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Mobile phone apps for health promotion have expanded in many low- and middle-income countries. Afghanistan, with high maternal and newborn morbidity and mortality rates, a fragile health infrastructure, and high levels of mobile phone ownership, is an ideal setting to examine the utility of such programs. We adapted messages of the Mobile Alliance for Maternal Action (MAMA) program, which was designed to promote healthy behaviors during pregnancy and a newborn’s first year of life, to the Afghan context. We then piloted and assessed the program in the provinces of Kabul, Herat, Kandahar, and Balkh.
The aim of this study was to assess the feasibility and acceptability of the MAMA pilot program, and to examine changes in reported maternal, newborn, and child health (MNCH) knowledge and attitudes among participants from baseline to follow up.
We conducted a single-group study with data collected within 10 weeks of enrollment, and data collection was repeated approximately 6 months later. Data were collected through face-to-face interviews using structured questionnaires. Eligible participants included pregnant women who had registered to receive fully automated mobile health messages and their husbands. Assessment questionnaires queried sociodemographic details; knowledge, attitudes, and health care-seeking practices; and intervention experience and acceptability at follow up. The number of messages received by a given phone number was extracted from the program database. We descriptively analyzed the feasibility and acceptability data and compared the change in MNCH knowledge between baseline and follow-up measures using the McNemar Chi square test.
Overall, 895 women were enrolled in the MAMA program. Data from 453/625 women (72.5% of the pretest sample) who received voice (n=302) or text (n=151) messages, and 276/427 men (64.6% of the pretest sample) who received voice (n=185) or text (n=91) messages contributing data at both time points were analyzed. At follow up, 699/729 (95.9%) participants were still enrolled in the MAMA program; voice message and SMS text messaging subscribers received 43 and 69 messages on average over the 6-month period, respectively. Participants who were voice message subscribers and female participants more commonly reported missing messages compared with the text message subscribers and men; predominant reasons for missed messages were the subscribers being busy with chores or not having their shared phone with them. Over 90% of men and women reported experiencing benefits from the program, mainly increased knowledge, and 226/453 (49.9%) of the female participants reported referring someone else to the program. Most of the participants (377/453, 83.2% women and 258/276, 93.5% men) believed it was beneficial to include husbands in the program. Joint decision making regarding maternal and child health care increased overall. The proportions of participants with correct knowledge significantly increased for all but one MNCH measure at follow up.
This assessment indicates that the pilot MAMA program is feasible and acceptable in the Afghan context. Further research should be conducted to determine whether program participation leads to improved MNCH knowledge, health practices, and health service utilization in this fragile setting prior to larger scale up.
Afghanistan has one of the highest maternal, newborn, and child mortality rates among Asian countries [
Among the factors associated with low uptake of essential maternal, newborn, and child health (MNCH) interventions are illiteracy and lack of education [
Within Afghanistan, mobile phone ownership and use have expanded markedly in the last decade, creating a potential channel to reach women and their families with health information. In a recent nationally representative survey, 91% of households reported owning a mobile phone [
The Mobile Alliance for Maternal Action (MAMA) program was launched in 2012 as a public-private partnership to scale up an evidence-based mobile health (mHealth) program that is already being used in two countries [
In this study, we assessed a pilot implementation of the MAMA program in four provinces of Afghanistan to determine whether it was feasible and acceptable to Afghan users, and whether users report changes in MNCH attitudes, health decision making, and knowledge of key MNCH concepts. The data from this assessment will guide program refinement, and are intended to improve program use and potential effectiveness at scale up in Afghanistan and adaptation in similar contexts.
We conducted a single-group, baseline/follow-up study to assess the feasibility, acceptability, and potential effect of the MAMA program on MNCH knowledge. The MAMA pilot program was implemented in 80 health post catchment areas in the Balkh, Herat, Kabul, Kandahar, and Nangarhar provinces of Afghanistan. Nangarhar province was not included in the program assessment as baseline recruitment was not possible within the study time frame due to insecurity. The selected pilot districts were semiurban or rural and predominantly agrarian. Eligible study participants included pregnant women and their husbands who enrolled in the MAMA program with the help of a community health worker between May and July 2018.
The study was reviewed and approved by the FHI 360 Protection of Human Subjects Committee (#1240522-2) and was approved by the Afghanistan Ministry of Public Health (MOPH) Institutional Review Board (protocol #444670) prior to implementation.
