How mobile phones are enabling quality maternal and child healthcare

In 1996, Aparna Hegde was a resident doctor at Sion Hospital, one of Mumbai’s largest public health facilities, when a woman who had just delivered a baby was rushed into emergency care.

“The baby was dead, it’s body stuck inside”, recalls Hegde. The woman too died a few days later.

“She was given a cursory check at her first antenatal visit and not told about potential complications and the need for regular check ups. She developed gestational diabetes in the sixth month.”

Such preventable deaths, Hegde soon realized, were far too common.

“The antenatal OPDs were extremely crowded so there was just enough time for a quick examination,” she says. “We could not offer any counselling. Nothing is worse than to see a woman dying in labour and to realize that you did not give her the information that could have saved her life. Doctors, the government and public health professionals preach that women must come to hospitals for antenatal care, but when they do we fail them.”

These experiences led her to conceive of mMitra – a free mobile voice call service that gives information on preventive care and simple interventions to reduce maternal and infant deaths. The messages are specific to the stage of pregnancy or the baby’s age. They are given in the language of choice and sent weekly or twice a week.

A mMitra member

A mMitra member

Launched in late 2014, mMitra services are available at 23 municipal hospitals in Mumbai. Nearly 1.5 lakh women have enrolled so far and Hegde hopes to reach 5 lakh women by 2016.

“We have a health worker in every hospital that enrols women when they come for the first antenatal visit”, says Hegde, who is a full-time doctor and heads ARMMAN, an NGO behind several maternal health initiatives. “We also partner with NGOs in slums to reach out to women who register late into the pregnancy and miss out on care during the initial months.”

Apart from high enrolments, there are promising signs of behaviour change in areas where mMitra is available.

“Slums at Nallasopara, outside Mumbai city, used to report very high rates of home births. Now they are down to zero”, says Hegde.

In a country that accounts for 17 per cent of maternal deaths worldwide, information and communication technologies (ICTs) hold out immense possibilities. The existing health infrastructure is clearly inadequate. There are 19 health workers for 10,000 people against the 25 prescribed by the WHO. Rural areas are home to 70 per cent of the population but have 30 per cent doctors and 3 per cent specialist physicians.

“ICTs can transform delivery of health education, help in behavior change communication, training of health workers, and enable an overall health system management”, says Akanksha Malhautra of Dasra, a strategic philanthropy organization that is working on a report on the role ICTs can play in improving reproductive maternal newborn and child health (RMNCH) in India.

The high mobile penetration helps with greater access to rural populations adds Malhautra. It is also cost effective and generates awareness about government and other health financing.

Through the report Dasra wants to highlight the potential and challenges in this sector, and to drive funding to organizations that are using ICT solutions in an impactful manner.

Similar to mMitra is Kilkari, a voice messaging service in operation across Bihar. It delivers time-sensitive information to pregnant women, mothers of young children and their families from the last trimester up until the child is a year old.

Kilkari was launched in 2013 under the Ananya program, a joint partnership between Bill and Melinda Gates Foundation and the Bihar government that is working towards improving RMNCH and nutrition outcomes. Over one lakh people in the state have subscribed to Kilkari so far.

Nearly 90 per cent of Bihar’s population is in rural areas with limited access to traditional media, which makes delivery of critical health information difficult, says Usha Kiran Tarigopula, BMGF.

In such a scenario community health workers play a critical role in delivering information on ante and post-natal care and interventions like breastfeeding.

“A 2011 benchmark survey revealed that 97 per cent of CHWs have access to a mobile phone so we have developed innovative tools, including mobile health technologies to help train, track and coordinate their efforts”, says Tarigopula.

Setting up an infrastructure that involves six operators including Airtel, BSNL, Idea, TATA, Reliance and Vodafone, who together provide nearly 90 per cent of the coverage, has enabled a wide reach.

