mLearning in the DR Congo A Mixed Methods Feasibility and Pilot Cluster Randomized Trial using the Safe Delivery App

Authors: Nancy E. Bolan (PI) Larry Sthreshley Faustin Ledy Davis Makasy Bernard Ngoy IMA World Health Kinshasa, DR Congo

Background: Sub-standard delivery care widely documented as a major cause of maternal mortality in health facilities. The Democratic Republic of Congo (DRC) has one of the highest maternal mortality ratios worldwide (846 maternal deaths per 100,000 live births). Little evidence of mLearning effectiveness.

Aims To assess the feasibility, acceptability, and potential impact of using a recently developed evidence-based mLearning app (Safe Delivery App, Maternity Foundation) © (SDA) with health workers providing Basic Emergency Obstetric & Neonatal Care (BEmONC) in health care facilities.

Health Center Kasuku II, Kindu, DRC

Methods In 2 health zones of central DRC, 8 facilities were randomized to either an mLearning intervention or to standard practice (control) from April - July 2017. Conducted with the DRC Ministry of Health and civil society. Knowledge in post-partum hemorrhage (PPH) and neonatal resuscitation (NR), as well as provider self-confidence in managing obstetric complications were assessed at baseline and at 3 months post-intervention.

Methods (cont’d) The PI conducted 18 interviews with app users and key stakeholders to assess feasibility and acceptability of mLearning and the use of the SDA in the context of central DRC. Maternal mortality was compared pre-and-post intervention between intervention and control facilities using a smartphone-based Open Data Kit (ODK) data application designed for this study.

Safe Delivery App: A training resource for emergency obstetric and neonatal care with visual guidance using animated videos and clinical management instructions. A training tool and job aide developed by the Maternity Foundation, University of Copenhagen, and the University of Southern Denmark.

Interventions Health workers in intervention facilities were trained on the use of a smartphone, the SDA, and the ODK data collection instrument. The French translation of the SDA was tested in this study. One smartphone with SDA and ODK was entrusted to each intervention facility for the study period, whereas control facilities received smartphones with ODK only.

Measures Primary outcomes were provider knowledge of clinical signs and management of PPH and of NR, and self-confidence on the provision of BEmONC services, before the intervention and after 3 months. Secondary outcomes included maternal mortality and other key outcome data in the facilities, and qualitative interview findings. Eighteen qualitative interviews were coded using the Theoretical Domains Framework.

Quantitative Results Quantitative analysis included 62 heath workers. Knowledge scores for PPH and NR increased significantly from baseline among intervention group participants compared with controls at 3 months post-intervention (mean difference, 17.4 out of 100; 95% CI, 10.7-24.0 and 19.4; 95% CI 11.4-27.4 respectively).

Quant results (cont’d) Self-confidence scores on 12 essential BEmONC procedures also significantly improved among intervention group participants compared with those of controls at 3 months (mean difference, 4.2 out of 48; CI 0.7 – 7.7). Increases were unaffected by health worker cadre, previous smartphone use, or provider gender.

Qualitative results Qualitative interviews with 18 SDA users and key stakeholders supported the feasibility and acceptability of the SDA and mLearning. Supported the potential for it to impact maternal and neonatal mortality in the DRC, in terms of making evidence-based, up-to-date global BEmONC guidelines available to health workers via an exciting mLearning app.

Conclusion SDA use and mLearning was feasible and acceptable to health workers and key stakeholders in the DRC. The app supported increased health worker knowledge and self-confidence in the management of obstetric and newborn emergencies 3 months after introduction, and it indicated preliminary encouraging effects on health workers’ BEmONC practices.