Potential Effects of WhatsApp on Maternal Health Services Uptake during COVID-19: A Cross-sectional Study in Ghana

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Safo, Daniel Opoku, Clement K. Sechim, Richard A. Bonney, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4902660/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Jan, 2025 Read the published version in BMC Health Services Research → Version 1 posted 19 You are reading this latest preprint version Abstract Background During the COVID-19 pandemic period Health Care Practitioners (HCPs) were seen to facilitate healthcare delivery by using their mobile phones also known as “informal mHealth”, especially in Sub-Saharan Africa (SSA). WhatsApp has become popular in recent years with over 380 million users. It has therefore been identified that the effective use of WhatsApp by HCP for health could positively impact it. This study aims to assess the potential effect of the use of WhatsApp by HCPs on Maternal Health Services (MHS) uptake during the COVID-19 pandemic in four primary healthcare facilities in the Kwadaso Municipality of Ghana. Methods A cross-sectional study design was adopted using a quantitative approach involving a census sampling technique to collect data on monthly Maternal Health Services (MHS) attendance from the District Health Information Management Systems (DHIMS 2). Data collection was for the period March 2019 to February 2020 and March 2020 to February 2021. Results During the COVID-19 pandemic, the introduction of WhatsApp as a mHealth intervention helped improve maternal health case management and patient confidence. This led to a 5.64% (p-0.02) increase in ANC attendance and a 5.62% (p-0.02) rise in health facility deliveries. However, although PNC service attendance dropped slightly (7.06%, p-0.95), it was not statistically significant. Overall, key maternal health indicators showed significant improvements from 2019 to 2021 COVID-19 period. Conclusion WhatsApp usage by HCPs for a positive and timely patient management showed an increased attendance for ANC and delivery services in Ghana during the COVID-19 pandemic. This reveals that the use of WhatsApp for maternal health services referrals can be used as a communication tool for the management of high-risk obstetric referrals also. COVID-19 maternal referral WhatsApp maternal health services Figures Figure 1 Background During COVID-19, one of the innovative approaches explored to mitigate the interruptions in healthcare provision was the use of telemedicine. Telemedicine helps patients to consult physicians which prevents unnecessary and avoidable COVID-19 exposures of people involved in healthcare delivery [ 1 ]. Upon the declaration of COVID-19 as a pandemic on March 11, 2020, by the World Health Organization (WHO), over 240 million confirmed cases of COVID-19, and around 5 million deaths were reported globally in less than two years [ 2 ]. Recent studies have found that WhatsApp has facilitated the improvement of public health among populations susceptible to COVID-19 complications [ 3 ]. Additionally, despite persistent issues with referral delays in various countries, the utilization of WhatsApp mobile messaging technology for enhancing communication and coordination along the referral process has been deemed viable [ 4 ]. In Sub-Saharan Africa and Ghana, maternal mortality remains unacceptably high at 546 and 319 deaths per 100,000 live births respectively [ 5 ]. Across 118 countries during the pandemic, between 8.3% and 38.6% increase in maternal deaths per month were projected as a result of disruptions in service provision and access [ 6 ]. COVID-19 restriction measures such as lockdowns and travel bans limited women’s access to quality services [ 7 ]. In particular, the provision of antenatal and postnatal care was reportedly disrupted in every one out of three countries worldwide, while one out of four countries reported disruptions in facility-based births [ 8 ]. Early reports on COVID-19 suggested an increase in iatrogenic preterm birth and cesarean birth in infected mothers, which accounted for an increased risk of maternal intensive care unit (ICU) admission and maternal mortality [ 9 ]. On maternal and perinatal mortality among adolescents, there was a significant increase in the proportion of fresh stillbirths from 0.9–1.0% (P = 0.0066) from the pre- to peri-COVID-19 period [ 10 ]. At the same time, there were several innovations were implemented to mitigate the interruptions to maternal healthcare provision. These included telemedicine (use of Information and Communication Technologies (ICT) in care provision), changes in anesthesia practices, reduction in the number of allowed companions during birth, as well as labor induction and early discharge after birth to minimize the duration women spend in hospitals [ 6 , 12 , 13 ]. Telemedicine or mobile health (mHealth) has been reported to have the potential to be an effective way of improving maternal and neonatal health in developing countries [ 14 ]. Telemedicine could be an effective tool in providing care to pregnant women in remote areas [ 15 ]. For instance, telemedicine can be used for prenatal monitoring and risk detection among others [ 16 ]. Maternal and newborn healthcare providers globally considered telemedicine of benefit during the pandemic and applied it on a wide scale on different aspects of maternal and newborn healthcare [ 17 ]. Also, patients who used telemedicine in the US have been reported to have experienced similar outcomes compared to those who visited the facility, indicating that maternal-fetal medicine (MFM) provided through telemedicine can serve as an effective substitute for in-person care [ 18 ]. A pilot project in Mali has enabled the development of a functional national telemedicine network supported in connecting several health institutions in Bamako, Segou, and Tombouctou, where medical teams have been trained for the use of internet-based tools [ 1 ]. In Uganda, the majority of women who were involved in a mobile phone consultation intervention during home visits by Community Health Workers for maternal and newborn care shared that the intervention improved access to maternal and newborn information, reduced costs of accessing care, and facilitated referral [ 19 ]. In Ghana, the Technology for Maternal and Child Health (T4MCH) was reported to have increased antenatal care attendance by 18 percentage points (ppts) [95% CI − 17.0, 52.0], facility delivery by 14 ppts [95% CI 6.0%; 21.0%], postnatal care by 27 ppts [95% CI 15.0, 26.0] and continuum of care by 15.0 ppts [95% CI 8.0, 23.0][ 20 ]. Also, the Mobile Technology for Community Health (MOTECH) deployed a “Client Data App” which was reported to be feasible, usable, and acceptable, and aided health workers in collecting and tracking data to improve maternal, neonatal, and child health services [ 21 ]. Similarly, WhatsApp has been explored as a mHealth-based telemedicine tool for referrals in the provision of maternal health services in Ghana. Therefore, this study provides evidence of the effect of this intervention by HCPs on maternal health outcomes. Methodology Study design A cross-sectional quantitative study design was employed for this study. This design was chosen to investigate associations between the usage of WhatsApp platforms by healthcare providers during the COVID-19 pandemic and the uptake of maternal health services. The platform was used for provider-to-provider communications and support with patient referrals. A