pre- respective articles or calculated as cRR based on available
sumably different origins and objectives. The first and data for binary outcomes (≥ 3 or < 3, ≥ 4 or < 4, and ≥ 6
most frequent type includes interventions investigat- or < 6 ANC visits). We did not include studies that did
ing the effectiveness of a single mHealth function, most not allow us to calculate effect estimates. Of 26 articles,
commonly mHealth Function 1, used as unidirectional mHealth Function 1 (client education and BCC) was the
communication (e.g., appointment reminders and edu- most commonly used function among these studies, fol-
cational information delivered via text messages to cli- lowed by mHealth 6 (electronic decision support) and
ents). The second type of intervention applied multiple Functions 8 (provider work planning and scheduling).
mHealth functions layered on existing parts of a health- Regarding effectiveness, seven studies [40, 42, 50, 54,
care system, attempting to fill a gap or expand its effec- 65, 120, 152] showed robust effect estimates, provid-
tiveness via mHealth interventions. An example of this ing evidence that mHealth interventions could increase
type is a study conducted in Ethiopia where health exten- the percentage of women receiving at least four ANC
sion workers (HEWs) registered women in the interven- visits as recommended by the World Health Organiza-
tion groups for their children’s immunization (mHealth tion (WHO) for low-income countries [165]. In a study
Table 1 Comparison of antenatal care attendance in the intervention and control groups
*
Study: The same study in multiple rows indicates multiple intervention groups [40, 42, 50, 54, 62, 65–77, 97–100, 107, 108, 118, 120, 125, 139, 144, 152]
**
Type of study: RCT, randomized controlled trial; C-RCT, cluster randomized controlled trial; Quasi, quasi-experimental study
†
Effect estimates: OR, odds ratio; RR, risk ratio; cRR, crude odds ratio
‡
mHealth functions: 1. Client education and behavior change communication (BCC); 2. Sensors and point-of-care diagnostics; 3. Registries and vital events tracking;
4. Data collection and reporting; 5. Electronic health records; 6. Electronic decision support; 7. Provider-to-provider communication; 8. Provider work planning and
scheduling; 9. Provider training and education; 10. Human resource management; 11. Supply chain management; 12. Financial transactions and incentives
§
The risk of bias was categorized into three levels: high (H), moderate (M), and low (L)
¶
The studies for which the crude risk ratios (cRR) were calculated by the authors of this systematic review
in South Africa, women in the intervention group who However, the risk of bias in these studies was high. Five
received text messages (mHealth Function 1) were more studies found no significant effect of mHealth inter-
likely to attend at least four ANC visits than the routine ventions on ANC attendance [66, 100, 107, 108, 125,
care group [54]. In rural Ethiopia, healthcare workers 139]. Seven articles presented results on ANC attend-
serving the intervention groups had access to provider ance in varying outcome formats and were not included
work planning and scheduling tools (mHealth Function in Table 1. Of these seven articles, four studies did not
8) and received text message reminders to conduct ANC assess the number of ANC attendance in isolation [95,
home visits. The results showed a 15%-point increase in 122, 131, 156]. Both Li et al. and Sabin et al. reported
ANC attendance from baseline to post-intervention, sig- composite outcomes, including ANC attendance, while
nificantly higher than the control group [40]. Xie et al. and Paratmanitya et al. focused on the timing
Five studies showed higher rates of ANC visits in the of the first ANC visit. The three remaining studies did
mHealth intervention groups compared to the routine not find a significant effect of mHealth interventions on
care groups [62, 77, 97–99, 118, 144]. However, many their ANC outcomes [84, 130, 154]. An additional article
other studies found only a borderline significance. Stud- by Coleman et al. [53] underwent full review; neverthe-
ies in India [42], Guinea [65], and Kenya [120] suggested less, it was not included in Table 1 due to potential data
the effectiveness of their interventions using mHealth overlap with a more recent article published by the same
Function 1 in women attending at least four ANC visits. authors [54].
Effects on delivery care or calculated as a cRR based on available data on the

