Abstract

This report synthesizes current evidence on the application of digital health technologies to improve Maternal, Newborn, and Child Health (MNCH) outcomes, with a specific focus on designing inclusive digital tools for rural mothers. It delineates the profound global burden of maternal and child mortality, particularly in low- and middle-income countries (LMICs), and explores how digital health offers transformative potential to bridge existing healthcare gaps. A comprehensive analysis of multifaceted barriers to digital health adoption—including infrastructural deficiencies, digital literacy disparities, socioeconomic constraints, and socio-cultural norms—is presented. The report then articulates foundational principles for inclusive digital tool design, emphasizing human-centered and participatory approaches, universal design, and cultural adaptation. Drawing on successful case studies, key success factors and challenges in scaling interventions are identified. Finally, critical ethical and governance considerations, such as data privacy, informed consent, and addressing the digital divide, are examined, culminating in actionable recommendations for advancing equitable and sustainable digital MNCH solutions.

1. Introduction

The global health landscape continues to grapple with significant disparities in maternal, newborn, and child health (MNCH) outcomes, particularly in rural and low-resource settings. While digital technologies offer a promising avenue to address these inequities, their effective and equitable implementation necessitates a nuanced understanding of both their potential and the complex barriers to their adoption. This report aims to provide a comprehensive analysis of these interconnected issues, culminating in a framework for designing inclusive digital tools that genuinely serve the needs of rural mothers.

1.1. The Global Imperative for Maternal, Newborn, and Child Health (MNCH) Improvement

Maternal health encompasses the well-being of women during pregnancy, childbirth, and the postnatal period, with the overarching goal of ensuring a positive experience that enables both women and their babies to achieve their full health and well-being potential.¹ Despite notable advancements over the past two decades, the global burden of maternal mortality remains unacceptably high. In 2020, approximately 287,000 women succumbed to complications during or after pregnancy and childbirth.¹ A significant majority of these deaths are preventable, stemming from direct causes such as excessive blood loss, infections, and high blood pressure, as well as indirect factors like anemia and heart disease.¹

The challenge extends to child mortality, with alarming statistics indicating that 5 million children died before reaching their fifth birthday in 2021, nearly half of whom (2.3 million) died within their first month of life.² Geographically, the burden is disproportionately concentrated, with Sub-Saharan Africa and Southern Asia alone accounting for 86% of global maternal deaths in 2017 and 58% of all under-five child deaths in 2021.¹ This concentration of mortality, particularly in fragile and humanitarian settings, is not merely a statistical anomaly but a stark indicator of systemic failures in healthcare access and quality.¹ The high prevalence of preventable deaths underscores a critical gap between existing medical knowledge and its application, pointing to profound health inequities rooted in geographical and socioeconomic disparities. Achieving universal health coverage (UHC) and the broader health aims of the Sustainable Development Goals (SDGs) therefore hinges on addressing these fundamental deficits in healthcare provision and accessibility.¹

1.2. Defining Digital Health and its Potential in Global Health

Digital health is an evolving and expansive field, broadly defined as the application of digital technologies to enhance health and healthcare.⁴ Its roots lie in “eHealth,” which refers to the use of information and communications technology (ICT) in support of health-related fields, with “mHealth” (mobile health) emerging as a subset focusing on mobile wireless technologies for public health.³ More recently, the term “digital health” has broadened to encompass not only eHealth and mHealth but also cutting-edge areas such as advanced computing sciences, big data analytics, genomics, artificial intelligence (AI), blockchain, and the Internet of Things (IoT).³ This comprehensive definition reflects a growing recognition of technology’s pervasive and integrated role in healthcare delivery.

Digital health interventions are discrete functionalities of digital technology designed to achieve specific health objectives.³ These interventions offer novel opportunities to address long-standing health system challenges, including enhancing the coverage and quality of health practices and services.³ For example, they can facilitate targeted communications, such as reminders and health promotion messages, to stimulate demand for services and broaden access to vital health information.³ The global digital health market, valued at approximately USD 245.3 billion in 2023, signifies substantial international interest and investment in this transformative domain.⁶ This considerable market value and the World Health Assembly’s unanimous approval of a resolution on Digital Health in 2018 ³ collectively demonstrate a global commitment to leveraging these tools. This indicates that digital health is increasingly perceived not as an optional addition but as a critical pathway to achieving universal health coverage and improving health outcomes, particularly in resource-limited settings where it can effectively overcome geographical barriers to care.³

1.3. The Critical Need for Inclusive Digital Tools for Rural Mothers

Digital health technologies hold immense promise for improving healthcare outcomes and reducing costs in low- and middle-income countries (LMICs) by effectively overcoming geographic and economic barriers that traditionally impede access to care.⁸ Empirical evidence supports this potential; for instance, a study in LMICs demonstrated that pregnant mothers receiving health-related text messages experienced a remarkable 174% increase in visits for essential prenatal care.⁸ Despite these compelling advantages, the successful application of digital health in mitigating existing health disparities is contingent upon overcoming a range of significant challenges. These include limited technology access, a pervasive lack of digital health literacy among target populations, and the absence of supportive policy frameworks.⁹

A critical concern is the potential for digital health interventions to inadvertently exacerbate existing inequalities if they are not implemented in a contextually relevant and inclusive manner.¹⁰ The presence of a “digital divide” ⁶ means that a standardized, “one-size-fits-all” approach, or one that assumes a baseline level of digital access and proficiency, is highly likely to fail vulnerable populations. Such an approach risks creating a new layer of exclusion, where those already marginalized by traditional healthcare systems are further disadvantaged by their inability to access or effectively utilize digital solutions. Therefore, the design process for digital health tools must be intentionally inclusive, deeply culturally sensitive, and directly address the fundamental social determinants of health (SDoH) that influence both digital access and literacy.⁹ This proactive approach is essential to ensure that digital health truly serves as an equalizer rather than a new source of inequity.

1.4. Structure and Objectives of the Paper

This report is structured to provide a comprehensive examination of digital health and MNCH technology, with a particular emphasis on designing inclusive digital tools for rural mothers. Section 2 will establish the current landscape of MNCH and digital health, detailing its evolution and potential. Section 3 will then delve into the multifaceted barriers hindering digital health adoption among rural mothers. Section 4 will articulate foundational principles and frameworks for inclusive digital tool design, including human-centered, participatory, and universal design approaches, alongside strategies for cultural and linguistic adaptation. Section 5 will present and analyze case studies of successful MNCH digital interventions, identifying key success factors and lessons learned for sustainable scale-up. Section 6 will address critical ethical considerations and governance issues pertinent to digital MNCH, such as data privacy, informed consent, and health equity. Finally, Section 7 will offer actionable recommendations for policymakers, developers, and implementers to advance inclusive digital health solutions in MNCH, followed by a concluding summary in Section 8. The overarching objective is to contribute to evidence-based strategies that foster equitable health outcomes for rural mothers and their children.

2. The Landscape of MNCH and Digital Health

Understanding the current state and trajectory of digital health, alongside the persistent challenges in MNCH, is crucial for identifying strategic opportunities for inclusive digital tool design. This section provides a foundational overview, highlighting the evolution of digital health and its potential to address critical gaps in maternal and child healthcare, particularly in underserved rural areas.

