Maternal_Monitoring_System

Maternal Monitoring: Lowering Child Mortality by Use of ICTs Ssemaluulu Paul Department of Information Technology Faculty of Computing and IT, Makerere University pssemaluulu@cit.mak.ac.ug Muma Wycliff Department of Information Technology Faculty of Computing and IT, Makerere University wycliffmuma@yahoo.com Katongole Paul Department of Information Technology Faculty of Computing and IT, Makerere University pkatongole@cit.mak.ac.ug Mwase Maria Department of Information Technology Faculty of Computing and IT, Makerere University mwase.maria@cit.mak.ac.ug mwase.maria@gmail.com In this paper, we describe the implementation of an Electronic Health Records System that automates record keeping procedures for both patients and medical practitioners in a health facility. We also demonstrate how maternal monitoring using ICTs can lower child mortality in developing countries. It should be realized that lowering child mortality is one of the 8 millennium development goals to be achieved by less developed countries by 2015. The Infant and Maternal Monitoring System seeks to lower infant mortality rates by encouraging pregnant women, as well as mothers to take their new born babies and infants to visit the nearest health centers for required healthcare checkups, vaccinations or immunizations . This has been achieved through the creation and use of SMS functionality on the created system. This system improves communication and collaboration between medical practitioners through discussion forums, thus increasing the rapidity and quality of patient care Keywords: ICTs, Maternal, Mortality 1. INTRODUCTION The United Nations ranks “Reducing Infant Mortality” as the fourth goal in the Millennium Development Goals (MDGs) to be achieved by 2015. Every year worldwide, four million infants die within their first month of life, representing nearly 40 percent of all deaths of children under age of five years. Almost all newborn deaths are in developing countries with the highest number in South Asia and the highest rates in sub-Saharan Africa (Sines et al., 2007). In Uganda the infant mortality rate is still abnormally high, with as many as 137 children out of 1,000 live births dying before their fifth birthday. On the other hand, 76 infants out of every 1,000 live births die before their first birthday (Mukasa, 2008). High quality prenatal and post natal care improves the survival and health of infants, while providing an entry point for health contacts with the pregnant women and mothers at a key point in the continuum of care (Lincetto et al., 2006). If provided, promoted, monitored, researched, and further tested, health care services such as: antenatal care and vaccinations will create lasting improvements in health systems and constitute major progress in meeting the MDGs. More importantly, it will save the lives of thousands of mothers and children annually (Sines et al., 2007). Lincetto et al., (2006) consider pregnancy as a crucial time to promote healthy behaviors and parenting skills. Good antenatal-care links the woman and her family with the formal health system, hence contributing to good health through the life cycle. Inadequate care during this time breaks a critical link in the continuum of care, and affects both women and their babies. One proposed explanation hindering the progress in lowering infant mortality in Uganda has been a decline in vaccinations, especially in the late 1990s. Moller (2002), states that the overall share of fully immunized children fell from 47% in 1995 to 37% in 2000 yet vaccinations are directly relevant to lowering infant mortality. Also, the share of pregnant women receiving at least one tetanus toxoid injection has fallen during this period, to the detriment of progress on infant mortality. Nevertheless, the recent substantial increases in public health expenditures should help to reverse these trends. In the past 20 years Information Technology (IT) has revolutionized virtually every facet of people’s everyday lives. Organizations of all types have long seen that IT when viewed comprehensively and deployed effectively can replace old challenges with new possibilities. However, one of the areas of slow evolution is the healthcare system. The Infant and Maternal Monitoring System is one such feasible solution, its practical uses are discussed below: Pinto (2006) notes that an automated Electronic Health Records System, (such as the Infant and Maternal Monitoring System), creates efficiencies and dramatically streamlines processes such as: patient registration and records management. It also improves communication by offering an intellectual knowledge base for medical practitioners over discussion forums which eases the rapidity of patient care. Poissant and Kawasumi (2005) noted that an Electronic Health Records System offers more comprehensive security measures than previously used methods such as locked cupboards or room storage. Password protection limits access to patient information to authorized users: Doctors, Nurses, and Midwives. In addition to the above, it solves the archived-records dilemma where pre-existing health records are in paper form. An electronic record stores both archived and active patient records in a centralized database (Pinto, 2006). It manifests itself as a cost-effective and technologically-viable alternative to manually paper-based patient record keeping and ensures that medical practitioners have access to the right patient data at the right time. An Electronic Health Records System efficiently reduces documentation time, and leads to better patient care with an increase in patient-interaction time (Jareethum and Titapant 2008; Poissant and Kawasumi, 2005) such as the implementation of the Infant and Maternal Monitoring System. 