A review of digital maternal health promotion to optimise access and utilization of care services in sub-Saharan Africa

: In sub-Saharan Africa, maternal mortality rates remains high among women as the vulnerable demographics of reproductive age and breastfeeding mothers compared to other parts of the world. The situation is exacerbated by the region’s underperforming healthcare systems. Although digital health interventions have increased since the emergence of COVID-19 pandemic to enhance health promotion in terms of maternal health vulnerability, the access to and utilization of care services, the record of positive impacts remains limited. The objective of this paper was to analyse the status of digital maternal health promotion in supporting female of reproductive age, first-time and nursing mothers to access and utilise maternal healthcare services during their perinatal and postpartum periods in underserved settings of sub-Saharan Africa. A literature review of peer-reviewed publications between 2020 and 2023 was conducted by searching online databases using keywords and filtering the results using a set of inclusion and exclusion criteria. Findings indicate that digital maternal health promotion is increasingly enabling access to hard-to-reach populations, but the utilization of associated care services remains relatively low. Particularly, mHealth and asynchronous audio-visual digital media are critical for delivering maternal health educational content to the targeted populations, including their partners, and are most likely to increase utilization of maternal care services. Digital promotion of maternal health requires multi-stakeholder collaboration to address the limiting socio-economic, cultural and technical factors that determine access to and utilization of care services during the perinatal and postpartum period, if mortality rates are to be reduced towards the sustainable development goal for good health and well-being.


Introduction
Health, wellness, and well-being are crucial for social and economic development and self-development.They are the hallmarks of prosperity, social progress and are at the centre of the realization of communal development, such as the United Nations sustainable development goals (SDGs) 2030 and the Africa Agenda 2063.Humans seek to achieve their highest level of well-being to ensure individual and community survival, fulfill their aspirations and meet their daily needs while coping with the environment.This requires principles and areas of action that enable people to synergistically increase control over their health improvement, hence health promotion [1].Thus, health promotion is associated with coordinated actions that encompass advocacy, enabling communication and mediation of health-related needs through a community participatory approach [2].Health promotion goes beyond the provision of information aimed at actively changing individual behaviour towards a wider perspective of social and environmental interventions through which primary health care contributes to building resilient health systems.However, the low and middle income countries (LMICs), particularly in sub-Saharan Africa (SSA), fall short of addressing the unsettling realities associated with maternal health, including postpartum complications, which are the scourge of an overburdened and less inclusive health system [3].
Maternal health refers to the state of a woman's (or girl's) well-being in the perinatal (antenatal, postnatal or postpartum) period.Due to peculiar challenges, SSA records high maternal mortality rate (MMR), accounting for two-thirds of global maternal deaths [3][4][5].Maternal mortality is the death of a woman that occurs during pregnancy or within 42 days after delivery due to some pregnancy-related complications such as infectious diseases comorbidities, haemorrhage and eclampsia [4].Other factors that influence high MMR and limit many health systems include poor state of public health infrastructure, staff shortage and socioeconomic status, which inhibits lack of access to quality maternal care [4,5].In addition, supply chain disruptions and impact of COVID-19 have contributed to the high MMR among pregnant women and girls [6,7].According to Onambele et al [4], the emergence of COVID-19 pandemic has exacerbated resource constraints in LMICs with significant threats to the progress in reducing MMR.As a result, the pandemic magnified constraints on health information resources, which requires a need for coordinated interventions to increase access, efficiency, quality, equity, and flexibility of maternal health services through digitalization so as to strengthen the health systems [8].As the pandemic strained health systems around the globe, several countries speedily adopted digital health technologies (DHTs) to enable the detection of and response to the pandemic [9,10].
The situation necessitated a rapid digitalization of health interventions as a way to increase the resilience of health systems in SSA to epidemic challenges.Particularly, digital interventions have the potential to improve pregnancy monitoring in rural areas, although the user of mobile phone is reported relatively low especially among mothers.The dawn of digital health innovations has prompted interventions directed at strengthening health systems to improve the outcomes of maternal health and promote wellness towards achieving health security [11,12].In this paper, we adopt the definition by Kutzin and Sparkes [13] health security refers to the ability of a health system to reduce vulnerability to health threats through its resilience to absorb and withstand destabilizing forces; it is able to adapt and respond to service needs accordingly.

