Evaluation of an mHealth SMS dialogue strategy to meet women’s and couples’ postpartum contraceptive needs in Kenya
Awarded 2016
Complex Family Planning Fellowship Research
Elizabeth Harrington, MD
University of Washington

Background and Purpose: Meeting women’s need for postpartum family planning has been acknowledged as a global priority in maternal and child health. The prevention of unintended pregnancies in sub-Saharan African countries, which carry the highest global burdens of maternal mortality and HIV infection, is projected to substantially decrease maternal and neonatal morbidity and mortality. Many barriers to contraceptive uptake exist, both within and outside of the postpartum time period, and include socio-cultural, economic, and supply-side factors. Furthermore, while the importance of engaging men in family planning programs has been acknowledged for decades, few interventions have succeeded in increasing male involvement in family planning while maintaining a focus on women’s empowerment. Innovative approaches to meeting the family planning needs of women and couples are urgently needed. We hypothesized that personalized short message service (SMS) dialogue between individual women/couples and health providers would support postpartum highly effective contraceptive (HEC) use. The purpose of this study was to evaluate the effect of a two-way SMS intervention on postpartum contraceptive use among individual women and couple dyads at 6 months postpartum.
Methodology: Mobile WACh XY was an unblinded randomized controlled trial conducted in two public county hospitals in western Kenya. Pregnant, HIV-negative women at least 14 years of age with estimated gestational age ≥28 weeks who had access to a mobile phone, were able to read and respond to SMS, and intended to remain in the area until trial completion were included. Women were randomly assigned (1:1) to receive two-way SMS or control (no SMS). Prior to randomization, partnered women had the option to refer male partners; if referred, study staff approached men for enrollment. Family planning (FP)-focused SMS messages were delivered weekly from enrollment to 6 months postpartum, and the SMS platform enabled SMS dialogue with a nurse. Follow up visits occurred at 6 and 14 weeks and 6 months postpartum. The primary outcome, self-reported HEC use at 6 months postpartum, was compared between groups by the c2 test, and Poisson regression with robust standard errors was used in adjusted analysis.
Findings: We enrolled 260 women (130 to each group), and 254 women were included in the analysis. Median maternal age was 23 (IQR 20-26.5), and 198 women (76.2%) were partnered, of whom 153 referred male partners for trial inclusion. Of these, 103 men were enrolled. At 6 months postpartum, 69.9% women who received two-way SMS were using HEC, compared with 57.4% in the control group. In an analysis adjusted for baseline differences in education, parity, and desire for future children, the adjusted risk ratio for HEC use was 1.26, 95% CI 1.04-1.52, p=0.02. Thus, there was a 26% increase in HEC use among women in the intervention group, and this difference was statistically significant.
Conclusion: Mobile WACh XY, a two-way SMS intervention focused on FP education and counseling, led to increased HEC use at 6 months postpartum among women and couples in Kenya. This study is among the first to rigorously measure the effects of a mobile health (mHealth), SMS-based intervention on contraceptive behavior and outcomes. Finally, this study demonstrated that the inclusion of men in a targeted FP mHealth intervention is feasible, and that men engaged in the intervention.