Moving beyond silos: How do we provide distributed personalized medicine to pregnant women everywhere at scale? Insights from PRE-EMPT.

While we believe that pre-eclampsia matters-because it remains a leading cause of maternal and perinatal morbidity and mortality worldwide-we are convinced that the time has come to look beyond single clinical entities (e.g. pre-eclampsia, postpartum hemorrhage, obstetric sepsis) and to look for an integrated approach that will provide evidence-based personalized care to women wherever they encounter the health system. Accurate outcome prediction models are a powerful way to identify individuals at incrementally increased (and decreased) risks associated with a given condition. Integrating models with decision algorithms into mobile health (mHealth) applications could support community and first level facility healthcare providers to identify those women, fetuses, and newborns most at need of facility-based care, and to initiate lifesaving interventions in their communities prior to transportation. In our opinion, this offers the greatest opportunity to provide distributed individualized care at scale, and soon

Usability and Feasibility of PIERS on the Move: An mHealth App for Pre-Eclampsia Triage.

BACKGROUND: Pre-eclampsia is one of the leading causes of maternal death and morbidity in low-resource countries due to delays in case identification and a shortage of health workers trained to manage the disorder. Pre-eclampsia Integrated Estimate of RiSk (PIERS) on the Move (PotM) is a low cost, easy-to-use, mobile health (mHealth) platform that has been created to aid health workers in making decisions around the management of hypertensive pregnant women. PotM combines two previously successful innovations into a mHealth app: the miniPIERS risk assessment model and the Phone Oximeter. OBJECTIVE: The aim of this study was to assess the usability of PotM (with mid-level health workers) for iteratively refining the system. METHODS: Development of the PotM user interface involved usability testing with target end-users in South Africa. Users were asked to complete clinical scenario tasks, speaking aloud to give feedback on the interface and then complete a questionnaire. The tool was then evaluated in a pilot clinical evaluation in Tygerberg Hospital, Cape Town. RESULTS: After ethical approval and informed consent, 37 nurses and midwives evaluated the tool. During Study 1, major issues in the functionality of the touch-screen keyboard and date scroll wheels were identified (total errors n=212); during Study 2 major improvements in navigation of the app were suggested (total errors n=144). Overall, users felt the app was usable using the Computer Systems Usability Questionnaire; median (range) values for Study 1 = 2 (1-6) and Study 2 = 1 (1-7). To demonstrate feasibility, PotM was used by one research nurse for the pilot clinical study. In total, more than 500 evaluations were performed on more than 200 patients. The median (interquartile range) time to complete an evaluation was 4 min 55 sec (3 min 25 sec to 6 min 56 sec). CONCLUSIONS: By including target end-users in the design and evaluation of PotM, we have developed an app that can be easily integrated into health care settings in low- and middle-income countries. Usability problems were often related to mobile phone features (eg, scroll wheels, touch screen use). Larger scale evaluation of the clinical impact of this tool is underway

Mobile phone apps for clinical decision support in pregnancy: a scoping review

BACKGROUND: The use of digital technology in healthcare has been found to be useful for data collection, provision of health information and communications. Despite increasing use of medical mobile phone applications (apps), by both clinicians and patients, there appears to be a paucity of peer-reviewed publications evaluating their use, particularly in pregnancy. This scoping review explored the use of mobile phone apps for clinical decision support in pregnancy. Specific objectives were to: 1. determine the current landscape of mobile phone app use for clinical decision support in pregnancy; 2. identify perceived benefits and potential hazards of use and 3. identify facilitators and barriers to implementation of these apps into clinical practice. METHODS: Papers eligible for inclusion were primary research or reports on the development and evaluation of apps for use by clinicians for decision support in pregnancy, published in peer-reviewed journals. Research databases included Medline, Embase, PsychoInfo, the Cochrane Database of Systematic Reviews and the online digital health journals JMIR mHealth and uHealth. Charting and thematic analysis was undertaken using NVivo qualitative data management software and the Framework approach. RESULTS: After screening for eligibility, 13 papers were identified, mainly reporting early stage development of the mobile app, and feasibility or acceptability studies designed to inform further development. Thematic analysis revealed four main themes across the included papers: 1. acceptability and satisfaction; 2. ease of use and portability; 3. multi-functionality and 4. the importance of user involvement in development and evaluation. CONCLUSIONS: This review highlights the benefits of mobile apps for clinical decision support in pregnancy and potential barriers to implementation, but reveals a lack of rigorous reporting of evaluation of their use and data security. This situation may change, however, following the issue of FDA and MHRA guidelines and implementation of UK government and other international strategies. Overall, the findings suggest that ease of use, portability and multi-functionality make mobile apps for clinical decision support in pregnancy useful and acceptable tools for clinicians

