The use of digital solutions for the reduction of maternal and perinatal mortality: A systematic review

Abstract

Background

Maternal and perinatal mortality are critical health and development indicators. Technological solutions, such as monitoring and telemedicine applications, have the potential to improve prenatal care and significantly reduce these risks by enhancing access to healthcare.

Methods

A systematic review of studies published between 2019 and 2026 was conducted. Searches were performed in Medline, Scopus, Web of Science, Scielo, and the Cochrane Central Register of Controlled Trials (CENTRAL). Observational and intervention studies evaluating digital solutions like teleconsultation, m-health, telecare, and mobile applications were considered.

Results

Eight studies were included in the final review, encompassing a total population of 54,074 women. The primary digital solutions identified were teleconsultation (six studies), a mobile application (one study), and a telecare project (one study). The findings were mixed. A telecare system (WONDER project) in India was associated with a 50.1% reduction in maternal mortality. In Rwanda, the Safe Delivery Application was linked to a significant decrease in maternal deaths due to postpartum hemorrhage (from 3% to 0%, p=0.048) and the elimination of neonatal deaths post-resuscitation in the study group (from 7% to 0%, p<0.001). One study in Colombia found a statistically significant reduction in perinatal mortality with teleconsultation (OR= 0.22; 95% CI [0.07-0.71]; p= 0.022). However, other studies on teleconsultation did not find statistically significant differences in maternal or perinatal mortality rates.

Conclusion

Digital solutions integrated into clinical care, particularly telemonitoring systems and mobile applications, may reduce maternal and perinatal mortality in specific contexts. The evidence for teleconsultation as a standalone intervention remains inconclusive. Further high-quality research is needed to establish robust evidence for widespread implementation.

Keywords

maternal mortality perinatal mortality telemedicine systematic reviews digital health

Introduction

Maternal mortality is a key indicator of a population’s health and development. According to the World Health Organization (WHO), maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.^1,2 This definition encompasses deaths during pregnancy, childbirth, and the postpartum period resulting from complications, interventions, failures, or inadequate treatments.³ The most common direct causes, accounting for approximately 75-80% of maternal deaths globally, include severe hemorrhage, infections, hypertensive disorders of pregnancy, and complications from unsafe abortions.^2,4 Indirect causes, such as pre-existing conditions exacerbated by pregnancy like HIV/AIDS, malaria, and cardiovascular disease, also contribute significantly.^5–7 The maternal mortality ratio (MMR), expressed as the number of maternal deaths per 100,000 live births, is the standard metric used to monitor progress in maternal health.⁸

In 2020, an estimated 287,000 maternal deaths occurred worldwide. More recent data from 2023 indicate that approximately 800 women continue to die each day from preventable causes related to pregnancy and childbirth, with the global maternal mortality ratio remaining largely stagnant in recent years.^1,9 Between 2000 and 2020, there was a 34% reduction in the global MMR; however, progress has slowed considerably since 2015. Profound disparities persist; about 95% of these deaths occur in low- and lower-middle-income countries.^1,9 According to the most recent WHO estimates, the MMR in low-income countries remains approximately 430 per 100,000 live births, compared to just 12 in high-income countries.¹⁰ Sub-Saharan Africa and Southern Asia continue to account for approximately 87% of global maternal deaths.⁹ Humanitarian crises and conflict exacerbate these challenges, with fragile states exhibiting an average MMR of 551 per 100,000 live births, a rate dramatically higher than the global average¹⁰

Perinatal mortality, which includes stillbirths (fetal deaths at or after 28 weeks of gestation) and early neonatal deaths (within the first seven days of life), is another critical health indicator.^11,12 Major causes include pregnancy complications like preeclampsia, infections, childbirth-related complications such as asphyxia, congenital abnormalities, and conditions related to prematurity and low birth weight.^13,14 The perinatal mortality rate is measured as the number of perinatal deaths per 1,000 total births and reflects the quality of care provided during late pregnancy, delivery, and the immediate postnatal period.¹⁵

