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American Journal of  Medical 
Science and Innovation (AJMSI) 

Effects of  Mobile Phone Tele-Reminder on the Prevalence of  Malaria and Antenatal 
Care Satisfaction among Pregnant Women Availing Antenatal Care at Phebe and

Charles B. Dunbar Hospitals, Bong County, Monrovia-Liberia A Cluster-Randomized 
Controlled Trial

Washington Kezelee1, Leila S. Africa1*, Corazon V. C. Barba1, Angelina R. Bustos1, Mark Bondi Arboleda2

Volume 2 Issue 2, Year 2023
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v2i2.1541
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: September 06, 2023
Accepted: October 03, 2023
Published: October 07, 2023

Pregnant women with malaria and other associated infections have an increased risk of  
developing anemia later in pregnancy. This study aimed to determine the effect of  mobile 
phone tele-reminder delivered through phone calls and SMS on the prevalence of  malaria 
infection during pregnancy. The study recruited 150 pregnant women seeking antenatal care 
for the first time at the Phebe and Charles B. Dunbar hospitals in Bong County, Liberia. The 
antenatal care screening room (units of  randomization) in both hospitals were randomized 
into six clusters. The 150 pregnant women were randomly assigned to an intervention group 
and a control group. A binary logistic regression using a generalized estimating equation 
model was run with a 95% Confidence Interval (CI). Malaria prevalence and antenatal 
care satisfaction were the primary outcome variables. The secondary outcome variable was 
the prevalence of  anemia.  Although there was a reduction in malaria infection in both 
groups, malaria prevalence between the intervention and control groups was not statistically 
significant (5 vs. 15%) (OR, 1.15; 95% CI, 0.71-1.85). Pregnant women in the intervention 
group were 4 times more likely to be very satisfied with ANC services compared with the 
control group (aOR, 4.01; 95%CI, 1.72-9.53). There was a positive trend toward anemia 
reduction among those in the intervention group. Integrating mobile phone technology 
in antenatal care services may help reduce the malaria infection rate and increase ANC 
satisfaction levels.

Keywords
Malaria Infection, Antenatal 
Care, Tele-reminders 

1  Institute of  Human Nutrition and Food (IHNF), University of  the Philippines Los Banos, Philippines
2  School of  Environmental Science and Management (SESAM), University of  Philippines, Los Banos, Philippines
* Corresponding author’s e-mail: lsafrica@up.edu.ph

INTRODUCTION
Women who are pregnant remain at risk of  malaria 
infection, particularly in low-income countries. The 
risk of  malaria infection and severe infection is greater 
for pregnant women than for nonpregnant women. 
Anopheline mosquito bites transmit malaria, which 
is transmitted congenitally and through exposure to 
infected blood products (Lagerberg, 2008). In the genus 
Plasmodium, four species of  protozoa cause malaria. 
Preterm delivery, low birth weight, stillbirth, congenital 
infection, and maternal death are some of  the effects of  
malaria during pregnancy. Around 19% of  infant LBWs 
are caused by malaria in malaria-endemic areas, and 6% 
of  infant deaths are caused by LBWs caused by malaria. 
A lower mean hemoglobin level is associated with malaria 
among pregnant women (Ouédraogo et al., 2013). In 
2019, the World Health Organization found that malaria 
was endemic in 31 low-income countries. Women with 
malaria and other associated infections later in pregnancy 
are at an increased risk of  low birth weight (Accrombessi 
et al., 2019). Statistically significant associations are found 
between asymptomatic malaria in pregnant women and 
their hemoglobin levels (Feleke et al., 2020).
Around 100,000 infants die every year in Sub-Saharan 
Africa due to malaria-related LBW (Guyatt & Snow,2004). 
At first antenatal booking, anemia is significantly 
associated with malaria parasitemia. The adverse birth 

outcomes in the United Republic of  Tanzania-impacts 
and prevention of  maternal risk factors showed that low 
birth weight and intrauterine fetal retardation are caused 
by malaria (Watson-Jones et al., 2007).  
WHO recommends a combination of  insecticide-treated 
nets (ITNs) and either intermittent preventive treatment 
in pregnancy (IPTp) with sulfadoxine-pyrimethamine 
for pregnant women. Despite relatively high rates of  
antenatal clinic attendance, coverage of  intermittent 
preventive treatment and use of  insecticide-treated nets 
by expectant women still falls far short of  international 
targets.This is true even though coverage has increased in 
the majority of  countries.
To determine whether the implementation of  WHO’s 
2012 policy update for intermittent preventive 
treatment—which seeks to streamline the message and 
align preventive treatment with the focused antenatal 
care schedule—leads to improvements in coverage—
should be evaluated, Van Eigk et al. (2013) recommend. 
Parasite resistance threatens the efficacy of  IPTp with 
sulfadoxine-pyrimethamine in sub-Saharan Africa. 
Improved knowledge and education of  women of  
childbearing age have a significant impact on malaria 
control during pregnancy (Iriemenam et al., 2011). The 
use of  insecticide-treated mosquito nets during pregnancy 
reduced the risk of  malaria infection (Fana et al., 2015; 
Apinjoh et al., 2015). 



