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Int Public Health J 2017;9(2):145-151 ISSN: 1947-4989

© Nova Science Publishers, Inc.

Mommy: A maternal health surveillance system

Julia CA Chaves1,*, Enrique Cifuentes2, Abstract

PhD, and Alessandra A Macedo1, PhD
1 Maternal mortality is a global public health challenge, with
Department of Computer Science and Mathematics,
University of Sao Paulo, Sao Paulo, Brazil 99% of deaths occurring in developing countries. Poor
2 pregnancy outcomes reflect a cycle of vulnerability to risk
Department of Environmental Health,
factors, most of which can be prevented. We propose the
Harvard TH Chan School of Public Health, creation of an electronic system (‘Mommy’) that will assist
Boston, Massachusetts, USA and monitor the health of pregnant women, minimize their
exposure to risk factors and break the cycle of maternal
mortality. We predict that implementation and widespread
use of Mommy may lead to healthier pregnancies and
reduce the number of both maternal and neonatal deaths.
This project will help to break the cycle and reach the
Sustainable Development Goal 2030 of reducing maternal
mortality and improving infants’ health.

Keywords: Maternal health, surveillance, mobile


Maternal mortality is defined as the death of a woman
during pregnancy or in the first year after delivery.
The World Health Organization (WHO) estimated
that 830 women die every day from preventable
causes related to pregnancy and childbirth, with 99%
of all maternal deaths occurring in developing
countries, and predominantly among young women
from low-income populations. The high rate of
maternal deaths reflects the social determinants
of health (e.g., race, income, education, physical
environment, among other characteristics) and
highlights the health gap between rich and poor (1, 2).
Pregnancy is a vulnerable period for both mother
and fetus, and many factors can increase their risk
(3-6). These factors can be divided into five
categories (7): 1) Preexisting health conditions;
2) Age; 3) Life style; 4) Pregnancy conditions and
Correspondence: Julia Carmona Almeida Chaves, University
of Sao Paulo, Department of Computer Science and
5) Environmental risks (8-9).
Mathematics, School of Medicine of Ribeirao Preto, Av With advances in technology, it has become
Bandeirantes, 3900, Ribeirão Preto, São Paulo, Brazil. useful to apply existing resources to improve health
E-mail: juhhcarmona@gmail.com
146 Julia CA Chaves, Enrique Cifuentes, and Alessandra A Macedo

and well-being. To this end, the term mHealth direct causes are treatable and can be prevented
(mobile health) was created. mHealth is a general if women receive appropriate prenatal care.
term for the use of mobile phones and other wireless Furthermore, some factors (sepsis, unsafe abortion,
technology in medical care (2). The most common hypertensive disorders) are clearly and directly related
application of mHealth is the use of mobile phones to the social determinants of health (SDH).
and communication devices to inform users about The Pan American Health Organization (PAHO)
preventive health care services anywhere in the world. evaluated the maternal mortality ratio (MMR) in the
Through smartphone technology, mHealth intends to Americas: the MMR fluctuated from 5.9/100,000 live
change the face of modern medical assistance, births in Canada to 690/100,000 live births in Haiti,
creating mobile systems that collect and analyze data illustrating the extreme socioeconomic inequality in
and interact with people. the region. In Brazil, the MMR has been reduced in
The risks on the gestational period can be reduced the last 18 years from 120/100,000 live births in 1990,
and neonatal outcomes can be improved when the 64/100,000 live births in 2005 to 58/100,000 live
appropriate preventive measures are taken. births in 2008, but the rate did not reach the expected
Smartphone technology can be used as a preventive threshold defined by the United Nations (10).
and efficient method that can be easily harnessed and According to the fifth Millennium Development Goal,
implemented and it is also practical for women in the annual reduction for MMR in Brazil should have
childbearing age. been 5.5%, but it was only 4% (9-10).
Neonatal mortality is frequently used as an
indicator of quality of life and well-being of a
Objectives population (13-15). Mortality on the first days of
life reflects the complex relationship between
To develop a computational system to monitor and biological, socioeconomic and welfare factors where
assist pregnant women to prevent or minimize their socioeconomic and welfare factors are strongly
exposure to environmental risk factors that can be related to the care provided to pregnant women and
harmful to themselves and/or their children. the newborn (16, 17). Neonatal mortality rates in
developing countries remain alarming: in Bolivia
there are 37.49 deaths per 1,000 live births (2), in
Hypotheses Africa there are 55 deaths per 1,000 live births, and in
Brazil the ratio is 13.82 deaths per 1,000 live births
The technology of smartphones can be harnessed to (16). The major causes of neonatal mortality are
prevent complications during pregnancy, and decrease related to diseases during pregnancy and childbirth:
maternal and neonatal death rates. This modern tool mainly preterm birth, low birth weight, respiratory
will allow improved patient monitoring, more and infectious diseases, and congenital malformations
personalized care and increase physician and patient (9). Neonatal mortality is inextricably connected with
satisfaction. maternal health conditions (18). The risk factors of
pregnancy can be divided into five categories (7):

