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American Journal of  Medical 
Science and Innovation (AJMSI) 

Does Mobile Phone Tele-Reminder Increased Iron Status and Diet Quality of  Pregnant 
Women Availing Antenatal Care Services at Phebe and Charles B. Dunbar Hospitals

Bong County, Liberia A Cluster Randomized Control 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.v2i2.1590
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: September 07, 2023

Accepted: October 03, 2023

Published: October 14, 2023

Anemia in pregnancy is a serious public health problem in Liberia. This study aimed to assess 
the effect of  mobile phone tele-reminder on the iron status and diet quality of  pregnant 
women in Liberia. A two-arm, double-blinded cluster randomized control trial was conducted 
in this study, with ANC screening rooms as a unit of  randomization. At the Phebe and 
Charles B. Dunbar hospitals in Bong County, Liberia, 150 pregnant women who had never 
previously attended an ANC were recruited for the study (75 intervention women and 75 
control women). Iron status measured as hemoglobin (g/dl) and diet quality were primary 
outcomes of  this study. Secondary outcome measures were adherence to daily iron and 
folic acid supplementation and prevalence of  anemia among pregnant women with malaria 
infection. The analysis was an intent-to-treat. The effect of  the intervention on the primary 
study outcome (iron status) was examined using an independent sample t-test (for group-level 
analysis). Effects of  treatment on diet quality was measured using the Fisher’s Exact Test. A 
binary logistic regression with a 95% Confidence Interval (CI) was used to analyze the effect 
of  treatment on secondary outcomes. Pregnant women assigned to the intervention group 
had a significantly greater mean hemoglobin level after the two interventions, t (2.4) = 447, 
p<0.05; d = 0.23). In the intervention group, there were significant odds in the consumption 
of  2-3 fish/meat/poultry products compared to the control group (93% versus 83%, adjusted 
odds ratio, 2.93; 95% CI, 0.99-8.70). A trend towards adherence to the IFA supplementation 
and an increase in consumption of  iron-rich foods was observed. In Liberia, mobile phone 
tele-reminders appeared to be effective in improving iron status, diet quality, and IFA 
supplementation adherence when integrated into an existing antenatal care protocol.

Keywords
Diet Quality, Hemoglobin, Iron 
Status, Tele-Reminder 

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
One of  the most life-threatening dietary and health-
related concerns is anemia in pregnancy. The World 
Health Organization (2001) defined anemia in pregnancy 
as hemoglobin less than 11 g/dl, while iron deficiency 
anemia (IDA) was characterized as serum ferritin <12 
ug/L, with a hemoglobin level of  less than 11 g/L 
and a hematocrit level of  less than 33% (Center for 
Disease Control and Prevention, 1998 and World Health 
Organization, 2001). In many developing countries, 
anemia in pregnancy is a major health problem associated 
with maternal and perinatal mortality, premature 
deliveries, low birth weight, and other adverse outcomes 
(Mahomed & Hytten, 1989). It is estimated that only 
15% of  pregnant women in developed countries suffer 
from anemia (WHO, 1993). Approximately 35%-75% of  
pregnant women in developing countries are anemic (van 
den Broek et al., 2000, Ogunbode 2003). In pregnancy, 
iron deficiency is the most common cause of  anemia 
(Van den Broke et al., 2000). Predisposing factors of  
anemia in pregnancy, include grand multiparity, low 
socioeconomic status, malaria infestation, late booking, 
HIV infection, and inadequate child spacing (Adinma 
et al., 2002, Van den Broek et al., 2000). Poor nutrition, 
iron deficiency, micronutrient deficiencies (folic acid, 
vitamin A, and vitamin B12 deficiency), diseases 
(malaria, hookworm infestation, schistosomiasis, HIV 

infection), and genetically inherited hemoglobinopathies 
(thalassemia) are all linked to iron deficiency anemia in 
pregnancy (Di Renzo et al, 2015). With antenatal care, 
maternal deaths can be reduced, and protecting the lives 
of  pregnant women and their unborn children can be 
achieved (Carroli, Rooney, & Villar, 2001).

