Impact of MomConnect Program in South Africa: A Narrative Review

Abstract

Background: There has been a growing trend related to the use of mobile health programs as an innovative approach to address complex health issues in low- to middle-income regions. MomConnect, a mobile health program in South Africa targeted at improving antenatal and maternal health, has gained global attention for its widespread national growth. This narrative review examines existing literature on MomConnect to establish its strengths and limitations, as well as the impacts the program has had on the antenatal and maternal healthcare system in South Africa.

Method: A total of 14 studies were included in this review; six were editorials by expert opinion, seven were cross-sectional studies, and one was a mixed-methods study including qualitative interviews and a randomized control trial.

Results: Findings from this review suggested that since the years from inception, MomConnect has had a positive impact on pregnant mothers using the mHealth program, as well as on South Africa’s healthcare system. The strengths of MomConnect were found to be its easy-to-use features, high accessibility, and usefulness of the health information delivered, while its limitations encompassed high maintenance costs, restrictions of using a USSD technological system, lack of universal coverage, and a deficiency in substantial research regarding its outcomes. MomConnect has the potential to continue to improve antenatal and maternal health in South Africa but requires future research to further explore its outcomes and impacts.

Introduction

Improving maternal health is a critical global health concern reflected in the 2030 Sustainable Development Goals, which are global goals embraced by all 193 member states of the United Nations (United Nations, 2015). Maternal deaths and poor maternal health outcomes are commonly concentrated in under-resourced regions, with 99% of maternal deaths occurring within so-called developing nations (World Health Organization, 2015). The highest maternal mortality rate of 66% occurs in Sub-Saharan Africa (World Health Organization, 2015). During the last decade, the number of maternal deaths has progressively decreased in some regions within Africa, particularly in South Africa. Despite improvements, South Africa’s maternal mortality rate still fell short of the Millennium Development Goal targets set for 2015 (Seebregts et al., 2018).

Countless maternal deaths around the world could be prevented if individuals who are pregnant in under-resourced regions had access to perinatal health resources, such as emergency care services, skilled attendants, and maternal and child health education (World Health Organization, 2015). An emergent strategy to improve antenatal and maternal health being employed in low-resource settings are mobile health (mHealth) initiatives tackling inefficiencies in health care systems that negatively impact expecting and current mothers (LeFevre et al., 2018; Peter, Benjamin, LeFevre, Barron, & Pillay, 2018). Some examples of these initiatives include Kilkari and mMitra in India, Text 4 Baby in the United States, and Aponjon in Bangladesh (Peter, Barron, & Pillay, 2015; Peter et al., 2018). Although South Africa did not reach the Millennium Development Goal targets for maternal and child health by 2015, they still attempted to reach it by implementing various public health interventions proposed in 2014 by Dr. Aaron Motsoaledi, who was the National Minister of Health at that time (Barron et al., 2018). One of those interventions was the mobile health service MomConnect (Skinner et al., 2018).

MomConnect is a mHealth initiative launched by the National Department of Health in South Africa to improve maternal health and antenatal services on a national level (LeFevre et al., 2018; Peter et al., 2018; Seebregts et al., 2018; Skinner et al., 2018; Xiong, Kamunyori, & Sebidi, 2018). The target end-users of MomConnect are women who are pregnant and expecting (LeFevre et al., 2018; Peter et al., 2018; Seebregts et al., 2018; Skinner et al., 2018; Xiong et al., 2018). The program has three main features: 1) registration of women who are pregnant into a national pregnancy registry, (2) weekly informative text messages, and (3) an interactive help desk (LeFevre et al., 2018; Peter et al., 2018; Seebregts et al., 2018; Skinner et al., 2018; Xiong et al., 2018).

