Impact of digital intervention on antenatal paper records: results from audit of antenatal records

BACKGROUND: Good recordkeeping is important in antenatal care (ANC). The mIRA study aimed to improve ANC quality through tablet-based electronic decision support systems (EDSS). Electronic data entry was implemented alongside existing paper-based ANC records, adding an additional record-keeping requirement for health care providers. This study assesses the impacts of the EDSS on paper-based ANC records. METHODS: The audit was conducted in 19 primary healthcare facilities in Nepal. We examined pregnant women's records before (n = 136) and after (n = 138) EDSS implementation. For eight selected indicators in the ANC card and ANC register, we estimated the percentage completeness (any value recorded) and agreement (whether values matched), comparing results before and after intervention, additionally examining EDSS records. RESULTS: Completeness of paper ANC records was high before intervention (>90% for all indicators, except for tetanus toxoid vaccination). There was general trend towards variables being more complete after implementation of the EDSS for both the ANC card and the ANC register. There was >15% improvement in completeness and in agreement of tetanus toxoid vaccination date records in ANC cards and ANC registers after the intervention. Completeness of variables in the EDSS was low, suggesting recordkeeping in ANC cards and ANC registers was prioritized. Percentage agreement increased slightly in all eight indicators after intervention. Amongst the selected eight indicators, only women's age records showed >90% agreement both before and after the intervention. CONCLUSIONS: EDSS did not have a negative impact on paper-based ANC records. Digital records are widely being used in high-income countries and the increasing implementation of electronic health records in low-resource settings increases the demand for evidence to understand the feasibility and impacts of digital health interventions in real-world settings. KEY MESSAGES: • The additional recordkeeping required by the EDSS resulted in general improvements in the completeness and agreement of ANC paper records. • Large-scale EDSS implementation should consider how to integrate digital and paper-based records to decrease burden on healthcare providers, and improve the standard of records.