Mobile Clinical Decision Support Systems – A Systematic Review

In this review article, we provide a descriptive analysis of the current state of mobile decision support systems in the healthcare domain based on studies published in the following databases: Business Source Complete, CINAHL, Cochrane library, MEDLINE, PsycINFO, PubMed, ScienceDirect and Web of Science databases. A total of 29 studies were identified and analyzed to understand the current state of development, evaluation efforts, usability and challenges to adoption by patients and care providers. Our aim is to evaluate these systems and identify the key challenges which hinders their widespread adoption. Although, mobile based decision support systems in healthcare context have the potential to improve clinical decision making, the current state with low adoption rate and early stage of development need to be addressed for successful health outcomes

Cardiometabolic Risk Factors in Pregnancy and Implications for Long-Term Health: Identifying the Research Priorities for Low-Resource Settings.

Cardiometabolic disorders (CMDs), including ischemic heart disease, stroke and type 2 diabetes are the leading causes of mortality and morbidity in women worldwide. The burden of CMDs falls disproportionately on low and middle-income countries (LMICs), placing substantial demands on already pressured health systems. Cardiometabolic disorders may present up to a decade earlier in some LMIC settings, and are associated with high-case fatality rates. Early identification and ongoing postpartum follow-up of women with pregnancy complications such as hypertensive disorders of pregnancy (HDPs), and gestational diabetes mellitus (GDM) may offer opportunities for prevention, or help delay onset of CMDs. This mini-review paper presents an overview of the key challenges faced in the early identification, referral and management of pregnant women at increased risk of CMDs, in low-resource settings worldwide. Evidence-based strategies, including novel diagnostics, technology and innovations for early detection, screening and management for pregnant women at high-risk of CMDs are presented. The review highlights the key research priorities for addressing cardiometabolic risk in pregnancy in low-resource settings

Development and internal validation of a multivariable model to predict perinatal death in pregnancy hypertension

Objective To develop and internally validate a prognostic model for perinatal death that could guide community-based antenatal care of women with a hypertensive disorder of pregnancy (HDP) in low-resourced settings as part of a mobile health application. Study Design Using data from 1688 women (110 (6.5%) perinatal deaths) admitted to hospital after 32 weeks gestation with a HDP from five low-resourced countries in the miniPIERS prospective cohort, a logistic regression model to predict perinatal death was developed and internally validated. Model discrimination, calibration, and classification accuracy were assessed and compared with use of gestational age alone to determine prognosis. Main outcome measures: Stillbirth or neonatal death before hospital discharge. Results The final model included maternal age; a count of symptoms (0, 1 or ⩾ 2); and dipstick proteinuria. The area under the receiver operating characteristic curve was 0.75 [95% CI 0.71 - 0.80]. The model correctly identified 42/110 (38.2%) additional cases as high-risk (probability >15%) of perinatal death compared with use of only gestational age <34 weeks at assessment with increased sensitivity (48.6% vs. 23.8%) and similar specificity (86.6% vs. 90.0%). Conclusion Using simple, routinely collected measures during antenatal care, we can identify women with a HDP who are at increased risk of perinatal death and who would benefit from transfer to facility-based care. This model requires external validation and assessment in an implementation study to confirm performance

Exploration of how a mobile health (mHealth) intervention may support midwives in the management and referral of women with pre-eclampsia in rural and remote areas of highland Scotland.