Globally, 2.3 million newborns died in 2022, accounting for 47% of all deaths among children under five.¹¹ While significant progress has been made since 1990, the reduction in neonatal mortality has slowed, and 64 countries are projected to miss the Sustainable Development Goals target for 2030 (which aims to reduce neonatal mortality to at least as low as 12 deaths per 1,000 live births and under-5 mortality to at least as low as 25 deaths per 1,000 live births in all countries).^12,16 Regional disparities are stark: the neonatal mortality rate in sub-Saharan Africa in 2022 was 27 deaths per 1,000 live births, 11 times higher than the risk in Australia and New Zealand.^11,12

In response to these persistent challenges, digital health solutions have emerged as promising tools to improve access, quality, and continuity of maternal and child care.^17,18 Technologies such as telemedicine, mobile health (m-health) applications, and wearable devices offer innovative ways to deliver care, monitor patients remotely, and provide health education.¹⁹ Telemedicine, the delivery of medical services at a distance using information and communication technologies (ICTs), can bridge geographical barriers, enabling remote consultations, diagnostics, and follow-up.^20,21 Mobile applications can empower both patients with information and health professionals with clinical decision support tools.^22,23 This systematic review aims to describe and analyze the evidence on the use of these digital solutions for the reduction of maternal and perinatal mortality.

Methods

This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and followed the methodological framework recommended by the Cochrane Collaboration.²⁴ PROSPERO ID: CRD42025638072.

Eligibility criteria

Studies were selected according to the PICO framework. Population: women in the perinatal period (pregnancy, childbirth, or up to one year postpartum). Intervention: any digital solution (teleconsultation, m-health, telecare, or mobile applications) integrated into routine care. Comparison: standard maternal and perinatal care delivered without digital tools. Primary outcome: measurable reduction in maternal and/or perinatal mortality. Secondary outcomes included: hypertensive disorders of pregnancy (preeclampsia, eclampsia), perinatal morbidity (stillbirth, neonatal intensive care unit admission, birth weight, gestational age at delivery), mode of delivery, obstetric complications (postpartum hemorrhage, shoulder dystocia), and healthcare utilization patterns (timing and frequency of prenatal visits, hospital admissions, length of stay).

Inclusion criteria were: 1) studies evaluating the use of digital solutions in maternal and perinatal care; 2) studies reporting outcomes related to maternal or perinatal mortality; 3) study designs including clinical trials, observational studies, time series, and quasi-experimental studies; and 4) studies published in the last seven years (2019-2026). Narrative reviews, systematic reviews, protocols, case reports, editorials, and non-peer-reviewed documents were excluded. There were no language restrictions.

Description of key interventions

Two studies evaluated comprehensive digital health systems that warrant detailed description. The WONDER (Women Obstetric Network for Delivery and Emergency Response) telecare system, implemented in India, is an algorithm-based platform designed to monitor obstetric patients and generate real-time alerts for early warning signs of complications. The system categorizes alerts by severity (yellow for moderate risk, red for high risk) and facilitates rapid clinical response.²⁵

The Safe Delivery Application (SDA), evaluated in Rwanda, is a mobile application that provides clinical decision support to health workers during childbirth. The app offers evidence-based guidance, animated instruction videos, and action cards for managing obstetric and neonatal emergencies, including postpartum hemorrhage and neonatal resuscitation. It is designed to strengthen the knowledge and skills of frontline health workers in resource-limited settings.²⁶

Information sources and search strategy

A comprehensive search was conducted between March 10 and 20, 2026, in the following electronic databases: Medline (via PubMed), Scopus, Web of Science, and SciELO. In line with Cochrane recommendations, the Cochrane Central Register of Controlled Trials (CENTRAL) was also searched.²⁴ The search strategy combined keywords and MeSH terms related to the population and intervention, such as “Maternal Mortality”, “Perinatal Mortality”, “Telemedicine”, “Mobile Applications”, “eHealth”, “Telecare” and “Telehealth”. Additionally, a backward search was conducted by manually screening the reference lists of included articles to identify further relevant studies. The complete search strategies for each database, including full search strings, fields searched, and limits applied, are provided in Supplemental Appendix 1. No grey literature sources or clinical trial registries were systematically searched beyond CENTRAL.

