MOTIF: MObile Technology for Improved Family Planning

MOTIF: MObile Technology for Improved Family Planning, is a research project that includes a clinical trial that will reliably establish the effectiveness of a mobile phone-based service to support post-abortion family planning (PAFP) in Cambodia. Unsafe abortion accounts for one in eight deaths related to childbirth in developing countries. Clients attending for abortion are often not using a method of family planning. In Cambodia, over 50% of women currently do not start using a reliable method of PAFP, and around 25% will have a repeat abortion within five-years. Mobile phones allow personalised support to be delivered inexpensively wherever the person is located. Studies have shown that mobile phone-based interventions have been effective in areas such as smoking cessation and HIV treatment. MOTIF is the first trial to evaluate a mobile phone-based family planning service in a low-income setting.

Key achievements to date include:
(1) Further understanding why women attend for abortion and why they might not use family planning
(2) Developing a PAFP mobile phone-based service in conjunction with local staff and clients to provide personalised support to clients after attending for abortion
(3) Commencing a clinical trial to evaluate the service by comparing contraceptive use amongst those receiving the intervention compared to standard care

The proposed research seeks to:
(1) Conduct in-depth analysis of the short term 4 month study follow up data that will already have been collected
(2) Conduct longer term 12 and 24-month follow up of trial participants already recruited in order to evaluate the long-terms health outcomes of the MOTIF service to support PAFP
(3) Learn about participants experience of receiving the MOTIF service, and assess the cost-effectiveness of the service
(4) Conduct a literature review of mobile phone-based interventions for family planning
(5) Conduct additional analysis of contraceptive discontinuation rates from the Cambodia Demographic and Health Survey 2010
(6) Provide the applicant with rigorous research training at the London School of Hygiene and Tropical Medicine in order to achieve the above objectives and become a world leader in the field of mHealth and reproductive health.

MOTIF: MObile Technology for Improved Family Planning services is a research project that includes a multisite individual RCT that will reliably establish the impact of a mobile phone-based intervention on use of post-abortion family planning (PAFP) in Cambodia. Unsafe abortion accounts for one in eight maternal deaths in developing countries. Clients attending for abortion often have an unmet need for family planning. In Cambodia, over 50% of clients do not use a reliable method of PAFP, and around 25% will have a repeat abortion within five years. Mobile phones allow personalised support to be delivered inexpensively wherever the person is located. MOTIF is the first trial to evaluate a mobile phone-based family planning intervention in a low-income setting.

Key achievements to date include:
(1) Conducting formative research to understand why women attend for abortion and reasons for not using PAFP
(2) Developing mobile phone-based intervention to support PAFP in Cambodia
(3) Commencing a RCT with 500 participants to evaluate the intervention

Key objectives of the proposed research are to:
(1) Conduct in-depth analysis of 4 month trial follow up data which will have been already collected
(2) Conduct 12 and 24-month follow up of trial participants already recruited in order to (a) evaluate the long-terms health outcomes of the MOTIF intervention to support PAFP and (b) conduct prospective analysis to calculate rates and risk factors of/for repeat abortion, pregnancy
(3) Conduct additional qualitative and cost-effectiveness analysis of the intervention
(4) Conduct a Cochrane review entitled 'Mobile phone-based interventions for improving adherence and acceptability of contraception'
(5) Conduct analysis of contraceptive discontinuation rates from the Cambodia Demographic and Health Survey 2010
(6) Provide the applicant with rigorous research training at LSHTM in order to achieve the above objectives and become a world leader in the field

Direct / immediate beneficiaries:
This relates to women seeking abortion at Marie Stopes International Cambodia (MSIC) clinics. Although we have not commenced trial follow up, and hence do not know the effect of the intervention on contraceptive use, we know that clients value the ongoing support via their mobile phone. It saves them time and money; for example, for a subsistence farmer living in a rural area experiencing minor side-effects from contraception, a short phone conversation is preferable, compared to the time and money spent attending clinic. The intervention aims to reduce repeat abortion. The economic costs associated with abortion are not insignificant. Estimates indicate Cambodian women can spend up to USD$100 and lose 36 days of productive time to receive abortion services. Furthermore, with large numbers of unsafe abortions still it is likely that unsafe abortion practice is contributing to the high maternal mortality rate in Cambodia. Therefore, an intervention that reduces repeat abortion will contribute towards both individuals, and the nations, health and wealth.

Indirect / longer-term beneficiaries:
This relates to key stakeholders and the wider research, policy and private sector community who will benefit from dissemination of research findings over the 1-3 year time period. These include:
(1) Women seeking abortion with other providers in Cambodia
This research will produce evidence for the effectiveness of mHealth interventions to support post-abortion family planning (PAFP) that can be presented to policy makers and key stakeholders in Cambodia.

(2) Women of childbearing age with unmet need for contraception
Although MOTIF is a service that is specifically offered to clients who attend for abortion, there have been interest in the project even at its early stage. The general public will benefit from this research through the media outlets such as radio where we will increase awareness of contraceptive methods and safe sexual and reproductive health providers.

(3) Cambodia Ministry of Health (MOH)
The MOH is the key health policy maker in Cambodia. Reducing repeat abortion is an area of priority for the MOH and findings from the research will be of interest; particularly how innovative mHealth solutions could be applied in a range of healthcare areas, that could result in increased efficiency of health care delivery and cost savings.

(4) Women seeking abortion at other MSI programmes globally
With MSI operating in over 40 countries worldwide, there is considerable potential for scale. Through effective dissemination and scale to other country programmes, women will be able to benefit from this research in other MSI country programmes (including the UK).

(5) Sexual and Reproductive Health (SRH) community
Collaboration with the respected MSI brand, means that MOTIF and its outcomes will benefit from high visibility allowing the wider family planning sector to learn from the intervention and potentially replicate the intervention within their own operations. The evidence on interventions to increase use of PAFP are limited. Thus, SRH providers worldwide will benefit from the research findings.

(6) mHealth community
Similarly, the research findings will be of value to the wider mHealth community. Few mHealth interventions have been subject to randomised controlled trials. This research will provide the highest level of evidence on the effectiveness of this intervention. The research will add to the profile and expertise of the Department of Population Health at LSHTM, which could attract future grants and/or consultancies on mHealth.

(7) Mobile phone companies
Mobile phone operators can benefit from the research findings to advocate for the effectiveness of mHealth interventions. Collaboration with healthcare providers, both through their corporate responsibility programmes, could also lead to increase revenue and market share, with benefits to both parties.