Mobile technology is revolutionising health and health care in developing countries enabling health promotion campaigns, reminders about therapy and data collecting. To women it could provide a lifeline for them during pregnancy and birth. But what evidence is there that mobile messages are accessible to women in these situations and that they could change women’s behaviour? In this blog for International Women’s day I describe two mobile services and look for some evidence about the impact of mobiles on women’s health.
About 800 women die each day from pregnancy and childbirth complications according to WHO. 99% are in developing countries. The reason is often that they had no access to a healthcare worker, or antenatal clinics for health checks. Less than half of births in developing countries is attended by anyone skilled. While a mobile cannot replace a skilled attendant or a clinic it could help women to recognise when they need to take action to see a healthcare worker, and what they can do to help themselves as well as allowing community health workers to keep in touch with expectant mums. Aponjon and Healthphone are examples of what mhealth services for women could do.
Aponjon is a Bangladeshi service for pregnant women launched by Mobile Alliance for Maternal Action (MAMA) in 2012. According to its website “The aim of the service is to dispel commonly held misconceptions about child birth, while informing mothers of genuine health dangers and warning signs. The service also offers guidance to local healthcare services and explains the benefits of family planning.” t provides text or voice messages twice a week for the mother and an option for other family members to join and get one message a week. It hit 100,000 subscribers in its first year. The cost is 2 Bangladeshi Taka (=approx 1.2 cents) a message.
Services like Aponjon need a subscription and a signal. Healthphone on the other hand is taking an approach that needs no subscription or signal, and is so more affordable, although you still need a phone. A video, audio and image library is preloaded directly onto the phone and so can be accessed for free at any time. The information is taken from the UN guide Facts for Life and so far covers not just maternal health in pregnancy and care of infants but 14 common health topics for family health. The project is being implemented in India at first.
Neither of these services has yet proved it has impacted women's behaviour or health yet. Its early days.
Mhealth will only work if the targetted women have access to a phone and can use it. Mobile ownership amongst women has risen a lot in the last few years but it does not equal that of men. According to a GSMA report on mobile use in women globally a woman 23% less likely to own a phone than a man if she lives in in Africa, 24% if she lives in the Middle East, and 37% if she lives in South Asia. USAID recently produced a report to show that in Afghanistan, one of the poorest countries, 80% of Afghan women had access to a phone and 48% owned one. However 10% of the women could not use a phone because their families didn’t permit it and another 10% could not afford one. So 20% of Afghan women are out of reach of services that could help them have healthy children safely. Illiteracy may also prevent mobile phone use in some rural areas where education for women is scarce. This can be addressed by using voice messaging instead or as well as SMS messages.
Does receiving messages change behaviour? Searching Global Health database, I can see that there is not much published research yet on the effectiveness of mhealth programmes for maternal and child health. What I found looked hopeful – a randomised study by a group of Swedish and Tanzanian researchers in Zanzibar (references 1 and 2) saw a definite improvement in behaviour in pregnant women who received SMS messages and a voucher that enabled them to contact a healthcare provider. The messages aimed to provide simple health education, appointment reminders for antenatal care, and to encourage skilled delivery attendance and postnatal care.
Women in the intervention group were more likely to attend four or more antenatal care visits; 44% of the women received four or more antenatal care visits versus 31% in the control group. For attendance at a skilled delivery, the study found that 60% of the women in the intervention group versus 47% in the control group delivered with skilled attendance.
However the intervention was really only successful in improving skilled delivery attendance amongst urban women. Over 80% of urban women attended skilled delivery compared with only 43% of rural women (rural control group attendance was 44%). The failure of the messaging to make a difference for rural women could have been due to the known barriers to travel (cost, distance, transport availability) as well as issues with literacy, phone signal coverage and charging. Mobiles don’t have all the answers yet and while they help, other issues also need to be addressed if maternal health is to improve for these women.
If you are interested in finding out more about mHealth the U.S. Agency for International Development (USAID) and its partner, the Knowledge for Health (K4Health) Project, with input from FHI 360 and the mHealth Working Group has produced a set of resources:
References sourced from Global Health database:
- Mobile phones improve antenatal care attendance in Zanzibar: a cluster randomized controlled trial Stine Lund, Birgitte B Nielsen, Maryam Hemed, Ida M Boas, Azzah Said, Khadija Said, Mkoko H Makungu and Vibeke Rasch. BMC Pregnancy and Childbirth 2014, 14:29
- Mobile phones as a health communication tool to improve skilled attendance at delivery in Zanzibar: a cluster-randomised controlled trial. S Lund, M Hemed, BB Nielsen, A Said, K Said, MH Makungu, V Rasch. BJOG: An International Journal of Obstetrics & Gynaecology Volume 119, Issue 10, pages 1256–1264, September 2012
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Universal Health Coverage (UHC) day, December 12th, focusses on achieving Health for All by expanding UHC, a key SDG, to low and middle-income countries and ensuring that it also reaches the poorest in wealthy countries. Everyone should have access to basic health services without suffering financial hardship. The G7 Ise-shima meeting linked it to achieving better health systems and the global health security agenda. WE discuss what LMIC provide as basic health services and what NGOs and the public health community would like to further include (neglected tropical diseases and provision for refugees and migrant workers in host countries).
9 December 2016