RoadMApp: a feasibility study for a smart travel application to improve maternal health delivery in a low resource setting in Zimbabwe

This paper reports part of a broader feasibility study of a mHealth tool called RoadMApp that seeks to address the most critical gaps in women’s travel to institutional birth facilities. Specifically, the paper aims to understand women’s experiences (end-users) in traveling to the institutional birth facility (context) and, to assess the coordination and resources needed to develop the RoadMApp mHealth tool.

We frame the paper using the Spiral Technology Action Research (STAR) Model. This model integrates health promotion theory, participatory action research, critical pedagogy, software development approaches, and change strategies borrowed from the field of organizational studies [21]. It contains the following iterative and evolutionary processes concepts: listen, plan, do, act, and study. As a result, we take a qualitative deductive approach as the papers’ objectives suit the first two steps (listen & plan) of the STAR model.

The case study research design suits the investigation of the complexity of community concerns. We chose Participatory Learning for Action (PLA) methods to engage the community in line with the STAR model. PLA combines action and participatory action research with several techniques borrowed from qualitative social research (participatory, visual techniques such as maps, transect walks, and problem trees) [22]. The discussion questions centred on travel time, availability of transport, cellular network coverage, and participants’ perceptions of the RoadMApp application (see Additional file 1, showing the research instrument).

We used registers and maps at the provincial level for the selection of study sites. We purposively sampled two hospitals (rural and urban), four rural health centres, two peri-urban clinics, and two urban clinics to get information-rich cases in the communities (see Fig. 2).

We based the selection criteria on health facilities providing obstetric care services, distance to the health facilities, and availability of mothers’ waiting shelters. We treated a radius of 40 km as the catchment area of each rural clinic. We then looked for representative cases (i.e., Kwekwe residents with experience and knowledge of travelling to institutional birth facilities) at each health centre. This purposive sampling strategy accounts for participants’ clinical variation (parity), demographic groups, geographical spread (i.e., rural, peri-urban, and urban). This is consistent with the goals of qualitative research to achieve credibility and transferability as opposed to validity and generalization used in quantitative studies [23]. We asked health workers to help identify people whose experiences could significantly contribute to the study (snowballing). An interview guide was used to solicit information from the participants. The participants included pregnant women, women of childbearing age (WOCBA), community members, older women (50 years and above), and men (i.e., their roles as household decision-makers) and health care providers. Participants provided written or verbal (particularly for the less literate) informed consent.

Data from the audio voice recorders were transcribed verbatim and later translated into English. Two translators verified the transcripts for authenticity. We imported the anonymized transcripts into Nvivo Pro 12™ to generate codes to aid in the analysis process. ZNJ and IMD performed first-cycle coding using elemental methods (i.e., descriptive and in vivo coding) [24]. They shared the coded data with the rest of the team to identify emerging themes. After the first-cycle, a thematic analysis summarized the data to identify and interpret the key features of the data, guided by the initial research questions [25]. Three authors cross-checked the themes with the transcripts and field notes to ensure consistency. We disseminated the preliminary findings to local authorities and the participants to verify if we had accurately represented their views.

Participants defined factors influencing the choice of transport as the affordability, transport network, safety of the transport, waiting for time travel, cost of travel, ambulance system, and waiting mothers’ shelters.

Cheaper modes of transport were available in urban areas. These included the government-subsidized Zimbabwe Urban Passenger Corporation (ZUPCO) buses. Some pregnant women shared rides in Honda Fit vehicles, which carried 6–8 passengers (instead of the standard capacity of 4) and commuter buses, which took 18 passengers (instead of 14). The women preferred these commuters and Honda Fit taxis because of availability and shorter waiting time. The cheaper buses also had challenges of long waiting times and overloading. The following excerpt sums up the women’s experiences on the use of public transport:

"ZUPCO is cheap but very hot (because of overloading). Passengers, drivers, and conductors seem not to understand or empathize with pregnant women. Even if I am pregnant, they expect me to stand. Sometimes when the bus is full, and they can leave you behind. However, smaller vehicles do not take time to load, but their design is not 'pregnant woman-friendly.' The poor road terrain even makes things worse," (An urban pregnant woman within the age range of 22-26).

Urban areas have an established road-network as compared to Kwekwe rural. The major roads in the urban and peri-urban areas were tarred, while the minor roads are dusty with gravel and potholes. Some peri-urban places were hard to access, and most vehicle owners were reluctant to use those routes because of probable damage to their vehicles. These hard-to-access areas negatively affect the waiting time, possibly leading to home births or born before arrival, as shown in the following comment:

"You wait for hours before they pick you as transporters would prefer to ferry people from areas where roads are good. I experienced labour pains at 9.00 am and immediately called the transporter who came 5 hours later. I could have given birth at home," (An urban postpartum woman within the age range of 18- 24).