Another device is Mobile Kunji, an IVR-based service that comes with a set of printed cards. Every card has a unique short code on it corresponding to a message. Health workers play the message, voiced by a character called Dr. Anita, to the family via their mobile phones, by dialling a number.

MobileKunji in use in Bihar

MobileKunji in use in Bihar

However, technology alone can do little and has to be matched by an improvement in health systems.

“ICTs can help remind a mother to get her child vaccinated, but not ensure availability of doctors and vaccines at the health center”, points out Malhautra.

As the Dasra report says, 10 per cent of India’s villages are not reached by any kind of mobile network. Issues like lack of digital infrastructure, mobile and broadband connectivity and digital literacy have to be addressed to enable an ICT revolution in health to kick off in India.

This article was published in the Business Standard

With many undocumented, younger brides are at a higher risk of domestic violence

The beatings started just days after Anuradha,15, got married. Her husband was a distant relative, 12 years older to her. The marriage was an arranged one, and she soon discovered that her husband had a violent temper.

“The smallest thing would set him off”, says Anuradha, “If the tea was not the right temperature, or if I spoke to a neighbour. He would return home drunk late at night, beat me and force me to have sex.”

Anuradha’s inlaws were indifferent and her parents advised her to find ways to keep her husband happy. They finally intervened after she attempted suicide at the age of 17.

Domestic violence, also known as intimate partner violence (IPV), accounts for five in 10 of reported crimes against women in India. Many cases go undocumented, and various studies show that nearly seven out of 10 women in India have suffered some form of DV..

A report released last month by Washington DC-based thinktank Population Reference Bureau says that India, alongwith Nepal, Pakistan and Sri Lanka, reports among the highest rates in the world, with one in three women reporting sexual and/or physical IPV, predominantly from a husband.

Early marriage is a particular risk factor. India has the highest number of child brides in the world – of the 10 million who marry as children every year, an estimated three million live in India.

One key reason why so many cases go unreported is because IPV has cultural sanction. According to the NFHS-3 survey, 57 per cent of boys and 53 per cent girls between 15-19 years believe that wife beating is acceptable in at least one circumstance.

Many women do not recognize that what they are facing is violence says Pouruchisti Wadia of SNEHA, a Mumbai charity that trains youth to conduct gender sensitization campaigns in slums in Mumbai.

“Younger brides have very poor negotiation skills. They also tend to believe that they have to play a subservient role, and that satisfying their partner’s sexual needs whenever he wishes is an implicit aspect of the deal. The idea that they can say “no” is not considered at all”, adds Wadia.

While there are laws against domestic violence, what is not widely understood and taken cognizance of, even at the policy level, is that it has enormous public health consequences.

Women who experience IPV are twice as likely to experience depression, and about 50% more likely to become HIV positive. Other negative outcomes are post-traumatic stress disorder (PTSD), gastrointestinal infections, suicide, and chronic pain. Studies also show that sexual IPV is associated with increased risk FOR unintended pregnancy that in turn compromises maternal, infant and child health.

“Our research in India has also demonstrated intersections of IPV and other forms of abuse and mistreatment that create a web of vulnerability for women and girls”, says Dr Anita Raj, Director, Center on Gender Equity and Health, University of California, San Diego, who has conducted extensive research on sexual and reproductive health and gender-based violence

Raj’s research analyzing national data documents links between IPV and female infant mortality as well as between IPV and girl child marriage, marriage of girls before the legal minimum age of 18 years. National data indicate that almost 40 per cent women, between 20 – 24 years, were married before the legal minimum age of 18 years.

“Women married as children are more likely to experience abuse from husbands. Among married women, sexual violence from husbands is most common among adolescent wives. These issues compromise mental health and have been linked to depression and high suicides in the region”, says Raj.

While the law prohibiting child marriage has helped bring down numbers significantly, they persist in rural areas due to ingrained traditional practices and rigid gender roles.