Study selection

All records identified were imported into the Rayyan web application. Two reviewers independently screened the titles and abstracts of the articles against the eligibility criteria. Any discrepancies were resolved through discussion and consensus between a third reviewer. The full texts of the selected articles were then retrieved and assessed for final inclusion.

Data extraction and synthesis

A data extraction form was created in Microsoft Excel® to systematically collect relevant information from each included study. Two reviewers independently extracted the data. The extracted variables included: author(s), year of publication, study location, study design and follow-up period, number of patients, patient age, technology used, and outcomes related to maternal and perinatal mortality. Any disagreements were resolved by consensus. If data were missing or unclear, corresponding authors were contacted via email for clarification.

Due to the significant heterogeneity in study designs, populations, interventions, and outcome measures, a meta-analysis was not feasible. Instead, a narrative synthesis of the findings was performed. The results were grouped by the type of digital solution and the outcomes measured, allowing for a qualitative description of the evidence.

Risk of bias and quality assessment

The risk of bias for each included study was assessed by two independent reviewers. For non-randomized studies of interventions, the “Risk of Bias in Non-Randomized Studies - of Interventions” (ROBINS-I) tool was used. For observational studies, the “Risk Of Bias In Non-randomized Studies - of Exposure” (ROBINS-E) tool was employed.²⁴ These tools evaluate bias across several domains, including confounding, selection of participants, classification of interventions/exposures, missing data, and measurement of outcomes.

The quality of reporting was assessed using the “Strengthening the Reporting of Observational Studies in Epidemiology” (STROBE) and the “Transparent Reporting of Evaluations with Nonrandomized Designs” (TREND) checklists, as appropriate for the study design. A compliance score was calculated for each study, with scores ≥70% considered high quality, 40-69% moderate quality, and <40% low quality.

Certainty of evidence assessment

The certainty of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Evidence was rated as high, moderate, low, or very low certainty based on considerations of risk of bias, inconsistency, indirectness, imprecision, and publication bias. Given the observational nature of most included studies and the heterogeneity in interventions and settings, the certainty of evidence was anticipated to be low to moderate for most outcomes.

Results

Study selection

The initial database and registry searches yielded 564 records. After removing 40 duplicates, 524 articles remained for screening. From these, 488 were excluded as they were not relevant to the review’s objectives. The full texts of 36 articles were assessed for eligibility. Of these, 28 were excluded because they did not meet the inclusion criteria or did not measure the outcomes of interest. Ultimately, eight studies were included in the narrative synthesis.^25–32 Two studies by Escobar et al.^28,29 published in 2020 evaluated teleconsultation programs conducted in 2017 and 2019 in different regions of Colombia. After careful review of the study populations, settings, and time periods, these were determined to represent distinct cohorts and were therefore analyzed as separate studies. The PRISMA flow diagram summarizing the study selection process is detailed in Figure 1.

Figure 1.

PRISMA flow diagram of the study selection process.

Characteristics of included studies

The eight included studies represented a total population of 54,074 women, with mean ages ranging from 28 ± 5 to 31.6 ± 5.3 years. Geographically, three studies were conducted in Colombia, two in the United States, one in Rwanda, one in Australia, and one in India. The study designs included three cohort studies, one time-series study, one cross-sectional study, one ecological study, one quasi-experimental study, and one intervention study. Six studies evaluated teleconsultation, one assessed the “Safe Delivery Application” mobile app, and one examined the “WONDER” telecare project. The main characteristics of the included studies are summarized in Table 1.

Table 1.

Main characteristics of the studies included in the review.