2. METHODOLOGY Before the model for the Infant and Maternal Monitoring System was designed, medical professionals within random health care units within Kampala city, in Uganda were given questionnaires and later interviewed. This involved Doctors, Nurses and Midwives all of reputable healthcare centers and having over 3 years experience in the fields of antenatal and infant health care. Purposive sampling was used, taking into account the reputation of the health care unit and the number of years the healthcare personnel had worked at their job. This led us to have 16 highly experiencing people from 4 randomly selected health units in Kampala. 3. ANALYSIS OF COLLECTED DATA Noting that in a standard health center, slightly over 350 pregnant women are registered annually, while considering the fact that approximately 200 of them complete the recommended minimum of 4 antenatal care visits. Each antenatal checkup over the course of the pregnancy (9 months or 3 trimesters) is of great importance in terms of effectively monitoring the health, progress and development of both the mother-to-be and her child. Table 1: The relevance of health care services |PREGNANCY STAGE |HEALTH CARE SERVICES |RELEVANCE | |First Trimester |Early trimester: |To confirm the pregnancy | |(1-3 months) |Health history is noted | | | |Physical examination | | | |Blood and urine tests carried out. | | | |Late trimester: |The ultrasound provides an image of the foetus and placenta.| | |Foetal ultrasound is performed | | | |Listen for a foetal heart beat using a Doppler |Screening tests uses your blood or urine sample to check | | |Pelvic Exam , Pap Smear and Breast Exam |perform a battery of tests especially where infections or | | |Blood Screening for HIV, amongst others |discrepancies are suspected so that the correct precautions| | |Blood pressure is checked |are taken | | |Mother’s weight is recorded |All the performed examinations serve to check the | | |Urine screening for protein and sugar |developmental progress of both mother and child | | |The fundal height is measured to check baby's growth | | | |Additional prenatal testing as needed | | |Second Trimester |Foetal ultrasound |Ultrasounds are used to monitor foetal heart beat and to | |(4-6 months) |Record mother’s weight |identify any foetal problems in growth | | |Fundal height is measured to check baby's growth |Screening tests uses blood or urine samples to check perform| | |Blood pressure is checked |a battery of tests especially where infections or | | |Urine sample is screened |discrepancies are suspected so that the correct precautions | | |Blood screening for HIV amongst others. |are taken. | |Third Trimester |Foetal ultrasound |Ultrasounds are used to monitor foetal heart beat and to | |(7-9 months) |Blood screening HIV amongst others |identify any foetal problems that may bring about high risk | | |Ultrasound scan |factor in delivery | | |Clinical examination |Screening tests uses blood or urine samples to check perform| | |Foetal and placental check |a battery of tests especially where infections or | | |Urine sample to screen for sugar and protein |discrepancies are suspected so that the correct precautions| | |Mother’s weight is recorded |are taken | | |Listen for baby's heart beat | | | |Palpate to check baby's position (vertex, breech, posterior,| | | |etc.) | | | |Fundal height is measured to check baby's growth | | | |Reviewing of delivery plan | | | |Mother’s blood pressure is checked | | | |Other Prenatal Testing Basics | | NOTE: All pregnant women ought to be screened for Human Immuno-deficiency Virus (HIV) infection to help prevent newborn HIV infection. Many pregnant women that fail to go for their antenatal checkups give their health care providers a number of reasons. These range from ignorance and/or forgetfulness, inadequate finances to pay off medical bills, and long distances from health centers. [pic]Figure 1: A pie chart showing ranking reasons women give for missing antenatal checkups As observed in Fig.1 above, ignorance of these women on how important these antenatal checkups are stands out as one of the areas that can be tackled to improve child mortality. Others attribute it to mere forgetfulness, however these expectant women assume that since they feel fine or healthy it is okay to dismiss these checkups. The presents a problem that the Infant and Maternal Monitoring System may remedy this using its SMS functionality; which will constantly remind these women to go for these much needed medical checkups. Out of the approximate 30 births recorded monthly in an average health center, it is estimated that 50 to 90 mothers out of the annually recorded 350 start and finish the immunization process. Many of these mothers also believe in the use of traditional remedies or self medication on their children for a number of treatable illnesses such as Malaria. These activities have influenced the numbers of recorded infection rates of both immunizable diseases and treatable illnesses in comparison to