Mumbai, India – A pioneering project to communicate with expectant and new mothers through mobile phone messages is transforming ante- and post-natal care in Mumbai.
Medics say the approach provides a valuable tool in the effort to bring down India’s stubbornly high maternal mortality rates. Although India’s maternal mortality rate (MMR) has dropped by 65 percent since 1990, a UN report released earlier this year reveals that it is lagging behind the UN-mandated Millennium Development Goal of a 75 percent decline by 2015, making it one of the worst in the world.
Mumbai’s LTMG Hospital – better known as Sion Hospital – launched the project mMitra last December through a public-private partnership between the hospital, an NGO called ARMMAN, and pharmaceutical company Glenmark’s CSR initiative.
With increasingly nuclear families, the pregnant woman has to fulfil many roles and her own health takes a back seat.
It aims to bridge a communication and counselling gap in care for pregnant women and recent mothers. So far, about 500 women who have visited the out-patient ward for ante-natal care at Sion Hospital have been registered for mMitra and are receiving the weekly messages on their mobile phones.
Women receive calls every week during pregnancy in either Hindi or Marathi at hours they have chosen. If they miss a call, other attempts are made. Once a child has been born, women receive daily messages tailored towards the care of the infant and are contacted thereafter at periodic intervals until the child turns a year old.
Sion Hospital seemed the ideal choice to be the launchpad for the project because it operates as one of the main hospitals for Mumbai’s poor. The hospital saw 14,000 deliveries in 2013, of which about 3,500 were Caesarian-section surgeries.
Dr Aparna Hegde, who helped found mMitra, believes that the project would have been futile if the messages sent were via text, since the target audience is barely literate women.
“We wanted short yet lucid messages under 90 seconds,” she told Al Jazeera. “Voice messages are more intimate than texts, and so we got an older woman to record them. Her voice gives the impression of an ‘elder sister’ speaking to the younger pregnant woman.”
When she was in medical residency 18 years ago, she discovered how a lack of information was a key reason for maternal mortality.
“A pregnant woman was unaware that she had developed diabetes. Through her labour, the infant’s head had managed to emerge, but its body had bloated and was stuck. The child – head out, body inside the womb – died of asphyxiation. I axed the child at its neck and performed a C-section to remove its dead body. I stitched the body together, to hand it to the family. The mother died three days later. Both were preventable deaths, only if the woman had known the symptoms and the care to be taken,” Hegde said.
Deaths during childbirth
|Women are briefed about the mobile messaging service at Sion Hospital [Priyanka Borpujari/Al Jazeera]|
This incident almost two decades ago is not out of the norm. According to the Society for Nutrition, Education and Health Action (SNEHA), an NGO that works in the slums of Dharavi which neighbours Sion Hospital, high blood pressure, convulsions, hepatitis, and malaria cause maternal deaths among the urban poor. In rural areas, the causes are late arrivals at the hospital and post-partum haemorrhage. Anaemia is also not uncommon.
The federal government’s Integrated Child Development Services (ICDS) programme, which provides nutrition to pregnant women, recent mothers, and children under five, is also widely considered to have been a failure.
Changes in Indian society also contribute to MMR. Previously, a village midwife and the extended family provided the necessary counselling to pregnant women.
“With increasingly nuclear families, the pregnant woman has to fulfil many roles and her own health takes a back seat,” said Dr Yogesh Nandanwar, head of Sion’s department of obstetrics and gynaecology.
Doctors have limited time to counsel pregnant women – at Sion Hospital, the three-hour ante-natal care outpatient ward sees about 300 patients daily and has just seven doctors.
But a larger issue is that women do not prioritise their own health. Nandanwar said that women can be careless about pregnancy as it is not an illness and may falter in basic hygiene or skip taking supplementary pills – raising the question of whether mMitra could play a counselling role.
Dr Shailesh Kore, an associate professor of obstetrics and gynaecology, believes nothing can replace counselling by a doctor. He said: “Even though the messages are tailored in mMitra, each message ends with, ‘Have you visited your doctor recently?'”
The repetition of messages is considered crucial to drive home key points, like the need to consume iron and folic acid (IFA) tablets. According to India’s National Family Health Survey-3, only 29 percent of women in Mumbai consumed IFA tablets during their pregnancy for at least 90 days.
Sapna Yadav, 28, is expecting her third child, and was registered with mMitra on the phone number of her husband, a rickshaw driver, meaning she would often miss the calls.
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“I told my husband to activate my dormant phone number so that I could receive the calls without waiting for him,” she said, adding, “The messages mention that I should eat spinach, methi [fenugreek] and eggs, and I am eating them to stay healthy. I did not eat these during my previous pregnancies.”
Project mMitra has had an indirect impact too. Sion health worker Shobha Rani says that as a result of it, nausea is no more viewed with fear by pregnant women, something she experienced as a 17-year-old two decades ago when she was expecting her first child. “When I see the young pregnant girls, I see myself in them, and feel more responsible towards their health,” she told Al Jazeera.
Sometimes women forget to call when they have delivered. Rita Yadav avoided lifting heavy objects during her pregnancy, as instructed in the messages she was receiving, and delivered a boy on July 1 – but she hasn’t been receiving any messages thereafter because she lost the number she was meant to call.
“I need those messages now to find out if it is normal for an infant to be vomiting,” she said.
Hegde now aims to provide the messages to middle-class women, for a nominal fee, and to introduce customised messages for women infected with HIV.
“Usually, large NGOs take up such work. But I could not wait – I worked through my regular job while living in the US and interacting with people in India, across time zones. Today, I am happy to see that pregnant women can no longer be in the dark about an important and beautiful phase of their lives,” she said.