Int Public Health J 2017;9(2):145-151
© Nova Science Publishers, Inc.
Mommy: A maternal health surveillance system
Julia CA Chaves1,*, Enrique Cifuentes2,
PhD, and Alessandra A Macedo1, PhD
1 Maternal mortality is a global public health challenge, with
Department of Computer Science and Mathematics,
University of Sao Paulo, Sao Paulo, Brazil
2 pregnancy outcomes reflect a cycle of vulnerability to risk
Department of Environmental Health,
Harvard TH Chan School of Public Health,
Boston, Massachusetts, USA
*
Correspondence: Julia Carmona Almeida Chaves, University
of Sao Paulo, Department of Computer Science and
Mathematics, School of Medicine of Ribeirao Preto, Av
Bandeirantes, 3900, Ribeirão Preto, São Paulo, Brazil.
E-mail: juhhcarmona@gmail.com
ISSN: 1947-4989
Abstract
99% of deaths occurring in developing countries. Poor
factors, most of which can be prevented. We propose the
creation of an electronic system (‘Mommy’) that will assist
and monitor the health of pregnant women, minimize their
exposure to risk factors and break the cycle of maternal
mortality. We predict that implementation and widespread
use of Mommy may lead to healthier pregnancies and
reduce the number of both maternal and neonatal deaths.
This project will help to break the cycle and reach the
Sustainable Development Goal 2030 of reducing maternal
mortality and improving infants’ health.
Keywords: Maternal health, surveillance, mobile
application
Introduction
Maternal mortality is defined as the death of a woman
during pregnancy or in the first year after delivery.
The World Health Organization (WHO) estimated
that 830 women die every day from preventable
causes related to pregnancy and childbirth, with 99%
of all maternal deaths occurring in developing
countries, and predominantly among young women
from low-income populations. The high rate of
maternal deaths reflects the social determinants
of health (e.g., race, income, education, physical
environment, among other characteristics) and
highlights the health gap between rich and poor (1, 2).
Pregnancy is a vulnerable period for both mother
and fetus, and many factors can increase their risk
(3-6). These factors can be divided into five
categories (7): 1) Preexisting health conditions;
2) Age; 3) Life style; 4) Pregnancy conditions and
5) Environmental risks (8-9).
With advances in technology, it has become
useful to apply existing resources to improve health
146 Julia CA Chaves, Enrique Cifuentes, and Alessandra A Macedo
and well-being. To this end, the term mHealth
(mobile health) was created. mHealth is a general
term for the use of mobile phones and other wireless
technology in medical care (2). The most common
application of mHealth is the use of mobile phones
and communication devices to inform users about
preventive health care services anywhere in the world.
Through smartphone technology, mHealth intends to
change the face of modern medical assistance,
creating mobile systems that collect and analyze data
and interact with people.
The risks on the gestational period can be reduced
and neonatal outcomes can be improved when the
appropriate preventive measures are taken.
Smartphone technology can be used as a preventive
and efficient method that can be easily harnessed and
implemented and it is also practical for women in
childbearing age.
Objectives
To develop a computational system to monitor and
assist pregnant women to prevent or minimize their
exposure to environmental risk factors that can be
harmful to themselves and/or their children.
Hypotheses
The technology of smartphones can be harnessed to
prevent complications during pregnancy, and decrease
maternal and neonatal death rates. This modern tool
will allow improved patient monitoring, more
personalized care and increase physician and patient
satisfaction.
Contextualization
Maternal mortality is one of the major health
problems in Brazil and other developing countries
(10). The direct causes of maternal mortality are
hemorrhage, sepsis, hypertensive disorders, unsafe
abortion, and prolonged and/or obstructed labor (11).
The indirect causes of maternal death are related to
poor health before pregnancy, or diseases that women
develop during pregnancy (12). Virtually, all the
direct causes are treatable and can be prevented
if women receive appropriate prenatal care.
Furthermore, some factors (sepsis, unsafe abortion,
hypertensive disorders) are clearly and directly related
to the social determinants of health (SDH).
The Pan American Health Organization (PAHO)
evaluated the maternal mortality ratio (MMR) in the
Americas: the MMR fluctuated from 5.9/100,000 live
births in Canada to 690/100,000 live births in Haiti,
illustrating the extreme socioeconomic inequality in
the region. In Brazil, the MMR has been reduced in
the last 18 years from 120/100,000 live births in 1990,
64/100,000 live births in 2005 to 58/100,000 live
births in 2008, but the rate did not reach the expected
threshold defined by the United Nations (10).
According to the fifth Millennium Development Goal,
the annual reduction for MMR in Brazil should have
been 5.5%, but it was only 4% (9-10).