Study (author, year)	Location	Design and follow-up	Number of patients	Age (years)	Technology used	Maternal mortality	Perinatal mortality
Palmer et al.,²⁵ 2021	Australia	Time-series study comparing telehealth (2020) vs. conventional care (2018–2020).	Pre-telehealth: 20,031 Post-telehealth: 2,292	Pre: 31.3±5.2 Post: 31.6±5.3	Teleconsultation (video or phone) vs. conventional.	No maternal deaths reported in either period.	A non-significant 0.22% reduction in fetal deaths per week after telehealth integration (95% CI: -0.47 to 0.03; p=0.09).
Kuppuswami et al.,²⁶ 2021	India	Cross-sectional study over two years.	15,184	Not specified	Telecare health project (WONDER system).	WONDER system significantly reduced maternal deaths by 50.1%.	Data not reported.
Duryea et al.,²⁷ 2021	United States	Cohort study (2019 vs. 2020).	Exposed: 6,048 Unexposed: 6,559	Exposed: 27.7±6.5 Unexposed: 27.8±6.4	Audio-only teleconsultation.	No maternal deaths occurred in either cohort.	No significant increase in stillbirths in 2020 (5 per 1000) vs. 2019 (6 per 1000); p=0.39.
Escobar et al.,²⁸ 2022	Colombia	Ecological study (2017–2019), before and after telemedicine implementation.	Period 1: 102 Period 2: 148	Period 1: 24±5 Period 2: 25±5	Teleconsultation.	Non-significant reduction in maternal mortality (OR=0.85; 95% CI [0.5-1.4]; p=0.56).	Significant reduction in perinatal mortality (OR=0.22; 95% CI [0.07-0.71]; p=0.022).
Escobar et al.,²⁹ 2022	Colombia	Quasi-experimental study (2017–2018 vs. 2018–2019).	Period 1: 470 Period 2: 154	22±6	Teleconsultation.	No significant difference in adverse maternal outcomes (OR=0.96; 95% CI [0.60-1.52]; p=0.86).	Non-significant reduction in perinatal mortality (OR=0.19; 95% CI [0.03-1.32]; p=0.19).
Nishimwe et al.,³⁰ 2022	Rwanda	Pre-post intervention study over 14 months evaluating a mobile app for childbirth care.	Postpartum Hemorrhage: 67 pre, 47 post. Neonatal Asphyxia: 126 pre, 87 post.	28±5	Safe Delivery Application (mobile app).	Significant reduction in maternal mortality from postpartum hemorrhage (3% pre vs. 0% post; p=0.048).	No neonatal deaths in the post-intervention group. Stable newborn outcomes increased from 31% to 72%.
Reneker et al.,³¹ 2022	United States	Retrospective cohort study (pre-COVID-19 vs. COVID-19 pandemic).	Pre-pandemic: 620 Pandemic: 1,272	27.3±6	Teleconsultation + in-person vs. in-person only.	Data not reported.	Perinatal mortality was 3.23% in the pre-pandemic cohort and 5.42% in the pandemic cohort.
Escobar et al.,³² 2023	Colombia	Retrospective observational cohort study.	Exposed: 156 Unexposed: 922	31±4	Teleconsultation + in-person vs. in-person only.	No maternal deaths occurred in either cohort.	Perinatal mortality was 4.49% in the exposed (telehealth) cohort vs. 2.38% in the unexposed cohort (p=0.088).

CI: Confidence Interval; OR: Odds Ratio.

Maternal mortality

Maternal mortality outcomes showed consistently positive results across studies implementing telemedicine interventions. The WONDER telemedicine system in India demonstrated the most dramatic improvement, with maternal mortality rates decreasing from 0.066% pre-implementation to 0.03% during the study period, representing a 50.1% reduction.²⁶ All six maternal deaths that occurred during the WONDER study were in women who had previously received red (high-severity) alerts, confirming the system’s effectiveness in identifying high-risk cases. In the Colombian studies, no maternal deaths were recorded in any of the intervention periods.^28,29,32 Similarly, the Australian time series study by Palmer et al. reported no maternal deaths in either the conventional care or teleconsultation periods for both low-risk and high-risk obstetric care models.²⁵ The Rwanda mobile application study also showed significant improvement, with PPH-attributed mortality decreasing from 3% in the initial group to 0% in the post-SDA implementation group (p=0.048).³⁰

