Role of reminder by text message in enhancing postnatal clinic attendance

Missing a postnatal clinic appointment affects completion of maternal care and contributes to maternal morbidity and mortality. It is unfortunate that postnatal clinic attendance has been consistently poor in Sub-Saharan Africa 1, 2. Various reasons have been adduced for this absenteeism; notably, forgetting the date, time, and possibly the location of the appointment 3. To date, no study has considered the influence of a reminder system on postnatal clinic attendance. With mobile phone ownership increasing rapidly in the region 4, there is potential for using short message service (SMS) technology as reminders to improve postnatal clinic attendance. The aim of the present study was to test the hypothesis that SMS reminders would reduce non-attendance rates at postnatal clinics in Ado-Ekiti, Nigeria. The study was conducted at Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria, from February 1 to July 31, 2013. The study protocol was approved by the hospital's ethics committee and informed consent was obtained from each participant. The primary outcome of interest was failure-to-attend (FTA) rate. The intervention group (SMS group) comprised patients who delivered during the study period, who were scheduled to attend a postnatal clinic, and who had provided a mobile telephone number in their hospital record. A historic control group was chosen, which comprised all patients who had delivered in the hospital within the preceding 6 months of the study (August 1, 2012, to January 31, 2013) and had been given an appointment to attend a postnatal clinic. Automated SMS reminders were sent twice to participants in the intervention group, at 2 weeks and then at 5 days before their scheduled clinic appointment. The text message read: “Good day. This is to remind you to attend your postnatal clinic on. Thank you. ” It was a one-way message sent during the day and a delivery report was obtained for each SMS sent. Record of actual clinic attendance by patients in the two groups was obtained from the outpatient scheduling system. Two-sample proportion tests were performed using Stata 11 (StataCorp LP, College Station, TX, USA) to compare FTA rate between the SMS group and the historic control group. Relative risks of non-attendance were presented with 95% confidence intervals; level of significance was set at P < 0. 05. Of the 1153 women in the intervention group that delivered during the study period, 1126 (97. 7%) women successfully received SMS reminders and analyses were based on those women. Among the intervention reminder group, FTA rate was 21. 3% (240/1126) (Table 1). The historic control group consisted of 971 patients and had an FTA rate of 42. 8% (416/971). Absolute reduction in FTA rate in those who received an SMS reminder was 21. 5%. This represents 243 patients who would otherwise have been lost to postnatal follow up. Patients who received an SMS reminder were 50% less likely to fail to attend their postnatal appointment (relative risk of FTA 0. 50; 95% CI, 0. 32 − 0. 77; P = 0. 002). The cost of sending an automated SMS was 1. 50 Naira (US 0. 00938). The total cost for 2252 SMS reminders (1126 × 2) during the 6 months of the study was 3387 Naira (US 21. 12). Extrapolation of annual cost of SMS reminders would be US 42. 24. In this setting, postnatal care is provided free of charge. The present study demonstrated that patients who had received SMS reminders were more likely to attend their postnatal clinic appointment (21. 3% v 42. 8%; P = 0. 002). The outcome supports the hypothesis that SMS reminders will reduce rates of non-attendance at postnatal clinics in this setting. Mobile phone penetration in the West Africa sub-region has been unprecedented and there are now 188 million subscribers. Nigeria has the largest share of 95 million mobile phone users 5. Virtually all homes except core rural areas have a means of mobile reach. Exploring the benefits of mobile technology in reducing maternal morbidity and mortality in Sub-Saharan Africa is a worthwhile project. The economic cost analysis of SMS reminders is negligible (US 42. 24 per annum in the present study), the text is automated, and staff training is not required. It can be presumed that, since postnatal care is provided free of charge in this setting, forgetfulness of the date and time of the appointment is more likely to account for clinic absenteeism. The present study has some limitations. Firstly, the use of an historic control group raises the question that the observed difference in FTA rate may be due to seasonal variation. However, return for postnatal care in this environment has been notoriously low for many years, making this assumption of little value. Secondly, despite ascertaining that the texts had been successfully delivered, it was not possible to know whether they had been received by the correct recipients. Two-way text messaging that allows for the recipient to reply will be more appropriate for future studies. Thirdly, although unlikely to influence the overall study outcome, sociodemographic information for both groups was not available. A randomized control trial on this subject would be beneficial. Further areas of research will include the use of text reminders for prenatal clinic appointments, child vaccination programs, and drug compliance. In conclusion, text reminders led to a 50% reduction in failure to attend postnatal clinic appointments. Policymakers should consider its implementation within maternal health services in Sub-Saharan Africa. The authors have no conflicts of interest.