Strengthening the extension of RMNCH services in Bangladesh with an electronic health registry: A cluster randomized controlled trial

Bangladesh has made great progress in addressing high maternal and child mortality over the last decade. Still, major gaps exist in the quality of care for mothers and their children. Electronic health registries, eRegistries, for women and children gather information on their health, and on essential care being provided to them. eRegistries can integrate multiple digital health interventions (DHIs) such as clinical decision support at point-of-care to contribute to the quality of care; health care performance dashboards for monitoring quality; and individualized communications using SMS messaging to empower clients and improve uptake of care. Building on the eRegistries framework, we worked in Matlab, Chandpur, Bangladesh, with the following objectives: I) To identify gaps in uptake and coverage of quality care, and in data flow for coordination and monitoring of care, as well as the corresponding DHIs that could support care in an eRegistry. II) To co-design an eRegistry with users, and implement it in the health system of Matlab to both track women and children in the continuum of care, and offer DHIs in support of the care providers and their clients. III) To undertake a randomized study of the effectiveness of the eRegistry in improving quality of health care provision and care seeking behavior to improve health of mothers and their newborns. We identified significant gaps in the uptake of public health care. Among 3284 pregnant women, utilization of timely first antenatal care (ANC) was 59% and as low as 4% for the recommended four ANC visits. While timely first ANC utilization was associated with several socio-economic factors, none were associated with subsequent uptake of four visits ? rather, there was a steady flow of clients from the public sector to the private sector with advancing gestational age. In-depth interviews revealed a low understanding of the purpose, timing and benefits of antenatal care in the population - the majority seeing visits only as a need if experiencing complications, not as a beneficial preventive health program. We designed and implemented an eRegistry for four cadres of workers at three clinic types and in the community, across two different arms of the Ministry of Health. The system was designed based on extensive interviews at all levels of the health system, and tested with intensive field-testing. We undertook a cluster-randomized controlled trial with an intervention arm using the eRegistry with three superimposed data-driven DHIs: i) health worker clinical decision support, ii) health worker feedback dashboards with action items, and iii) targeted client communication to pregnant women. Outcome measures on attendance, quality of care, and maternal and newborn health have been collected through the eRegistry and interviews of women after delivery. Recruitment ended in June 2020 due to futility to reach the intended sample size during the Covid-19 pandemic. Follow-up (5380 women) was concluded in February 2021. The trial is registered as ISRCTN69491836 and results are under analysis.

We have leveraged extensive Norwegian development investments in innovative DHIs built on the globally leading open source DHIS2. We have systematically shared incremental system improvements and implementation experiences back to the source code and the global implementer community. DHIS2 eRegistries are now being deployed to support health systems in maternal and child health, immunization, tuberculosis, and child nutrition programs, and more, in multiple low- and middle-income countries. This project is poised for high scientific impact, as it responds directly to high priority research questions from the WHO Guideline: Recommendations on Digital Interventions for Health System Strengthening. The guideline recommends both registry based systems for decision support and targeted client communication, but recognizes the weak evidence and has called specifically for more research on effectiveness and implementation considerations - both of which this project is responding to.

In this game changing project for reproductive, maternal, newborn and child health (RMNCH), we utilize a proven model for improving RMNCH public health in Matlab, Bangladesh, and strengthen it with mHealth innovations with an electronic maternal and child health registry as the backbone, integrated in the national DHIS2 health information system. The mHealth solutions will address bottlenecks in provision of universal health coverage for mothers and children, such as information continuity across care levels and providers, training and decision support in the health system, reduction of health inequities and women lost to follow up, demand creation and care reminders, and individualized education of women with behavior change communication. We will provide the highest level of scientific evidence for its efficiency through a cluster randomized controlled trial (RCT). The partners of this proposal combine a long pedigree of successful implementation of DHIS2 health information systems in 46 countries (Univ. Oslo, Norway), with scientific excellence in intervention sciences for maternal and child health, and more than 50 years of local research and implementation know-how in Bangladesh (International center for diarrheal disease research (icddr,b)). Bridging scientific excellence with a sustainable systems approach, we partner closely with the Bangladeshi Ministry of Health, recipients of a 2011 United Nations award for their work in digital health. In this rich milieu of international scientific excellence, innovation and implementation, PhDs and PostDocs will benefit from prolonged stays in partner institutions for mutual capacity building. Not only is this systems approach to technology innovation for maternal and child health highly prioritized by Globvac, but the trials will directly respond to the specific needs of Bangladesh in capacity building for mHealth, and support the national plans of Bangladesh to develop maternal and child health registration in DHIS2.