Maternal and Child Health Journal

, Volume 16, Issue 5, pp 1092–1101

Special Delivery: An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World

Authors

    • Healthcare Innovation and Technology Lab
    • Indian Institutes of Technology
    • Healthcare Innovation and Technology Lab
Article

DOI: 10.1007/s10995-011-0836-3

Cite this article as:
Tamrat, T. & Kachnowski, S. Matern Child Health J (2012) 16: 1092. doi:10.1007/s10995-011-0836-3

Abstract

Mobile health (mHealth) encompasses the use of mobile telecommunication and multimedia into increasingly mobile and wireless health care delivery systems and has the potential to improve tens of thousands of lives each year. The ubiquity and penetration of mobile phones presents the opportunity to leverage mHealth for maternal and newborn care, particularly in under-resourced health ecosystems. Moreover, the slow progress and funding constraints in attaining the Millennium Development Goals for child and maternal health encourage harnessing innovative measures, such as mHealth, to address these public health priorities. This literature review provides a schematic overview of the outcomes, barriers, and strategies of integrating mHealth to improve prenatal and neonatal health outcomes. Six electronic databases were methodically searched using predetermined search terms. Retrieved articles were then categorized according to themes identified in previous studies. A total of 34 articles and reports contributed to the findings with information about the use and limitations of mHealth for prenatal and neonatal healthcare access and delivery. Health systems have implemented mHealth programs to facilitate emergency medical responses, point-of-care support, health promotion and data collection. However, the policy infrastructure for funding, coordinating and guiding the sustainable adoption of prenatal and neonatal mHealth services remains under-developed. The integration of mobile health for prenatal and newborn health services has demonstrated positive outcomes, but the sustainability and scalability of operations requires further feedback from and evaluation of ongoing programs.

Keywords

mHealthPrenatalNeonatalMobile technologyMaternal

Introduction

The global proliferation of mobile technology has generated a new tool to address public health challenges and shift the paradigm of health care access and delivery. According to the International Telecommunications Union, mobile coverage has increased to reach 90% of the world’s total population and 80% of the global population living in rural areas [1]. The growing ubiquity and penetration of mobile phones has helped fuel the initiation of mobile health (mHealth), the integration of mobile telecommunication and multimedia into increasingly mobile and wireless health care delivery systems [2, 3]. Mobile phones, in particular, are thriving in resource-limited health systems despite the scarcity of other technologies and infrastructure; the organic permeation offers new means to address health needs, particularly in the global south [310].

This article examines the use of mHealth along three stages of the continuum of care for maternal, newborn, and child health (MNCH) as defined by the World Health Organization (WHO). The MNCH consists of a comprehensive trajectory for the health needs of women and children beginning with adolescence/pre-pregnancy to the postpartum and maternal phase of the mother; among children, the continuum commences with the neonatal period and extends through infancy and childhood (Fig. 1) [11]. Specifically, this study focuses on the modalities and limitations of mHealth interventions that target the prenatal and neonatal components of the continuum, covering the period from conception to 28 days following birth. It represents a critical window in which up to 75% of maternal and 70% of newborn mortality could be averted, respectively, through comprehensive and evidence-based interventions [7].
https://static-content.springer.com/image/art%3A10.1007%2Fs10995-011-0836-3/MediaObjects/10995_2011_836_Fig1_HTML.gif
Fig. 1

Applications of mHealth along the “Continuum of Care” for maternal and newborn health from both patient and health worker perspectives

Previous studies have highlighted the ways in which mHealth can improve health information systems and bolster health services including treatment adherence, disease surveillance, emergency medical response, health promotion, and point-of-care support [3, 7, 12]. In addition, there is substantial literature linking mHealth with the Millennium Development Goals (MDGs), the United Nations-endorsed global targets for health and development indicators to be achieved by 2015 [3]. Studies demonstrate that leveraging mHealth can be an effective strategy for MDG targets 4–6, which aim to reduce child mortality; improve maternal health; and combat HIV/AIDS, malaria, and other diseases [3, 1316]. Moreover, the slow progress and funding constraints in achieving the MDG targets for child and maternal health have stimulated the use of mHealth for these public health priorities [3, 4, 1316]. Despite this escalation, few studies have focused exclusively on mHealth’s use in the prenatal and neonatal arena.

