Stakeholders' Perspectives on the Challenges of Emergency Obstetric Referrals and the Feasibility and Acceptability of an mHealth Intervention in Northern Iraq

The health system in northern Iraq has been weakened by conflict and the internal displacement of over three million people. Mobile phone-based interventions (mHealth) may improve maternal and neonatal health outcomes by enabling emergency referrals, facilitating communication between patients and providers, and improving patient data management; however, they have not been sufficiently studied in conflict-affected settings. We explored stakeholders' perspectives on challenges to obstetric referrals and the feasibility and acceptability of a mobile phone-based application to reduce delays in reaching emergency obstetric care in order to inform its development. We conducted a qualitative study in the Kurdistan region of northern Iraq from May to July, 2018. Using purposive sampling, we carried out 15 semi-structured interviews with coordination actors including healthcare management staff, government health officials, non-government health program managers and ambulance staff. The interviews explored obstetric care delivery, referral processes, mobile phone usage and mHealth implementation strategies. Eleven focus group discussions, which incorporated participatory activities on similar topics, were conducted with ambulance drivers, hospital and primary health center staff. Audio-recorded, transcribed and translated data were coded iteratively to identify emerging concepts, and analyzed thematically. Sixty-eight stakeholders (36 women and 32 men) participated. Challenges regarding the referral system included resource limitations, security concerns, costs and women's reluctance to be transported in male-staffed ambulances. In terms of obstetric care and decision-making, participants noted gaps in communication and coordination of services with the current paper-based system between health care providers, ambulance drivers, and hospital staff. Ambulance drivers reported incurring delays through lack of patient information, poor road conditions, and security issues. A prototype mobile phone application was found to be acceptable based on perceived usefulness to address some of the challenges to safe obstetric care and focused on phone usage, access to information, Global Positioning System (GPS), connectivity, cost, and user-friendliness. However, the feasibility of the innovation was considered in relation to implementation challenges that were identified, including poor connectivity, and digital literacy. Implementation of the app would need to account for the humanitarian context, cultural and gender norms regarding obstetric care, and would require substantial commitment and engagement from policymakers and practitioners.