Contextual relevance of digital health in post COVID-19 SSA
Digital health involves the use of computing tools and techniques for healthcare and related purposes, creating a coordinated continuum of care to ensure resilience [14].In the efforts by national governments to contain the consequences of ongoing COVID-19 pandemic, the use of DHTs to combat the menace has been ubiquitous [15].For instance, mobile health technologies, electronic health records, decision support systems and telemedicine have provided platforms for specialists such as Gynaecologists to track health-related matters and make data-driven decisions [16,17].SSA countries continue to make incremental efforts towards using digital health to address the challenges experienced in engaging hard-to-reach populations in underserved and remote areas for health promotion.For instance, at the peak of COVID-19 pandemic, South Africa adopted a variety of digital technologies and preventative measures to provide healthcare services.Examples of such digital technologies include SMS-based solutions such as MomCnnect and NurseConnect to link pregnant women and first-time mothers to healthcare workers [18,19].These digital technologies are being leveraged in various ways for health service delivery, such as creating awareness and communication for management of maternal health, surveillance and monitoring of infectious and noninfectious diseases, medication and treatment compliance [20].
The World Health Organisation's (WHO) vision for the global digital health strategy is to improve the health of all people everywhere by accelerating the adoption of digital health, hence the need for digital health promotion [21].Digital health promotion plays a crucial role in protecting the global population from acute public health events; and, in particular, to redress issues relating to maternal mortality.Digital health is instrumental in information management, to track and predict health problems based on digital health data for evidenced-driven contextual decision-making [22,23].By using digital tools in SSA, maternal health care can be digitized, thereby improving service delivery and enabling people to take more control through proactive and reactive approaches.For example, the use of digital health has been reported to improve treatment support and facilitate person-centred interventions, which is relevant to address pregnancy-related complications on a case-bycase basis [14][15][16].Although there is a positive trend in digital health interventions, it remains critical to evaluate the consistency and effectiveness of solutions in providing positive outcomes to maternal health services in SSA.

Digital maternal health promotion in SSA
The benefits of digital health for promoting maternal health nudge SSA towards attaining health security and SDG 3 -good health and well-being for all.Successful digital maternal health promotion includes ensuring increased accessibility to maternal care, enhanced digital health literacy, established trust towards increasing receptivity of utilizing antenatal care (ANC), nutrition adherence, improved facility-based delivery, and child immunization among other services [27, 28].However, challenges identified include misinformation, socioeconomic inequalities, privacy issues, cybersecurity threats, non-contextual implementations, and cultural issues [3,29].These challenges delay the opportunities and benefits associated with digital maternal health promotion in a region that is already struggling with the crisis of a weak healthcare system, non-communicable diseases and re-emerging infectious diseases.
Despite the opportunities and benefits associated with the increased use of DHTs to strengthen health systems globally since COVID-19 pandemic, maternal health awareness and advocacy in underserved areas in SSA continues to yield limited results [15,24,25].These limitations could be attributed to critical factors such as users' unfamiliarity with digital devices in underserved areas, infrastructural disparities in rural areas compared to urban areas and unsafe sociocultural practices [30].Other factors that impede digital health interventions in SSA can be categorized into organizational, financial, political and regulatory factors [15].Ultimately, these factors contribute to underserved settings in SSA not benefiting from innovation while recording the highest maternal mortality rates.
Hence, this paper seeks to analyse the role of digital health in offering the necessary support to pregnant women or girls and nursing mothers to access and utilize maternal health information and care services, mediate communication, and advocate for healthier choices of lifestyle during the perinatal and postpartum periods to achieve health security.The guiding question of the paper is: How can digital health interventions be optimized to improve access to maternal health information and services for nursing mothers in SSA during the perinatal and postpartum periods?The objective of this paper was to conduct a literature review that would establish the: • status of digital health technologies in supporting maternal health care services and health security within SSA. • enabling factors that influence optimization of access and utilization of digital maternal health promotion in post-COVID-19 SSA.

Materials and methods
To achieve the aims of this paper, an analysis of the existing literature on the use and outcomes of DHTs to promote maternal health was considered.A literature review was conducted by the authors as a strategy to highlight the available and prospective opportunities for improving the utilization of DHTs to optimize maternal health promotion in underserved areas in SSA.A threestep process was followed to conduct the literature review, as informed by the previous studies prescribed by [31] and operationalised by [32,33].The steps include a search for relevant literature (using keywords to identify and retrieve), screening (inclusion and exclusion criteria) and summarizing (critique of existing studies).These steps are described in the subsequent paragraphs.