Methods

To identify discussions of the implementation of mHealth for prenatal and neonatal healthcare, we conducted an electronic literature review in December 2010 of six databases: Google, Google Scholar, PubMed, Web of Science, Science Direct and ProQuest. Both authors contributed to selecting search terms that would incorporate mHealth and maternal and newborn topics, including keyword combinations of “maternal,” “mobile,” “technolog*,” “informatics,” “health,” “eHealth,” “mHealth,” “ICT,” “tele*,” “newborn,” “neonatal,” “antenatal,” and “prenatal.”

The authors limited the review to English-language peer-reviewed articles, presentations, and institutional reports published between 2000 and 2010, which yielded a total of 1,538 possible documents for review (Fig. 2). The primary author reviewed all document titles based on inclusion/exclusion criteria pre-determined by both authors. The exclusion criteria filtered out articles with titles that referred to genetics, fetal exposure to mobile phones, or pertained exclusively to eHealth, telehealth, and non-mobile forms of information communications technology (ICT.) Eligible articles were included for review only when abstracts contained explicit information about the uses of mobile technologies in maternal and newborn health or in reference to the MDGs. Researchers also scoured reference lists to identify other papers that fit the inclusion criteria.
https://static-content.springer.com/image/art%3A10.1007%2Fs10995-011-0836-3/MediaObjects/10995_2011_836_Fig2_HTML.gif
Fig. 2

Literature review search results and exclusion criteria

The primary author extracted information from eligible articles to identify the following details for each study: target population, geographic location of the intervention, maternal and/or newborn health need addressed, health indicators assessed, financing scheme for implementation, and limitations and strategies for the sustainable integration of the mobile technology. The information was then classified by the primary author according to themes identified in policy papers [24, 7, 12].

Results and Discussion

In total, 34 articles satisfied the inclusion criteria, which included studies with quantitative (n = 4), qualitative (n = 26), and mixed (n = 4) designs (Fig. 2). The articles revealed specific evidence of the impact of mobile technologies on prenatal and newborn health needs (Table 1) or highlighted the best practices and impediments for sustaining such mHealth activities.
Table 1

Implementation overview of mHealth interventions focusing on prenatal and newborn health (listed by appearance in article)

mHealth function

Location

Intervention

Target population/size

Findings

Funding

Emergency medical support

Rural northwest Bangladesh

Observational study among families who own mobile phones

11,451 families with mobile phones

55% of families used mobile phone for pregnancy emergencies, of which 72% called a health provider, 57% asked for medical advice, 33% arranged transport, 21% asked for financial aid [Unpublished data]

Johns Hopkins University [5]

Emergency medical support/Health promotion

Dangme West District, Ghana

Provision of mobile phones and phone credit

21 health professionals; 7 community health volunteers; 30 pregnant women and recent mothers interviewed

Program not yet evaluated but pre-intervention research indicates mHealth can expedite emergency obstetric referrals; mHealth can promote prenatal behavior changes among expecting mothers

Bill and Melinda Gates Foundation [7]

Emergency medical support

Brikama, The Gambia

Provision of mobile phones and phone credit

83 Traditional Birth Attendants; 48 volunteer health workers

Facilitated emergency referrals; shortage of skilled health professionals and funds for emergency transport challenged sustainability

World Health Organization [20]

Emergency medical support

Iganda District, Uganda

Provision of walkie-talkies and tricycles

Catchment population of 6 health units and 1 referral health unit. 5 midwives; 10 traditional birth attendants; 3 project administrators; 4 women of reproductive age interviewed

Increased referrals, maternal mortality ratio decreased by 50% in 3 years; challenges in emergency transport

World Bank [22]

Emergency medical support

Madya Pradesh, India

24-h obstetric help lines, health workers using community members’ mobile phones and logistical resources

Community members and health workers

24-h obstetric help lines in previous pilot programs contributed to reducing delays associated with deciding when to seek medical care, identifying health facilities for appropriate services, and care delivery

UNICEF [7, 26]

Point-of-care support

Muzaffargarh & Chakwal, Pakistan

Provision of mobile phones and phone credit

242 community health workers

Not yet studied; expected to increase emergency obstetric referrals

GSMA Development Fund and UNFPA [21]

Point-of-care support

Remote Locations, Pakistan

Toll-free interactive voice response service

Community health workers

Not yet studied; application still under development

Microsoft Research [23]

