By providing antenatal care information to rural women through voice messages on their mobile phones, mMitra wants to change their beliefs and practices during pregnancy and post-partum
Across 250 villages in Maharashtra, pregnant women are feeling a little less confused. They have someone telling them how to take care of themselves this week. A friend, if you like. They receive this counsel through voice messages on the mobile phone. They receive this counsel where they wish to receive it, even in the privacy of their homes. This is relevant in a state where only 43% of women have freedom to travel alone outside (1). These messages may spur them to change certain behaviours to benefit them and their babies. This is also a state where 1 million newborn babies die every year. (2)
The messages they are receiving are part of mMitra, a mobile health project that uses voice messages to provide rural women information on antenatal care. Developed by Mumbai-based NGO Armman, the project is hoping to change the way women access knowledge during pregnancy and post-partum, and their behaviour as a result.
It's a tall hope.
But Dr Aparna Hegde, founder and chairperson of Armman, does not seem intimidated. She seems infused with the sort of restless energy that might just make this work. "This is the first implementation of the project," she says, showing me a doorstopper of a vision document. "In different places, we are looking to collaborate with community health partners on the ground. We are in talks with many people."
This implementation in Osmanabad, Solapur and Washim districts is in partnership with Swayam Sikshan Prayog (SSP) and has been funded by Department for International Development (DFID), a department of the British government. SSP, which mobilises rural women for sustainable development processes, has a network of community health workers (called Arogya Sakhis) to implement mMitra. They carry mobile phones with them and help pregnant women listen to these messages. In some villages, they also provide monitoring, diagnostic and treatment interventions at home for a nominal fee.
"We're hoping that this technology will help us reach more women," says Naseem Shaikh, Project Director, SSP. "Many women cannot take time out from work to attend counselling sessions. They work in the fields from morning to evening."
In the absence of counselling, misconceptions abound. Women do not know how to care for themselves and their unborn child. "They don't eat, don't take tablets on time," says Shaikh. "When they have morning sickness in the first trimester, they are not able to describe their problems to the health worker. They just stop eating. Then people tell them iron and calcium tablets will make the baby too heavy so they stop taking the tablets."
Middle class women in urban India have many ways to access pregnancy-related information. Books are easily available at the shop around the corner. Private gynaecologists answer questions on the phone or at monthly check-ups. An army of baby websites hold one's hand from first trimester blues to labour throes and beyond. In rural India, it's a different story.
Women are supposed to get their health information from government health workers known as ASHAs (Accredited Social Health Activists). These are women from within the community who are meant to motivate women to give birth in hospitals, bring children to immunisation clinics, encourage family planning via sterilisation, and perform a host of other tasks related to health and sanitation. Their roster is large. The government is banking heavily on them.
But according to Armman, there are 74,000 fewer ASHAs than needed. They are stretched too thin which means they don't always convey all the information or convey it patiently enough. Their limited education (grade 8) and training (23 days) also limits their effectiveness, says Dr Hegde.
Combined with low attendance at counselling sessions, these factors are a dangerous mix. Women do what they feel is adequate, depend on neighbours for advice, and endanger themselves and their unborn babies with pregnancy-related complications which are preventable. According to National Health Survey figures, 59% of women deliver their babies at home (3) in India and the maternal mortality ratio (MMR) is unacceptably high at 235 per 100,000. (4) One woman dies from complications related to pregnancy and childbirth every seven minutes while 20 others suffer pregnancy-related illness. (5)
mMitra, which means 'm(mobile) Friend' in Hindi, seeks to plug this gap between ignorance and information.
In areas where mMitra is implemented, pregnant women or those who have delivered can sign up free of charge. They will then receive voice messages on their cell phones, tailored to the month of pregnancy or the age of the child. The messages will tell the woman what she can expect, what she can look forward to, what she needs to be careful about. They will tell her about potential complications and possible preventive measures. The messages will be in the local dialect.
"We will be with a woman from pregnancy right until her child is five," Dr Hegde says. "She will get messages every week, twice a week or monthly depending on the stage."
Creating the vast bank of voice messages—clinically approved and in the local dialect—is one of the biggest challenges, says Dr Hegde. The messages run into the thousands. They need to address the cultural norms, myths, practices and nutrition specific to the area. Currently, they have been vetted by the Mumbai Obstetrics and Gynaecological Society and Armman plans to partner with other organisations as well to ensure that they meet medical and ethical standards.
Elsewhere in the world, such services have used text messages. Wouldn't this have been simpler? Yes, but not as useful, according to Dr Hegde. Text messaging services will be useless for 46% of rural Indian women who are illiterate. They also have character limitations and lack emotional content. The last becomes an important consideration where people are used to relying on folklore and traditional stories for information. Breaking through barriers of scepticism will be a challenge, especially since there is a large hope that culturally appropriate and comprehensive information will make women reach out for those tablets, ask for those supplements, travel for those check-ups.
With a project like this, the obvious question of financial sustainability comes up. mMitra has been envisioned as a free service for the women. Armman plans to generate advertising revenue using text, voice and animated content. Given that they are trying to reach a vast network of rural women, they may become an important avenue for rural marketers. If this takes off, FMCG companies should make a beeline for them. Armman plans to look at paid advertising for low-cost medical products, family planning services, water/sanitation products and messaging from NGOs promoting family planning and HIV/AIDS prevention. They also plan to negotiate with mobile phone companies to reduce prices.
Armman intends to tie up with ASHA workers, community health partners and government hospitals to ensure that women are registered for the mMitra service through multiple avenues. But relying on community workers to carry the messages to the women may not always be possible. Dr Hegde believes it will not be necessary either.
"Women in many places will be able to enrol and receive the messages on their own phones. This is because of the success of mobile phones in rural India. Many women have phones or their husbands do and they can access them at a particular time in the day."
She envisions more and more women will call a toll-free number and enrol themselves. After that, they only have to wait for the phone to ring.
(Anindita Sengupta is a writer and journalist. She is covering maternal and reproductive health with a grant from the International Reporting Project (IRP), a non-profit journalism organization in Washington DC)
1) Ministry of Health and Family Welfare Government of India. 2008. Maharashtra. National Family Health 2005-06 Survey (NFHS-3) India
2) Government of Indian Ministry of Home Affairs. 2011
3) National Family Health Survey III. Government of India. 2006; http://www.nfhsindia.org/NFHS- 3%20Data/VOL-1/Summary%20of%20Findings%20%286868K%29.pdf
4) UNICEF Statistics, India. 2008 ; http://www.unicef.org/infobycountry/india_statistics.html
5) UNICEF. The State of the World's Children. 2009; http://www.unicef.org/sowc09/
Infochange News & Features, March 2013