comparison was done for pre-and-during the COVID-19 pandemic period. Sampling and participants A census sampling was used to consider all pregnant women and mothers within twelve months before and during COVID-19. The study was conducted at the Kwadaso Municipality. All postpartum and pregnant women who assessed services from selected health facilities (Seventh Day Adventist (SDA) Hospital, HopeXchange Medical Center, Apatrapa Health Center, and Maranatha Hospital) from March 2019 to February 2020 and March 2020 to February 2021 were included in this study. The total sample for this study was 34,345 (i.e., 16,465 from March 2019 to February 2020 and 17,880 from March 2020 to February 2021). Data collection procedure Secondary data was extracted from the District Health Information Management System (DHIMS) into Microsoft Excel using a data extraction sheet. The data was collected from the Health Information Department at the Kwadaso Municipal Health Directorate. Data collected included ANC attendance, PNC registrants, and deliveries within the period under study. Data analysis Data from the Excel spreadsheet was exported into STATA 16.0 for statistical analyses and presented in tables and charts. A two-paired sample t-test analysis was done to compare the means of ANC attendance, PNC registrants, and deliveries before and during the COVID-19 pandemic to establish if there was any difference. Statistical significance for all tests was at a p-value of 0.05. Results This study sought to assess the effect of WhatsApp usage among healthcare providers during the COVID-19 pandemic to facilitate maternal health services. With the advent of WhatsApp as a mHealth intervention by the Municipal Health Directorate, all the specialists and other cadre of staff for the management of maternal health cases were on it hence, most of the respondents were able to quickly identify and manage cases such as Vaginal Birth After Cesarean (VBAC), immunosuppression, hemorrhage, pre-eclampsia or eclampsia during the COVID-19 pandemic than before. This promoted patient confidence in the healthcare provision by the facilities in the municipality. This increased patient attendance for ANC by 5.64% during the COVID-19 pandemic as compared to attendants before the COVID-19 pandemic (see Fig. 1 ). These were statistically significant in their mean differences (p-value = 0.02) (see Table 1 ). This difference might happen because HCPs do more intra-facility referrals than before. Health facility deliveries increased by 5.62% during the COVID-19 pandemic compared to before. Their mean differences were statistically significant (p-value = 0.02) (see Table 1 ). This was not so for PNC services among the four selected facility sites, with over fifty percent of the respondents (53.53%) reporting for PNC services before COVID-19 as compared to during COVID-19 at the advent of the WhatsApp mHealth (see Fig. 1 ). Additionally, its mean difference was not statistically significant (p-value = 0.95) (see Table 1 ). Table 1 Two-sample t-test with equal variances Variable Mean (SD) p-value Antenatal Care During 1183.00 (± 148.81) 0.02 Before 1056.50 (± 135.76) Delivery During 147.33(± 18.88) 0.02 Before 131.67 (± 15.72) Postnatal Care During 159.67 (± 30.24) 0.95 Before 183.91(± 38.55) The data provided in Table 2 outlines the performance of various maternal and neonatal indicators over the period under study. The indicators included maternal mortality ratio, ANC coverage, ANC registrants making 8th visits, skilled delivery, PNC coverage, the proportion of mothers receiving PNC within 48 hours from birth, and the proportion of mothers who made at least four ANC visits. There was a significant improvement in the institutional maternal mortality ratio, dropping from 53.3 per 100,000 in 2019 to zero in both 2020 and 2021, indicating substantial progress in maternal health and safety. ANC coverage showed a significant increase over the period. In 2019, the coverage was 31.8%, which increased to 37.6% in 2020 and further to 53.1% in 2021 (see Table 2 ). This upward trend indicates an improvement in pregnant women accessing ANC services, which is crucial for monitoring and promoting the health and well-being of both the mother and the fetus. The percentage of ANC registrants making their 8th visit fluctuated slightly over the years. In 2019, it was at 50.0%, rising to 56.4% in 2020, before dropping back to 50.0% in 2021 (see Table 2 ). While there was an initial improvement, maintaining a consistent rate suggests a need for targeted interventions to encourage pregnant women to complete all recommended ANC visits. The data also revealed that the proportion of mothers who made at least four ANC visits increased from 92.0% in 2019 to 96.7% in 2020 but then decreased to 86.5% in 2021 (see Table 2 ). The proportion of skilled deliveries saw a steady increase, rising from 24.8% in 2019 to 26.7% in 2020, and significantly to 41.2% in 2021 (see Table 2 ). This growth is indicative of improved access to skilled birth attendants, which is essential for reducing maternal and neonatal mortality and complications during childbirth. PNC coverage initially decreased from 35.2% in 2019 to 28.9% in 2020, before experiencing a substantial increase to 75.0% in 2021 (see Table 2 ). The proportion of mothers who received PNC within 48 hours of birth saw significant improvements, starting at 49.3% in 2019, increasing to 86.5% in 2020, and further to 90.9% in 2021 (see Table 2 ). Early postnatal care is crucial for identifying and addressing any complications that may arise immediately after delivery. Table 2 Maternal and Neonatal Indicators Variable Performance 2019 2020 2021 Institutional maternal mortality ratio 53.3/100,000 0 0 ANC coverage 31.8% 37.6% 53.1% ANC registrants making 8th visits 50.0% 56.4% 50.0% The proportion of mothers who made at least four ANC visits 92.0% 96.7% 86.5% Skilled delivery 24.8% 26.7% 41.2% PNC coverage 35.2% 28.9% 75.0% The proportion of mothers receiving PNC within 48 hours from birth 49.3% 86.5% 90.9% Discussion This study sought to assess the potential effect of WhatsApp as a mHealth-based telemedicine tool for referrals in providing maternal health services. Among the key findings made from this study is an increase in ANC service uptake by 5.64% and hospital deliveries by 5.62%. However, the PNC service saw a decrease in uptake by 7.06%. The increase in ANC service uptake highlights the importance of accessible and timely healthcare during pregnancy. WhatsApp referrals likely improved communication between healthcare providers leading to more women accessing necessary support. This enhanced engagement contributes to better maternal and fetal health outcomes, early complication detection, and overall improved pregnancy experiences. The rise in hospital deliveries suggests a shift towards safer childbirth practices, reducing maternal and neonatal mortality and morbidity due to skilled birth attendants and emergency care availability. WhatsApp referrals likely influenced more women to choose hospital births, ensuring access to essential medical facilities and professional care, thereby lowering the risks associated with home births. The decrease in PNC service uptake is concerning, as the postpartum period is crucial for monitoring maternal recovery, and newborn health, and providing breastfeeding and family planning support. Addressing this is essential to prevent untreated postpartum complications, missed early interventions for newborns, and insufficient support for new