When they got married two years ago, Meena Yadav’s husband gifted her a mobile phone. Little did the 22-year-old imagine that the phone would become her close ally – her “mobile saheli” or mobile friend – when she got pregnant. Yadav lives in Patkalpada, a slum strewn over a hillock in Nalasopara, on the edges of Mumbai. The homes here have been built illegally and have no electricity and water supply. Rows of houses are divided by narrow lanes. In the middle of each alley runs a gutter.
Yadav was enrolled in a free mobile voice call service called mMitra through which she received short voice messages that guided her through what she descrbed as the “most challenging period of her life” by a local health worker.
“Phone wali aurat ne bataya ke hospital mein naam likhana padega.” The lady on the phone told me that I have to get my name registered, said Yadav, referring to the voice messages she receives as a part of the mMitra project run by non-profit organisation, Armman.
Unlike many pregnant women in the slum, Yadav decided to get three ultrasound scans during her pregnancy. Yadav, a Class XI drop-out, learnt from her mobile saheli that the ultrasound could help pick anomalies in her unborn child.
In April, Yadav had an “uneventful” delivery, by which she means that there were no complications such as high blood pressure, diabetes or bleeding before or during childbirth. Bleeding or haemorrhage before, during or after childbirth is the leading cause of maternal deaths in India. A pregnant woman can also develop pregnancy-induced hypertension and diabetes which needs to be controlled for safe childbirth.
According to World Bank estimates, 174 pregnant women died in India for every 100,000 live births in 2015. In neighbouring Sri Lanka, the maternal mortality ratio is just 30. Armman, the brainchild of uro-gynaecologist Dr Aparna Hegde, started the voice call service in 2013 with the aim of reducing maternal and infant mortality by merely telling women what they must and must not do while pregnant.
Poornima Chandanshive, who supervises the enrolment of pregnant women in Nalasopara into the programme, feels that women like Yadav are making the right decisions after listening to the voice messages. “Earlier, no one would eat iron folic acid tablets even if the doctor told them,” said Chandanshive. “Now, they eat it because they know that folic acid has something to do with the brain nerves and all mothers want their children to be smart.”
A study about the project in the Indian Journal of Maternal and Child Health project found that though 95.2% women knew the importance of taking iron folic acid during pregnancy, only 52.1% actually took the supplement. “Information alone does not always result in behaviour change,” the study concluded.
Consuming folic acid helps prevent neural-tube defects that manifest themselves as spina bifida, which is a birth defect of the spine, and anencephaly, which is a condition where the child is born without the parts of the brain and skull. Iron deficiency during pregnancy is associated with low birth weight, pre-term delivery and infant mortality.
A study published in British Medical Journal found that one-third of women who had their deliveries in government hospitals in Assam had moderate to severe levels of anaemia, which increased their risk of bleeding during childbirth and having a stillbirth. In some regions, doctors say that the proportion of severe anaemia in pregnant women is as high as 50%.
“It is not just mortality,” said Nandanwar. “If the mother is sick after childbirth she will be unable to care for the child impacting the child’s health adversely.”
Where information is hard to get
Women like Yadav from low-income families who go to overcrowded ante-natal clinics get little or no information about proper care. “Doctors don’t have enough time to counsel pregnant women today,” said Dr YS Nandanwar, head of obstetrics and gynaecology department at Lokmanya Tilak Municipal General Hospital in Mumbai, where about 15,000 children are born every year.
Hegde conceptualised mMitra based on her experiences during her residency at Lokmanya Tilak Municipal General Hospital in 1999 where she closely saw how lack of access to preventive care information led to loss of lives that were completely avoidable.
One traumatic experience Hegde recalled from her residency was of a woman who developed gestational diabetes and did not know. “When she finally went into labour at a peripheral hospital, the baby developed a condition known as shoulder dystocia where the head is delivered and the body remains stuck inside as it is too huge to deliver,” she said.
The woman was transferred to Mumbai’s Sion hospital in this horrific state where Hegde was on emergency duty. The child died since it could not be delivered and the woman died three days later. “We did not have the time to counsel her on why it was important to come back for regular antenatal visits, what are the danger signs during pregnancy, what are the possible complications,” said Hegde. “And she never came back.”
So Hegde set about creating a robust voice platform with sound medical advice dispersed in the form of recorded voice messages and dispatched at time slots chosen by the user.
A review of mobile health interventions similar to mMitra published in international medical journal PLOS One found that “interventions targeted at pregnant women increased maternal and neonatal service utilisation shown through increased antenatal care attendance, facility-service utilization, skilled attendance at birth, and vaccination rates”.
