How a pack of cards helped improve maternal health in Bihar

While India has been reporting a steady decline in its maternal mortality rate, the country still accounts for the largest number of maternal deaths in the world. In 2010, India recorded 56,000 maternal and 1.3 million infant deaths — the highest for any country. According to the Millennium Development Goals, India’s target is to reduce its MMR by three-quarters, from 437 maternal deaths per 100,000 live births in 1990-91, to 109 by the end of 2015. India’s MMR was at 190 per 100,000 births in 2013, according to the latest figures from UNICEF and the World Bank — leading experts to project India won’t reach its MMR goal by the end of the year. But such dismal statistics, in a nation striving to be known more for technological innovation and as an economic powerhouse rather than mothers dying on the floor from preventable deaths, have spurred inventive efforts to combat the issue. Given that 75 percent of India’s health infrastructure is concentrated in urban areas where only 27 percent of the population lives, entrepreneurs have recognized mobile technology’s huge potential to improve health outcomes in rural communities. Mobile Kunji In 2010, BBC Media Action India introduced a job aid for front-line health workers called Mobile Kunji, which was designed to persuade rural women to adopt better health practices. It’s a pack of 40 illustrated cards, which communicates health messages to rural families about safe delivery, early initiation of breast-feeding and family planning, among others. Each card has a toll-free code that when dialed by the front-line health worker from her mobile phone, takes the listener to an audio recording that reinforces the health message that the particular card carries. A fictional doctor known as Dr. Anita delivers the voice message. “Earlier, women didn’t trust us but now when I visit them with the job aid, they believe what I’m saying,” said Chotki Paswan, a front-line health worker in the Sulpanpuri Ghato village in the Samastipur district in the eastern Indian state of Bihar. Paswan said that since she began using Mobile Kunji, which requires front-line health workers to undergo mobile-based training before they use it, she’d noticed four major changes in her village. “A lot of deliveries were happening at home — we were telling women not to do it but it was still happening. There was also this preconceived notion that a mother’s first milk was impure so they were throwing it away,” she explained. “Women also didn’t know that until six month’s age, a baby should only have milk — they were giving other solubles. [In addition] there was this belief that complementary feeding would mean mashed food would get stuck in the baby’s mouth.” Geetha Dava, who has a five-month-old baby, is one of the women who has benefited from Mobile Kunji. She used to believe everything her mother-in-law tells are about giving birth and what to feed her baby. “But when the [accredited social health activist] and anganwadi worker (development worker focusing on women and child health) started coming to my house, I started believing what they were telling me. I thought delivering a baby at home was no different to giving birth at a hospital,” she recounted. “My mother-in-law has a lot of experience but the times have changed. When a health worker came with knowledge and mobile technology that backs up what she is telling me, I relied on her experience so I decided to trust her and what she was saying.” Health care gaps In 2005 the government, under the National Rural Health Mission, launched a conditional cash transfer scheme providing pregnant women with cash incentives for giving birth in hospitals. Despite government action, there are still fundamental gaps in the country’s health care system, as a report last year titled “Dead Women Talking: A Civil Society Report on Maternal Deaths in India,” written by civil society networks CommonHealth and Jan Swasthya Abhiyan, noted. “Our position has been that institutional deliveries in poorly equipped and overcrowded health facilities with poor adherence to asepsis can hardly be assumed to be synonymous with ‘safe’ deliveries, as is often assumed,” the report read. “It is important that the focus be on ensuring that women have safe deliveries, meaning not only the absence of mortality and morbidity in the mother and newborn, but respectful and caring services that are of technically high quality,” it further stated. BBC Media Action’s regional coordinator in Bihar, Sandeep Tah, echoed the report’s findings. “It’s great to tell the women to go to hospitals to give birth, but they’re unhygienic and ill-equipped. So the demand has increased but [the system] can’t keep up,” Tah said. “For example, we’ve told all pregnant women to take iron folic acid tablets and we’ve generated demand and interest, but a few months ago, there was no supply. The government has to fix this. There has to be a link between getting people to practice better health and actually being able to deliver it.” But there is good news. A 2012 study on India’s progress toward achieving its MDG on maternal health, published in the WHO Southeast Asia Journal of Public Health, found that aside from West Bengal, Bihar — India’s poorest state — had made the greatest reduction in maternal deaths since 1997. If the pace of linear decline continues, Bihar is predicted to reach the MDG goal by 2016. The northeastern state of Assam isn’t expected to reach the goal until 2046, while Rajasthan and Haryana aren’t expected to meet the target until 2023 and 2050, respectively. Meanwhile, a recent impact study, which looked at how Mobile Kunji was influencing family health outcomes, found that almost 90 percent of women exposed to the job aid believed front-line health workers were a credible source of information on family planning compared with 65 percent of women who hadn’t been exposed. The study, which is yet to be finalized, also found that pregnant women exposed to Mobile Kunji were better prepared for giving birth, including identifying transport to the hospital and having an emergency contact saved. mHealth’s transformative potential So in a country with more than 900 million mobile phone users, what does the future hold for mHealth in rural India? “Most donors and the government want something fancy. Mobile Kunji is low key and low tech,” Siddhartha Swarup, director of family health projects at BBC Media Action India, said. “However, we expect that most front-line health workers and men will have a smartphone within the next three years. That is completely game changing.” Anushka Patel, chief scientist at the George Institute for Global Health, said there was enormous potential for mobile technology to improve rural health by supporting weak systems. “Mobile health has the potential to be transformative in India, primarily because the fundamental issue of accessibility can be addressed. However, for this potential to be realized there needs to be more focus on how mHealth can provide end-to-end system support for holistic care, rather than having a limited focus on specific conditions,” she said. How can the global health community and the technology sector harness the transformative potential of mHealth, particularly in the rural areas? Share your thoughts below. Check out more insights and analysis for global development leaders like you, and sign up as an Executive Member to receive the information you need for your organization to thrive.