2.1. Evolution and Scope of Digital Health and mHealth

Digital health represents a dynamic and expanding domain that leverages digital technologies to enhance health and healthcare delivery.⁴ This field has evolved from earlier concepts such as “eHealth,” defined as the application of information and communications technology (ICT) in health and related sectors, and “mHealth,” a subset of eHealth specifically focusing on the use of mobile wireless technologies for public health.³ The term “digital health” has since broadened to encompass a wider array of advanced computing sciences, including big data analytics, genomics, artificial intelligence (AI), blockchain, the Internet of Things (IoT), and telemedicine.³ This expansion reflects a growing recognition of technology’s pervasive and integrated role in health systems.

The progression from eHealth to mHealth and now to the comprehensive “Digital Health” signifies a profound strategic shift in global health approaches. This evolution indicates an acknowledgment that technology is no longer a peripheral tool but a central, integrated component for strengthening health systems and achieving universal health coverage (UHC).³ This movement implies a transition from isolated technological applications to a more holistic, interconnected digital ecosystem that leverages diverse technologies to address complex health needs and improve the efficiency and quality of care.⁴ The World Health Organization (WHO) has actively championed this transformation, with its 2018 World Health Assembly Resolution on Digital Health unanimously recognizing the value of digital technologies in advancing UHC and Sustainable Development Goals (SDGs).³ The substantial global digital health market, estimated at USD 245.3 billion in 2023, further underscores the significant international investment and confidence in this transformative field.⁶ This collective commitment positions digital health as a critical enabler for global health objectives, particularly in resource-limited settings where it can overcome geographical barriers that traditional healthcare models struggle to address.³

2.2. The Disproportionate Burden of Maternal and Child Mortality in Rural and Low-Resource Settings

The global health community continues to face the urgent challenge of reducing preventable maternal and child deaths, a burden that falls disproportionately on rural and low-resource settings. In 2020, approximately 287,000 women died during or immediately following pregnancy and childbirth.¹ A staggering 86% of these global maternal deaths in 2017 occurred in Sub-Saharan Africa and Southern Asia.¹ Maternal mortality rates (MMR) in low-income countries stood at 430 per 100,000 live births in 2020, significantly exceeding global averages and highlighting severe regional disparities.²

Similarly, child mortality remains a critical concern. In 2021, 5 million children died before reaching their fifth birthday, with Sub-Saharan Africa accounting for 58% of these deaths.² More than half of all maternal deaths occur in fragile and humanitarian settings, which are often characterized by pervasive challenges such as chronic underfunding, severe shortages of healthcare personnel, and underdeveloped infrastructure.¹ These conditions dramatically worsen health outcomes.⁸ The underlying causes of these high mortality rates, such as limited access to skilled health professionals, inadequate clinical facilities, and a scarcity of essential medicines and supplies, reveal a healthcare system that is profoundly strained and often inaccessible to the most vulnerable populations.¹ This disproportionate burden is a stark indicator of systemic vulnerability, where existing health inequalities are exacerbated by a lack of resilient health systems and basic infrastructure, directly contributing to preventable deaths.¹⁰ The fact that over 50 countries are currently off track to meet the Sustainable Development Goals (SDGs) for maternal, newborn, and child mortality further emphasizes the urgent need for comprehensive and systemic interventions.¹³

2.3. The Promise of Digital Technologies in Bridging Health Gaps

Digital technologies offer a transformative pathway to bridge critical health gaps, particularly in low- and middle-income countries (LMICs) and rural areas where traditional healthcare infrastructure is often insufficient. These tools can significantly increase access to care, enhance disease surveillance, and provide crucial support for healthcare workers.⁸ Telemedicine and mobile health applications, for instance, enable remote consultations, thereby reducing the need for costly and time-consuming travel, and facilitating early detection and monitoring of disease outbreaks.⁸ The impact of such interventions is evident: a study in LMICs reported a 174% increase in prenatal care visits among pregnant mothers who received health-related text messages.⁸ Telemedicine has also demonstrated effectiveness in managing high-risk conditions during pregnancy, such as preeclampsia and other hypertensive disorders, proving particularly beneficial for marginalized populations.⁹

Beyond direct patient care, digital tools empower individuals to actively monitor and self-manage their health, increasing access to timely and convenient care and improving medication adherence.¹² They also play a vital role in strengthening the healthcare workforce by facilitating remote training for local community health workers (CHWs), enabling them to identify and address common maternal mental health problems during pregnancy.¹² The transformative potential of digital health lies in its unique ability to overcome traditional geographical and economic barriers, effectively enabling “last-mile” healthcare delivery.³ By providing remote consultations, continuous monitoring, and accessible health education ⁸, digital tools can circumvent the need for extensive physical infrastructure and human resources, which are often lacking in rural areas.¹⁰ This capability not only improves direct patient access but also empowers individuals with critical health information and supports local healthcare providers, thereby enhancing the overall resilience and reach of health systems in underserved regions.¹²

3. Multifaceted Barriers to Digital Health Adoption for Rural Mothers

Despite the significant promise of digital health, its adoption and effective utilization by rural mothers are impeded by a complex interplay of interconnected barriers. These challenges span infrastructural, educational, socioeconomic, and socio-cultural dimensions, often reinforcing existing health inequities.

3.1. Infrastructural Deficiencies: Connectivity, Power, and Device Access

A primary and pervasive challenge to scaling digital health interventions, particularly in low- and middle-income countries (LMICs), is the fundamental lack of adequate infrastructure.⁸ This includes widespread internet connectivity, reliable electricity supply, and access to appropriate digital devices.¹⁸ Many LMICs and rural areas struggle with unreliable power sources and limited access to electronic devices, rendering digital health tools impractical or unusable.¹⁸

In rural areas, high-speed internet access is frequently limited or entirely unavailable, creating vast “digital deserts” that exacerbate existing disparities in healthcare access.¹⁹ For instance, in the United States, 21 million people, including 14 million rural Americans, lack broadband access.¹⁹ Data indicates that rural households are significantly less likely to have high-speed internet (77.4% access) compared to their urban counterparts (98.5% access).²⁰ This disparity extends to device ownership, with rural high-needs areas exhibiting lower rates of smartphone, laptop, and tablet ownership.²² Furthermore, when devices are available in rural households, they are often shared among multiple family members, which can limit personal access, privacy, and consistent use for health purposes.²³ This interconnected web of infrastructural deficiencies means that the lack of reliable internet directly impacts the feasibility of telemedicine and data transfer, while unreliable power sources make digital devices unusable or difficult to charge.²⁴ Consequently, even where connectivity might technically exist, the limited availability and affordability of personal digital devices mean that individuals may lack the fundamental means to access digital services. This creates a compounding disadvantage, where communities already lacking physical healthcare facilities also lack the digital infrastructure to compensate, thereby amplifying existing health inequities.²¹ Innovative solutions, such as solar-powered systems designed to operate with intermittent network connectivity, are being developed to digitize and share vital health data even in areas without consistent mobile network access, offering a potential pathway to overcome these power supply challenges.²⁵

3.2. Digital Literacy and Educational Disparities

Beyond physical infrastructure, a significant barrier to digital health adoption is the prevailing low level of digital literacy, particularly among rural women.²⁶ Digital literacy is not merely about possessing a device or internet access; it encompasses the cognitive and linguistic abilities required to effectively navigate, understand, and utilize digital tools. Studies reveal substantial disparities in digital skills, confidence in using digital tools, and overall access to technology, often directly correlated with educational attainment.²⁶

Many rural women have limited formal education, which can make it exceedingly difficult to comprehend digital content, especially when it is not presented in their native language or local dialect.²³ Digital interfaces, often designed with assumptions of higher literacy and familiarity with Western UI conventions, can appear complex and intimidating to those not fluent in reading and writing.²³ Moreover, limited health literacy, which is closely linked to socioeconomic factors, education level, ethnicity, and age, further compounds this challenge, particularly during the critical prenatal stage.⁹ This confluence of low formal education and language barriers creates a significant “usability gap.” Digital tools designed without explicit consideration for low literacy and diverse linguistic backgrounds become inherently inaccessible, thereby reinforcing existing educational and health disparities.⁹ This highlights that even if the physical infrastructure were perfectly in place, the cognitive and linguistic barriers would prevent effective engagement, underscoring the necessity for tailored interventions and content that actively bridges this divide.

