Introduction

Over the past decade, there has been significant growth in mobile health (mHealth) projects in low and middle-income countries (LMICs). Mobile health is defined as the use of mobile devices, such as mobile phones or smartphones, to transmit various health content and services.1 Mobile health is a component of electronic health (eHealth), which is defined by the World Health Organization as the integration of information and communications technology to facilitate communication, delivery of health services, and management of health systems.2 By the end of 2016, 4.8 billion people, or two-thirds of the world's population, had a mobile phone, making it a technology that is integral to most people's lives.3,4 Short messaging service (SMS), or text messaging, is one of the most popular uses on mobile phones after voice calls.4 Text messages are relatively cost-effective;5 can be accessed remotely at any time, decreasing travel time and expenses;6,7 and can be provided through a variety of ways: written (e.g. SMS messages), visual (e.g. multi-media messages), or oral (e.g. voice messages).8,9 With this growth in access to mobile technology, there has also been growth in using mobile technology to address challenges in healthcare access, delivery, and knowledge.10 Mobile health has been argued to hold promise in reducing health disparities by reaching individuals who have fewer resources and difficulty accessing traditional healthcare settings.11 The first reported formal evaluation of a SMS-based health intervention was in 200212 on childhood asthma and the first randomized control trial, on smoking cessation, occurred in 2005.13 Since then, there has been steady growth in the number of mHealth interventions that have been developed for health promotion interventions with the goal to facilitate the delivery of health messages as well as influence positive health behaviours.4

Broadly speaking, mHealth interventions can be classified into different uses, including prevention and education (e.g. health information delivery, reminders), information sharing (e.g. data collection, test result sharing), or communication (e.g. peer or group support, or psychological).14 Of particular interest to mHealth interventions targeting mothers is prevention and education for improving their own health as well as their children's, focusing on illness prevention, health promotion, and health education. Evidence suggests that mothers in many LMICs do not receive the recommended antenatal or postnatal clinic contacts which can impact the number of opportunities for healthcare providers to share health promotion knowledge with mothers.15 The use of mHealth interventions across the perinatal period has particular relevance to illness prevention, health promotion and education whereby information can be shared with mothers about essential newborn care and mothers can also be encouraged to attend clinics to obtain additional in-person support as needed. The perinatal period is defined by the World Health Organization as the period from 22 weeks of gestation to seven days postbirth.16 For the purposes of this review, the perinatal period will be extended to 42 days post-birth, in order to be consistent with the World Health Organization definition of the postnatal period.17 Additionally, to capture all studies addressing the antenatal period, any intervention targeting a pregnant women, regardless of gestation age of the newborn, will be included. Therefore, in this review, the term perinatal refers to conception through 42 days post birth.

One particular area that has seen a growth in mHealth interventions is maternal and newborn health.18,19 With high rates of maternal and newborn mortality and morbidity rates in many LMICs,20,21 gaps remain in mothers' access to and use of perinatal care as well as the knowledge and self-efficacy needed to provide ongoing newborn care at home. Ideally, mothers should receive a minimum of eight antenatal contacts and four postnatal contacts, according to the World Health Organization.17,22 Challenges in attending these appointments are vast, including, but not limited to: level of education, place of delivery, economic status, and distance from health centre.23-26 Due to these missed appointments, mothers do not receive adequate information about their own and their newborns' health and expected outcomes. Studies have shown that antenatal and postnatal clinic attendance is poor,24,25,27,28 yet this is the most important time for mothers and newborns to ensure survival and best health outcomes. While most antenatal education focuses on maternal health and ensuring safe delivery,22 the quality and quantity of postnatal education is key to ensure survival post birth,17 making it an essential component to consider when examining mHealth interventions.