mothers. Women’s health throughout pregnancy, childbirth, and postpartum is important [ 22 ]. Studies have shown that the introduction of mHealth interventions can lead to the uptake of maternal health services [ 23 ]. The findings of this study correspond with a similar study that showed that WhatsApp could be utilized as a communication medium for high-risk obstetric referrals [ 4 ]. It can further be emphasized that there is a necessity to keep enhancing urban referral procedures due to delays that have been recognized as possibly contributing to unsatisfactory outcomes. This study revealed that the uptake of ANC services and deliveries was significantly different from before and during the COVID-19 pandemic. This is contrary to reports by other studies that reported a decline in ANC uptake during the COVID-19 pandemic [ 24 – 27 ]. This could be because expectant mothers involved in this study received prompt and needed services facilitated by the intervention, which had a positive effect on their health behavior. For this reason, ANC services uptake remained high even though the pandemic could have served as a barrier to access. The COVID-19 pandemic disrupted healthcare services globally, leading to concerns about reduced ANC uptake. However, this study suggests that timely and accessible mHealth interventions could mitigate such disruptions. By facilitating prompt access to needed services, even during a pandemic, expectant mothers can continue to receive essential care without interruption. Concerning PNC services, mHealth has been reported to have given mothers confidence that, if they followed recommended newborn procedures their babies would have better outcomes, such as cord healing [ 19 ]. However, the findings from this study on PNC services uptake during the COVID-19 period did not reflect the positive effect of the intervention. The uptake of PNC services before and during the pandemic was not statistically significant. This suggests that despite efforts to promote PNC services, there was no marked increase in utilization rates during the pandemic. The implications of these findings are profound as PNC plays a critical role in monitoring the health of mothers and newborns after childbirth, providing essential medical checks, vaccinations, and support for breastfeeding and maternal mental health. Lower PNC uptake could affect maternal morbidity and infant mortality rates, emphasizing the importance of continuous adaptation and improvement in healthcare delivery models. This highlights the need for targeted interventions that can effectively address these barriers and ensure that maternal and child health services remain accessible and utilized during crises. Documented instances of “informal mHealth” often resemble “formal” mHealth programs that have been put in place in Africa and other regions of the world including a study that identified that Community Health Workers (CHWs) utilized similar interventions through phone calls to facilities in advance to let health providers at other health facilities know about referrals, which increased facility readiness [ 28 – 35 ]. It offers a potentially affordable way to help the provision of healthcare in Ghana. The significance of this has increased since a study [ 36 ] discovered a significant level of interest in mHealth activities among Ghanaian medical practitioners. Therefore, mHealth can help in attaining universal health coverage when properly deployed and regulated by closing the access gap in healthcare services between the rich and the poor as well as in rural and urban areas [ 37 ]. This would accelerate efforts to fulfill the mission of leaving no one behind [ 38 ]. Effective usage of mHealth applications can be improved by providing healthcare providers with thorough training on mHealth interventions [ 39 – 41 ]. Limitations This study provides good insight into the effects of WhatsApp usage by healthcare providers for referrals during the COVID-19 pandemic on ANC, delivery, and PNC services; however, this study is limited by scope and could be explored in other settings for a better understanding from other parts of the world. The study excluded patients’ access to the WhatsApp platform. Conclusion The study demonstrates that using WhatsApp for maternal healthcare significantly increased attendance for ANC and delivery services during the COVID-19 pandemic. This highlights the platform’s potential as an effective communication tool for managing high-risk obstetric referrals. WhatsApp’s accessibility and real-time messaging capabilities facilitated timely reminders, consultations, and emotional support, overcoming barriers to physical visits and ensuring continuous care. It also enabled efficient coordination and follow-up among healthcare providers, improving referral processes and patient outcomes. These findings suggest that integrating WhatsApp into routine maternal health services can enhance healthcare delivery, especially in resource-limited settings. Future efforts should focus on scaling up this approach, developing formal protocols, and conducting further research to evaluate long-term impacts and optimize implementation strategies. We recommend a quasi-experimental study to be conducted to include both the HCPs and patients’ usage of the WhatsApp intervention. Abbreviations ANC - Antenatal care CHWs - Community Health Workers COVID-19 - Coronavirus 2019 DEL - Delivery HCPs - Health Care Practitioners mHealth - Mobile Health MHS - Maternal Health Services PNC - Postnatal Care VBAC - Vaginal Birth After Cesarean Declarations Ethical approval and consent to participate Ethical clearance was sought from the KNUST Committee for Human Research, Publications, and Ethics (CHRPE) in Kumasi, with reference number CHRPE/AP/450/22. Permission was also sought from the Kwadaso Municipal Health Directorate. During data collection and coding, the anonymity and confidentiality of interviewees were guaranteed by the avoidance of using names that could lead to individual partakers. Consent for publication Not applicable. Availability of data and materials The data set supporting the conclusions of this article is available in the District Health Management Systems (DHIMS 2) Competing interests The authors declare that they have no competing interests. Funding This work was supported by the eHealth Research Partner Group (eHRPG) at the Kwame Nkrumah University of Science and Technology, Kumasi under Grant No.: 01DG20020 from the budget of the German Federal Ministry of Education and Research (BMBF). The funding source was not involved in the design, conduct, or reporting of the work. Authors’ contributions Conceptualization: KSS, KAM, DO; Methodology: KSS, KAM, RAB, DO; Data curation: KSS, CKS, RAB; Formal analysis: KSS, DO, RAB, CKS; Writing initial draft: KSS, RAB; Reviewing and editing: KAM, DO, RAB, CKS; Project administration: DO, RAB; Supervision: KAM; Acquisition of funding: DO. All the authors have read and approved the final manuscript. Acknowledgments The authors acknowledge the management at Kwadaso Municipal Health Directorate. Similarly, the authors are grateful to the eHealth Research Partner Group at the KNUST for the research training support. Authors’ information 1 eHealth Research Partner Group (eHRPG) at the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Kwame S. Safo, Daniel Opoku, Kofi A. Mensah, Clement K. Serchim & Richard A. Bonney 2 School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Kwame S. Safo, Daniel Opoku, Kofi A. Mensah, Clement K. Serchim & Richard A. Bonney 3 Seventh-Day Adventist Hospital, Kwadaso, Ghana Kwame S. Safo 4 Department of Health Care Management, Technische Universität Berlin, Berlin, Germany Daniel Opoku & Richard A. Bonney 5 DGerman-West African Centre for Global Health and Pandemic Prevention (G-WAC), Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. References Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. 