TulaSalud: An m-health System for Maternal and Infant Mortality Reduction in Guatemala

Andrés Martínez-Fernández et al. | Journal of Telemedicine and Telecare | March 12, 2015


The Guatemalan NGO (Non-Governmental Organization) TulaSalud has implemented an m-health project in the Department of Alta Verapaz. This Department has 1.2 million inhabitants (78% living in rural areas and 89% from indigenous communities) and in 2012, had a maternal mortality rate of 273 for every 100,000 live births. This m-health initiative is based on the provision of a cell phone to community facilitators (CFs). The CFs are volunteers in rural communities who perform health prevention, promotion and care. Thanks to the cell phone, the CFs have become tele-CFs who able to carry out consultations when they have questions; send full epidemiological and clinical information related to the cases they attend to; receive continuous training; and perform activities for the prevention and promotion of community health through distance learning sessions in the Q’eqchí and/or Poqomchi’ languages. In this study, rural populations served by tele-CFs were selected as the intervention group while the control group was composed of the rural population served by CFs without Information and Communication Technology (ICT) tools. As well as the achievement of important process results (116,275 medical consultations, monitoring of 6,783 pregnant women, and coordination of 2,014 emergency transfers), the project has demonstrated a statistically significant decrease in maternal mortality (p < 0.05) and in child mortality (p = 0.054) in the intervention group compared with rates in the control group. As a result of the telemedicine initiative, the intervention areas, which were selected for their high maternal and infant mortality rates, currently show maternal and child mortality indicators that are not only lower than the indicators in the control area, but also lower than the provincial average (which includes urban areas).


With a Human Development Index (HDI) of 0.581, Guatemala is considered one of the least developed countries in Latin America (only Haiti has a lower HDI) and ranked 133rd in the list of 161 countries included by UNDP (United Nations Development Programme) in the Human Development Report 2013.1 The Department of Alta Verapaz, one of 22 departments in the country (a department is a division of the country for administrative purposes), was chosen by the NGO TulaSalud for the development of their rural telemedicine pilot project. Alta Verapaz has nearly 1.2 million inhabitants of whom 78% live in rural areas and 89% are from indigenous communities,2 48% of whose population lives in extreme poverty. In this Department, 74 maternal deaths and 27,052 live births were registered in 2012, denoting a Maternal Mortality Ratio (MMR) of 273 deaths per 100,000 live births. With 389 deaths registered in the same year, the infant mortality rate (IMR) for children under one year of age was 14.38 deaths per 1,000 live births.

The main causes of maternal mortality in Latin America and the Caribbean are hypertensive disease (25% of total deaths), postpartum haemorrhage (21%), obstructed labour (13%), abortions (12%) and sepsis/infections (8%).3 Meanwhile, the main causes of infant mortality in developing countries are pneumonia (19%), diarrhoea (18%) and malaria (8%), followed by episodes related to pregnancy and childbirth, such as prematurity (10%), neonatal sepsis (10%) and asphyxia at birth (8%).4
TulaSalud was established in 2007 to combat high maternal and child mortality rates, and address the serious problems of access to health services in rural areas of Guatemala with indigenous communities. Inspired by the work of the EHAS Foundation (in Spanish “Enlace Hispano Americano de Salud”, in English “Hispanic American Health Link”) among rural indigenous communities,5,6 TulaSalud embarked upon a program for strengthening health care in Alta Verapaz using Information and Communication Technologies (ICT).

To support the work of community health workers is an extended strategy to curb maternal and child mortality in developing countries,7 and TulaSalud’s telemedicine work follows this action line by providing remote support to community facilitators (CFs). The CF is a volunteer from a rural community who, having received basic training and a small stipend from the Ministry of Health and Social Welfare (MSPAS), performs prevention, promotion and health care (with a kit of essential drugs) to a population of around 1,500 inhabitants. The CFs are visited by a team of health professionals (qualified nurses) approximately once a month.

The innovation introduced by TulaSalud to a sample of 125 CFs in Alta Verapaz was the provision of a cell phone which enabled them to become tele-CFs. The cell phone allows the CF to make consultations regarding issues about which they are unsure; send full epidemiological and clinical information related to the cases they attend; receive continuous training, and perform community health promotion and prevention activities through distance learning sessions in the Q ‘eqchí and/or Poqomchi’ languages.

TulaSalud also conducts other activities such as the distance training of nursing technicians (through a 3 year course) and nursing assistants (through a 1 year course) using a multi-video-conference system. This training is carried out in collaboration with the Coban School of Nursing and has involved more than 1,100 students in 29 remote locations across the country. The impact of this part of TulaSalud’s work has, however, not been included in the study presented in this paper.

The use of m-health solutions to support the primary health care system in rural areas of developing countries is a very promising trend that has been explored in several projects. In Uganda the RapidSMS system was used to manage the roll out of malaria’s rapid diagnostic test8; in Zambia a SMS system was employed to reduce delay in sending infant HIV testing results from a centralized laboratory to remote rural health facilities;9 in Malawi a SMS system was designed to improve communication among health workers for family planning and reproductive health in rural areas10 and to improve influenza surveillance;11 in Botswana m-health is used for improving clinical education, decision making, and patient adherences;12,13 and in India a m-health systems was used to build a health information system14. These studies were mostly focused on improving health processes and only a few of them analysed the impact on health indicators, such as HIV virological failure.15 Moreover, only two projects were found working to improve maternal and infant health care. In Rwanda a mobile phone-based communication system was deployed to monitoring pregnancy and reducing bottlenecks in communication associated with maternal and newborn deaths.16 However this project did not analyse the impact on maternal or infant mortality. The solution proposed in17 managed to reduce perinatal mortality, but it was different from the one here presented because it was not designed to remotely support the CFs, but to communicate with the pregnant women and allow them to follow-up pregnancies through a SMS system. Given that is hard to find significant evidence on the impact of m-health projects in developing countries,18,19 the objective of this research was to evaluate the impact of the previously explained m-health project on maternal and child mortality in the selected rural area of Guatemala...


The study enables us to conclude that the m-health system introduced by the Guatemalan NGO TulaSalud has significantly reduced maternal mortality (p < 0.05) and child mortality (p = 0.054) in the Department of Alta Verapaz. A detailed analysis of the information shows that impact becomes noticeable two years after the start of the intervention, leading us to reflect on the difficulty of obtaining significant short-term impact results in telemedicine projects. While this study has focused on evaluating results among the most vulnerable groups in Alta Verapaz (pregnant women and children under 1 year of age), we believe it would be interesting to conduct the same study with morbidity and mortality data in general.