To address challenges in LMICs associated with perinatal care, mHealth has increasingly been used to improve maternal attendance at antenatal and postnatal clinic contacts.29-31 For instance, a study in Nigeria examined the impact that one-way SMS reminders had on mothers' postnatal clinic attendance and found that, compared to a historical control, two messages sent reduced the failure-to-attend rate by 21.5%, meaning mothers were 50% less likely to fail to attend their postnatal appointment.30 Similarly, a cluster randomized controlled trial in Brazil using a two-way SMS for pregnant women found an improvement in the coverage of recommend antenatal care practices, including syphilis and HIV testing.29

Additionally, there have also been studies on the use of mHealth for the improvement of maternal knowledge, self-efficacy and newborn health outcomes, through health promotion outside of the traditional clinic setting. One example, Mobile Midwife, is a mobile application that sends messages in local languages to mothers.32 Its use was evaluated in Ghana and was found to help mothers' knowledge about the birth process and newborn care practices and also help them gain self-efficacy in their ability to care for their children.32 Similarly, an educational session provided over the phone by a nurse in Ecuador resulted in higher levels of exclusive breastfeeding and fewer newborn illnesses compared to standard discharge education.5

These preliminary mHealth interventions provide evidence that mHealth may have the ability to not only increase the attendance at antenatal and postnatal appointments, but also to improve maternal knowledge, self-efficacy and newborn outcomes as a complement to existing in-person education. Therefore, the current review seeks to explore the impact of mother-targeted mHealth educational interventions on antenatal and postnatal clinic attendance and knowledge and self-efficacy related to newborn care in LMICs. Due to the early emergence of mHealth in this field, there is a limited number of studies to our knowledge published on newborn mortality outcomes, yet as an important consideration of the effectiveness of mHealth interventions, an objective is to explore the impact of identified mHealth interventions on newborn mortality and morbidity.

To date, mHealth reviews in LMICs have been broad and sweeping, exploring many mHealth initiatives and reporting outcomes ranging from impact of behaviour change interventions to efficacy, uptake and adoption.4,33,34 There have been reviews on mHealth interventions in LMICs related to maternal and newborn health, exploring the strengths, limitations and opportunities10,19,35,36 as well as evaluating the mHealth potential to improve antenatal and postnatal care contacts37,38 and immunization rates.37 What is missing from these previous reviews is a targeted consideration of maternal behaviour change related to not only increased antenatal or postnatal contacts, but also maternal knowledge and self-efficacy in their ability to care for their newborn. Additionally, none of these current reviews report on the impact on newborn outcomes, such as morbidity and mortality, in conjunction with maternal outcomes. The following databases were searched for existing systematic reviews on the topics and no review was located: MEDLINE, PROSPERO, Cochrane and JBI Database of Systematic Reviews and Implementation Reports.

Inclusion criteria

Participants

The review will consider studies that include mHealth education interventions that target mothers during the perinatal period in LMICs as defined by the World Bank.39 While this review will exclude interventions not targeting mothers (i.e. interventions targeting fathers only), we will include studies that include mothers as part of the targeted population (e.g. with fathers, grandparents), if the data is reported separately. Studies will be excluded if the mHealth intervention targets non-family caregivers (e.g. healthcare providers, community health workers) or were conducted in high income countries.

Interventions

This review will consider studies that evaluate mother-targeted mHealth education interventions during the antenatal or postnatal period. Mobile health interventions include mobile phones, smartphones, or tablets. The mHealth intervention must be initiated during the antenatal period (conception through birth) through six weeks postnatally, with no limitations on the frequency of contacts during or beyond this period. Interventions will be excluded if they began prior to pregnancy or began later than six weeks postnatally, are community/population-wide interventions, or address maternal health outcomes only, pregnancy, or intrapartum care alone. All eHealth interventions not associated with mobiles will be excluded, including, but not limited, to telemedicine, video conferencing, and web cameras. Any mHealth interventions that focus solely on information collection (e.g. data collection) or communication (e.g. peer or group support) will be excluded.