Community meetings discussions showed a preference for locally available transporters arguing that there was a reduction of waiting time as prearrangements would have been made. Local transporters knew the road network and the accessibility of roads during different seasons. Participants said commercial transporters to be unreliable, as when the need arose, they would be elsewhere doing business. They were also reportedly charging exorbitant fees. A community member said:

"Our people can navigate their way to the health facilities using the worst of roads, and they show a human face in that they are prepared to get the woman to the health facility irrespective of the wear and tear of their cars," (Female FGD participant, age range 35–40)

To make the RoadMApp workable, spouses suggested having a list of drivers to choose from and standardised costs.

Women both urban and rural do not feel safe to catch a ride in a car whose driver is unknown, as they had heard of criminals who were prowling most places taking advantage of unavailability or poor lighting. One older woman said:

"It is dangerous to board a vehicle from an unknown driver as we have heard reports of people being murdered by unknown assailants," (FGD participant, age range 55-60).

Walking any distance during labour could be problematic in the day and worsened at night. The following excerpt summarizes the ordeal of a woman who went into labour at night:

"I called our local transporter when my daughter got into labour, and he told me he had other errands to do, and he would only be available after 3hrs. That would have been a serious delay as the labour pain had intensified. I asked her siblings to accompany her. They walked in the dark for 2 hours before they got transport to the health facility. They could have been robbed, or she could have delivered in the forest," (An elderly woman within the age range 55-60).

To safeguard pregnant women, community meetings suggested a creation of a list of all eligible drivers, a community resource that would be shared with women during their antenatal classes (ANC). The older women and some men raised concerns about the cultural appropriateness of allowing men to transport women who were not their wives to the health facility. An elderly woman reiterated:

"We have heard stories of pregnant women being abused en-route to the health facilities," (Participant age range 55-60).

The men gave suggestions to the team for the male spouse or relative to accompany the woman to the health facility.

Vehicle owners/drivers were reportedly charging high prices because they took advantage of clients who would be (a) panicking, (b) desperate, and, (c) with an acute need of transport, especially during the night. The remotest village had the highest cost of hiring a car during an emergency, with some women asked to pay an equivalent of USD$100 (Z$1000) for a distance of 20 km. The amount they paid was equivalent to fares for distances of 230 km. To justify excessive charges, a transport provider revealed that transporting pregnant women was risky as the drivers lacked skills of handling emergencies that could occur on the way to the health facilities. One transporter commented:

"Seeing a woman delivering is not anything that a male would want to witness. By ferrying a woman in labour to the clinic, you put yourself at risk", (Male transporter within age range 33-40).

Communities throughout the District requested for a standardised model of pricing by transporters to avoid discrepancies and overcharging. They also recommended basic emergency care training and the provision of essential medical supplies for dedicated transport operators as a way of bridging the gap where there were no ambulances.

Ambulances that were based at the District or General hospitals were only called in cases of emergency for both urban and rural women. The ambulances whose standard charges were the equivalent of USD$3 were overwhelmed and often delayed. The delays were further compounded by the rampant fuel shortages in the country. Ambulance drivers were said to demand only cash for their services, yet cash was not easily accessible because of the economic crisis in the country. A health worker commented on the complexity of issues about ambulance availability:

"We only have one ambulance for all clinics. Imagine if there are complications at the same time. The ambulance is not for emergencies only. We also use it for duties like the collection of drugs from other health facilities", (A key informant from one of the rural clinics, age range 30-35).

Local authority officials attributed the inefficiency of the ambulance system to an increase in the population, with some citing that on a single day, they could receive a maximum of 10 calls for one ambulance. The desperation for transport led to the usage of fire brigades for emergency transportation of women to the health facilities. Because of the unreliability of the ambulance services, some urban and peri-urban residents with medical aid cover used private ambulances. There were no private ambulance services in rural areas, as most of the population did not have any form of health insurance. A single ambulance in rural communities could cover a radius of over 200 km in rough terrain, and pregnant had to be transported by scotch carts or wheelbarrows to accessible places.

The unavailability of cash was worse in rural areas. Some community members highlighted that ambulance drivers demanded payment in kind (e.g., goats or chickens). The communities suggested the use of electronic mobile fund transfers for the success of the RoadMApp initiative.

The non-availability of mothers’ shelters at some rural clinics/hospitals presented a need for readily available transport systems for a referral to the next level of care, which in most cases were in urban areas that were very far from the women’s homes. The length of stay affected the women as they did not have a social support system. Some women were absconding referrals and opting for risky home deliveries. A health care worker commented:

"Rural women are reluctant to be referred to the next level of care because of lack of accommodation and support, particularly in urban settings," (Female Key informant within the age range 40-45).

The telecommunications network providers have tried to ensure that most areas in Zimbabwe have network coverage. The RoadMApp intervention will heavily rely on the network accessibility and hence the importance of understanding the network patterns in the study areas.