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LITERATURE REVIEW
Malaria Situation in Liberia   
The Liberian Health System remains one of  the most 
fragile in the world. Ebola outbreaks in 2014-2016 and 
the recent Covid-19 pandemic are key factors driving 
the disruption of  the health system in Liberia (Tarr-
Attia et al., 2018). Despite the adoption of  WHO 
recommendations on ANC for a positive pregnancy 
experience in 2016, malaria infection during pregnancy 
has become so alarming in Liberia. Increasingly, pregnant 
women in Liberia are exposed to malaria, exposing 
Liberia’s health system’s weakness. Malaria, which is 
primarily a major public health problem of  pregnant 
women, is preventable, treatable, and curable, in Liberia. 
Children and expectant mothers are especially vulnerable 
to malaria. To lessen the negative effects of  malaria on 
a pregnant woman’s health, the WHO advises using a 
three-pronged strategy: rapid diagnosis and treatment 
of  infections that have been confirmed, use of  long-
lasting insecticidal nets (LLINs), and IPTp (WHO 2004). 
Pregnant women who are receiving routine prenatal care 
are given intermittent prevention of  malaria in pregnancy 
(IPTp), an antimalarial medication. IPTp can help prevent 
cases of  malaria, anemia, placental parasitemia, low birth 
weight, and neonatal mortality.  The percentage of  women 
receiving one or more IPTp doses has increased from 
58% in 2009 to 90% in 2019–20, and the percentage of  
women receiving two or more doses has increased from 
47% to 70%. In the period between 2011 and 2019, 40% 
of  women received three or more IPTp doses (LDHS 
2019). Plasmodium falciparum infections are anticipated 
to affect at least one in every eight women receiving 
their first antenatal care at private clinics in Monrovia 
outside of  the wettest months, despite all the efforts the 
government is making to reduce the prevalence of  malaria. 
Young primigravidae have a higher risk of  contracting P. 
falciparum, claim Martnez-Pérez et al. (2018). 
  
Use of  Mobile Phones in Liberia’s Health System
The most popular form of  communication in Liberia 
now is through mobile phones. Even though the country’s 
GSMs have increased their investment, the Liberia Health 
System has not yet integrated mobile phones into the 
delivery of  healthcare services. A report from Digital 
Liberia 2021 states that there were 3.39 million mobile 
connections overall, with many people having multiple 
connections, up 19,000, or 0.6 percent, between January 
2020 and January 2021. In the mobile sector, competition 
led to some of  the lowest call prices in the country. 
Internet penetration was 14.9 percent in January 2021, 
equating to 761,000 internet users in the country. The 
number of  internet users increased by 132,000, or 22 
percent, between January 2020 and January 2021. About 
84% of  urban households and 50% of  rural households 
own mobile phones (LDHS 2019-2020).

Use of  Insecticide Treated Nets (ITNs) by Pregnant 
Women in Liberia
During the night before the conduct of  the National 

Demographic and Health Survey in Liberia (2019-
2020), 47% of  pregnant women aged 15-49 slept under 
a mosquito net, while 78% of  pregnant women in 
households with at least one mosquito net slept under 
a mosquito net. In 2019, 47% of  pregnant women used 
ITNs, up from 33% in 2009. The proportion of  pregnant 
women aged 15-49 who slept under an ITN the night 
before the survey is markedly lower in Greater Monrovia 
(34%) than in other urban areas (57%) and rural areas 
(48%) (Table 12.8).

Intermittent Preventive Treatment of  Malaria in 
Pregnancy in (IPTp)
Pregnant women who want to prevent malaria are given 
an entire therapeutic course of  antimalarial medication 
during routine prenatal care visits. This method is known 
as an intermittent preventive treatment of  malaria in 
pregnancy (IPTp). IPTp aids in reducing the risk of  
neonatal mortality, low birth weight, maternal and fetal 
anemia, placental parasitemia, and episodes of  malaria in 
pregnant women. In Liberia, sulfadoxine-pyrimethamine 
(SP), also known as Fansidar is the drug of  choice for 
IPTp). Women who received one or more IPTp doses 
increased from 58% in 2009 to 90% in 2019–20, while 
those who received two or more doses rose from 47% to 
70%. The proportion of  females receiving three or more 
IPTp doses rose from 11% to 40% during the same time 
frame (LDHS 2019-2020).