3.3. Socioeconomic and Financial Constraints

Socioeconomic status emerges as a fundamental determinant of access to maternal healthcare and, by extension, to digital health services. Poverty and financial limitations profoundly influence a woman’s ability to access essential care, including the costs associated with transportation, healthcare services, and medications.²⁹ This economic constraint extends directly to the adoption of digital health tools.

In contexts of resource scarcity, rural women often face difficult choices, prioritizing immediate family needs over expenditures on digital tools or internet subscriptions.²² The cost of mobile data and devices remains a significant barrier in many low-income countries.²⁷ This economic disparity also indirectly prevents participation in digital literacy programs, as the costs of travel to training centers can be prohibitive.²³ The inability of rural mothers to afford personal devices or consistent internet access directly translates into digital exclusion, even in areas where technical infrastructure might theoretically be available. This financial barrier is not merely an individual challenge but a systemic issue that perpetuates health inequities. It actively prevents vulnerable populations from leveraging digital tools that could otherwise reduce their healthcare burdens and improve outcomes, thereby widening the gap between those who can access digital health benefits and those who cannot.²²

3.4. Cultural, Social, and Gendered Norms Affecting Technology Use

Deeply entrenched cultural, social, and gendered norms present profound barriers to the effective adoption of digital health tools, extending beyond mere technical or economic limitations. Digital tools designed without consideration for diverse cultural backgrounds often prove ineffective in rural settings.²⁹ A significant oversight in many digital health interventions is the exclusion of key family members, such as fathers, grandparents, and other extended family members, who play crucial roles in maternal and child health decisions. These interventions are frequently conceptualized based on nuclear family structures, which do not accurately represent the broader family and community dynamics prevalent in many rural contexts.¹⁰

Furthermore, traditional gender-based roles can actively discourage rural women from engaging with digital technologies. Women are often perceived primarily as homemakers and caregivers, with little recognition of the need for digital knowledge within these roles.²³ This societal expectation is frequently reinforced by a lack of financial autonomy among rural women, limiting their ability to independently invest in digital learning or acquire personal digital tools.²³ Social stigma or skepticism from family members or community leaders can also deter women from using digital tools, creating an unwelcoming environment for technology adoption.²³ In certain contexts, such as among Black, mixed-race, and Hispanic populations in the US, digital tools have been reported to not align with personal needs or cultural backgrounds, highlighting a critical mismatch between design and user reality.³² These challenges reveal that digital health interventions, if not carefully designed, can inadvertently reinforce existing social inequalities. A purely technical solution is destined to fail if it does not account for the complex socio-cultural fabric of a community, necessitating interventions that are not just culturally

adapted but genuinely culturally co-designed to ensure their relevance, acceptance, and empowering potential.¹⁰

3.5. Healthcare System Weaknesses and Fragmentation

The inherent weaknesses and fragmentation within existing healthcare systems represent a critical, often overlooked, barrier to sustainable digital health adoption. In many low-income countries, healthcare systems are severely under-resourced, leading to a scarcity of skilled healthcare providers, inadequate physical infrastructure, and inefficient care pathways.²⁹ These systemic constraints contribute directly to a low quality of care, inadequate diagnosis and treatment, and persistently high maternal and child mortality rates.¹⁰

The deployment of digital health solutions in such environments is further complicated by challenges such as the poor coordination of numerous, often mushrooming, pilot projects.¹⁴ This lack of a unified strategy and interoperability among different digital solutions leads to a proliferation of multiple, parallel platforms that are neither integrated nor capable of seamless data exchange.¹⁴ The consequence is redundancy, duplication of effort, and a fragmented digital health landscape that hinders comprehensive care coordination.¹⁴ This piecemeal approach, frequently driven by external funding and often lacking long-term sustainability plans, undermines the potential for lasting impact and erodes trust within the health system.¹⁴ Digital tools, in this context, struggle to transition from isolated experiments to integrated, scalable solutions that genuinely strengthen the health system as a whole. This systemic disconnect and unsustainability highlight that even the most innovative digital tools cannot achieve their full potential if they are introduced into a fragmented and under-resourced healthcare ecosystem without a clear strategy for integration and long-term support.³⁴

Table 1: Key Barriers to Digital Health Adoption for Rural Mothers

Category	Specific Barriers
Infrastructural Deficiencies	Limited/unreliable internet connectivity (digital deserts) 8, Unreliable power supply 8, Low ownership/affordability of personal digital devices 22, Shared household devices 23, Lack of mobile network connectivity 35
Digital Literacy & Educational Disparities	Low digital literacy levels 26, Lack of digital skills and confidence 26, Low formal education levels impacting content comprehension 23, Language barriers and lack of localized content 23, Limited health literacy 9
Socioeconomic & Financial Constraints	Poverty and financial barriers to healthcare access 29, Inability to afford digital tools/internet subscriptions 22, Prioritization of immediate family needs over digital investments 23, High cost of mobile data 27
Cultural, Social, & Gendered Norms	Exclusion of key family members (fathers, grandparents) from interventions 10, Traditional gender roles discouraging women’s technology use 23, Lack of women’s financial autonomy for digital investments 23, Social stigma/skepticism towards digital tools 23, Cultural mismatches in technology design 31, Distrust in technology/providers 30
Healthcare System Weaknesses & Fragmentation	Lack of healthcare providers and inadequate physical infrastructure 29, Inefficient care pathways and low quality of care 10, Poor coordination of pilot projects 14, Weak health systems and lack of interoperability 14, Fragmented digital solutions and duplication of efforts 14, Unsustainable, externally funded initiatives 14

Value of Table 1: This table systematically categorizes the multifaceted barriers to digital health adoption for rural mothers. Its value lies in providing a clear, structured overview that moves beyond a simple list of problems. By grouping related challenges, it highlights the interconnected nature of these impediments. For instance, infrastructural deficiencies are not just about lack of internet but also about power and device access, which are all interdependent. Similarly, cultural barriers are linked to gendered norms and social stigma. This categorization aids in understanding the complexity of the problem space, which is essential for developing holistic and truly inclusive design strategies, as addressing one barrier in isolation may not yield significant results if interconnected barriers persist.

4. Principles and Frameworks for Inclusive Digital Tool Design

To effectively address the multifaceted barriers to digital health adoption among rural mothers, the design of digital tools must be guided by principles of inclusivity and equity. This section explores foundational design concepts and methodologies that prioritize user needs, cultural contexts, and varying levels of digital literacy.