Participants reported network coverage to be good in urban areas where all telecommunication service providers had a substantial number of base stations. However, network challenges were experienced when there were intermittent electricity supplies, a common occurrence in Zimbabwe. The farther away rural communities were from the urban areas, the weaker the network. Despite the low network coverage in most rural settings, voice calls and messages could still be received, but there was poor Internet connectivity. The communities knew the best spots to pick up signals for communication. However, this was a challenge for nurses who had to disrupt their duties to connect to networks. One participant said:

"At this place, we have serious network challenges, and it becomes difficult when our wives need emergency help. Sometimes one has to go up a tree to access the network," (Rural male participant age range 28-35).

The community suggested that the RoadMApp application should have a communication system that did not rely much on the Internet and which could use the simplest mobile phones to benefit all communities. They suggested the adoption of platforms used by local mobile money wallet operators such as Econet, Netone, and Telecel, which can be accessed by punching a set of preprogrammed numbers.

Discussions revealed that most people in urban settings owned mobile phones, but this was not always the case in rural areas. Failure to possess a phone in the rural areas was because of the low-income levels and unavailability of electricity. Owning a phone meant that one had to have solar charging equipment. The reduced network availability in most rural areas caused communities to rely less on mobile phones and mobile banking applications. People in rural areas were reluctant to use mobile money transactions, yet it was the only medium of exchange. Those without mobile phones requested help from friends or family members. The rural participants mentioned that community members were always willing to share their phones in cases of emergencies.

The participants perceived introducing the RoadMApp intervention as a strategic way of reducing pregnant women’s woes of delays in accessing transport and reaching health care facilities in remote rural communities. Unlike the urban areas, the catchments of some clinics or hospitals in the rural areas were as far as 40 km because of the spatial distribution of settlements, landscapes, and rivers in between. There were also cases where pregnant women in urban areas accessed health centres far from their homes because of different socio-cultural and economic realities. For example, referrals for primigravida and multiparous women and travelling to access scans or a caesarean section specialist. The cost of these regular check-ups was costly. Hence, the women were advocating for shared rides, which would cut on the waiting time and provide social support. Consideration of the community needs by the RoadMApp mHealth would increase the chances of its acceptability.

Although communities appreciated the need for BPCR, there were some obstacles. For example, the issue of obstetric emergencies among women who were not booked for antenatal care (ANC). Women who booked late were reportedly aware of pregnancy preparation, but this awareness did not translate to preparedness because of financial constraints. Communities had limited sources of income to enable savings (due to low/unstable incomes and no sources of livelihood) and volatile costs of transport (because of macroeconomic issues). The community argued that RoadMApp would be adversely affected by the lack of savings for pregnancy. One community participant had the following to say:

"There could be cases where a woman is alerted to report to the health facility, but she might not raise money for transportation. We are all aware that irrespective of the nonuser fees for maternal health care, pregnant women are still delaying in accessing health care," (Rural woman of childbearing age range 26-31).

The lack of maternal savings also affected women who booked early. The women regarded adequate savings as a panacea to generate money to pay for transport and out-of-pocket payments (OOPs). Hence, communities expected the RoadMApp intervention to handle mobile savings and bridge the gap between service providers who did not accept mobile money. In this way, the intervention would act as a health savings scheme targeting financially excluded communities. The savings were expcted to grow into investments to enable access to other services (food, medications) at the health facilities.

Discussions revealed that the economic downturn was taking a toll on pregnant women, as most of them had become household breadwinners. Partners were often migratory labourers, leaving pregnant women to fend for their families (with the help of neighbours and relatives). Most husbands were artisanal miners from other districts or miners working underground and inaccessible during emergencies. A participant reflects this in the expert below:

"Most of these women's husbands are illegal miners, and they go underground when they are needed the most," (Female participant, age range 40-45).

We can consider the economy a “wicked problem” (a significant societal or cultural problem that the communities, researchers, and the study cannot solve). Across all interviews, participants strongly felt that the RoadMApp intervention would be successful if there were funding attached to it. There were concerns about whether the response had enough funds to withstand the rapid hyperinflation, considering that participants would make savings in the local currency. Some even suggested that the World Bank initiative, which had introduced free maternity services, could be extended to the RoadMApp intervention.

Another wicked problem cited by the participants was the inadequate or non-existent road infrastructure, which poses a challenge to the RoadMApp intervention. The poor road network makes most rural areas inaccessible. Women experiencing labour or complication signs cannot reach health facilities on time. Discussions during the community engagement suggested that the RoadMApp initiative should also budget for the rehabilitation of roads, particularly in the rural areas. One male participant asked:

"We hope fixing roads is one of your plans if this noble initiative is to succeed, " (Male spouse, age range 35-40).

A limitation of the study was that we excluded private ambulance operators from the data collection, making it difficult for the authors to transfer the findings to their context. This may affect the project in the later stages, especially when introducing the RoadMApp mHealth to groups with health insurance of scaling up to different locales.

The level of digital literacy among the respondents was not assessed [36]. Without this sound evidence, it is hard to predict if RoadMApp will integrate into the lives of the community - especially those in rural areas. The study findings cannot be generalized because of the small sample size. The collected information is, however, rich enough to advise the RoadMApp intervention.