Benefits of  Mobile Phone Technology in Antenatal 
Care
In Africa, mobile phones are increasingly crucial 
for strengthening healthcare systems (Howitt 2012). 
According to Jareethum and others (2008), there is a higher 
satisfaction level of  pregnant women who receive SMS via 
mobile phone during their antenatal service compared to 
the general antenatal care group. A more satisfactory level 
of  patient satisfaction can be achieved when antenatal 
care consultations are improved to meet the desired needs 
of  pregnant women in developing countries (Alhaqbani 
& Bawazir, 2022). Mobile phone tele-reminder likely 
increased counseling about IFAS, resulting in a higher 
level of  adherence to IFA supplementation among 
pregnant women who participated in the intervention 
(Demis, Geda, Alemayehu, & Abebe, 2019. A significant 
association exists between frequencies of  antenatal care 
(ANC) visits to the level of  knowledge and the level 
of  practice of  mothers about preventing anemia in 
pregnancy (Ghimire & Pandey, 2013). In Nigeria, mobile 
phones also contribute to health promotion, prevention, 
and early identification of  diseases, reducing maternal 
and child mortality (Odetola & Okanlawon, 2016). Using 
mobile phone applications in clinical settings increases the 
number of  antenatal care visits and improves the quality 
of  ANC services (Lund et al., 2014). A study carried out 
in Bangladesh to outline the association and the use of  
mobile phones and essential maternal health care services 
showed pregnant women who utilized mobile phones 
utilized antenatal care services and professional delivery 



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services more than those who did not (Tang et al., 2019). 
Additionally, with the use of  mobile phone technology in 
healthcare settings, women felt more confident seeking 
medical care during pregnancy and childbirth and 
recognizing signs of  illness in their newborns (Entsieh, 
Emmelin, & Pettersson, 2015). 
Using a mobile phone application, Odetola & Okanlawon 
(2016) evaluated the effects of  a nursing intervention on 
the uptake of  antenatal care, tetanus toxoids, and malaria 
prevention among pregnant women in Nigeria. Mobile 
phone use by nurses during ANC was associated with 
increased attendance at antenatal clinics and IPT uptake. 
Women who received the SMS every week were more 
likely to attend eight ANC visits than those who did not 
(Osanyin et al., 2022). Women who utilized mobile phones 
were more likely to use iron tablets and attend ANC 
in a randomized controlled trial conducted by Bangal 
et al. (2017). Despite not increasing the proportion of  
women receiving three doses of  IPTp-SP, mobile phone 
intervention did increase the proportion of  timely ANC 
visits (Ouédraogo et al., 2022). 
Using mobile phones to send short message services 
on focused antenatal care (FANC) positively affects the 
uptake of  attentive antenatal care among pregnant women 
in middle and low-income countries (Wagnew et al., 
2018). Compared with the general antenatal care group, 
there is a higher satisfaction level of  pregnant women 
who receive SMS via mobile phone during their antenatal 
service. Higher confidence and lower anxiety levels are 
seen in pregnant women who get SMS via mobile phone 
during the antenatal period (Jareethum et al., 2008).

METHODOLOGY
Study Design
In two major referral hospitals, we conducted a three-
month cluster randomized controlled trial with two arms. 
Phebe and Charles B. Dunbar hospitals, Bong County, 
Republic of  Liberia, were the study sites between May 

2022 and August 2022. Units of  randomization were 
antenatal care screening rooms with midwives assigned 
to care for pregnant women. Group participants are 
randomly assigned to each treatment arm in a cluster 
randomized control trial rather than individuals. There 
were three ANC screening rooms in each hospital 
dedicated to pregnant women.  Trained midwives provide 
all antenatal care in the screening rooms. This study 
considered each screen room as a cluster. There were two 
intervention groups in these two arms trials (control and 
experimental).  As there was a possibility that pregnant 
women receiving antenatal care at Phebe Hospital might 
be close relatives of  pregnant women receiving antenatal 
care at Charles B. Dunbar Hospital, we decided to conduct 
a cluster randomized controlled trial. There was a risk of  
contamination within and between clusters due to this 
relatedness. The cluster randomized control trial minimizes 
the risk of  contamination. The administration of  the Phebe 
Hospital provided ethical clearance for the study.