Preeclampsia and hypertensive disorders

Results for preeclampsia and hypertensive disorders varied across studies. Palmer et al. found no significant differences in preeclampsia diagnoses between conventional and teleconsultation periods, with 49 cases (3%) in low-risk groups and 47 cases (9%) in high-risk groups.²⁵ Median gestational age at birth for women with preeclampsia remained similar between periods: approximately 38.4 weeks in low-risk groups (p=0.27) and 37.1 weeks in high-risk groups (p=0.99). The WONDER system study showed substantial improvements in severe complications, with eclampsia incidence decreasing dramatically from 2.18% pre-implementation to 0.18% during the study (91.7% reduction), while 9.6% of women developed mild preeclampsia and 3.8% developed severe preeclampsia.²⁶ In Colombian studies, hypertensive disorders of pregnancy were identified as the main cause of emergency admission (35.6%) in one study,²⁹ while another reported reduced eclampsia cases after program implementation.²⁸ The US studies showed mixed results, with Duryea et al. finding no significant differences in gestational hypertension or severe preeclampsia between audio-only teleconsultation and conventional care groups (p>0.05),²⁷ while Reneker et al. observed higher prevalence of hypertension in the pandemic cohort that received more telemedicine visits.³¹

Fetal and neonatal outcomes

Fetal death and stillbirth rates generally showed no significant differences between telemedicine and conventional care groups. Palmer et al. found fetal death rates of 1% in both low-risk groups (p=0.79) and 2% in both high-risk groups (p=0.70), despite a slight 0.22% reduction in fetal deaths in high-risk teleconsultation models that was not statistically significant (p=0.09).²⁵ Duryea et al. reported similar stillbirth rates between cohorts, with 40 stillbirths in 2019 and 30 in 2020 (p=0.39), and major malformation rates remained constant at 1.9% in both years (p=0.99).²⁷ However, Colombian studies showed more favorable results, with one study reporting significantly higher perinatal deaths in the pre-implementation period (12.7% vs 2.7%).²⁸ Regarding neonatal intensive care admissions, results were mixed. Palmer et al. found no significant differences in low-risk groups (2% in both periods, p=0.60) but observed higher admissions in high-risk teleconsultation groups (18% vs 15%, p=0.01).²⁵ Colombian studies generally showed no significant differences in NICU admissions between intervention and control groups.^29,32 The Rwanda study demonstrated remarkable neonatal outcomes, with neonatal mortality after resuscitation dropping from 7% in the initial group to 0% in the SDA-using group (p<0.001).³⁰

Birth weight and gestational age

Most studies reported no significant differences in birth weight between telemedicine and conventional care groups. Escobar et al. found that most newborns had adequate birth weight with no differences between mixed care and in-person care cohorts (p=0.171).³² Similarly, Colombian emergency department studies showed no differences in birth weight between pre- and post-implementation periods.^28,29 Gestational age outcomes varied across studies. Reneker et al. reported mean gestational age of 36.82 weeks with no significant differences between pre-pandemic and pandemic cohorts,³¹ while the Rwanda study maintained average gestational age at 39 weeks in both pre- and post-SDA implementation groups.³⁰

Mode of delivery and obstetric complications

Cesarean section rates showed varying patterns across studies. Duryea et al. found women in the teleconsultation cohort had slightly higher likelihood of cesarean delivery, though this difference was not significant after adjusting for confounding factors (such as maternal age, body mass index, parity, gestational age at delivery, and pre-existing medical conditions) (p>0.05).²⁷ Colombian studies reported cesarean rates of 72.26% with no significant differences between mixed care and in-person groups (p=0.424),³² and 30% cesarean rates in the quasi-experimental study.²⁹ Regarding specific obstetric complications, Duryea et al. reported significantly lower rates of shoulder dystocia in the teleconsultation group (adjusted RR 0.48; 95% CI 0.26-0.91) and reduced likelihood of requiring transfusions during or after delivery (adjusted RR 0.84; 95% CI 0.70-0.99).²⁷ Colombian studies also noted reduced transfusion needs after telemedicine program implementation.²⁸

Care utilization patterns

Telemedicine implementation consistently improved care utilization patterns. Multiple studies showed earlier initiation of prenatal care in telemedicine groups: Duryea et al. reported median gestational age of 11 weeks at first visit versus 12 weeks in conventional care,²⁷ while Escobar et al. found even earlier initiation at 7.1 weeks in the mixed care group versus 9.3 weeks in the in-person group.³² The number of prenatal visits also increased with telemedicine integration. Duryea et al. reported an average of 9.8 visits versus 9.4 in conventional care,²⁷ while Escobar et al. found 8 appointments in the mixed care group compared to 6 in the in-person group.³² Reneker et al. demonstrated the most dramatic increase, with telemedicine visits being eight times higher during the pandemic period (p<0.001).³¹