The MAMA message program relays essential MNCH information to guide actions for pregnant women and families with children under 12 months of age through mobile phones. Educational messages are sent twice weekly and are timed to the stage of pregnancy or age of the newborn. In a report exploring MAMA program implementation experiences in four countries, several factors were noted that may impact feasibility and acceptability [
For pilot program implementation, female community health workers were selected from communities with active health posts. Each selected community health worker was trained to recruit and enroll 10 pregnant women and offer enrollment to their husbands, in collaboration with the Provincial Health Directorate and the Basic Package of Health Services implementer. Recruitment was primarily achieved through home visits to prospective clients, although some participants were recruited at locations such as health posts and adult literacy classes. For this pilot program, eligibility for registration was confined to pregnant women and their husbands who lived within the catchment area of the health post of the recruiting community health worker and had access to a functional mobile phone. Potential clients were informed that program staff might call them to confirm message receipt and program functionality. The community health workers ensured that women and men who registered were eligible and provided clients with a choice of written text (SMS) messages or automated recorded voice calls, as well as a choice for time of day to receive the calls or text messages. If the couple shared a phone, the woman was offered these choices, as she was considered the primary subscriber. The first message was timed to the woman’s current week of pregnancy and continued sequentially from that point. Messages encouraged clients to discuss MNCH care with their spouses and families, and promoted healthy practices such as exclusive breastfeeding and seeking health care services, including antenatal care, skilled attendance at delivery, and infant immunization.
Monitoring was conducted by HEMAYAT program staff and community health supervisors through three approaches: direct field supervision and mentoring during the community health worker-led registration process; monitoring of the data dashboard incorporated with the MAMA platform reflecting the number of messages sent, received, and nonresponsive numbers; and project staff calls to registered clients to confirm number validity, message receipt, and whether the registered client met the criteria for the pilot registration process. As the first and third approaches were employed early in pilot program implementation, system errors such as some mobile networks not receiving messages were identified and repaired.
For baseline data collection, all households that had enrolled in the MAMA program in the four included provinces were approached and program subscribers were recruited to participate in the study no more than 10 weeks after enrolling in the MAMA program. The community health workers who had promoted the program and registered subscribers introduced the data collection team to female subscribers and their husbands or male heads of household. Eligible participants were pregnant women and their husbands subscribing to the pilot program at least 4 weeks earlier and verbally consenting to study participation. Following explanation of the assessment, participation was offered, and verbal informed consent was obtained from subscribers interested in study participation by data collectors of the same sex. For follow-up data collection, households were revisited approximately 6 months after the baseline survey.
Structured interviews using paper questionnaires were conducted with study participants by trained, sex-matched data collectors fluent in the language(s) predominantly spoken in that province. Translated questionnaires for women and men were field-tested with volunteers from different ethnic groups across implementation sites. The baseline questionnaire included sections detailing household characteristics, the program registration process, and MNCH-related knowledge and attitudes. Interviewers asked program participants about their attitudes toward discussing MNCH and specific practices, household decision making about MNCH care, and their knowledge of several maternal and newborn health issues featured in MAMA messages. We developed the knowledge questions based on content used to measure MNCH knowledge among men and women in assessments and evaluations performed in Afghanistan both within our group and in larger household-level surveys [
Feasibility measures included the proportion of female respondents who had to ask permission to register and from whom they asked permission; whether they were asked what time of day they prefer to receive messages and whether they received messages at their preferred time; continued to subscribe and receive messages after 6 months and the number of messages that respondents reported receiving per week on average; and reports of missed messages with stated reasons for missing the MAMA messages. Acceptability measures included the proportion of respondents who reported any and specific benefits to their participation in MAMA; reported that a member of their household listened to or read the messages and who it was (eg, husband, mother-in-law); stated that including their husband or their mother-in-law was beneficial; recommended MAMA use to someone else; and discussed MAMA with other pregnant women or new mothers.
Trained male and female data collectors administered the study instruments to consenting participants of the same sex in a private room in the household. The same data collectors conducted interviews at baseline and follow-up sessions; community health workers introduced the data collection team at households during study recruitment and at baseline data collection, consistent with cultural norms. Baseline data were collected in July and August 2018. Follow-up interviews were conducted with the same participants in January and February 2019, using a similar structured questionnaire including the same knowledge and attitude questions and adding questions on exposure to and acceptability of the MAMA program. Additionally, the MAMA mobile platform and database automatically recorded the dates and time of messages that were sent and received. We extracted the overall number of messages received for each participant at follow-up data collection.