Facility delivery number of events in each group. mHealth Function 1
The effect of mHealth interventions on place of deliv- (education and BCC) was most commonly used (n = 12,
ery was assessed in six RCTs, 11 cluster RCTs, and five 60%) [66, 74, 77, 83, 98, 99, 108, 125, 131, 151, 42, 50, 62]
quasi-experimental studies. Table 2 displays the indi- either as a sole function or one of the multiple functions
vidual effect estimates obtained in individual articles employed in the intervention. mHealth Function 4 (data
Table 2 Comparison of facility delivery in the intervention and control groups
*
Study: The same study shown in multiple rows indicates multiple intervention groups in the study [40, 42, 44, 50, 62, 66, 74, 77, 83, 97–100, 107, 108, 125, 126, 131,
135, 139, 151–153]
**
†
‡
§
¶
collection and reporting) was also commonly used (n = 9, articles—child immunization rates, exclusive breastfeed-
45%) [40, 44, 50, 74, 77, 126, 135, 139, 153], followed by ing, and early breastfeeding initiation.
mHealth Function 6 (electronic decision support, n = 8,
40%) [44, 50, 74, 77, 125, 126, 135, 153], mHealth Func- Child immunization
tion 8 (provider work planning and scheduling, n = 6, Twelve articles assessed childhood immunization cov-
30%) [40, 50, 74, 77, 125, 139], mHealth Function 5 (elec- erage per national guidelines until approximately
tronic health records, n = 6, 30%) [44, 125, 126, 135, 139, 12 months of age [49, 54, 55, 58, 50, 66–68, 71, 84, 107,
153], and mHealth Function 3 (registries and vital events 108, 149, 152], a combination of vaccinations for a
tracking, n = 5, 25%) [40, 44, 126, 135, 153]. Other func- shorter or longer duration [40, 43, 56, 85, 109], includ-
tions used by other studies included mHealth Function ing boosters [125, 134]. Nine RCTs, six cluster RCTs,
7 (provider-to-provider communication, n = 2, 10%) [40, and six quasi-experimental studies assessed the effect
100], mHealth Function 9 (provider training and edu- of mHealth interventions on childhood immunization.
cation, n = 2, 10%) [83, 139], and mHealth Function 12 Table 3 displays the individual effect estimates obtained
(financial transactions and incentives, n = 1, 5%) [152]. in individual articles or calculated as a cRR based on the
Eight articles included in this review presented the available data on the number of events in each group.
effect of mHealth interventions in increasing deliveries As with the studies assessing other outcomes, mHealth
in health facilities, though with varied effect sizes [40, 62, Function 1 (education and BCC) was the most commonly
74, 77, 97–100, 139, 62]. In Uganda, village health teams used (n = 13/15) as a sole function or one of the multi-
conducted educational sessions with families on relevant ple functions employed in the interventions. Two studies
MNCH topics and could call professional health workers used other functions, such as financial transactions and
(mHealth Function 7) on challenging matters [100]. The incentives (mHealth Function 12), and one study used
study found a significant difference in the proportion of electronic health records (mHealth Function 5), elec-
facility delivery between the intervention and routine tronic decision support (mHealth Function 6), and pro-
care groups. Another study in Tanzania equipped CHWs vider work planning and scheduling (mHealth Function
with smartphone-based job aids for data collection, deci- 8).
sion-making support, and home-visit scheduling func- As for the outcome effects, seven articles found that
tions (mHealth Functions 4, 6, and 8). The CHWs were mHealth intervention improved immunization rates
prompted to counsel pregnant women on the importance [43, 49, 58, 84, 107, 108, 149, 152]. For example, a study
of the delivery place (mHealth Function 1). The propor- in Zimbabwe sent text message reminders (mHealth
tion of women giving birth in a facility was significantly Function 1) to women in the intervention group before
higher in the intervention than in the control group [74]. the 6th, 10th, and 14th week vaccination appointments
In a study in India, female frontline workers received resulting in a significant increase in immunization cover-
mobile phone tools for scheduling reminders for ANC age among the intervention group at 6 weeks (96.7% vs.
home visits. The proportion of women delivering in a 82.2%, p < 0.001), 10 weeks (96.1% vs. 80.3%, p < 0.001),
health facility increased significantly in the intervention and 14 weeks (94.7% vs. 75.0%, p < 0.001) compared to the
group relative to the control and the quasi-control groups control group. Furthermore, the controls had a more sig-
[77]. In Kenya, ANC appointment reminders were sent nificant delay in vaccination [43]. Three studies in Nige-
to pregnant women directly with relevant educational ria sent reminders to women using text messages, emails,