Registration is free of charge and can occur through an individual’s initial clinical antenatal appointment at a healthcare facility (Barron et al., 2018), or can be done through self-subscription by an individual themselves (Skinner et al., 2018). Registration is done on an unstructured supplementary service data (USSD) system and end-users are identified by their phone number (Peter et al., 2015). This system can work on most mobile phones, including lower-end mobile phones (Peter et al., 2015). Once registered, weekly SMS-text messages are sent to the phones at no cost to the end-user (Skinner et al., 2018). MomConnect sends specific types of informative messages based on the user’ stage of pregnancy and continues to send texts after birth until the child is one year of age (Skinner et al., 2018). Messages cover a wide range of content including but not limited to nutrition, diet, drug use, warning signs for medical issues, fetal development, postnatal care, and social support (Skinner et al., 2018). The program also includes an interactive helpdesk feature through which end-users can ask questions regarding antenatal, maternal and child health, as well as report feedback such as complaints or praises about their experiences with MomConnect and the healthcare facilities used during their pregnancy (Xiong et al., 2018). Helpdesk staff can respond to frequently asked questions, while registered nurses respond to non-frequently asked questions such as clinical questions, with a response tailored to the individual’s needs (Xiong et al., 2018).

With the use of cellphones increasing globally (Mehl, Tamrat, Bhardwaj, Blaschke, & Labrique, 2018), mHealth has the potential to be an efficient and effective method of addressing antenatal and maternal health concerns. This review summarizes the impacts, strengths and limitations of MomConnect, and discusses its prospective implications in national health care services and healthcare research. We chose to review MomConnect because it is a recent maternal mHealth program that scaled to a large number of users within a short period. A review of the current state of knowledge related to MomConnect can identify the benefits, limitations, research gaps, and possible effects of maternal mHealth programs. Findings can then guide the development of future maternal mHealth programs in low to middle-income countries by highlighting key transferrable features essential in MomConnect’s success.

This integrative review paper has been divided into 5 sections: introduction, methods, findings, discussion and conclusion. The findings and discussion sections include a description of included studies, impacts, strengths, and limitations of MomConnect; future directions and implications of the program; and limitations of this review.

Methods

This paper was written as a narrative review, which was informed by the principles of a scoping review study framework (Arksey & O'Malley, 2005). The narrative review approach was used because this paper has specific research questions regarding a particular mHealth program rather than large overview research questions of a broad topic, which is the focus of a scoping study. However, several elements of a scoping review, such as systematic search and summarizing the data through a charting system, were utilized to improve the rigorousness of the study.

Research questions
There were four research questions in this integrative review paper, including: (1) what are the impacts of MomConnect on South Africa’s healthcare system? (2) what are the strengths of MomConnect as an innovative health informatics intervention? (3) what are the limitations of MomConnect as an innovative health informatics intervention? and (4) what are some future directions of MomConnect?

Data source
The literature search was conducted using the following medical, health-related, social and sociocultural science databases: ProQuest, EBSCO, BMJ, PubMed and Ovid.

Eligibility criteria
This review paper included an assortment of English language articles and grey literature published up to 2018. All forms of quantitative and qualitative research and project reports related to MomConnect were included. The exclusion criteria included articles that did not have a text document version that was accessible electronically and articles that did not explore MomConnect as their main topic.

Search strategy
The databases were systematically searched using the keywords: “MomConnect”, “mHealth”, “global health”, “South Africa”, “pregnant” and “maternal” until 2018. The citations were exported into EndNote to remove any duplicates and articles were screened by title and abstract based on the established eligibility criteria. All eligible articles were read in full and the Critical Appraisal Skills Program Checklists were used as quality assessment tools to determine studies for inclusion (Critical Appraisal Skills Programme, 2017). Ultimately, 14 articles were selected for the review.

Data extraction
The various data were extracted by reviewers from each article, including authors, year of publication, study population, research design, recruitment method, sample size, sample characteristics, comparison group, outcomes, measurements, and significant findings. The data were collected and organized into an Excel spreadsheet.

Data analysis
Once the data was organized in Excel, descriptive statistics were used to present the characteristics of included studies. Thematic analysis was then used to summarize the findings to each research question. Any disagreements among reviewers were resolved with a consensus decision.

Findings

Description of included studies
There were 14 studies included in this review (Table 1). Among the studies, six (43%) studies were editorials by an expert opinion, three (21%) were quantitative research studies, two (14%) were mixed-method studies, one (14%) was a descriptive study, one (14%) was a qualitative study consisting of interviews, and one (14%) was a cross-sectional study. All studies were published between 2016 and 2019. Thirteen studies examined MomConnect, while one study reported on NurseConnect, a mHealth application for nurses based on MomConnect.