We used STATA Version 15 (StataCorp LP, College Station, TX, USA) to descriptively analyze sociodemographic characteristics, message exposure, and acceptability measures, disaggregated by sex and message type (SMS text or voice message). Results were summarized at baseline and at follow up for attitudes, decision making, and knowledge of MNCH topics. Additionally, we conducted exploratory analyses to examine the change in selected MNCH knowledge measures between baseline and follow up using the McNemar Chi square test for paired data, with a two-sided alpha of .05 and 80% power.
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.
Across the four provinces sampled, 895 pregnant women were registered in the MAMA pilot program from May to August 2018. Over two-thirds (625/895, 69.8%) of female program participants and 427 husbands who were confirmed subscribers to the program agreed to participate in the study. A total of 499/625 (79.8%) women and 306/427 (71.7%) men completed both baseline and follow-up questionnaires. In some households, more than one woman or man enrolled in the study. However, because telephone numbers were used as the unique identifier to link baseline and follow-up data for participants, if more than one person of the same sex had the same phone number, it was impossible to link the data from the two time points to the correct participant. Thus, due to this uncertainty, we removed records for both participants from the final dataset. Therefore, we present results from 453/625 women (72.5% of the pretest sample) and 276/427 men (64.6% of the pretest sample) with complete baseline and follow-up data, disaggregated by sex.
Among both women and men, about two-thirds of participants (487/729, 66.8% ) opted to receive voice messages and one-third (242/729, 33.2%) chose to receive SMS text messages. Sociodemographic and household characteristics of participants indicate that many women did not own a phone and used someone else’s phone to access the program, and most of the participants had primary-level or no education (
Sociodemographic characteristics of participants, by sex and message modality, across four provinces in Afghanistan (N=729).
Characteristic | Women | Men | |||
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Voice (n=302) | Text messaging (n=151) | Voice (n=185) | Text messaging (N=91) |
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Balkh | 77 (25.5) | 56 (37.1) | 58 (31.4) | 42 (46.2) |
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Herat | 73 (24.2) | 48 (31.8) | 36 (19.5) | 29 (31.9) |
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Kabul | 66 (21.9) | 38 (25.2) | 28 (15.1) | 12 (13.2) |
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Kandahar | 86 (28.5) | 9 (6.0) | 63 (34.1) | 8 (8.8) |
Age (years), mean (SD) | 28.6 (12.7) | 26.3 (10.9) | 32.5 (9.6) | 30.5 (7.5) | |
Phone ownership, n (%) | 176 (58.3) | 104 (68.9) | 185 (100.0) | 88 (96.7) | |
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Own | 123 (40.7) | 70 (46.4) | 134 (72.4) | 57 (62.6) |
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Spouse’s | 146 (48.3) | 67 (44.4) | 42 (22.7) | 29 (31.9) |
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Mother/father’s | 1 (0.3) | 6 (4.0) | 3 (1.6) | 3 (3.3) |
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Mother-in-law/father-in-law’s | 20 (6.6) | 1 (0.7) | 3 (1.6) | 0 (0) |
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Brother/sister’s | 2 (0.7) | 5 (3.3) | 1 (0.5) | 2 (2.2) |
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Brother-in-law/sister-in-law’s | 7 (2.3) | 2 (1.3) | 0 (0) | 0 (0) |
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No formal education | 234 (77.5) | 46 (30.5) | 84 (45.4) | 29 (31.9) |
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Primary | 31 (10.3) | 25 (16.5) | 38 (20.5) | 12 (13.2) |
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Secondary | 25 (8.3) | 25 (16.6) | 19 (10.3) | 14 (15.4) |
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High school | 10 (3.3) | 40 (26.5) | 25 (13.5) | 21 (23.1) |
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Higher | 1 (0.3) | 13 (8.6) | 12 (6.5) | 12 (13.2) |
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Vocational or Madrassa | 1 (0.3) | 2 (1.3) | 7 (3.8) | 3 (3.3) |
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0 | 53 (17.6) | 37 (24.5) | 39 (21.1) | 26 (28.6) |
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1-2 | 82 (27.2) | 56 (37.1) | 40 (21.6) | 35 (38.5) |
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3-4 | 84 (27.8) | 40 (26.5) | 54 (29.2) | 19 (20.9) |
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5 or more | 83 (27.5) | 18 (11.9) | 52 (28.1) | 11 (12.1) |
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Electricity | 228 (75.5) | 136 (90.1) | 153 (82.7) | 85 (93.4) |
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Radio | 72 (23.8) | 36 (23.8) | 69 (37.3) | 24 (26.4) |
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Television | 168 (55.6) | 116 (76.8) | 102 (55.1) | 76 (83.5) |
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Mobile phone with internet | 53 (17.6) | 61 (40.4) | 57 (30.8) | 32 (35.2) |
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Mobile phone without internet | 268 (88.7) | 121 (80.1) | 173 (93.5) | 86 (94.5) |
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Born alive and healthy | 272 (89.2) | 138 (95.6) | 165 (89.2) | 87 (95.6) |
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Stillbirth | 13 (4.9) | 4 (1.1) | 9 (4.9) | 1 (1.1) |
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Otherc | 17 (6.0) | 9 (3.3) | 11 (6.0) | 3 (3.3) |
aMAMA: Mobile Alliance for Maternal Action.