Clustering and Randomization
The randomization units were antenatal care screening 
rooms with licensed midwives. In cluster randomized 
controlled trials, the groups are randomized rather than 
the individual participants. In each of  these hospitals, 
three screening rooms were dedicated solely to providing 
ANC to pregnant women. Each screening room was 
considered a cluster by the researcher in this study. There 
were three clusters at Phebe Hospital, referred to as 1, 2, 
and 3, while there were three clusters at Charles B. Dunbar 
Hospital, referred to as 4, 5, and 6. A team of  midwives 
administered ANC to six clusters of  pregnant women 
receiving ANC for the first time. In clinical research, 
randomization refers to assigning study participants 
to either a treatment or control group solely by chance 
(Figure 1). The six screening rooms (six clusters) were 
randomized into an intervention (clusters 1,4, & 6) and a 
control group (clusters 2,3, & 5).

Figure 1: Operationalization of  the Study



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Setting
Phebe and Charles B. Dunbar hospitals were the research 
areas. The two hospitals which are situated in Bong 
County are key referral hospitals in Liberia. Bong County 
is a centrally located county with diverse ethnic groups. In 
1964, Bong County was established. Dominant among the 
12 ethnic groups in the county, is the Kpelleh-speaking 
people. Among the 15 counties in Liberia, Bong County 
ranks third in terms of  area and population. Lofa and 
Gbarpolu counties border it on the north, Margibi and 
Montserrado counties on the west, Grand Bassa County 
on the south, and Nimba County on the east. In addition 
to rice production, the county is one of  Liberia’s food 
baskets. Cocoa, coffee, rubber, and palms are also grown 
in the county. Approximately 450,000 rural Liberians 
receive quality healthcare at Phebe Hospital. Lutheran 
Church in Liberia helped establish the hospital in 1921. 
The Liberian government founds the hospital. 

Participants
Pregnant women availing antenatal care for the time 
in their current pregnancy were the participants in this 
study. Pregnant women who have had prior antenatal care 
at clinics, hospitals, or health centers, were not allowed to 
take part in this study. For this study, Phebe and Charles 
B. Dunbar hospitals were selected because of  their high 
attendance at antenatal care, equipped medical and 
laboratory facilities, access to more than two screening 
rooms for pregnant women, and patient diversity. 

Sample Size Calculation
The sample population consisted of  all consenting 
pregnant women receiving their first ANC visit. Malaria 
is one of  the leading causes of  anemia among pregnant 
women in Liberia. In the Demography and Health Survey 
Report (2019), anemia is more prevalent among pregnant 
women (52%) compared to breastfeeding women (48%). 
As a result of  this new intervention, malaria prevalence 
among pregnant women in Liberia is expected to be 
reduced, thereby eradicating anemia among them. 
Controlling malaria infection can reduce anemia 
prevalence among pregnant women by 25%. In a cluster 
randomized control trial, similarity among subjects within 
preexisting groups or clusters minimizes the variability of  
responses in a cluster sample, making it challenging to 
detect actual differences between groups. We used the 
intracluster correlation coefficients (ICC) to measure 
the degree of  dependence within each cluster. We also 
adjusted for individual and cluster-level characteristics, 
and the adequate sample size was determined using 
the median ICC in primary healthcare research of  
0.005 (Adams et al., 2004). The researcher’s first step 
was to calculate the sample size required for individual 
randomized controlled trials. Next, the derived sample 
size from the individual randomized controlled trial was 
then adjusted for the design effect (DE). In this study, 
150 pregnant women who were getting ANC for the first 
time were recruited. The study included 75 participants in 

each treatment arm. Three clusters were present in each 
treatment arm. A total of  25 participants were randomly 
assigned to each cluster.

Admission of  Participants
Each hospital had three screening rooms dedicated 
exclusively to ANC services. A pregnant woman seeking 
ANC for the first time was directed to the registration 
room to obtain a valid hospital card and identification 
number. In subsequent hospital visits, the patient used 
the hospital card and identification number to access 
health care services. HIV/AIDS counseling follows the 
registration process, which aims to prevent mother-to-
child transmission of  HIV/AIDS. After counseling, the 
midwives assigned to those rooms took the patient’s card 
to any of  the screening rooms for further processing. A 
patient received healthcare from the screening room, where 
her card was transferred. Six clusters (screening rooms) were 
randomized, so three (3) clusters administered standard/
routine interventions during the study period, while the 
remaining three administered intervention treatment. As 
mentioned in the selection criteria, the admission criteria 
were the same for both arms. The control and intervention 
groups were blinded. Certain information that might 
influence participants was kept from them. During the 
intervention, midwives were blinded.

