Healthy Pregnancy

Most of the maternal and neonatal deaths in rural communities of low-income countries could be prevented with adequate Prenatal Care. However, it becomes impossible due to the lack of qualified and well-equipped staff. "Healthy Pregnancy" overcomes the barriers of remote zones by training and equipping nurses of the public health system with a portable Prenatal Care Kit powered by a folding solar panel for areas without electricity. It integrates an ultrasound scanner to detect obstetric risks and blood and urine test strips to complete a quality prenatal check-up. Moreover, gynaecologists remotely supervise this risk screening through a Health Information System. Obstetric complications are referred to facilities with appropriate resources, avoiding risky childbirths in rural areas. This solution ensures high-quality pregnancy monitoring and contributes to equity and universal coverage of essential services, and has shown a reduction in maternal and neonatal mortality of more than 35% in rural communities of Guatemala.

The gap in access to adequate reproductive healthcare is a violation of human rights affecting millions of women worldwide. According to WHO, 99% of the 303,000 women who died in 2015 due to pregnancy-related causes lived in developing countries, where the probability of dying from these causes is 30 times higher than in high-income countries. In Guatemala, where this solution is being implemented, Maternal Mortality Ratio (MMR) was 105 deaths per 100,000 births in 2018, reaching double in remote zones, far from the target of 70 of the Sustainable Development Goals. Most of these deaths occur in rural communities where only 56% of births receive the recommended prenatal care, mainly because of the severe deficiencies of the public health system in remote zones, as the lack of technical resources and specialists. In these areas, women must travel several hours to reach the nearest health facility attended by health technicians with basic training in medicine. Also, these facilities often lack any power supply or telecommunication networks, as well as adequate tools to perform a pregnancy monitoring that guarantees a diagnosis, such as ultrasound or blood and urine tests which are considered essential for the detection of obstetric risks worldwide.

An essential aspect for reducing maternal and neonatal mortality is to improve pregnancy monitoring to anticipate obstetric complications and approach the delivery safely. This project strengthens prenatal check-ups in rural communities with an innovative, efficient and low-cost solution that uses relevant technology, professional qualification, and a diagnostic validation through telemedicine to decrease maternal and neonatal morbid-mortality where this gap causes more deaths. The solution overcomes isolations barriers of remote zones with a portable Prenatal Care Kit that allows performing two tests recommended by WHO to prevent up to 70% of pregnancy complications: ultrasound scans and blood and urine analysis. The kit, carried in a backpack and powered by a folder solar panel, is designed for no specialized health staff as the one available in rural zones, mainly nurses, who are trained to perform a basic but decisive ultrasound to early detect risk pregnancies. The kit includes a Health Information System that allows gynaecologists to validate diagnosis remotely and reinforce nurses' capacities. The solution involves a crucial screening for timely referring pregnancy complications to a health facility with adequate resources, avoiding high-risk childbirths in rural communities, and reducing the health gap between urban and rural environments.

This project focuses on improving prenatal care, so the direct beneficiaries are pregnant women and their children from rural communities of Guatemala, who are mainly indigenous people living in conditions of poverty. Likewise, the project addresses three determining causes for social exclusion such as gender, ethnicity and social class. In fact, maternal and neonatal mortality highlights the physical damage by deficient healthcare during pregnancy and delivery, and the consequences of social discriminations. Women generally hold a lower social status due to gender inequality, which contributes to making their specific needs invisible and explains the absence of appropriate services to meet them. The intervention is based on the promotion of women of excluded communities as subjects of rights, offering them access to quality prenatal care without displacements and respecting local cultural specificity. This project takes advantage of the enormous potential of public services as engines of equity, strengthening them to guarantee social protection for the most vulnerable groups. The solution boost women confidence in public health services, protect their physical wellbeing and improve their living conditions as a fundamental requirement to guarantee their full participation in the development processes of their communities.

The gap in technical and human resources of the prenatal healthcare services causes that women in rural communities are the least likely to receive adequate pregnancy monitoring. This project takes advantage of the enormous opportunities offered by technology and innovation to expand access to high-quality and affordable prenatal care in vulnerable areas. The solution allows for providing essential medical tests in isolated zones through a portable Prenatal Care kit. It also includes the training for the nurses and linking them to specialists through a remote supervision process, and integrating the solution into the public health system.