Point-of-care support/data collection

Aceh Besar, Indonesia

Provision of mobile phones and phone credit

123 midwives; 15 midwife coordinators

Midwives with mobile phones more likely to turn to health center personnel for medical advice; increased confidence in accurate data collection and storage

World Vision [24]

Point-of-care support

Aceh Besar, Indonesia

Provision of mobile phones and phone credit

224 midwives; 15 midwife coordinators

Increased communication flows and knowledge-seeking behavior among midwives with mobile phones; challenges in sustaining financial cost of mobile credits

World Vision [27]

Health promotion

Serbia

Automated SMS-based prenatal health support based on pregnancy stage

3,200 pregnant women (as of 2007)

No outcomes research available

European Union and National Ministry of Health [7]

Health promotion/data collection

Zanzibar, Tanzania

Provision of mobile phones and phone credit; SMS-based prenatal health support

2,400 pregnant women

Increased odds for skilled delivery attendance and prenatal care visits among pregnant women with mobile phones

DANIDA [25]

Health promotion/data collection

Thai/Myanmar Border, Thailand

Automated SMS-based reminders for prenatal care visits

280 pregnant women

Increased odds for on-time prenatal care visits among women who received reminders

Thailand Ministry of Public Health [29]

Health promotion/data collection

Bangkok, Thailand

SMS-based prenatal health support

68 pregnant women

Pregnant women who received SMS had increased satisfaction and confidence in health workers during delivery

Mahidol University [30]

Data collection

Ucayali, Peru

Provision of smartphones to collect and communicate data among health workers

Outreach health workers; medical experts

No outcomes research available

USAID [4]

Data collection

Haryana, India

Provision of handheld computers to collect data on immunization, prenatal care visits, and demographic changes

Outreach health workers

No outcomes research available

Dimagi, Media Lab Asia, All India Institute of Medical Sciences [7]

Data collection

Andhra Pradesh, India

Provision of handheld computers to collect and monitor nutrition, maternal and child health activities

800 rural outreach workers, 250 frontline health workers

No outcomes research available

UNICEF [16]

Accordingly, the findings of this review first describe the outcomes of mHealth prenatal and neonatal programs implemented across the globe (Fig. 3). The studies are organized according to common functions of mobile technologies identified in previous studies [24, 7, 12] as the following:
https://static-content.springer.com/image/art%3A10.1007%2Fs10995-011-0836-3/MediaObjects/10995_2011_836_Fig3_HTML.gif
Fig. 3

Geographic coverage of prenatal and neonatal mHealth programs featured in literature review

  • Emergency medical response

  • Point-of-care support

  • Health promotion

  • Data collection and management

Secondly, the literature review examined barriers and strategies as they relate to the following themes for operationalizing mHealth interventions, as identified in previous studies [2, 4, 12]:
  • Financial issues

  • Policy frameworks

  • Socio-cultural context

Impact of mHealth on Prenatal and Neonatal Health Outcomes

Emergency Medical Response

Studies show that mHealth tools can help minimize time barriers and facilitate urgent care during emergency obstetric referrals [7, 12, 14, 1726]. One of the earlier reports supporting this observation involved the Rural Extended Services and Care for Ultimate Emergency Relief (RESCUER) program launched in 1996 in rural Uganda [22]. The program trained community-based volunteer Traditional Birth Attendants (TBAs) on the signs and protocols for pregnancy complications and equipped them with walkie-talkies linked to health units, along with basic clinical obstetric instruments. Upon the recognition of delivery-related challenges, TBAs used the walkie-talkies to notify referral health centers for emergency transport [22]. Following this comprehensive intervention, the maternal mortality rate in the study locations decreased by approximately 50% due to increases in referrals to health facilities, although the study author cited some logistical issues, which may have compromised the study outcomes [22].

According to a presentation by Labrique, the Johns Hopkins-sponsored “JiVitA” program in rural Bangladesh linked the use of mobile phones with pregnancy-related complications. Researchers found that 55% of families who had phones used them during emergencies: 72% of those families contacted a healthcare provider, 57% sought medical advice, 33% arranged transport, and 21% asked for financial support [5(unpublished)].

