This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Pediatrics and Parenting, is properly cited. The complete bibliographic information, a link to the original publication on http://pediatrics.jmir.org, as well as this copyright and license information must be included.
Maternal mortality remains high in many low- and middle-income countries where limited access to health services is linked to low antenatal care utilization. Effective communication and engagement with care providers are vital for the delivery and receipt of sufficient health care services. There is strong evidence that simple text-based interventions can improve the prenatal care utilization, but most mobile health (mHealth) interventions are not implemented on a larger scale owing to the lack of context and preliminary evidence on how to make the transition.
The objective of this study was to determine access to mobile phones by pregnant women attending antenatal care as well as willingness to receive a text message (short message service, SMS)–based mHealth intervention for antenatal care services and identify its associated factors among pregnant women attending an antenatal care clinic in Gondar Town Administration, Northwest Ethiopia, Africa.
A cross-sectional quantitative study was conducted among 422 pregnant women attending antenatal care from March 27 to April 28, 2017. Data were collected using structured questionnaires. Data entry and analysis were performed using Epi-Info version 7 and SPSS version 20, respectively. In addition, descriptive statistics and bivariable and multivariable logistic regression analyses were performed. Furthermore, odds ratio with 95% CI was used to identify factors associated with the willingness to receive a text message–based mHealth intervention.
A total of 416 respondents (response rate 98.6%, 416/422) were included in the analysis. About 76.7% (319/416) of respondents owned a mobile phone and 71.2% (296/416) were willing to receive an SMS text message. Among the mobile phone owners, only 37.6% (120/319) were having smartphones. Of all women with mobile phones, 89.7% (286/319) described that they are the primary holders of these phones and among them, 85.0% (271/319) reported having had the same phone number for more than a year. Among the phone owners, 90.0% (287/319) described that they could read and 86.8% (277/416) could send SMS text messages using their mobile phones in their day-to-day activities. Among pregnant women who were willing to receive SMS text messages, about 96.3% (285/296) were willing to receive information regarding activities or things to avoid during pregnancy. Factors associated with willingness were youth age group (adjusted odds ratio [AOR] 2.869, 95% CI 1.451-5.651), having attained secondary and higher educational level (AOR 4.995, 95% CI 1.489-14.773), and the frequency of mobile phone use (AOR 0.319, 95% CI 0.141-0.718).
A high proportion of pregnant women in an antenatal care clinic in this remote setting have a mobile phone and are willing to receive an SMS text message–based mHealth intervention. Age, educational status, and the frequency of mobile phone use are significantly associated with the willingness to receive SMS text message–based mHealth interventions.
Maternal health is a critical issue to be addressed worldwide. Every minute of every day, somewhere in the world, women lose their lives because of complications related to pregnancy and childbirth. It is estimated that globally every day about 830 women die from preventable causes related to pregnancy and delivery, and about 99% of all maternal deaths occur in developing countries where access to antenatal care (ANC) services is limited [
According to the Ethiopian Demographic and Health survey 2016 key indicators report, maternal mortality ratio in Ethiopia is 412/100,000 [
Mobile phones are increasingly used in health care systems in low- and middle-income countries and are considered as innovative solutions that have immense potential to overcome barriers of access to ANC service [
In Ethiopia, mobile subscribers are increasing exponentially and the mobile network coverage is expanding [
Therefore, the objectives of this study are as follows:
To assess the access to mobile phone among pregnant women attending ANC clinics in Gondar Town Administration
To determine the willingness of those women to receive SMS text message–based mHealth interventions
To identify the factors associated with the willingness to receive SMS text message–based mHealth interventions among pregnant women attending ANC
A cross-sectional quantitative study was conducted at 8 health facilities from March 27 to April 28, 2017, in the Gondar Town Administration, Northwest Ethiopia. The Gondar Town Administration is divided into 8 clusters namely Gondar, Ginbot 20, Azezo, Gebriel, Maraki, Woleka, Teda, and Belajig; the administration has a total of 24 Kebele (13 urban and 11 rural). In addition, the administration has a total of 23 public health facilities, 1 referral hospital, 8 health centers, and 14 health posts. Of the estimated population of the town, 49.5% (162,192/327,661) are females and 50.5% (165,469/327,661) are males. Among the total population, 260,183 are urban inhabitants and the rest 67,478 are rural inhabitants. In the 2016-17 budget year, the number of women in the reproductive age group was 77,262 and the estimated number of pregnancies was 11,042 (data from Gondar Town health department). In the Ethiopian context, health center means a health facility that provides primary health care and urban area implies a town that consists of at least 2000 residences.