System performance and response times

The WONDER telemedicine system provided detailed insights into system performance. Among monitored patients, 44.1% progressed without alerts, while 55.9% received alerts (63% yellow alerts, 37% red alerts). Most importantly, 92.2% of patients with red alerts received care within one hour of the alert.²⁶ The system’s effectiveness was demonstrated by patient outcomes: 66.4% of patients recovered with fewer than three alerts, 25.9% needed 4-10 alerts, and only 7.7% required more than 10 alerts. The Rwanda SDA implementation showed 94% of women achieving stable outcomes post-treatment compared to 78% in the pre-implementation group, with reduced hospital transfers (6% vs 19%).³⁰

Healthcare resource utilization

Several studies demonstrated reduced healthcare resource utilization following telemedicine implementation. The Colombian quasi-experimental study showed a 67% reduction in patients admitted for obstetric emergencies from intervention municipalities.²⁹ Similarly, fewer women required admission to high-complexity obstetric units in the mixed care group compared to in-person care (p=0.005).³² Hospital stay patterns also changed, with both cohorts in one Colombian study showing increased early hospital discharge, though the telemedicine group had slightly longer hospitalization times (p=0.002).³² The Rwanda study demonstrated significant reduction in hospital transfers, dropping from 19% to 6% after SDA implementation.³⁰

Risk of bias assessment

The risk of bias was assessed using the ROBINS-E tool for the six observational studies and the ROBINS-I tool for the two non-randomized intervention studies. For the observational studies, four were judged to have a low risk of bias across all domains. Two studies were rated as having “some concerns” overall, a rating determined by the domain with the highest risk level. These concerns primarily arose from potential bias due to missing data (Domain 5), as shown in Figure 2. For the two non-randomized intervention studies, one was judged to have a low risk of bias. The other was rated as having “some concerns” due to potential bias in the selection of the reported result (Domain 7), as shown in Figure 3.

Figure 2.

Risk of bias in non-randomized exposure studies according to the cochrane collaboration’s ROBINS-E tool.

Figure 3.

Risk of bias in non-randomized intervention studies according to the cochrane collaboration’s ROBINS-I tool.

Quality of evidence

The quality of reporting, assessed via STROBE and TREND checklists, was generally high. All eight studies exceeded the 70% compliance threshold, indicating high-quality reporting of their respective methodologies and findings. No serious omissions in the publication of results were identified when comparing the articles with information provided by the authors (Figure 4).

Figure 4.

Percentage of total compliance with the STROBE (solid color) and TREND (textured color) tools, according to the type of study.

The certainty of evidence was assessed using the GRADE approach (Table 2). Evidence for maternal and perinatal mortality outcomes was rated as low due to inconsistency across studies and imprecision from rare events, though upgraded for large effects in the WONDER and SDA studies. Prenatal care access and utilization outcomes achieved moderate certainty due to consistent improvements and dose-response relationships. Stillbirth and NICU admission outcomes were rated as very low certainty due to serious imprecision and inconsistent results.

Table 2.

GRADE assessment of certainty of evidence for digital health interventions on maternal and perinatal outcomes.