information (mHealth Function 1) via text messages and or voice recordings (mHealth Function1) and increased
phone calls. The study found a significant increase in immunization rates in intervention groups [49, 58, 84].
facility delivery rates in the intervention group [62]. Similar findings were observed in studies in India [107,
Two other articles from Rwanda and Nigeria found 108] and Bangladesh [149]. In Kenya, women received
improvement in facility delivery [119, 130]. However, conditional cash transfers (mHealth Function 12) equiv-
we did not include them in Table 2 as the outcome for- alent to US$4.5 per visit to health facilities for ANC,
mat did not allow us to derive a comparable effect esti- delivery, PNC, and childhood immunization. A modest
mate. The remaining 12 studies did not find a significant increase in childhood immunization appointments was
increase in facility delivery rates attributable to the reported [152].
respective mHealth intervention [42, 44, 50, 66, 83, 125, However, eight studies did not find significant effects of
126, 131, 135, 151–153]. mHealth interventions on immunization [50, 54, 66, 71,
85, 109, 125, 134]. We did not include six studies [40, 55,
Effect on postnatal care (PNC) 56, 67, 68, 116] in Table 3 because the outcomes reported
For PNC outcomes, we report findings on the most did not allow us to extract or calculate effect estimates.
frequently measured outcomes among the reviewed Among these studies, the results were contradictory, with
Table 3 Comparison of childhood immunization in the intervention and control groups
*
Study: The same study in multiple rows indicates multiple intervention groups [43, 49, 50, 54, 58, 66, 71, 84, 85, 107–109, 125, 134, 149, 152]
**
†
‡
scheduling; 9. Provider training and education; 10. Human resource. management; 11. Supply chain management; 12. Financial transactions and incentives
§
¶
two studies showing significant mHealth intervention feeding [46, 47, 140, 155], complementary feeding, sup-
effects on immunization rates Field [75, 82], while four plementary feeding, bottle feeding, formula feeding, and
had no significant impact. breastfeeding awareness [34, 39, 61, 100, 102, 124, 135,
140].
Feeding practices In terms of mHealth functions, all 18 articles on exclu-
Table 4 shows the outcomes of exclusive breastfeeding sive breastfeeding and early breastfeeding initiation used
reported in 17 papers [34, 39, 46, 47, 50, 63, 64, 67, 68, mHealth Function 1 (education and BCC). A study in
78–80, 86, 91, 102, 112, 140, 146, 151, 155]. Six of these India additionally used mHealth Function 4 (data collec-
studies additionally assessed the effect of mHealth on tion and reporting), mHealth Function 6 (electronic deci-
early breastfeeding initiation within one-hour post-deliv- sion support), and mHealth Function 8 (provider work
ery [34, 46, 64, 140, 155, 50]. planning and scheduling) [50, 107, 108].
We reviewed seven articles on early breastfeeding Results of the effectiveness of mHealth interven-
initiation, as shown in Table 5, including a study from tions on exclusive breastfeeding and early breastfeed-
India [107, 108]. Some studies also assessed the effect on ing initiation were mixed. Nine studies [59, 79-86, 89-]
colostrum feeding [46, 47, 64, 107, 108, 140], pre-lacteal found moderate to higher exclusive breastfeeding rates
Table 4 Comparison of exclusive breastfeeding in the intervention and control groups
*
Study: The same study in multiple rows indicates multiple intervention groups [34, 39, 47, 50, 63, 64, 78–80, 86, 91, 102, 112, 140, 146, 151, 154]
**
†
‡
§
¶
attributable to mHealth interventions, of which two [64, breastfeeding rate was significantly higher among the
140] further demonstrated their effectiveness on early intervention than the control group.
breastfeeding initiation. Examples of effective exclu- Studies reporting effectiveness in exclusive breastfeed-
sive breastfeeding interventions include an RCT study ing and early breastfeeding initiation include a cluster
in Iran in which pregnant women in the intervention RCT in Nigeria, where pregnant women were provided
group received breastfeeding self-efficacy education ses- with breastfeeding learning sessions and educational
sions, information booklets, and biweekly text messages text messages (mHealth Function 1), together with songs
(mHealth Function 1). The exclusive breastfeeding rates and dramas conveying the information and messages.
differed significantly between the intervention and con- The study found significantly higher rates of exclusive
trol groups at 8 weeks postpartum [39]. In a study in breastfeeding at six months and early breastfeeding ini-
Bangladesh [78], nurses underwent training on infant tiation in the intervention group than in the routine care
and young child feeding. They subsequently provided group [64]. A similar study in India demonstrated strong