4.1. Foundational Concepts: Human-Centered Design (HCD) and User-Centered Design (UCD)

At the core of inclusive digital tool development are the methodologies of Human-Centered Design (HCD) and User-Centered Design (UCD). These approaches fundamentally shift the focus of design from technology capabilities to the needs, capabilities, and contexts of the end-users.³⁶ HCD is a problem-solving process that begins with a deep understanding of the community and context surrounding a challenge, recognizing that even technically sound digital solutions will fail if they do not account for human perceptions, actions, and distractions.³⁷ It emphasizes that no health expert or digital strategist possesses more knowledge about solving a problem than a Community Health Worker or a Nurse operating within the local context.³⁷

UCD, often used interchangeably or as a component of HCD, is an iterative process that prioritizes user experience and accessibility, aiming to make products usable, useful, and desirable.³⁶ This process typically involves four main stages: an analysis phase to gather comprehensive data about users, their requirements, and the environment; a design phase for formulating preliminary concepts and prototypes; an evaluation step involving user testing and feedback; and an implementation stage for deploying and monitoring the improved product.³⁸ The success of mHealth applications, particularly in rural or low-resource settings, is highly dependent on their alignment with user needs and preferences.³⁸ The UCD approach ensures that the application interface is intuitive, engaging, and tailored to user expectations, thereby increasing satisfaction and adoption rates.³⁸ This iterative feedback loop is crucial for continuous improvement, leading to interfaces that are not only easier to understand but also more gratifying to use.³⁸ By involving users from the conception phase, designers can ensure that solutions are molded to enable everyone to have access to the information presented, preventing the creation of “unusable” designs.³⁹

4.2. The Role of Participatory and Co-Design Methodologies

Building on HCD and UCD, participatory design (PD) and co-design methodologies are critical for developing digital health tools that are truly inclusive and contextually relevant. These approaches involve actively engaging intended audiences, including diverse users, stakeholders, and community members, throughout the entire design and development process.³³ This deep involvement ensures that interventions are not only relevant and acceptable but also address the specific needs and realities of the target population.³³

Co-design is particularly valuable for developing information visualizations that aim to improve health outcomes through enhanced comprehension, communication, and behavioral changes.⁴⁰ It is an iterative process where changes are made based on continuous feedback from participants.⁴⁰ Studies highlight the importance of involving community partners from the very inception of a project, including defining the problem to be solved, the chosen approach, and their roles within the project.⁴² This collaborative approach helps build relationships and trust, which are essential for successful implementation, especially in communities where skepticism or distrust of external interventions may exist.⁴¹ Participatory approaches can leverage various digital formats, such as web-based platforms, visual formats, and mapping tools, offering benefits like enhanced participant anonymity, increased time and cost efficiency, and greater flexibility in scheduling.⁴³ However, challenges such as sufficient internet connectivity, required technical skills, and online fatigue must be considered.⁴³ Despite these challenges, co-design has been shown to clarify educational needs and develop engaging resources, particularly for low-literacy users, by incorporating their lived experiences and preferences.⁴⁴ The inclusion of diverse perspectives, including those of community health workers (CHWs), is vital for ensuring cultural appropriateness and bridging technological gaps.²⁷

4.3. Applying Universal Design Principles for Broad Accessibility

Universal Design is a methodology that aims to create mainstream products and services that are accessible to, and usable by, as many people as reasonably possible without the need for special adaptation or specialized design.³⁶ This principle moves beyond simply accommodating people with disabilities to improving the product experience for a broad range of users, effectively making it “better design”.³⁶ In the context of digital health, universal design means creating solutions that accommodate the diverse needs of all populations by adopting a sociotechnical lens that considers the interplay between social factors (such as culture, inclusivity, and accessibility) and technical aspects (such as design, functionality, and data integration) in every decision.⁴⁶

Well-implemented universal design principles offer a promising pathway to truly inclusive digital health.⁴⁶ For example, they can enable patients with limited digital literacy to initiate an online video-based consultation using a familiar technology like a telephone, or provide visually impaired individuals with accessible interfaces.⁴⁶ WHO’s strategic vision for digital health explicitly supports equitable and universal access to quality health services, emphasizing that digital health can enhance efficiency and sustainability while delivering good quality, affordable, and equitable care.⁷ This approach ensures that inclusivity is not an afterthought but is embedded within the design process, fostering a culture where equitable and inclusive decisions become the default.³⁶ By meeting the needs of those typically excluded, universal design improves the product experience for a wider user base, leading to more functional, usable, and desirable digital health tools.³⁶

4.4. Strategies for Cultural and Linguistic Adaptation

Effective digital health interventions for rural mothers must incorporate robust strategies for cultural and linguistic adaptation. This involves tailoring content and design to align with distinct local norms, beliefs, and values, thereby ensuring relevance, engagement, and acceptability among diverse populations.³³ A critical aspect of this adaptation is addressing language barriers. Many rural women have low levels of formal education and may not be fluent in dominant national languages, making digital content inaccessible if not provided in local dialects or regional languages.²³ Therefore, translation of materials, adaptation of language register, and modification of metaphors, scenarios, and visuals to reflect local culture and context are essential.³³

Beyond language, cultural adaptation involves understanding and integrating the lived experiences of the target community.⁴⁸ This includes addressing social stigma or skepticism towards technology, which can deter women from using digital tools.²³ It also means designing interventions that acknowledge and incorporate the roles of extended family members, such as fathers and grandparents, who are often excluded from nuclear-family-centric designs but play vital roles in MNCH decisions.¹⁰ Successful interventions, such as those in the Yi ethnic community in China, have demonstrated the effectiveness of multifaceted, participatory, and culturally-tailored health education delivered via digital platforms, which addressed barriers like low health literacy, outdated gender norms, and transportation costs.⁴⁹ Strategies include community involvement and co-design, allowing users to choose content relevant to their background, using culturally appropriate language and peer-led narratives to build trust and reduce stigma, and integrating links to local support services.³³ This iterative testing and feedback process with the target community is crucial for refining content and delivery, ensuring that the digital tool resonates deeply with the cultural fabric of the users.³³

4.5. Tailoring Design for Low Digital Literacy Populations

Designing digital tools for populations with low digital literacy is paramount for achieving inclusivity in MNCH interventions. The goal is to create interfaces that are as intuitive and welcoming as a familiar conversation, rather than confusing or overwhelming.²⁸ Several key design principles can facilitate this:

• Simple and Predictable Navigation: Digital tools should feature clear, recognizable labels instead of jargon, avoid deep menus (limiting to 2-3 layers), and place key actions prominently. For example, a “Pay Bill” button should be front and center, not buried in settings.²⁸ Users should be able to start and stop processes across different communication channels and easily reset passwords.⁵¹
• Plain Language and Avoidance of Tech Speak: Complex instructions must be replaced with simple, step-by-step guidance. Instead of “Authenticate your account with a one-time passcode,” use “Enter the 6-digit code we just sent to your phone”.²⁸ All content should be written in plain language, avoiding medical or technical terminology, and ideally, in local languages or dialects.²³
• Visual Cues and Step-by-Step Instructions: Progress bars should indicate task advancement (e.g., for form completion), and step-by-step guides with illustrations can make processes like app registration less intimidating.²⁸ Repeatable icons and visual cues help build user familiarity and confidence.⁵¹
• Error Prevention and Friendly Messages: Digital tools should be designed to prevent errors where possible, and when errors do occur, provide clear, non-judgmental messages. Vague pop-ups like “Something went wrong” should be replaced with specific, helpful guidance, such as “Oops! Looks like you missed your phone number. Please enter it here”.²⁸
• Touch-Friendly Interactions: For mobile interfaces, large, easy-to-tap buttons are essential, with properly spaced UI elements to minimize accidental clicks.²⁸ Mobile-responsive designs are also crucial.⁵¹
• Guided Walkthroughs and Onboarding: For first-time users, tooltips, overlays, or simple video tutorials can provide initial guidance. A banking app for seniors, for instance, might include an interactive demo for mobile check deposits.²⁸
• Support for Older Devices and Browsers: Recognizing that rural populations may have limited access to newer technologies, digital tools should be compatible with older devices and browsers.⁵¹

Ultimately, designing for low digital literacy means not assuming prior knowledge of digital tools.⁵¹ It requires progressive disclosure, showing only essential information upfront with options to “Learn More”.²⁸ This user-centric approach ensures that technology empowers rather than intimidates, making digital experiences accessible and intuitive for everyone, regardless of their digital proficiency.²⁸

5. Case Studies and Lessons Learned from MNCH Digital Interventions

The theoretical principles of inclusive design are best understood through their application in real-world settings. This section examines notable digital health interventions in MNCH, particularly in rural and low-resource contexts, to distill key success factors and identify persistent challenges for sustainable scale-up.

