Impact of digital antenatal care intervention on paper-based antenatal care recordkeeping: a before-and-after study in primary healthcare facilities in Nepal

OBJECTIVE: To assess the impact of introducing electronic decision support systems (EDSS)-electronic data entry implemented alongside existing paper-based antenatal care (ANC) records-on the completeness and agreement of ANC records. DESIGN: Two-phase cross-sectional (before and after) substudy of the mobile health integrated model of hypertension, diabetes and ANC (mIRA project) process evaluation. SETTING: Four rural districts in Bagmati Province, Nepal, in 19 primary healthcare facilities. PARTICIPANTS: ANC records from pregnant women attending facilities before (n=136) and after (n=138) EDSS implementation. MAIN OUTCOME MEASURES: or Fisher's exact test, as appropriate, was used to assess differences in completeness before and after implementation. RESULTS: Completeness of paper-based ANC records was high before implementation (>90%) for all indicators, except tetanus vaccination (<80%). After EDSS implementation, there was >15% improvement in the completeness of tetanus vaccination date in paper-based ANC records (77.0%-96.4% for ANC cards and 81.9%-98.9% for ANC register). Agreement between the ANC card and ANC register increased slightly for all indicators after implementation, and the tetanus vaccination date showed the largest increase (38.2%-57.2%). Indicator completeness in the EDSS was low, ranging from 38.2% to 88.7%. CONCLUSION: We found slight improvements in the completeness and agreement of paper-based ANC records following EDSS implementation. The lower percentage of completeness in the EDSS suggests that any large-scale implementation should consider how to integrate digital and paper-based records to decrease the data entry burden on ANC providers. However, the study's small sample size limited the ability to examine variation in effects.