2020;20(1):1193. Organization WH. The impact of COVID-19 on health and care workers: a closer look at deaths. World Health Organization; 2021. Oliveira SC de, Costa DG de L, Cintra AM de A, Freitas MP de, Jordão C do N, Barros JFS, et al. Telenursing in COVID-19 times and maternal health: WhatsApp® as a support tool. Acta Paul Enferm. 2021;34:eAPE02893. Owen MD, Ismail HM, Goodman D, Batakji M, Kim SM, Olufolabi A, et al. 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Supplementary Files SupplementarysheetDHIMS2.xls Cite Share Download PDF Status: Published Journal Publication published 14 Jan, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 04 Nov, 2024 Reviews received at journal 04 Nov, 2024 Reviews received at journal 02 Nov, 2024 Reviewers agreed at journal 02 Nov, 2024 Reviewers agreed at journal 01 Nov, 2024 Reviewers agreed at journal 01 Nov, 2024 Reviewers agreed at journal 01 Nov, 2024 Reviewers agreed at journal 30 Oct, 2024 Reviewers agreed at journal 21 Oct, 2024 Reviewers agreed at journal 11 Oct, 2024 Reviewers agreed at journal 07 Oct, 2024 Reviewers agreed at journal 06 Oct, 2024 Editor invited by journal 04 Oct, 2024 Reviewers agreed at journal 28 Aug, 2024 Reviewers agreed at journal 23 Aug, 2024 Reviewers invited by journal 22 Aug, 2024 Editor assigned by journal 14 Aug, 2024 Submission checks completed at journal 12 Aug, 2024 First submitted to journal 12 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4902660","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":351181692,"identity":"e7257126-f062-471c-9de3-9fd8b8561195","order_by":0,"name":"Kwame S. Safo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIie2RMUvDQBSAD4RmOcn6jpP8hjcFBfG3BApxObFTF0EDhWYw3ZUO/oWI4FwpNEschRy3uKhLh07S4Ya+1MViUuomct/yPrj7uDuOMYfjDwLfBCc0feYlNPBw90QkvB4IbcVmwtYJRBsLPxA33bd8YU/ORTq4n5CALz5e8mUPmJ9eR02JhDjUt8Pu0ZjPek8kIMaqrzO6GJTPeVMSyCg0+8keBqBwSnKJRsUVpwThrCU5/TTWXn0lJIC6jLXdkkipQsM6U5R1QgJYeTOz7RRxN+/r0bBAkdFbSEBkqmMOEHjbW6AsHqulvUAoBg8LEvC94l3P7XHgp6PGpAm+/iC+6/Ya7/U3ux0Oh+P/swKocWbvJBGxFgAAAABJRU5ErkJggg==","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Kwame","middleName":"S.","lastName":"Safo","suffix":""},{"id":351181693,"identity":"94637f29-a86d-43f5-8838-d6d8261fb952","order_by":1,"name":"Daniel Opoku","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Opoku","suffix":""},{"id":351181694,"identity":"4dc868cc-7b2e-4130-b5e7-8fde4f97c045","order_by":2,"name":"Clement K. Sechim","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Clement","middleName":"K.","lastName":"Sechim","suffix":""},{"id":351181695,"identity":"47dfeed4-3e31-4c34-afbe-b5a9774a17ca","order_by":3,"name":"Richard A. Bonney","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Richard","middleName":"A.","lastName":"Bonney","suffix":""},{"id":351181696,"identity":"4723f662-f15e-449f-b43c-b84523b39e85","order_by":4,"name":"Kofi A. Mensah","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kofi","middleName":"A.","lastName":"Mensah","suffix":""}],"badges":[],"createdAt":"2024-08-12 19:53:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4902660/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4902660/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-12245-3","type":"published","date":"2025-01-14T15:57:17+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66124232,"identity":"2f103494-cfc4-49c5-bc5a-2e31a04c52dd","added_by":"auto","created_at":"2024-10-08 02:34:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":52016,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMaternal Health Services before and during COVID-19\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4902660/v1/1538abf9c0655f1a2dedb253.png"},{"id":74284548,"identity":"b2a87662-fbad-4e59-91f9-c5edf7dd9444","added_by":"auto","created_at":"2025-01-20 16:08:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":629765,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4902660/v1/dfb2368c-e6f6-47b0-8df5-e6b3c508baed.pdf"},{"id":66125800,"identity":"7c240b2b-e33c-4996-b5d7-f472fd48ca0a","added_by":"auto","created_at":"2024-10-08 02:42:39","extension":"xls","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31744,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarysheetDHIMS2.xls","url":"https://assets-eu.researchsquare.com/files/rs-4902660/v1/2f128ac87d50721737effd88.xls"}],"financialInterests":"No competing interests reported.","formattedTitle":"Potential Effects of WhatsApp on Maternal Health Services Uptake during COVID-19: A Cross-sectional Study in Ghana","fulltext":[{"header":"Background","content":"\u003cp\u003eDuring COVID-19, one of the innovative approaches explored to mitigate the interruptions in healthcare provision was the use of telemedicine. Telemedicine helps patients to consult physicians which prevents unnecessary and avoidable COVID-19 exposures of people involved in healthcare delivery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Upon the declaration of COVID-19 as a pandemic on March 11, 2020, by the World Health Organization (WHO), over 240\u0026nbsp;million confirmed cases of COVID-19, and around 5\u0026nbsp;million deaths were reported globally in less than two years [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Recent studies have found that WhatsApp has facilitated the improvement of public health among populations susceptible to COVID-19 complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Additionally, despite persistent issues with referral delays in various countries, the utilization of WhatsApp mobile messaging technology for enhancing communication and coordination along the referral process has been deemed viable [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In Sub-Saharan Africa and Ghana, maternal mortality remains unacceptably high at 546 and 319 deaths per 100,000 live births respectively [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Across 118 countries during the pandemic, between 8.3% and 38.6% increase in maternal deaths per month were projected as a result of disruptions in service provision and access [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. COVID-19 restriction measures such as lockdowns and travel bans limited women\u0026rsquo;s access to quality services [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In particular, the provision of antenatal and postnatal care was reportedly disrupted in every one out of three countries worldwide, while one out of four countries reported disruptions in facility-based births [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEarly reports on COVID-19 suggested an increase in iatrogenic preterm birth and cesarean birth in infected mothers, which accounted for an increased risk of maternal intensive care unit (ICU) admission and maternal mortality [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. On maternal and perinatal mortality among adolescents, there was a significant increase in the proportion of fresh stillbirths from 0.9\u0026ndash;1.0% (P\u0026thinsp;=\u0026thinsp;0.0066) from the pre- to peri-COVID-19 period [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. At the same time, there were