Developing a contextualized mHealth integrated system for tracking and reporting obstetric violence incidences in Tanzania

Theresia J. Masoi1,*, Stephen M. Kibusi2,a, Lilian Teddy Mselle3,b, Siphael Betuel4,5,c, Abraham Macha4,5,d, Nathanael Sirili6,e

1Department of Clinical Nursing, the University of Dodoma, Dodoma, Tanzania

2Department of Public Health and Community Nursing, the University of Dodoma, Dodoma, Tanzania

3Department of Clinical Nursing, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

4Department of Computer Science and Engineering, the University of Dodoma, Dodoma, Tanzania

5Department of Information Systems and Technology, the University of Dodoma, Dodoma, Tanzania

6Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

*jtheresia2008@yahoo.com

askibusi@gmail.com

bnakutz03@gmail.com

csiphaelbetuel@gmail.com

dagmacha20@gmail.com

ensirili@yahoo.co.uk

Abstract

Background: Obstetric violence, characterized by abuse during pregnancy, childbirth, and after childbirth, is a critical obstacle to maternal health globally especially in low-resource settings. Studies have found that many women have reported experiencing violence. The actual prevalence of obstetric violence is likely underestimated due to cultural norms that often discourage women from speaking out about their negative experiences encountered during pregnancy and childbirth. This study presents the development of a contextualized mobile health (m-Health) system, designed to monitor and report incidences of obstetric violence in the Central Zone of Tanzania.

Methodology: The first phase involved a qualitative study that examined context-specific components of obstetric violence among postnatal mothers, healthcare providers, and key community informants. The components identified from this qualitative study were used to develop the contextualized mHealth system. The contextualized system was designed using the Laravel framework, a robust Model-View-Controller (MVC) PHP framework designed for web application development. MySQL was selected as the relational database management system for data storage. Java was used to implement specific features, while XML was utilized for designing user interface layouts. During the pilot testing, 25 pregnant women and seven health care providers were randomly selected and followed for four weeks in one of the health care facility in Dodoma city. The sampling frame were pregnant women attending the Antenatal visits with the gestation age between 34 and 36 weeks.

Results: Overall, the system successfully captured 17 incidents of obstetric violence during pilot testing phase and sent 128 messages within a four-week period. A notable pattern was lack of supportive care and treatment 6 (35.4%), verbal violence 5(29.5%), lack of autonomy 2(11.8%), stigma and discrimination 1(5.9%), psychological and emotional violence 1(5.9%), Sexual violence 1(5.9%) and lack of privacy 1(5.9%). On the other hand, the system was also able to capture five self-reflection messages from the healthcare providers. Feedback on system functionalities was also received, and improvements were made.

Conclusion: The m-Health system has the potential to empower women and healthcare providers, offering an easily accessible reporting system. By incorporating local languages, and the use of regional technology infrastructure, this mHealth solution can be a significant step towards reducing obstetric violence.

Keywords: mHealth, Obstetric violence, Respectful care, Context-specific, Digital health

Introduction

Obstetric violence (OV) is recognized worldwide as a serious public health issue, with women in numerous countries reporting various forms of mistreatment during pregnancy, childbirth, and postpartum, affecting women's physical and emotional wellbeing. The estimated global prevalence is 59% (1), 44% to 51.5% in Sub-Saharan Africa and and in Tanzania the prevalence ranges between 51.5 and 73.15 (2–5). Obstetric violence includes various abusive behaviors such as physical and verbal abuse, non-consensual medical procedures, lack of confidential and respectful care, discrimination, abandonment, and detention in healthcare facilities. OV is recognized as a violation of women’s human rights (6,7). Studies have shown that many women report experiencing obstetric violence during pregnancy, childbirth and after child birth worldwide , still, the true prevalence is likely underestimated due to social stigma and cultural norms surrounding childbirth that often discourage women from speaking out about their negative experiences out of fear of not being believed or being identified (8,9). Obstetric violence is so normalized that it is not (yet) considered violence against women in most of society and is even the case in some settings in Tanzania, sometimes, society tells women that everything is alright, what is important is that the baby has to come out alive (10) .This cultural context greatly contributes to the underreporting of obstetric violence, highlighting a gap between the reported experiences and the actual occurrences (11) .Additionally, most studies have primarily involved women who have given birth, with little research focusing on healthcare providers’ perspectives or systemic factors that contribute to underreporting (12).The lack of scientific investigation into these areas suggests that obstetric violence may be more widespread than currently documented.