Beliefs that organizations like SNEHA and the Institute of Health Management in Maharashtra, are trying to tackle in pioneering ways. Since 1996 IHMP has been working in parts of Marathwada, among marginal farmers and landless labourers.

“Early marriage is an expression of the discrimination that girls suffer in patriarchal societies and we believe the answer lies in empowering girls”, says Dr Ashok Dyalchand, Director, IHMP.

IHMP’s programs include life-skills training, educating girls about their rights, and counseling. The average age of marriage among girls in IHMP’s focus areas used to be 11-12 years. Now 71 per cent get married at 18.

“The fact is that parents are decision makers and girls have to be taught how to negotiate”, says Dyalchand. “A major component of our program is engaging with and educating parents. When we tell them that their girls face a five times higher risk of morbidity when they marry young, it makes a difference.”

In 2013 the program was scaled up to include newly married couples to tackle domestic violence. “Our experience is that domestic violence should get addressed when it is initiated. Otherwise it becomes a norm”, he says.

Tackling IPV calls for a substantial change in attitudes and behaviors. Worldwide, there is growing acknowledgement that working with adolescents and youth is the most effective approach – one that needs as much as investment and commitment as rehabilitative responses.

This article appeared in The Indian Express

Tackling child malnutrition the Aahar way

A few months short of his first birthday, Sushma’s firstborn died. Underweight at birth, Vicky was always sickly and suffered from frequent diarrhea.

A ragpicker, Sushma lives in Govandi, home to one of Mumbai’s largest slum colonies and an area that reports a large number of malnutrition-related deaths.

According to a recent study, 6000 children die everyday in India and nearly half of them are malnutrition-linked. Mumbai alone reports 26000 deaths every year.

“The maximum deaths due to malnutrition take place between six months and two years”, says Dr Armida Fernandez, founder-trustee, SNEHA, the Society for Nutrition, Education and Health Action, a Mumbai-based non-profit which seeks to address the needs of women and children in urban, underprivileged communities by working with the public health system. “The problem is that the ICDS program takes on children after they turn three years old and by then the damage is done”.

ICDS or the Integrated Child Development Scheme is a government welfare program that provides food and health facilities to children below the age of 6 as well as their mothers.

The problem, experts say starts as at a very early stage.

“Girls are often treated as less valuable and their health and nutrition is accorded low priority,” says Shreya Manjrekar, a program coordinator with SNEHA. “When she gets pregnant, her poor nutrition level affects the baby.”

Early marriage and high teenage pregnancy rates add to the problem. And compounding it is the lack of awareness about exclusive breastfeeding and nutritious diet.

Exclusive breastfeeding for six months after birth is widely established as an effective way to reduce malnutrition and ensure that every child has a fighting start in life.

Not only does early and exclusive breastfeeding help children survive, it also supports healthy brain development, improves cognitive performance and is associated with better educational achievement at age 5. Breastfeeding is the foundation of good nutrition and protects children against disease.  In this and many other fundamental ways, breastfeeding allows all children to thrive and develop to their full potential

What goes into a nutritious diet

What goes into a nutritious diet

Breastfeeding also contributes to maternal health because it helps reduce the risk of postpartum haemorrhage after delivery.  In the short term, it delays the return to fertility and in the long term, it reduces type 2 diabetes and breast, uterine and ovarian cancer.

Yet myths and misinformation regarding breastfeeding are plenty.

“I did not nurse my children but fed them cow’s milk because that is better for health. I told my daughter-in-law to do the same” says Alka, Sushma’s mother-in-law.

Her neighbor Usha adds, “I started nursing my daughter three days after she was born because the first milk is dirty and it should be thrown out”. She has never been told that the first milk or colostrum contains antibodies that are essential to build immunity.

Counselling by SNEHA workers

Counselling by SNEHA workers

The impact of this lack of awareness finds reflection in India’s infant mortality rate. At 1.34 million under-five deaths, India reports the highest IMR according to a 2014 UN report. Many of these deaths can be prevented with breastfeeding.