This solution brings to rural areas two medical tests considered essential worldwide to identify pregnancy complications: ultrasound scans and blood and urine analysis. Both tests are common in developed countries, but they are not provided in rural areas of low-income countries due to the lack of technical resources and skilled health personnel. In recent years other innovative solutions have been developed to overcome the maternal health gap. However, these solutions offer more simple pregnancy monitoring tests such as the fetal heartbeat or educational Apps targeted at mothers (MOMIND). Other initiatives use portable ultrasound scans (GE Healthcare Africa) or telemedicine between nurses and gynaecologists (Dawa Health). However, they are not adapted to areas without electricity supply or telecommunication networks. As far as we know, there are no solutions adapted to rural environments that integrate ultrasound scans and blood and urine analysis as WHO recommends. We have also proved that we can integrate this solution into the public health system, which allows offering it at a very low cost. We have also reached a high number of attentions and shown an impact on maternal mortality. Currently, the only alternative in Guatemala is the displacement of pregnant women of rural areas to urban health facilities. However, the cost of travel and the price of these tests in private clinics reaches US$ 35, which is unaffordable for the population living in poverty. Therefore, this solution contributes in an innovative, direct and appropriate way to open the access to quality prenatal care in vulnerable areas.

This solution adapts prenatal care tests through three key technology points:

1. Appropriated Equipment: This solution overcomes isolation barriers of rural areas by a portable Prenatal Care Kit carried on a backpack and powered by a folding solar panel that guarantees its autonomy. It contains an ultrasound probe USB connected to a laptop or tablet, allowing to perform ultrasound scans and identify essential parameters to anticipate obstetric risks such as foetal heartbeat, gestational age, delivery date, twin pregnancies, placenta praevia, amniotic fluid or foetal malposition. It also contains blood and urine test strips that do not require cold chain and offers an immediate result, analyzing diseases with a high risk of vertical transmission (HIV, Syphilis or Hepatitis B), urinary infections, Glucose and Haemoglobin. Both tests allow a crucial screening process for timely detecting pregnancy complications in rural areas.
2. Continuous Training of Rural Nurses: The solution use tools are employed by nurses, who are responsible for antenatal care in rural areas and proposes a paradigm shift that strengthens their capacities. Motivating and training the nurses is a crucial aspect of the project, and we have designed a multimedia platform that supports this process.
3. Remote Quality Control: Specialists in gynaecology supervise the screening through a Health Information System (HIS) integrated into the Prenatal Care Kit that stores data and ultrasound images. The HIS allows validating diagnoses, reinforcing nurses' capacities and evaluating the project impact. This HIS works offline and shares the information when an internet connection is available.

"Healthy Pregnancy" has been operating in Guatemala since 2012 to reinforce public health institutions in rural areas with an innovative, efficient and low-cost solution to decrease maternal and neonatal morbid-mortality. We implemented an initial pilot between September 2012 and November 2013 with three kits. Later, we conducted an observational study that compared the impact achieved in maternal and neonatal mortality by this solution versus the common practice in rural Guatemala. No maternal deaths were reported in the intervention group versus six maternal deads found in the control group. Neonatal mortality was also lower in the intervention group (results available in http://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-016-0237-6). These results helped us to gather support from  International Development Agencies such as USAID (United States Agency for International Development), MIF-IDB (Multilateral Investment Fund of Interamerican Development Bank) or AECID (Spanish Agency of International Cooperation for Development), as well as the Ministry of Public Health and Social Assistance of Guatemala. With that support, the project scaled to the Departments of Alta Verapaz and San Marcos. A new evaluation was conducted after approximately 10,000 prenatal controls, demonstrating a reduction of 35% in maternal mortality and 38% in neonatal mortality.  The evaluation results have been published in the scientific magazine "Reproductive Health" (available in https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0748-z). Until today more than 21,000 women have been attended in both departments, 30 Prenatal Care kits have been delivered to public health institutions, and 50 nurses have been trained to use the portable Prenatal Care kits.

