Can text messages improve postpartum care?
Promising evidence from four Indian states.
“Can educational text messages delivered to families meaningfully increase recommended care practices for newborns and postpartum mothers?”
This was the question that Jamie Sewan Johnston, Shirley Yan, and their co-authors set out to answer in a study that ran from March 2021 to January 2022 in four Indian states. Johnston is the research and evaluation director for Digital Medic at the Stanford Center for Health Education; Yan is the associate director of learning and evaluation at Noora Health.
The results of the research, recently published in the Bulletin of the World Health Organization (WHO), suggest that postnatal messaging can build effectively on other forms of health education. Mothers who received the intervention — text messages promoting WHO-recommended practices in their first six weeks postpartum — were more likely to report using many of those practices, including breastfeeding, skin-to-skin care, and better cord care, as well as nonrestrictive maternal eating and drinking.
India has especially high rates of neonatal and maternal mortality, most concentrated among the country’s poorest households. Despite recent improvements following sustained national and state efforts, the subcontinent contributes a quarter of global newborn deaths. The growth of smartphone use in India across all demographics presents an opportunity to bring health information into low-resource settings. Families in the study mainly had low and middle incomes, with close to 6 in 10 owning a ‘below poverty line’ card. Fewer than half owned a refrigerator and fewer than a fifth owned a washing machine. For many, the mobile phone enrolled in the texting program was the only phone in the house.
In this interview, Johnston and Yan discuss what motivated their research, how they designed the study, their principal findings, and the implications for healthcare policy and practice.
Prefer reading? Find the full transcript below.
0:23 | Introductions
Shirley: My name is Shirley. I’m the associate director for learning and evaluation at Noora Health, and part of that position is to think about the impact of our programs. In Noora Health, one of the big things that we’re trying to think about is caregiver education and how do we pull in and involve family caregivers so that they’re part of the formal healthcare process?
They are the ones who are loving and caring for patients, both in the hospital and at home, but often aren’t given the opportunity to really show up in the most effective way possible.
Jamie: Hi, my name is Jamie Johnston and I am the research and evaluation director for the Stanford Center for Health Education at Stanford University. Our center’s Digital Medic initiative focuses on efforts to ensure that all communities have access to engaging and evidence-based health information.
Research and evaluation are really central to this mission to understand, broadly speaking, how health, education, digital and otherwise — but increasingly digital with advances in technology — can be scaled effectively and cost-effectively across contexts.
1:24 | What critical gaps in postnatal care in India motivated this research?
Shirley: We know that families need help and support when they are discharged from the hospital, especially when they’re at home. Some families aren’t able to return to the health facility because of distance or resources that are available to them or even their relationship to the formal healthcare system.
So, providing another resource that they can access through their phones is really important. Understanding how a digital health service like the Mobile Care Companion Program can fill in those gaps becomes really important and critical. I think in global health there’s always a question about resource utilization. Where does it make sense for governments and the larger community to invest resources?
So it’s really important that we answer the question of whether any intervention is really filling the gap that we hope it’s filling to improve health outcomes for moms and babies postpartum.
Jamie: One thing I’ll just add is that we know from the research literature that just-in-time information, really timed for the moment at which new parents and caregivers need that information, is critically important.
With the proliferation of mobile services and WhatsApp, it’s really an opportune time to try to test providing that information at the moment that families are in need.
2:44 | Tell us a bit about the study: What were you investigating, with whom, and how did you design the study?
Shirley: We had partnered with four Indian states — Madhya, Pradesh, Maharashtra, Karnataka, and Punjab. We looked at 25 facilities across these four states and really tried to understand: If we randomized which facilities received the Mobile Care Companion Program and which ones didn’t and just had the in-facility Care Companion Program component, what do we see in terms of knowledge change, behavior change, and other health outcomes as well?
Jamie: In the context of this study, I’ll just add that we looked at this in the maternal child health context. These were newly-delivering mothers who were having infants in the hospital and then attending these in-person sessions along with other family members, family caregivers, which often included fathers, maternal paternal grandmothers. The Mobile Care Companion was then a service that was provided for six weeks following discharge from the hospital after the birth of the baby. It gave key information on infant and mother caregiving practices. Those covered encouragement of exclusive breastfeeding, best practices with cord care, how to deal with fevers, when to vaccinate, and other key caregiving information.
4:03 | What were the principal findings, and what stood out to you as the most significant or impactful?
Jamie: We looked at self-reported measures from mothers at the follow-up point, around 6–8 weeks after discharge from the hospital. It was really notable that we saw impact across many of the different types of caregiving practices for infants, including breastfeeding, best practices in core care, as well as skin-to-skin care practiced by mothers, and also significant impact on the best practices for maternal nutrition and postpartum.
