Sunday, April 12, 2015

All you need is...a phone

I met Dr. Aparna Hegde, the Founder and Chairperson of Armman, an NGO that designs and implements sustainable solutions to reduce maternal, neonatal and child mortality and morbidity in underprivileged urban and rural communities in India. To give a little context, I met her on Easter this year. I had attended midnight mass the night before and it had left me empty. Throughout the proceedings I had strained to find some meaning, some message I could take home with me. But zilch. I was really irritated and the next morning I had to meet this lady. But I am so glad I did! By the end of the interview I was literally trembling. These are the people who should be talking in churches! These are the stories we need to hear! Not some diatribe on what did or did not happen millions of years ago. When you say Christ died for humanity, what do you mean really? It is such a hazy concept for most. What if, instead, you spoke about people who give their lives to help others? Wouldn't that inspire more? Anyways, I had to tell her story, so here goes: 

Aparna’s father had come to Bombay from a small village in Karnataka, his only support – his monetary savings of Rs.100. Finding a job in Standard Batteries, he managed to secure a one room kitchen chawl in the Pant Nagar locality of Ghatkopar. It was here that she was born. 

Surrounded by children her age with little or no interest in studying – their parents either vegetable vendors or peons – Aparna remembers being a very grateful child. Grateful for the school she went to, for the books that lay in her shelf, the films waiting to be explored. Grateful for the opportunities that lay ahead. “I don’t know where I got this sense of gratitude from, but I remember it always being there. I just felt very lucky,” she says.

By the age of ten, she had already read all the classics of English literature. Her father, not a very well read man himself, saw to it that his daughter would never want. Every year, he took her to the Children’s Film Festival, a ten-day event that would expose both father and child to some of the greatest films in the world – French, Italian and many more. He grew with her.

Always a topper in school and an ardent Math fan, she decided to take up engineering after school, but she also always saw her future self as someone helping other people live better lives. So when her father insisted on the medical stream, she gave in and was accepted into Sion Medical College.

“Till then life was perfect. But the first year of Medical school changed everything. It was hell,” she says. Overworked, perennially tired and never feeling her best, she dragged herself through the long hours, always thinking that everyone had the same complaints. But what Aparna and everyone around her was unaware of was that she was suffering from severe hypo-thyroidism. Fatigue, constipation, weight gain, muscle weakness, irregular menstrual periods, and depression became a part of her life. Putting her trust in psychiatrists, she surmised that it was just because of the problems she was facing on the personal front. It was only after 11 years, when her voice suddenly became very hoarse and she was admitted to a hospital, that she was finally diagnosed. 

However, the ordeal did not end there. “I was put on medication for my condition, but nothing seemed to change. I was still depressed, still fatigued,” she says. Meanwhile, giving up hope in the education system that only seemed to focus on rote learning and clearing exams, she decided to go back to her books. “I was very disillusioned by the system,” she says. “There was no push to understand the higher concepts of science, no emphasis on research. Our library was filled with these wonderful books, but we never had the time to read them because we were busy trying to clear exams. I had had enough.” Re-reading her books all over again, reading new ones, she slowly re-ignited her love for science. “And these were the books that saved my life,” she declares. Putting two and two together after reading several books, she diagnosed herself with B-12 deficiency. “When I got a check up done, I had almost zero level of B12. Once I started B12 medication, I finally started regaining my health.”

By then she was a practicing doctor at Sion Hospital, one of the best tertiary hospitals in Mumbai. But her passion for research and her drive to push her horizons made her seek an MS degree in biological sciences at Stanford University. “I got through but since Stanford does not offer full scholarships, I only got a part scholarship and had to arrange for the remaining money. My family was very middle-class and there was no way we could afford it, but my parents decided to mortgage our house so I could go,” she says.