The Theory of Change of this solution is based on the central idea that, according to WHO, the access to quality healthcare services is essential for the enjoyment of the right to health, and in particular, is decisive for women to have a healthy pregnancy. However, nowadays, serious inequities remain between urban and rural areas in low-income countries, where the highest rates of maternal and neonatal mortality are concentrated due to the lack of technical and human resources for pregnancy monitoring. Indeed, the FINAL OUTCOME of this solution is the reduction of maternal and neonatal mortality in rural zones, which has already been estimated at 35% of reduction. To reach this outcome, the project contributes to ensuring women's access to quality and complete prenatal healthcare in remote communities (INTERMEDIARY OUTCOME) with a solution that overcomes its isolation barriers with innovative, appropriate and sustainable tools and protocols.

The improvement in prenatal healthcare also contributes to increasing women's confidence in the health system (INTERMEDIARY OUTCOME). The Prenatal Care kit allow women to see the fetus in the ultrasound scan, which promotes their interest in attending prenatal controls. In a survey performed in the project, 100% of women reported feeling satisfied with the healthcare improvement. 

Following the sequence, the project's OUTPUTS are the reinforcement of primary healthcare in rural areas, providing tools and protocols that strengthen rural prenatal care to detect risk pregnancies. The project provides easy-to-use prenatal kits and also trains rural nurses to use them (INPUTS). These kits allow nurses of the public health system to timely detect complications using obstetric ultrasounds and blood and urine tests. Some low-risk complications can be treated locally, for example, non-severe anemia. However, when nurses identify high-risk pregnancies, they refer them to a health centre with adequate resources. This helps to ensure proper treatment and avoid risky deliveries in rural areas. During this process, a gynecologist remotely supervises the exam through a Health Information System built into the kit. The gynecologist offers a second opinion on the result of the screening, provides feedback to the nurses and identifies knowledge gaps that must be reinforced.

After the pilot experience in 2012, "Healthy Pregnancy" started in 2014 its expansion phase in the Guatemalan departments of Alta Verapaz and San Marcos, having attended until today more than 21,000 women. The annual average of beneficiaries is around 4,000 women attended each year with complete and high-quality prenatal check-ups.

The number of annual pregnancies in San Marcos and Alta Verapaz is 24,180 and 33,966 respectively. In San Marcos, the percentage of the rural population is 80%, while in Alta Verapaz it is 76%, mostly from indigenous communities in both cases. In Guatemala, 56% of rural pregnancies do not receive the recommended prenatal care because of the lack of human and material resources of the rural health system, which respectively means a total of 11,103 and 10,068 women per year in the target departments. It is not realistic to reach all these women but could serve al least 50% of them if we receive support to scale the initiative. This means that this solution could serve around 10,000 women in the next year.

If a similar analysis is performed for the whole country, the number of annual pregnancies in Guatemala is approximately 381.000 and 53% of them belongs to women living in rural areas. 56% of these pregnancies do not receive the recommended prenatal care, which means a total of 114,000 women and in 5 years this solution could reach approximately 40% of them annually (45,600) by extending "Healthy Pregnancy" to the whole country.

EHAS Foundation aims to improve maternal and infant health in those rural areas where mortality is still too high. To achieve this, EHAS expects to build a sustainable social business that offers support to the Ministries of Health to implement the "Healthy Pregnancy" strategy. The model will be based on leasing the equipment and provide the training for the health ministries, that will pay the service with part of the savings that the project brings to the health system. This social business will offer assistance to different governments in low and middle-income countries because this solution is modular and can be adapted to different contexts. EHAS has an extended network of partners in Latin America and has previous experience collaborating with public health institutions in countries such as Peru, Guatemala, Bolivia, Colombia or Ecuador. Therefore, Latin America would be the first area of intervention. Nevertheless, EHAS is willing to find partners and start projects in other regions interested in this solution.