Comparators

This review will compare studies that use any comparators, including, but not limited to, standard care (e.g. discharge education that is currently being provided in hospital) or a control group receiving an "attention" text, which are SMSs to differentiate the effect of receiving a text message compared to the content of the message.40

Outcomes

This review will consider studies that include the following outcomes:

* Knowledge, defined in relation to each study measured using self-report questionnaires, surveys, tests, or other measures as reported by studies.

* Self-efficacy, defined in relation to each study measured using standardized self-reported questionnaires (e.g. Perceived Maternal Parenting Self-Efficacy (PMP S-E) tool,41 Infant Care Self-Efficacy42) or other measures as reported by studies.

* Attendance at antenatal clinic and/or postnatal clinic, reported as the number of contacts.

* First day newborn mortality, defined as death within 24 after birth.

* Early newborn mortality, defined as death with (a) seven days and (b) 24 days post birth.

* Newborn morbidity outcomes as reported by studies within postnatal period (including but not limited to, diarrhea, infection, need for readmission, etc.).

Types of studies

This review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies will be considered for inclusion. Studies published in English will be included.43 Studies published after 2000 will be included to be in line with the emergence of eHealth technologies in the LMICs and consistency with other systematic reviews on eHealth interventions in LMICs.10,37

Methods

Search strategy

The search strategy will aim to find both published and unpublished studies. An initial limited search of PubMed has been undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. This informed the development of a search strategy that will be tailored for each information source. The search strategy for LMICs will utilize the predeveloped strategy by the Cochrane Effective Practice and Organization of Care (EPOC) group.44 A full search strategy for PubMed is detailed in Appendix I. The reference list of all studies selected for critical appraisal will be screened for additional studies.

Information sources

The databases to be searched include: CINAHL, PubMed and Embase. The search for unpublished studies will include Google Scholar (scholar.google.ca) as well as the following organizations engagement in mHealth initiatives: http://www.k4health.org and http://www.mhealthknowledge.org.

Study selection

Following the search, all identified citations will be collated and uploaded into Covidence (Covidence, Melbourne, Australia) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Studies that may meet the inclusion criteria will be retrieved in full. The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review report. Included studies will undergo a process of critical appraisal. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Assessment of methodological quality

Selected studies will be critically appraised by two independent reviewers at the study level for methodological quality in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute.45 Any disagreements that arise will be resolved through discussion or with a third reviewer. Following critical appraisal, studies that do not meet a certain quality threshold will be excluded. The decision to exclude will be based on a score less than 50% on the applicable critical appraisal instrument, as studies below this cut-off would be considered of too poor quality to include the data synthesis. While a description of the studies excluded will be provided in text, their data will be not included in the synthesis.

Data extraction

Data will be extracted from papers included in the review using the standardized data extraction tool available in Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI) by two independent reviewers.45 The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data where required.

Data synthesis

Papers will, where possible, be pooled in statistical meta-analysis. Effect sizes will be expressed as either odds ratios (for dichotomous data) or mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard chi-squared and I squared tests. The choice of model (random or fixed effects) and method for meta-analysis will be based on the guidance by Tufunaru et al.46 Subgroup analyses will be conducted where there is sufficient data to investigate differences between mHealth interventions targeting the antenatal period alone, postnatal period alone, or across the perinatal period. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. A funnel plot will be generated to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry will be performed where appropriate.

Assessing certainty in the findings

A Summary of Findings will be created using GRADEPro GDT software (McMaster University, ON, Canada). The GRADE approach for grading the quality of evidence will be followed. The Summary of Findings will present the following information where appropriate: absolute risks for treatment and control, estimates of relative risk, a ranking of the quality of the evidence based on study limitations (risk of bias), indirectness, inconsistency, imprecision and publication bias. The following outcomes will be included in the Summary of Findings: maternal knowledge, maternal self-efficacy, perinatal clinic attendance, newborn mortality and newborn morbidity, as applicable.

