Maintenance Notice

Due to necessary scheduled maintenance, the JMIR Publications website will be unavailable from Wednesday, July 01, 2020 at 8:00 PM to 10:00 PM EST. We apologize in advance for any inconvenience this may cause you.

Who will be affected?


Citing this Article

Right click to copy or hit: ctrl+c (cmd+c on mac)

Published on 08.12.17 in Vol 5, No 12 (2017): December

Preprints (earlier versions) of this paper are available at, first published Jun 26, 2017.

This paper is in the following e-collection/theme issue:


    Texting Condolences: Adapting mHealth Programs After Unexpected Pregnancy and Infant Outcomes

    1Global Center for Integrated Health of Women, Adolescents and Children, Department of Global Health, University of Washington, Seattle, WA, United States

    2Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States

    3Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya

    4Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya

    Corresponding Author:

    Jennifer A Unger, MPH, MD

    Global Center for Integrated Health of Women, Adolescents and Children

    Department of Global Health

    University of Washington

    Harborview Medical Center

    Seattle, WA,

    United States

    Phone: 1 206 388 8141



    Mobile health (mHealth) short message system (SMS) interventions for maternal and child health (MCH) are being implemented globally. In many low- and middle-income settings in which these mHealth interventions are being rolled out, stillbirths and neonatal and infant deaths are common. It is important that mHealth solutions do not exacerbate emotional stress and pain by continuing with routine messaging for pregnancy or infant care when someone has experienced loss. In this brief viewpoint paper, we argue that SMS programs for maternal and child health need to adapt and make available messaging for miscarriage, stillbirth, and infant loss.

    JMIR Mhealth Uhealth 2017;5(12):e176



    Mobile health (mHealth) short message system (SMS) text messaging interventions such as Text4baby [1] and MomConnect [2] are increasingly incorporated within maternal child health (MCH) care systems globally. Evidence regarding effectiveness of these interventions to improve MCH health services uptake and outcomes is limited to date but accruing [3-5]. Studies suggest that these interventions may improve beliefs and attitudes about behaviors and preparedness during pregnancy [1,6] and that women appreciate access to information [7] throughout pregnancy and the postpartum period. Message development for MCH text message programs has involved tailoring messaging to the stage of pregnancy and infant age and targeting key behaviors that can improve health outcomes. As women connect to the health care system through text messaging, there is increasing programmatic responsibility to get the messaging right for these participants. Messaging needs to be culturally appropriate, accurate, and reflect realities to be a credible resource that has positive impact on maternal and child outcomes.

    An unanticipated challenge we faced during a recent mHealth randomized controlled trial (RCT), Mobile WACh (Mobile Solutions for Women’s and Children’s Health) [NCT01894126], was responding to the high number of neonatal and infant deaths, stillbirths, or miscarriages. Unfortunately, in many low- and middle-income settings in which mHealth interventions are being rolled out, stillbirths and neonatal and infant deaths are not infrequent [8]. Although mHealth MCH systems automate text messaging based on timing of gestation or postpartum status, most are not built to capture the real-time vital status of mother or infant. Thus, a woman may continue to receive messages from the program about actions to keep her pregnancy or baby healthy after the occurrence of a miscarriage, stillbirth, or infant death. Women could end messaging by sending a STOP message, but this leaves these women without access to a potentially valuable source of support. Women with adverse outcomes may especially benefit from access to advice and encouragement at this difficult time. In our RCT, we found that when we contacted women for study follow-up, most women who experienced a stillbirth or infant death wanted to continue receiving messages. In addition, women in the bidirectional text messaging group wanted to be able to continue a message dialog with the nurse.