5.1. Overview of Successful Digital Health Initiatives in Rural LMICs

Digital health interventions have demonstrated tangible benefits in improving MNCH outcomes in various rural and low-resource settings across LMICs. These initiatives often leverage widely available mobile technologies to deliver critical health information, facilitate care-seeking, and support healthcare providers.

• Chipatala Cha Pa Foni (CCPF) in Malawi: Known as ‘health centre by phone,’ CCPF offers a toll-free hotline providing health information, advice, and referrals, alongside automated personalized tips and reminders (T&R) via mobile messaging for pregnant women and caregivers.⁵² Recognizing that only about one-third of rural Malawians have personal mobile phones, community-identified village volunteers ensure access for those without devices, often through community phones and interactive voice response (IVR) systems.⁵² This service aims to reduce maternal and child mortality by improving access to timely information and generating demand for services like antenatal and postnatal care, and facility births.⁵²
• Mobile for Mothers (India): This mHealth application, designed for Java-enabled Android smartphones, targets users with low educational attainment.⁵³ It provides pregnancy, maternal, and child care information through texts, photographs, and voice prompts in local languages like Hindi, with modules for antenatal, intranatal, and postnatal care. Accredited Social Health Activists (ASHAs) lead the intervention, acting as crucial intermediaries.⁵³
• ReMIND mHealth Intervention (India): Similar to Mobile for Mothers, ReMIND aims to improve awareness and access to MNCH services in rural Uttar Pradesh, also serving as a job aid for ASHAs.⁵³
• MomConnect (South Africa): This SMS-based solution links pregnant women and new mothers to healthcare workers, providing essential health information and reminders.⁵⁴
• Telemedicine for Maternal Health: Telemedicine platforms enable virtual consultations, remote monitoring, and access to specialists for pregnant women, particularly beneficial in rural areas lacking specialized care.⁹ Programs like “OB Nest” for low-risk pregnancies have shown lower reported pregnancy-related stress and higher patient satisfaction, allowing for in-home monitoring of vital signs.¹⁶ For high-risk pregnancies, telemedicine facilitates remote consultations with maternal-fetal medicine (MFM) specialists, reducing the need for long-distance travel and enhancing local care capacity.¹⁶
• Digital Adaptation Kits (DAKs) for Antenatal Care: WHO has developed DAKs as part of its SMART guidelines initiative, providing software-neutral, operational documentation based on WHO recommendations to inform the design of digital systems for antenatal care.⁵⁷ These kits include linked health interventions, user scenarios, data elements, and decision support, aiming to standardize and improve digital ANC services.⁵⁷
• Digitalized ANC Program in Burundi: A digital intervention using a reminder model successfully increased antenatal care (ANC) attendance in rural Burundi, demonstrating high maternal satisfaction (96.2%) and positive reactions to automated reminders (77.1%).⁵⁸ This program leveraged collaboration between midwives, nurses, and community health workers, centrally connected through automated communications.⁵⁸
• Postnatal Care mHealth Interventions: Studies in Nepal and Ethiopia highlight the potential of mHealth to improve postnatal care utilization through educational reminder messages focusing on visits, family planning, and breastfeeding.⁵⁹ These interventions address barriers like lack of awareness and distance to facilities.⁶⁰

These diverse examples illustrate that digital health interventions, ranging from simple SMS messages to complex telemedicine platforms, can significantly enhance access to care, improve health literacy, and promote positive health behaviors in underserved rural populations.¹⁵

5.2. Analysis of Key Success Factors and Best Practices

The successful implementation and scaling of digital health interventions for MNCH in rural areas consistently point to several critical factors and best practices:

• Community Health Workers (CHWs) as a Critical Link: CHWs play a transformative and indispensable role in bridging technological gaps and ensuring cultural appropriateness.²⁷ As trusted members of the communities they serve, CHWs understand local needs, customs, and barriers to care.⁶³ They extend health services beyond facilities through home visits, provide education, distribute resources, manage illnesses, and facilitate referrals.⁶³ Mobile health (mHealth) tools significantly boost CHW effectiveness by assisting in data collection, providing timely information and reminders, and supporting training and performance monitoring.⁶³ Their involvement is crucial for ensuring that digital solutions are integrated into existing workflows and accepted by the community.⁶⁵
• User-Centered and Participatory Design: A key lesson learned is that user-centered design is paramount for the widespread adoption of digital tools.⁶⁶ Successful interventions define a clear use case and value proposition, establishing a user-friendly solution for the target audience.⁶⁶ This involves deep engagement with users, including mothers and healthcare providers, from the outset to understand workflows, pain points, and communication channels.⁴⁵ Iterative design processes, where continuous user feedback is incorporated, are essential for developing intuitive, engaging, and culturally appropriate applications.³⁸
• Strong, Country-Led Partnerships: Scaling up and sustaining digital tools successfully requires strong, country-led partnerships involving government agencies, healthcare organizations, funders, and innovators.⁸ Solutions that have scaled effectively often benefit from close, long-established partnerships with committed governments.⁶⁶ This collaboration ensures alignment with national health strategies and promotes the long-term integration of digital solutions into existing health systems.³⁴
• Adaptable and Context-Sensitive Technologies: The use of adaptable digital tools that are designed to be used in various contexts is crucial.⁶⁶ This flexibility allows implementers to focus on the content and user experience rather than being constrained by rigid technology.⁶⁶ Interventions that are context-sensitive and account for infrastructural, socio-cultural, and technological barriers are more likely to succeed.²⁷ This includes designing platforms that work with slower internet speeds and can run on basic phones, with easy-to-use interfaces and content in local languages.³¹
• Timely Information and Reminders: Mobile phone-based interventions, particularly SMS and voice calls, have proven effective channels for delivering timely maternal health information, reminders for antenatal care (ANC) appointments, and postnatal care.²⁷ These targeted communications can significantly increase care-seeking behaviors and improve health literacy.⁸
• Remote Monitoring and Data Collection: Digital tools enable real-time data collection on patient health status and services, supporting continuous monitoring of maternal and fetal health metrics.³ This facilitates early detection of potential issues and timely interventions, while also strengthening disease surveillance and data-driven decision-making for public health policies.⁸
• Training and Capacity Building: Providing adequate training and ongoing support for healthcare workers on new digital tools is essential for their effective uptake and utilization.¹⁷ This includes basic tips on data security and remote learning opportunities.³¹

These best practices collectively underscore that successful digital health interventions are not merely technological deployments but rather integrated, human-centered initiatives that address the complex social, cultural, and systemic realities of rural communities.