bMultiple responses allowed.
cOther responses included abortion, miscarriage, and women who had not yet given birth.
The majority (312/453, 68.9%) of female participants overall reported that they had to seek the permission of a gatekeeper to enroll in the MAMA program; this gatekeeper was usually the woman’s husband, although in some cases it was the mother-in-law (
After 6 months of program participation, the automated database confirmed that across groups, 95%-97% of respondents had not cancelled their subscription and were continuing to receive messages (
Most women and men cited multiple benefits when asked about perceived program benefits (
Feasibility of Mobile Alliance for Maternal Action (MAMA) program registration and use among participants, by sex and message modality, in four provinces of Afghanistan (N=729).
Feasibility measure | Women | Men | |||
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Voice (n=302) | Text messaging (n=151) | Voice (n=185) | Text messaging (n=91) |
Woman had to ask permission to registera | 213 (70.5) | 99 (65.6) | 131 (70.8) | 47 (51.7) | |
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Husband | 174 (78.4) | 83 (79.8) | 96 (69.6) | 34 (66.7) |
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Mother-in-law | 32 (14.4) | 18 (17.3) | 34 (24.6) | 14 (27.5) |
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Father-in-law | 13 (5.9) | 3 (2.9) | 8 (5.8) | 3 (5.9) |
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Brother-in-law | 2 (0.9) | 0 (0) | 0 (0) | 0 (0) |
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Other (specify): | 1 (0.45) | 0 (0) | 0 (0) | 0 (0) |
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Not offered the choice of a preferred time | 101 (33.4) | 39 (25.8) | 40 (21.6) | 18 (19.8) |
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Yes | 136 (45.0) | 89 (58.9) | 76 (41.1) | 38 (41.8) |
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No | 49 (16.2) | 18 (11.9) | 11 (5.9) | 9 (9.9) |
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Refused or don’t know | 16 (5.3) | 10 (6.6) | 58 (31.4) | 26 (28.6) |
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Morning | 88 (29.1) | 43 (28.5) | 40 (21.6) | 23 (25.3) |
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Afternoon | 27 (8.9) | 18 (11.9) | 18 (9.7) | 8 (8.8) |
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Evening | 31 (10.3) | 9 (6) | 17 (9.2) | 2 (2.2) |
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Night | 55 (18.2) | 39 (25.8) | 12 (6.5) | 7 (7.7) |
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Anytime | 0 (0) | 3 (2) | 9 (4.9) | 9 (9.9) |
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No choice given/don’t know | 101 (33.4) | 39 (25.8) | 89 (48.1) | 42 (46.2) |
Current MAMA subscription at posttestc, n (%) | 286 (94.7) | 145 (96) | 180 (97.3) | 88 (96.7) | |
Total messages received, mean (SD) | 43 (17.6) | 69.4 (13) | 43.7 (17.7) | 68.5 (12.5) | |
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0 | 2 (0.7) | 2 (1.3) | 5 (2.7) | 1 (1.1) |
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1-2 | 240 (79.5) | 137 (90.7) | 104 (56.2) | 62 (68.1) |
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3-5 | 47 (15.6) | 12 (8) | 63 (34.1) | 25 (27.5) |
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6+ | 13 (4.3) | 0 (0) | 13 (7) | 3 (3.3) |
Ever missed messages, n (%) | 142 (47) | 36 (23.8) | 49 (26.5) | 14 (15.4) | |
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N=142 | N=36 | N=49 | N=14 | |
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No balance or charge | 14 (7.7) | 1 (2.3) | 13 (17.8) | 4 (19.1) |
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Busy with chores | 73 (40.3) | 18 (41.9) | 37 (50.7) | 8 (38.1) |
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Someone else had phone | 67 (37) | 18 (41.9) | 19 (26) | 7 (33.3) |
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Wrong time | 7 (3.9) | 0 (0) | 0 (0) | 1 (4.8) |
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Someone else took the call | 5 (2.8) | 3 (7) | 0 (0) | 0 (0) |
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Other | 15 (8.3) | 3 (7) | 4 (5.5) | 1 (4.8) |
aMale participants were asked whether their wives were required to obtain permission to register.
