Using SMS and Interactive Voice Response to strengthen continuity of care for planned cesarean delivery in Uganda

<title>Abstract</title> <p> Background Planned pre-labor cesarean delivery for high-risk pregnancies is rare in sub-Saharan Africa, where up to 90% of cesareans are performed emergently with high risks of adverse outcomes. Improving the number of planned pre-labor cesareans requires attention to antenatal-intrapartum continuity of care. We developed an mHealth intervention using SMS and Interactive Voice Response (IVR) to support birth preparedness for planned cesarean delivery among high-risk pregnant women in Uganda. Methods We conducted a prospective pilot study at Mbarara Regional Referral Hospital, Uganda, among pregnant women (≥ 28 to &lt; 39 weeks' gestation) with antenatal indications for pre-labor cesarean. Participants received educational SMS and IVR messages at 14, 7, and 2 days before their scheduled cesarean, covering delivery timing, danger signs, logistical planning, and perioperative preparation. Feasibility was assessed through platform-confirmed message delivery, self-reported receipt, and IVR call duration. Acceptability was assessed via a post-delivery survey capturing preferences, comprehension, and satisfaction. Descriptive statistics summarized outcomes; feasibility and acceptability were compared by digital access adequacy. Results Seventy-one women were enrolled between June 2024 and February 2025 (mean gestational age 33.1 weeks; 93% with ≥ 2 prior cesareans). Fifty-one percent delivered before their scheduled date, reducing exposure to later messages. Among those still pregnant at each time point, platform-confirmed message delivery exceeded 77% for SMS and 86% for IVR, with self-reported receipt closely mirroring these rates. Mean IVR call duration ranged from 70 to 108 seconds, with over 95% of calls exceeding 30 seconds. Among 59 respondents completing the acceptability survey, all rated message length and pacing as appropriate and content as easy to understand. Most preferred SMS over IVR (68% vs. 32%) and preferred weekly messaging. No participants reported concerns regarding privacy, network connectivity, or phone sharing. No differences in delivery or receipt were observed by digital access adequacy. Conclusions An SMS/IVR intervention for cesarean-specific birth preparedness was highly feasible and acceptable among high-risk pregnant women in Uganda. Further evaluation is warranted to assess clinical effectiveness and scalability. Trial Registration: clinicaltrials.gov; trial registration number: NCT07696325; Registered retrospectively July 6 ^th, 2026. </p>