Wireless Monitor Aims to Reduce Maternal Mortality in Uganda

An obstetrician at Massachusetts General Hospital works closely with African colleagues to improve maternal outcomes after birth. In the first study in Africa to use a wireless monitoring device to monitor obstetric vital signs continuously, she found that the device improved the quality of care in the high-risk period immediately after birth.

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"Where you happen to give birth or be born matters so much. It affects your chances of survival, quality of life, and potential complications," says Adeline Boatin, MD, MPH, co-director of the Global OB/GYN Program in the Department of Obstetrics and Gynecology at Massachusetts General Hospital. "My research portfolio is focused on leveraging technology, innovation, strategy, and systems thinking to improve the quality of care in reproductive health services."

Reducing Maternal Mortality

There are significant disparities in maternal mortality among various countries. According to the World Health Organization, the U.S. rate is 1 in 3,000—a stark contrast to countries in sub-Saharan Africa. For example, Zambia has a rate of 1 in 1,800, Ghana 1 in 81, and Chad 1 in 15. Mothers also experience high rates of other complications and long-term disabilities after birth, Dr. Boatin says.

To explore this issue on the ground, she spent extended time at Mbarara Regional Referral Hospital in southwestern Uganda. The institution has its own OB/GYN training program and an established partnership with Mass General. The hospital performs about 10,000 births per year, compared to Mass General's 3,000 to 4,000 per year. Despite the larger number of births, the hospital has much fewer staff. About 22 nurse midwives perform all of the duties of both nurse and midwife.

"Staffing affected their ability to regularly monitor patients during the high-risk time for complications after birth," Dr. Boatin explained. "We found almost no monitoring in the first 24 hours, compared to women at Mass General, whose vital signs are monitored every 15 minutes for the first two hours and frequently thereafter. Although they understood the importance of monitoring to prevent maternal deaths, they simply did not have the resources."

Continuous Wireless Monitoring in the Period Just After Birth

To address the issue, Dr. Boatin and her colleagues, including Joseph Ngonzi, MBChB, MMED, FCOG (ECSA), PhD, dean of Faculty of Medicine at Mbarara University of Science and Technology, designed a pilot study that used one of two devices to continuously monitor maternal respiratory rate, heart rate and temperature: a small patch on the chest or a smartphone-sized device strapped to the arm.

Data from the devices are sent to the cloud, then made available for a clinician to access on a computer or smartphone app. Clinicians can easily view trends for multiple patients, and they receive alerts when an individual's vital signs fall outside normal ranges.

"The project sought to establish several things: Can we do this in an obstetric population, among women who may be breastfeeding or moving around after birth? Also, can we do this in an area with low resources, including unreliable internet or electricity?" Dr. Boatin explains. "In addition, will clinicians accept this tool? In a setting where clinicians don't have a paging system or an electronic health record, can we fully integrate this technology into the workflow? And finally, does it improve outcomes?"

Dr. Boatin's study, funded by a National Institutes of Health K award, recruited 1,500 women who had a Cesarean section. To ethically achieve randomization, the researchers alternated between two-week periods when the devices were used on all patients or no patients.

Almost 80% of patients had successful continuous monitoring for the first 24 hours after C-section. Mothers reported that the device was comfortable and didn't interfere with movement or breastfeeding.

Clinicians also found value in the device. When they received an alert, they could see most patients within 30 minutes. Overall, 90% of patients with alerts were assessed by a nurse midwife. Of note, clinicians reported that the device improved the quality of care in unexpected ways. For example, elevated heart rate alerted clinicians to pain, which could be treated. Lower temperature alerts sometimes indicated a simple need for a blanket.

Dr. Boatin is currently assessing whether the device improved complications or mortality rates. In addition, she's adjusting the algorithm to have maximum sensitivity to detect clinically significant events without creating alert fatigue for clinicians.

Learning From Global Health

Dr. Boatin was born in Zambia and spent much of her childhood in Ghana. Her father was a researcher for the World Health Organization, so her family moved a lot. She attributes her career path largely to her upbringing.

She adds that her work is also possible because she works at Mass General, a center of excellence where people constantly push the boundaries. She completed her residency training at Mass General and then stayed on because of the rich opportunity for clinical and research experiences domestically and globally.

"We're constantly pushing the boundaries and thinking about how to do things better, even though we are already doing things well," she says. "We take those lessons and share them with colleagues overseas and vice versa. We learn lessons from colleagues overseas in different settings, bring them back here, and think about how we can apply that in our context. There are different ways of doing things, and we can all learn from each other."

Learn more about Mass General Global OB/GYN

Refer a patient to the Department of Obstetrics & Gynecology