5.3. Challenges Encountered and Lessons for Sustainable Scale-Up

Despite the successes, the implementation and scaling of digital health interventions in MNCH, particularly in rural and low-resource settings, have encountered significant challenges that offer crucial lessons for future efforts:

• Low Digital Literacy and Gendered Access: A persistent challenge is the low digital literacy among target populations, especially rural women, which impacts the effectiveness and scalability of interventions.²⁷ This is compounded by gendered access to mobile technology, where women may have less personal access to devices or face cultural restrictions on their use.²³ This highlights that simply providing technology is insufficient; comprehensive digital literacy programs tailored to women’s needs are essential.
• Intermittent Network Coverage and Infrastructure: Unreliable internet connectivity and intermittent network coverage remain recurrent themes impacting effectiveness.²⁷ Many LMICs struggle with widespread internet connectivity and electricity capacity, hindering the consistent use of digital tools.⁸ Solutions must be designed to function effectively even with low bandwidth or offline capabilities, and investments in robust infrastructure are critical.¹⁷
• Language Barriers and Cultural Appropriateness: Digital resources and training programs are often not localized for dialects or regional languages, making them inaccessible to a large segment of rural women.²³ Furthermore, interventions frequently fail to include communities early and inclusively enough in the design process, leading to a lack of understanding of lived experiences and exclusion of key family members (e.g., fathers, grandparents).¹⁰ This lack of contextual relevance can exacerbate inequalities.¹⁰
• Financial Constraints and Sustainability: The cost of digital tools, internet subscriptions, and participation in training programs can be prohibitive for low-income rural populations.²³ Many pilot projects are externally funded and unsustainable, failing to translate into widespread scalable and rational application within health programs.¹⁴ Long-term financial planning and government commitment are essential for sustainability.¹⁴
• Uncoordinated Pilots and Lack of Interoperability: The proliferation of uncoordinated pilot projects has resulted in multiple, parallel digital platforms that are neither interoperable nor integrated.¹⁴ This leads to redundancy, duplication of efforts, and hinders the ability to generate, link, and use data effectively across the health system.¹⁴ A shift from siloed digitalization approaches to a digital transformation of health systems as a whole, with strong leadership and interoperability strategies, is needed.³⁴
• Trust and Misuse of Technology: Challenges such as lack of trustworthiness and potential misuse of technology have been expressed by women and healthcare providers.⁶⁷ This underscores the importance of building trust through community engagement and transparent communication about data use and security.
• Limited Evaluation and Evidence: There is a recognized need for rigorous evaluation of eHealth and digital health interventions to generate evidence and promote appropriate integration.³ Many studies do not adequately meet essential criteria for evidence reporting, and there is a dearth of application of design science-based methods and theory-based frameworks in developing mHealth interventions.⁶⁸ This limits the ability to definitively assess effectiveness and refine interventions.

These challenges highlight that simply deploying technology is insufficient. Sustainable scale-up requires a holistic approach that addresses not only technological gaps but also socio-cultural contexts, economic realities, and systemic weaknesses within the healthcare ecosystem. The lessons learned emphasize the critical importance of user-centered design, strong country-led partnerships, and long-term vision for integrated and equitable digital health solutions.³⁴

6. Ethical Considerations and Governance in Digital MNCH

The increasing integration of digital health tools into MNCH services, particularly for vulnerable rural populations, introduces a complex array of ethical considerations and necessitates robust governance frameworks. These issues are crucial for ensuring that digital interventions genuinely promote health equity rather than inadvertently creating new forms of disparity.

6.1. Ensuring Data Privacy and Security for Vulnerable Populations

The collection and storage of health information via digital platforms introduce significant data privacy and security concerns, especially for vulnerable populations who may have limited understanding or control over their data. Health information is inherently sensitive, and its protection is paramount.⁶⁹ However, mHealth apps, while offering numerous benefits like remote monitoring and increased diagnostic accuracy, can also pose risks to user privacy and confidentiality.⁶⁹ Studies indicate that many apps operate with insecure infrastructure and that security is often not a priority for developers.⁶⁹ This leads to concerns about sensitive personal data being accessed or shared with third parties without adequate consent or protection.⁶⁹ A national survey revealed that concerns about data gathering are a common reason for people not downloading health apps.⁶⁹

For vulnerable populations, the implications of data breaches or misuse can be particularly severe, potentially leading to judgment, discrimination, or even penalties based on their health status.⁷⁰ The fear of receiving more personalized advertisements, surprisingly, has been cited as a frequent concern, highlighting a broader distrust in how personal data is utilized.⁷⁰ This underscores the critical need for robust legal frameworks and technical solutions to safeguard health data.⁶ To comply with WHO guidance, digital health tools must adhere to international standards for data protection (e.g., GDPR, ISO 270001) and ensure data is pseudonymized, collected, stored, transferred, and handled according to applicable local regulations.⁷¹ Key strategies for safe design include safety reserves, fail-safe mechanisms, and procedural safeguards.⁷² Ultimately, building trust among users requires transparent data protection policies and strong cybersecurity measures, ensuring that the benefits of digital health are not undermined by privacy concerns.¹⁸

6.2. Navigating Informed Consent with Low Digital and Health Literacy

Obtaining truly informed consent for digital health interventions from individuals with low digital and health literacy presents a unique and significant challenge. The legal doctrine of informed consent, which traditionally focuses on a patient’s understanding of risks and treatment options, often inadequately considers an individual’s health literacy.⁷³ This issue is compounded by the advent of digital health, where patients are increasingly expected to acquire and process health information through technological interfaces.⁷³

Low health literacy is a pervasive problem, affecting a substantial portion of the adult population, and it is distinct from general literacy due to its specialized vocabulary and understanding of healthcare systems.⁷³ When digital tools are introduced, a new layer of “digital literacy” is required, which may be lacking in vulnerable populations, including those with low socioeconomic status, the elderly, and individuals with disabilities.⁷⁴ This limitation directly impacts their ability to make informed decisions and can lead to digital exclusion.⁷⁴

To address this, practical strategies for obtaining genuine informed consent must go beyond merely presenting a digital form or relying on a “click-through” agreement:

• Plain Language and Simplified Communication: All information related to the digital intervention, its purpose, risks, benefits, and data practices, must be presented in plain language, devoid of medical, technical, or legal jargon.⁷³ Recommendations suggest writing at a fourth to sixth-grade reading level.⁷³ Sentences should be short and convey one thought at a time.⁷⁵
• Verbal Explanation and Discussion: Informed consent should be primarily supported by direct verbal communication and discussion with a healthcare provider or trained community health worker, rather than solely by a signed or clicked form.⁷³ This human element is crucial for clarifying complex information and addressing individual concerns.⁷³
• Visual Aids and Multimedia: Utilizing visual cues, illustrations, infographics, and short, animated videos can significantly enhance comprehension for individuals with low literacy.²⁸ Audio explanations should also be provided for those with reading difficulties or who prefer listening.⁷³
• “Teach-Back” Method: Implementing the “teach-back” or “repeat-back” method, where the patient explains the information in their own words, is an effective way to confirm understanding.⁷³ This can be integrated into both in-person and remote consultations.
• Iterative and Flexible Consent Processes: The consent process should be flexible and adaptive, potentially offering layered information where users can delve deeper if desired, but ensuring core information is always presented simply.⁷³ It should also support older browsers and devices, as well as provide clear options to undo actions or exit if confused.⁵¹

Ultimately, achieving genuine informed consent requires a shift in attitude from assuming understanding to actively ensuring it, recognizing that a mere signature or click does not equate to true comprehension, especially for vulnerable populations.⁷³