One of the notable things that we also saw was that there was active engagement among family caregivers as part of this intervention. So among nearly a fifth of households receiving the intervention, we actually observed that a family caregiver was the one that was initiating enrollment in the service itself. We also observed a significant increase in the practice of skin-to-skin care among fathers as well.
Shirley: Just to add to what Jamie was sharing: The future of the Mobile Care Companion Program is that we have medical support executives and a larger team of doctors and nurses and translators who answer questions when people ask them. It’s not just us sharing information and content. When people are confused about what they should do, or something that’s happened, or can they really eat something or do something — we’re answering those questions.
But actually, not so many people were using the question-and-answer function. While it is an opportunity for us to think more about how to increase that type of engagement on the Mobile Care Companion Program, it is also an interesting point of view, because it means that we were able to see such promising results with such low engagement on the Q&A function. So, how do we think about using the medical support executives to really serve families who really need it, and triage them more effectively in the future?
Jamie: And I can just add to that, this is an area we’re really looking at for the future. While the interactivity was minimal, what we’re thinking about is who are those families, who are those individuals who really are utilizing that interactive service. They may, in fact, be families that are more at risk or have more risk factors that they need to be initiating more support for triage.
What we’re trying to think about is how we can actually leverage the service to be better able to react to those questions and get those kinds of lifesaving information out to families or mothers and babies.
6:34 | Were there any limitations you encountered?
Shirley: One of the evergreen challenges that we face when it comes to research at Noora Health is how to balance wanting to generate really rigorous evidence with the fact that we’re also scaling and implementing organization.
One logistical challenge was that we were only able to include so many facilities as part of this [study], which can limit the power in terms of the effect size that we were able to see for the study. That balance is always going to be there. As much as I’d love if we had infinite resources, we could always be doing evaluations, but unfortunately, that’s not practical, with the government stakeholders we’re working with. Their timelines are always, “Please implement this right away.” So that’s one of the challenges that we faced in the study.
7:18 | How do you see these findings influencing healthcare policy and practice in India and globally?
Jamie: One of the incredible strengths of Noora Health is the diverse network of government partners involved in implementation and research. And really, the ability to work with these government partners to share key findings and promote the types of care and investments that will allow us to see this type of impact. These findings really speak to the future direction of how to evolve the Mobile Care Companion Program to really reach even beyond the impacts that we’re already seeing.
This work also informs work outside the Noora Health context as well, particularly for the Stanford Center for Health Education, on how we think about deploying education resources in the community health setting. And broadly, how can we leverage new digital technologies to get people the information they need? So I think this [study] is very impactful for the field.
Shirley: We, as a community, we need to know more about what’s working and what’s not. Especially in this day and age, where the types of resources that are available for global health programing are more and more either under scrutiny or it’s difficult to secure funding for. When we do have the opportunity to evaluate and to share, we definitely should take that.
And when we think about AI, for example, technology is just going to become a greater part of how our world looks like. And so we as a community need to be better informed about what’s working and what’s not.
8:48 | What key research questions emerge from this work that would be important to address next?
Jamie: We alluded to this before, but really we’re trying to think about how to optimize and improve the mobile messaging service to better serve at-risk mothers and babies. Currently, the service is limited with respect to scale and content delivery, but we are thinking innovatively and the Noora Health team is thinking about how to develop that kind of capacity to really not only improve the service, but to scale it widely across multiple countries.
The team is already exploring how different GenAI tools can be used to expand this capacity and improve the services.
Shirley: One thing that we know is a big part of the families that we work with — but couldn’t really focus on in the study — is the question of phone ownership and how that looks within families. Phones, especially in India, and other countries that we work in, are often shared.
It’s not just one member who has it all the time, but maybe a different person in the morning, in the evening. Understanding how information gets shared will help illuminate what our intervention can look like going forward. And another question, which is always a challenge when thinking about scale is: This worked well in India, but how does this work in other countries or other contexts as well? Maybe that’s not necessarily research we do, but other research that other partners might think about and take on.
Jamie: So we encourage you to check out our full set of findings in our paper in the Bulletin of the World Health Organization.
Shirley: And if you want to engage more, please reach out to either Jamie or me. We’d love to interact and engage more on this topic.
This video was made possible with brand and design support from Rohina Thapar; production and editing support from Rachana Deshpande and Abhijit Sarker Arka; and overall production support from Jenny James Robinson, Kelly Hagler, and Tanaya Jagtiani — thank you!
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