Search strategy
In the search strategy of this paper, keywords were used to search online databases including Google Scholar, Scopus and PubMed.However, Google Scholar was selected as the reference database to conduct the search because it has a wider range of indexed publications to avoid duplicates and, most importantly, because the strings of keywords are retrieved via the title, abstract and full text.The keywords selected include "health promotion", "digital health", and "maternal health".A combination of keywords with the logical operator 'AND' was used to query the online database.For instance, the string of keywords is "digital health" AND "maternal health" AND "health promotion" AND "Africa".A threeyear time frame (2020-2023) was selected to represent the periods during and after COVID-19 pandemic, when the adoption of digital health for diverse purposes, including health promotion, increased rapidly.

Inclusion and exclusion criteria
To screen the results, inclusion and exclusion criteria ( as shown in Table 1) were used to filter yielded articles.The inclusion criteria considered peer-reviewed journal and conference publications on the different forms of digital health used to facilitate health promotion.Only articles published in English were retrieved, as this is the authors' first language and studies conducted in SSA were prioritized.Also, the focus themes include the use of digital health to raise awareness, teach and promote health The exclusion criteria were applied to discard studies written in other languages, closed access articles were not retrieved, dissertations and books were not included.Subsequently, the titles and abstracts of included articles were read to further exclude articles that did not align with how digital health is used to promote maternal health in SSA.The initial process of filtering was performed by two authors, while a third author verified that the data extracted satisfied the objectives of the paper and ensured a consensus of eligible publications by extension.

Thematic analysis
A thematic analysis was conducted to operationalise the objectives of this study.The procedure followed was to operationalise the variables of the objectives in relation to the key findings of the included articles.Firstly, the authors summarised the attributes of the included articles based on the key findings and implications for achieving health security as described in Table 2. Subsequently, words or phrases that indicated the extent to which digital health technologies (DHTs) are being used to promote health for pregnant women and girls of reproductive age in SSA were extracted.For example, the type of DHTs used, cases of access or utilization for specific purposes, experiences from usage of DHTs, and the outcomes described were used to determine the status and enabling factors that optimises access and utilisation of maternal health services.
The summary of selected literature included attributes such as: title, author, context, the type, and purpose of DHTs and implications of the findings regarding their use in achieving health security and SDG 3 in SSA to enable analysis of existing studies.Summarising these attributes enabled the authors to assess the status of digital health for health promotion and identify the factors that enable the use of digital health in maternal healthcare services in underserved settings of SSA.Ultimately, the authors were able to address the extent to which DHTs have been and can be adopted to promote access to relevant health information, mediate communication between key stakeholders, and raise the awareness of healthier lifestyles in terms of preventative practices against critical maternal health problems.

Results
The initial query from the search strategy produced a total number of 1, 380 publications.Subsequently, the yielded results were screened by applying the inclusion and exclusion criteria with a total number of 614 publications being eliminated.To identify the eligible articles for inclusion, the titles and abstracts were further filtered as illustrated in Figure 1.After screening, the publications were reduced by 755 and the included articles that satisfied the objectives of the paper was 11.The included articles are mainly aimed at improving the access and utilization of maternal health services in the underserved settings of SSA.The countries in which the included studies were conducted include Burundi, Ghana, Nigeria, South Africa and Uganda.Two of the included studies adopted qualitative research, while three deployed quantitative research techniques.Four of the studies conducted different types of literature reviews, while another two studies conducted randomized control trials.
The included peer-reviewed publications represent those articles published between 2020 and 2023 and are summarized in Table 2.The attributes of the included paper include title and year of publication, aim of study, context/country, type/purpose of digital health, key findings, and implications towards achieving health security and SDG 3.