Neonatal mortality is frequently used as an
indicator of quality of life and well-being of a
population (13-15). Mortality on the first days of
life reflects the complex relationship between
biological, socioeconomic and welfare factors where
socioeconomic and welfare factors are strongly
related to the care provided to pregnant women and
the newborn (16, 17). Neonatal mortality rates in
developing countries remain alarming: in Bolivia
there are 37.49 deaths per 1,000 live births (2), in
Africa there are 55 deaths per 1,000 live births, and in
Brazil the ratio is 13.82 deaths per 1,000 live births
(16). The major causes of neonatal mortality are
related to diseases during pregnancy and childbirth:
mainly preterm birth, low birth weight, respiratory
and infectious diseases, and congenital malformations
(9). Neonatal mortality is inextricably connected with
maternal health conditions (18). The risk factors of
pregnancy can be divided into five categories (7):
 Pre-existing health conditions: These are
conditions that are present before women
become pregnant, for example diabetes and
obesity.
 Age: Pregnant teenagers have higher
probability of developing high blood
pressure, anemia, and are more likely to
deliver prematurely. Also, teenagers are less
likely to access pre-natal care and do not
always understand the risks of pregnancy.
 Mommy
Women who have their first child after
35 years of age usually have a normal
pregnancy, however they have a higher risk
to have a caesarean section, to have
complications in childbirth, and their child
have higher risk of having genetic conditions,
such as Down syndrome.
 Life style: Pregnant women who consume
alcohol have a higher risk of premature birth,
and infants with Fetal Alcohol Syndrome.
Women who smoke during pregnancy also
put their fetuses at risk of premature birth,
genetic abnormality, and sudden death
syndrome. Passive smoking or ‘second hand
smoke’ also increases the risk of health
problems in both fetus and mother.
 Pregnancy conditions: Multiple pregnancies
(i.e., twins, triplets, or more) increase the risk
of premature birth and frequently require
cesarean section. Infants from multiple
pregnancies, in general, are smaller and more
likely to be premature than singletons. Also,
premature infants are more likely to have
respiratory distress with associated increase
in morbidity and mortality.
Figure 1. International cycle of environmental health disparities (23).
147
 Environmental risk factors: Environmental
exposures as, for example: air pollution and
pesticides may cause premature birth, low
birth weight, and congenital malformations.
These babies have a higher risk of dying,
and those who survive have higher risk for
brain, respiratory and digestive disorders.
Environmental exposure is also related to the
development of heart diseases and diabetes in
adulthood (8-9).
According to the World Health Organization,
maternal deaths significantly reflect social
determinants of health, limited access to adequate
health care and lack of timely information (1).
Neonatal mortality reflects complex relationship
between environment, genes, socioeconomic status,
access to health services, and maternal literacy status.
Neonatal mortality can thus be prevented by stronger
public health policy targeting antenatal and immediate
postnatal care (19-22).
Figure 1 shows the cycle of environmental health
disparities. This project focuses on to prevent the
health risk factors and consequently to break this
cycle by offering the pregnant women information,
and a facilitated contact with the physician.
148 Julia CA Chaves, Enrique Cifuentes, and Alessandra A Macedo
Related work
Many mHealth systems are currently in use, and those
focusing on improving maternal and neonatal health
have been well received (23). “Wired mothers” is an
mHealth application that combines communication,
education on pregnancy, reminders of antenatal care
visits, and an emergency medical response system,
and has been demonstrated to decrease perinatal
mortality rate by 50% (23). “mMamee” is another
mHealth application that does monitor and assess
environmental exposures that could potentially affect
the health of pregnant women (24). The platform
relies on the combination of user descriptive input and
urban sensing measurements. Their goal is to
determine the long-term impact of various exposure
factors on maternal and fetal health (24).
A study conducted by Sondaal et al., assessed the
effect of mHealth interventions in improving maternal
and neonatal care in low- and middle-income
countries; the studies, however, have not reviewed
used the sensors of the smartphone to obtain
environmental data to allow preventive alerts (23).
Mommy is an innovative approach among
mHealth applications in that it will use the full
Figure 2. Mommy’s architecture.
Pregnant women will register with an email
address and password. After that, they will be asked
to input some additional information about the
pregnancy such as:
 Stage: How many weeks of gestation have
passed since last period?
capacity of the smartphone by incorporating an
environmental sensor to create a more effective
prevention tool.
Mommy architecture
The architecture of the system is shown in Figure 2.
The system will have: 1) a mobile application that
will be installed on the smartphones of pregnant
women; 2) a web system that will be used by the
health professional providing prenatal care; 3) a
central system that will be responsible to process the
information.
The smartphone of the pregnant woman will be
the interaction interface of the system: 1) It will
collect the environmental data 2) send it to the central
system 3) which will process and store the data 4).
