Dr. Peter Winch - mHealth Plans for Mali

1. Developing an mHealth
intervention to improve maternal
health in Sélingué Health District,
Mali
Peter Winch
pwinch@jhu.edu

2. 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 Center 2

3. Mali,
West
Africa
3

4. 4

5. Major conflict in northern Mali in 2012-2013
On-going skirmishes and attacks in 2015
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6. 6

7. 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

8. What is MMR in Mali?
Community Health Center in Kayes District, Mali
Population Density: 23/km2
Photo: Cecilia Flatley
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9. Sisterhood method: 4 questions
Source - 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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10. 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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11. 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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12. 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

13. 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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14. Study site: Sélingué
Health 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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15. Sikasso Region
Lake
Sélingué
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16. 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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17. Role of ASC
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Assessment and
treatment of sick
children
Coordination and
communication of health
system at community level

18. ASC
RC RC RC RC
Auxiliary
Nurse-
Midwives
Women and their families
Improved communication with
community-based providers
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19. ASC
Community leaders,
committees,
transport system
Community Health
Center
District Hospital
Strengthened referral and
emergency transport systems
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20. ASC
RC RC RC RC
Auxiliary
Nurse-
Midwives
Community leaders,
committees,
transport system
Community Health
Center
District Hospital
Women and their families 20

21. 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

22. 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 system
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23. 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

24. 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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25. 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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