In response to this gap, the World Health Organization (WHO) and other international organizations have called for more robust and localized solutions that empower women by ensuring accountability and improving the quality of maternal health services(13,14).Evidence increasingly demonstrates the effectiveness of mobile health services in supporting conventional healthcare, particularly among underserved communities where mobile health technologies (mHealth) can facilitate the collection of high-quality data and enhance reporting processes (15).

Mobile health (mHealth) technologies, particularly in sub-Saharan Africa, offer a promising platform for addressing these challenges. mHealth systems have demonstrated success in improving healthcare delivery, monitoring health outcomes, and providing individualized care, making them an ideal vehicle for tackling and reporting obstetric violence, as well as for education and monitoring purposes (11,16).

Several mobile health initiatives have been designed to support and address maternal health, including national SMS programs such as South Africa’s MomConnect, targeted mHealth education and reminder apps in India and Uganda (Mobile for Mothers , MatHealth ). Others includes; Community health worker support systems like Rapid SMS in Rwanda , Interactive mHealth application system in Tanzania for improving antenatal care service utilization, all of which have demonstrated improved maternal health knowledge, service utilization, or care practices in maternal and newborn (16–19) , but few have specifically targeted the reporting and prevention of obstetric violence . By considering this gap, this study aimed to describe the development process of a contextualized mobile health (mHealth) system designed to track and report incidents of obstetric violence among women and health care providers. The main goal was to design a user-friendly and confidential mobile application that considers local languages, context-specific, and the technological infrastructure.

Methods

Phase 1: Obtaining the contextual components of obstetric violence

The methods and findings presented in this section are drawn from a previously published study that described the process of developing and validating the context specific components of obstetric violence (20).The study employed insight obtained from in-depth interviews , key informant interviews , group discussions with postnatal mothers, healthcare providers and key community informants (religious leaders ,ten-cell leaders , traditional birth attendants, and male partners) in two regions of the Central Zone of Tanzania . The gathered and validated context specific obstetric components included; physical violence, lack of supportive care and treatment, subjugation care, unfavourable care environment, sexual violence, verbal violence, emotional and psychological violence. Detailed methods and findings for this phase have been reported in (20) https://doi.org/10.1371/journal.pone.0326362.The contextual components of obstetric violence gathered from the previous study were then integrated into the mHealth system development in the current study as educational materials. This phase was included in the current study to provide background and rationale for the subsequent development of the mHealth integrated system.

Phase 2: Contextualized mHealth integrated system design and development

Aim: To develop a contextualized mobile health application system that allows women to anonymously report instances of obstetric violence and providers to do self-reflection of their practices by considering local language, social and cultural norms.

The implementation site

The contextualized mHealth integrated system was developed by experts from the College of Informatics and Virtue Education at the University of Dodoma , Tanzania. The intervention is being implemented in one of the health facilities in Dodoma Municipal Council, one among the seven districts of the Dodoma Region, the Capital city of Tanzania (21), with approximately 25,484 deliveries annually (22). According to the 2022 Tanzania National census, the population of Dodoma Municipal council was 765,179, covering an area of 2,607 km² (23). It has a good number of women delivering at home, with one of the reasons being fear of mistreatment from health care providers (24). Within the Municipality, there are three major public health facilities: one Health Center, which serves as the main antenatal care facility; one Regional referral hospital; and one zonal referral hospital, the highest level of referral hospital in the region.

Contextualize mobile health application system design and monitoring

The contextualized m-Health system was developed using the Laravel framework, a robust Model-View-Controller (MVC) PHP framework designed for building web applications (25,26). Laravel facilitated rapid development by providing a structured environment and built-in functionalities that streamline common tasks such as routing, authentication, and database management (27). For data storage, MySQL was chosen as the relational database management system (28–30), allowing for the efficient organization and retrieval of user data, health records, and application information.