“A major problem we see is that of stunting”, says Dr Fernandez. “Babies in India are getting shorter”. This too is attributed to under-nutrition in the first 1,000 days of a baby’s life, including during gestation.

To bust such myths and promote nutrition in this crucial 1000 days period, SNEHA holds yearly camps called Aahar in areas that are home to a large number of informal settlements or slums.

One in six of Mumbai’s population lives in slums, and many of them live under the threat of constant displacement. Like Sushma, they have no fixed means of income and often travel long distances for work. In such a scenario, food takes the lowest priority.

Using street theatre to tackle malnutrition

Using street theatre to tackle malnutrition

By using innovative strategies and tools like flash cards, puzzles, games and videos SNEHA counsellors work with the ICDS staff to promote awareness about breastfeeding techniques, complementary feeding, and healthy cooking practices.

Apart from this, SNEHA also holds workshops and sessions where they directly engage with the communities. “We do this through home visits and group meetings where we demonstrate healthy methods of cooking”, adds Manjrekar.

“We reach out to not just mothers, but all the women in the community because the decision on what to feed is not entirely in the mother’s hands. The in-laws play a big role”, says Anagha Waigankar, associate program director, Aahar. “We also educate the mothers about immunization, hygiene and care during illness because if the women change their habits about cooking and child care, it benefits the entire family.”

An internal impact assessment report by SNEHA shows a 35% reduction in wasting through 2 ½ years of intervention.

India’s urban population is estimated to double to over 800 million over the next five years. A quarter of them, nearly 200 million, will live in poverty, in slums like Govandi.

The solution to tackling child malnutrition lies in models like Aahar that can be scaled up to address a critical public health issue that has direct economic implications on India’s national growth.

Let’s talk about men as agents of change

A Google search for campaigns promoting girls’ rights launched in 2014 throws up plenty that were launched from around the world – Girls Unlimited, Kishori Abhiyaan, Too Young to Wed, Girls not Brides, Bring Back Our Girls, to name just a few. A similar exercise for adolescent boys yields barely a handful.

Which raises the question – when it comes to investing in the 1.8 billion youth alive today, are the concerns of boys and young men getting overlooked?

A look close at home seems to confirm that impression. Down the decades, government campaigns in India – be it on family planning, nutrition, gender violence, early marriage and safe pregnancy – have targeted girls. Boys have not been reached out to on the same scale.

Given the enormous challenges girls in India face, the interventions are necessary.

India ranks 127 out of 152 countries in gender inequality

India ranks 127 out of 152 countries in gender inequality

The UNDP’s Human Development Report ranks India 127 out of 152 countries on gender inequality. A 2012 World Bank study says that nearly 2.5 lakh girls were killed in India every single year over the last two decades because of their gender. 40% of married women are subjected to violence from their husbands, while 54% believe that spousal violence is justified according to NFHS-3 figures.

The same data also makes a compelling case for interventions among boys. Over 50% of boys between 15-24 years are in the labour force as per NFHS-3 data, while over 80% are married. One out of every 5 boys between 10-19 years is illiterate,

However, apart from including men in a specific aspect like violence prevention or improved family planning, there is no evidence of a larger reaching out says Dr Aparajita Gogoi, Director, Centre for Catalyzing Change, India, a non-profit that aims to empower women to become full partners in development.

One out of 5 boys between 15-19 years is illiterate

One out of 5 boys between 15-19 years is illiterate

“A few years after we started our program for girls in Bihar, we realized that for our core mission to succeed, we needed to change existing gender norms and attitudes among boys and young men as well”, she says.

A perspective shared by many organizations working in health and gender programmes worldwide.

“About a dozen years ago, working on male engagement was seen as a zero sum game”, says Charlotte Feldman-Jacobs, Program Director, Gender, at the Population Reference Bureau, a Washington D.C.-based nonprofit that informs people about population, health and the environment for research and academic purposes.