women in the intervention group with tailor-made sup- effects of the mHealth intervention on prolonging exclu-
port on breastfeeding, contacted them biweekly, and had sive breastfeeding and early breastfeeding initiation com-
a lactation consultant available as needed. The exclusive pared to a control group receiving routine care [140].
Table 5 Comparison of early initiation in the intervention and control groups
*
Study: The same study in multiple rows indicates multiple intervention groups [34, 47, 50, 64, 107, 108, 140, 154]
**
†
‡
§
¶
However, a study in India [50] in which ASHAs were achieving high and timely childhood immunization cov-
equipped with a mobile application to provide health erage [170]. Concerning the feeding practice, the effects
information, guidelines, and checklists (mHealth Func- of mHealth were inconsistent, which may reflect a com-
tion 6), patient tracking and data collection (mHealth plex interplay of barriers in promoting exclusive breast-
Function 4), and automated scheduling tools (mHealth feeding [171]. However, improving awareness among
Function 8) found no evidence of improved exclusive pregnant women and mothers and performing regular
breastfeeding six months postpartum. However, the follow-ups are crucial to addressing low breastfeeding
effect on early breastfeeding initiation was statistically rates [172–174], and the significant role the mHealth may
significant. Seven studies found no significant impact of play is envisaged.
mHealth interventions on exclusive breastfeeding rates Besides the study quality, the inconsistent results in
[34, 50, 63, 86, 91, 146, 151, 155]. We did not include a this review may be due to the complex interaction of a
study in Malawi [67, 68] in Table 4 because the reported plethora of determinants that mHealth cannot fully
outcome did not allow us to extract an effect estimate. address. The factors may include sociocultural beliefs,
economic and physical accessibility, knowledge and per-
Discussion ception of benefits and needs, and service quality [175].
Overall, this systematic review suggests that mHealth The mHealth behavior change interventions must be
interventions targeting MNCH may increase attendance designed based on theoretically validated mechanisms
in ANC. However, the high heterogeneity between stud- and guided by formative research of the specific target
ies and the limited reporting quality prohibited calcu- populations and their behavioral determinants [176, 177].
lating a pooled estimate. mHealth interventions can be In the LMIC context, the gap mHealth can fill is often not
considered adequate for improving vaccination timeli- the only missing link to improve the MNCH [178]. For
ness for those who attend their appointments. However, example, nudging women with information and remind-
the effects of mHealth on facility-based deliveries or child ers may not necessarily result in women delivering at
immunization attendance were inconsistent. The synthe- facilities or improving feeding practices, as these behav-
sized evidence suggests the positive impact of mHealth iors are highly affected by socio-economic, environmen-
reminders and information provision on ANC and PNC tal, cultural, and health system factors [175, 179]. In this
attendance, although the effects were moderate [22, 166– context, evaluating mHealth interventions implemented
169]. A review by Colaci et al. found that text messages with high fidelity may provide an opportunity to identify
enhanced the acceptability of maternal care among preg- further gaps in health programming.
nant women, including skilled birth attendance [168]. In terms of mHealth functions, we observed that all 12
Another meta-analysis of studies from 11 LMICs by Eze functions of mHealth described by Labrique et al. [163]
et al. suggests that SMS reminders can contribute to was used in the reviewed articles. The most frequently
used function among the reviewed studies by far was “cli- studies, mobile phone ownership was often a prerequisite
ent education and BCC” (mHealth Function 1), as seen in to participation in mHealth programs, and some of the
past reviews [22, 164, 167], providing relevant informa- participating women relied on shared devices with part-
tion and reminders for ANC/PNC appointments, child- ners or families. When devices are shared, client confi-
birth, immunization, and breastfeeding, which had the dentiality and autonomy can be compromised. Mobile
advantage of simplicity, feasibility, and achievability. phone ownership, literacy, rural and urban residency,
mHealth functions as direct support for health workers and socio-economic status could risk further marginal-
(mHealth Functions 6–9) were employed in 7–13% of the izing vulnerable groups [21, 187, 188]. For the HCPs and