Table 1: Characteristics of included studies

Impacts of MomConnect

MomConnect’s rapid scaling has made it one of the largest mHealth initiatives in the world (Pillay & Motsoaledi, 2018). Within its first year of launching, MomConnect scaled to over half a million end-users (Seebregts et al., 2018). Presently, MomConnect has over one and a half million end-users (LeFevre et al., 2018; Peter et al., 2018) covering over 60% of the total number of women who are pregnant in South Africa that have received formal antenatal care and 95% of public health facilities that supply antenatal care (Barron et al., 2018).

MomConnect has improved the quality of care in South Africa’s antenatal and maternal health care system. The program helped tackle inefficiencies in antenatal care services through the use of the helpdesk feature where end-users were able to rate and send compliments or critiques regarding their antenatal care experiences at a given healthcare facility (Engelhard et al., 2018). Each facility has its own unique identification code allowing it to be linked to end-user feedback (Barron et al., 2018), producing data regarding the quality of care given by a specific facility. An analysis done on data collected from 2014 to 2016 regarding the feedback received through MomConnect found that about 20% to 40% of complaints were regarding the antenatal services they received (Barron et al., 2018). These complaints helped highlight issues in the healthcare system such as shortage of drugs and vaccines, long wait times (Barron et al., 2018), clinical abuse, and patient neglect by healthcare professionals (Engelhard et al., 2018). Data regarding when, where and how often issues arise in a facility can be used by health managers at facilities to implement facility-specific changes to improve efficiency and the quality of care. Complaints against facilities can also be analyzed at the regional level to identify health system shortcomings.

For instance, regional level issues were identified in the provinces of Gauteng and North West, where multiple reports of iron supplement shortages in clinics identified the need to improve drug management within these districts, as well as to explore this issue nationally (Barron et al., 2018). A high rate of resolving user feedback has improved the quality of care within some local facilities (Xiong et al., 2018). The success of MomConnect has resulted in enthusiasm from MomConnect stakeholders, health managers, and members of the National Department of Health in South Africa for expanding MomConnect to address other healthcare issues (Barron et al., 2018). For example, the success of MomConnect inspired the creation of NurseConnect, a mHealth resource tailored to assist nurses and midwives in South Africa (Fischer, Sebidi, Barron, & Lalla-Edward, 2019).

Findings in the literature revealed the majority of experiences using MomConnect have been positive at the individual end-user level, with many women reporting high levels of satisfaction (Barron, Pillay, Fernandes, Sebidi, & Allen, 2016; Skinner et al., 2018). A qualitative study found that women using the program felt that they had a greater understanding and more confidence regarding maternal and child care during pregnancy and postpartum, especially first-time mothers (Skinner et al., 2018). Women also reported that the weekly text messages increased their excitement regarding their pregnancy, and some women expressed wanting more text messages per week (Skinner et al., 2018). This excitement was found to be transferred to the father of the baby and other family members, increasing the readiness for labour among the family (Skinner et al., 2018). Through the helpdesk feature, MomConnect has answered over 300,000 questions and received 9,700 compliments and 1,300 complaints, resolving 80% of complaints (LeFevre et al., 2018). Data showed that eight times more compliments than complaints were received (Pillay & Motsoaledi, 2018), further evidence of the positive impact felt by end-users. In addition, MomConnect’s helpdesk allowed women to report harassment or violence experienced at specific facilities, such as verbal abuse and neglect by nurses and doctors, allowing for critical changes to be implemented to improve the standards of patient care and engagement toward patients (Engelhard et al., 2018). Since the implementation of MomConnect, there has also been a national increase in antenatal clinic visits (LeFevre et al., 2018). Through sending informative messages and reminders regarding appointments and follow-ups all while promoting supportive health care service environments, MomConnect has the capability of increasing patient compliance and adherence to appointments and treatments, (LeFevre et al., 2018) and of encouraging healthier practices by patients (Amoakoh et al., 2019; Engelhard et al., 2018).