Recruitment of  Midwives 
Six (6) licensed and trained midwives were hired to 
administer the intervention. Phebe and Charles B. Dunbar 
Hospitals employed these midwives full-time. In addition 
to the three midwives recruited from Phebe Hospital, 
three additional midwives were recruited from Charles B. 
Dunbar Hospital. The head midwives of  both hospitals 
recommended and recruited the midwives. Among 
their responsibilities was administering all treatments to 
participants in both groups. Providers of  the intervention 
treatment were guided by the teleconsultation manual 
designed for this study. Three midwives were randomly 
selected and charged with administering the intervention 
treatment throughout the study. The remaining three 
midwives provided the standard/routine treatment to the 
control group. The researcher provided a one-day training 
to the three midwives accountable for administering 
the intervention. Midwives in the intervention group 
were trained to use the tele-reminder manual to deliver 
an effective treatment. However, all the midwives were 
blinded. Neither the primary nor secondary outcomes 
variables were disclosed to them.

Data Collection
This study used several validated methods to collect 
accurate and insightful. All stages of  this study were 
supervised by the researcher. For quality assurance, the 
researcher scrutinized every data report by the midwives. 
In both hospitals, midwives were hired to administer 
the interventions. Each participant at baseline, follow-
up, and end line was tested for malaria and anemia 



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by trained laboratory technicians designated by the 
hospitals. A participant with a positive malaria smear 
was designated as having malaria. The participant with a 
hemoglobin level of  less than 11g/dl was considered as 
having anemia. Those participants who had malaria and 
anemia at baseline were treated by doctors assigned at the 
hospitals before they could fully participate in the study. 
Data collection forms were designed to collect all the 
data. Filling out the form was facilitated by the midwives. 
The data collection form did not mention participants’ 
names or personal identities, which might raise concerns 
about stigmatization. As part of  the ANC satisfaction 
assessment, participants were asked how they felt about 
the hospital’s treatment during the past three months.

Outcomes
The primary outcome was malaria prevalence and 
antenatal care satisfaction level. The secondary outcome 
variable measured was the prevalence of  anemia. 

Treatment in the Control Group
The control group received all routine and standard 
ANC services (Table 1). The participants in this group 
were followed up every month. A similar pattern of  
routine ANC services was followed in every subsequent 
follow-up.  Every follow-up included measurements of  
primary outcome variables (malaria prevalence and ANC 
satisfaction) and the secondary outcome variable (anemia 
prevalence).

Table 1: Treatment in the Interventions and Control Clusters
Treatment Types Control group (Routine Care) Intervention Group 

(Routine + New treatment)
Reference 

Diet Intervention -Pregnant women were counseled 
about healthy eating and physical 
activity during pregnancy. 
-Using Visual aid containing the 
various food groups, pregnant 
women were counseled on 
the need to eat food from the 
different food groups daily to be 
kept healthy during pregnancy.

-Diet counseling focused on 
iron-rich foods (vegetables, 
fruits, and meat/fish 
products). 
-Participants were reminded 
biweekly to consume daily 
iron- and vitamin-rich foods 
from local markets and 
backyard gardens.

Sunuwar et al, (2019).
Otoo & Adam (2016)
WHO recommendations 
on ANC for a positive 
pregnancy experience 
(2016)

Iron and Folic acid 
supplements

Both hospitals routinely 
provided daily oral iron and folic 
acid supplementation to each 
participant

-Biweekly tele-reminders 
reminded participants to take 
iron and folate supplements. 
-IFA supplementation was 
emphasized in all

Gomes et al. (2021).
WHO recommendations 
on ANC for a positive 
pregnancy experience 
(2016)

Malaria Prevention A mosquito net was given to each 
participant to prevent malaria. 
In the second trimester of  
pregnancy, participants received 
intermittent preventive treatment 
with sulfadoxine-pyrimethamine 
(IPTp - SP). Based on hospital 
practice, dosing was determined

A biweekly tele-reminder 
emphasized the use of  
mosquito nets and the 
importance of  adhering to 
IPTp-SP guidelines.
A message (SMS) reminded 
them to use mosquito nets 
regularly and take the IPTp-SP. 

Ngabo et al. (2012).
WHO recommendations 
on ANC for a positive 
pregnancy experience 
(2016)

Hygiene Education Participants were instructed to 
wash their hands with soap and 
water after using the latrine and 
touching contaminated surfaces.
Participants were encouraged to 
keep their environment clean at 
all time

During follow-up visits, 
participants received 
handwashing soaps in 
addition to tele-reminders. 
Participants were reminded 
of  the importance of  
washing their hands 
 with soap and water after 
using the toilet, before 
cooking, and before eating
Participants were also 
reminded biweekly to keep 
their environment clean 

Sheth et al. (2010).
WHO recommendations 
on ANC for a positive 
pregnancy experience 
(2016)

Prevention of  
intestinal parasites/
worm

Participants were treated with preventive anthelmintics according 
to hospital practice before undergoing their first ANC in the 
second trimester

WHO recommendations 
on ANC for a positive 
pregnancy experience 
(2016)



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Treatment in the Intervention Group
Each participant in the intervention group received 
slightly different interventions than those administered to 
respondents in the control group.  A mobile phone tele-
reminder was delivered biweekly through phone calls and 
SMS to participants in the intervention group. During the 
mobile phone calls, Participants were counseled only on 
food groups with rich sources of  iron (Table 1).