studies. These mHealth interventions may have had an CHWs, health systems and the workforce often lack the
indirect impact on the health outcomes of the beneficiar- capacity to manage data and digital technology [189],
ies. However, these functions were often used alongside and the introduction of mHealth tools could burden the
other functions that directly targeted the beneficiaries, users [190]. At the same time, mHealth is often consid-
and the effect attributable to each function was not meas- ered to promote their empowerment, autonomy, and
ured independently. The potentially powerful sensors and improved incentives. Implementation science research to
point-of-care diagnostics, human resource management, explore usability, feasibility, and acceptability in the spe-
supply chain management, and financial transaction cific context is strongly recommended as part of RCTs to
(mHealth Functions 2, 10, 11, and 12) were not com- enhance the adoption and informativeness of the overall
monly used in the reviewed studies, reflecting a possible trial interventions [191, 192]. Coupled with high-quality
limitation of our search strategy or a genuine scarcity of evidence with large-scale and more rigorous RCT designs
such interventions in the area of MNCH in LMICs. to establish the validity and cost-effectiveness of mHealth
Concerning quality, our analysis found that several fac- interventions, accumulating such evidence will guide the
tors may account for the absence of definitive results in replication and scaling-up of effective intervention mod-
this review: (1) moderate or high risk of bias among the els while enabling optimal allocation of limited resources
more significant proportion of studies (62%); (2) lack of in the LMICs.
power due to small sample size (a characteristic of pilot This systematic review focused exclusively on experi-
studies), high rates of loss to follow-up, and the multitude mental and quasi-experimental studies at the risk of
of outcomes reported by each study (especially for edu- neglecting the complete picture of the currently avail-
cational interventions); (3) data reliability of self-reported able evidence. This selection was to ensure the qual-
outcomes (such as with infant feeding practices); and ity of the review by excluding observational studies,
(4) circumstantial challenges such as technological fail- which lack internal (i.e., methodological strength) and
ures, staff turnover, and relocation of participants. Stud- external (i.e., generalizability) validity. We limited our
ies have pointed out that mHealth studies are typically search to English-language papers published in peer-
under-theorized, poorly specified, and vaguely described, reviewed journals, which may have resulted in the omis-
and as a result, lack the specific rigor required for experi- sion of informative articles on trials, including those
mental studies [8, 180, 181]. We found that the articles conducted by organizations outside conventional aca-
in this review commonly would have benefitted from demia. By focusing on LMICs, we excluded the studies
more detailed descriptions of randomization processes, in high-income countries, including studies investigat-
allocation concealment, and blinding, without which the ing mHealth use in disadvantaged or marginalized pop-
validity of the methodology could not be established. Ref- ulations in those countries, who may have had much in
erencing the evaluation guidelines for reporting evidence common with residents of LMICs. Finally, we acknowl-
of mHealth interventions, such as the Mobile Application edge the time lapse between the initial search and the
Rating Scale (MARS) [182] and WHO’s mHealth Evi- completion of the analysis. The comprehensive analyses
dence Reporting and Assessment (mERA) checklist, in necessitated more than 12 months to complete, involv-
addition to standard guidance on trials such as Consoli- ing meticulous review of a significant number of included
dated Standards of Reporting Trials (CONSORT) [183, studies. This extensive process ensured accurate com-
184] is strongly recommended for future studies. parison of effect measures across heterogeneous studies,
Our review further exposed the critical need to con- precise categorization, thorough quality assessment, and
sider the digital infrastructure and technical capacity in comprehensive descriptive reporting.
LMIC settings, which can often be the significant barri-
ers to flourishing mHealth implementation [180, 185]. Conclusions
There persist apparent age and sex, not to mention Our review demonstrated that mHealth interventions
urban–rural gaps in access to mobile communication could be a practical approach to increase ANC attend-
technology, especially in LMICs [186]. In the reviewed ance and improve the timeliness of child immunization.
However, their effects on facility-based deliveries, child Authors’ contributions