LITERATURE REVIEW
Anemia Situation in Liberia
Anemia is a major concern among pregnant women, 
leading to increased maternal mortality and poor birth 
outcomes as well as reductions in work productivity.  
Anemia in pregnancy has become a serious health and 
nutritional problem. Pregnant women (52%) are more 
likely than their breastfeeding counterparts (48%) and 
non-breastfeeding/non-pregnant (43%) to suffer from 
anemia. About 45 percent of  women in Liberia suffer 
from anemia, according to a study from the Demography 
and Health Survey (2019-2020). Only 43% of  expectant 
mothers took iron supplements for at least 90 days. 
About 64% of  pregnant women took deworming drugs. 
Six percent (6%) of  pregnant women did not take an 
iron supplement (LDHS 2019). Due to an increase in 
blood volume during pregnancy, women are more likely 
to develop anemia. Due to an increased risk of  blood 
loss during labor, early delivery, low birth weight, and 
perinatal mortality, severe anemia can be dangerous for 



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both the mother and the child. Pregnant women are 
advised to consume iron-rich foods, take iron-folate 
supplements, and practice good sanitation and hygiene to 
avoid intestinal worms, in order to prevent anemia. 

Causes of  Anemia in Pregnancy
The main causes of  anemia during pregnancy are 
nutritional deficiencies, bacterial, parasitic, and inborn 
red blood cell disorders like thalassemia. Micronutrient 
deficiencies such as those in folic acid, vitamin A, and 
vitamin B12, and HIV infection can cause anemia in 
pregnancy (Breymann, 2015; Di Renzo et al., 2015). 
Additional factors associated with anemia during 
pregnancy include gestational age at the first prenatal, 
educational status, and antenatal intake of  iron pills 
(Chotnopparatpattara et al., 2003, Suega et al., 2002). Non-
compliance to antenatal care services is key challenging 
factor in combating anemia in pregnancy (Mithra et al., 
2014).

Diet and Anemia in Pregnancy 
In low-income countries, pregnant women need continual 
dietary counseling because their diets are both poor in 
vitamins, minerals, and other essential nutrients that can 
improve the level of  iron.   Plant sources of  iron have low 
bioavailability, according to Allen and Gillespie (2001) 
(only 2-5 percent of  iron absorbed). Failure to take dark 
green leafy vegetables and inadequate consumption of  
chicken is determinants of  anemia in pregnancy (Tadesse 
et al, 2017). In low-income countries, diets are high in 
protein, vitamins, and minerals which are too expensive 
for many families. Nutritional anemia occurs when the 
daily intake of  key micronutrients is insufficient, resulting 
in the body being unable to fulfill the physiological needs 
of  growth, maintenance, or loss (Gleason et al, 2007). Poor 
diet, suboptimum ANC, and being underweight were 
associated with moderate and severe anemia (Agbozo et 
al., 2020). Ages of  the mothers, counseling on the iron-
folate supplement, knowledge of  anemia, knowledge 
of  iron-folate supplement, and frequency of  ANC 
visits were found to be significantly associated factors 
of  compliance with iron-folate supplementation during 
pregnancy (Arega, Abebe, & Aman 2015). Anemia has 
been linked to postpartum hemorrhage, premature labor, 
low birth weight, small for gestational age newborns, and 
perinatal death (Sifakis & Pharmakides, 2000; Smith et 
al, 2019). Work productivity has been discovered to be 
affected by iron deficiency anemia, which could result in 
a loss of  1.3 percent of  GDP (Plessow et al, 2015).

