Toy Contigo: Using SMS to improve prenatal and neonatal health outcomes in Nicaragua

Launched: May 2016

Nicaragua is characterized by the presence of two autonomous Regions on the Caribbean Coast of the country. The two autonomous regions are the North Caribbean Coast Autonomous Region (RACCN) and South Caribbean Coast Autonomous Region (RACCS). 

The South Caribbean Autonomous Region (RACCS) is very unique in its socio-cultural context with a dispersed, multicultural, multiethnic, multilingual and historically marginalized population of Miskitos, Creoles, Mayangnas, Garifunas and Ramas, generating very different contexts from one community to the next.

In 2013, UNICEF Nicaragua and the Government of the RACCS (GRACCS) jointly started designing a regional policy for children and adolescents, a process characterized by the use of Human-Centered Design methodologies. A multidisciplinary team, together with local communities, ran co-creation workshops and implemented investigation tools to identify the main problems of children and adolescents in the region. As a result of this participatory diagnosis process, five priority areas for RACCS children and adolescents were established: 

  • Prenatal health
  • Birth registration
  • Child labor and education
  • Violence abuses
  • Recreation and socialization

To address these different issues with input from the Human-Centered Design processes, the Regional Policy and Strategy for Children and Adolescents was designed to address the different priority areas. As a result, Nicaragua country office developed an initiative using the RapidPro platform to address prenatal health issues called Toy Contigo.

Foto58.ToyContigo_RACCS_A._Jirón_ copy.jpg

Each week the mother receives useful information for each specific week of pregnancy. Jacqueline Cortez, 31 weeks pregnant, receives messages from ToyContigo Counseling at Bluefields, RACCS.

In Nicaragua, only 3 out of every 10 mothers with newborns between 0-6 months are practicing Exclusive Breastfeeding (EBF) (Demographic and Health Survey (DHS), 2011) and the situation has not changed for more than 10 years (DHS, 1998, 2006, 2011/12). Although the national rate coverage of antenatal care is around 70%, it is barely 50% in the RACCS. Expectant mothers should know the benefits of practicing EBF for the first 6 months; however, adherence is hindered by barriers such as incorrect information, propagation of common myths, lack of household support, and limited community resources to support mothers, as well as a limited access to health facilities. This project aims to increase the rate of mothers who practice 6 months-EBF, to improve stimulation during the first months of life and to foster the early identification of warning signs to contribute to the reduction of maternal and infant mortality.

The strategy is based on fostering knowledge through sending text messages to pregnant mothers and their family and/or friends to generate attitude and behavior changes of the mothers and the people who are with them during pregnancy and first months of the baby’s life. Once the mothers are registered by health Centers, text messages are sent from the RapidPro platform. These predefined series of educative messages have been developed by the Mobile Alliance for Maternal Action (MAMA) and have been linguistically and culturally adapted to the context of the Nicaraguan Caribbean Coast. These tailored messages are transmitted to reinforce proper EBF habits, encourage adherence and increase contact with health systems which would normally be limited by geography. 

Foto66.Toy_Contigo._A._Jirón copy.jpg

The Toy Contigo Counseling also offers recommendations to pregnant women about the adequate diet to be followed during pregnancy, according to their possibilities, to ensure their nutrition and that of the baby. 

Since the project started, 700 mothers have been supported during their pregnancy and first months of the baby’s life and 400 spouses, friends and relatives have received messages to accompany them. In total, about 45,000 messages have been sent to these different key actors. The preliminary results of an internal assessment based on the KAP methodology (Knowledge, Attitudes and Practices) has provided data to identify the areas in which the project has generated impact. For example, in relation to the messages linked with maternal nutrition, the number of mothers who eat meat (beef, pork and chicken) to provide iron and folic acid increased by 27.7% between the first survey (baseline) and the second one (after they received the messages). These results demonstrate an acceptable level of acceptance of the advice by the mothers and the people who are with them.

In the short term, the pilot phase has been extended to rural communities surrounding the urban Bluefields area. Based on the lessons learned, registration of the participants which has previously been made by the health Centers through a paper based system will be digitized. To make the registration easier and faster, information will be collected using RapidPro. Messages will also be translated to Miskito and English Creole as these ethnic groups represent a significant part of the RACCS population. 

Additionally, an internal assessment of the project is about to be completed and an evaluation will be led by the Nicaragua country office later this year. The conclusions of these two processes will provide input on the impact and prospects for sustainability and scale of the project. The results will also be used to lobby local and national authorities to expand the this project to other communities. 

Here, you can watch a video about the beneficiaries' experiences (in Spanish).

For more information, please contact: Emmanuel Michaud, UNICEF Nicaragua -