In the first year, EHAS expects to implement this business model in two departments of Guatemala. Then we will start scaling it to other departments of Guatemala, trying to reach the whole country in 5 years. At the same time, we will work to replicate this model in other countries. We are starting a pilot in Bolivia (in the Department of Cochabamba) in collaboration with local NGOs and the Health Ministry, and we are also designing similar pilots in Mexico and Nicaragua.

Previous stages of the project allow us to identify four main risks:

1. TECHNICAL RISKS: The use of novel medical equipment implies homologation processes in the intervention country that can be delayed in time and even turn out to be negative.
2. CULTURAL RISK: There is a threat of a cultural rejection to the ultrasound test or the blood collection by pregnant women in rural communities due to the particularities of their cultural codes and worldview, in addition to mistrust in the public health system that does not cover all their demands and needs.
3. INSTITUTIONAL RISK: This project was designed to ensure its institutional consolidation since it is based on the nurses of the public system to provide prenatal care. However, there is a risk of unavailability of these health personnel in low-income countries due to the high turnover of staff or possible lack of resources for their salary. In case of budget collapse, the cuts usually begin in rural areas, where there is less capacity for advocacy or social mobilization.
4. PROFESSIONAL RISK: One of the innovative procedures of this solution is that the health personnel that performs the prenatal care do not need to be specialized (gynaecologists or radiologists), but rather train local nurses for prenatal care. This may mean a risk of mistrust of quality attention or professional rejection.
5. PUBLIC INVOLVEMENT RISK: For the project to be successful, we need the participation and resources of the ministry of health, but this may depend on each government strategies and budgets.

Previous stages of the project allow us to identify the following mitigation actions:

1. TECHNOLOGICAL RISK: The project equipment has the American (FDA) and European (CE marked) certification with internationally accepted quality standards (ISO 13485), which facilitates the homologation at each country.
2. CULTURAL RISK: To overcome this threat, we involve nurses covering rural areas as influential positions to sensitize women to the importance of prenatal care. We also engage a community trusted figure, traditional midwives, who have a vital role in the monitoring of pregnancies and deliveries in rural communities.
3. INSTITUTIONAL RISK: We prioritize the incorporation into the project of nurses who are civil servants with more job stability to guarantee their permanence in the project. Also, the project trains an extensive list of nurses to have available staff to cover temporary leaves.
4. PROFESSIONAL RISK: The action implemented to mitigate this risk is integrated into the essence of the solution, which has been designed with clearly identified 2 phases: screening and quality control. Nurses do not diagnose but perform screening tests. If any abnormality is detected, the patient is referred to a hospital to be diagnosed by specialized personnel before applying any treatment. Moreover, gynaecologists validate the screening using the HIS.
5. PUBLIC INVOLVEMENT RISK: The control mechanism focuses on the coordination with the local health authorities of each department, who are more accessible and more aware of rural needs. They can support the project directly, and with their intermediation, it is easier to get the support of central ministries.

Not applicable.

"Healthy Pregnancy" is led by the Director of EHAS Foundation and the Director of TulaSalud, the local partner in Guatemala, covering 2 departments (Alta Verapaz and San Marcos). As the full-time staff, 2 Nurses are the Prenatal Care Coordinators and 2 Informatic Technicians maintain the technology (one for each department). Regarding part-time staff, 2 Gynaecologists work on the training and quality control of the diagnoses, and 1 Project Manager on the technical and economic management. Finally, prenatal care is performed in rural communities by 30 nurses that already belongs to the public health system.

EHAS Foundation is a Spanish nonprofit organization that researches and implements innovative solutions for development. EHAS has been working for more than 15 years to strengthen public health systems in Latin America and Africa through innovation and telemedicine. Our appropriate and sustainable solutions take tests and medical specialists to isolated areas where the most vulnerable populations live. We have an extended network of partners in Latin America and has previous experience leading projects with public health institutions in countries such as Peru, Guatemala, Bolivia, Colombia or Ecuador. For that projects, EHAS has received funding from the European Union, the Ibero-American Program of Science and Technology for Development (CYTED), the Multilateral Investment Fund of Interamerican Development Bank (MIF-IDB), the United States Agency for International Development (USAID), the Development Bank of Latin America (CAF) or the Spanish Agency of International Cooperation for Development (AECID). The results of these projects have been published in scientific journals of high impact such as IEEE Technology and Society Magazine, Journal of Telemedicine and Telecare, Reproductive Health, Telemedicine and eHealth, Frontiers in Public Health Journal, etc. Therefore, Latin America would be the first area of intervention. Finally, EHAS is committed to technology at the service of health, aiming that all people, regardless of where they live, have opportunities to access quality essential services that guarantee their right to health.