bMultiple responses allowed.
cSubscription and messages received data were extracted from the MAMA system database. All other data presented were based on self-reporting.
dMen were asked how many messages their wives received per week.
Mobile Alliance for Maternal Action (MAMA) program acceptability among participants, by sex and message type, in four provinces of Afghanistan (N=729).
Acceptability measure | Women | Men | |||||||
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Voice (n=302) | Text messaging (n=151) | Voice (n=185) | Text messaging (n=91) | ||||
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Information for own (wife’s) health | 218 (72.2) | 108 (71.5) | 109 (58.9) | 60 (65.9) | ||||
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Information for child’s health | 201 (66.6) | 107 (70.9) | 114 (61.6) | 58 (63.7) | ||||
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Able to get health information at home | 121 (40.1) | 47 (31.1) | 56 (30.3) | 23 (25.3) | ||||
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Learned new health information | 85 (28.2) | 39 (25.8) | 47 (25.4) | 14 (15.4) | ||||
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Other | 11 (3.6) | 2 (1.3) | 10 (5.4) | 8 (8.8) | ||||
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None | 10 (3.3) | 4 (2.7) | 8 (6) | 0 (0) | ||||
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No one | 79 (26.2) | 53 (35.1) | 116 (62.7) | 64 (70.3) | ||||
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Husband | 182 (60.3) | 73 (48.3) | N/Ab | N/A | ||||
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Mother-in-law/Mother (for husband) | 76 (25.2) | 16 (10.6) | 47 (25.4) | 17 (18.7) | ||||
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Sister(s)-in-law | 28 (9.3) | 14 (9.3) | 9 (4.9) | 6 (6.6) | ||||
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Sister(s) | 26 (8.6) | 9 (6) | 12 (6.5) | 14 (15.4) | ||||
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Father-in-law/father (for husband) | 19 (6.3) | 2 (1.3) | 14 (7.6) | 3 (3.3) | ||||
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Other | 12 (4) | 2 (1.3) | 17 (9.2) | 5 (5.5) | ||||
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Yes | 256 (84.8) | 121 (80.1) | 173 (93.5) | 85 (93.1) | ||||
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No | 31 (10.3) | 21 (13.9) | 4 (2.2) | 2 (2.2) | ||||
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Don’t know | 15 (5) | 9 (6) | 8 (4.3) | 4 (4.4) | ||||
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Yes | 151 (50) | 77 (51) | 114 (61.6) | 62 (68.1) | ||||
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No | 76 (25.2) | 43 (28.5) | 38 (20.5) | 15 (16.5) | ||||
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Don’t know | 29 (9.6) | 6 (4) | 33 (17.8) | 14 (15.4) | ||||
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Mother-in-law didn’t listen to messages | 46 (15.2) | 25 (16.7) | N/A | N/A | ||||
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Mother-in-law helps participant understand messages | 89 (29.5) | 52 (34.4) | 65 (35.1) | 36 (39.6) | ||||
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Helps participant follow instructions in messages | 48 (15.9) | 25 (16.6) | 35 (18.9) | 27 (29.7) | ||||
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Increased mother-in-law’s awareness of participant’s health needs | 64 (21.2) | 26 (17.2) | 63 (34.1) | 21 (23.1) | ||||
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Needs information on health care during pregnancy | 68 (22.5) | 17 (11.3) | 25 (13.5) | 8 (8.8) | ||||
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Other | 1 (0.3) | 2 (1.3) | 1 (0.5) | 3 (3.3) | ||||
Discussed MAMA with other pregnant women or new mothers, n (%) | 175 (58) | 88 (58.3) | N/A | N/A | |||||
Recommended the MAMA program, n (%) | 145 (48) | 81 (53.6) | 67 (36.2) | 39 (42.9) | |||||
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Family member | 66 (45.5) | 41 (50.6) | 24 (35.8) | 17 (43.6) | ||||
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Friend | 55 (37.9) | 32 (39.5) | 42 (62.7) | 17 (43.6) | ||||
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Neighbor | 68 (46.9) | 31 (38.3) | 39 (58.2) | 12 (30.8) | ||||
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Others | 3 (2.1) | 0 | 2 (3.0) | 3 (7.7) |
aMultiple responses possible.
