Implementation of a Technology-Based Mobile Obstetric Referral Emergency System (MORES): Qualitative Assessment of Health Workers in Rural Liberia
BackgroundMaternal mortality remains a persistent challenge in low- and middle-income countries, where evidence-based interventions of obstetric triage and prehospital communication remain sparse. There is limited implementation evidence for technology-based approaches to imp...
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JMIR Publications
2024-11-01
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| Series: | JMIR mHealth and uHealth |
| Online Access: | https://mhealth.jmir.org/2024/1/e58624 |
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| author | Christopher W Reynolds HaEun Lee Joseph Sieka Joseph Perosky Jody R Lori |
| author_facet | Christopher W Reynolds HaEun Lee Joseph Sieka Joseph Perosky Jody R Lori |
| author_sort | Christopher W Reynolds |
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BackgroundMaternal mortality remains a persistent challenge in low- and middle-income countries, where evidence-based interventions of obstetric triage and prehospital communication remain sparse. There is limited implementation evidence for technology-based approaches to improve obstetric care in such contexts. Liberia struggles with maternal mortality, particularly in rural areas where deaths are attributable to delays from absent triage and interfacility communication. We implemented a Mobile Obstetric Referral Emergency System (MORES) in rural Bong County to improve prehospital transfer, health worker attentiveness, and patient care for critical obstetric patients. MORES consisted of triage training and a 2-way, templated WhatsApp communication system to reduce delays among patients transferred from rural health facilities (RHF) to hospitals.
ObjectiveThis study aimed to examine MORES implementation outcomes of usability, fidelity, effectiveness, sustainability, and scalability, as well as additional impacts on the wider health system.
MethodsA structured case study design interview was developed by Liberian and US experts in obstetric triage. Participants included 62 frontline obstetric health providers including midwives (38/62, 61%), nurses (20/62, 32%), physicians assistants (3/62, 5%), and physicians (1/62, 2%) from 19 RHFs and 2 district hospitals who had used MORES for 1 year. Individual interviews were conducted on MORES implementation outcomes, transcribed, and analyzed in NVivo (version 12; Lumivero) with a team-based coding methodology. Content analysis with a deductive approach examined implementation outcomes of usability, fidelity, effectiveness, sustainability, and scalability, while an inductive approach categorized the unanticipated impacts of MORES on the wider health system.
ResultsFour domains were identified regarding MORES implementation: Usability and Fidelity, Effectiveness, Sustainability and Scalability, and Health System Impact. All participants perceived MORES to have high usability and fidelity, as the triage and messaging system was implemented as intended for critical obstetric patients (62/62, 100%). For effectiveness, MORES accomplished its intended aims by improving prehospital transfer (57/62, 92%), increasing health worker attentiveness (39/62, 63%), and contributing to improved patient care (34/62, 55%). MORES was perceived as sustainable and scalable (62/62, 100%), particularly if technological barriers (21/62, 34%) and staff training (19/62, 31%) were addressed. MORES impacted the wider health system in unanticipated ways including improved coordination and accountability (55/62, 89%), feedback mechanisms for hospitals and RHFs (48/62, 77%), interprofessional teamwork (21/62, 34%), longitudinal follow-up care (20/62, 32%), creating a record of care delays (17/62, 27%), and electronic health record infrastructure (13/62, 21%).
