Using SMS and Interactive Voice Response to strengthen continuity of care for planned cesarean delivery in Uganda

Technical Summary: SMS and IVR for Continuity of Care in Planned Cesarean Delivery

Problem Statement
In sub-Saharan Africa, access to timely, safe cesarean delivery remains severely limited, with the region accounting for a disproportionate share of global maternal and perinatal deaths. While emergency cesareans are common (80–90% of cases), planned pre-labor cesareans for high-risk pregnancies are rare, despite being recommended to reduce morbidity and mortality. Achieving a planned cesarean requires robust continuity of care from the antenatal to the intrapartum period. However, in low-resource settings like Uganda, health workforce shortages and a lack of cesarean-specific birth preparedness interventions often result in women presenting for delivery in advanced labor, contrary to clinical guidelines. Existing mHealth interventions have largely focused on general birth preparedness for vaginal delivery or low-risk pregnancies, leaving a gap in evidence for high-risk pregnancies requiring surgical intervention.

Methodology
The authors conducted a prospective pilot study at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda between June 2024 and February 2025.

• Participants: 71 pregnant women (28 to <39 weeks gestation) with antenatally identified indications for pre-labor cesarean delivery (e.g., ≥2 prior cesareans, prior classical cesarean, persistent breech).
• Intervention: An mHealth educational tool using Short Message Service (SMS) and Interactive Voice Response (IVR) via the EngageSpark platform.
  • Content: Messages covered delivery timing, danger signs, logistical planning, and perioperative preparation.
  • Schedule: Messages were scheduled for 14, 7, and 2 days prior to the scheduled cesarean date.
  • Modality: At 14 and 7 days, participants received two SMS messages and one IVR call. At 2 days, they received one SMS and one IVR call. Messages were delivered in English or Runyankole based on preference.
  • Support: Participants could request follow-up calls for clarification, handled by research assistants or obstetricians.
• Data Collection: Feasibility was measured via platform-confirmed delivery, self-reported receipt, and IVR call duration. Acceptability was assessed via a post-delivery survey covering preferences, comprehension, satisfaction, and privacy concerns.
• Analysis: Descriptive statistics summarized outcomes. Feasibility and acceptability were compared between groups with adequate versus limited digital access.

Key Results

• Demographics: The cohort had a mean age of 31.6 years, with 93% having ≥2 prior cesarean sections. Digital readiness was high: 96% owned a personal phone, 99% had network access, and 100% had reliable charging access.
• Feasibility (Delivery and Engagement):
  • Reach: Due to early deliveries, 89%, 75%, and 56% of participants were still pregnant at the 14-day, 7-day, and 2-day message windows, respectively.
  • Delivery Fidelity: Platform-confirmed delivery rates were high: SMS ranged from 77% to 88%, and IVR from 86% to 92% among those still pregnant.
  • Engagement: Self-reported receipt closely mirrored platform data. IVR call durations were substantial, with a mean of 70–108 seconds and over 95% of calls exceeding 30 seconds, indicating active listening.
  • Digital Access: No significant differences in message delivery or receipt were observed between participants with adequate versus limited digital access.
• Acceptability:
  • Among 59 respondents, 100% rated message length and pacing as "just right" and found content easy to understand.
  • Preferences: 68% preferred SMS over IVR (32%). Most participants (98%) preferred weekly messaging.
  • Timing: The majority preferred afternoon (69%) or evening (27%) delivery.
  • Barriers: No participants reported concerns regarding privacy, network connectivity, or phone sharing.
• Clinical Outcomes: Of 69 participants with follow-up data, 97% delivered at MRRH. 87% were in early or no labor (<4 cm dilation) at the time of cesarean. There were no maternal deaths or stillbirths.

Key Contributions

1. Targeted mHealth for High-Risk Surgery: This study provides novel evidence on the use of combined SMS/IVR interventions specifically for cesarean-specific birth preparedness in high-risk pregnancies, a population previously underrepresented in mHealth literature.
2. Dual-Modality Design: By combining text (SMS) and voice (IVR), the intervention addresses varying literacy levels and phone access profiles, enhancing inclusivity in low-resource settings.
3. Integration with Clinical Workflows: The intervention was embedded within an existing cesarean scheduling system at a tertiary referral hospital, demonstrating a practical model for strengthening continuity of care without overburdening clinical staff.
4. Feasibility in Resource-Constrained Settings: The study demonstrates that high message delivery and engagement rates are achievable even in settings with infrastructure challenges, provided there is a baseline of digital readiness.

Significance and Claims
The paper concludes that an SMS/IVR intervention for cesarean-specific birth preparedness is highly feasible and acceptable among high-risk pregnant women in Uganda. The authors assert that such mHealth tools can play a critical role in strengthening the continuity of care for high-risk pregnancies, particularly where staffing constraints limit repeated in-person counseling.

The study modestly frames its findings as a pilot, noting that while the intervention is promising, further evaluation is required to assess:

• Clinical effectiveness in reducing emergency cesarean sections.
• Impact on maternal and neonatal outcomes.
• Scalability and generalizability to more rural settings with lower digital readiness.
• Integration with electronic scheduling systems for automated updates.

The authors emphasize that the intervention shows strong "contextual fit" but that long-term viability depends on addressing system-level factors, such as patient identification processes and integration with clinical records, to ensure the planned delivery pathway is executed effectively.