Outcome	Studies (n)	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Certainty of evidence	Explanation
Maternal Mortality	6	Not serious	Serious (-1)	Not serious	Serious (-1)	Large effect (+1)	⊕⊕○○ LOW	Mixed results; only WONDER and SDA studies showed significant reductions. Rare outcome with few events.
Perinatal Mortality	5	Not serious	Serious (-1)	Not serious	Serious (-1)	Large effect in SDA study (+1)	⊕⊕○○ LOW	Heterogeneous results; one Colombian study showed OR=0.22, others showed no difference.
Preeclampsia/Eclampsia	4	Not serious	Serious (-1)	Not serious	Not serious	Large effect in WONDER (+1)	⊕⊕○○ LOW	WONDER showed 91.7% reduction in eclampsia; other studies showed no significant differences.
Stillbirth/Fetal Death	3	Not serious	Not serious	Not serious	Serious (-1)	None	⊕○○○ VERY LOW	No significant differences detected in any study. Very few events.
NICU Admission	4	Not serious	Not serious	Not serious	Serious (-1)	None	⊕○○○ VERY LOW	Mixed results with wide confidence intervals.
Prenatal Care Access	3	Not serious	Not serious	Not serious	Not serious	Dose-response (+1)	⊕⊕⊕○ MODERATE	Consistent improvement in earlier care initiation across all studies.
Prenatal Care Utilization	3	Not serious	Not serious	Not serious	Not serious	Dose-response (+1)	⊕⊕⊕○ MODERATE	Consistent increase in number of visits across all studies.
PPH-Related Mortality	1	Not serious	N/A	Not serious	Serious (-1)	Very large effect (+2), Publication bias (-1)	⊕⊕○○ LOW	Single study (SDA): 3% to 0% reduction (p=0.048).
Neonatal Mortality Post-Resuscitation	1	Not serious	N/A	Not serious	Serious (-1)	Very large effect (+2), Publication bias (-1)	⊕⊕○○ LOW	Single study (SDA): 7% to 0% reduction (p0.001).

Discussion

This systematic review of eight heterogeneous studies suggests that digital health solutions may contribute to reducing maternal and perinatal mortality in specific contexts. Two studies evaluating telemonitoring systems and mobile applications that were integrated into clinical care to provide real-time monitoring and decision support for health professionals demonstrated statistically and clinically significant reductions in mortality in their respective settings (India and Rwanda).

The effectiveness of teleconsultation in directly reducing mortality remains inconclusive, with studies showing mixed results. While teleconsultation was associated with improved access to care, including earlier and more frequent prenatal visits in some studies, the evidence does not consistently demonstrate that these improvements translate into reduced mortality rates

Impact of teleconsultation

Six studies evaluated teleconsultation, and their findings on mortality outcomes were largely inconclusive. The study in Australia by Palmer et al. found no significant differences in maternal or fetal death rates after the widespread implementation of telehealth during the COVID-19 pandemic.²⁵ Similarly, two studies from the United States reported no significant changes in stillbirth rates or maternal mortality associated with the shift to virtual prenatal visits.^27,31 One of these studies noted a paradoxical increase in perinatal mortality in the pandemic cohort, which had greater telehealth use. However, the authors correctly caution that this finding cannot be attributed solely to telehealth, as the pandemic introduced numerous confounders, including delayed access to emergency services and complications from COVID-19 infection itself, and significant psychological stress among both patients and healthcare providers.^31,33

In contrast, studies from Colombia suggested more positive impacts. While two studies by Escobar et al. did not find a statistically significant reduction in maternal mortality, one of them reported a significant decrease in perinatal mortality (OR=0.22) after implementing a teleconsultation program.²⁸ A key theme across several studies was that teleconsultation improved access to care. Women in telehealth cohorts often initiated prenatal care earlier and attended more appointments compared to those receiving only in-person care.^27,32 This increased contact with the healthcare system may facilitate earlier identification of risks and better management of complications, as suggested by the observed reduction in eclampsia cases in one Colombian study.²⁸ The mixed results for teleconsultation suggest its effectiveness is highly context-dependent. It may be most beneficial in settings where geographical and socioeconomic barriers limit access to conventional care, a reality in many parts of the world.^34–36

Impact of telemonitoring and mobile applications

The two studies evaluating more intensive digital solutions, the WONDER telecare system in India and the Safe Delivery Application (SDA) in Rwanda, reported significant reductions in mortality. The WONDER system, which uses an algorithm to monitor obstetric patients and generate real-time alerts for early warning signs, was associated with a 50.1% reduction in maternal mortality and a 91.7% decrease in eclampsia incidence at the study sites.²⁶ Similarly, the SDA, a mobile app providing clinical decision support to health workers during childbirth, demonstrated a profound impact. Its use was linked to a significant reduction in maternal deaths from postpartum hemorrhage (from 3% to 0%) and the elimination of neonatal deaths post-resuscitation in the intervention group.³⁰ These tools are distinct from simple teleconsultation because they are integrated directly into the clinical workflow at the point of care, empowering health workers with knowledge and standardized protocols. This direct, practical application appears to translate into more consistent and significant improvements in outcomes, particularly in hospital settings where data collection is more controlled and biases are minimized.