other ailments such as this is illustrated in Fig.2 below [pic] Figure 2: A bar chart showing disease contraction of infants in an average health center Most infant deaths result from a combination of preventable or treatable diseases such as: acute respiratory infections like Pneumonia, Diarrhea, and Malaria and immunizable diseases such as: Tuberculosis and Measles. Some of these diseases can easily be prevented through simple improvements in basic health services and proven interventions, such as oral rehydration therapy, insecticide-treated mosquito nets and vaccinations. Though the government through the Ministry of Health has endeavored to curb these high infant mortality rates by carrying out malaria awareness campaigns calling for the use of insecticide-treated mosquito nets, and recent immunization drives, the above as well as other factors still contribute to such high statistics. These are given in Table 2 below. Table 2: Factors that contribute to such high infant mortality rates |FACTORS |REASONS | |Poor immunization coverage |A notable drop in immunization levels from 47% in 1995 to 37% in 2000 as noted by Moller (2002). | | |Low political support for vaccination policies. | | |Lack of popularity for the National Immunization Programme. | |Malnutrition or under-nutrition |Families especially in rural Uganda cannot afford to have a balanced diet which is vital to the proper| | |growth and development of a child’s health. | |Low socio-economic status |Families usually cannot afford basic health care this is worsened by recent economic turmoil with the | | |“credit crunch”- where prices seem to have sky rocketed. | |Poor antenatal and post natal care |Inadequate services: | | |One midwife having over 200 pregnant women to oversee. | | |The proportion of deliveries assisted by a trained medical professional was essentially stagnant at | | |38% in 1989 and 39% in 2001 | | |Poor attitude of health workers who are overworked and underpaid | |High HIV infection rates amongst |The presence of HIV has serious implications for antenatal care and delivery , it increases risks of | |pregnant women |maternal and infant mortality | |Mothers lack of a basic education. |This is especially because of the high number of Adolescent pregnancies which contributes to the cycle| | |of maternal deaths and childhood mortality | All in all, the medical professionals were in total agreement that by reminding pregnant women to have antenatal checkups and as well as reminding mothers or guardians to bring their children for immunization would be a positive step toward lowering infant mortality rates especially if implemented alongside with the already existing health campaigns that the Ministry of Health has already put in place. 4. DESIGN The existing medical Information System uses paper-based records with specialized cards designed by the Ministry of Health for healthcare units in Uganda. In a given health care facility, a pregnant woman is presented with an antenatal card which is used to capture their background information as well as some health related questions. This information is helpful to the midwife or doctor that is administering pre-natal health care. This same card serves as a progress form for the pregnant woman for the duration of her pregnancy, with the aim of ensuring normal foetal health and development. In the case of an infant, a child health card is presented at birth indicating birth weight, other relevant health information and background information. It is using this form that an infant’s health progress is monitored in terms of immunization, de-worming, weight gain and general growth to ensure normal progress. Patients are registered once, after which with each visit their medical records (cards) are pulled up for viewing and to check on their medical progress. 4.1 User Requirements The system has the following specified user requirements: 1. Midwives should be able to view and update information about patients 2. Doctors should be able to view information about patients 3. Nurses should be able to enter the data provided by the patients. 4.2 Functional Requirements The following are the system’s functional requirements: 1. The system should capture processes and store patient information. 2. The Infant and Maternal Monitoring System should permit the querying of patient records by authorized users. 3. The system should allow users to view patient information as needed and generates patient reports based on end users command. 4. The system should send SMS text messages to respective patients when necessary. 5. The system users should be able to post articles on the website as well as discuss topics in the discussion forum. 6. The system should be able to computing estimated date of delivery. 4.3 System Architecture [pic] Figure 3: Infant Maternal Monitoring System SMS Functionality using Ozeki Message Server [Adapted from http://www.ozeki.hu] 5. IMPLEMENTATION • MS SQL 2005 was the Database Management System (DBMS) used to implement the system’s database. It was chosen because it was an easy to use, highly customizable yet low maintenance as a database management system. • IIS (Internet Information Service): a web server application developed as a part of Windows server 2003 OS; with the aim of hosting web applications for example websites or other application that require web connectivity to share and access resource. It acts as the system’s web server and functions as a launch pad for sending short messages to the different mothers. • Ozeki: an SMS Messaging Server serves as an interface between the system application and the telecom company service provider which then routes messages to the respective patient’s mobile telephones with the help of SQL queries.  