Mobile health (mHealth) interventions have elsewhere been shown to support midwives in the early identification of pregnancy complications in rural and remote locations. The purpose of this thesis was to undertake a qualitative and descriptive investigation into whether an mHealth intervention might be acceptable and useful to rural midwives in detecting and managing women who are presenting with possible pre-eclampsia, and in making timely referrals. The study also investigated whether an mHealth intervention might offer any advantage and/or improvement over current practice. Globally, hypertensive disorders account for 12% of all maternal deaths and, in the UK, pre-eclampsia affects up to 6% of pregnant women. Severe cases of eclampsia, progressing from pre-eclampsia, develop in up to 2% of these pregnancies. The early identification of pre-eclampsia and being able to appropriately manage it before the onset of eclampsia is recognised as a way to prevent complications, and to mitigate the worst effects of pre-eclampsia. This study made use of the growing body of evidence on the efficacy of mobile health (mHealth) interventions. It explored whether such interventions could support midwives in the management of women with pre-eclampsia in rural and remote settings in the Scottish highlands. The research involved gathering and analysing data from midwives (n=18) at three focus groups in Highland Scotland during June and July 2017. These midwives were asked to consider whether a new mLearning/ mHealth toolkit might support their practice regarding women presenting with pre-eclampsia. The investigation found that geographic and digital isolation are real challenges, and most of the midwives in the study saw advantages in an intervention that requires no internet connectivity. They welcomed being able to work on their continuous professional development (CPD) whilst on the move, as well as the inclusion of an audio-visual module to help explain pre-eclampsia to women. However, participants were less in agreement on the value to midwives of an intervention that provided advice on how to diagnose pre-eclampsia, although it was suggested that this could be of value to healthcare practitioners with less experience of pre-eclampsia. This thesis contributes to the emergent body of knowledge concerning the need for and efficacy of mHealth interventions in reproductive, maternal and child health, and may help to inform future initiatives in other regions and cultures. The study has also informed the parallel development of a prototype device that is currently being tested with multidisciplinary healthcare teams in highland Scotland. This thesis also suggests that there is the potential to develop a tool that could assist in building psycho-social resilience and support retention among midwives and other healthcare workers, in rural and remote areas of Scotland and other locations. The scope of this study was limited in that participants were recruited from only one health board, and in that it focused only on pre-eclampsia. Further research could expand the scope to widen participation or address other areas

Medical mobile technologies - what is needed for a sustainable and scalable implementation on a global scale?

Current advances within medical technology show great potential from a global health perspective. Inexpensive, effective solutions to common problems within diagnostics, medical procedures and access to medical information are emerging within almost all fields of medicine. The innovations can benefit health care both in resource-limited and in resource-rich settings. However, there is a big gap between the proof-of-concept stage and implementation. This article will give examples of promising solutions, with special focus on mobile image-and sensor-based diagnostics. We also discuss how technology and frugal innovations could be made sustainable and widely available. Finally, a list of critical factors for success is presented, based on both our own experiences and the literature.Peer reviewe

Preventing deaths due to the hypertensive disorders of pregnancy:Ending Preventable Maternal and Newborn Deaths

In this chapter, taking a life cycle and both civil society and medically oriented approach, we will discuss the contribution of the hypertensive disorders of pregnancy (HDPs) to maternal, perinatal and newborn mortality and morbidity. Here we review various interventions and approaches to preventing deaths due to HDPs and discuss effectiveness, resource needs and long-term sustainability of the different approaches. Societal approaches, addressing sustainable development goals (SDGs) 2.2 (malnutrition), 3.7 (access to sexual and reproductive care), 3.8 (universal health coverage) and 3c (health workforce strengthening), are required to achieve SDGs 3.1 (maternal survival), 3.2 (perinatal survival) and 3.4 (reduced impact of non-communicable diseases (NCDs)). Medical solutions require greater clarity around the classification of the HDPs, increased frequency of effective antenatal visits, mandatory responses to the HDPs when encountered, prompt provision of life-saving interventions and sustained surveillance for NCD risk for women with a history of the HDPs

Utilisation of Digital Health in Early Detection and Treatment of Pre-Eclampsia in Primary Health Care Facilities South Africa: Literature Review

Gestational hypertension and pre-eclampsia are the most prevalent in Sub-Saharan Africa leading to undesirable perinatal and maternal outcomes. In South Africa, a high rate of maternal death was noted due to pre-eclampsia. However, the use of digital maternal health in South Africa has become of significance for reinforcement of health care. Digital health initiatives such as mobile health technologies were developed to improve better access to communities in low and middle-income countries. The implementation and practices of digital health seem to be growing expandable to achieve the UHC goals in the provision of care to all globally and nationally. This review aims to review existing literature on the use of digital maternal health to minimise admission of pre-eclampsia and early identification of gravid women who are at risk of developing pre-eclampsia