Contextualization  Pre-existing health conditions: These are

conditions that are present before women
Maternal mortality is one of the major health become pregnant, for example diabetes and
problems in Brazil and other developing countries obesity.
(10). The direct causes of maternal mortality are  Age: Pregnant teenagers have higher
hemorrhage, sepsis, hypertensive disorders, unsafe probability of developing high blood
abortion, and prolonged and/or obstructed labor (11). pressure, anemia, and are more likely to
The indirect causes of maternal death are related to deliver prematurely. Also, teenagers are less
poor health before pregnancy, or diseases that women likely to access pre-natal care and do not
develop during pregnancy (12). Virtually, all the always understand the risks of pregnancy.
Mommy 147

Women who have their first child after  Environmental risk factors: Environmental
35 years of age usually have a normal exposures as, for example: air pollution and
pregnancy, however they have a higher risk pesticides may cause premature birth, low
to have a caesarean section, to have birth weight, and congenital malformations.
complications in childbirth, and their child These babies have a higher risk of dying,
have higher risk of having genetic conditions, and those who survive have higher risk for
such as Down syndrome. brain, respiratory and digestive disorders.
 Life style: Pregnant women who consume Environmental exposure is also related to the
alcohol have a higher risk of premature birth, development of heart diseases and diabetes in
and infants with Fetal Alcohol Syndrome. adulthood (8-9).
Women who smoke during pregnancy also
put their fetuses at risk of premature birth, According to the World Health Organization,
genetic abnormality, and sudden death maternal deaths significantly reflect social
syndrome. Passive smoking or ‘second hand determinants of health, limited access to adequate
smoke’ also increases the risk of health health care and lack of timely information (1).
problems in both fetus and mother. Neonatal mortality reflects complex relationship
 Pregnancy conditions: Multiple pregnancies between environment, genes, socioeconomic status,
(i.e., twins, triplets, or more) increase the risk access to health services, and maternal literacy status.
of premature birth and frequently require Neonatal mortality can thus be prevented by stronger
cesarean section. Infants from multiple public health policy targeting antenatal and immediate
pregnancies, in general, are smaller and more postnatal care (19-22).
likely to be premature than singletons. Also, Figure 1 shows the cycle of environmental health
premature infants are more likely to have disparities. This project focuses on to prevent the
respiratory distress with associated increase health risk factors and consequently to break this
in morbidity and mortality. cycle by offering the pregnant women information,
and a facilitated contact with the physician.

Figure 1. International cycle of environmental health disparities (23).

148 Julia CA Chaves, Enrique Cifuentes, and Alessandra A Macedo

Related work capacity of the smartphone by incorporating an

environmental sensor to create a more effective
Many mHealth systems are currently in use, and those prevention tool.
focusing on improving maternal and neonatal health
have been well received (23). “Wired mothers” is an
mHealth application that combines communication, Mommy architecture
education on pregnancy, reminders of antenatal care
visits, and an emergency medical response system, The architecture of the system is shown in Figure 2.
and has been demonstrated to decrease perinatal The system will have: 1) a mobile application that
mortality rate by 50% (23). “mMamee” is another will be installed on the smartphones of pregnant
mHealth application that does monitor and assess women; 2) a web system that will be used by the
environmental exposures that could potentially affect health professional providing prenatal care; 3) a
the health of pregnant women (24). The platform central system that will be responsible to process the
relies on the combination of user descriptive input and information.
urban sensing measurements. Their goal is to The smartphone of the pregnant woman will be
determine the long-term impact of various exposure the interaction interface of the system: 1) It will
factors on maternal and fetal health (24). collect the environmental data 2) send it to the central
A study conducted by Sondaal et al., assessed the system 3) which will process and store the data 4).
effect of mHealth interventions in improving maternal After processing the data, the system will send alerts
and neonatal care in low- and middle-income and tips to the woman [5 and 6], and include the
countries; the studies, however, have not reviewed crucial information into the health professional report
used the sensors of the smartphone to obtain [7]. This report can be visualized through the web
environmental data to allow preventive alerts (23). interface [8].
Mommy is an innovative approach among
mHealth applications in that it will use the full

Figure 2. Mommy’s architecture.