Effects of  Mobile Phone Technology on Anemia 
Prevention in Pregnancy
There is no research on how mobile phones can improve 
iron status and diet quality of  pregnant women in Sub-
Saharan Africa, of  which Liberia is a part. However, 
mobile phone use in health care settings has been shown 
to reduce maternal death from anemia in recent studies. 
However, In Africa, more than 600 million people own 

a cell phone. To strengthen healthcare systems, mobile 
phones are becoming increasingly important (Howitt et 
al, 2012). In clinical settings, mobile phone use increases 
ANC visits and improves early recognition of  pregnancy-
related situations (Lund et al, 2014). Pregnant women 
who utilized mobile phones utilized antenatal care 
services and professional delivery services more than 
those who did not (Tang et al, 2019).  Pregnant women 
feel more confident about seeking medical care during 
pregnancy and childbirth and recognizing signs of  illness 
in their newborns with teleconsultation (Entsieh et al., 
2015). Women who received the SMS every week were 
more likely to attend eight ANC visits compared to 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). Using mobile phones to send 
short message services on focused antenatal care (FANC) 
has positive effects on the uptake of  focused antenatal 
care among pregnant women in middle and low-income 
countries (Wagnew et al., 2018).

METHODOLOGY
Design
This study was three months, two-arm double-blinded 
cluster randomized controlled trial conducted in two 
major referral hospitals. The study took place from May 
2022 to August 2022 at the Phebe and Charles B. Dunbar 
hospitals, Bong County, Republic of  Liberia. The antenatal 
care screening rooms with assigned midwives, caring for 
pregnant women who avail antenatal care services were the 
units of  randomization. A cluster randomized control trial 
randomizes groups of  participants rather than individuals 
to each treatment arm. Each of  the selected hospitals has 
three active and functional screening rooms for 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 (control 
and experimental) in these two arms trials.  We adopted 
a cluster randomized controlled trial because there was 
a possibility that pregnant women receiving antenatal 
care at the Phebe Hospital would be close relatives of  
pregnant women receiving antenatal care at the Charles 
B. Dunbar Hospital. There was a risk of  contamination 
within and between clusters due to this relatedness. The 
cluster randomized control trial minimizes the risk of  
contamination. 

Ethical Consideration
This study was approved by the Research Ethics Board 
of  the University of  the Philippines Los Banos. The 
administration of  the Phebe Hospital also provided 
ethical clearance for the conduct of  this study. The 
trial is registered In Pan African Clinical Trial Registry 
(PACTR202204658979734).

Clustering and Randomization
The randomization units were antenatal care screening 



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rooms with licensed midwives. In cluster randomized 
controlled trials, the groups are randomized, rather than 
the individual participants. In each of  these hospitals, 
there were three screening rooms 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 the assignment 
of  study participants to either a treatment group or a 
control group solely by chance. The six screening rooms 
(six clusters) were randomized into an intervention 
(clusters 1,4, & 6) and a control group (clusters 2,3, & 5). 

Setting
The study was conducted in Phebe and the Charles B. 
Dunbar hospitals. In Liberia, the two hospitals are located 
in Bong County, which is a centrally located county. In 
1964, Bong County was established.  In terms of  area and 
population, Bong County ranks third in Liberia. One of  
15 counties that comprise the first level of  administrative 
division in the nation, Bong County has twelve districts. 
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 once 
became known as the food basket of  Liberia. Cocoa, 
coffee, rubber, and palms are also grown in the county.  
 In rural Liberia, Phebe Hospital provides health care to 
about 450,000 people. In 1921, the Lutheran Church co-
founded the hospital. Through the national budget, the 
government has funded the hospital for years. Charles B. 
Dunbar Hospital is the only hospital in central Liberia 
that specializes in maternity care.  

Participants
Hospitals and individual levels of  analysis were considered 
in this cluster randomized control trial. For this study, 
hospitals with the highest attendance at antenatal care-
equipped medical and laboratory facilities, and more ANC 
screening facilities were selected. Phebe and Charles B. 
Dunbar hospitals are centrally located referral hospitals in 
Liberia with high ANC attendance rates. As far as ANC 
services are concerned, both of  these hospitals meet the 
minimum recommendations for providing ANC services 
in Liberia.  The sample population was pregnant women 
receiving ANC for the first time at the selected hospitals. 