MomConnect may also facilitate healthcare data collection for health research by creating a master patient index (Mehl et al., 2018). MomConnect registers women who are pregnant into a database and collects information on pregnancy statuses and gestational age (Heekes et al., 2018); this information is used to produce a national universal pregnancy registry. Since pregnant women can self-register to the mobile application, MomConnect can capture pregnancies that may not be documented in the healthcare system, such as cases where a woman did not go to a clinic yet to register her pregnancy (Heekes et al., 2018). Thus, MomConnect can assist in creating a more accurate reading regarding how many women are pregnant at a given time (Mehl et al., 2018) while giving these women information they need to have a safer and healthier pregnancy. This can help to improve maternal health on both an individual and national level. MomConnect’s technological infrastructure was also built keeping sustainability and scalability in mind and has the technological feasibility to grow into other systems such as an electronic medical system or a vitals system that can capture and store more patient data (Heekes et al., 2018). Establishing an electronic medical system is especially advantageous because it can promote faster transfer of healthcare and medical data between facilities, as well as assist with health research by facilitating centralized data.

As a recently developed mobile application, MomConnect continues to be advanced and improved. To date, there is limited evidence on the measurement of its direct impact on end-users and South Africa’s healthcare system. The available evidence suggests that MomConnect has had an overall positive effect on end-users. In the future, the program has the potential to be beneficial to South Africa’s healthcare system. Further research and monitoring are required to explicitly establish a relationship between MomConnect and improved maternal health outcomes in South Africa.

Strengths of MomConnect

MomConnect has been reported to have high acceptance by its end-users. Possible reasons for the high acceptability can be attributed to its easy-to-use features, high accessibility to the mHealth program, and the usefulness of health information delivered. These characteristics have resulted in receptiveness by end-users using MomConnect, allowing the program to scale in South Africa.

Ease of usage

As a mHealth program with voluntary participation, MomConnect’s success relies on its high acceptability, which is powered by its easy-to-use features. End-users commonly found the registration process fast and simple, with some reporting feeling empowered by being able to register themselves (Skinner et al., 2018), although issues did arise at registration due to system time-outs delaying registration processes (LeFevre et al., 2018). The texts end-users received after registering were available in 11 different languages, using layman terminology and covering a broad range of biomedical and social topics (Skinner et al., 2018). The text messages were brief and tailored to the individual’s stage of pregnancy in an attempt to avoid providing an excess of information that could be perceived as overwhelming or easily ignored (Skinner et al., 2018). These strengths were highlighted in an interview with a MomConnect user, who commented that the weekly texts caught her attention more than informative posters (Skinner et al., 2018). MomConnect’s interactive helpdesk was not actively advertised to end-users, but still had a high engagement rate and allowed a woman to interact with a trained help desk staff or nurse in less than a day on average (Xiong et al., 2018).

High accessibility

Because MomConnect is free of charge to the user, it is more equitable and accessible to individuals of varying socioeconomic statuses. This is a significant strength because maternal health and mortality rates tend to be worse in underprivileged regions and among populations with low socioeconomic statuses. In addition, MomConnect’s compatibility on most devices (Peter et al., 2015) helped to scale it to a large end-user population, as 90% of South Africa’s population has access to some version of a mobile phone (Mehl et al., 2018). MomConnect allows end-users to conveniently receive, access and share information. Thus, information is not only accessible to the end-user, but also to whomever the end-user may want to share it with, such as the baby’s father, their families, friends, or other mothers (Skinner et al., 2018).

Usefulness of health information

The information distributed by MomConnect, especially for first-time mothers, offered relief and guidance promoting healthier and less stressful pregnancies (Xiong et al., 2018). Many women using MomConnect reported high levels of satisfaction with the program with some wishing it extended beyond the first year of the baby’s life (Barron et al., 2016; Skinner et al., 2018). An analysis of a telephone survey of 10,000 MomConnect users found that 98% reported the messages sent to them were useful, 81% shared MomConnect texts with others, 77% felt more confident and prepared regarding delivery, and 70% requested more MomConnect messages weekly (Peter et al., 2015). The research found that end-users felt excited and empowered by messages (Skinner et al., 2018). Women also reported that messages regarding sensitive topics such as domestic abuse awareness made them feel supported (Skinner et al., 2018), extending MomConnect’s impact beyond just biomedical issues. The helpdesk feature was also used by many end-users to ask questions regarding maternal and child health outside the scope of the program, suggesting users wanted to learn more about their own health and the health of their baby (Xiong et al., 2018).