“But the more we heard from women in developing countries it became clear that they themselves needed and wanted us to work with their male partners. They needed the men to understand the change that was needed for lives to get better for them, the families, and men themselves”, she adds.

Do Kadam Barabari Ki Ore (Steps towards Equality), a partnership initiative launched by the Centre for Catalyzing Change in Bihar’s Nawada district is a step in that direction. Launched at Nehru Yuva Kendra Sangathans across 28 villages, it has so far reached out to about 600 boys between 13-21 years.

An impact study carried out a year after the launch showed a better understanding of the differences in how girls and boys are raised and the myths and facts about masculinity.

“Initially, very few boys would turn up and we realized that was because every time they attended a session they were losing a day’s wages”, says Gogoi. “So we tweaked the approach by adding sports and vocational skills development and the numbers grew”.

An earlier program, Better Life Options for Boys launched by C3 has been adopted by many organizations and is currently in operation in 11 states.

Reaching out to boys, however, comes with many challenges.

Perhaps the toughest is dealing with strongly entrenched notions of masculinity and patriarchy, says Rujuta Teredesai, Director, Equal Community Foundation.

ECF’s Action for Equality programme reaches out to 40,000 people in 20 communities in Pune, targeting boys between 14-17 years from low-income communities.

ECF reaches out to 20 communities in Pune

ECF reaches out to 20 communities in Pune

“A young man in our programme typically spends 3- 6 hours a week learning how to manage his behaviour”, says Teredesai. “When he tries to change by participating in domestic chores he gets challenged from different angles. His father will say ‘It’s your sister’s job, don’t do it’. And then there are advertisements, which continue to show only women doing domestic work. Teachers too share examples that reinforce what the father or ads say.”

Pressures that Baba Shaikh, 14, who joined the programme two months ago, is struggling to cope with.

“My 18-year-old sister does all the housework while I get to play and watch TV. I have come to realize that is unfair and I want to lend a hand. But my parents say its a girl’s job and stop me”.

To facilitate a larger change in mindset in the community are peer educators like Pravin Katke. “We meet with the parents every two weeks and address such issues. We tell them that if the boys help out, it will benefit the family. And that if their sons misbehave with women, it will give them a bad name”.

Volunteers from the community lend a hand as well. Like Mehboob Mulla, 17, who joined the ECF programme two years ago.

“I used to believe that girls and boys are unequal. At home when something special to eat was made or bought like sweets, my sisters would get to eat it after everyone else had eaten their fill. Often nothing would be left for them. When I realized how wrong this was and I started speaking out my parents said I was mad”, says Mulla.

They eventually changed their views because Mulla would regularly share what he was learning at these sessions. “I have an older brother who is 20 and refuses to enroll, but my parents are now determined to get him into the program!”

To keep the boys engaged, ECF has developed several interesting modules. Games play an integral part.

“We focus on human rights”, says Katke. “We ask them to imagine what kind of rights they would have in place for citizens if they had to establish a country. We draw examples from their lives and ask them to decide what is right and wrong”.

Like women, men too are victims of inequality believe experts, and they need the opportunity to learn and understand how it destroys them as well as the women around them.

An ECF volunteer at work

An ECF volunteer at work

“We are often asked questions like ‘Why would men attend’, ‘Do they really change?’ I think it is time to change the conversation and talk about men as agents of change rather than potential perpetrators of violence”, says Teredesai. “And this can happen only when we create an enabling environment. One that will encourage, support and allow men to sustain that change”.

This article was published in the Indian Express

Sports a potential game-changer for rural Indian youth

Its 5 AM and undeterred by the chill in the morning air, some 50 odd children, most of them girls, go through their martial arts moves, closely watched by 18-year-old Neha*.

They are students of Abhyudaya Ashram, a residential school in Morena, Madhya Pradesh that has produced many state and national-level taekwondo and kabaddi players over the decades.

Listen to their stories and you learn that they are champions every day.