All women who were pregnant and attending ANC service at health centers during the study period were used as the study population.
The sample size of this study was determined using the single population proportion formula (
We could not find any studies conducted to determine the mobile phone ownership among pregnant women attending ANC in Ethiopia, although the general subscriber identity module (SIM or subscriber identification module) population in Ethiopia is 48.3% [
Women exiting ANC visit were approached for interviews at each of the 8 health centers. The interviews included sociodemographic characteristics, physical accessibility to a health care facility, electricity and network availability, patterns of mobile phone use, and women’s opinion and willingness to receive health information via SMS text messages through mobile phones. Questionnaires were first developed in English, which then underwent forward and backward translation to ensure semantic consistency (English to Amharic then English), for the appropriateness and easiness in approaching study participants. Of note, a pretest of the questionnaire was conducted among pregnant women attending ANC (5% of the sample) before the study period at health centers in the Debre-tabor Town Administration, following which necessary modifications were made on the basis of pretest findings. Research personnel, including 2 health information technicians, 2 nurses with bachelor degrees acting as supervisors, and 8 clinical nurses serving as data collectors or interviewers, received a 1-day training course on implementing the evaluation, which included training on research ethics, providing informed consent, data collection procedures, data collecting tools, how to approach participants, data confidentiality, respondents’ right and all the study protocols to be followed throughout the course of the data collection period. In addition, continuous monitoring by supervisors was done throughout the data collection period to ensure that the data were collected according to the study protocol. The completed questionnaires were stored in binders in nurses’ class until collected by the principal investigator.
Data were entered using Epi-Info version 7 and transferred to SPSS version 20. Descriptive statistics were performed to describe the study population. We used the binary logistic regression to analyze the association of each study variable on the outcome variable. The dependent variable was designated as “no”=0 (have no willingness) and “yes”=1 (for having willingness). Variables significantly associated with the outcome variable (
Ethical clearance was obtained from the ethical review board of the University of Gondar. In addition, oral consent was obtained from study participants after narrating the objective of the study; they were also informed about the benefits of the study. If they felt discomfort during the interview, they were informed that they could stop at any time. Moreover, confidentiality assurance was provided to study participants on any information provided by them; the data collection procedure was anonymous, and their privacy was upheld.
A total of 422 pregnant women from 8 public health centers were approached; of them, 416 responded to complete all the questionnaires at each health center (response rate 98.6%). Of all respondents, 81.3% (338/416) were urban residents. The age of respondents ranged from 18 to 45 years (mean age 26.6 [SD 5.4] years). In addition, 94.5% (393/416) of them were married, 67.3% (280/416) were housewives, and 51.7% (215/416) had attained at least secondary educational level (
In this study, 97 pregnant women had no mobile phone; main reasons reported for not owning a mobile phone currently were cannot afford to buy (53/97, 54.6%), followed by mobile phone broken (17/97, 17.5%).
Of all women with mobile phones, 89.7% (286/319) described that they are the primary holders of these phones; however, 29.8% (94/319) of them described that they share their mobile phone with others, especially with other family members. In addition, 51.4% (164/319) of them locked their mobile phone with a password and 30.1% (96/319) put their mobile phone in a place where others can see and access it easily. Furthermore, 31.3% (100/319) of women reported that there were times or places where they did not answer calls and 14.7% (47/319) reported switching-off mobile phones during the daytime.
Of the respondents with mobile phones, 85.0% (271/319) reported having had the same phone number for more than a year; the other 15.0% (48/319) reported changing their mobile phone number in the last 1 year. In addition, 37.6% (120/319) of current mobile phone owners had smartphones. Among current mobile phone owners, 47.3% (151/319) of pregnant women described that they accessed the internet through their mobile phones, which could be either a basic phone or smartphone; of them, 94.7% (143/151) reported using the Facebook app mainly to stay in touch with friends and relatives through this social media platform.
