Smart Paper Technology for maternal and newborn health data in The Gambia: A qualitative study of early...

Many low- and middle-income countries rely on paper-based maternal and child health records that are often incomplete, fragmented, and difficult to use for continuity of care and decision-making. Smart Paper Technology (SPT), a hybrid paper-digital documentation system, has been proposed as a practical alternative to fully electronic medical records in resource-constrained settings. This study explored the early implementation of SPT in maternal and infant health services in The Gambia, focusing on feasibility and acceptability. We conducted a qualitative descriptive implementation evaluation guided by Rapid Assessment Procedures (RAP) in two pilot facilities in the Western Region of The Gambia between September and December 2024. Data were collected through 30 semi-structured interviews; four focus group discussions with 30 participants spanning facility-level clinical, management, and administrative staff, Ministry of Health staff, and technical and implementing partners; and non-participant observations across key service delivery areas. Data were analysed thematically using NVivo 14. Participants described SPT as feasible and broadly acceptable because it built on familiar paper-based workflows, was introduced through a participatory process, and offered advantages in reporting, information retrieval, and maternal-infant record linkage. However, these benefits were contingent on the implementation context. Key challenges included uneven training coverage, dual documentation, limited internet connectivity, scanning and data capture errors, storage constraints, and concerns about data governance. Staff adapted through peer mentoring, remote troubleshooting, and local workarounds. Participants emphasised that successful scale-up would require sustained training, clear governance arrangements, adequate human and technical resources, and a phased transition to government ownership. SPT offers a practical pathway towards digitisation in maternal and infant health services in LMICs, but its success depends on strong organisational systems, workforce support, and implementation processes that are responsive to routine service realities.