Other reports point to the breadth of possible implementation schemes, but reveal the complexity of improving processes and obtaining outcomes data. Emergency services departments in the Gambia furnished mobile phones to TBAs and outreach workers trained to recognize pregnancy complications and refer women exhibiting signs of obstetric complications [20]. Health records from the project indicate improvements to the emergency response system in which 101 pregnant mothers and newborns received critical assistance between May 2007 and March 2010 [20]. However, the article does not provide details on the percent change and mentions that challenges such as the shortage and low morale of health workers at facilities and unreliable transportation services diminished the efficacy of the program.

A UNICEF-funded program in Madhya Pradesh, India offered pregnant women a health telephone helpline, complimentary ambulance system, and drivers equipped with mobile phones in the effort to reduce delays in seeking obstetric care [7]. Although the literature did not render any project evaluations, qualitiative evidence from pilot programs in similar locations in India demonstrated that 24-hour obstetric mobile-phone-based helplines mitigated delays associated with deciding when to seek medical care, identifying appropriate health facilities, and receiving treatment [7, 26]. These studies also cited the need for improved household-level awareness of pregnancy complications and upgraded capacity of health facilities to provide critical services such as blood transfusions [26]. Similarly, the Kenyan Ministry of Health has implemented a mHealth program to enable communication and promote institutional deliveries and referrals [7]; however, the program is in the pilot stage and did not offer project assessment reports to be included in this review.

These studies also demonstrated that it is not sufficient to just distribute cell phones; successful programs incorporate a comprehensive approach that also addresses logistical and human resource constraints. For example, all of the aforementioned initiatives provided mobile communications tools as part of a broad emergency maternal health response strategy that included training on the early detection of pregnancy risks and the provision of transport facilities to minimize logistical barriers [7, 20, 22, 26]. However, researchers of the interventions in Uganda and the Gambia reported that unreliable emergency transport, coupled with poor quality of services at health facilities, compromised the health outcomes.

Point-of-Care Support

Health systems are also leveraging mHealth to address the low coverage of qualified health personnel and alleviate the professional seclusion of mid- and low-level health workers delivering care with minimal guidance [3]. WorldVision’s 2005 mobile-midwives project in Aceh Besar, Indonesia, presents evidence on healthcare providers using mobile technology to bolster point-of-care support [24, 27]. This program equipped midwives with mobile phones and phone credit to consult with specialists while providing obstetric care in remote locations [24]. Findings highlighted the strengthened capacity of midwives to address more complex cases, and improved collaboration with both patients and the health professionals based at referral sites [24, 27]. Midwives demonstrated a statistically significant increase in their confidence to solve challenging health problems (p < 0.10). In addition, midwives with mobile phones had more frequent consultations with experienced health staff (p < 0.10) and access to medical information from facility-based health personnel (p < 0.10) [27]. Qualitative evaluations of this project also substantiated the increased confidence in accurate data management and more attuned knowledge-seeking behavior among midwives equipped with mobile phones [24].

Similarly, Global System for Mobile Association (GSMA) documented the use of mobile technology among community-based “Lady Health Workers” in Pakistan who utilize handsets to contact supervisors for consultation and timely referrals of emergency cases [21]. Also for use in rural Pakistan, Microsoft Research is devising toll-free voice response mechanisms for health outreach workers with low literacy to reinforce their limited training when delivering health services in remote locations [23]. Both programs in Pakistan are in their infancy and have not produced conclusive evidence on attaining their objectives.

Health Promotion

mHealth also supports the exchange of information for health promotion, often through an asynchronous modality [28] that generates short-message service (SMS) to expecting mothers [25, 29, 30]. Thailand’s “Better Border and Healthcare Program” disseminated information via SMS regarding antenatal care appointment visits and the expanded program on immunization (EPI) for women along the Thai-Myanmar border [29]. After this intervention, Kawekungwal et al. [29] reported that the odds of on-time antenatal visits and EPI increased by 1.91 and 2.13, respectively, for mothers enrolled in the program. Similarly, the “Wired Mothers” project in Zanzibar, Tanzania employed mobile phones to link pregnant women with health units, send reminders on antenatal care appointments, and faciliate access to skilled attendants for obstetric care [25]. Preliminary data indicates 42% of the pregnant women with mobile phones called their midwives, and the group’s odds for skilled delivery attendance and antenatal care visits increased [25].