Acknowledgments

This review is part of JD's dissertation project. The authors would like to thank Dalhousie University's librarian, Robin Parker, for her assistance with search strategy development.

Funding

JD is funded through a Canadian Institute of Health Research Doctoral Award to Honour Nelson Mandela (FRN154341) as a PhD in Health trainee at Dalhousie University. MCY is funded through the Canadian Child Health Clinician Scientist Program Career Development and Canadian Institute of Health Research New Investigator.

Appendix I: Search strategy for PubMed

((((family[Title/Abstract] OR familial[Title/Abstract] OR maternal[Title/Abstract] OR paternal[Title/Abstract] OR caregiver^*[Title/Abstract] OR mother^*[Title/Abstract] OR father^*[Title/Abstract] OR parent[Title/Abstract] OR parents[Title/Abstract] OR parental[Title/Abstract] OR parenting[Title/Abstract] OR women[Title/Abstract] OR woman[Title/Abstract]))) OR parents[MeSH Terms] OR caregiver[MeSH Terms] OR caregiver, family[MeSH Terms] AND ((neonatal[Title/Abstract] OR postnatal[Title/Abstract] OR post-natal[Title/Abstract] OR postpartum[Title/Abstract] OR post-partum[Title/Abstract] OR newborn^*[Title/Abstract] OR baby[Title/Abstract] OR babies[Title/Abstract] OR infant[Title/Abstract] OR infants[Title/Abstract] OR neonate^*[Title/Abstract] OR antenatal[Title/Abstract] OR prenatal[Title/Abstract] OR pre-natal[Title/Abstract] OR ante-natal[Title/Abstract] OR perinatal[Title/Abstract] or pregnant[Title/Abstract] OR pregnancy[Title/Abstract]) OR (postpartum[MeSH Terms] OR postnatal care[MeSH Terms] OR Infant, Newborn[MeSH Terms] OR care, prenatal[MeSH Terms] OR prenatal education[MeSH Terms] OR Perinatal Care[MeSH Terms] AND (((eHealth[Title/Abstract] OR e-Health[Title/Abstract] OR mHealth[Title/Abstract] OR m-Health[Title/Abstract] OR mobile health[Title/Abstract] OR cellphone^*[Title/Abstrast] OR cell-phone^*[Title/Abstract] OR information technology[Title/Abstract] OR FaceTime[Title/Abstract] OR smartphone^*[Title/Abstract] OR smart phone^*[Title/Abstract] OR mobile phone^*[Title/Abstract] OR iPhone^*[Title/Abstract] OR iPad^*[Title/Abstract] OR handheld[Title/Abstract] OR text messag^*[Title/Abstract] OR tele-medicine[Title/Abstract] OR telemedicine[Title/Abstract] OR tele-health[Title/Abstract] OR telehealth[Title/Abstract] OR SMS[Title/Abstract] OR MMS[Title/Abstract]))) OR (cell phone[MeSH Terms] OR text messaging[MeSH Terms] OR telemedicine[MeSH Terms] OR mobile health[MeSH Terms] OR mobile phone[MeSH Terms] OR medical informatics[MeSH Terms] OR computer, handheld[MeSH Terms]) AND ((("developing country"[tw] OR "developing countries"[tw] OR "developing nation"[tw] OR "developing nations"[tw] OR "developing population"[tw] OR "developing populations"[tw] OR "developing world"[tw] OR "less developed country"[tw] OR "less developed countries"[tw] OR "less developed nation"[tw] OR "less developed nations"[tw] OR "less developed population"[tw] OR "less developed populations"[tw] OR "less developed world"[tw] OR "lesser developed country"[tw] OR "lesser developed countries"[tw] OR "lesser developed nation"[tw] OR "lesser developed nations"[tw] OR "lesser developed population"[tw] OR "lesser developed populations"[tw] OR "lesser developed world"[tw] OR "under developed country"[tw] OR "under developed countries"[tw] OR "under developed nation"[tw] OR "under developed nations"[tw] OR "under developed population"[tw] OR "under developed populations"[tw] OR "under developed world"[tw] OR "underdeveloped country"[tw] OR "underdeveloped countries"[tw] OR "underdeveloped nation"[tw] OR "underdeveloped nations"[tw] OR "underdeveloped population"[tw] OR "underdeveloped populations"[tw] OR "underdeveloped world"[tw] OR "middle income country"[tw] OR "middle income countries"[tw] OR "middle income nation"[tw] OR "middle income nations"[tw] OR "middle income population"[tw] OR "middle income populations"[tw] OR "low income country"[tw] OR "low income countries"[tw] OR "low income nation"[tw] OR "low income nations"[tw] OR "low income population"[tw] OR "low income populations"[tw] OR "lower income country"[tw] OR "lower income countries"[tw] OR "lower income nation"[tw] OR "lower income nations"[tw] OR "lower income population"[tw] OR "lower income populations"[tw] OR "underserved country"[tw] OR "underserved countries"[tw] OR "underserved nation"[tw] OR "underserved nations"[tw] OR "underserved population"[tw] OR "underserved populations"[tw] OR "underserved world"[tw] OR "under served country"[tw] OR "under served countries"[tw] OR "under served nation"[tw] OR "under served nations"[tw] OR "under served population"[tw] OR "under served populations"[tw] OR "under served world"[tw] OR "deprived country"[tw] OR "deprived countries"[tw] OR "deprived nation"[tw] OR "deprived nations"[tw] OR "deprived population"[tw] OR "deprived populations"[tw] OR "deprived world"[tw] OR "poor country"[tw] OR "poor countries"[tw] OR "poor nation"[tw] OR "poor nations"[tw] OR "poor population"[tw] OR "poor populations"[tw] OR "poor world"[tw] OR "poorer country"[tw] OR "poorer countries"[tw] OR "poorer nation"[tw] OR "poorer nations"[tw] OR "poorer population"[tw] OR "poorer populations"[tw] OR "poorer world"[tw] OR "developing economy"[tw] OR "developing economies"[tw] OR "less developed economy"[tw] OR "less developed economies"[tw] OR "lesser developed economy"[tw] OR "lesser developed economies"[tw] OR "under developed economy"[tw] OR "under developed economies"[tw] OR "underdeveloped economy"[tw] OR "underdeveloped economies"[tw] OR "middle income economy"[tw] OR "middle income economies"[tw] OR "low income economy"[tw] OR "low income economies"[tw] OR "lower income economy"[tw] OR "lower income economies"[tw] OR "low gdp"[tw] OR "low gnp"[tw] OR "low gross domestic"[tw] OR "low gross national"[tw] OR "lower gdp"[tw] OR "lower gnp"[tw] OR "lower gross domestic"[tw] OR "lower gross national"[tw] OR lmic[tw] OR lmics[tw] OR "third world"[tw] OR "lami country"[tw] OR "lami countries"[tw] OR "transitional country"[tw] OR "transitional countries"[tw]))) OR (((((Developing Countries[MESH] OR Africa[MESH] OR Africa, Northern[MESH] OR Africa South of the Sahara[MESH] OR Africa, Central[MESH] OR Africa, Eastern[MESH] OR Africa, Southern[MESH] OR Africa, Western[MESH] OR Asia[MESH] OR Asia, Central[MESH] OR Asia, Southeastern[MESH] OR Asia, Western[MESH] OR Caribbean Region[MESH] OR West Indies[MESH] OR South America[MESH] OR Latin America[MESH] OR Central America[MESH] OR Afghanistan[MESH] OR Albania[MESH] OR Algeria[MESH] OR American Samoa[MESH] OR Angola[MESH] OR "Antigua and Barbuda"[MESH] OR Argentina[MESH] OR Armenia[MESH] OR Azerbaijan[MESH] OR Bahrain[MESH] OR Bangladesh[MESH] OR Barbados[MESH] OR Benin[MESH] OR Byelarus[MESH] OR Belize[MESH] OR Bhutan[MESH] OR Bolivia[MESH] OR Bosnia-Herzegovina[MESH] OR Botswana[MESH] OR Brazil[MESH] OR Bulgaria[MESH] OR Burkina Faso[MESH] OR Burundi[MESH] OR Cambodia[MESH] OR Cameroon[MESH] OR Cape Verde[MESH] OR Central African Republic[MESH] OR Chad[MESH] OR Chile[MESH] OR China[MESH] OR Colombia[MESH] OR Comoros[MESH] OR Congo[MESH] OR Costa Rica[MESH] OR Cote d'Ivoire[MESH] OR Croatia[MESH] OR Cuba[MESH] OR Cyprus[MESH] OR Czechoslovakia[MESH] OR Czech Republic[MESH] OR Slovakia[MESH] OR Djibouti[MESH] OR "Democratic Republic of the Congo"[MESH] OR Dominica[MESH] OR Dominican Republic[MESH] OR East Timor[MESH] OR Ecuador[MESH] OR Egypt[MESH] OR El Salvador[MESH] OR Eritrea[MESH] OR Estonia[MESH] OR Ethiopia[MESH] OR Fiji[MESH] OR Gabon[MESH] OR Gambia[MESH] OR "Georgia (Republic)"[MESH] OR Ghana[MESH] OR Greece[MESH] OR Grenada[MESH] OR Guatemala[MESH] OR Guinea[MESH] OR Guinea-Bissau[MESH] OR Guam[MESH] OR Guyana[MESH] OR Haiti[MESH] OR Honduras[MESH] OR Hungary[MESH] OR India[MESH] OR Indonesia[MESH] OR Iran[MESH] OR Iraq[MESH] OR Jamaica[MESH] OR Jordan[MESH] OR Kazakhstan[MESH] OR Kenya[MESH] OR Korea[MESH] OR Kosovo[MESH] OR Kyrgyzstan[MESH] OR Laos[MESH] OR Latvia[MESH] OR Lebanon[MESH] OR Lesotho[MESH] OR Liberia[MESH] OR Libya[MESH] OR Lithuania[MESH] OR Macedonia[MESH] OR Madagascar[MESH] OR Malaysia[MESH] OR Malawi[MESH] OR Mali[MESH] OR Malta[MESH] OR Mauritania[MESH] OR Mauritius[MESH] OR Mexico[MESH] OR Micronesia[MESH] OR Middle East[MESH] OR Moldova[MESH] OR