Development of  Antenatal Care Tele-Reminder 
Messages
Health messages delivered to the study’s participants 
are referred to in this study as “Core Antenatal Care 

Tele-Reminder Messages.” There were three phases 
to the development of  these core healthcare reminder 
messages (Table 2). In phase one, the researcher reviewed 
World Health Organization guidelines on antenatal care 
published in 2016. Healthcare messages supported by 
evidence-based practice were selected from the World 
Health Organization’s antenatal care guidelines. During 
phase two of  the development of  core healthcare 
reminder messages. The researcher and the six midwives 
who administered the treatment (intervention and 
control) reviewed the components of  the World Health 
Organization antenatal care guidelines incorporated into 
the local Liberian ANC guidelines (Figure 2).

Table 2: Core Health Messages Sent Via SMS
Types of  Treatment Core Health Messages Via SMS
Iron and Folate acid supplementation “Increase your blood volume by taking one iron tablet a day.”
Malaria Prevention “Before you sleep, please hang the mosquito net over you.”
Adherence to the ANC visit schedule “Come to the hospital at the end of  the month for treatment.”
Hygiene Practices “To prevent sickness, wash your hands frequently after using the toilet, 

before eating, and before cooking”. Always keep your surrounding clean.

Phase two was intended to prevent giving health messages 
to the participants that the Ministry of  Health of  Liberia 
did not approve. In Phase Three, the six midwives 
pretested the critical health messages among ten mothers 
(pregnant women) who were not part of  the study but 
received ANC services at Phebe Hospital.

Data Quality Control
CELL-DYN Emerald 22, an automated hematology 
analyzer designed for low-volume clinical settings, 
was used for hemoglobin testing. A blood Smear was 
conducted for malaria on all participants following all 
standard procedures followed by trained laboratory 
technicians at both hospitals. Licensed laboratory 
technicians collected blood samples for hematological 
(malaria smear) analysis. To ensure data quality control, 
a regular supervision visit was conducted to ensure that 
standard operating procedures were followed during blood 
sample collection. Blood specimens were transported in 
proper containers under the supervision and taken at the 
recommended time to the analyzer. Test materials were 
observed to avoid negative impacts on test results and to 
ensure they were properly stored and cleaned. For quality 
assurance purposes, laboratory technicians were treated 

blinded. All laboratory results were immediately entered 
into the laboratory request form of  the participants.

Data Analysis Method
The primary outcome variables were malaria prevalence 
and ANC satisfaction. Participants with Positive malaria 
smears were considered as having malaria infection. 
The Chi-square test of  independence (for categorical 
data) was used to assess the treatment effects on the 
outcome variables. A logistic regression analysis based 
on longitudinal data was used to determine the treatment 
effects on malaria infection and the level of  antenatal care 
satisfaction. As facilities rather than individual pregnant 
women were randomized, a generalized estimating 
equation was used to account for within-cluster 
correlation coefficients. 

RESULTS
Age and Pregnancy Profile of  Participants
Participants range in age from 23 to 24 years old. There 
was no statistically significant difference between the ages 
of  participants in the intervention group and the control 
group. Most participants were in their first trimester of  
pregnancy (Table 3).

Table 3: Age and Pregnancy Profile of  Participants at Baseline
Variables Intervention group n = 75 Control group n = 75 Independent Sample 

T-Test p-valueMean ±SD Mean ±SD
Age of  participants 24.57 ± 6.280 23.45 ± 6.803 0.297
Age in months of  pregnancy 3.15 ± 1.245 3.27 ± 1.044 0.513
Total pregnancy 2.11 ± 1.640 1.89 ± 1.956 0.470
Total living children 1.23 ± 1.341 1.16 ± 1.525 0.777 
Age in the month of  the last child 26.17 ± 28.974 20.75 ± 26.568 0.234



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Participants have varying educational backgrounds. There 
were, however, a significant number of  them who had at 
least a primary education. According to statistics (Table 
4), there is no statistical difference between the groups 
regarding their educational attainment. The study also 
showed that more than half  of  the participants were 
cohabiting couples.

Comparing the Use of  Insecticide-Treated Net and 
Intermittent Preventive Treatment (Iptp) at Baseline 
and End Line           
In both groups, participants were asked if  they took 
intermittent preventive treatment (IPTp). In terms 

of  IPTp use before the study, there was no significant 
association between the two groups (p = 0.267). In Table 
5, the Fisher’s Exact test after the intervention showed 
no difference between the intervention group and the 
control group in terms of  IPTp adherence (p = 0.221). 
At baseline, participants were also asked if  they had used 
insecticide-treated nets the night before the study. There 
was no significant difference between the intervention 
and control groups regarding insecticide-treated net use 
the night before the study (p = 0.095). As a result of  the 
intervention, there was a significant difference in IPTp 
usage between the intervention and treatment groups (p 
= 0.034).