In addition, a randomized controlled trial in an urban hospital in Thailand researched the emotional health of women who received SMS-based guidance throughout the course of their pregnancy [30]. The findings of the study revealed that pregnant women receiving messages during the prenatal period were significantly less anxious and felt more confident about health workers at the time of delivery (p < 0.05); however, there were no significant differences on the pregnancy outcomes of the two groups [30]. Lastly, an overview report identified the Beba Dolazi program in Serbia, which sends weekly health education messages via SMS to pregnant women on based on the progression of their pregnancy [7], but this study could not retrieve information on the health outcomes of women enrolled in the program.

Data Collection and Management

The introduction of mHealth has also improved mechanisms for data collection and management. Often, health workers collect data in tandem with the delivery of other health services such as the execution of referral care and immunization programs [4, 18, 29, 30]. For example, in the prenatal health promotion programs in Tanzania and Thailand, SMS services were linked to central health data systems that contained records of pregnant women and their weekly progression [25, 29, 30]. In Haranya, India, outreach workers used handheld computers to collect data on immunization records, prenatal care schedules, and routine demographic information that fed into centralized electronic health records for easy access by rural paramedics [7]. By entering the household number, frontline nurses could track and respond to the health needs of individuals within the identified household [7]. Midwives in Indonesia [7, 24] and outreach workers in Peru [4] also collected patient information and communicated it to databases at medical facilities in order to expedite the ability of health professionals to monitor progression and prescribe therapy, even though they were physically separated from patients.

The UNICEF-funded Sisu Samrakshak (SSK) program in Andhra Pradesh, India, which has been running since 2000, also exemplifies the incorporation of data management into primary health care services using mobile technology [16]. This initiative equips frontline “Anganwadi” workers with handheld devices that monitor the health development in their catchment area and communicate the data to the nearest rural health centers. Subsequently, the same mobile device disseminates necessary information related to topics such as pregnancy, nutrition, and immunizations [16], although the literature did not provide any outcomes data.

Barriers and Strategies in Integrating mHealth for Maternal and Newborn Health Services

Financial Issues

The financial considerations of implementing mHealth programs pose some barriers for their sustainable integration. One major challenge is the cost to both pregnant women and local health workers, as studies indicate that mobile communication fees may be prohibitive and discourage users to continue with introduced mHealth services [20, 24, 27, 31]. Health systems have to negotiate the financial implications for all stakeholders, including platform providers, government bureaus, donors, and end users who all participate in evaluating the returns and value of the mHealth service [2, 31, 32]. Vital Wave Consulting examined these sets of financial relationships and elucidated on value chain models that outlined incentives for various actors, including the patient, mobile subscriber, health care provider, foundation, equipment provider, and government [4]. According to this value chain model, low-scale operations pose greater financial costs because there is a limited volume for diffusing the fees from private telecommunications businesses [4]. However, the financial inputs are less intensive for one-way SMS-based activities because they primarily require an initial investment with a relatively low and stable operational cost, regardless of the scale of the program [4].

Ideally, initiatives that offer the potential to maximize volume and scalability can better distribute the costs by increasing users, thereby optimizing the returns among stakeholders [4]. As such, interventions require thorough financial analysis to ensure that the target populations of mothers and health personnel have access to the mHealth services using tested, cost-effective means.

Another financial issue that affects the incorporation of mHealth services is the source and availability of funding. International non-governmental and United Nations organizations supported the implementation of the majority of the mHealth interventions we reviewed. This reliance on external parties contributes to the precariousness of programs once donors phase out. Accordingly, the evaluators of the mobile-midwives project in Indonesia recommend extensive exit strategies that hand over implementation to government agencies and educate society members on the social benefits of the services [27]. One example of a sustainable program has been the “Better Border Healthcare Program” of Thailand in which the Ministry of Public Health has absorbed the financial costs of generating SMS to pregnant women and permitted the program to sustain its operations [29]. Furthermore, this financing scheme substantiates the value chain model of one-way SMS-based operations [4], in which text messages offer a less prohibitive maintaince cost, and relieve some of the financial strains associated witht adopting mHealth programs.

Lastly, a common funding challenge cited in the literature includes the interaction between mHealth programs and the infrastructure constraints of the broader under-resourced health ecosystem. Many of the reviewed articles documented that the costs of sustaining emergency transport systems, such as fuel and vehicle maintenance, and payment for health services contributed to challenges in the continuation of programs [20, 22, 24]. The emergency care programs implemented in the Gambia and Uganda demonstrated the interdependence between mHealth and the overall health ecosystem, in which breakdowns in the transportation system and unavailability of qualified health staff hampered the delivery of health services. In addition, prohibitive healthcare financing schemes such as user fees constrict access to mHealth services [7, 17, 33].