several innovations were implemented to mitigate the interruptions to maternal healthcare provision. These included telemedicine (use of Information and Communication Technologies (ICT) in care provision), changes in anesthesia practices, reduction in the number of allowed companions during birth, as well as labor induction and early discharge after birth to minimize the duration women spend in hospitals [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTelemedicine or mobile health (mHealth) has been reported to have the potential to be an effective way of improving maternal and neonatal health in developing countries [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Telemedicine could be an effective tool in providing care to pregnant women in remote areas [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. For instance, telemedicine can be used for prenatal monitoring and risk detection among others [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Maternal and newborn healthcare providers globally considered telemedicine of benefit during the pandemic and applied it on a wide scale on different aspects of maternal and newborn healthcare [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Also, patients who used telemedicine in the US have been reported to have experienced similar outcomes compared to those who visited the facility, indicating that maternal-fetal medicine (MFM) provided through telemedicine can serve as an effective substitute for in-person care [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA pilot project in Mali has enabled the development of a functional national telemedicine network supported in connecting several health institutions in Bamako, Segou, and Tombouctou, where medical teams have been trained for the use of internet-based tools [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In Uganda, the majority of women who were involved in a mobile phone consultation intervention during home visits by Community Health Workers for maternal and newborn care shared that the intervention improved access to maternal and newborn information, reduced costs of accessing care, and facilitated referral [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In Ghana, the Technology for Maternal and Child Health (T4MCH) was reported to have increased antenatal care attendance by 18 percentage points (ppts) [95% CI\u0026thinsp;\u0026minus;\u0026thinsp;17.0, 52.0], facility delivery by 14 ppts [95% CI 6.0%; 21.0%], postnatal care by 27 ppts [95% CI 15.0, 26.0] and continuum of care by 15.0 ppts [95% CI 8.0, 23.0][\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Also, the Mobile Technology for Community Health (MOTECH) deployed a \u0026ldquo;Client Data App\u0026rdquo; which was reported to be feasible, usable, and acceptable, and aided health workers in collecting and tracking data to improve maternal, neonatal, and child health services [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Similarly, WhatsApp has been explored as a mHealth-based telemedicine tool for referrals in the provision of maternal health services in Ghana. Therefore, this study provides evidence of the effect of this intervention by HCPs on maternal health outcomes.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eA cross-sectional quantitative study design was employed for this study. This design was chosen to investigate associations between the usage of WhatsApp platforms by healthcare providers during the COVID-19 pandemic and the uptake of maternal health services. The platform was used for provider-to-provider communications and support with patient referrals. A comparison was done for pre-and-during the COVID-19 pandemic period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSampling and participants\u003c/h2\u003e \u003cp\u003eA census sampling was used to consider all pregnant women and mothers within twelve months before and during COVID-19. The study was conducted at the Kwadaso Municipality. All postpartum and pregnant women who assessed services from selected health facilities (Seventh Day Adventist (SDA) Hospital, HopeXchange Medical Center, Apatrapa Health Center, and Maranatha Hospital) from March 2019 to February 2020 and March 2020 to February 2021 were included in this study. The total sample for this study was 34,345 (i.e., 16,465 from March 2019 to February 2020 and 17,880 from March 2020 to February 2021).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection procedure\u003c/h2\u003e \u003cp\u003eSecondary data was extracted from the District Health Information Management System (DHIMS) into Microsoft Excel using a data extraction sheet. The data was collected from the Health Information Department at the Kwadaso Municipal Health Directorate. Data collected included ANC attendance, PNC registrants, and deliveries within the period under study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData from the Excel spreadsheet was exported into STATA 16.0 for statistical analyses and presented in tables and charts. A two-paired sample t-test analysis was done to compare the means of ANC attendance, PNC registrants, and deliveries before and during the COVID-19 pandemic to establish if there was any difference. Statistical significance for all tests was at a p-value of 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study sought to assess the effect of WhatsApp usage among healthcare providers during the COVID-19 pandemic to facilitate maternal health services. With the advent of WhatsApp as a mHealth intervention by the Municipal Health Directorate, all the specialists and other cadre of staff for the management of maternal health cases were on it hence, most of the respondents were able to quickly identify and manage cases such as Vaginal Birth After Cesarean (VBAC), immunosuppression, hemorrhage, pre-eclampsia or eclampsia during the COVID-19 pandemic than before. This promoted patient confidence in the healthcare provision by the facilities in the municipality. This increased patient attendance for ANC by 5.64% during the COVID-19 pandemic as compared to attendants before the COVID-19 pandemic (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). These were statistically significant in their mean differences (p-value\u0026thinsp;=\u0026thinsp;0.02) (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This difference might happen because HCPs do more intra-facility referrals than before. Health facility deliveries increased by 5.62% during the COVID-19 pandemic compared to before. Their mean differences were statistically significant (p-value\u0026thinsp;=\u0026thinsp;0.02) (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This was not so for PNC services among the four selected facility sites, with over fifty percent of the respondents (53.53%) reporting for PNC services before COVID-19 as compared to during COVID-19 at the advent of the WhatsApp mHealth (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Additionally, its mean difference was not statistically significant (p-value\u0026thinsp;=\u0026thinsp;0.95) (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTwo-sample t-test with equal variances\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAntenatal Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDuring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1183.00 (\u0026plusmn;\u0026thinsp;148.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1056.50 (\u0026plusmn;\u0026thinsp;135.