Ozeki Message Server connects to the database through a standard ActiveX Data Objects (ADO) or Open Database Connectivity (ODBC) connection (Figure 3). Using this connection Ozeki periodically queries the system database with the help of SQL queries. And creates a database table called ozekimessageout from where it then broadcasts the messages accordingly. • Visual Basic.Net (VB.NET): a multi-purpose computer programming language from Microsoft that is suitable for most development needs. The language was employed with Rapid Application Development in mind; it provided several tools to shorten development time. VB.NET served to create the electronic medical forms and patient records. • ASP.NET: a web application framework developed and marketed by Microsoft to allow programmers to build dynamic web sites, web applications and web services. This web development language helped in the programming of the system to send SMS’ to the different mothers. In conjunction with HTML (HyperText Markup Language) it also served to help in the creation of a website that enables registered user to send questions and receive answers from other registered users. Pregnant women with internet access may also post their queries and learn more about healthy living. 5.1 THE PROTOTYPE The prototype has a front end interface, whereby a user has to enter his\her user name and password to Login. This is important since it ensures that the system is only accessed by authorized users. As seen below. [pic] Figure 4: User Login for the System Electronic medical forms are used to register patients. These help to ensure accuracy and consistency. As shown below: [pic] Figure 5: Registration Form 5.2 System Validation The complete system was presented to end user representatives (experts) to verify whether the developed system addresses all the requirements and satisfies all the intended user needs. A questionnaire was designed to capture their responses, thoughts and impressions for consideration by system developers. 92% of the experts were of the opinion that the system satisfied all the requirements. 5.3 Results/Findings The Infant and Maternal Monitoring System as an Information System that automates the existing manually driven patient record keeping facility while serving to encourage and remind pregnant women to go to health facilities for antenatal checkups and reminding guardians to take children under their care for regular immunizations; at the same time it offers a means of information sharing between medical practitioners using discussion forums. 6. Conclusion The challenge of lowering infant mortality rates in Uganda can be remedied using the Infant and Maternal Monitoring System. With its use of the Short Message Service (SMS) functionality to encourage pregnant women and mothers to take their infants to visit their nearest health centers to enable them get the required healthcare checkups, vaccinations or immunizations and basic health care. The discussion forum functionality, improves communication and collaboration between medical practitioners thus increasing the rapidity and quality of patient care. All the while, the system automates the existing manually driven patient record keeping facility. Most consulted health care providers were in agreement that the Infant and Maternal Monitoring System if properly implemented would indeed lower infant mortality rates. References 1. Accenture. (2006). Insights into the Introduction of Electronic Health Records in South Africa (Retrieved 7 March, 2009, from http://www.accenture.com) 2. Health Canada (2005). Nova Scotia: Canada Health Act Annual Report. (Retrieved 20 March, 2009, from http://gov.ns.ca/health/reports.html) 3. Jareethum, R. and Titapant, V. (2008). Satisfaction of Healthy Pregnant Women Receiving Short Message Service via Mobile Phone for Prenatal Support: A Randomized Controlled Trial. Journal of Medical Association Thailand, 4: 458-63. 7. Lincetto, O., Mothebesoane-Anoh, S. and Gomez, P. (2006). Antenatal Care: Opportunities for Africa’s Newborns. (Retrieved 4 March, 2009, from http://www.popline.com) 8. Moller, C.L. (2002). Infant Mortality in Uganda1995-2000: Why the Non-Improvement. Uganda Heath Bulletin, .8 (3/4): 211 – 214. 9. Mukasa, H. (2008, June 1). Uganda: Infant Mortality Rate Still High. Kampala: New Vision (Retrieved 19 March, 2009, from www.newvision.co.ug) 10. Pinto, M. (2006). The Easiest Path to EMR Healthcare Document Management for Provider Organizations. (Retrieved 19 March, 2009, from www.scribd.com/doc/3623451) 11. Poissant, L. and Kawasumi, Y. (2005). The Impact of Electronic Health Records on Time Efficiency of Physicians and Nurses: A Systematic Review. Journal of the American Medical Informatics Association. (Retrieved 22 March, 2009, from www.clinepi.mcgill.ca) 12. Sines, E. and Worley, H. (2007). Postnatal Care: A Critical Opportunity to Save Mothers and Newborns. Population Reference Bureau. (Retrieved 19 March, 2009, from www.prb.org/pdf07) ----------------------- Database MS SQL Application, SQL statement, Database trigger ODBC