April 20, 2013

Unequal Knowledge: pregnancy and discrimination

We all know that mothers and babies in India are dying. We have some of the highest rates of maternal and infant mortality in the world and tragically, a lot of it is preventable. Access to information is key. Quite simply, many women do not do the right things because they don’t know what they are. Across rural India, this need is being tackled through government healthcare workers or ASHAs (Accredited Social Health Activists). There are those who say that the ASHA program needs to be improved in terms of how ASHAs are selected, trained and rewarded. There’s certainly no arguing that a lot is riding on the ASHAs and the quality of information they give out.

ASHAs are supposed to advise pregnant women on institutional delivery (why it’s better to deliver in hospital), keeping the baby warm after birth, nutrition, breastfeeding and family planning methods through a series of antenatal sessions. So far so good. But how effective are these sessions and what are the possible pitfalls?

Like any system that is heavily dependent on lots of people, there are danger areas caused by the specific attitudes and personalities of these people. A study published in PLOS collections points out one such danger area: the deep-seated inequality that is present in the system. According to the study published in 2012, richer women who visit antenatal centres are likely to receive more information than poorer women.

The researchers studied seven components of advice and found marked differences. To begin with, women who visited higher level facilities had a greater chance of getting advice compared to those who visited lower level facilities. This can be a matter of life and death. For example, 65% of women availing of antenatal care in the higher level facilities were given advice on keeping the baby warm compared to only 59% among those who availed themselves of antenatal care in the lower level facilities. This means 41% did not receive advice on keeping their babies warm after birth. Many parts of rural India get bitterly cold at night. Consider lack of adequate sheets / linen, the fatigue of the mother and the general lack of information. It adds up to dead infants. When I visited Dr Abhay Bang’s non-profit organisation SEARCH in Gadchiroli, he mentioned that hypothermia is a leading cause of infant mortality in rural India.

Rich women were also more likely to receive advice on institutional delivery, nutrition and breastfeeding. According to the report, the advice given to pregnant women was also quite variable. While most women were advised on breastfeeding and nutrition, about 35% of pregnant women were not advised on keeping the baby warm. About 39% did not receive advice on institutional delivery and visiting a health facility for pregnancy complications. This means a lot of women not knowing what to do when they start bleeding in their seventh month or when they swell up dramatically and need to be checked for preeclampsia.

What this study concludes is that health workers “proffer advice to their clients based on their own perceptions of the clients’ needs.”

The solution seems like common sense: train and sensitise health workers about the catastrophic effects of their inbuilt biases. But here are some questions. Given that we are a country steeped in bias, what kind of training programmes are effective? Who conducts these programmes? How can we be certain that the trainers themselves are not passing on biases? In other words, who watches the watchers?

This is where technology could play an important role. Projects such as Dimagi’s CommCare in Bihar and Armaan’s mMitra in Maharashtra depend on the healthcare worker but also try to standardise the information she will give out.

The technological solutions provide the healthcare workers with ready-made modules of information when she visits pregnant women in their homes. This may go some way toward reducing the element of human bias and ensuring that all women receive a certain basic amount and type of information. (Of course, it could still have loopholes. Healthcare workers may simply not visit poorer women as often or not play the entire module for them. Still, it tackles some of the gaps.) Technology can’t replace counselling. We still need to do work toward changing mindsets and biases. Health workers are the most important link in this chain and investing in them is a huge priority. But we shouldn’t ignore the possibilities of technology either. Tech solutions that systematise  or regularise some of the processes are bound to help. Techies, CSR types, other head honchos — are you listening?  In the meantime, this blog post covers various ICTs for maternal and child health that are currently being piloted in India.

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