MRK and SY conceived the study. MRK, MN-H, and RL conducted the search
immunization coverage, and breastfeeding practices and retrieval. MRK, MN-H, RL, and SY conducted the analyses and drafted the
were inconclusive. Nonetheless, mHealth’s potential to manuscript. CHS, MU, SO, ELYY, MZ, and SY reviewed and provided critical
fill the longstanding gaps in BCC and data collection in inputs. All authors read and approved the final manuscript.
resource-limited LMICs is unquestionable. However, Funding
while the number of mHealth studies in LMICs has been This review was funded by the Bill & Melinda Gates Foundation as part of
proliferating, weak and inconsistent evidence contin- the i-MoMCARE trial (INV-022514) and the UHS-SSHSPH Integrated Research
Programme, Saw Swee Hock School of Public Health, National University of
ues to plague the field, thus preventing us from draw- Singapore.
ing robust conclusions. Further quantitative research
with high rigor to assess the effectiveness of mHealth Availability of data and materials
No additional data are available.
and implementation research to explore the context-
specific facilitators and intervention barriers are highly
warranted. Declarations
Ethics approval and consent to participate
Abbreviations Not applicable.
ANC Antenatal care
ASHA Accredited Social Health Activist Consent for publication
BCC Behavior change communication Not applicable.
CHW Community health worker
CINAHL Cumulative Index to Nursing & Allied Health Competing interests
cOR Crude odds ratio The authors declare that they have no competing interests.
cRR Crude risk ratio
CONSORT Consolidated Standards of Reporting Trials Author details
1
HCP Health care provider Saw Swee Hock School of Public Health, National University of Singapore
HEW Health extension worker and National University Health System, Singapore, Singapore. 2 KHANA Center
ImTeCHO Innovative Mobile-phone Technology for Community Health for Population Health Research, Phnom Penh, Cambodia. 3 Public Health Pro‑
Operations gram, College of Education and Health Sciences, Touro University California,
JBI Joanne Briggs Institute Vallejo, CA, USA.
LMIC Low- and middle-income country
MARS Mobile Application Rating Scale Received: 23 November 2023 Accepted: 1 May 2024
MeSH Medical subject heading
MNCH Maternal, newborn, and child health
mERA MHealth Evidence Reporting and Assessment
mHealth Mobile health
OR Odds ratio References
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Knop et al.

BMC Medicine (2024) 22:196 BMC Medicine

REVIEW Open Access

Impact of mHealth interventions

Background low broadband requirements [15]. However, the authors

Fig. 1 Flow diagram of the study selection process

Fig. 2 Number of included studies by 12 mHealth functions

Effects on delivery care or calculated as a cRR based on available data on the

Table 2 Comparison of facility delivery in the intervention and control groups

Table 3 Comparison of childhood immunization in the intervention and control groups

Table 4 Comparison of exclusive breastfeeding in the intervention and control groups

Table 5 Comparison of early initiation in the intervention and control groups

However, their effects on facility-based deliveries, child Authors’ contributions

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