Digital maternal health interventions in resource-constrained settings: a RE-AIM evaluation of the e-SAATHI chatbot in Assam, India

Despite national progress in maternal health, Assam continues to face high maternal mortality and persistent gaps in antenatal (ANC) and postnatal care (PNC). Digital platforms offer scalable solutions to strengthen service uptake in resource-constrained settings. The objective is to assess the reach, effectiveness, adoption, implementation, and maintenance of the e-SAATHI intervention in improving maternal health service utilization and engagement in Assam between 2023 and 2025. e-SAATHI was implemented as a stage-based digital intervention delivering tailored health information, reminders, and referral support to pregnant and postpartum women (up to 15 weeks after delivery). The evaluation was grounded in the RE-AIM framework, drawing on both quantitative and qualitative data sources. Data sources included system-generated analytics, user feedback, and routine health facility records. Key indicators assessed included user enrollment, message delivery fidelity, service uptake (ANC and PNC), and user satisfaction. The intervention expanded from one pilot site to five districts, onboarding 54,297 women across 180 + facilities. Assisted onboarding via QR codes and offline forms enabled inclusion of remote populations. Message delivery fidelity exceeded 98%, supported by iterative adaptations such as simplified sign-up and multimedia content. In paired facility-based surveys of postpartum women in Assam (pre-intervention n = 210; post-intervention n = 303), reported first-trimester ANC registration was higher in the post-intervention phase, rising from 66% to 83%, completion of ≥ 4 ANC contacts increased from ~ 49.5% to 61.7%; selected provider-delivered care indicators were also higher. As the evaluation was single-arm and based largely on self-report, these differences cannot be attributed to e-SAATHI. Monthly ANC confirmations surpassed 1,000 by 2025, and PNC engagement increased tenfold after content upgrades. Over 95% of users rated messages as “very useful,” and health workers reported enhanced client preparedness. Adoption was facilitated by integration into state workflows and real-time dashboards. Government endorsement and scale-up funding support sustainability. The e-SAATHI intervention shows that human-supported, digitally enabled solutions can be delivered at scale in low-resource settings, with wide reach, strong adoption and high fidelity of implementation. Embedding such tools within routine health systems and adapting them to user needs are critical for scale and sustainability. Future efforts should focus on expanding postpartum support, enhancing personalization, and conducting rigorous impact evaluations. Not required.