Pregnant women will register with an email  “Twins information”: How many fetuses is
address and password. After that, they will be asked the pregnant carrying, i.e., is it a single fetus
to input some additional information about the or multiple fetus pregnancy?
pregnancy such as:  Weight: Information about weight gain
during pregnancy.
 Stage: How many weeks of gestation have  Symptoms: There will be a list of common
passed since last period? pregnancy symptoms that the patient will be
Mommy 149

prompted to check. There will be also an Preto, Brazil. The technology is currently being
option to add additional symptoms. elaborated along with the development of new
 General well-being: The patient will be functionalities. This is a work in progress.
prompted to enter information on how she
is feeling about sleep quality, mobility,
appetite, and other factors during the Discussion
pregnancy, using a five-star rating bar.
mHealth interventions have been developed to
Shortly after registering, the system will invite improve maternal health, antenatal and postnatal
her to fill in information about her medical clinic attendance, improved vaccination rates, and
information on conditions, such as personal medical delivery at staffed facilities (23). These interventions,
history, family medical history, pregnancy history, however, have shown little impact on maternal and
and health habits (smoking, alcohol drinking, physical neonatal health outcome (23). However, as shown by
activity) to allow more accurate alerts. Sondaal et al., none of the methods utilized to develop
The doctor’s report will store the health related mHealth applications used the environmental data of
information including data such as medications, the pregnant women to access daily risks. In addition,
vaccines, high-risk travel, and physical activity. The none of the applications reviewed by the study put
doctor’s report is crucial for better results, but the together all the functionalities that Mommy proposes.
pregnant woman will have control over who can Mommy intends to access and process the
access her data. This is especially important for the environmental data and send alerts to allow the
empowerment of the patient. woman to make changes on her daily habits. There
The system will provide reliable information will be also incentive messages seeking to motivate
throughout pregnancy as the fetus develops. Mommy the pregnant women to improve their health habits,
will also allow the pregnant woman to submit making use of multivariate visualization tools to make
questions and concerns to health professionals. The it easier to understand what the most important
system will provide instructions to help her recognize aspects are that need to be improved. Furthermore, the
signs and symptoms that require further evaluation. A system has the potential to be a valuable surveillance
communication channel with the doctor will be tool for doctors in that they can monitor the status of
available for emergencies. their patients through the electronic reports that will
Other proposed functionalities are the tracking of be generated.
medication use, and the monitoring of sleep, physical The next step of the system development is the
activity, and fluid intake. Tips regarding healthy diet medication tracker functionality which will be
will also be included in the system. The location evaluated and a ‘first version’ will be released to
tracker is fundamental. The women will be alerted if users. Also, new functionalities of Mommy, such as
they plan to travel to high risk areas, such as those the physical activity tracker will also be developed.
with high pollution levels or areas with reported cases Mommy has the potential to be a functioning
of Zika. health care application that even low- and middle-
A prototype of the system was implemented and income populations can access. Technology is
the Medication Tracker functionality was developed becoming more accessible and smartphones are
which manages medications that the pregnant woman becoming cheaper. There are more than 281 million
is taking. Moreover, it reminds her when she needs to mobile phones in Brazil, with about three
take another dose of medication, and it will alert her if smartphones for each ten people (25). With a
the medication that she is taking is not deemed safe population of 200 million, the number of cellphones
during pregnancy. exceeds the number of people in the country (26),
Although Mommy has been partially developed, while the number of doctors is not enough; there are
it has not yet been tested, and, consequently, has not on average only 1.95 doctors per thousand inhabitants
been released for general use. It was developed to test with an uneven distribution favoring more urban
the system at the Hospital das Clinicas at Ribeirao affluent areas where there are 2-4 doctors per
150 Julia CA Chaves, Enrique Cifuentes, and Alessandra A Macedo

thousand inhabitants while in the poorer areas there .br/saude/2014/05/oms-brasil-reduz-mortalidade-

are less than 1 per thousand, which is comparable to materna-em-43-de-1990-a- 2013.
[9] Morse M, Fonseca S, Barbosa M, Calil M, Eyer F.
the poorest countries in Africa (27). This scenario
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Acknowledgment mortalidade materna e infantil: Um dever de todos.
URL: http://www.prefeitura.sp.gov.br/cidade/secretarias
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Casa de Limeira who provided insight and expertise pdf.
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