Sociodemographic characteristics of pregnant women attending antenatal care follow-up at health centers in the Gondar Town Administration, Northwest Ethiopia, 2017.
Sociodemographic characteristics | Pregnant women (n=416), n (%) | Pregnant women owning a mobile phone (n=319), n (%) | |||
15-24 | 160 (38.5) | 118 (37.0) | |||
≥25 | 256 (61.5) | 201 (63.0) | |||
Urban | 338 (81.3) | 298 (93.4) | |||
Rural | 78 (18.7) | 21 (26.6) | |||
Not married | 14 (3.4) | 10 (3.1) | |||
Married | 393 (94.5) | 303 (95) | |||
Othera | 9 (2.2) | 6 (1.9) | |||
Cannot read and write | 70 (21.9) | 21 (6.6) | |||
Informal education | 21 (5.0) | 12 (3.8) | |||
Primary | 110 (26.4) | 85 (26.6) | |||
Secondary and above | 215 (51.7) | 201 (63.0) | |||
Housewife | 280 (67.3) | 192 (60.2) | |||
Civil servant | 49 (11.8) | 49 (15.4) | |||
Merchant | 48 (11.5) | 46 (14.4) | |||
Daily laborer | 24 (5.8) | 20 (6.3) | |||
Student | 12 (2.9) | 10 (3.1) | |||
Otherb | 3 (0.7) | 2 (0.6) | |||
Family | 385 (92.5) | 294 (92.2) | |||
Alone | 24 (5.8) | 21 (6.6) | |||
Parents | 7 (1.7) | 4 (1.3) | |||
No child | 185 (44.5) | 160 (50.2) | |||
1 | 77 (18.5) | 59 (18.5) | |||
2 | 80 (19.2) | 60 (18.8) | |||
3 | 44 (10.6) | 29 (9.1) | |||
≥4 | 30 (7.2) | 11 (3.4) |
aSeparated, windowed, and died.
bFarmer, driver, and jobless.
Of all respondents with mobile phones, 90.0% (287/319) described that they could read and 86.8% (277/416) could send SMS text messages using their mobile phones. However, 6.3% (18/319) of them described that they deleted SMS text messages without reading them. Among those who currently owned a mobile phone, only 33.2% (106/319) used their mobile phone for health-related information or purposes; of them, 50.0% (53/106) respondents used to set the alarm to take medication, 36.9% (39/106) received health-related SMS text messages or calls from health organization or health care providers, 32.1% (34/106) used their phones to consult health professionals, and 24.5% (26/106) used their phones to browse health-related information using the internet.
As shown in
Respondents who used their phones as an alarm reminder to take their medication were more willing to receive SMS text message–based mHealth interventions than those who did not (85% vs 75.2%). This willingness was also observed in respondents who received SMS text messages from health organization before compared with those who had not (79.5% vs 76.4%). The frequency of the mobile phone use also correlated with the willingness to accept an SMS text message–based mHealth intervention. Of note, 229 women (80.1%) who “always” used their mobile phones were willing to receive SMS text messages compared with those who only used their mobile phones “sometimes” 16 (48.5%). The willingness to receive SMS text messages was higher among respondents who locked their mobile phone with a password than those who did not lock their mobile phone with a password (80.5% vs 72.9%). In addition, internet users via their mobile phone were also more willing than noninternet users (82.1% vs 72%).
In this study, 71.2% (296/416) respondents were willing to receive SMS text messages with information regarding ANC (
The time of day at which they would want to receive SMS text messages varied greatly. Overall, 19.9% (59/296) of women preferred receiving an SMS text message at morning only (8 am-before 12 pm), 6.8% (20/296) in the afternoon only (12 pm-before 4 pm), 12.8% (38/296) in the evening only (4 pm-before 8 pm), whereas 60.5% (179/296) described they could receive the SMS text messages at any time of the day. Among respondents who were willing to receive SMS text messages, more than three-fourth preferred receiving them at a frequency of once a week.