Sample Size Calculation
The sample population consisted of  all consenting 
pregnant women receiving their first ANC visit. 
According to the Demography and Health Survey Report 
(2019), anemia is more prevalent among pregnant women 
(52%) than breastfeeding women (48%). The new 
intervention is proposed to reduce anemia prevalence 
among pregnant women by 25%. Similarity among 
subjects within preexisting groups or clusters reduces 
the variability of  responses in a cluster sample, making 
it difficult to detect true differences between groups. 
Intracluster correlation coefficients (ICC) measure the 
degree of  dependence within a cluster. After adjusting for 
individual and cluster-level characteristics, the effective 
sample size was determined by using the median ICC in 
primary healthcare research of  0.005 (Adams et al., 2004). 
To determine the effective sample size, the first step 
was to calculate the sample size required for individual 
randomized controlled trials. In the second step, the 
derived sample size from the individual randomized 
controlled trial was then adjusted for the design effect 
(DE). The effective sample size was 150 pregnant 
women in their first trimester of  pregnancy. Seventy-five 
pregnant women were assigned to each treatment arm. 

Figure 1: Operationalization of  the Study



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Each treatment arm was further randomized into three 
clusters. For every cluster, 25 participants were assigned.

Selection Criteria
This study included pregnant women who sought 
antenatal care for the first time, consented, and was free 
of  chronic illnesses receiving antenatal care at Phebe and 
Charles B. Dunbar hospitals. Self-ownership of  a mobile 
phone or close relatives in the same household was added 
as a selection criterion.

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 followed 
the registration process, which aims to prevent mother-
to-child transmission of  HIV/AIDS. The patient card 
was taken to any of  the screening rooms for further 
processing by the midwives assigned to those rooms 
after counseling. A patient received healthcare from 
the screening room where her card was transferred. Six 
clusters (screening rooms) were randomized so that three 
(3) clusters administered standard/routine interventions 
during the study period, while the remaining three clusters 
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. Neither the primary 
nor secondary outcomes were disclosed to the midwives 

during the study. During training, the three midwives 
selected randomly for the intervention treatment learned 
how to use the Tele-reminder manual effectively. The 
remaining three midwives who administered the control 
treatment were not trained to use the tele-reminder manual.

Outcomes
The primary outcome was iron status measured as 
hemoglobin (g/dl). Low iron status was defined as 
hemoglobin less than 11 g/dl. The secondary outcome 
variables were adherence to IFA supplementation, 
antenatal care satisfaction, and consumption of  2-3 iron-
rich foods per day.

Treatment in the Control Group
The control group received routine and standard ANC 
services. 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 and secondary 
outcomes. The assigned midwives administered routine 
ANC during each ANC visit. Iron status measured in 
hemoglobin (g/dl) was the primary outcome variable. In 
addition, monthly adherence to IFA supplementation, 
ANC satisfaction level, and consumption of  2-3 iron-rich 
foods per day were also measured as secondary outcome 
variables (Table 1).

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 through phone calls and SMS 
biweekly to participants in the intervention group.
During the mobile phone calls, Participants were 

Table 1: 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 go to 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”

Table 2: Treatment in the Control and Treatment 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)



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counseled only on food groups with rich sources of  
iron. They were also counseled on the consumption 
of  vitamin-rich foods that enhance iron absorption. 
In this group, participants were presented with a list 
of  affordable, available, and accessible local foods that 
are good sources of  iron and vitamins. We developed a 
tele-reminder manual that midwives used as a guide in 
administering the treatment to the participants.