In terms of programming languages, Java was used to implement specific features within the Android application (SMS Gateway) (31), while XML was employed for designing user interface layouts on Android (32). This combination of technologies ensured that the mobile application not only functioned well but also offered a visually appealing user experience. The development process was supported by two Integrated Development Environments (IDEs): Visual Studio Code (33), which was used for writing and managing code across various components, and Android Studio (34), which provided specialized tools for Android development, including debugging and testing capabilities. To ensure the quality and reliability of the application, several testing tools were integrated into the development process. JUnit (35)was used for unit testing Java code, while the Flutter Testing Framework (36) facilitated comprehensive testing of the mobile application, as illustrated in Fig. 1.

Figure 1: Architectural design

Anonymous Reporting: This feature allows pregnant mothers to report incidents of obstetric violence anonymously, ensuring their privacy and safety. They can easily submit reports through Short Message Service (SMS) using their mobile phones, allowing them to communicate their experiences without fear of being identified.

Self-Reflection: This feature enables healthcare providers to effectively evaluate their practices. They can report their daily activities and reflections by sending messages using their mobile phones, facilitating self-assessment and promoting continuous improvement in their care delivery.

SMS Gateway: This feature provides SMS notifications for users without smartphones, allowing all pregnant mothers and healthcare providers to report obstetric violence anonymously while also receiving important reminders and educational messages. This approach ensures effective two-way communication and enhances accessibility for everyone, regardless of his or her technological access.

The report feature enables researchers to create a range of significant documents, including obstetric violence reports, self-reflection reports, etc. Obstetric violence reports provide critical data on the occurrence and nature of incidents, helping to identify trends and areas for intervention. Self-reflection reports summarize healthcare providers’ assessments of their practices, offering insights into their perceptions and experiences.

Final look of the system after the design and development process

After completing system development, the final application features a comprehensive dashboard, a dedicated section for mothers, and a record of maternal histories, among others. Users can easily navigate to health facilities and access relevant information tailored to their needs. Each feature is designed for intuitive use, ensuring a seamless experience. The dashboard provides summaries of the data collected (Fig. 2).

Figure 2: Final look of the system

Dashboard Access: Researchers can access a centralized dashboard that offers a summary of registered pregnant mothers, healthcare providers, and health facilities. This feature also provides insights into the total messages sent to and received from pregnant mothers and healthcare providers.

Mothers and mothers' histories: This feature offers a dedicated space for recording and storing mothers' details and health histories. It ensures that all relevant information is organized and easily accessible. By maintaining comprehensive records, researchers can track important data about pregnant mothers, including incidents of violence, the time and day when these incidents occurred, and the frequency of such acts.

Received messages: This feature enables researchers to view and manage messages received from pregnant mothers and healthcare providers. It plays a crucial role in tracking incidences of obstetric violence against pregnant mothers. By analyzing these messages, researchers can identify patterns and trends related to maternal safety.

Self-reflection: This feature enables researchers to access self-reflection messages submitted by healthcare providers. It provides valuable insights into the experiences and perceptions of providers in their interactions with pregnant mothers. By analyzing these messages, researchers can identify areas for improvement in care delivery to improve the quality of care.

Evaluation reports: This feature allows pregnant mothers and healthcare providers to evaluate the system and the messages received (the entire implementation process), as illustrated in Fig. 3. These examples of pilot testing feedback were used to improve the system before the actual implementation began. The system generates comprehensive evaluation reports that analyze the effectiveness of communications and user engagement. By identifying strengths and areas for improvement, researchers can ensure the system effectively meets the needs of its users.

Figure 3: Examples of the evaluation features

Design and quality check of the SMS

The messages sent to pregnant mothers and healthcare providers were carefully crafted to ensure clarity and understanding. Clear and straightforward language (Swahili) was used to make the content accessible to everyone. This approach enables effective communication of important information and instructions.

On the other hand, educational messages were designed to be brief, short, and direct, typically limited to 160 characters per SMS. This approach ensures that essential information is communicated quickly and effectively. Additionally, the tone, style, and terminology were carefully maintained across all messages to ensure consistency. This uniformity helps create a recognizable voice for the communication. By adhering to the same standards, we enhance clarity and user understanding. Thorough proofreading was conducted on all SMS to eliminate any grammatical errors, typos, or misleading information that could confuse users.