Table 4: Educational level and Marital status, Baseline
Variables and Category Intervention group n = 75 Control group n =75 Fisher’s Exact 

test p-valueN % n %
Highest Education 
Attainment

Primary education 54 72 53 70 0.500
Secondary education 21 28 22 29

Marital status Cohabiting 51 68 54 72  0.361
Not married 24 32 21 28

Table 5: Intermittent Preventive Treatment (IPTp) Comparison at Baseline and end line
Used mosquito net in 
the past one night

Intervention group 
n = 75

Control group 
n = 75

Fisher’s Exact 
Test p-value

Binary Logistic 
Regression

n (%) n (%) Odds Ratio (95% CI)
Baseline  30 (40) 39 (52) 0.095  1.3 (0.46-3.76)
Endline 68(91) 59 (79) 0.034
Intake of  IPT
Baseline 7(9) 4 (5) 0.267 2.6 (0.49-13.88)
Endline 73 (97) 70 (93) 0.221

Comparing Malaria Prevalence at Baseline and After 
Treatment    
In both intervention and control groups, the prevalence 
of  malaria infection was high at baseline (Table 6); 
however, no significant difference was observed between 
the intervention and control groups. (43% vs. 45%; p = 

0.869). As a result of  treatment, the prevalence of  malaria 
among pregnant women in the intervention group was 
lower than that among those in the control group (5% 
vs. 15%). However, the intervention group did not differ 
significantly from the control group (p = 0.050).

Table 6: Comparing Malaria Prevalence at Baseline and After Treatment
Malaria 
Prevalence

Intervention group n = 75 Control group n = 75 Fisher’s Exact Test p-value
n (%) n (%)

Baseline 32 (43) 34 (45)  0.869
Endline 4 (5) 11 (15)  0.050
McNemar 
Test P value

0.000 0.000 Unadjusted OR* (95%CI) 0.32  (0.09-1.08) 
Binary Logistic Regression

Treatment Effect on Antenatal Care Satisfaction     
When adjusted for the age and education level of  
participants, most of  the participants (95%) were very 
satisfied with ANC services in the intervention group and 
86% in the control group (Table 7). Between pregnant 
women in the intervention group and those in the 
control group, the odds of  being very satisfied with ANC 

services were significantly different (aOR, 4.01; 95%CI, 
1.72-9.53).  The study showed a significant difference 
between the intervention and control groups in terms 
of  not wanting to quit antenatal care (Adjusted odds 
ratio “aOR,” 2.17; 95%CI, 1.09-4.32). Pregnant women’s 
satisfaction is a reflection of  the patient’s judgment of  
different domains of  health care, including technical, 



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Table 7: Treatment Effect on Antenatal Care Satisfaction
Indicators Intervention 

groups n (75)
Control group 
n = 75

Unadjusted 
OR*(95% CI)

Adjusted OR** 
(95% CI)

Logistic 
Regression 
p-valuen (%) n (%)

Very satisfied 71(95) 64(86) 5.98 (4.15-8.61) 4.06 (1.72-9.53) 0.001
Had no desire to quit ANC 69 (92) 58 (78) 3.51 (2.49-4.96) 2.17 (1.09-4.32) 0.027

interpersonal, and organizational aspects. Satisfaction 
with varying elements of  received antenatal care improves 
health outcomes, continuity of  care, treatment adherence, 
and the relationship with the provider.

Effect of  Treatment on Anemia Prevalence
The prevalence of  anemia was a significant difference 
between Pregnant women in the intervention and 
control groups (4% vs. 13%; p = <0.039). The result 

also showed that pregnant women assigned to the 
intervention group had a significantly greater mean 
hemoglobin level after the two interventions, t (2.4) = 
445, p<0.013; d = 0.23. The effect size of  the analysis 
(d = 0.23) was found to be small (Table 8). These results 
indicate that pregnant women in the intervention group 
(M = 12.8, SD = 0.71) experienced a small increase 
in hemoglobin levels than did pregnant women in the 
control group (M =11.7, SD = 0.63).