After processing the data, the system will send alerts
and tips to the woman [5 and 6], and include the
crucial information into the health professional report
[7]. This report can be visualized through the web
interface [8].
 “Twins information”: How many fetuses is
the pregnant carrying, i.e., is it a single fetus
or multiple fetus pregnancy?
 Weight: Information about weight gain
during pregnancy.
 Symptoms: There will be a list of common
pregnancy symptoms that the patient will be
 Mommy
prompted to check. There will be also an
option to add additional symptoms.
 General well-being: The patient will be
prompted to enter information on how she
is feeling about sleep quality, mobility,
appetite, and other factors during the
pregnancy, using a five-star rating bar.
Shortly after registering, the system will invite
her to fill in information about her medical
information on conditions, such as personal medical
history, family medical history, pregnancy history,
and health habits (smoking, alcohol drinking, physical
activity) to allow more accurate alerts.
The doctor’s report will store the health related
information including data such as medications,
vaccines, high-risk travel, and physical activity. The
doctor’s report is crucial for better results, but the
pregnant woman will have control over who can
access her data. This is especially important for the
empowerment of the patient.
The system will provide reliable information
throughout pregnancy as the fetus develops. Mommy
will also allow the pregnant woman to submit
questions and concerns to health professionals. The
system will provide instructions to help her recognize
signs and symptoms that require further evaluation. A
communication channel with the doctor will be
available for emergencies.
Other proposed functionalities are the tracking of
medication use, and the monitoring of sleep, physical
activity, and fluid intake. Tips regarding healthy diet
will also be included in the system. The location
tracker is fundamental. The women will be alerted if
they plan to travel to high risk areas, such as those
with high pollution levels or areas with reported cases
of Zika.
A prototype of the system was implemented and
the Medication Tracker functionality was developed
which manages medications that the pregnant woman
is taking. Moreover, it reminds her when she needs to
take another dose of medication, and it will alert her if
the medication that she is taking is not deemed safe
during pregnancy.
Although Mommy has been partially developed,
it has not yet been tested, and, consequently, has not
been released for general use. It was developed to test
the system at the Hospital das Clinicas at Ribeirao
149
Preto, Brazil. The technology is currently being
elaborated along with the development of new
functionalities. This is a work in progress.
Discussion
mHealth interventions have been developed to
improve maternal health, antenatal and postnatal
clinic attendance, improved vaccination rates, and
delivery at staffed facilities (23). These interventions,
however, have shown little impact on maternal and
neonatal health outcome (23). However, as shown by
Sondaal et al., none of the methods utilized to develop
mHealth applications used the environmental data of
the pregnant women to access daily risks. In addition,
none of the applications reviewed by the study put
together all the functionalities that Mommy proposes.
Mommy intends to access and process the
environmental data and send alerts to allow the
woman to make changes on her daily habits. There
will be also incentive messages seeking to motivate
the pregnant women to improve their health habits,
making use of multivariate visualization tools to make
it easier to understand what the most important
aspects are that need to be improved. Furthermore, the
system has the potential to be a valuable surveillance
tool for doctors in that they can monitor the status of
their patients through the electronic reports that will
be generated.
The next step of the system development is the
medication tracker functionality which will be
evaluated and a ‘first version’ will be released to
users. Also, new functionalities of Mommy, such as
the physical activity tracker will also be developed.
Mommy has the potential to be a functioning
health care application that even low- and middle-
income populations can access. Technology is
becoming more accessible and smartphones are
becoming cheaper. There are more than 281 million
mobile phones in Brazil, with about three
smartphones for each ten people (25). With a
population of 200 million, the number of cellphones
exceeds the number of people in the country (26),
while the number of doctors is not enough; there are
on average only 1.95 doctors per thousand inhabitants
with an uneven distribution favoring more urban
affluent areas where there are 2-4 doctors per
150 Julia CA Chaves, Enrique Cifuentes, and Alessandra A Macedo
thousand inhabitants while in the poorer areas there
are less than 1 per thousand, which is comparable to
the poorest countries in Africa (27). This scenario
argues for the potential of Mommy in Brazil
particularly for the people living in low resource
areas.
By helping to change the mother’s habits that can
be harmful to her health and her child’s health and
improve her quality of life, we expect to break the
cycle of environmental health disparities (see Figure
1) and contribute directly to a better maternal and
neonatal health outcome.
Acknowledgment
We thank Dr. Ligia Marcola, Neonatologist at Santa
Casa de Limeira who provided insight and expertise
that greatly assisted the research, and the Break the
Cycle Team for comments that greatly improved the
project.
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Submitted: July 18, 2016. Revised: August 20, 2016.
Accepted: September 02, 2016.
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Further reproduction prohibited without permission.