bN/A: not applicable; option/item not asked of men.
We assessed attitudes toward MNCH, including comfort discussing maternal and newborn care with family members, correct knowledge and acceptance of exclusive breastfeeding and birth spacing, and attitudes about utilizing facility-based care during pregnancy and delivery (
With respect to decision making about MNCH care, and when to seek services, reported joint decision making by respondents and their spouses together increased between time points (
We examined differences between baseline and follow up in participants’ MNCH knowledge that overlapped with the MAMA message content. Generally, knowledge was higher for all indicators among women compared to men at both time points (
Attitudes toward maternal, newborn, and child health care at baseline and follow up, by participant sex, in four provinces of Afghanistan (N=729).
Item | Women (n=453) | Men (n=276) | |||
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Baseline, n (%) | Follow up, n (%) | Baseline, n (%) | Follow up, n (%) | |
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Agree | 395 (87.2) | 405 (89.4) | 228 (82.6) | 247 (89.5) |
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Neutral | 33 (7.3) | 25 (5.5) | 21 (7.6) | 18 (6.5) |
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Disagree | 19 (4.2) | 20 (4.4) | 10 (3.6) | 5 (1.8) |
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Refused | 6 (1.3) | 3 (0.7) | 17 (6.2) | 6 (2.2) |
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Agree | 395 (87.2) | 413 (91.2) | 224 (81.2) | 248 (89.9) |
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Neutral | 33 (7.3) | 24 (5.3) | 28 (10.1) | 13 (4.7) |
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Disagree | 19 (4.2) | 14 (3.1) | 12 (4.4) | 11 (4) |
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Refused | 6 (1.3) | 2 (0.4) | 12 (4.4) | 4 (1.5) |
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Agree | 333 (73.5) | 334 (73.7) | 206 (74.6) | 222 (80.4) |
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Neutral | 42 (9.3) | 62 (13.7) | 29 (10.5) | 11 (4) |
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Disagree | 35 (7.7) | 32 (7.1) | 21 (7.6) | 29 (10.5) |
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Refused | 43 (9.5) | 25 (5.5) | 20 (7.3) | 14 (5.1) |
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Agree | 333 (73.5) | 327 (72.2) | 215 (77.9) | 219 (79.4) |
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Neutral | 42 (9.3) | 56 (12.4) | 27 (9.8) | 11 (4) |
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Disagree | 36 (8) | 43 (9.5) | 18 (6.5) | 33 (12) |
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Refused | 42 (9.3) | 27 (6) | 16 (5.8) | 13 (4.7) |
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Agree | 94 (20.8) | 67 (14.8) | 73 (26.5) | 35 (12.7) |
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Neutral | 31 (6.8) | 12 (2.7) | 26 (9.4) | 17 (6.2) |
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Disagree | 310 (68.4) | 359 (79.3) | 158 (57.3) | 205 (74.3) |
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Refused | 18 (4) | 15 (3.3) | 19 (6.9) | 19 (6.9) |
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Agree | 171 (37.8) | 76 (16.8) | 138 (50) | 118 (42.8) |
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Neutral | 44 (9.7) | 31 (6.8) | 29 (10.5) | 39 (14.1) |
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Disagree | 220 (48.6) | 341 (75.3) | 95 (34.4) | 113 (40.9) |
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Refused | 18 (4) | 5 (1.1) | 14 (5.1) | 6 (2.2) |
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Agree | 360 (79.5) | 340 (75.1) | 236 (85.5) | 226 (81.9) |
|
Neutral | 26 (5.7) | 47 (10.4) | 11 (4) | 13 (4.7) |
|
Disagree | 32 (7.1) | 40 (8.8) | 19 (6.9) | 16 (5.8) |
|
Refused | 35 (7.7) | 26 (5.7) | 10 (3.6) | 21 (7.6) |
Reported health decision makers within the household among participants, by sex, across four provinces in Afghanistan (N=729).