Limitations of MomConnect

MomConnect’s limitations include its high cost of maintenance, the USSD based system, and a lack of universal coverage. These limitations can threaten the future sustainability and scalability of MomConnect. There is also limited research regarding the health outcomes of MomConnect.

High maintenance costs

Although a USSD based-system has many benefits, including user-friendly navigation and the ability to be used on most types of mobile devices, it is expensive to maintain (Barron et al., 2018). The cost of the USSD system is billed to the service providers of MomConnect in order for MomConnect to be free of cost to end users. The system requires about US $1 million dollars annually to maintain; this cost threatens the future sustainability and maintenance of the program (Barron et al., 2018). MomConnect was created using a public-private partnership between South Africa’s National Department of Health and private companies, resulting in philanthropic donors providing MomConnect’s funding (Barron et al., 2018). This poses limitations to the program becoming nationally self-sustaining without the assistance of donors (Peter, 2018).

System technical issues

MomConnect’s simple USSD system also results in collected data to be limited to the gestational age, age of the end-user, identification of the end-user, the identification code associated with the facility they receive antenatal care from, and the language choice (Barron et al., 2018). This limits how detailed of a registry can be produced. Reports also indicate that the USSD-based system is vulnerable to network issues (Barron et al., 2018), such as failed sent messages, which has contributed to a 10% drop out rate (LeFevre et al., 2018), and late messages due to issues regarding reception (Skinner et al., 2018). To continue scaling up to achieve universal coverage of all pregnant women in South Africa, dropout rates must be reduced by improving network connections. A USSD-based system also limits messages to 160 characters, which hinders sharing more detailed or comprehensive information (Barron et al., 2016; Seebregts et al., 2018). One study also found issues regarding the accurate translation of messages into the Xhosa language. Poor accuracy in translation can impede the reach and effectiveness of the program (Skinner et al., 2018).

Lack of universal coverage

Although 90% of the population in South Africa has access to a cellphone, the remaining 10% of the population does not, and this latter group includes the poorest and most rural South Africans (Mehl et al., 2018). This reduces the ability to capture an accurate national registry; this inability is a significant problem because infant and maternal mortality rates are higher in poorer and rural regions. Although one of MomConnect’s fundamental missions is to be accessible to all women, one study found that rates of registration were low among some of the most vulnerable women including pregnant teens, pregnant older women, and women who found out about their pregnancy outside of a primary care clinic (Heekes et al., 2018).

Limited research data

There is limited data regarding health outcomes associated with using MomConnect; this limitation makes it difficult to conclude about the program’s effect on antenatal and maternal health in South Africa. Longitudinal studies following a cohort of pregnant women or randomized controlled trials to find associations and causations between MomConnect and facility improvements, maternal health outcomes, appointment adherence, and behavioural changes are needed. It is also important to study the impact of MomConnect nationwide, as well as regionally, as studies show that the rate of registration and usage of MomConnect can differ drastically between provinces (LeFevre et al., 2018).

Discussion

Impacts

Our review highlights that MomConnect has a large user group with over half a million users and overwhelmingly positive end-user feedback. In comparison to other mHealth applications for pregnant women, MomConnect has one of the largest numbers of active users. For example, the Motech mHealth application for pregnant women in rural regions of southeast Asia and Africa had about 30,000 users in Ghana and 100,000 users in India as of 2013 (Al Dahdah, 2017). Similar to MomConnect, Motech in Ghana caters to a diverse population as it is offered in regional languages (Al Dahdah, 2017). Our review also indicated that the majority of users had positive experiences using MomConnect. Similarly, an overwhelming majority of pregnant women in Kenya participating in a weekly SMS maternal health program viewed their experience with the mHealth application positively, as 92% of participants in a weekly SMS wanted to continue receiving text messages (Kazi et al., 2017).

