Text4Baby: New Media Health Care

"Congratulations, you're going to be a mom! Text4baby wishes you a happy & healthy pregnancy. Thanks for including us in this special time."

This is the first text you'll receive if you sign up for a new mobile information service providing free week-to-week health information for pregnant women and new mothers via text messages.

Unveiled last week, the service "Text4baby," provides everything from emotional support messages to reminders about birth defect prevention and immunizations. The unique service is a project of the National Healthy Mothers, Health Babies Coalition (HMHB) and includes a mind boggling array of partners including the White House Office on Science and Technology, HHS, Planned Parenthood Federation of America, CTIA - The Wireless Foundation, March of Dimes, MTV, American Public Health Association, Postpartum Support International and others.

I don't think there are many other coalitions you can call upon in this country that wield more power on reproductive health than this impressive list of partners. 

The project is being touted as a way to "promote maternal and child health." Clearly it aims to ensure healthier newborns and mothers. But there is a broader problem left unaddressed. In a country where we spend billions of dollars on maternity care and yet rank 41st out of 171 nations for our (rising) maternal mortality rates, and in which we have one of the highest infant mortality rates in the industrialized world, it's critical that we address all of the factors that contribute to poor health outcomes - including maternal death - for pregnant women and infants.

For many women, cell phones and smart phones are their primary means of communication. PPFA's press release states: "Research shows that, while 90 percent of Americans have a mobile phone, fewer have access to the Internet, and texting is more prevalent among women of childbearing age."

It makes perfect sense to develop a text-messaging campaign to help educate, inform and connect women to the information they need to maintain their health during pregnancy. Most of the major wireless carriers are partners so that, essentially, any woman who has a wireless phone now has access to information about what she can do to maintain a healthy pregnancy.

What else needs to happen in order to make a true impact on maternal and newborn health outcomes?

"Folic acid helps prevent some serious birth defects of the baby's brain & spine. Take a prenatal vitamin each day with 600 mcg of folic acid."

While reminding women to take prenatal vitamins, not to drink or smoke during pregnancy, and assuring women about what is perfectly "normal" to experience (mood swings, common physical symptoms, etc.) is helpful, it's only one piece of a larger puzzle.

As Jennifer Block puts it,

"I think it's a great sign that PPFA [and its partners] is stepping into this realm of "family planning," but the texting campaign seems to put the onus squarely on women, when we know that the biggest causes of infant mortality have to do with clinical practice and how the health system is organized, i.e. 5-minute prenatal appointments, an epidemic of labor induction and scheduled cesareans, poverty and institutional racism. So it seems a little simplistic to say that all women need is a text reminder to eat more protein or get that flu vaccine. An automatic text is not a stand-in for accessible, quality providers, continuity of care, and a supportive community--elements that are proven to reduce preterm birth."

In an article on RH RealityCheck about rising maternal death rates in California, Nathaneal Johnson notes that it is more dangerous to give birth in California than in Kuwait or Bosnia. Johnson writes,

"Other factors are contributing to the rise in deaths, but the researchers in California are most interested in the areas where they have control, such as the high C-section birth rate: It's easier for doctors to improve medical care than to fix more intractable problems like poverty and obesity."

The most common surgical procedure in the U.S. is now the c-section.  Almost one out of every three women in the United States are now giving birth via cesarean section and the rate only seems to be rising. The World Health Organization recommends, and recent studies confirm, the optimal c-section rate should be no more than 5 to 10 percent of all births. According to Childbirth Connection, rates above 15 percent "seem to do more harm than good." Cesarean sections are major surgery and carry with them all of the risks of surgery but when they are necessary, they are critical. The problem currently is that in the United States the majority of c-sections seems to be medically unnecessary, and therefore may be exposing both mother and baby to unnecessary health risks. Add to this an increase in medical interventions overall, including labor induction, and electronic fetal monitoring, and we have created a maternity care system in this country that exposes pregnant and laboring women and their babies to unnecessary health risks increasing poor health outcomes.

Also, it bears endless repeating - African American women are four times more likely to die from causes related to pregnancy and childbirth, as are Caucasian women. This is not simply because they aren't being given proper information. It's a combination of access issues, institutional racism and quality of care.

It's not that I don't think that messages about quitting smoking, accessing prenatal care and getting tested for HIV aren't crucial. I just want to make sure that we're not selling women's health short by offering bite-sized pieces of information without the necessary follow-up.

Some partners in the initiative clearly recognize these broader issues: The March of Dimes is clear that smoking cessation programs and healthcare during and after pregnancy are key to healthy outcomes but, in fact, they focus keenly on quality improvement in maternity care as well:

"For example, the Intermountain Healthcare in Utah reduced its elective inductions before 39 weeks to about 2 percent from about 30 percent.  At Geisinger Health System in Pennsylvania, pregnant women are screened for chronic conditions and risks factors that can be treated proactively to lower the risk of preterm birth. A program run by the Hospital Corporation of America based in Tennessee, which delivers about 5 percent of all U.S. births in the 21 states it serves, reduced the primary C-section rate, lowered maternal and fetal injuries and reduced the cost of obstetric malpractice claims by 500 percent."

I will hand it to the coalition. They do use inclusive language when it comes to referring to providers, with messages like:

"You can choose who you see for pregnancy care. Midwives, family docs, OBs & nurse practitioners can all provide care. Call 800-311-2229 for free/low-cost care & to find a provider who's right for you."

Potential partners like the American College of Nurse Midwives (ACNM) have encouraged "provider neutral" language to ensure that women are aware of their options - to the extent that women have the option to use a midwife in their state (Certified Nurse Midwives are usually an option for women with insurance - or without - while Certified Professional Midwives are still not uniformly licensed to practice around the country, while some are covered through Medicaid and some are not). ACNM says that the project "has the potential to be a great thing" and will likely sign on a supporter. 

And the text messages sent to women who opt in once they've given birth (and up to a year after) include information on postpartum mood disorders and breastfeeding - two areas where women need the most support and information immediately following childbirth, for sure. 

It's heartening to be spending much of my time these days covering programs with a focus on maternal and newborn care. Between the Transforming Maternity Care report--which arose from a multi-year collaboration between key maternity care stakeholders and outlines a strategy for drastically improving both the quality and value of maternity care in the U.S.--and outreach programs like this one, we'll start seeing higher quality care, better health outcomes for women and newborns and a decrease in maternal and infant mortality rates. Without question, pregnant and postpartum women need information about their health, so the texting campaign is an important initiative. But there are deep fissures in the maternal health care provision system in this country. And the only way we'll reach our maternal and newborn health reduction goals is if both are addressed effectively.