Development of  Antenatal Care Tele-Reminder 
Messages
Health messages delivered to the participants in this study 
are referred to as “Core Antenatal Care Tele-Reminder 
Messages”. There were three phases to the development 
of  these core healthcare reminder messages. In phase 
one, the researcher reviewed World Health Organization 
guidelines on antenatal care published in 2016. Healthcare 
messages that were supported by the 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 along with 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. Phase two was intended 

to prevent giving health messages to the participants that 
were not approved by the Ministry of  Health of  Liberia. 
In Phase Three, the six midwives pretested the key health 
messages among 10 mothers (pregnant women) who 
were not part of  the study but were recipients of  ANC 
services at Phebe Hospital.

Data Collection
This study used several validated techniques to collect, 
measure, and analyze accurate insights. We supervised all 
stages of  this research. In both hospitals, midwives were 
hired to administer the interventions. The researcher 
scrutinized every data report by the research assistants 
(midwives) for quality assurance purposes. In addition, the 
researcher hired laboratory technicians for blood sample 
collection and biochemical analysis, in consultation with 
the medical director of  both participating hospitals. All 
data were collected using questionnaires for analysis. 
Filling out questionnaires was facilitated by the midwives. 
The questionnaires did not mention participants’ names 
or personal identities which might raise concerns 
about stigmatization. At baseline, an assessment of  the 
socio-demographic profiles of  participants, along with 
dietary assessment using the qualitative food frequency 
questionnaire. Hemoglobin test before and after the 
treatment was measured using an automated hematology 

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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analyzer designed for low-volume clinical settings, the 
CELL-DYN Emerald 22. 

Blood Sample Collection
Blood specimens for anemia testing were collected from 
all pregnant women availing of  antenatal care for the 
first time at the Phebe and Charles B. Dunbar Maternity 
Hospitals in Bong County, Liberia. Blood samples were 
drawn from a drop of  blood taken from a finger prick 
and collected in a microcuvette.
Hemoglobin test before and after the treatment was 
measured using an automated hematology analyzer 
designed for low-volume clinical settings, the CELL-DYN 
Emerald 22. Each participant had their hemoglobin result 
recorded on their hospital cards. Those participants with 
hemoglobin less than 11g/dl, were referred to doctors for 
further intervention.

Data Quality Control
For quality assurance purposes, laboratory technicians 
were treated blinded. CELL-DYN Emerald 22, an 
automated hematology analyzer designed for low-
volume clinical settings, was used for hemoglobin 
testing. Licensed laboratory technicians collected blood 
samples for hematological 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. 

To avoid negative impacts on test results, test materials 
were observed to ensure they were properly stored and 
cleaned. To avoid errors in the data recording process, 
all laboratory results were immediately entered into the 
laboratory request form of  the participants.

Data Analysis Method
All available data were included in the analysis. The primary 
outcome was iron status. It was measured as hemoglobin 
level in g/dl. The secondary variable of  interest included 
the consumption of  2-3 iron-rich foods per day, and 
adherence to IFA supplementation. Baseline data were 
analyzed using descriptive statistics (SPSS v. 25). Fisher’s 
Exact test was used to determine whether two categorical 
variables were associated. A t-test (for continuous 
variables) was used to compare the mean of  baseline data. 
The MacNemar test was used to analyze paired nominal 
data between two related samples. A logistic regression 
analysis based on longitudinal data was used to assess the 
treatment effects on secondary outcome measures, while 
an unpaired sample t-test was used to assess the treatment 
effects on the primary outcome measure. 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 
Participants range in age from 23 to 24 years old. There 
was no statistically significant difference between the ages 

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

of  participants in the intervention group and the control 
group. The majority of  participants were in their first 
trimester of  pregnancy (Table 3).

Trimesters and Health Profiles
A significant number of  participants had positive malaria 

smear test results. Forty-three percent of  those in the 
intervention and 45% in the control groups were malaria 
positive at baseline. In the past month, the majority of  the 
participants did not have any history of  illness in the past 
month (Table 4). There were no HIV/AIDS diagnoses 
among any of  the participants in the study.