Overall, women were interested in receiving pregnancy and related information via SMS text messages. Among pregnant women who were willing to receive SMS text messages, about 96.3% (285/296) were willing to receive information regarding activities or things to avoid during pregnancy.
Those who intended to receive health information regarding delivery courses via SMS text messages were 90.5% (268/296). In addition, respondents were willing to receive SMS text messages about what to expect at various stages of pregnancy (249/296, 84.1%), prenatal dietary information (236/296, 79.7%), appointment reminders (209/296, 70.6%), when to call a doctor during pregnancy (107/296, 36.1%), and physical activities during pregnancy (88/296, 29.7%). Among respondents who were willing to receive SMS text messages, 78.4% (232/296) indicated that they were willing to pay for the service based on the current SMS text messaging rates.
Variables in the bivariable analysis of sociodemographics, patterns of mobile phone use, access to a health facility, and ANC-related factors around the willingness to receive SMS text messages that had
Willingness to receive the short message service (SMS) text message–based mHealth intervention by patterns of mobile phone use among pregnant women attending antenatal care follow-up at health centers in the Gondar Town Administration, Northwest Ethiopia, 2017 (N=319).
Mobile phone use patterns | Total, n (%) | Willingness to receive SMS text messages, n (%) | ||
Yes | No | |||
Smart | 120 (37.6) | 101 (84.2) | 19 (15.8) | |
Standard | 199 (62.4) | 144 (72.4) | 55 (27.6) | |
Yes | 229 (71.8) | 184 (80.3) | 45 (19.7) | |
No | 90 (28.2) | 61 (67.8) | 29 (32.2) | |
Yes | 106 (33.2) | 85 (80.2) | 21 (19.8) | |
No | 213 (66.8) | 160 (75.1) | 53 (24.9) | |
Yes | 53 (16.6) | 45 (85) | 8 (15) | |
No | 266 (83.4) | 200 (75.2) | 66 (24.8) | |
Yes | 39 (12.2) | 31 (79.5) | 8 (19.5) | |
No | 280 (87.8) | 214 (76.4) | 66 (23.6) | |
Yes | 34 (10.7) | 26 (76.5) | 8 (23.5) | |
No | 285 (89.3) | 219 (77) | 66 (23) | |
Yes | 26 (8.2) | 20 (77) | 6 (23) | |
No | 293 (91.9) | 225 (76.8) | 68 (23.8) | |
Always | 286 (89.6) | 229 (80.1) | 57 (19.9) | |
Sometimes | 33 (10.3) | 16 (48.5) | 17 (51.5) | |
Yes | 48 (15) | 35 (72.9) | 13 (27.1) | |
No | 271 (85) | 210 (77.5) | 61 (22.5) | |
Yes | 22 (6.9) | 20 (90.9) | 2 (9.1) | |
No | 297 (93.1) | 225 (75.8) | 72 (24.2) | |
Yes | 47 (14.7) | 34 (72.3) | 13 (27.7) | |
No | 272 (85.3) | 211 (77.6) | 61 (22.4) | |
Yes | 108 (33.9) | 82 (75.9) | 26 (24.1) | |
No | 211 (66.1) | 163 (77.5) | 48 (22.7) | |
Yes | 100 (31.3) | 75 (75) | 25 (25) | |
No | 219 (68.7) | 170 (77.6) | 49 (22.4) | |
Yes | 164 (51.4) | 132 (80.5) | 32 (19.5) | |
No | 155 (48.9) | 113 (72.9) | 42 (27.1) | |
No | 223 (69.9) | 182 (81.6) | 41 (18.4) | |
Yes | 95 (29.8) | 64 (67.4) | 31 (32.4) | |
No | 224 (70.2) | 181 (80.8) | 43 (19.2) | |
Yes | 277 (86.8) | 219 (79.1) | 59 (209) | |
No | 42 (13.2) | 26 (61.9) | 16 (38.1) | |
Yes | 287 (90) | 226 (78.7) | 61 (21.3) | |
No | 32 (10) | 19 (59.4) | 13 (40.6) | |
Yes | 18 (6.3) | 17 (94.4) | 1 (5.6) | |
No | 269 (93.7) | 211 (78.4) | 58 (21.6) | |