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDelivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDuring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e147.33(\u0026plusmn;\u0026thinsp;18.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e131.67 (\u0026plusmn;\u0026thinsp;15.72)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePostnatal Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDuring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e159.67 (\u0026plusmn;\u0026thinsp;30.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e183.91(\u0026plusmn;\u0026thinsp;38.55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe data provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e outlines the performance of various maternal and neonatal indicators over the period under study. The indicators included maternal mortality ratio, ANC coverage, ANC registrants making 8th visits, skilled delivery, PNC coverage, the proportion of mothers receiving PNC within 48 hours from birth, and the proportion of mothers who made at least four ANC visits.\u003c/p\u003e \u003cp\u003eThere was a significant improvement in the institutional maternal mortality ratio, dropping from 53.3 per 100,000 in 2019 to zero in both 2020 and 2021, indicating substantial progress in maternal health and safety. ANC coverage showed a significant increase over the period. In 2019, the coverage was 31.8%, which increased to 37.6% in 2020 and further to 53.1% in 2021 (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This upward trend indicates an improvement in pregnant women accessing ANC services, which is crucial for monitoring and promoting the health and well-being of both the mother and the fetus. The percentage of ANC registrants making their 8th visit fluctuated slightly over the years. In 2019, it was at 50.0%, rising to 56.4% in 2020, before dropping back to 50.0% in 2021 (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). While there was an initial improvement, maintaining a consistent rate suggests a need for targeted interventions to encourage pregnant women to complete all recommended ANC visits. The data also revealed that the proportion of mothers who made at least four ANC visits increased from 92.0% in 2019 to 96.7% in 2020 but then decreased to 86.5% in 2021 (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe proportion of skilled deliveries saw a steady increase, rising from 24.8% in 2019 to 26.7% in 2020, and significantly to 41.2% in 2021 (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This growth is indicative of improved access to skilled birth attendants, which is essential for reducing maternal and neonatal mortality and complications during childbirth. PNC coverage initially decreased from 35.2% in 2019 to 28.9% in 2020, before experiencing a substantial increase to 75.0% in 2021 (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The proportion of mothers who received PNC within 48 hours of birth saw significant improvements, starting at 49.3% in 2019, increasing to 86.5% in 2020, and further to 90.9% in 2021 (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Early postnatal care is crucial for identifying and addressing any complications that may arise immediately after delivery.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMaternal and Neonatal Indicators\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003ePerformance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitutional maternal mortality ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53.3/100,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eANC coverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eANC registrants making 8th visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe proportion of mothers who made at least four ANC visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e92.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkilled delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePNC coverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe proportion of mothers receiving PNC within 48 hours from birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study sought to assess the potential effect of WhatsApp as a mHealth-based telemedicine tool for referrals in providing maternal health services. Among the key findings made from this study is an increase in ANC service uptake by 5.64% and hospital deliveries by 5.62%. However, the PNC service saw a decrease in uptake by 7.06%. The increase in ANC service uptake highlights the importance of accessible and timely healthcare during pregnancy. WhatsApp referrals likely improved communication between healthcare providers leading to more women accessing necessary support. This enhanced engagement contributes to better maternal and fetal health outcomes, early complication detection, and overall improved pregnancy experiences. The rise in hospital deliveries suggests a shift towards safer childbirth practices, reducing maternal and neonatal mortality and morbidity due to skilled birth attendants and emergency care availability. WhatsApp referrals likely influenced more women to choose hospital births, ensuring access to essential medical facilities and professional care, thereby lowering the risks associated with home births. The decrease in PNC service uptake is concerning, as the postpartum period is crucial for monitoring maternal recovery, and newborn health, and providing breastfeeding and family planning support. Addressing this is essential to prevent untreated postpartum complications, missed early interventions for newborns, and insufficient support for new mothers.\u003c/p\u003e \u003cp\u003eWomen\u0026rsquo;s health throughout pregnancy, childbirth, and postpartum is important [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Studies have shown that the introduction of mHealth interventions can lead to the uptake of maternal health services [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The findings of this study correspond with a similar study that showed that WhatsApp could be utilized as a communication medium for high-risk obstetric referrals [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It can further be emphasized that there is a necessity to keep enhancing urban referral procedures due to delays that have been recognized as possibly contributing to unsatisfactory outcomes. This study revealed that the uptake of ANC services and deliveries was significantly different from before and during the COVID-19 pandemic. This is contrary to reports by other studies that reported a decline in ANC uptake during the COVID-19 pandemic [\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This could be because expectant mothers involved in this study received prompt and needed services facilitated by the intervention, which had a positive effect on their health behavior. For this reason, ANC services uptake remained high even though the pandemic could have served as a barrier to access. The COVID-19 pandemic disrupted healthcare services globally, leading to concerns about reduced ANC uptake. However, this study suggests that timely and accessible mHealth interventions could mitigate such disruptions. By facilitating prompt access to needed services, even during a pandemic, expectant mothers can continue to receive essential care without interruption.