Before sending messages to pregnant mothers and healthcare providers, thorough testing was conducted to confirm that messages are sent and received as intended. This process included verifying delivery times and identifying any technical issues with the SMS gateway. By ensuring reliability, we enhance the effectiveness of our communication.

Confidential reporting

The system is designed to allow women and providers to report incidents of obstetric violence anonymously and receive feedback immediately. It is an interactive system/a two-way communication system

Training of system users

Healthcare providers enrolled in the system received training on its use over four consecutive days. Additionally, pregnant women are also being trained about the system and what is required from them when they registered. Two research assistants were also oriented to different system functionalities, as they are the ones who will be used as the help desk in responding to queries received from pregnant women and health care providers. The system is now available at; https://oviolence.comhic.website

Phase 3: Pilot testing and system refinement

The system was piloted with 25 pregnant women and seven healthcare providers over four weeks. Women and providers were encouraged to report any incidents of obstetric violence they experienced during pregnancy, during childbirth, and postpartum, aiming to test the system's functionality and response to sent and received messages. Additionally, the pilot collected feedback on system usability and clarity of language. The system's security features were also evaluated to ensure user confidentiality and data protection. Providers were asked to reflect on their practices and report them to the system. The feedback from the pilot testing was used to improve the overall functionality of the system. More data that are substantial will be generated during the subsequent implementation phase involving large sample size, which will be reported separately.

Study population, participants recruitment and sample size

Participants for the pilot testing were recruited in January 2025, and followed for four weeks in one of the health care facility in Dodoma city. Pregnant women were randomly selected by systematic approach, in which every third pregnant woman among those who met the inclusion criteria and consented to participate in the study was selected. The sampling frame were pregnant women attending the antenatal care (ANC) visits with the gestation age between 34 and 36 weeks. Other eligibility criteria included: receiving antenatal care and planning to deliver at the study health facility, owning and have regular access to a mobile phone. Women who were severely ill or unable to provide informed consent were excluded. Written informed consent was obtained, and recruitment continued until 25 women were enrolled into a contextualized m-Health system. A sample size of 25 pregnant women was in line with common practice in pilot and feasibility, studies of digital health interventions and methodological guidance in the mHealth intervention, that suggest a sample size between 8–90 participants can be adequate for assessing feasibility and usability (37,38). As for this pilot testing stage, a sample of 25 pregnant women was considered appropriate to assess feasibility, usability, and functionality of the contextualized mHealth system and allows basic descriptive analysis and system refinement prior to actual implementation with the large sample. In addition, seven health care providers working in maternity units in the selected health facility were also enrolled to the system for them to do a self-reflection of their practices

Data collection tool

During the pilot testing, a semi structured interview guide (the evaluation feature in the system) was used to gather feedback on system functionality, usability, and other relevant parameters from both pregnant women and healthcare providers. Data regarding obstetric violence incidences were reported direct to the system by pregnant women and health care providers. The English version of the interview guide is provided as supplementary file (Supplementary File 1)

Data analysis

The data collected to the system was exported into different formats such as spreadsheets and comma separated values (CSV) .The mHealth system automatically converted the data into these formats ready to be analysed using SPSS version 29.0. Before conducting the analysis, the error checking, completeness, and accuracy of data (data cleaning) was performed by using Frequency distribution tables to ensure the overall accuracy of data. Descriptive analysis was employed to determine the frequencies and percentages of reported incidences and their types. Data on the system functionality were collected through a feature called “Evaluation” .The purpose of these feature was to capture user feedback after interacting with the system.

Risk mitigation and safety procedures

Given the sensitive nature of obstetric violence reporting, specific measures are incorporated to mitigate potential risks to participants. The mHealth system is designed as a reporting and documentation tool .Participants who reported severe forms of obstetric violence are being provided with in-app messages and guidance encouraging them to seek immediate assistance from health facility staff, trusted family members, or available local support services. Contact information from the research team was shared to participants at enrollment in case of emergency. During the pilot phase, the research team periodically reviewed submitted reports. If a report suggested a potential risk of imminent harm, predefined ethical protocols were followed, including referral to appropriate health or support services (Social welfare workers), in line with institutional ethical approval and national guidelines for research involving violence against women. Participants are being prioritize while maintaining privacy and confidentiality of the shared information.

