Aim of this review
We assessed the effect of sending targeted messages by mobile devices to pregnant women and parents of young children about health and healthcare services.
Key messages
There are gaps in the evidence regarding the effects of targeted messages by mobile devices to pregnant women and parents of young children about health and healthcare services. Some of these messages may improve some people's health and their use of health services, but others may make little or no difference. The existing evidence is mostly of low or very low certainty.
What was studied in the review?
Targeted client communication (TCC) is an intervention in which the health system sends information to particular people, based on their health status or other factors specific to that population group. Common types of TCC are text messages reminding people to attend appointments or that offer healthcare information and support. Our review assessed whether TCC can change pregnant women's and parents' behaviour, health service use, health, and well-being.
What happens when pregnant women receive targeted messages by mobile device?
Compared to women who get no messages
Women may breastfeed more in settings where exclusive breastfeeding is not common. They may also go to more antenatal care appointments. They may use skilled birth attendants more where this is less common. We do not know if the messages affect women's or babies' health because the certainty of the evidence is very low.
Compared to women who get messages sent in other ways
Women and newborns may have fewer health problems during the first 10 days after birth. The messages may make little or no difference to the number of women who breastfeed. We do not know if they make women use more health services.
Compared to women who get untargeted messages
The messages may make little or no difference to whether women get influenza vaccines during pregnancy. We do not know if the messages affect women's or babies' health or lead women to use skilled birth attendants more because the evidence is lacking or of very low certainty.
What happens when pregnant women living with HIV receive targeted messages by mobile device?
Compared to women who get no messages
Women may go to slightly more antenatal care appointments. We do not know whether the messages lead more women to give birth in a health facility or improve babies' health because the evidence is of very low certainty. The messages may make little or no difference to whether pregnant women and babies follow antiretroviral (ARV) treatment (used to treat HIV) according to plan. We do not know if the messages affect women's health because the evidence is missing.
Compared to women who get messages sent in other ways
We do not know what the effect of these messages is because we lack evidence.
Compared to women who get untargeted messages
More parents may follow their babies' ARV treatment according to plan. We do not know if the messages improve women's or babies' health or their use of services because the evidence is missing.
What happens when parents of young children receive targeted messages by mobile device?
Compared to parents who get no messages
More parents may take their children to healthcare services such as vaccination appointments. But we do not know if the messages improve children's health or their health behaviour because the evidence is missing.
Compared to parents who get messages sent in other ways
Slightly more parents may take their children to vaccination appointments. The messages may make little or no difference to children's toothbrushing habits. We do not know if the messages affect children's health because the evidence is missing.
Compared to parents who get untargeted messages
Fewer parents may take their children to vaccination appointments, but this evidence is mixed. We do not know if the messages affect children's health due to lack of evidence.
How up-to-date is this review?
We searched for studies published up to August 2017. We carried out a search update in July 2019 and relevant studies are reported in the 'Characteristics of studies awaiting classification' section.
The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High-quality, adequately powered trials and cost-effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality.
The global burden of poor maternal, neonatal, and child health (MNCH) accounts for more than a quarter of healthy years of life lost worldwide. Targeted client communication (TCC) via mobile devices (MD) (TCCMD) may be a useful strategy to improve MNCH.
To assess the effects of TCC via MD on health behaviour, service use, health, and well-being for MNCH.
In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.
We included randomised controlled trials that assessed TCC via MD to improve MNCH behaviour, service use, health, and well-being. Eligible comparators were usual care/no intervention, non-digital TCC, and digital non-targeted client communication.
We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second.
We included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low-, middle- or high-income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle-income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls.
Pregnant and postpartum women
TCCMD versus standard care
For behaviours, TCCMD may increase exclusive breastfeeding in settings where rates of exclusive breastfeeding are less common (risk ratio (RR) 1.30, 95% confidence intervals (CI) 1.06 to 1.59; low-certainty evidence), but have little or no effect in settings where almost all women breastfeed (low-certainty evidence). For use of health services, TCCMD may increase antenatal appointment attendance (odds ratio (OR) 1.54, 95% CI 0.80 to 2.96; low-certainty evidence); however, the CI encompasses both benefit and harm. The intervention may increase skilled attendants at birth in settings where a lack of skilled attendants at birth is common (though this differed by urban/rural residence), but may make no difference in settings where almost all women already have a skilled attendant at birth (OR 1.00, 95% CI 0.34 to 2.94; low-certainty evidence). There were uncertain effects on maternal and neonatal mortality and morbidity because the certainty of the evidence was assessed as very low.
TCCMD versus non-digital TCC (e.g. pamphlets)
TCCMD may have little or no effect on exclusive breastfeeding (RR 0.92, 95% CI 0.79 to 1.07; low-certainty evidence). TCCMD may reduce 'any maternal health problem' (RR 0.19, 95% CI 0.04 to 0.79) and 'any newborn health problem' (RR 0.52, 95% CI 0.25 to 1.06) reported up to 10 days postpartum (low-certainty evidence), though the CI for the latter includes benefit and harm. The effect on health service use is unknown due to a lack of studies.
TCCMD versus digital non-targeted communication
No studies reported behavioural, health, or well-being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low-certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low-certainty evidence).
Pregnant and postpartum women living with HIV
TCCMD versus standard care
For behaviours, TCCMD may make little or no difference to maternal and infant adherence to antiretroviral (ARV) therapy (low-certainty evidence). For health service use, TCC mobile telephone reminders may increase use of antenatal care slightly (mean difference (MD) 1.5, 95% CI –0.36 to 3.36; low-certainty evidence). The effect on the proportion of births occurring in a health facility is uncertain due to very low-certainty evidence. For health and well-being outcomes, there was an uncertain intervention effect on neonatal death or stillbirth, and infant HIV due to very low-certainty evidence. No studies reported on maternal mortality or morbidity.
TCCMD versus non-digital TCC
The effect is unknown due to lack of studies reporting this comparison.
TCCMD versus digital non-targeted communication
TCCMD may increase infant ARV/prevention of mother-to-child transmission treatment adherence (RR 1.26, 95% CI 1.07 to 1.48; low-certainty evidence). The effect on other outcomes is unknown due to lack of studies.
Parents of children aged less than five years
No studies reported on correct treatment, nutritional, or health outcomes.
TCCMD versus standard care
Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low-certainty evidence); however, the effect estimates varied widely between studies.
TCCMD versus non-digital TCC
TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low-certainty evidence), and may make little or no difference to oral hygiene practices (low-certainty evidence).
TCCMD versus digital non-targeted communication
TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low-certainty evidence).
No trials in any population reported data on unintended consequences.