Project Summary / Abstract Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality, particularly in LMICs. Home BP monitoring is an emerging strategy to promote frequent monitoring of BPs, however unique challenges exist in LMICs. Given widespread smartphone use in urban Ghana, we will leverage accessible technology, adapted to the Ghanaian setting, to overcome barriers to home BP monitoring. Aim 1 (R21) will adapt a home BP monitoring smartphone app to the Ghanaian context, using the ADAPT-ITT framework. Stakeholder focus groups and cognitive interviews will be held with Ghanaian pregnant women, midwives, and Obstetrician/Gynecologists to iteratively adapt the smartphone app, with a focus on cultural relevance, locally appropriate language and phrasing, and useability in low literacy and numeracy populations. Aim 2 (R21) will assess the feasibility, acceptability, and fidelity of a smartphone app-enhanced home BP monitoring intervention among pregnant patients in Ghana. We will engage 100 pregnant participants over 4 weeks of home BP monitoring using the refined smartphone app, and complete pre-and-post validated scales of acceptability, appropriateness, and feasibility. Fidelity will be evaluated by examining stored values in the BP monitor and smartphone app to determine if concerning combinations of elevated BPs and preeclampsia symptoms correctly trigger clinical alerts. Aim 3 (R33) will measure the adherence to BP monitoring with a smartphone app-enhanced home BP monitoring intervention among pregnant patients in Ghana. We will engage a prospective cohort of 200 pregnant participants in home BP monitoring from enrollment through delivery. Adherence to BP monitoring will be measured both as frequency and time to drop-off of monitoring over the course of pregnancy. Aim 4 (R33) will evaluate the clinical response to elevated BPs with a smartphone app-enhanced home BP monitoring intervention among pregnant patients in Ghana. Automatic alerts, triggered by BPs and symptoms, will be sent to study nurses trained on clinical response protocols. Timely clinical response (routine alert: <4 hours; urgent alert: <1 hour) will be evaluated by comparing times of a recorded elevated BP to the outgoing phone call by the nurse and successful contact with the participant. Appropriateness of clinical response will be assessed using an expert consensus approach. Outcome of clinical response will be evaluated by the proportion of participants who adhere with clinical advice provided by the study nurse. Smartphone app-enabled home BP monitoring is a novel strategy to address challenges in managing HDP. Implementing home BP monitoring in LMICs will provide a critical step toward frequent assessment of BPs, earlier diagnosis of HDP, and prevention of serious maternal morbidity and mortality.