The school exclusively admits children from the tribal Bedia community, a nomadic clan where women traditionally practice sex work.

They are sole breadwinners and parents introduce girls to the trade when they hit puberty. Men are largely unemployed. They are not expected to work, but pimp for the women at best. Any attempt to challenge this is met with strong resistance.

Tradition, activists say, is an excuse and that the men have become used to leading a life of little responsibility.

Neha’s mother supported her desire to study so unlike other Bedia girls she did not take up sex work but went to school. “My father and grandmother were very unhappy but my mother was very firm”, she says.

All that changed when she was killed in an accident. Neha was 14.

“My father and grandmother started putting a lot of pressure on me to take up sex work”, she says. “They would try to convince me by talking about the fancy clothes and jewelry I would get to wear.”

When that didn’t work Neha was beaten up. Then one day she overheard her father making plans to sell her at Sonagachi, Kolkata’s red-light district.

Neha ran away from home and sought shelter at Abhyudaya Ashram.

“My mother had told me about the school so I knew I would find help here”, she says.

The centre was started in 1992 by the eminent anti-trafficking crusader Ram Sanehi. A Bedia himself, he challenged the community tradition.

“We teach them taekwondo, kho-kho and kabbadi in the morning,and in the evening they participate in other sports”, says Aruna who is a teacher here. “We focus a lot on sports for the girls as it helps build mental and physical strength and self-esteem”.

So far Abhyudaya Ashram has reached out to over 4000 Bedia children, most of them girls. Many, like Aruna, have gone on to pursue higher education and return as counselors, teachers and activists and work within the community

That sports or games has the power to bring about meaningful change for children and youth is acknowledged the world over. This is particularly true for those at risk due to poverty and gender inequality.

There is growing evidence that if used in the right manner, it can contribute towards promoting health, improving academic outcomes, gender empowerment, and even conflict resolution.

The impact on girls is especially significant because it provides safe spaces where they can meet, speak freely and build support networks.

Large organizations too are sending the potential. Standard Chartered, Nike and Barclays have initiated or are funding sports for development initiatives like Grassroot Soccer in Africa and Yuwa in Jharkhand, to name a few.

In rural Jharkhand, children from tribal backgrounds rarely finish school. Girls’ fare especially worse – 6 in 10 drop out before 12 years and become child brides. Between 60,000-100,000 girls are trafficked every year. Those who seek work locally as rag pickers or construction workers are vulnerable to abuse.

Which makes Rinki’s journey a truly remarkable one.

Yuwa team celebrates goal at the Donostia-San Sebastian

Yuwa team celebrates goal at the Donostia-San Sebastian

A tribal from Hutup village, she was 14 when she led a football team to the 2013 Gasteiz Cup in Spain. The team lifted the bronze among 10 all-girls’ teams from around the world. Playing alongside were tribal girls from neighbouring villages. In 2014 they made history again as the first Indian football team to compete in the USA Cup.

These girls are members of Yuwa, a not-for-profit co-founded in 2009 by American Franz Gastler It reaches out to 200 girls between the ages of 6-18 years in Jharkhand’s Ormanjhi block.

Yuwa uses football to empower girls and gives them a platform to fight against early marriage and trafficking. Through lessons in English, computers and Math, they are encouraged to think critically and develop employability skills.

“My mother went to school for just two days because her parents decided that she had to watch the cows”, says Rinki. “She was married off at 15 and earns a living and does the housework as my father is an alcoholic.”

She believes her situation would have been no different had it not been for football.

supergoats 2014“My life had no direction until I joined Yuwa. Now when my parents talk about marriage, I firmly tell them that I am not ready”.

Gastler believes that given the space to explore their abilities and challenge themselves, children can be change-makers.

“At Yuwa we witness how girls can improve their communities, act as leaders and support their families. Remember, these girls will raise their own children differently.”

*Name changed upon request

This article was published in Business Standard Online