\u003c/p\u003e \u003cp\u003eConcerning PNC services, mHealth has been reported to have given mothers confidence that, if they followed recommended newborn procedures their babies would have better outcomes, such as cord healing [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, the findings from this study on PNC services uptake during the COVID-19 period did not reflect the positive effect of the intervention. The uptake of PNC services before and during the pandemic was not statistically significant. This suggests that despite efforts to promote PNC services, there was no marked increase in utilization rates during the pandemic. The implications of these findings are profound as PNC plays a critical role in monitoring the health of mothers and newborns after childbirth, providing essential medical checks, vaccinations, and support for breastfeeding and maternal mental health. Lower PNC uptake could affect maternal morbidity and infant mortality rates, emphasizing the importance of continuous adaptation and improvement in healthcare delivery models. This highlights the need for targeted interventions that can effectively address these barriers and ensure that maternal and child health services remain accessible and utilized during crises.\u003c/p\u003e \u003cp\u003eDocumented instances of \u0026ldquo;informal mHealth\u0026rdquo; often resemble \u0026ldquo;formal\u0026rdquo; mHealth programs that have been put in place in Africa and other regions of the world including a study that identified that Community Health Workers (CHWs) utilized similar interventions through phone calls to facilities in advance to let health providers at other health facilities know about referrals, which increased facility readiness [\u003cspan additionalcitationids=\"CR29 CR30 CR31 CR32 CR33 CR34\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. It offers a potentially affordable way to help the provision of healthcare in Ghana. The significance of this has increased since a study [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] discovered a significant level of interest in mHealth activities among Ghanaian medical practitioners. Therefore, mHealth can help in attaining universal health coverage when properly deployed and regulated by closing the access gap in healthcare services between the rich and the poor as well as in rural and urban areas [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This would accelerate efforts to fulfill the mission of leaving no one behind [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Effective usage of mHealth applications can be improved by providing healthcare providers with thorough training on mHealth interventions [\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study provides good insight into the effects of WhatsApp usage by healthcare providers for referrals during the COVID-19 pandemic on ANC, delivery, and PNC services; however, this study is limited by scope and could be explored in other settings for a better understanding from other parts of the world. The study excluded patients\u0026rsquo; access to the WhatsApp platform.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study demonstrates that using WhatsApp for maternal healthcare significantly increased attendance for ANC and delivery services during the COVID-19 pandemic. This highlights the platform\u0026rsquo;s potential as an effective communication tool for managing high-risk obstetric referrals. WhatsApp\u0026rsquo;s accessibility and real-time messaging capabilities facilitated timely reminders, consultations, and emotional support, overcoming barriers to physical visits and ensuring continuous care. It also enabled efficient coordination and follow-up among healthcare providers, improving referral processes and patient outcomes. These findings suggest that integrating WhatsApp into routine maternal health services can enhance healthcare delivery, especially in resource-limited settings. Future efforts should focus on scaling up this approach, developing formal protocols, and conducting further research to evaluate long-term impacts and optimize implementation strategies. We recommend a quasi-experimental study to be conducted to include both the HCPs and patients\u0026rsquo; usage of the WhatsApp intervention.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eANC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Antenatal care\u003c/p\u003e\n\u003cp\u003eCHWs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Community Health Workers\u003c/p\u003e\n\u003cp\u003eCOVID-19\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Coronavirus 2019\u003c/p\u003e\n\u003cp\u003eDEL\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Delivery\u003c/p\u003e\n\u003cp\u003eHCPs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Health Care Practitioners\u003c/p\u003e\n\u003cp\u003emHealth\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mobile Health\u003c/p\u003e\n\u003cp\u003eMHS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Maternal Health Services\u003c/p\u003e\n\u003cp\u003ePNC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Postnatal Care\u003c/p\u003e\n\u003cp\u003eVBAC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Vaginal Birth After Cesarean\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was sought from the KNUST Committee for Human Research, Publications, and Ethics (CHRPE) in Kumasi, with reference number CHRPE/AP/450/22. Permission was also sought from the Kwadaso Municipal Health Directorate. During data collection and coding, the anonymity and confidentiality of interviewees were guaranteed by the avoidance of using names that could lead to individual partakers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data set supporting the conclusions of this article is available in the District Health Management Systems (DHIMS 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the eHealth Research Partner Group (eHRPG) at the Kwame Nkrumah University of Science and Technology, Kumasi under Grant No.: 01DG20020 from the budget of the German Federal Ministry of Education and Research (BMBF). The funding source was not involved in the design, conduct, or reporting of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: KSS, KAM, DO; Methodology: KSS, KAM, RAB, DO; Data curation: KSS, CKS, RAB; Formal analysis: KSS, DO, RAB, CKS; Writing initial draft: KSS, RAB; Reviewing and editing: KAM, DO, RAB, CKS; Project administration: DO, RAB; Supervision: KAM; Acquisition of funding: DO. All the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the management at Kwadaso Municipal Health Directorate. Similarly, the authors are grateful to the eHealth Research Partner Group at the KNUST for the research training support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eeHealth Research Partner Group (eHRPG) at the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana\u003c/p\u003e\n\u003cp\u003eKwame S. Safo, Daniel Opoku, Kofi A. Mensah, Clement K. Serchim \u0026amp; Richard A. Bonney\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eSchool of Public Health,\u0026nbsp;Kwame Nkrumah University of Science and Technology, Kumasi, Ghana\u003c/p\u003e\n\u003cp\u003eKwame S. Safo, Daniel Opoku, Kofi A. Mensah, Clement K. Serchim \u0026amp; Richard A. Bonney\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eSeventh-Day Adventist Hospital, Kwadaso, Ghana\u003c/p\u003e\n\u003cp\u003eKwame S. Safo\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eDepartment of Health Care Management,\u0026nbsp;Technische Universit\u0026auml;t Berlin, Berlin, Germany\u003c/p\u003e\n\u003cp\u003eDaniel Opoku \u0026amp; Richard A. Bonney\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e5\u003c/sup\u003eDGerman-West African Centre for Global Health and Pandemic Prevention (G-WAC), Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMonaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. 