"Healthy Pregnancy" is being implemented by EHAS Foundation in collaboration with TulaSalud Association as the counterpart in Guatemala, with whom it has been working since 2012. TulaSalud is a Guatemalan NGO that aims to support the Guatemalan Ministry of Public Health and Social Assistance to improve healthcare services in rural zones using innovative tools. The organization, funded mainly by the Tula Foundation of Canada, develops e-Health solutions with an intercultural, gender and environmental focus and transfers experience and technology to strengthen the rural coverage of the public health system. It has worked on tele-education for remote training of nursing technicians and on a rural tele-medicine system to implement diagnostic support through mobile telephony, focusing on reducing maternal and child mortality and malnutrition. TulaSalud was recognized in 2008 with a prize for best practices in Guatemala from the European Union's SOLAR-ICT Project for Innovation in the Information Society.

The project also has an institutional partnership with the Health Directorates of the Guatemalan departments of Alta Verapaz and San Marcos that belong to the Ministry of Public Health and Social Assistance of Guatemala, as well as with funders such as USAID, MIF-IDB or AECID. Finally, EHAS has involved other partners with a common commitment to innovation at the service of health, such as URJC (Rey Juan Carlos University) and UPM (Technical University of Madrid), both leading academic institutions in the ICT field which focus on find interdisciplinary solutions to global problems.

The SDGs establish the reduction of maternal and neonatal mortality as a fundamental target. This opens a significant opportunity for strategies aimed at strengthening prenatal care services because there is an institutional interest in the search for solutions that address this health gap in low-income countries, especially for rural areas where most of these deaths are concentrated. Therefore, the "Healthy Pregnancy" business model is articulated through the public health system, establishing a partnership with the Guatemalan Ministry of Health to incorporate this initiative in its health protocols and cover rural communities. This incorporation is feasible because of its low cost (between US$ 5-10 per pregnant woman attended) and to be highly modular and easily scalable. The solution takes advantage of the public health staff available in rural zones, without creating parallel structures but rather local capacities to make it sustainable, and means important savings because of the adequately transfer obstetric complications instead of urgent referrals, whose cost are very high in isolated areas. The Business Model focuses on offering 3 services to the public health institutions: equipment renting, training of rural health personnel and remote quality control. The "renting" approach avoids the difficulties of the public system to have the necessary initial capital for purchasing the equipment. This strategy allows to ensure the availability of equipment from the beginning and to maintain the technology to guarantee its productivity (lack of maintenance is one of the common problems in public systems in developing countries).

In the pathway to scale through the public sector, we have considered that Ministries of Health usually lack enough human resources to carry out the training, quality control and equipment maintenance tasks that this strategy requires. For this reason, it would be interesting for governments to receive support in these tasks from external entities, at least in the early stages of implementation. In this line, this project has developed, thanks to the "pro-bono" help of the company PwC (Price Waterhouse Coopers), a scaling model for countries with an average Human Development Index, based on the concept of "social entrepreneurship". It must be highlighted that the triple health service of renting, training and Quality Control offers benefits from the third year of implementation (assuming a 4-year amortization period for the equipment), with a price of US$ 5-20 per pregnant woman (including 2 ultrasounds and urine analysis tests and 1 of blood). It must be noted that the benefits of social entrepreneurship would be used to replicate the model in other regions of the world. Project studies show a potential market of more than 2 million pregnant women without ultrasound in Latin America and more than 70 million in all developing countries. In this way, the "Healthy Pregnancy" strategy could be implemented quickly and efficiently, and progressively strengthen the Ministries of Health of different countries so that they fully incorporate it into their antenatal care protocols in rural areas.