    Textbox 1. Example text messages for women participating in mHealth programs after a miscarriage or infant death.
    View this box

    With scale-up of mHealth in MCH systems, the intersection between messaging projects and infant deaths is not insignificant. For example, South Africa has rolled out MomConnect countrywide to improve maternal and child outcomes. The infant mortality rate in South Africa is 33 infant deaths per 1000 live births [9], and MomConnect has messaged over 700,000 pregnant women since its launch in 2013. Thus, an estimated 23,100 women receiving MCH-related text messages will also experience the loss of their baby. It is important that mHealth solutions do not exacerbate emotional stress and pain with perhaps unwanted reminders of this loss, and programs need to be thoughtful about how these women and their families could benefit from adapted messages tailored to this scenario.

    One approach that may also lessen the stigma of miscarriage, stillbirth, and infant death is to develop messaging around these sad events (Textbox 1). The messages in our trial were developed and revised after formative work, both pre-RCT focus group discussions and post-RCT interviews, with representative women from the communities where we work. Although there are limitations to all counseling messages and they may not address the concerns of all women, messaging could be designed to support women and encourage healthy behaviors around grief and depression. Women would then have the option to remain connected to the program and not experience a loss of support. Building such a system would require some design innovations to enable prompt notification of infant deaths by integrating more closely with primary health care workers but could ultimately provide valuable information about infant deaths and the needs and experiences of participating women and result in long-term improved outcomes for these families.


    1. Evans WD, Wallace JL, Snider J. Pilot evaluation of the Text4baby mobile health program. BMC Public Health 2012;12:1031 [FREE Full text] [CrossRef] [Medline]
    2. MomConnect: launching a national digital health program in South Africa. Geneva: United Nations Foundation; 2016.   URL: [accessed 2017-10-31] [WebCite Cache]
    3. Lund S, Hemed M, Nielsen BB, Said A, Said K, Makungu MH, et al. Mobile phones as a health communication tool to improve skilled attendance at delivery in Zanzibar: a cluster-randomised controlled trial. BJOG 2012 Sep;119(10):1256-1264 [FREE Full text] [CrossRef] [Medline]
    4. Lund S, Nielsen BB, Hemed M, Boas IM, Said A, Said K, et al. Mobile phones improve antenatal care attendance in Zanzibar: a cluster randomized controlled trial. BMC Pregnancy Childbirth 2014 Jan 17;14:29 [FREE Full text] [CrossRef] [Medline]
    5. Jiang H, Li M, Wen LM, Hu Q, Yang D, He G, et al. Effect of short message service on infant feeding practice: findings from a community-based study in Shanghai, China. JAMA Pediatr 2014 May;168(5):471-478 [FREE Full text] [CrossRef] [Medline]
    6. Evans WD, Wallace BJ, Szekely D, Nielsen P, Murray E, Abroms L, et al. Initial outcomes from a 4-week follow-up study of the Text4baby program in the military women's population: randomized controlled trial. J Med Internet Res 2014;16(5):e131 [FREE Full text] [CrossRef] [Medline]
    7. Jareethum R, Titapant V, Chantra T, Sommai V, Chuenwattana P, Jirawan C. Satisfaction of healthy pregnant women receiving short message service via mobile phone for prenatal support: a randomized controlled trial. J Med Assoc Thai 2008 Apr;91(4):458-463. [Medline]
    8. Levels and trends in child mortality 2013.: UNICEF; 2013.   URL: [accessed 2017-10-31] [WebCite Cache]
    9. You D, Hug L, Ejdemyr S, Idele P, Hogan D, Mathers C, United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation. Lancet 2015 Dec 05;386(10010):2275-2286. [CrossRef] [Medline]


    MCH: maternal child health
    Mobile WACh: Mobile Solutions for Women’s and Children’s Health
    RCT: randomized controlled trial
    SMS: short message service

    Edited by G Eysenbach; submitted 26.06.17; peer-reviewed by A Ashman, M Ashford, S Meaney; comments to author 13.09.17; revised version received 06.10.17; accepted 11.10.17; published 08.12.17

    ©Jennifer A Unger, John Kinuthia, Grace John-Stewart. Originally published in JMIR Mhealth and Uhealth (, 08.12.2017.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mhealth and uhealth, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.