Table 8: Impact of  Treatment on anemia prevalence
Hemoglobin Level in g/dl Intervention group Control group Independent Sample T-test 

p-value(Mean ± DS) (Mean ± DS)
Baseline 10.9 ± 0.94 10.8 ± 0.92 0.108
Endline 12.8 ± 0.71 11.7 ± 0.65 0.013
Paired T-test (p-value) 0.047 0.000 Cohen’s d Test: 0.23
Anemia Prevalence Intervention group n (%) Controlgroup n (%) Fisher’s Exact Test (p-value)
Baseline 36 (48) 39 (52)  0.37
Endline 3 (4) 10 (13) 0.039
McNemar Test P value 0.000 0.000 Odds Ratio (Binary Logistic 

Regression): 3.7 (0.97- 14.00)

Anemia Prevalence among Participants with Malaria 
and History of  Past Illnesses
Based on Table 9, 56% of  intervention participants and 
38% of  control participants with malaria at baseline had 
anemia. Participants were asked at baseline whether they 

had experienced any illness in the past month. As a result, 
25% of  participants in the intervention group and 19% 
of  participants in the control group who experienced 
illness in the past month had anemia at baseline.

Table 9: Anemia Prevalence Among Participants with Malaria and History of  Past Illnesses at Baseline
Treatment Groups Participants with malaria & anemia 

at baseline n = 66
Participants with a history of  past   
illnesses with anemia at baseline n = 51

n (%) n (%)
Intervention Group 18 (56) 6 (25)
Control Group 13 (38) 5 (19)
Fisher’s Exact Test p-value 0.217 0.412

DISCUSSION
There is no doubt that malaria during pregnancy can have 
devastating effects on mothers and their babies, and it is a 
leading cause of  maternal and infant mortality. Pregnancy 
is most affected by malaria in sub-Saharan Africa, of  
which Liberia is a member. Preventive strategies for 
malaria in pregnancy in Liberia include intermittent 
preventive treatment (IPTp) with three or more doses 
of  sulphadoxine-pyrimethamine (SP), using long-lasting 
insecticide-treated nets, and managing clinical malaria and 
anemia effectively. Pregnant women receive information 

about malaria causes and prevention during antenatal care 
visits. However, preventive measures may be overlooked if  
these educative messages are not consistently reinforced. 
There was a lower malaria prevalence in the intervention 
group than in the control group. However, the study 
found that pregnant women who received the mobile 
phone tele-reminder did not significantly differ in their 
odds of  not contracting malaria compared to pregnant 
women who did not receive the intervention. However, 
despite this, the use of  mobile phone tele-reminder as 
part of  antenatal care was of  great assistance in educating 



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pregnant women regarding the need for insecticide-
treated nets and the causes of  malaria infection. By using 
the mobile phone tele-reminder, midwives may be able 
to create a balance between myths and realities about 
malaria infection during pregnancy (Entsieh et al., 2015). 
In developing countries, such as Liberia, some of  the 
challenges associated with accessing malaria information 
among pregnant women may be overcome by midwives 
by using their mobile phones to reinforce antenatal care 
counseling (Mbunge et al., 2011). These findings agree 
with Odetola and Okanlawon (2016) findings, who 
found that pregnant women were more likely to receive 
intermittent preventive treatment (IPT) when nurses used 
mobile phones to deliver ANC.
In a study by Lund et al. (2014), pregnant women who 
received the intervention had significantly higher levels 
of  satisfaction with their antenatal care than those 
who did not. To reinforce the counseling messages 
given to participants at the hospital, midwives used 
SMS reminders and phone calls. As a result of  such an 
integrated intervention approach, pregnant women seem 
motivated to seek antenatal care to give birth to a healthy 
baby. There is a possibility that midwives may be able to 
contribute to adherence to antenatal care in low-income 
countries if  they deliver services using mobile phones. 
Despite still enjoying the comfort of  home and family, 
pregnant women find that receiving healthcare through 
mobile phone technology is more encouraging and 
exciting than receiving healthcare in person. According 
to this study, pregnant women are more likely to seek care 
timely, suggesting that they are satisfied and anxiety free 
with the care they receive with the help of  the mobile 
phone application (Jareethum et al., 2008). A more 
satisfactory level of  patient satisfaction can be achieved 
when antenatal care consultations are improved to meet 
the desired needs of  pregnant women in developing 
countries (Alhaqbani & Bawazir, 2022). 

Acknowledgement
My first and foremost thanks go to the members of  
my guidance committee, Dr. Leila S. Africa (Chair), Dr. 
Corazon V.C. Barba (Co-chair), Dr. Angelina R. Bustos 
(member), and Dr. Mark Donda Arboleda (member) 
for their support and guidance. Last but not least, I 
would like to express my gratitude to my family for their 
unconditional love and support.

Abbreviation
ANC: Antenatal Care, 
g/dl: gram per deciliter
HIV: Human Immune Virus
IFA: Iron & Folic Acid
SMS: Short Message Services
WHO: World Health Organization

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