Pilot testing results

Social demographic and Obstetric characteristics of the participants

Twenty five pregnant women were recruited and participated in the pilot testing. The mean age of respondents in the entire sample was 26.8 years. The most prominent age group, 15 (60%), ranged from 20 to 34 years. Additionally, most of the participants 12(48%) were pet traders. This study also explored obstetric characteristics among pregnant women. As indicated in table 1, out of 25 pregnant women, 12(48%) were primigravida (first pregnancy), and the majority, 17(68%), started their first antenatal contact at 13–26 weeks (Table 1).

Table 1: Demographic and obstetric characteristics of the pregnant women (N = 25)

Variable	Frequency (n)	Percentage (%)
Age (Year)
Mean age 26.48 Years
< 20	2	8
20–34	15	60
≥ 35	8	32
Education level
No formal education	3	12
Primary Education	7	28
Secondary Education	9	36
College/University level	6	24
Occupation
Peasant/farmer	5	20
Pet trader	12	48
Housewife	5	20
Government employee	2	8
Private sector employee	1	4
Marital Status
Not married	8	32
Married	14	56
Cohabiting	3	12
Health insurance use
Yes	2	8
No	23	92
Gravidity
1	12	48
2–4	8	32
≥ 5	5	20
Parity
0	12	48
1	6	24
2–4	3	12
≥ 5	4	16
Gestation age at first visit in weeks
1–12 weeks	7	28
13–26 weeks	17	68
27–40 weeks	1	4
Total	25	100

Health care providers' characteristics

In the pilot-testing phase, seven (7) health care providers participated. Their profession, work unitand level of experience were diverse. The majority of the participants were midwives, which was 57.1% of the sample (n = 4). Two (28.6%) participants were medical doctors, and one was a medical student, accounting for 14.3% (n = 1). Participants were drawn from three units, and majority of them 57.1% (n = 4), were from the labor ward (Table 2).

Table 2: Health care providers characteristics N = 7

Variable	Frequency (n)	Percentage (%)
Health care providers category
Midwives	4	57.1
Medical Doctor	2	28.6
Medical students	1	14.3
Working units
RCH	2	28.6
LW	4	57.1
Postnatal	1	14.3
Years of working experience
1–4 years	2	28.6
5–9 years	2	28.6
≥ 10	3	42.8
Total	7	100

Feedback on the system functionality

Overall, during pilot testing, the system was able to send 128 SMS within four weeks

Tracking the incidents

25 pregnant women were registered in the system. The system was able to track 17 incidences of obstetric violence reported by pregnant women. A notable pattern was lack of supportive care and treatment 6 (35.4%) example providers being busy with their phones and ignoring their concern, verbal violence 5(29.5%), lack of autonomy 2(11.8%), stigma and discrimination 1(5.9%) and psychological and emotional violence 1(5.9%), Sexual violence 1(5.9%) and lack of privacy 1(5.9%). . The most involved units were the labor ward and the Reproductive and Child Health clinics (RCH), additionally, the system was able to track two concerns from pregnant women that were not related to obstetric violence, and some were appreciative of the health education they received from the system. The remaining 2 (8%) of the pregnant women did not submit any response to the system.

On the other hand, the system was also able to pick five self-reflection messages from the health care providers, and the main issues tracked were verbal violence, as providers reported that women sometimes do not follow their instructions (Table 3).