Status of DHTs for maternal health promotion in SSA
The WHO has recognised technology as a crucial building block for strengthening the health system.Therefore, it is important to continuously evaluate digital health interventions, their impact on healthrelated services and health outcomes [40].Based on the literature review, there is a growing number of literatures that demonstrates the need to improve access to maternal health for hard-to-reach populations, improve utilization of maternal health services, and empower vulnerable women and girls of reproductive age as well as nursing mothers in the underserved settings of SSA [36,41].Several studies have considered and developed digital health interventions to address the identified needs, but the underutilization of maternal health services remains unabated [7,8].Therefore, the authors argue for an intensification of existing interventions or opportunities associated with the promotion of digital maternal health through frugal innovation based on contextual peculiarities and limited resources attributed to SSA.
Limited access to services, communication gaps between pregnant women or nursing mothers and healthcare professionals, and advocacy for healthier lifestyles can be addressed with context-appropriate technologies.Existing literature on maternal health promotion indicates that the innovative use of wireless-enabled mobile devices such as smartphones is ubiquitous in SSA countries [42].The ubiquity can be attributed to the continued expansion of cellular mobile communication systems and fourth generation (4G) services that enable short message services (SMS), near real-time instant messaging, and sharing capabilities of digital media [43,44].The 4G services support two-way communication between healthcare professionals and pregnant women to bring them closer to care and enable asynchronous sharing of audio-visual educational content for inclusive participation [20].Therefore, the promotion of digital maternal health offers interventions that facilitate communication with pregnant women in underserved settings and influences the necessary behavioural changes to improve maternal health care utilization.
The promotion of digital maternal health not only enables access to health care services, but also facilitates communication.For example, there are mobile devices and apps such as instant messengers and social networks that can be used to establish peer support groups including pregnant women, nursing mothers and community health workers [19,20,37].The proximity to internetenabled digital devices also supports telemedicine in the unforeseen events that pregnant women are unable to access or cannot afford to utilize facility-based maternal health care.Both text and audio-visual communication ensure that pregnant women minimize their risk of falling victim to misinformation associated with pregnancy and the postpartum period [28].Simultaneously, individuals who understand audio-visual communication in their native language are targeted.As a result, advocacy for maternal health continues to grow in SSA.
Some of the studies that investigated the development of digital health in pregnant women indicate that partners need to participate in pregnancy journeys, while the cautionary and encouraging messages shared are likely to influence positive behavioural change [43].For example, positively worded messages that encourage seeking of professional care against pregnancy complications, early warning signs and debunking of harmful sociocultural beliefs were preferred to authoritative and rebukingworded messages [3,28].In SSA, the households of pregnant women or girls largely depend on their male partners for economic support.Therefore, it is imperative that men become actively involved and encourage utilization of professional support [35].In other words, support programs created by stakeholders including government and non-government organizations, nurses and community health workers should consider the inclusion of men and be aware of how influential the tone of messages are perceived by pregnant women and its impact on their willingness to self-express, including the use of technology.The advocacy for antenatal care (ANC) utilisation, facility-based delivery and healthier nutrition would likely yield and extend positive maternal health outcomes.To evaluate a mHealth messaging app to promote maternity service use among pregnant women in Uganda.

Southwestern, Uganda
Randomized control trial -qualitative and quantitative methods Support moms-Uganda mHealth to promote the use of maternal services Digital maternal health interventions are accepted when the technology is easy to use, useful, interesting and engaging.
Digital maternal health promotion that leverages social support networks, personalized educational content and timely messaging influence the uptake of maternal care services.To achieve SDGs 3 and health security, there is a need to scale such interventions through collaborative partnerships between the government and private sector.This will help to collect relevant data for informed decision-making that includes hard-to-reach populations.
Evaluating the effect of maternal mHealth text messages on uptake of maternal and child health care services in South Africa: a multicentre cohort intervention study [39] To evaluate the effects of mHealth intervention on maternal health services uptake and use.

Johannesburg inner-city, South Africa
Quantitative research One-way maternal health information sent twice in a week to pregnant women receiving ANC.
When pregnant women receive maternal health information via SMS, the utilization of ANC visits increases.
The timing and relevance of maternal health messages shared through digital platforms is likely to influence behavioural change in pregnant women to complete the continuum of care.In this way, the risks and complications associated with pregnancy are managed towards reducing the high records of maternal mortality. A