6.3. Addressing the Digital Divide to Promote Health Equity

The digital divide, characterized by disparities in access to and utilization of digital technologies, poses a fundamental ethical challenge to health equity. While digital health tools have the potential to transform patient care, existing barriers such as limited broadband access, low digital literacy, and cultural mismatches in technology design can exacerbate existing health disparities.⁷⁶ This disproportionate impact is particularly evident in rural, low-income communities and among racial and ethnic minorities.⁹

The issue extends beyond mere connectivity; it encompasses “digital determinants of health” that include infrastructure challenges, individual digital literacy, and structural biases embedded in policies that can lead to “digital redlining” in marginalized neighborhoods.¹¹ For instance, during the COVID-19 pandemic, vaccination sign-ups heavily reliant on internet access disadvantaged individuals in rural or low-income areas, highlighting how digital exclusion can directly translate into health inequities.⁷⁶

Promoting health equity requires intentional strategies to bridge this divide:

• Expand Technology Access: This involves prioritizing efforts to improve broadband infrastructure, digital literacy, and affordability to ensure equitable access to healthcare services for all patients.⁹ This includes providing affordable devices and improving connectivity in “digital deserts”.²²
• Improve Digital Literacy: Enhancing digital literacy is crucial for addressing health disparities, as populations with lower digital skills often struggle to access vital health information and services.⁹ This necessitates tailored interventions, including digital skill training and access enhancement programs, to empower rural women to engage fully with digital resources.²⁶
• User-Centered and Culturally Relevant Design: Digital health tools must be designed with input from diverse communities, ensuring they are culturally and contextually relevant.⁷⁶ This means avoiding a “one-size-fits-all” approach and actively adapting technologies to meet local needs.⁷⁶ For example, ensuring content is available in local languages and considering alternative, non-digital methods (like phone-based sign-ups) alongside digital tools.³¹
• Multi-stakeholder Collaboration: Bridging the digital divide requires collaboration among diverse stakeholders, including patients, caregivers, community leaders, public health officials, healthcare developers, vendors, and policymakers.⁷⁶ This collaborative approach is essential for assessing and addressing equity throughout the entire lifecycle of digital health solutions, from planning and development to implementation and monitoring.⁷⁶

By addressing the digital divide, digital health interventions can move beyond simply offering technological solutions to actively promoting health equity, ensuring that every individual, regardless of their socioeconomic status, race, ethnicity, or geographic location, has equitable access to health services and resources.⁹

6.4. Developing Robust Governance Frameworks for Digital Health Data

The rapid expansion of digital health technologies necessitates the urgent development and implementation of robust governance frameworks for health data. Effective data governance is crucial for managing and controlling healthcare data throughout its lifecycle, ensuring its accuracy, privacy, security, and accessibility for authorized users.⁷⁸ Without such frameworks, the transformative potential of digital health risks being undermined by concerns over privacy breaches, misuse of sensitive information, and a lack of trust.

Key aspects of developing robust governance frameworks include:

• Harmonized Approaches and National Strategies: There is a need for harmonized regional and national approaches to health data governance to strengthen national frameworks, ensure alignment, and foster collaboration while safeguarding individual rights.⁷⁸ The WHO emphasizes that national or regional digital health initiatives must be guided by a robust strategy that integrates ethical considerations.³
• Prioritizing Equity, Trust, and Ethical Use: Governance frameworks must explicitly prioritize equity, trust, and ethical use as core principles.⁷⁸ This involves recognizing health data as a unique category requiring rigorous protections and robust governance instruments.⁷⁸ The African Union (AU) Data Policy Framework (2022), for instance, recommends the development of sector-specific data governance and emphasizes the need for legal and regulatory frameworks for personal data protection and privacy.⁷⁸
• Legal and Regulatory Frameworks: Strong legal and regulatory frameworks are essential for digital health, including guidelines for health data protection and usage.³ These frameworks should address cross-border data sharing and ensure compliance with international data protection standards.⁷¹
• Interoperability and Data Sharing: Governance frameworks should promote interoperability and data sharing standards to prevent fragmented systems and enable seamless integration of diverse digital health technologies.¹⁸ This ensures that data can be effectively linked and analyzed to improve diagnosis, personalize care, and support public health initiatives.⁷⁹
• Community Engagement and Public Trust: Building public trust is fundamental. This requires transparency in data practices and active engagement with communities to ensure their values and preferences are considered in data governance policies.⁷⁸ Health data is not merely technical information; it represents the real experiences of individuals, underscoring the ethical imperative to protect it with dignity.⁷⁸
• Addressing Gaps and Generating Evidence: The WHO highlights the need to fill gaps in digital health, develop clear indicators for impact and economic value, and embrace inclusive development.⁸⁰ This includes generating strategic evidence on the effectiveness, acceptability, feasibility, resource use, and equity considerations of digital health interventions.⁷¹

In essence, robust data governance frameworks are not just about compliance; they are about building a trustworthy digital health ecosystem that prioritizes individual rights, promotes equity, and maximizes the public health benefits of digital innovation, particularly for vulnerable populations in LMICs.⁷⁸

7. Recommendations for Advancing Inclusive Digital Health in MNCH

To truly harness the transformative potential of digital health for Maternal, Newborn, and Child Health (MNCH) in rural areas, a multi-pronged approach is required. This involves strategic interventions across policy, infrastructure, community engagement, and funding, all underpinned by principles of inclusivity and equity.

7.1. Policy and Regulatory Enhancements

Effective digital health implementation requires supportive and adaptable policy and regulatory environments that prioritize equity and inclusion.

• Develop Comprehensive National Digital Health Strategies: Governments should formulate and operationalize integrated national digital health strategies that align with global goals like Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs).⁴ These strategies must move beyond siloed pilot projects to a holistic digital transformation of health systems.³⁴
• Establish Robust Data Governance and Privacy Laws: Implement strong legal and regulatory frameworks for health data governance, ensuring accuracy, privacy, security, and ethical use of sensitive health information.⁶ These frameworks should adhere to international standards (e.g., GDPR) and address concerns about data sharing, misuse, and algorithmic bias, particularly for vulnerable populations.⁸
• Mandate Inclusive Design Principles: Policy should require the integration of Human-Centered Design (HCD), User-Centered Design (UCD), and Universal Design principles from the conceptualization phase of all digital health interventions.³⁹ This includes ensuring cultural and linguistic adaptation, and designing for low digital literacy.²³
• Promote Interoperability and Standardization: Policies should encourage the development and adoption of interoperable digital health systems to prevent fragmentation, redundancy, and duplication of efforts.¹⁴ This facilitates seamless data exchange and integrated care pathways.
• Incentivize Rural Telehealth Expansion: Policy measures should actively promote and provide incentives for the expansion of telehealth services in rural and underserved areas, recognizing its potential to overcome geographical barriers and reduce travel costs.⁸ This includes exploring sustainable reimbursement models.⁵⁰

7.2. Strategic Investments in Infrastructure and Device Accessibility

Addressing the fundamental infrastructural and device access barriers is non-negotiable for equitable digital health adoption.