The “Healthy Pregnancy” project is a solution that address one of the most serious health gap worldwide, maternal and neonatal mortality, by adapting to the needs of rural areas, where most of these deaths occur. After having attended more than 21,000 women in rural communities of Guatemala, the project has shown a high health impact as well as a great scaling potential to reach other countries or regions. The EHAS Foundation has designed a business model that offers the solution to the public health institutions through a leasing service, in order to avoid a high initial investment to buy the equipment (Prenatal Care kits), which becomes complex due to the scarce resources that the goverments of low-income countries usually have to scale these kind of solutions on their own quickly. EHAS has a vast experience working on improving primary health care in rural areas of low and middle-income countries, and with the support of SOLVE and MIT networks, it would be possible to analyze this business model and assess new ways of financing that complement the contribution of public health institutions, searching for a financing model based on public and private alliances that guarantees the right of health to pregnant women in rural areas.

One of the main supports that would strengthen the solution is the adaptation of the ultrasound probes software to the needs of the context, in order to simplify ultrasound tests as much as possible for rural health personnel (language, connection to Health Information System to store data, etc.). To this end, an alliance with ultrasound probe providers and/or software developers would be valuable.

On the other hand, the support of experts in funding and revenue models would allow exploring alternatives for financing the solution that complement the contribution of public health institutions, which is very limited due to the scarce funds available in low-income countries.

Finally, in terms of communication, it would be essential to design a good communication strategy to reach stakeholders in a clear and concise way, seeking to create alliances, spreading the service and replicating the model in new areas.

The EHAS Foundation would be interested in forming strategic alliances with healthcare technology providers, in particular with the company Philips, creator of the Lumify ultrasound probes that are perfectly adapted to the remote zones in which "Healthy Pregnancy" works. In the same way, the Butterfly iQ company has a portable probe model that could be incorporated in the Prenatal Care kits developed by this project. These alliances would allow to acquire these devices at a more competitive price, and to collaborate with these providers to adapt their software to the needs of health personnel in rural communities, as it has been mentioned in the previous question.

On the other hand, EHAS would also appreciate the support of MIT experts to analyze the solution's business model and assess new ways of financing that will strengthen it. Likewise, given the wide network in which MIT works, these experts would be key to identify complementary solutions, such as in the area of perinatal health, that can be integrated into "Healthy Pregnancy" and offer a more complete maternal health service to the Ministries of Health.

"Women are not dying from disease we cannot treat; they are dying because societies have yet to make the decision that their lives are worth saving". Mahmoud Fathalla (Gynaecologist and Obstetrician, 2009 United Nations Population Award) denounces with these words that high rates of maternal and neonatal mortality of poor rural areas are undoubtedly avoidable nowadays. "Healthy Pregnancy" relies on innovation to provide quality healthcare for pregnant women in remote zones with a portable Prenatal Care kit, contributing to reduce social inequalities and emphasizing human rights that must be guaranteed regardless of the region where people live. The improvement of women health in rural communities is decisive to reinforce their environments and promote their participation in society in decent and equal terms. In addition to the health benefits, this solution strengthens the technical and human capacities of the public health network that covers rural areas, mainly in the hands of female nurses, who acquire new skills and take on new professional challenges. The intervention is based on strengthening the right to health as a determining factor to empower women and stimulate structural changes that contribute to eliminate inequalities. The Innovation for Women Prize will help to analyze the solution's business model and assess new ways of financing that complement the contribution of public health institutions, very limited due to the scarce funds available in low-income countries. The final purpose is to define a financing model based on public and private alliances that guarantees prenatal controls for women in greater vulnerability.