Table 3: Acts of obstetric violence reported to the system by pregnant women on pilot test

Violence category	n	%
Lack of Supportive care and treatment	6	35.4
Verbal violence	5	29.5
Lack of freedom/autonomy (subjugation care)	2	11.5
Stigma and discrimination (Psychological/emotional violence)	1	5.9
Psychological/emotional violence	1	5.9
Sexual violence	1	5.9
Lack of privacy and confidentiality (unfavorable care environment)	1	5.9
Total	17	100

Evaluation of the contextualized m-health system functionality

The system also captured feedback on its functionality and received suggestions on areas that needed improvement. A total of 21 (84%) women reported to the system that they felt their privacy was protected. However, this was a bit different from providers who were much worried about the information they provided, as they might risk their jobs despite the assurance given to them during training about the system being anonymous. Feedback was also received on the length of the messages sent, the language used, and the frequency of the messages sent per week, all of which were used to improve the system functionality as suggested.

Discussion

Mobile health technologies have emerged as a powerful tool in improving the quality of healthcare. Creating a contextualized mHealth integrated system to track and report obstetric violence tackles an important public health and human rights concern.

The goal of this study was to develop a culture and user friendly mHealth system that enables both women and providers to report incidences of obstetric violence in real time and anonymously .These insights have been also reported in other studies (39,40) that indicated such a system could improve accountability, foster respectful maternity care, and further inform policy and practice interventions as women may document their experiences without any fear of being known and be able to voice their concern .

Additionally, the development of contextualized mHealth systems may enable healthcare providers to receive feedback on their practices, which can help improve the way they interact with their clients. This insight aligns with findings from other studies which also emphasized the importance of improving communication between clients and health care providers (40,41) .

One significant understanding that emerged during the design and development phase is the value of cultural context in contextualizing components of obstetric violence. Interaction with local stakeholders, who shared their perspectives on obstetric violence, was instrumental in designing and developing a reporting tool that takes into account local culture, language, and communication patterns. The value of community and stakeholder engagement have also been identified in other studies as critical across various contexts and an integral part of most research (42,43). This approach not only facilitated better engagement but also may enhance trust and acceptance of the mHealth system, which is crucial for sensitive matters such as obstetric violence (43).

In terms of technical design and development, the system caters to all socioeconomic groups, not just smartphone users as such the integration of an SMS reporting feature allows individuals with basic phones to utilize the system as well. Although smartphone usage is on the rise in Tanzania, a large segment of the population still uses basic phones with simple technologies. The combination of SMS mobile applications, and web interfaces broadens the user base, which helps minimize digital marginalization. Different studies have also emphasized the issue of information access to all individuals and reducing the “digital divide” (44)

During the pilot testing, both the benefits and the challenges of the system were revealed. On the positive side, health workers demonstrated the readiness to use the system for self-reflection and in reporting acts of obstetric violence.

Pregnant women also provided feedback on system functionality. They suggested some issues and features that need improvement, such as the length of the sent SMS and adding more features to health education packages that cover other aspects of maternal health, not just obstetric violence.

Both women and healthcare providers had concerns regarding possible retaliation and confidentiality breaches of their information sent to the system, particularly during the development and design processes. The anonymity of the sender and the care taken to protect the information were carefully considered. Baihan Lin also emphasized a similar insight through the privacy gradient model, highlighting the potential of mHealth systems to enhance patient engagement, improve care coordination, and accelerate medical research while safeguarding individual privacy rights (45). This indicates the need for strong data protection assurance for system users, which has been taken very seriously during the development process.

Training refreshers and community awareness were identified as critical components for long term effectiveness and sustainability of the system. These findings are also supported by principles of designing health information systems, especially on the issue of flexibility and the importance of receiving feedback from key actors of the system, as it has been done in the current system (46)

Strengths and limitations

Obstetric violence is a major public health issue in Tanzania and many other areas. By developing a system to track and report these incidents, it may help to raise awareness and promote accountability among healthcare providers and the broader community.

The study give women a platform to report obstetric violence incidents and voice out their concern without fear of being known . Increased support for women's rights in maternal healthcare settings may result from this empowerment. Real time data collection and reporting may be possible by integrating mobile health (mHealth) technology. This can enhance healthcare systems' ability to respond to violent incidents, enabling faster and more effective interventions.

The study emphasizes contextualizing the system to ensure that it respects cultural, social, and economic aspects in Tanzania. This localized approach might increase the likelihood of community acceptance and effective implementation. The data collected through this system can provide valuable insights into the prevalence and types of obstetric violence occurring in Tanzania. This information can inform policy changes and improve the quality of care.