Mongolia[MESH] OR Montenegro[MESH] OR Morocco[MESH] OR Mozambique[MESH] OR Myanmar[MESH] OR Namibia[MESH] OR Nepal[MESH] OR Netherlands Antilles[MESH] OR New Caledonia[MESH] OR Nicaragua[MESH] OR Niger[MESH] OR Nigeria[MESH] OR Oman[MESH] OR Pakistan[MESH] OR Palau[MESH] OR Panama[MESH] OR Papua New Guinea[MESH] OR Paraguay[MESH] OR Peru[MESH] OR Philippines[MESH] OR Poland[MESH] OR Portugal[MESH] OR Puerto Rico[MESH] OR Romania[MESH] OR Russia[MESH] OR "Russia (Pre-1917)"[MESH] OR Rwanda[MESH] OR "Saint Kitts and Nevis"[MESH] OR Saint Lucia[MESH] OR "Saint Vincent and the Grenadines"[MESH] OR Samoa[MESH] OR Saudi Arabia[MESH] OR Senegal[MESH] OR Serbia[MESH] OR Montenegro[MESH] OR Seychelles[MESH] OR Sierra Leone[MESH] OR Slovenia[MESH] OR Sri Lanka[MESH] OR Somalia[MESH] OR South Africa[MESH] OR Sudan[MESH] OR Suriname[MESH] OR Swaziland[MESH] OR Syria[MESH] OR Tajikistan[MESH] OR Tanzania[MESH] OR Thailand[MESH] OR Togo[MESH] OR Tonga[MESH] OR "Trinidad and Tobago"[MESH] OR Tunisia[MESH] OR Turkey[MESH] OR Turkmenistan[MESH] OR Uganda[MESH] OR Ukraine[MESH] OR Uruguay[MESH] OR USSR[MESH] OR Uzbekistan[MESH] OR Vanuatu[MESH] OR Venezuela[MESH] OR Vietnam[MESH] OR Yemen[MESH] OR Yugoslavia[MESH] OR Zambia[MESH] OR Zimbabwe[MESH] OR Zanzibar[MESH]))) OR ((Africa[tw] OR Asia[tw] OR Caribbean[tw] OR West Indies[tw] OR South America[tw] OR Latin America[tw] OR Central America[tw] OR Afghanistan[tw] OR Albania[tw] OR Algeria[tw] OR Angola[tw] OR Antigua[tw] OR Barbuda[tw] OR Argentina[tw] OR Armenia[tw] OR Armenian[tw] OR Aruba[tw] OR Azerbaijan[tw] OR Bahrain[tw] OR Bangladesh[tw] OR Barbados[tw] OR Benin[tw] OR Byelarus[tw] OR Byelorussian[tw] OR Belarus[tw] OR Belorussian[tw] OR Belorussia[tw] OR Belize[tw] OR Bhutan[tw] OR Bolivia[tw] OR Bosnia[tw] OR Herzegovina[tw] OR Hercegovina[tw] OR Botswana[tw] OR Brasil[tw] OR Brazil[tw] OR Bulgaria[tw] OR Burkina Faso[tw] OR Burkina Fasso[tw] OR Upper Volta[tw] OR Burundi[tw] OR Urundi[tw] OR Cambodia[tw] OR Khmer Republic[tw] OR Kampuchea[tw] OR Cameroon[tw] OR Cameroons[tw] OR Cameron[tw] OR Camerons[tw] OR Cape Verde[tw] OR Central African Republic[tw] OR Chad[tw] OR Chile[tw] OR China[tw] OR Colombia[tw] OR Comoros[tw] OR Comoro Islands[tw] OR Comores[tw] OR Mayotte[tw] OR Congo[tw] OR Zaire[tw] OR Costa Rica[tw] OR Cote d'Ivoire[tw] OR Ivory Coast[tw] OR Croatia[tw] OR Cuba[tw] OR Cyprus[tw] OR Czechoslovakia[tw] OR Czech Republic[tw] OR Slovakia[tw] OR Slovak Republic[tw] OR Djibouti[tw] OR French Somaliland[tw] OR Dominica[tw] OR Dominican Republic[tw] OR East Timor[tw] OR East Timur[tw] OR Timor Leste[tw] OR Ecuador[tw] OR Egypt[tw] OR United Arab Republic[tw] OR El Salvador[tw] OR Eritrea[tw] OR Estonia[tw] OR Ethiopia[tw] OR Fiji[tw] OR Gabon[tw] OR Gabonese Republic[tw] OR