ConclusionsMORES was perceived to have high usability, fidelity, effectiveness, sustainability, and scalability by frontline obstetric providers in rural Liberia. MORES accomplished the intended aims of improving prehospital transfer, increasing health worker attentiveness, and contributing to improved patient care. Additionally, MORES strengthened the health system through 6 domains which impacted individual and system levels. Future studies should quantitatively evaluate delay and morbidity reductions and strategies for scaling MORES. |
| format | Article |
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| institution | OA Journals |
| issn | 2291-5222 |
| language | English |
| publishDate | 2024-11-01 |
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| series | JMIR mHealth and uHealth |
| spelling | doaj-art-1650e9760e7948ff9a3ebbcba69316da2025-08-20T02:14:43ZengJMIR PublicationsJMIR mHealth and uHealth2291-52222024-11-0112e5862410.2196/58624Implementation of a Technology-Based Mobile Obstetric Referral Emergency System (MORES): Qualitative Assessment of Health Workers in Rural LiberiaChristopher W Reynoldshttps://orcid.org/0000-0001-6634-391XHaEun Leehttps://orcid.org/0000-0002-1259-6425Joseph Siekahttps://orcid.org/0000-0003-0538-4501Joseph Peroskyhttps://orcid.org/0000-0002-1992-8111Jody R Lorihttps://orcid.org/0000-0003-0564-5783 BackgroundMaternal mortality remains a persistent challenge in low- and middle-income countries, where evidence-based interventions of obstetric triage and prehospital communication remain sparse. There is limited implementation evidence for technology-based approaches to improve obstetric care in such contexts. Liberia struggles with maternal mortality, particularly in rural areas where deaths are attributable to delays from absent triage and interfacility communication. We implemented a Mobile Obstetric Referral Emergency System (MORES) in rural Bong County to improve prehospital transfer, health worker attentiveness, and patient care for critical obstetric patients. MORES consisted of triage training and a 2-way, templated WhatsApp communication system to reduce delays among patients transferred from rural health facilities (RHF) to hospitals. ObjectiveThis study aimed to examine MORES implementation outcomes of usability, fidelity, effectiveness, sustainability, and scalability, as well as additional impacts on the wider health system. MethodsA structured case study design interview was developed by Liberian and US experts in obstetric triage. Participants included 62 frontline obstetric health providers including midwives (38/62, 61%), nurses (20/62, 32%), physicians assistants (3/62, 5%), and physicians (1/62, 2%) from 19 RHFs and 2 district hospitals who had used MORES for 1 year. Individual interviews were conducted on MORES implementation outcomes, transcribed, and analyzed in NVivo (version 12; Lumivero) with a team-based coding methodology. Content analysis with a deductive approach examined implementation outcomes of usability, fidelity, effectiveness, sustainability, and scalability, while an inductive approach categorized the unanticipated impacts of MORES on the wider health system. ResultsFour domains were identified regarding MORES implementation: Usability and Fidelity, Effectiveness, Sustainability and Scalability, and Health System Impact. All participants perceived MORES to have high usability and fidelity, as the triage and messaging system was implemented as intended for critical obstetric patients (62/62, 100%). For effectiveness, MORES accomplished its intended aims by improving prehospital transfer (57/62, 92%), increasing health worker attentiveness (39/62, 63%), and contributing to improved patient care (34/62, 55%). MORES was perceived as sustainable and scalable (62/62, 100%), particularly if technological barriers (21/62, 34%) and staff training (19/62, 31%) were addressed. MORES impacted the wider health system in unanticipated ways including improved coordination and accountability (55/62, 89%), feedback mechanisms for hospitals and RHFs (48/62, 77%), interprofessional teamwork (21/62, 34%), longitudinal follow-up care (20/62, 32%), creating a record of care delays (17/62, 27%), and electronic health record infrastructure (13/62, 21%). ConclusionsMORES was perceived to have high usability, fidelity, effectiveness, sustainability, and scalability by frontline obstetric providers in rural Liberia. MORES accomplished the intended aims of improving prehospital transfer, increasing health worker attentiveness, and contributing to improved patient care. Additionally, MORES strengthened the health system through 6 domains which impacted individual and system levels. Future studies should quantitatively evaluate delay and morbidity reductions and strategies for scaling MORES.https://mhealth.jmir.org/2024/1/e58624 |
| spellingShingle | Christopher W Reynolds HaEun Lee Joseph Sieka Joseph Perosky Jody R Lori Implementation of a Technology-Based Mobile Obstetric Referral Emergency System (MORES): Qualitative Assessment of Health Workers in Rural Liberia JMIR mHealth and uHealth |
| title | Implementation of a Technology-Based Mobile Obstetric Referral Emergency System (MORES): Qualitative Assessment of Health Workers in Rural Liberia |
| title_full | Implementation of a Technology-Based Mobile Obstetric Referral Emergency System (MORES): Qualitative Assessment of Health Workers in Rural Liberia |
| title_fullStr | Implementation of a Technology-Based Mobile Obstetric Referral Emergency System (MORES): Qualitative Assessment of Health Workers in Rural Liberia |
| title_full_unstemmed | Implementation of a Technology-Based Mobile Obstetric Referral Emergency System (MORES): Qualitative Assessment of Health Workers in Rural Liberia |
| title_short | Implementation of a Technology-Based Mobile Obstetric Referral Emergency System (MORES): Qualitative Assessment of Health Workers in Rural Liberia |
| title_sort | implementation of a technology based mobile obstetric referral emergency system mores qualitative assessment of health workers in rural liberia |
| url | https://mhealth.jmir.org/2024/1/e58624 |
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