The impact of a direct to beneficiary mobile communication program on reproductive and child health outcomes: a randomised controlled trial in India

Abstract

Background: Direct-to-beneficiary communication mobile programmes are among the few examples of digital health programmes to have scaled widely in low-resource settings. Yet, evidence on their impact at scale is limited. This study aims to assess whether exposure to mobile health information calls during pregnancy and postpartum improved infant feeding and family planning practices.

Methods: We conducted an individually randomised controlled trial in four districts of Madhya Pradesh, India. Study participants included Hindi speaking women 4-7 months pregnant (n=5095) with access to a mobile phone and their husbands (n=3842). Women were randomised to either an intervention group where they received up to 72 Kilkari messages or a control group where they received none. Intention-to-treat (ITT) and instrumental variable (IV) analyses are presented.

Results: An average of 65% of the 2695 women randomised to receive Kilkari listened to ≥50% of the cumulative content of calls answered. Kilkari was not observed to have a significant impact on the primary outcome of exclusive breast feeding (ITT, relative risk (RR): 1.04, 95% CI 0.88 to 1.23, p=0.64; IV, RR: 1.10, 95% CI 0.67 to 1.81, p=0.71). Across study arms, Kilkari was associated with a 3.7% higher use of modern reversible contraceptives (RR: 1.12, 95% CI 1.03 to 1.21, p=0.007), and a 2.0% lower proportion of men or women sterilised since the birth of the child (RR: 0.85, 95% CI 0.74 to 0.97, p=0.016). Higher reversible method use was driven by increases in condom use and greatest among those women exposed to Kilkari with any male child (9.9% increase), in the poorest socioeconomic strata (15.8% increase), and in disadvantaged castes (12.0% increase). Immunisation at 10 weeks was higher among the children of Kilkari listeners (2.8% higher; RR: 1.03, 95% CI 1.00 to 1.06, p=0.048). Significant differences were not observed for other maternal, newborn and child health outcomes assessed.

Conclusion: Study findings provide evidence to date on the effectiveness of the largest mobile health messaging programme in the world.

Trial registration number: Trial registration clinicaltrials.gov; ID 90075552, NCT03576157.

Keywords: child health; immunisation; individual randomized trial; nutrition.

Figure 1

Summary of Kilkari content during pregnancy and up to 1 year post partum. WASH, water and sanitation.

Figure 2

Consolidated Standards of Reporting Trials flow diagram.

Figure 3

The number of successful* Kilkari calls and per cent of listening by call over time for those randomised to the intervention arm in four districts of Madhya Pradesh, India. *Successful calls are those which are delivered to the handset and answered for 1 s or more.

Figure 4

Number of call attempts needed to reach subscribers by sociodemographic characteristic. Dark blue bars denote the more marginalised subscribers as compared with those in the lighter blue. OBC, other backward castes.

Figure 5

Proportion of those exposed versus not exposed using reversible modern contraceptive methods by sociodemographic characteristics. OBC, other backward castes.