Strengths

Studies identified in our review showed that MomConnect has several key strengths including easy-to-use features, high accessibility, and provision of useful information. The majority of MomConnect users who participated in the included research provided positive feedback due to helpful features in the application, such as the helpdesk, which allowed users to submit specific questions, feedback and complaints. Other popular mHealth applications for pregnant women do not always have these key features. For example, other mHealth applications in low-income countries typically include simple SMS or voice reminders (Feroz, Perveen, & Aftab, 2017) and may not have features such as a helpdesk. Results from studies of this review also showed that many users appreciated MomConnect’s ease of usage and felt empowered because they were able to register themselves. Similarly, users of Motech in India and Ghana reported having greater autonomy and independence, as they felt ownership over messages received over their own mobile devices. In particular, they felt greater autonomy because their mHealth application provided knowledge and education about their own health (Al Dahdah, 2017).

Although the majority of MomConnect users felt that the text messages were helpful, few studies showed a concrete association between MomConnect usage and improved health outcomes. Other studies of mHealth applications for pregnant women have, however, revealed that these cellphone applications may have direct positive outcomes on antenatal and postnatal health. In particular, one study revealed that mHealth interventions for pregnant women in low-income countries increased usage rates of healthcare services and vaccination rates of children (Sondaal et al., 2016). Another study revealed that these mobile applications can improve micronutrient intake, such as iron and calcium supplements, by helping track diet in pregnant women (Saronga, Burrows, Collins, Ashman, & Rollo, 2019). In addition, another study showed women who received SMS interventions had twice the odds of breastfeeding after birth compared to women who did not receive messages (Lee et al., 2016). Last, studies on Motech revealed that mHealth applications can help address cultural myths on practices surrounding pregnancy, such as cultural beliefs on breastfeeding frequency (Al Dahdah, 2017).

Limitations

Our review revealed that high maintenance costs, restrictions of using the USSD-based system, lack of universal coverage, and lack of research are key limitations of MomConnect. However, although our review suggested that the cost of maintenance can be a limitation of MomConnect, other research has indicated that mHealth applications for pregnant women may lower long-term healthcare costs. In particular, increasing health awareness for pregnant women may potentially aid in the prevention of complications through symptom education and decreased unnecessary doctor visits (Al Dahdah, 2017). Thus, long-term healthcare benefits may outweigh the short-term costs of maintaining mHealth software. However, studies of other mHealth applications suggested that cost to users may decrease the success of the program. For example, Motech in India charges users 1 rupee per text (Al Dahdah, 2017), which equates currently to 0.013 US dollars or 0.019 Canadian dollars. For women in poverty, weekly texts can, therefore, be unaffordable and charging end-users to engage in a program may not be an appropriate approach. 

Lack of universal coverage is an important limitation in many mHealth programs. Our findings also highlighted that approximately 10% of South Africa’s population does not have access to a mobile phone and that the majority of these people may be affected by poverty. Therefore, mHealth resources may not be universally accessible to some of the most vulnerable women. Similarly, a study of mHealth in Kenya revealed that women living in rural regions were less likely to have access to a phone (Kazi et al., 2017). In addition, women living in rural areas may be more likely to own basic phones that do not support smartphone applications, further limiting their accessibility (Al Dahdah, 2017). Furthermore, fewer women in rural regions in Asia and Africa own mobile phones compared to men (Al Dahdah, 2017). These authors highlighted that men may control cellphone usage in families that only have one mobile phone (Al Dahdah, 2017).

One limitation that was not reported in our review was the impact of cultural barriers on mHealth resources. Users of Kilkari in India and Mobile Midwife in Ghana reported that they sometimes felt that their mHealth application provided advice that was not in agreement with their cultural health beliefs (Al Dahdah, 2017). For example, text messages that inform women that a cultural belief is ‘wrong’ or is a myth may appear insensitive towards traditional customs. Thus, mHealth resources should be cognizant of their wording and aim to be culturally sensitive.