Health is a fundamental condition to ensure development processes since physical wellbeing is essential to promote social cohesion and work capacity. However, serious health gaps remain in rural poor areas due to the lack of technical and trained human resources, as shown by the high rates of maternal and neonatal mortality. Nowadays there are simple, proven and routine solutions that guarantee a safe pregnancy for women in developed countries, like ultrasound and blood and urine tests, but inaccessible in remote zones of low-income countries due to the lack of political will and resources to perform them. "Healthy Pregnancy" takes advantage of the enormous opportunities offered by technology and innovation to bring both tests closer to where it is not reaching, by training rural nurses to use a portable Prenatal Care kit that allows to performance a quality and complete prenatal control to detect pregnancy risks on time, according to WHO standards . After having demonstred a 35% reduction in maternal and neonatal mortality in rural communities in Guatemala, the Health Workforce Innovation Prize would be used to analyze the solution's business model and assess new ways of financing that complement the contribution of public health institutions, which is very limited due to the scarce funds available in low-income countries. The final purpose is to define a financing model based on public and private alliances that guarantees prenatal controls for women in greater vulnerability.

The EHAS Foundation aims to apply technology to improve healthcare in rural areas of low-income countries. This includes using the most advanced data analysis and processing techniques. Universities compose the EHAS Foundation' board, and some of our collaborators are experts on data analysis, artificial intelligence, or machine learning. Having quality data is the starting point for doing this type of study, and “Healthy Pregnancy” is in that situation. The “Healthy Pregnancy” Project uses a Health Information System (HIS) based on the Open Medical Record System (OpenMRS)  platform. The HIS stores medical information from prenatal controls, such as blood pressure, haemoglobin levels, glycemia, weight and height,  previous diseases, urinary tract infections, communicable diseases… The HIS also stores the ultrasound images, and some information obtained from those images: length of the femur, biparietal diameter, the weight of the fetus, estimated delivery date, among others.  To date, we have registered more than 21,000 prenatal controls in this database, and we plan to apply data science techniques to identify possible linear and non-linear relationships among the different variables stored and the risks factors for the pregnancy. This could offer relevant insights to better tailor the Healthy Pregnancy strategy to the needs of specific groups. For example, we could prioritize women of particular age ranges or certain areas, or identify relationships between different pathologies or find some stationarity in the data. If we identify a useful application of this kind of technologies, it could be eventually embedded inside the Health Information System and serve as an expert system to support nurses' work and decision-making.

On the other hand, currently, nurses have to draw lines and curves on the images to measure lengths and diameters using the ultrasound software. These measurements are essential to determine the fetus size, its gestational age and to identify possible growth problems.  We want to apply image analysis techniques to automatically calculate the measurements and thus extract the information more accurately and quickly. This would help avoid mistakes when nurses perform imaging measurements or even detect incoherencies in the ultrasound image interpretation.

All this would help to improve prenatal care in rural areas where gynaecologist is not available.

An essential strategy to reduce maternal and neonatal mortality is to improve pregnancy monitoring to anticipate obstetric complications and approach the delivery safely. This project provides innovative tools and methodologies to strengthen prenatal check-ups in rural communities where this gap health causes more deaths. The solution overcomes isolations barriers by training and equipping nurses of the rural health system with a portable and autonomous Prenatal Care Kit to perform ultrasound scans and blood and urine analysis following WHO standards, and early detect risk pregnancies. This risk screening is remotely supervised by gynaecologists through a Health Information System. Obstetric complications are referred in advance to centres with appropriate resources, so rural health establishments avoid facing risky childbirths. All the process, ultrasound and analysis with remote supervision, ensure a pregnancy monitoring with similar quality to those offered in urban areas, contributing to equity and universal coverage of basic services.

“Healthy Pregnancy” has been operating in Guatemala since 2012 with the support of USAID, MIF-IDB and AECID, attending until today more than 21,000 women of 2 departments (Alta Verapaz and San Marcos). It has trained more than 50 nurses, delivered 30 Prenatal Care kits to the public health system, and demonstrated a reduction of 35% in maternal and neonatal mortality. The solution has been recognized by the 2019 1st Vidanta Foundation Award "Contributions to the reduction of poverty and inequality in Latin America and the Caribbean" and the 2017 MAPFRE Foundation Award "Best Health Promotion Initiative". The results achieved by the proyect were also published in 2019 by the scientific magazine “Reproductive Health” in the article “Detection of high-risk pregnancies in low-resource settings: a case study in Guatemala”.