• Expand and Improve Broadband Connectivity: Governments and partners must prioritize significant investments in expanding high-speed internet infrastructure, particularly in rural and remote “digital deserts”.¹⁹ This may require innovative solutions like satellite internet or mobile hotspots in challenging terrains.³¹
• Ensure Reliable Power Supply: Implement sustainable power solutions for health facilities and households in remote areas, such as solar-powered systems and mini-grids, to ensure consistent device functionality and data transmission.²⁵
• Enhance Device Availability and Affordability: Develop programs to increase the availability and affordability of appropriate digital devices (e.g., low-cost smartphones, tablets) for rural mothers.²² This could include subsidies, community device-sharing programs, or partnerships with telecommunication providers.⁸³
• Support Offline Functionality: Design digital tools that can operate effectively with intermittent or no internet connectivity, allowing for data collection and information access offline, with synchronization when connectivity is available.²⁵

7.3. Community-Led Approaches and Capacity Building

Empowering communities and local healthcare workers is crucial for the acceptance and sustainability of digital health interventions.

• Integrate Community Health Workers (CHWs): Systematically integrate CHWs into digital health ecosystems, leveraging their role as trusted community liaisons.²⁷ Provide CHWs with appropriate digital tools, comprehensive training, and ongoing support to facilitate data collection, health education, and referrals.¹⁷
• Implement Participatory and Co-Design Methodologies: Actively involve rural mothers, their families, and community leaders in all stages of digital tool design, development, and evaluation.¹⁰ This ensures cultural relevance, addresses local needs, and builds trust and ownership.¹⁰
• Develop Tailored Digital Literacy Programs: Design and implement context-specific digital literacy and health literacy training programs for rural women, addressing varying educational backgrounds and language barriers.¹⁷ These programs should use plain language, visual aids, and hands-on practice.²⁸
• Foster Local Content Creation: Encourage the development of digital health content that is culturally sensitive, linguistically appropriate (including local dialects), and relevant to the specific health challenges and social norms of rural communities.²³

7.4. Fostering Sustainable Partnerships and Funding Models

Long-term sustainability and scalability of digital MNCH interventions depend on robust partnerships and diversified funding.

• Cultivate Multi-Stakeholder Partnerships: Promote strong collaborations between governments, local communities, healthcare organizations, technology developers, academia, funders, and civil society organizations.⁸ These partnerships should be country-led and aligned with national health priorities.⁶⁶
• Diversify Funding Sources: Move beyond short-term, project-based external funding towards diversified and sustainable financing models.¹⁴ This includes advocating for increased government allocation, exploring public-private partnerships, and leveraging innovative financing mechanisms.⁸
• Invest in Long-Term Maintenance and Support: Recognize that digital health interventions require ongoing maintenance, technical support, and updates to remain effective and relevant.¹⁸ Allocate resources for these long-term operational costs to ensure sustainability.
• Strengthen Monitoring, Evaluation, and Learning: Implement rigorous monitoring and evaluation frameworks to assess the impact, cost-effectiveness, and scalability of digital health interventions.³ Share lessons learned, both successes and failures, to inform future development and policy.³⁴

By strategically implementing these recommendations, stakeholders can work towards building an inclusive digital health ecosystem that effectively empowers rural mothers, strengthens MNCH services, and contributes significantly to global health equity.

8. Conclusion

The global imperative to improve Maternal, Newborn, and Child Health (MNCH) outcomes remains a critical challenge, particularly in rural and low-resource settings where systemic vulnerabilities lead to disproportionately high mortality rates. Digital health technologies offer a transformative pathway to bridge these profound health disparities by overcoming geographical, economic, and logistical barriers to care. The evolution of digital health from eHealth and mHealth to an all-encompassing field signifies a strategic shift towards integrated, technology-driven health system strengthening, with significant global investment underscoring its recognized potential.

However, the effective and equitable adoption of digital health tools by rural mothers is hindered by a complex interplay of multifaceted barriers. These include pervasive infrastructural deficiencies such as unreliable internet connectivity, inconsistent power supply, and limited access to affordable digital devices, which collectively create “digital deserts” and compound existing health inequities. Furthermore, low digital and health literacy, coupled with educational disparities and linguistic barriers, create a significant “usability gap” that renders many digital tools inaccessible. Socioeconomic constraints, including poverty and the inability to afford devices or internet subscriptions, act as fundamental determinants of digital exclusion. Deeply entrenched cultural, social, and gendered norms, often reinforced by a lack of women’s financial autonomy and the exclusion of key family members in design processes, further impede technology acceptance and utilization. Finally, the fragmentation and inherent weaknesses within existing healthcare systems, characterized by uncoordinated pilot projects and a lack of interoperability, undermine the sustainability and scalability of digital interventions.

To navigate these complexities, the design of digital tools must be intentionally inclusive, guided by foundational principles of Human-Centered Design (HCD) and User-Centered Design (UCD). These methodologies emphasize deep user understanding, iterative development, and a focus on usability, usefulness, and desirability. The integration of participatory and co-design approaches, involving diverse community members and stakeholders from the outset, is crucial for ensuring cultural relevance, building trust, and fostering local ownership. Applying Universal Design principles ensures that mainstream digital products are accessible to the widest possible population without special adaptations, accommodating varying capabilities and contexts. Furthermore, specific strategies for cultural and linguistic adaptation, including local content creation and addressing social stigma, are essential. Tailoring design for low digital literacy populations through simple navigation, plain language, visual cues, and guided walkthroughs is paramount for effective engagement.

Successful MNCH digital interventions, such as Chipatala Cha Pa Foni in Malawi and Mobile for Mothers in India, demonstrate the tangible benefits of these principles. Key success factors include the pivotal role of Community Health Workers (CHWs) as trusted intermediaries, robust user-centered design, strong country-led partnerships, and the use of adaptable, context-sensitive technologies that deliver timely information and enable remote monitoring. However, lessons learned highlight the persistent challenges of low digital literacy, intermittent network coverage, the need for sustainable funding models, and the risks of uncoordinated pilot projects.

Ethical considerations are paramount in this domain. Ensuring data privacy and security for vulnerable populations necessitates robust legal frameworks, adherence to international standards, and transparent data handling practices to build trust. Navigating informed consent with low digital and health literacy requires a shift from mere signatures to genuine understanding, facilitated by plain language, verbal explanations, visual aids, and “teach-back” methods. Addressing the digital divide is an ethical imperative to promote health equity, requiring strategic investments in infrastructure, device accessibility, and targeted digital literacy programs. Finally, developing robust governance frameworks for digital health data, prioritizing equity and ethical use, and fostering multi-stakeholder collaboration are essential for a trustworthy and impactful digital health ecosystem.

Future Directions for Research and Implementation

Future research should focus on rigorous, long-term evaluations of inclusive digital health interventions, employing robust study designs to generate stronger evidence on effectiveness, cost-effectiveness, and scalability. There is a particular need for studies that explore the longitudinal impact of co-designed and culturally adapted tools on MNCH outcomes in diverse rural contexts, moving beyond pilot phases to assess sustainable integration into national health systems. Research should also investigate the optimal models for integrating AI and other emerging technologies ethically and inclusively within MNCH, ensuring that these advancements do not further marginalize vulnerable populations.

For implementation, a sustained commitment to the recommendations outlined in this report is vital. This includes prioritizing national digital health strategies that embed equity and inclusion from conception, making strategic investments in universal broadband access and reliable power solutions, and ensuring the affordability and availability of appropriate digital devices. Crucially, fostering community-led approaches, empowering CHWs, and investing in tailored digital and health literacy programs will be essential for building local capacity and ensuring the acceptance and sustainability of digital tools. Finally, cultivating strong, diversified, and country-led partnerships will be key to mobilizing resources, sharing knowledge, and scaling effective interventions, ultimately contributing to a future where every rural mother and child has equitable access to high-quality healthcare, supported by thoughtfully designed digital technologies.

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