Enabling factors that drive DHTs for maternal health promotion
Given the complex situational realities associated with underserved settings in sub-Saharan African (SSA), the authors sought to identify the factors that drive digital maternal health promotion towards the realization of SDG 3. The success and sustainability of digital maternal health promotion depends on the presence, availability and suitability of socio-cultural, socio-economic and technical factors.These factors influence the willingness and commitment of pregnant women to embrace technology, raise awareness and change behaviour to make healthier lifestyle choices to reduce the high rates of maternal and infant mortality in SSA.Socio-economic conditions such as inadequate education, unemployment and poverty affect the affordability of the internet and ownership of smart devices [3].It has been found that many women in households in underserved settings are not financially stable and have low levels of literacy [4,38].
However, the literature on digital maternal health promotion has shown that the most feasible initiatives are driven by mobile health (mHealth), which require access to or ownership of phones, internet and digital literacy [35,37].mHealth enables access to services, mediates communication and can be a suitable tool to support advocacy for pregnant women in underserved settings to express their rights and concerns [45].Suffice it to say that there is a correlation between some of the socio-economic determinants faced by pregnant women in underserved settings and socio-cultural beliefs or practices.Socio-cultural beliefs are mostly driven or influenced by historical gender roles [3].These gender roles are pervasive in the underserved settings of SSA to the extent that they tend to relegate women to the households and prevent them from the participation in lucrative economic activities [4].Thus, women's lack of economic participation restricts their access to financial empowerment to own smart or internet-enabled digital devices and limits their time to participate in health promotion programs because they spend most of their time in the household front.
However, the success of digital maternal health promotion depends on the autonomy of women to participate in activities that guarantee economic stability, the active inclusion of male partners, and the freedom to engage in peer support groups, either face-to-face or through digital health initiatives [30].The literature on digital maternal health promotion points to the technical requirements that should be in place as facilitating conditions to ensure the success of digital health initiatives in terms of health security and the inclusion of pregnant women in underserved settings [36,46].Table 3 highlights the facilitating conditions that must be met.These include an internet infrastructure that ensures meaningful connectivity and affordable mobile devices that are easy to use for communication and exchange of audio-visual maternal health content.Based on the discussion section, Table 3 summarises the categories of enabling factors that influence the optimisation of access and utilisation of maternal health information and care services.There is a considerable number of growing publications in SSA researching how pregnant women or girls of reproductive age and nursing mothers in hard-to-reach populations of SSA utilize digital health, but less on their participation in the development processes of these interventions.While a behavioural change is observed in the increased rates of ANC visits and continuum of care when interventions such as mHealth-facilitated promotion are introduced, assimilation, scalability and consequences remain sparse [12].The unintended consequence of low participation is that digital health is not considered fit for purpose in terms of promoting maternal health to influence long-term behavioural change among the intended demographic [47].Ultimately, digital health technologies are discarded while users are dissatisfied, and positive maternal health outcomes are rarely achieved, especially with persisting constraints by socioeconomic, sociocultural, and technical factors.

Conclusions
The objective of this study was to identify the status and enabling factors for digital health technologies (DHTs) to optimise access to and utilisation of maternal healthcare services during the perinatal and postpartum period in SSA.The findings show that the proliferation of mobile technologies and digital content sharing in SSA has been utilised by different stakeholder groups to develop digital health solutions that facilitate maternal health advocacy and enable communication and mediation of perinatal care and postpartum needs by community health workers to support pregnant women or girls.The enabling factors that influence the optimal utilisation of digital maternal health promotion and care services are the socioeconomic realities of pregnant women and girls, their sociocultural beliefs and the technical facilitating conditions provided by the relevant institutions.
The provision of essential maternal care in lowand middle-income societies is a complex issue that requires integrated, multidisciplinary and context-based interventions to build a resilient health system in SSA.In particular, the influence of partners of pregnant women and nursing mothers serves as a critical sociocultural factor in the development of programs tailored to the utilisation of maternal healthcare services.Although, studies in SSA have evaluated the impact of digital health interventions, most are limited to single issues and outcomes.DHTs can be deployed strategically to promote health and reduce the urban-rural divide that consistently leaves out the low-and middle-income societies.The main limitations of this work are that relevant scholarly articles might have been omitted due to lexical semantics, publications in journals with limited access due to university's limited subscription, and the use of a single online reference database from Google Scholar.
The challenges associated with digital maternal health promotion necessitate that an assessment of needs and interventions should be conducted across the lifecycle, through multi-stakeholder collaborations to figure out context-specific solutions and to determine key performance indicators to measure the impact of DHTs on maternal health outcomes.In protecting humans and resources for future societies, health promotion models must further explore the autonomy of pregnant women and girls to empower them with health information and behaviours through DHTs, to reduce the risk of maternal mortality.These considerations should be in line with social protection and well-being promotion by collaboratively working towards reorientation of health services, upskilling and nurturing supportive environments.

Figure 1 .
Figure 1.Flow diagram of literature analysis on eligible publications based on paper objectives

Table 1 .
Inclusion and exclusion criteria of eligible publications

Table 2 .
Summary of literature on digital maternal health promotion

Table 3 .
Enabling factors driving digital maternal health promotion.