2020;20(1):1193. \u003c/li\u003e\n\u003cli\u003eOrganization WH. The impact of COVID-19 on health and care workers: a closer look at deaths. 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Hum Resour Health. 2014;12:1\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eZurovac D, Sudoi RK, Akhwale WS, Ndiritu M, Hamer DH, Rowe AK, et al. The effect of mobile phone text-message reminders on Kenyan health workers\u0026rsquo; adherence to malaria treatment guidelines: a cluster randomised trial. Lancet. 2011;378(9793):795\u0026ndash;803. \u003c/li\u003e\n\u003cli\u003eZurovac D, Talisuna AO, Snow RW. Mobile phone text messaging: tool for malaria control in Africa. PLoS Med. 2012;9(2):e1001176. \u003c/li\u003e\n\u003cli\u003ePeprah P, Abalo EM, Agyemang-Duah W, Gyasi RM, Reforce O, Nyonyo J, et al. Knowledge, attitude, and use of mHealth technology among students in Ghana: A university-based survey. BMC Med Inform Decis Mak. 2019;19:1\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eLaar AS, Bekyieriya E, Isang S, Baguune B. Assessment of mobile health technology for maternal and child health services in rural Upper West Region of Ghana. Public Health. 2019;168:1\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eMariwah S, Machistey Abane A, Asiedu Owusu S, Kasim A, Robson E, Castelli M, et al. Formalising \u0026lsquo;informal\u0026rsquo; mHealth in Ghana: Opportunities and challenges for universal health coverage (UHC). Glob Public Health. 2022;17(5):768\u0026ndash;81. \u003c/li\u003e\n\u003cli\u003eGinsburg AS, Delarosa J, Brunette W, Levari S, Sundt M, Larson C, et al. mPneumonia: development of an innovative mHealth application for diagnosing and treating childhood pneumonia and other childhood illnesses in low-resource settings. PLoS One. 2015;10(10):e0139625. \u003c/li\u003e\n\u003cli\u003eMunyua S, Rotich G, Kimwele M. Factors affecting the adoption of mHealth in maternal health care in Nakuru provincial general hospital. Int J Sci Technol Res. 2015;4(11):1\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003ePraveen D, Patel A, Raghu A, Clifford GD, Maulik PK, Abdul AM, et al. SMARTHealth India: development and field evaluation of a mobile clinical decision support system for cardiovascular diseases in rural India. JMIR mHealth uHealth. 2014;2(4):e3568.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, maternal referral, WhatsApp, maternal health services","lastPublishedDoi":"10.21203/rs.3.rs-4902660/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4902660/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDuring the COVID-19 pandemic period Health Care Practitioners (HCPs) were seen to facilitate healthcare delivery by using their mobile phones also known as \u0026ldquo;informal mHealth\u0026rdquo;, especially in Sub-Saharan Africa (SSA). WhatsApp has become popular in recent years with over 380\u0026nbsp;million users. It has therefore been identified that the effective use of WhatsApp by HCP for health could positively impact it. This study aims to assess the potential effect of the use of WhatsApp by HCPs on Maternal Health Services (MHS) uptake during the COVID-19 pandemic in four primary healthcare facilities in the Kwadaso Municipality of Ghana.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study design was adopted using a quantitative approach involving a census sampling technique to collect data on monthly Maternal Health Services (MHS) attendance from the District Health Information Management Systems (DHIMS 2). Data collection was for the period March 2019 to February 2020 and March 2020 to February 2021.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eDuring the COVID-19 pandemic, the introduction of WhatsApp as a mHealth intervention helped improve maternal health case management and patient confidence. This led to a 5.64% (p-0.02) increase in ANC attendance and a 5.62% (p-0.02) rise in health facility deliveries. However, although PNC service attendance dropped slightly (7.06%, p-0.95), it was not statistically significant. Overall, key maternal health indicators showed significant improvements from 2019 to 2021 COVID-19 period.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWhatsApp usage by HCPs for a positive and timely patient management showed an increased attendance for ANC and delivery services in Ghana during the COVID-19 pandemic. This reveals that the use of WhatsApp for maternal health services referrals can be used as a communication tool for the management of high-risk obstetric referrals also.\u003c/p\u003e","manuscriptTitle":"Potential Effects of WhatsApp on Maternal Health Services Uptake during COVID-19: A Cross-sectional Study in Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-08 02:34:35","doi":"10.21203/rs.3.rs-4902660/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-04T07:50:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-04T07:31:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-02T22:17:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133719880335404764625910456051054839475","date":"2024-11-02T07:05:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"43915127127372014467140175355619297734","date":"2024-11-01T22:02:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128505138945737045822402783196862577314","date":"2024-11-01T10:01:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6028665645130883407677228403695703691","date":"2024-11-01T08:46:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"149744753604398637135065052567131395548","date":"2024-10-30T22:06:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137540566082347615341288980807504517313","date":"2024-10-21T09:18:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273963233569056225289235125197985733274","date":"2024-10-11T23:00:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202987949243386727827117094348679825004","date":"2024-10-07T15:26:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282387879146487690040950135446166487917","date":"2024-10-06T19:53:59+00:00","index":"hide","fulltext":""},{"type":"editorInvited","content":"","date":"2024-10-04T12:17:41+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"171377921659857016113105838106832390673","date":"2024-08-28T05:58:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166259893455406782862207868534049028792","date":"2024-08-23T11:40:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-22T20:31:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-14T19:04:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-13T01:48:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-08-12T19:49:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"554703e0-db63-411f-94e1-73d3e519a873","owner":[],"postedDate":"October 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-20T16:00:51+00:00","versionOfRecord":{"articleIdentity":"rs-4902660","link":"https://doi.org/10.1186/s12913-025-12245-3","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-01-14 15:57:17","publishedOnDateReadable":"January 14th, 2025"},"versionCreatedAt":"2024-10-08 02:34:35","video":"","vorDoi":"10.1186/s12913-025-12245-3","vorDoiUrl":"https://doi.org/10.1186/s12913-025-12245-3","workflowStages":[]},"version":"v1","identity":"rs-4902660","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4902660","identity":"rs-4902660","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}