It was a dream come true, but 3 months after she left for the US, her father passed away. “I was lonely and depressed for a year, but I stuck on and was rewarded. My mentor was an amazing guide and I can’t thank him enough for all that he did for me. He opened my eyes to a whole new world of science and concepts and ideas. I could finally do all the research that I wanted to, I could finally study my way,” she says.

By then the seeds of Armman were already planted in her mind. During her residency in obstetrics and gynecology at Sion hospital, she had witnessed how pervasive systemic problems in the provision of health care to underprivileged pregnant women and children led to deaths that were actually preventable. “There is this one incident that I witnessed that I always see as the beginning of Armman in my head. It was 1 am when I was called to the emergency room at Sion Hospital to examine Aruna, a 25 year old primipara with undiagnosed gestational diabetes whose baby had developed macrosmia. She had been transferred from a rural hospital in Thane district in Maharashtra with her baby’s head sticking out of her vagina but the body stuck inside due to shoulder dystocia. Her baby was half out of her womb but couldn’t be taken out fully because it had developed diabetes while it was inside the womb. This had caused the body to swell and so only the head had come out,” she says. “I will never forget the first sight of her: a frail young woman with the head of a beautiful baby sticking out of her vagina. The baby was dead of course, but now the woman had also started turning black and blue due to a ruptured uterus due to the baby stuck in it for more than 4 hours. When an emergency surgery was performed, the baby’s neck was too jammed for us to be able to deliver it through the incision. Since I was the junior most it was left to me to behead the baby on the operating table. And since we could not hand over a beheaded baby back to the family, it was also my job to sew the head back to the body once it was out. Aruna died three days later. That was when I realized where our system had failed.”
The way it works where pregnancy check ups are concerned is that a woman comes in once she knows she is pregnant, mostly in the third month of pregnancy. A lower income group woman will visit a government hospital where hundreds like her come everyday. Each doctor will attend to atleast a hundred patients a day where they write down the tablets she needs to start taking and tell her to come back for a checkup after a month. “This is good, but not enough. Doctors are so overworked that they do not have the time to explain to her why she needs to come in, what problems she is likely to face if she doesn’t, why she should take the tablets they have prescribed,” says Aparna. “Most of the women I saw were probably in a hospital for the first time in their life. They were accompanied by their husbands, who lost a day’s wage because they had skipped work. Many of the women were impeccably attired and made up because this is probably the first time in months that they had got out of the house. These women are not going to come back every month for check ups. Women I’d seen in the early stages of their pregnancy as outpatients were coming back to me in the operating theatre, dying. I opened one woman’s papers and saw my handwriting telling her to come back for a check up. But I hadn’t had the time to explain to her why it was so important.  Aruna’s death will always stay with me, not just because she died a horrible death but also because it was so easily preventable. I saw her case papers. She had gone for her first antenatal visit in the first trimester but she had not be counseled about the remaining visits, the potential complications and the danger signals. That’s when I realized I had to find a different way to reach these women with the information we doctors were just too busy to communicate,” says Aparna.

The need to fill this gap in information is what led to Armman (Advancing Reduction in Mortality and Morbidity of Mothers, Children and Neonates), a non-profit dedicated to designing cost-effective solutions at scale for complex health care problems.

“I came back from Stanford and started looking for funding and trustees. I got funding from organisations in the US and that is how it began,” she says. While the first project she started (The HERO Project, which aims to computerize hospital databases of bed and ventilator availability so people don’t waste time running from one hospital to another) is yet to come to fruition, Armman’s second project ‘mMitra’ (Mobile Mitra) is quietly revolutionizing maternal and neo-natal health care in India.

What is mMitra?

mMitra is a free mobile voice call service that delivers simple, culturally appropriate health messages to India's poorest and most vulnerable women. It provides  comprehensive information on preventive care and simple interventions to reduce maternal and infant mortality and morbidity in urban India. The voice calls are in the local dialect, specific to the womens's gestational age or the age of the infant and are sent weekly/twice a week free of cost directly to pregnant women and mothers with infants. These voice calls are delivered to the mother from the second month of pregnancy till her child turns 1.

mMitra was awarded the “People Choice’s Award” at the Saving Lives at Birth grant event in Washington DC in 2011. The project also won a place on Nominet Trust’s prestigious list of the world’s best uses of technology-for-social-change NT100.