Very likely | 26 (8.1) | 17 (65.4) | 9 (34.6) | |
Likely | 57 (17.9) | 38 (66.7) | 19 (33.3) | |
Unlikely | 71 (22.3) | 55 (77.5) | 16 (22.3) | |
Very unlikely | 165 (51.7) | 135 (81.8) | 30 (18.2) | |
Yes | 151 (47.3) | 124 (82.1) | 27 (17.9) | |
No | 168 (52.7) | 121 (72) | 47 (28) | |
Yes | 143 (94.7) | 123 (86) | 20 (14) | |
No | 8 (5.3) | 1 (12.5) | 7 (87.5) | |
Yes | 88 (58.3) | 77 (87.5) | 11 (12.5) | |
No | 63 (41.7) | 47 (74.6) | 16 (25.4) | |
Yes | 46 (30.5) | 39 (84.8) | 7 (15.2) | |
No | 105 (69.5) | 85 (81) | 20 (19)) | |
Yes | 48 (31.8) | 42 (87.5) | 6 (12.5) | |
No | 103 (68.2) | 82 (79.6) | 21 (20.4) |
Attitude and willingness to receive short message service (SMS) text message–based mHealth interventions among pregnant women attending antenatal care follow-up at health centers in the Gondar Town Administration, Northwest Ethiopia, 2017.
Attitude and willingness to receive SMS text message | Pregnant women, n (%) | ||
Yes | 296 (71.2) | ||
No | 120 (28.8) | ||
Ruins privacy | 50 (41.7) | ||
SMS text message is annoying | 2 (1.6) | ||
Difficult to operate | 54 (45) | ||
Not important | 14 (11.7) | ||
Before 1 month | 117 (39.5) | ||
From 3 months | 163 (55.1) | ||
From 6 months | 10 (3.4) | ||
From 9 months (before birth | 6 (2.0) | ||
Morning (8 am-before 12 pm) | 59 (19.9) | ||
Afternoon (12 pm-before 4 pm) | 20 (6.8) | ||
Evening (4 pm-before 8 pm) | 38 (12.8) | ||
Any time | 179 (60.5) | ||
1 per week | 223 (75.3) | ||
3 per week | 70 (23.6) | ||
5 per week | 2 (0.7) | ||
7 per week | 1 (0.3) | ||
Yes | 232 (78.4) | ||
No | 64 (21.6) | ||
Yes | 285 (96.3) | ||
No | 11 (3.7) | ||
Yes | 107 (36.1) | ||
No | 189 (63.9) | ||
Yes | 236 (79.7) | ||
No | 60 (20.3) | ||
Yes | 209 (70.6) | ||
No | 87 (29.4) | ||
Yes | 249 (84.1) | ||
No | 47 (15.9) | ||
Yes | 88 (29.7) | ||
No | 208 (70.3) | ||
Yes | 268 (90.5) | ||
No | 28 (9.5) |
Bivariable and multivariable analyses of factors with the willingness to receive short message service (SMS) text message–based mHealth interventions to improve antenatal care (ANC) among pregnant women attending ANC at health centers in the Gondar Town Administration, Northwest Ethiopia (N=416).
Factors | Willingness, n | Crude odds ratio (95% CI) | Adjusted odds ratio (95% CI) | ||
Yes | No | ||||
15-24 | 133 | 27 | 2.810 (1.729-4.569) | 2.869 (1.451-5.651)a | |
≥25 | 163 | 93 | Refb | Ref | |
Urban | 255 | 83 | 2.773 (1.667-4.612) | — | |
Rural | 41 | 37 | Ref | — | |
Cannot read and write | 34 | 36 | Ref | Ref | |
Informal education | 13 | 8 | 1.721 (0.634-4.666) | 5.032 (0.792-31.978) | |
Primary | 78 | 32 | 2.581 (1.383-4.815) | 3.040 (1.001-9.230)a | |
Secondary and above | 171 | 44 | 4.115 (2.318-7.305) | 4.995 (1.489-14.773)a | |
Smart | 101 | 19 | 2.030 (1.136-3.627) | — | |
Standard | 144 | 55 | Ref | — | |
Always | 229 | 57 | Ref | Ref | |
Some times | 16 | 17 | 0.234 (0.112-0.492) | 0.319 (0.141-0.718)a | |
Yes | 132 | 32 | 0.110 (0.652-1.102) | — | |
Yes | 64 | 31 | Ref | — | |
No | 181 | 43 | 2.039 (1.181-3.508) | — | |
Yes | 124 | 27 | 1.784 (1.044-3.047) | — | |
No | 121 | 47 | Ref | Ref |
aStatistically significant at
bRef: reference.
