Promoting Antenatal Care Attendance Through a Text Messaging Intervention in Samoa: Quasi-Experimental Study

BACKGROUND: Antenatal care (ANC) has the potential to improve maternal health, but it remains underutilized and unevenly implemented in many low- and middle-income countries. Increasingly, text messaging programs for pregnant women show evidence that they can improve the utilization of ANC during pregnancy; however, gaps remain regarding how implementation affects outcomes. OBJECTIVE: This study aimed to assess facilitators and barriers to implementation of an SMS text messaging intervention for pregnant women in Samoa and to assess its impact on ANC attendance. METHODS: This study took place in Upolu, Samoa, from March to August 2014 and employed a quasi-experimental design. Half (n=3) of the public antenatal clinics on the island offered adult pregnant women the SMS text messaging intervention, with 552 women registering for the messages. At the comparison clinics (n=3), 255 women registered and received usual care. The intervention consisted of unidirectional text messages containing health tips and appointment reminders. The outcome of interest was the number of attended antenatal visits. Implementation data were also collected through a survey of the participating midwives (n=7) and implementation notes. Data analysis included a comparison of women’s baseline characteristics between the two groups, followed by the use of negative binomial regressions to test for associations between participation in the intervention and increased ANC attendance, controlling for individual characteristics and accounting for the clustering of women within clinics. RESULTS: The comparison of ANC attendance rates found that women receiving the SMS text messaging intervention attended 15% fewer ANC visits than the comparison group (P=.004), controlling for individual characteristics and clustering. Data analysis of the implementation process suggests that barriers to successful implementation include women registering very late in pregnancy, sharing their phone with others, and inconsistent explanation of the intervention to women. CONCLUSIONS: These results suggest that unidirectional text messages do not encourage, and might even discourage, ANC attendance in Samoa. Interpreted with other evidence in the literature, these results suggest that SMS text messaging interventions are more effective when they facilitate better communication between patients and health workers. This study is an important contribution to our understanding of when SMS text messaging interventions are and are not effective in improving maternal health care utilization.