The project is supported by MamaText, an initiative of USAid, BabyCentre, Johnson & Johnson and United Nations Foundation launched by then Secretary of State Hillary Clinton in 2011. A remarkably cost-effective project, its next target is to enroll 1 million urban poor in India over the next 3 years, with backing from the United Nations. 

India has over 900 million mobile phone subscribers. Almost 63.5% of households have mobiles in the slums of India. mMitra leverages this unique opportunity of using mobile technology to reach out to pregnant women and mothers of infants with relevant information. The information is appropriately timed to the stage of pregnancy or age of child and targeted to influence adoption of the health seeking behaviour among pregnant women and mothers of infants. mMitra is a friend and companion that guides the woman and the family through pregnancy and childhood.

The women

I spoke to many women who use the mMitra service. For most of them, this is the first time they have had access to information, or have been given any sort of priority or value within a family. "I registered for the program in the 3rd month of my pregnancy," says Deepa Sanjay Shrivastav, a 27 year old homemaker from Malvani, Malad. "I get calls twice a week. At first there is a voice of a baby laughing. Then they tell me what stage the baby is in - the eyelashes are being formed or the face is being formed. They tell me what tablets to take and why I should take them. They also tell me what I should eat and when I am due for injections or check ups. My parents died when I was a child so this guidance is priceless for me. My husband also thinks it is a good program so he bought a mobile phone for me just for this. The best part is that it is free - we don't have to make calls, they call us."




The voice calls

The voice messages have been developed by Babycenter that were validated by Federation of Obstetrics and Gynecological Society of India (FOGSI) experts. These messages were dubbed in Hindi and Marathi before pre-testing it with women in the community.

A total of 145 individualized voice messages of 60 – 90 seconds are being sent directly to the mobile phones of each enrolled woman, based on the stage if her pregnancy or age of the infant, with the following frequency:
·      Pregnancy: Two messages per week
·      First week after birth: Once a day
·      Infancy until month 3: Two messages per week
·      Infancy month 3 to Infancy month 12: One message per week
  
Registration into the service:
Enrolment is done in the slums directly through community partners and in the government hospitals where mMitra is being offered as a part of their antenatal care.

Unique features of the service:
·      The voice calls are simple, pedagogically and culturally appropriate and specific for the time point in the pregnancy or child’s development. The medically accurate messages have been developed through a rigorous evidence based research process.  
·      Information is tailored to the needs of the population and addresses the cultural norms, myths, practices and nutrition specific to the study area.  
·      As it is a voice messaging service, it is an easy to use technology even for illiterate end users as opposed to text messages.  
·      Services can be used either from mobile phone or a fixed land line. 
·      The women are given a choice of three time slots in the week when they can choose to get the voice call

Thus, mMitra can improve interaction between women and the health care system and increase demand for
skilled birth assistance and other skilled obstetric and neonatal interventions known to reduce maternal and child mortality. It can do this far better than current alternatives such as text messaging (which is not suitable for illiterate women) and radio and TV messages (which have lower penetration than mobile phones). 
Technology for mMitra has been built by the Inscripts Pvt. Ltd. pro bono.

Implementation
-         5000 women attending the antenatal clinic of Sion hospital, Mumbai will now have mMitra as a part of their antenatal care (funded by Glenmark Foundation). 
-         MAMA (a global alliance of Johnson and Johnson, UN Foundation, USAID, mhealthalliance and Babycenter) will fund ARMMAN to reach across to one million urban poor women in Mumbai and other cities. DASRA will help ARMMAN build the capacity needed to implement the project. 


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