Policy Frameworks

The dearth of overarching policy and management frameworks within national health strategies presents another challenge to the scaled adoption of mHealth services [12]. A policy framework offers the opportunity to ensure that projects align with objectives for national maternal and newborn health care and to devise strategies for synergizing these initiatives with other health sectors such as HIV/AIDS [10, 34, 35]. In addition, coordination between different government bureaus is essential to establish and enforce guidelines on the content and technological design of services, exchange of data, and ICT infrastructure, including network coverage [12]. Furthermore, policy frameworks may delineate protocols for health workers executing treatment based on support from remote consultations, health personnel prescribing therapy despite their physical isolation, and intermediaries involved during patient referalls. For example, 31% of midwives in Indonesia who used mobile phones for point-of-care support were apprehensive about trusting the information emanating from remote consultations due to the lack of guidelines for quality assurance and assigning accountability [27].

In addition, mHealth operations require more analytical evaluations that can guide and influence national health strategies to appropriately invest in and scale up activities [12]. Governments can then work towards developing informed practices that could promote the integration of mHealth, such as the gradual adoption of toll-free services for health related mobile communication in Rwanda [36]. The toll free services are currently operating in Mayange, Rwanda, but NGOs, government bureaus and the platform provider Mobile Telephone Networks (MTN) are negotiating ways to extend this amenity to other mHealth project sites in Kenya, Tanzania, and Uganda [36].

Socio-Cultural Context

Engaging local partners to develop culturally appropriate and language-friendly messages is another common theme for the integration and sustainability of mHealth applications [4, 22, 24, 27]. The mobile-midwives project in Aceh Besar demonstrated that technologies which permitted the use of the local Indonesian Bahasa were more accessible and effective compared to other digital media that solely used English [27]. Similarly, the “Wired Mothers” study in Zanzibar, Tanzania showed that SMS services intended for pregnant women had to be adapted to the local context in order for the adoption of the behavioral change practices [25].

Interventions also often employed a strategy that anchored mHealth programs at the community level and utilized personnel with the most immediate outreach capacity to pregnant women. Invariably, emergency response and point-of-care support programs incorporated frontline workers, volunteer auxiliaries and paid health workers who were embedded in their communities’ health ecosystem [7, 20, 2227]. For example, the RESCUER program in Uganda demonstrated that empowering community-based health workers with mobile communication provided the opportunity to strengthen linkages between community members and health facilities [22]. In addition, the “Lady Health Worker” initiative in Pakistan worked with ubiquitous and socially accepted health workers who had easy access to mothers and could bridge disenfranchised populations with the formal health system [21]. Accordingly, programs should build upon the local context and resources while still introducing an innovative tool for healthcare delivery.

Conclusion

mHealth presents a new and pervasive platform for addressing prenatal and newborn health, and evidence indicates that mobile technology is an effective tool that empowers pregnant women and healthcare providers [6, 7, 1020]. The scope of mHealth programs retrieved in the literature review focused primarily on the global South due to its relatively dismal maternal mortality ratios and consequent concentration of funding for interventions (Fig. 3). Generally, programs focused on specific points of the MNCH continuum of care such as emergency responses during birth, with fewer projects that intervened at multiple points along the continuum (Fig. 1).

Overall, mHealth can be part of a comprehensive approach in expediting emergency obstetric referrals and enabling health workers to collaborate and improve delivery of care. Likewise, the use of mHealth can bolster preventive services through the enhanced dissemination of prenatal and neonatal education and promotion of antenatal care. However, the literature review revealed the paucity of project evaluations and a general lack of management and policy frameworks for guiding and coordinating the adoption of mHealth services into the broader health system.

Limitations

The relative scarcity of articles with a quantitative design challenged the ability to statistically corroborate the impact of mHealth. Although qualitative studies provided thematic assessments, this review could have benefitted from articles with outcomes data that explicitly correlated with maternal and newborn health indicators.

Acknowledgments

The authors would like to thank the HIT Lab team, including Ilene Hollin and Annie Alley, who were involved in the editing of the manuscript.

Copyright information

© Springer Science+Business Media, LLC 2011