Table 4: Gestational and Health Profiles of  Participants at Baseline
Variables and Category Intervention group n = 75 Control group n =75 Fisher’s Exact 

test p-valueN % n %
Gestational period First trimester 38 51 44 59 0.20

Second trimester 37 49 31 41
Malaria test result Negative 43 57 41 55 0.43 

Positive 32 43 34 45
Ill in the past month Yes 24 32 27 36 0.36 

No 51 68 48 64



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Education and Marital Status
Participants have varying educational backgrounds. 
There were, however, a significant number of  them who 
had at least a primary education. According to statistics 

(Table 15), there is no statistical difference between the 
groups when it comes to their educational attainment. 
Furthermore, more than half  of  the participants in the 
study are cohabiting couples.

Table 5: 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

Treatment Effect on Iron Status
The result 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 6). 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 6: Effects of  Treatment on Iron Status Measured in Hemoglobin (Primary Outcome)
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 (%) Control group 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):  0.27 (0.07- 1.03)

Anemia Prevalence among Participants with Malaria 
and History of  Past Illnesses
At baseline, 66 participants had malaria infection and 
34 participants had history of  past illnesses. Based on 

Table 7, 27% of  intervention participants and 20% 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, 

Table 7: Anemia Prevalence Among Participants with Malaria and History of  Past Illnesses at Baseline
Treatment Groups Prevalence of  anemia among those with 

a malaria infection at baseline n = 66
Prevalence of  anemia among those with 
a history of  past   illnesses at baseline
n = 34

n (%) n (%)
Intervention Group 18 (27) 6 (18)
Control Group 13 (20) 5 (15)
Total Anemia cases 31 11

18% of  participants in the intervention group and 15% 
of  participants in the control group who experienced 
illness in the past month had anemia at baseline.

Adherence to IFA Supplementation
Data were adjusted for the level of  education of  
participants. The odds of  completing the monthly 
iron and folic acid supplementation (≥28 days) were 
significantly different between pregnant women who 

received the intervention and those who did not (Adjusted 
odds ratio “aOR” 5.0; 95% CI, 1.29-19.42). This result 
indicates that pregnant women in the intervention group 
adhered to the monthly prescribed dose of  IFA tablets at 
a higher rate than those in the control group (96 vs. 84%). 
The prevalence of  those who adhered to taking one IFA 
tablet per day in the intervention group was higher than 
those in the control group (95% vs. 85%). This means 
the odds of  adhering to 1 IFA tablet per day were 3 times 



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higher among the intervention group compared with the 
control group (Adjusted odds ratio “aOR” 3.04; 95% 
CI, 0.92-10.08). Women in the intervention group were 
twice as likely to be aware of  the importance of  IFA 
supplementation during pregnancy than women in the 
control group (adjusted odds ratio, 2.05; 95% confidence 
interval, 0.36-11.56). According to Table 7, 95% of  
participants in the intervention group and 91% of  
participants in the control group missed at least one day 
without taking IFA tablets due to a perceived risk of  side 
effects. Despite this, there was no statistically significant 

difference between the two groups (Adjusted odds ratio 
= 1.8; p>0.35).

Consumption of  Iron Rich Food
Pregnant women in the intervention group consumed 
more fruits per day when exposed to mobile phone 
tele-reminder every two weeks (91% compared to 72%, 
adjusted odds ratio “aOR”, 3.77, 95%CI, 1.49-9.54). In 
the intervention group, there were significant odds in 
the consumption of  2-3 fish/meat/poultry products 
compared to the control group (93% versus 83%, 

Table 8: Impact of  Treatment on Adherence to Iron and Folic Acid Supplementation
Intervention 
groups n (75)

Control group 
n = 75

Unadjusted 
OR*(95% CI)

Adjusted OR** 
(95% CI)

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

Acknowledged that Iron 
and folic acid supplements 
can prevent and treat 
anemia in pregnancy