Health decision maker | Women (n=453) | Men (n=276) | |||
|
Baseline, |
Follow up, |
Baseline, n (%) | Follow up, n (%) | |
|
|
|
|
|
|
|
Respondent | 100 (22.1) | 83 (18.3) | 65 (23.6) | 79 (28.6) |
|
Spouse | 151 (33.3) | 139 (30.7) | 41 (14.9) | 29 (10.5) |
|
Respondent and spouse jointly | 73 (16.1) | 114 (25.2) | 89 (32.3) | 104 (37.7) |
|
Mother-in-law/mother | 80 (17.7) | 76 (16.8) | 57 (20.7) | 42 (15.2) |
|
Husband/wife and mother-in-law/mother jointly | 18 (4) | 8 (1.8) | 4 (1.5) | 0 (0) |
|
Other relative | 27 (6) | 33 (7.3) | 17 (6.2) | 21 (7.6) |
|
No response/refused | 4 (0.9) | 0 (0) | 3 (1.1) | 1 (0.4) |
|
|
|
|
|
|
|
Respondent | 106 (23.4) | 110 (24.3) | 54 (19.6) | 49 (17.8) |
|
Spouse | 125 (27.6) | 109 (24.1) | 60 (21.7) | 49 (17.8) |
|
Respondent and spouse jointly | 93 (20.5) | 127 (28) | 89 (32.3) | 116 (42) |
|
Mother-in-law/mother | 86 (19) | 73 (16.1) | 55 (19.9) | 41 (14.9) |
|
Husband/wife and mother-in-law/mother jointly | 21 (4.6) | 3 (0.7) | 2 (0.7) | 4 (1.5) |
|
Other relative | 16 (3.5) | 31 (6.8) | 15 (5.4) | 17 (6.2) |
|
No response/refused | 6 (1.3) | 0 (0) | 1 (0.4) | 0 (0) |
|
|
|
|
|
|
|
Respondent | 82 (18.1) | 81 (17.9) | 90 (32.6) | 74 (26.8) |
|
Spouse | 214 (47.2) | 152 (33.6) | 28 (10.1) | 27 (9.8) |
|
Respondent and spouse jointly | 64 (14.1) | 115 (25.4) | 93 (33.7) | 118 (42.8) |
|
Mother-in-law/mother | 48 (10.6) | 64 (14.1) | 34 (12.3) | 28 (10.1) |
|
Husband/wife and mother-in-law/mother jointly | 11 (2.4) | 12 (2.7) | 2 (0.7) | 4 (1.5) |
|
Other relative | 31 (6.8) | 29 (6.4) | 27 (9.8) | 24 (8.7) |
|
No response/refused | 3 (0.7) | 0 (0) | 2 (0.7) | 1 (0.4) |
Comparison of reported maternal, newborn, and child health care awareness and knowledge differences by time point and sex across four provinces in Afghanistan with the paired McNemar Chi square test (N=729).
Item | Women (n=453) | Men (n=276) | |||||
|
Baseline, n (%) | Follow up, n (%) | Baseline, n (%) | Follow up, n (%) | |||
Knew any reason to take iron supplements | 265 (58.5) | 377 (83.2) | <.001 | 129 (46.7) | 161 (58.3) | .004 | |
Knew ≥4 antenatal care visits recommended | 297 (65.6) | 345 (76.2) | <.001 | 164 (59.4) | 188 (68.1) | .03 | |
Knew ≥1 pregnancy warning signs | 382 (84.3) | 436 (96.3) | <.001 | 197 (71.4) | 246 (89.1) | <.001 | |
Knew ≥1 childbirth warning signs | 395 (87.2) | 433 (95.6) | <.001 | 211 (76.5) | 252 (91.3) | <.001 | |
Knew ≥1 way to keep baby warm | 351 (77.5) | 427 (94.3) | <.001 | 185 (67.0) | 242 (87.7) | <.001 | |
Knew to apply chlorhexidine to cord | 201 (44.4) | 303 (66.9) | <.001 | 80 (29.0) | 183 (66.3) | <.001 | |
Knew when to start breastfeeding | 400 (88.3) | 422 (93.2) | .01 | 151 (54.7) | 222 (80.4) | <.001 | |
Knew recommended duration to practice exclusive breastfeeding | 392 (86.5) | 427 (94.3) | <.001 | 130 (47.1) | 207 (75.0) | <.001 | |
Knew maximum time LAMa can be practiced | 63 (13.9) | 57 (12.6) | .50 | 22 (8.0) | 39 (14.1) | .02 |
aLAM: lactational amenorrhea method.