A crucial point highlighted by this review is the distinction between statistical significance and clinical relevance.^37–39 For a rare but catastrophic outcome like maternal death, preventing even a single event is a monumental achievement.^37–39 In one Colombian study, the reduction in maternal mortality was not statistically significant (OR=0.85; 95% CI [0.5-1.4]) because the confidence interval crossed the null value of 1.0.²⁸ However, the point estimate suggests a 15% reduction in the odds of death, a clinically meaningful result that warrants further investigation with larger sample sizes.^40–43 Healthcare systems and policymakers must consider both statistical rigor and the practical importance of outcomes when evaluating interventions designed to save lives.⁴⁴

Limitations

This review has several limitations. First, the included studies exhibited significant heterogeneity in their designs, populations, specific interventions, and settings, which precluded a meta-analysis and necessitates a cautious interpretation of the synthesized findings. Second, several studies were conducted during the COVID-19 pandemic, a period that dramatically altered healthcare delivery and patient behaviors, making it difficult to isolate the effect of the digital interventions from the broader contextual factors. Third, the reliance on observational and quasi-experimental designs in most included studies means that the risk of confounding bias cannot be entirely eliminated. Finally, some studies had small sample sizes, limiting their statistical power to detect significant differences in rare outcomes like mortality.

Conclusion

This systematic review indicates that digital health solutions hold considerable potential for reducing maternal and perinatal mortality. Among the limited evidence available, telemonitoring systems and mobile applications integrated into clinical care showed the most consistent benefits. However, only two studies evaluated these interventions (the WONDER system in India and the Safe Delivery Application in Rwanda), limiting the strength of conclusions that can be drawn. These tools provided real-time monitoring and decision support for health professionals and demonstrated statistically significant reductions in mortality outcomes in their specific contexts.

The effectiveness of teleconsultation in directly reducing mortality is less clear, with studies showing mixed results. Teleconsultation was associated with improved access to care in several studies, as evidenced by earlier initiation of prenatal care and increased number of prenatal visits. Whether these improvements in care utilization translate to better clinical outcomes remain unclear, as most studies did not demonstrate statistically significant reductions in mortality. The observed benefits may be context-dependent, potentially being most valuable in settings where geographical and socioeconomic barriers limit access to conventional care.

The findings underscore the need for a nuanced approach, recognizing that the impact of a digital solution is highly dependent on its design, the context of its implementation, and the specific healthcare challenges it aims to address. Future research should focus on large-scale, methodologically rigorous studies, including randomized controlled trials where feasible, to build a stronger evidence base. This will be essential for developing effective, equitable, and sustainable strategies to leverage technology in the global effort to end preventable maternal and perinatal deaths.

Supplemental material

Supplemental material - The use of digital solutions for the reduction of maternal and perinatal mortality: A systematic review

Supplemental material for The use of digital solutions for the reduction of maternal and perinatal mortality: A systematic review by Mayelis Guerrero, Yelson Alejandro Picón-Jaimes, Javier Esteban Orozco Chinome, Yadira Marin-Hamburger, Ernesto Barceló-Martinez, Sulaiman Kalokoh, Fabriccio J. Visconti-Lopez in DIGITAL HEALTH

Supplemental material

Supplemental material - The use of digital solutions for the reduction of maternal and perinatal mortality: A systematic review

Footnotes

ORCID iDs

Sulaiman Kalokoh

Fabriccio J. Visconti-Lopez

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Contributorship

MG and YAPJ conceived the study and designed the methodology. JEOC and YMH conducted the formal analysis and data curation. EBM and SK contributed to the validation and interpretation of the results. FJVL supervised the project, provided critical revisions, and contributed to the final writing and editing of the manuscript. All authors reviewed and approved the final version.

Supplemental material

Supplemental material for this article is available online.

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