73(97) 71(95) 2.05 (0.36-11.58) 2.05 (0.36-11.56) 0.416

Adhere to taking one IFA 
supplement (tablet)/per day

71(95) 64(85) 3.05 (0.92-10.06) 3.04 (0.92-10.08) 0.068

Adhere to taking ≥28 
tablets/supplement of  
IFA/Month

72 (96) 62(84) 4.5 (1.23-16.93) 5.0 (1.29-19.42) 0.020

Did not take IFA tablet a 
day due to perceiving risk 
of  side effects

71 (95) 68 (91) 1.8 (0.51-6.52) 1.8 (0.50-6.50) 0.35

Table 9: Treatment Effects on Daily Iron-Rich Food Consumption Between Treatment Groups
Intervention group 
N (%)

Control group 
N (%)

Fisher’s Exact 
Test p-value

Adjusted Odds Ratio (95% CI) 
Binary Logistic Regression

2-3 fruits consumption/day
Baseline 12 (16) 10 (13) 0.40 3.77 (1.49- 9.54)
Endline 68 (91) 54 (72) 0.003
Consumption of  2-3 vegetables/per day
Baseline 53 (71) 57 (76) 0.29 3.69 (0.97-14.00)
Endline 72 (96) 65(87) 0.039
Consumption of  2-3 meat/fish/poultry products per day
Baseline 31 (41) 35 (47) 0.31 2.93 (0.99- 8.70)
Endline 70 (93) 62 (83) 0.038

adjusted odds ratio, 2.93; 95% CI, 0.99-8.70). According 
to Table 8, pregnant women in the intervention group 
consumed 2-3 types of  vegetables per day more than 
pregnant women in the control group. (96% compared 
with 87%, Adjusted odds ration “aOR”, 3.69; 95%CI, 
0.97-14.00).\

DISCUSSION
In this study, the null hypothesis stated that, compared 
to women in the control group, there were no significant 
changes in the mean hemoglobin level of  pregnant 
women availing of  antenatal care services who received 

mobile phone tele-reminder. On the other hand, the 
alternative hypothesis stated that, compared to women in 
the control group, there was a significant difference in the 
mean hemoglobin level of  pregnant women availing of  
antenatal care services who received mobile phone tele-
reminder. Since the p-value = .013 is less than the a = 
0.05, the study rejects the Ho. It is now concluded in this 
study that at a = 0.05, there is sufficient evidence to say 
that integrating mobile phone tele-reminder into existing 
antenatal care is associated with increased iron status 
among pregnant women availing antenatal care services 
at the Phebe and Charles B. Dunbar hospitals. According 



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to the study, integrating mobile phone tele-reminders into 
existing ANC services appeared to improve iron status 
significantly. Hemoglobin levels in pregnant women in 
the intervention group were higher than those in the 
control group. A simple mobile phone audio call and SMS 
were used to address irregular attendance and inadequate 
utilization of  essential antenatal care services.
It is essential to utilize all antenatal care services 
appropriately throughout pregnancy to identify health 
problems that may contribute to anemia during pregnancy. 
We found significant improvement in the consumption 
of  iron-rich foods that include vegetables and meat/fish/
poultry products among participants in the intervention 
group compared with those in the control group. Vitamin 
C in fruits enhances the absorption of  iron in food. It 
has been found that tele-reminder can greatly increase 
the consumption of  vitamin-rich foods during pregnancy. 
Red meat, fish, and poultry products are some of  the 
animal products that contain hemoglobin. Heme-based 
sources of  iron are the most readily absorbed by the 
body Participants in the intervention group again were 
more likely to adhere to IFA supplementation, compared 
with those in the control group. We agree with Lund and 
others (2014) that integrating mobile phone technology 
into existing ANC protocol, may increase ANC visits and 
improve quality care with more pregnant women receiving 
quality preventive health services. In accordance with 
Wagnew and others (2018), this study found that sending 
short message services on focused antenatal care to 
pregnant women increased the likelihood that they would 
adhere to antenatal care. In addition, the study agrees 
with Bangal and others (2017) that pregnant women who 
use mobile phones during ANC have a higher likelihood 
of  taking IFA tablets, which can help prevent pregnancy-
related anemia.