Our results indicate that the adapted MAMA program was feasible and acceptable to implement in Afghanistan. Consistent with other evidence from Afghanistan, most participants preferred to receive voice calls rather than SMS text messages [
The proliferation of mobile phones is an important development in the Afghan context [
A recent review found mixed results and insufficient evidence that mHealth interventions improve MNCH outcomes [
Another unique aspect of this study is the comparison of voice to SMS text message formats regarding participant characteristics, feasibility, and acceptability measures. In several studies conducted in a variety of contexts, voice calls were preferred over SMS text messages [
Two papers have presented findings from different analyses of the MAMA program in Bangladesh, called Aponjon, which is operated by the nonprofit social enterprise Dnet [
There are several limitations of this study. We acknowledge that the single-group study design precludes attributing changes in knowledge, attitudes, and decision making to the MAMA intervention, and therefore we treat these results as exploratory. The ability to generalize our findings is also limited. Those who opted to subscribe to the MAMA program may differ substantially from those who opted not to subscribe; however, community health workers reported that very few of the women they approached did not subscribe. Additionally, our analyses included only 55% of women who subscribed to the pilot program; therefore, these results may not reflect subscribers as a whole. Participants who could be located and consented to be interviewed at both time points may have had higher engagement and more positive views of the program. Our measurement of MNCH knowledge items reflects participant knowledge at different stages of partial exposure to the program. Because the baseline interview was administered in some cases up to 10 weeks after enrollment and participants were at various stages of pregnancy, some participants were already exposed to some of the knowledge items we assessed at baseline, while others were not. At follow up, participants had similarly varying exposure to newborn care messages. Similarly, due to phone sharing within households, we elected not to assess whether knowledge change was proportionate to the number of messages received. Finally, there may have been confounding effects through exposure to other MNCH information channels during the pilot program. Community health workers at the community level and health care providers are the primary sources of MNCH messages and education in rural Afghanistan, although some households may also receive health information from other community-level volunteers (eg, Family Health Action Group members), radio, or television [
We found that Afghan women and men welcomed an mHealth MNCH educational program and were largely able to enroll and access weekly voice or text messages with few technological complications, and continued program use from pregnancy through early infancy. Participants reported that they benefited by gaining health knowledge, and many stated that they discussed the messages with their family and peers. Joint decision making between spouses appears to have increased during the intervention period, and including husbands in the program was more often described as beneficial by participants when compared with the discussion of messages with mothers-in-law; both are potential areas for further research in this cultural context. There were improvements in MNCH knowledge measures among both male and female participants; however, given the important limitations of the research that has been conducted on this approach, future research of this and similar programs should be designed to rigorously evaluate the effect of the intervention on MNCH knowledge and health behaviors. Prior to further effectiveness evaluation, we hope that the data from this assessment will be used to secure ongoing and sustained support to allow the MAMA program to be refined and implemented at a greater scale in Afghanistan.
Helping Mothers and Children Thrive in Afghanistan
Mobile Alliance for Maternal Action
mobile health
maternal, newborn, and child health
Ministry of Public Health
short message service
United States Agency for International Development
We thank the participants and their families for their time and trust, and for permitting study workers into their homes and communities for data collection. We thank the Basic Package of Health Services implementing partner staff and the provincial health department program staff in Balkh, Herat, Kabul, and Kandahar provinces for their time and efforts in guiding study workers within communities and facilitating study activities. We also acknowledge the efforts of our study workers for intensive efforts in engaging families, community leaders, and community health workers in a time-sensitive fashion and for their attention to detail. Last, this publication has been made possible by the generous support of the American people as part of the United States Agency for International Development (USAID) HEMAYAT project and the USAID Afghanistan FP/MNCH Project (AID-306-A-15-00002). The contents of this manuscript are the responsibility of the authors and the HEMAYAT Project/Jhpiego Corporation and do not necessarily reflect the views of USAID or the US Government.
None declared.