– by Dr. Aparna Hegde, Founder, Chairperson and Managing Trustee, Armman
I vividly remember the antenatal OPDs at Sion hospital that I manned during my houseman days. Invariably exhausted from the all-nighter imposed on me by a pink card holder going into labour the previous night (a literal pink card is given to a pregnant woman with high risk factors during her pregnancy. The unit which managed her during pregnancy period has to take care when she returns in labour), the antenatal OPD at 2:30 pm with almost 100 patients waiting outside in a line wasn’t something I looked forward to. Barely awake, I went through the motions on OPD days. It was a quick two minutes with each low-risk woman; a quick history: check; Hb, blood pressure, urine protein report noted: check and then quick advice (bai, take these tablets): check. This was followed by a quick stewarding of the women into the examination section with 3-4 women squeezed into a row waiting at each of the three examination tables. An equally tired senior registrar quickly examined the patients’ abdomen and if everything seemed normal, it was the end of the antenatal visit. We barely counseled the low-risk women. There was no time: the high risk patients had to be counseled a bit, there were a few women who needed to be admitted, there was already a few calls from the ward regarding another pink card holder who had arrived in labour and there was another who had to be rushed to the OR for a Cesarean section. The so-called low risk women could not be given time.
Yes, there was a sense of unease that rose once in a while regarding the care that I gave. But there was truly no time. There was truly no time to discuss her worries regarding the pregnancy, no time to share in her joys, no time to appraise her about danger signs of pregnancy, and no time to ensure that the woman came back for her next antenatal visit. And many never came back during the antenatal period. Some came back in labour with some undetected high risk factor that often led to terrible consequences only to be asked why she had not attended the antenatal OPD regularly. It was hard to accept any blame for not ensuring why she had not come back. There truly was no time.
The numbers suggest that my experience is not isolated. The direct result of lack of counseling and behavior change communication (as it is called in public health jargon) is lack of adoption of right behaviors, behaviors that will ensure good health for the mother and child. According to the National Family Health-Survey-3, in Mumbai, Delhi and Meerut, only 36-39% of urban poor women used any modern method of family planning. Only 29% of women in Mumbai consumed iron and folic acid (IFA) tablets during their pregnancy for at least 90 days. In Delhi, the consumption of IFA tablets was almost 22-23% lower among slum women than non-slum women. All indicators of delivery and postnatal care were consistently better in non-slum areas when compared to slum areas in most Indian cities in NFHS-3 . Almost 45% of children under age five in Mumbai and 41% in Delhi were found to be stunted in the NFHS-3 indicating that they had been undernourished for some time. Data from the National Nutrition Monitoring Board for 5 population groups across 35 cities suggest that slum populations have the worst dietary and nutritional profiles, with only 13% of children having normal weight for age.
Don’t get me wrong: my alma mater and other such tertiary public hospitals are doing a tremendous job: there is a place where poor people can access free care in India. Access to care is immediate in Indian cities and one does not have to wait months to get care, unlike in other public health systems in other parts of the world. The doctors do a great job under tremendous resource constraints. The problems in providing care are genuine. India’s population is so huge that it is difficult to create a system where appropriate behavior change communication is a part of a comprehensive system of care.
Having said that, just provision of information is not enough. Pregnancy and infancy are dynamic; situations change in a matter of weeks and sometimes hours. Hence for behavior change communication to be effective, it has to reach the right people at the right time!! More specifically, it should be:
– Timed to the age of pregnancy or age of the child.
– Targeted to those who need it
– Culturally specific and gender sensitive
– In the local dialect
– Reinforced by repetition
The solution: mMitra voice call service.
One remarkable aspect of India’s growth story has been the incredible rise in wireless connections. According to the Department of Telecommunications, Government of India, annual report of 2012-2013, the number of mobile phone subscribers in India is in the range of 865 million with an urban tele-density of more than 145%. This provides us with an unique opportunity to reach the women directly. You can read about mMitra here. However, mMitra is a voice messaging service in which automated voice calls of 60 -90 seconds duration, will be made to the enrolled women twice a week/weekly in the local dialect from the first month of pregnancy until the fifth year of child’s life. The voice messages will be culturally specific, timed to the women’s gestational age or age of the child, targeted directly to the women’s phones and reinforced by regular repetition. mMitra will be a true friend of the enrolled women: gently guiding them through pregnancy and infancy, sharing in her joys, appraising her of potential issues, reminding her when it is time to go for an antenatal visit or vaccinations or just telling her about how grown her baby is inside her. It is just the thing that would have complemented the care I gave to the women who visited my antenatal OPD during my residency days.
I am very happy to let you know that now all women attending the antenatal OPD of Sion hospital will get mMitra as a part of their routine antenatal care. Glenmark Foundation is funding this initiative. In July 2013, our trustee and honorary managing director, Mr Srinivaas Sirigeri, signed a Memorandum Of Understanding with Ms Cheryl Pinto of Glenmark Foundation which set the ball rolling!!! We spent the next four months, from August until November, getting the necessary permissions from the DEAN and the department of Obstetrics and Gynecology, perfecting our technology platform, perfecting the voice messages, appointing staff, designing the impact studies that will happen simultaneously, getting the two studies through the IRB (Institutional Review Board) process and finally the launch happened in December 2013. More about the launch in the next blog.