cParticipants with mobile phone ownership, n=319.
This study shows that access to mobile phone among pregnant women attending ANC at health centers in the Gondar Town Administration was high, with over three-quarters of women owning phones in this study. In addition, age, educational level, and frequency of the mobile phone use were among the notable factors associated with the willingness of pregnant women to receive SMS text message–based mHealth interventions.
The mobile phone ownership of women in this study (319/416, 76.7%) is lower than that reported in studies from Argentina (93.2%) [
In addition, 90.0% (287/319) and 86.8% (277/416) of current mobile phone owners could read and send an SMS text message, respectively, making an SMS text message–based intervention technically feasible. Furthermore, there is evidence that respondents were willing to receive SMS text message–based interventions, with a majority wanting the messages to begin early during pregnancy at 3 months, and a preference for once-weekly messages. Similar high willingness rates for SMS text message–based interventions have been observed in Argentina (96%) [
From those who were willing to receive SMS text messages, about 21.6% (64/296) of respondents were not willing to pay for SMS text messaging on current tele tariff rates, even though the benefit was clearly stated. An explanation for this could be that ANC services in Ethiopia are provided free of charge by the Ethiopian government and, thus, mothers might not want to take up any new costs. This finding has important implications for program managers and designers, as they may need to devise alternative payment mechanisms for SMS text messages in future intervention strategies.
This study identified some factors significantly associated with the willingness to receive SMS text message–based mHealth interventions among pregnant women. Younger pregnant women were more likely to be willing to receive SMS text messages; this result is consistent with a study from Kenya [
This analysis indicated that women who achieved secondary or higher education were more likely to be willing to receive SMS text message–based mHealth interventions. This study is in line with a study from Ethiopia among ART patients [
This study shows that the place of residence, source of information for ANC, using the internet through mobile phones, mobile phone type, and mobile phone usage privacy variables, like locking the mobile phone with a password, and sharing a mobile phone with others were not found to be markedly associated with the willingness.
There are some limitations to this study. As the study was an institution–based cross-sectional survey, only respondents who came for ANC visit were interviewed, thereby excluding those who did not visit the health centers. Moreover, this study was conducted at health centers in a major town or urban administration, which could have overstated the accessibility of women to mobile phones and their willingness to receive the SMS text message–based mHealth intervention. In addition, the survey was interviewer-administered, and even if we used neutral interviewers, there might be an interviewer and social desirability bias that could have made more participants to respond in the affirmative. These limitations have to be considered when generalizing these results.
A high proportion of respondents attending ANC clinics in a resource-poor urban setting of Ethiopia have mobile phone access and are willing to receive SMS text message–based mHealth interventions. Thus, mobile phone–based interventions to improve maternal health should be tried and explored further. Moreover, age, educational status, and frequency of the mobile phone use are significant factors associated with the willingness.
antenatal care
adjusted odds ratio
antiretroviral therapy
subscriber identity module or subscriber identification module
short message service
The authors would like to thank facilitators and the study participants for their dedicated cooperation and made the study possible. This study was funded by the University of Gondar Community Service and Research Vice President Office as master’s thesis grant.
BFE contributed to conception and design or acquisition of data, data collection supervision, data analysis, data interpretation, and manuscript preparation. BT and ANW agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. BT and ANW were involved in drafting the manuscript or revising it and have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The manuscript was critically reviewed and edited by BT, RL, and MW.
None declared.