Future directions and implications

Based on the findings of this integrative review, some potential directions can help MomConnect secure sustainability in the future in South Africa’s national healthcare system. First, MomConnect needs to tweak its existing features such as the USSD system, which is prone to network issues (Barron et al., 2018), fix issues regarding the translation of messages into different languages (Skinner et al., 2018), and address delays in registration processes (LeFevre et al., 2018). Adding a triage system to the helpdesk feature that can detect sensitive and high priority messages, such as those relating to mistreatment in a healthcare setting or drug shortages, could be beneficial by rapidly identifying serious and avoidable risks to maternal health (Engelhard et al., 2018). Second, MomConnect can also expand to increase data registries and the types of data collected to create a more comprehensive registry. This can include creating a mHealth program that facilitates a data registry for children born to a mother using the MomConnect program. Universal registries are a useful tool for monitoring and storing large amounts of data within a system and may be used to monitor the progress towards the Sustainable Development Goals targets, such as those around maternal and child mortality rates. Third, it is important to establish legal guidelines regarding the privacy and confidentiality of the data to ensure the data are being accessed and utilized in an appropriate, ethical and legal manner. Future research regarding the use of MomConnect should explore the privacy implications of the program. Privacy concerns can revolve around maintaining end-user confidentiality and data security, as well as determining who will have access and ownership of data collected from MomConnect, especially of personal health information that can identify end-users. Fourth, due to limited existing research on the outcomes of MomConnect, further research should also focus on measuring and analyzing its ability to improve the health outcomes of end-users, improve patient care relationships, and positively impact health care management and research.

Since mHealth programs can be expensive to create, implement and maintain in low- to middle-income countries, multi-stakeholder partnerships with diverse partners from the public and private sectors may be developed to support MomConnect in the future (LeFevre et al., 2018; Peter et al., 2018). Indeed, the multi-stakeholder partnership used to develop and implement MomConnect has been credited with its success (LeFevre et al., 2018; Peter et al., 2018). However, it is important to recognize a reliance on multi-stakeholder partnerships and donor funding can impede the initiative’s ability to be nationally sustainable because donor funding can be reliant on political and economic factors that may change over time (Elbagir, Leposo, & Mackintosh, 2019). This is a critical aspect to take into consideration in the future by low to middle-income countries who choose to adopt a similar framework of MomConnect.

Limitations of this narrative review

Limitations of this narrative review encompass the quantity and quality of the research literature incorporated. A key limitation was that there was a finite amount of literature on the topic of MomConnect, with 14 papers fitting the criteria to be included in this review. Among the 14 papers, there was a lack of diversity regarding the types of papers, with most being either a cross-sectional study or editorials by expert opinions. Within the cross-sectional studies, common limitations included the inability to interpret causal relationships between MomConnect and outcomes, as well as small sample sizes and selection bias from how participants were chosen that reduced the generalizability of the data to the rest of the population. Within editorials, many were written by expert opinions associated with stakeholders in MomConnect project, including industry partners of South Africa’s National Department of Health, which raises the issue of the possibility of bias or conflict of interest. These limitations further highlight the need for more quantitative and qualitative research on MomConnect and its impacts.

Conclusion

MomConnect is a promising mHealth resource for antenatal and maternal health information. It has the potential to improve health outcomes for women in South Africa, although more research is needed. MomConnect has a number of key strengths and limitations. Users emphasized MomConnect’s simplicity, accessibility and usefulness in providing antenatal and maternal health information. Limitations included high maintenance costs, technical software restrictions, and a lack of universal coverage throughout South Africa. When these strengths and limitations are compared to other mHealth programs, stakeholders should also consider the cost to end-users and cultural sensitivity of health information. To improve engagement with these programs, and therefore their chances of success in changing health outcomes in developing countries with many women living in poverty, mHealth services should be free to end-users, have easy-to-use features, and deliver culturally sensitive messages.

Author Contributions: conceptualization, R.J. and P.Z.; methodology, P.Z.; validation, R.J. and P.Z.; formal analysis, R.J. and P.Z.; writing - original draft preparation, R.J. and P.Z.; writing - review and editing, Y.H. and L.J.; supervision, P.Z.

Funding: This research received no external funding.

Conflicts of Interest: The authors declare no conflict of interest.

The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.