CONCLUSION
 It is imperative to place anemia in pregnancy on the local 
and international health agendas. A lack of  reduction or 
prevention of  anemia during pregnancy may result in 
impaired health and quality of  life for millions of  women, 
as well as adverse effects on children’s development and 
learning. The world must take action now to prevent the 
death of  many pregnant women in developing countries 
due to anemia, which can be realistically prevented by 
national and international consensus. 
Anemia in pregnancy is defined by the World Health 
Organization (WHO) as hemoglobin levels of  less than 
11 grams per deciliter.  A person with anemia has fewer 
red blood cells or a lower hemoglobin concentration 
than normal. If  a pregnant woman has too few or 
abnormal red blood cells, or not enough hemoglobin, 
the blood can’t carry oxygen to the tissues of  the body. 
The most common causes of  anemia during pregnancy 
are nutritional deficiencies, particularly iron deficiency, 
but also folate, vitamin B12, and vitamin A deficiency. 
Other causes of  anemia in pregnancy include infectious 
diseases, such as malaria, tuberculosis, HIV, and parasitic 

infections. During three months, a two-arm, double-
blinded cluster randomized control trial was conducted 
in two referral hospitals. In Bong County, Liberia, the 
study was conducted at the Phebe and Charles B. Dunbar 
hospitals. The purpose of  this study was to determine 
whether mobile phone tele-reminder affects iron status 
and diet quality of  pregnant women seeking antenatal 
care for the first time. Randomly assigned to intervention 
and control groups were 150 pregnant women. There 
were six clusters of  midwives caring for pregnant women 
in the study. Among the six clusters, three were randomly 
assigned to provide the mobile phone tele-reminder and 
the remaining three to provide control treatment. Each 
cluster had 25 participants, respectively. Participants in 
both groups were followed up every month. Participants 
in the intervention group were contacted every two weeks 
by telephoning and as well as sending SMS messages. To 
collect baseline, midline, and end-line data, questionnaires 
were used throughout the study. 
To analyze baseline data, descriptive statistics (mean, 
SD, percentage, and frequency) were used. At baseline, 
two categorical or nominal variables were tested for 
independence by using Fisher’s Exact test. Intent-to-treat 
analysis was used to analyze the findings. An independent 
sample t-test was used to determine the effect of  the 
treatment on the primary outcome of  the study. The 
longitudinal data were analyzed using binary logistic 
regression to determine the effect of  the treatment on 
the secondary outcomes. 
Based on baseline data, both groups had similar ages, 
gestational ages, number of  pregnancies, number of  
living children, and last child’s age in month. The majority 
of  participants in both groups had completed primary 
education. The majority of  participants in both groups 
were still cohabiting. Clinical findings indicated a high 
prevalence of  malaria at baseline. Both groups had more 
than half  of  their participants in their first trimester. In 
both groups, the hemoglobin level was below 11 grams 
per deciliter. HIV/AIDS was not present in any of  the 
participants. A few of  the participants consumed 2-3 fruits 
per day on average at baseline. In both groups, more than 
half  of  the participants consumed 2-3 vegetables per day, 
and most consumed more fish, meat, and poultry products. 
As far as iron status is concerned, Mobile Phone Tele-
Reminder significantly increases iron status measured in 
hemoglobin (g/dl). Despite this, the intervention had a 
small effect size on hemoglobin levels. The intervention 
significantly increased the likelihood of  pregnant women 
taking their iron and folic acid supplements regularly. 
The intervention increased the consumption of  iron and 
vitamin-rich foods during pregnancy.

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 



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would like to express my gratitude to my family for their 
unconditional love and support.

Abbreviation
ANC: Antenatal Care, g/dl: gram per deciliter, IFA: Iron, 
SMS: Short Message Services

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