The most challenging task, Hegde found, was to actually formulate the messages. “The messages were formed to create an emotional bond with the mother layered upon which is the medical content,” she said. “One of the message is about sex during pregnancy, a topic women are not comfortable talking about. Women are making their own decisions regarding contentious issues like family planning”
But women don’t have phones
Last January, India’s Ministry of Health and Family Welfare launched a project similar to mMitra. The project called Kilkari, the Hindi word for a child’s laughter, was set up as part of Prime Minister Narendra Modi’s vision of Digital India but is yet to begin operations. It aims to reach pregnant women in six states including Odisha and Uttar Pradesh in the first phase.
The challenge is that many women do not own mobile phones. According to a 2015 research by GSMA, an international cell phone regulatory group, women in India are 36% less likely than men to own a mobile phone.
Some evidence of this is seen in the urban slum where 25-year-old Rinky Ghori, a mother of two who works as a sweeper, lives. Ghori does not own a mobile phone and depends on her husband for making or receiving phone calls. Before her second child Saurabh, who is now four months old, was born, she was registered with mMitra on her husband’s number. “If he is at home, he will give me the phone to listen to the call,” said Ghori. When asked if it would be easier if she had her own mobile phone, she said she is better off without it. “My husband may start doubting me,” she said. “Why make things messy?”
This was a challenge that Chandanshive and her colleagues were confronted with when they started the mMitra project in Patkalpada, where most families have migrated from Uttar Pradesh, Bihar, Haryana and Karnataka. “Husbands were not comfortable with the idea that an outsider is going to call and talk to their wives,” said Chandanshive who spends a considerable time convincing husbands and father-in-laws of pregnant women that the voice call is a recorded message and there is no possibility of an interaction.
To ensure that women who do not own mobile phones can listen to the calls, the project has devised a method by which the message can be in a second time slot. There is also a missed call system if the woman has missed all three opportunities to the message. “Many husbands record the calls and ask their wives to listen to it,” said Hegde adding that the involvement of the father is vital. “One mother told us that her husband, who was until then not involved in the care of the baby at all – after listening to a call about playing with the baby – came home and started playing with the child and that has led to a close bond now between them.”
Voice calls not enough
Community worker Usha Rathod, has been registering women for the voice call service for the past three years. “I visit women who are in their third trimester to make sure they are listening to the calls and following the advice,” she said. She also accompanies pregnant women to the hospital for their visits.
Rathod’s biggest concern is that the women she registers actually get to the hospital when they experience labour pain. When Pooja Badal, 25 years old and a mother of four, experienced excruciating pain in her ninth month she called 108, the free ambulance service operated by the Maharashtra government. But there is no road leading to or anywhere close to Badal’s house. “We walked down the hill till the rickshaw stand,” Badal recalled. “The ambulance had not arrived and my mother-in-law bundled me in the rickshaw and halfway to the hospital we saw the ambulance.”
Fortunately, Badal reached the hospital in time and gave birth to Ayush who is now seven months old. Badal’s first delivery was at her hutment where a dai or traditional midwife conducted the childbirth.
Chandanshive said that an increasing number of women are now opting for institutional delivery following the mMitra intervention and access t o better healthcare infrastructure. “Few months ago, a government hospital was started which is closer to our locality,” she said. “Earlier women had to travel for about an hour to reach the closest hospital.” Chandanshive pushed for a female gynaecologist at the newly built hospital as women in the slums of Nalapsopara were not comfortable with a male gynaecologist.
There are other problems that mMitra cannot solve here. Owing to the illegal nature of the settlements, most women do not have any documents to access maternity entitlements implemented by the state and central government. None of the women interviewed by Scroll.in had received any monetary remuneration under existing government schemes.
On New Year’s Eve, Modi reiterated that pregnant women can get monetary assistance of Rs 6,000, this time linked through their Aadhaar numbers to their bank or post office accounts.
Surekha Chavan, 23, whose first child was delivered at a private hospital spent Rs 60,000. Chavan and her mother had to pawn their gold jewellery to pay the hospital bill. Chavan, who is nine months pregnant and has been receiving voice calls, has registered with the local hospital this time. “We had a tough time paying off that loan,” said Chavan. After learning about the monetary schemes, she asked if the money can be deposited in her husband’s account as she did not have one.
This reporting project has been made possible partly by funding from New Venture Fund for Communications.