Gambia[tw] OR Gaza[tw] OR Georgia Republic[tw] OR Georgian Republic[tw] OR Ghana[tw] OR Gold Coast[tw] OR Greece[tw] OR Grenada[tw] OR Guatemala[tw] OR Guinea[tw] OR Guam[tw] OR Guiana[tw] OR Guyana[tw] OR Haiti[tw] OR Honduras[tw] OR Hungary[tw] OR India[tw] OR Maldives[tw] OR Indonesia[tw] OR Iran[tw] OR Iraq[tw] OR Isle of Man[tw] OR Jamaica[tw] OR Jordan[tw] OR Kazakhstan[tw] OR Kazakh[tw] OR Kenya[tw] OR Kiribati[tw] OR Korea[tw] OR Kosovo[tw] OR Kyrgyzstan[tw] OR Kirghizia[tw] OR Kyrgyz Republic[tw] OR Kirghiz[tw] OR Kirgizstan[tw] OR "Lao PDR"[tw] OR Laos[tw] OR Latvia[tw] OR Lebanon[tw] OR Lesotho[tw] OR Basutoland[tw] OR Liberia[tw] OR Libya[tw] OR Lithuania[tw]))) OR ((Macedonia[tw] OR Madagascar[tw] OR Malagasy Republic[tw] OR Malaysia[tw] OR Malaya[tw] OR Malay[tw] OR Sabah[tw] OR Sarawak[tw] OR Malawi[tw] OR Nyasaland[tw] OR Mali[tw] OR Malta[tw] OR Marshall Islands[tw] OR Mauritania[tw] OR Mauritius[tw] OR Agalega Islands[tw] OR Mexico[tw] OR Micronesia[tw] OR Middle East[tw] OR Moldova[tw] OR Moldovia[tw] OR Moldovian[tw] OR Mongolia[tw] OR Montenegro[tw] OR Morocco[tw] OR Ifni[tw] OR Mozambique[tw] OR Myanmar[tw] OR Myanma[tw] OR Burma[tw] OR Namibia[tw] OR Nepal[tw] OR Netherlands Antilles[tw] OR New Caledonia[tw] OR Nicaragua[tw] OR Niger[tw] OR Nigeria[tw] OR Northern Mariana Islands[tw] OR Oman[tw] OR Muscat[tw] OR Pakistan[tw] OR Palau[tw] OR Palestine[tw] OR Panama[tw] OR Paraguay[tw] OR Peru[tw] OR Philippines[tw] OR Philipines[tw] OR Phillipines[tw] OR Phillippines[tw] OR Poland[tw] OR Portugal[tw] OR Puerto Rico[tw] OR Romania[tw] OR Rumania[tw] OR Roumania[tw] OR Russia[tw] OR Russian[tw] OR Rwanda[tw] OR Ruanda[tw] OR Saint Kitts[tw] OR St Kitts[tw] OR Nevis[tw] OR Saint Lucia[tw] OR St Lucia[tw] OR Saint Vincent[tw] OR St Vincent[tw] OR Grenadines[tw] OR Samoa[tw] OR Samoan Islands[tw] OR Navigator Island[tw] OR Navigator Islands[tw] OR Sao Tome[tw] OR Saudi Arabia[tw] OR Senegal[tw] OR Serbia[tw] OR Montenegro[tw] OR Seychelles[tw] OR Sierra Leone[tw] OR Slovenia[tw] OR Sri Lanka[tw] OR Ceylon[tw] OR Solomon Islands[tw] OR Somalia[tw] OR Sudan[tw] OR Suriname[tw] OR Surinam[tw] OR Swaziland[tw] OR Syria[tw] OR Tajikistan[tw] OR Tadzhikistan[tw] OR Tadjikistan[tw] OR Tadzhik[tw] OR Tanzania[tw] OR Thailand[tw] OR Togo[tw] OR Togolese Republic[tw] OR Tonga[tw] OR Trinidad[tw] OR Tobago[tw] OR Tunisia[tw] OR Turkey[tw] OR Turkmenistan[tw] OR Turkmen[tw] OR Uganda[tw] OR Ukraine[tw] OR Uruguay[tw] OR USSR[tw] OR Soviet Union[tw] OR Union of Soviet Socialist Republics[tw] OR Uzbekistan[tw] OR Uzbek OR Vanuatu[tw] OR New Hebrides[tw] OR Venezuela[tw] OR Vietnam[tw] OR Viet Nam[tw] OR West Bank[tw] OR Yemen[tw] OR Yugoslavia[tw] OR Zambia[tw] OR Zimbabwe[tw] OR Rhodesia[tw] OR Zanzibar[tw])))

References