Although mHealth has considerable potential, technical obstacles may prevent the system from being used effectively, such as limited electricity or internet access. There may be resistance from some healthcare providers who may feel threatened by being monitored or reported on their practices. This could affect their willingness to cooperate with the system or engage positively with clients. This has been taken into consideration by ensuring the sender of the information remains anonymous. Ensuring its sustainability, the system requires ongoing funding, training, and support from local authorities and stakeholders. Without this, scaling up the system usage might be challenging.

Conclusion

The development and piloting of the implementation of the contextualized mHealth system for tracking and reporting obstetric violence in Tanzania’s Central Zone might be a significant step toward improving maternal healthcare and women’s rights. The pilot testing results showed that the system could be feasible to be implemented in the Tanzanian context.

The pilot testing also demonstrated that mothers prefer the system to integrate other aspects of maternal health especially in education, such as education on danger signs, birth preparedness, instead of focusing only on obstetric violence. Healthcare providers also emphasized the importance of addressing issues of privacy and anonymity.

This system can provide a unique, context-sensitive solution to a persistent issue in maternal health, with the potential to drive broader systemic change.

This initiative has the potential to have implications not only for improving maternal health outcomes but also for fostering systemic change within healthcare delivery.More importantly, contextualizing this system was necessary to ensure its compatibility with the cultural, social, and economic situation in the Central Zone. The involvement of local stakeholders was crucial in ensuring that the system was user-friendly and culturally relevant.

Training programs should be continuously introduced to enable users to utilize the technology effectively. Evaluation and feedback mechanisms should be further improved to assess the effectiveness of the mHealth integrated system on an ongoing basis, allowing for adjustments based on user experience and emerging community needs.

Future steps focus on scaling up the system, addressing infrastructural challenges, and providing continuous education to healthcare providers, women, and the broader community. In addition, understanding how educational level relates to digital access is important for assessing the scalability and broader implementation of mHealth interventions that future studies should take into consideration and include larger and more diverse samples to examine digital access disparities and their implications for intervention success.

Abbreviations

ANC: Antenatal care

IDEs: Integrated development environments

mHealth: Mobile health

MUHAS: Muhimbili university of health and allied sciences

MVC: Model-view-controller

OV: Obstetric violence

SMS -Short message service

SQL- Structured query language

UDOM: University of dodoma

WHO: World Health Organization

XML: Extensible markup language

Acknowledgements

Heartfelt thanks to the University of Dodoma for providing support to conduct this study, Muhimbili University for providing ethical approval, local administrative leaders at all levels, research assistants, and all the research participants

Author contributions

T. J. M: Conceptualization, Data collection, Formal analysis, Methodology, Resources, Writing – original draft, Writing – review & editing. S. M. K: Conceptualization, Methodology, Supervision, Writing – review & editing. N. S: Conceptualization, Methodology, Supervision, Writing – review & editing. L. T. M: Conceptualization, Methodology, Supervision, Writing – review & editing. S.B: Methodology, Writing – review. A.M: Methodology, Writing – review

Funding

The first author received some support from the University of Dodoma to support her doctoral studies. However, the funder had no role in the study design, data collection, data analysis, or manuscript writing and publication.

Data availability

The datasets used and analyzed in this study are available from the corresponding author upon request.

Ethical approval and consent to participate

Ethical approval of this study was obtained from the Senate Research and Ethics Committee of the Muhimbili University of Health and Allied Sciences in Tanzania with the reference number (DA. 282/298/01.C/1758). Permission for data collection was obtained from the Ministry of Health, the Ministry responsible for local government, regional and district authorities, Heads of health facilities, and community leaders. Written informed consent was obtained individually from each study participant before the commencement of the interview or the discussion. The objective and importance of the study were explained to participants in both the data collection and validation processes, as well as during pilot testing. Participants were encouraged to communicate freely, as their information would only be used for research purposes. They were further informed that their participation was purely voluntary and they could withdraw from the interview or study at any time they wished to do so. Confidentiality of the information shared was also ensured .

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing financial interests or personal relationships that could have influenced this work.

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