Shifting prenatal monitoring away from the clinic and into the home setting is increasingly common in the US, although the Bluetooth-enabled blood pressure cuffs to be used in the project—and the companion smartphone app the devices pair with—are more high-tech than the systems currently in use by many US healthcare systems, Michigan Medicine included.
“Home blood pressure monitoring has been rapidly integrated since COVID, to the point where the devices are routinely covered by insurance companies,” said Assistant Professor of Obstetrics and Gynecology Emma Lawrence, MD, MS. “But what we’re going to be doing in Ghana will be more technologically advanced than what is currently in use at U-M, which is very exciting.”
Lawrence is the lead in the project, funded by an NIH Fogarty International Center Innovation Award to develop mobile health applications in limited-resource settings. The study builds on efforts she and collaborators at the University of Ghana started in 2021, when they conducted a yearlong feasibility study that combined at-home monitoring with a telephone resource hotline staffed by nurses.
In Ghana, hypertensive disorders account for some 18% of maternal mortality. Regular blood pressure monitoring can help identify issues early before they become severe and potentially life-threatening. While the early work showed promise, the new study brings significant tech upgrades to hopefully offset some of the early challenges.
“Success depends on the ability to recognize that your blood pressure is too high. But especially among participants who have little to no formal education, that numeracy understanding can be prohibitive,” Lawrence said. “The app can prompt you to re-check your blood pressure. It can send a voice prompt in someone’s language of choice. It can automatically send an alert to a midwife.
“I’m not traditionally a tech person in my personal life or my research life, but there is so much great technology now that lets us directly address these barriers,” she continued. “The dream would be to scale this up to other health centers. To get out of the big urban teaching hospital and into rural health centers to see if we are able to improve health outcomes for moms and babies. That’s the long-term plan.”
Because cellular networks have expanded and device ownership has risen so quickly across the continent, leaders in many parts of Africa are increasingly turning to mobile technology for potential solutions to public health challenges. Ghana is no exception; as of 2020, according to the World Bank, there were 120 cellular phone subscriptions for every 100 people in Ghana, higher than the regional average for all of sub-Saharan Africa (89), and higher even the United States (110).
While not all of these mobile phones are smartphones with apps and internet capabilities, an increasing number are. One 2019 survey of more than 300 households in and around Accra, where Lawrence’s work is based, found that 74% of the respondents were using smartphones. Among the current cohort for Lawrence’s study, 80% of the participants report owning a smartphone. “And of the 20 percent who did not own one, all told us that someone in their household does,” she said. “The technology prevalence is there and in the five years, which is the expected duration of our study, the numbers will be even higher. There is huge potential in this space.”
The first phase of the study will adapt the mobile app, first developed in the Netherlands, and the companion monitors to be used in the local context. A planned phase two will incorporate twice as many participants, monitoring them from sign-up through delivery to assess their adherence to the home monitoring regimen, as well as measure the timeliness and effectiveness of clinical responses in cases of auto-triggered alerts.
Lawrence’s Ghanaian collaborators on the project include Samuel Oppong and Titus Beyuo, both Associate Professors of Obstetrics and Gynecology. Also on the project team are her U-M colleagues, Assistant Professor of Learning Health Sciences and Ob-Gyn Cheryl Moyer, and Professor of Nursing Jody Lori. Collaborators at Utrecht University, where the app was first developed, are engaged as advisors. Most members of team—particularly Lawrence’s Ghanaian colleagues—have been engaged in the work since she started the project as a resident at UMMS.
“I’ve loved working with this team. Up until now, I’ve always had a mentee role, but this time we are co-collaborators, which is an exciting jump for me personally and professionally,” Lawrence said. “Many of these people have become close friends, coming up together as residents and establishing our careers. We’ve stayed at each other’s houses. Our families know each other. That’s a special part of global health research.”