mMitra is a free mobile voice call service that provides culturally appropriate comprehensive information on preventive care and simple interventions to reduce maternal and infant mortality and morbidity in urban and rural India. The voice calls are in the local dialect, speciﬁc to the woman’s gestational age or the age of the infant and are sent weekly/twice a week directly to pregnant women and mothers with infants in their chosen language and timeslot.
|“It was 1 am and a busy on call night. Suddenly I was called to the emergency room 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 delivered but the body stuck inside due to shoulder dystocia. I will never forget the first sight of her: a beautiful frail young woman with the head of a beautiful bonny baby sticking out of her vagina.|
She was sinking due to a ruptured uterus due to the baby stuck in it for more than four hours. When an emergency explorative surgery was performed, the baby’s neck was too jammed for us to be able to deliver it through the incision. So we had to behead the baby on the operating table. Since we could not hand over a beheaded baby to the relatives, I had to sew the baby’s head to the rest of the body. Aruna died three days later. The sight of the bonny beheaded baby will forever haunt me. The memory of sewing the baby’s head onto its body still gives me nightmares. Aruna’s death will forever stay with me. Not just because she died a most horrible death, but also because it was so easily preventable. She had gone for her first antenatal visit in the first trimester. But she had not been counseled about the remaining visits and the danger signals. She had never been informed of the potential complications. If only she had been.” – A personal experience of Dr Aparna Hegde, during her first post as a resident doctor in Mumbai.
India ranks first among the countries that account for 2/3rd of the maternal and under-5 mortality in the world. Lack of access to preventive care information is a major cause. The rhetoric of urban bias in development and better conditions in urban vis-à-vis rural has masked the real picture of urban poor.
1 Urban slums populations rank among the poorest and most under-served groups in terms of health.
2 The infant mortality rate for urban infants with low standard of living index is 76.1 and the neonatal mortality rate is 48.8 per thousand, which is higher than the national average. All indicators of delivery and postnatal care were consistently poorer in slum areas when compared to non-slum areas in most Indian cities in NFHS-3.
India has over 1 billion 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 Voice Calls
The voice messages have been developed by BabyCenter and have been 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 – 120 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.
Women are enrolled through two verticals:
Hospital Vertical – Health workers are posted in the antenatal/postnatal clinics of municipal hospitals and maternity homes who register women during their ﬁrst checkup visit.
Community Vertical – Enrollment in the slum is done through partner NGOs working in slum communities. More than 7000 Sakhis have been trained who enroll women directly in the early stages of pregnancy for a small incentive.
Registration requires that the women provide their primary mobile number, preferred one hour time-slot to receive the calls, preferred language and age of pregnancy/age of the child.
The mMitra Missed call system
For each message, there are three tries; once in the chosen timeslot daily for three days.
If the woman has missed a message despite three tries, she can give a missed call on the designated number to receive a call back from the system immediately with the missed message.
The mMitra Call centre
The enrolled women can call the mMitra call centre if
a. She has changed her number
b. She has delivered and needs to switch to infancy voice calls
c. Her preferred one hour time-slot has changed
d. She has had an abortion or stillbirth and needs to stop the calls.
Her call is automatically disconnected and the call centre executive calls her back and takes down the necessary details and also counsels her in case of an abortion/ stillbirth.
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.
The mMitra program was piloted in the antenatal clinic of Sion Hospital, Mumbai (funded by Glenmark Foundation) in December 2013 and was received well by the women. Johnson and Johnson Global Foundation has been supporting the mMitra program since January 2014.
mMitra which began its services in 2013 from a single Hospital in Mumbai, has now expanded to enroll 1,939,000+ women across Mumbai, Nasik, Pune, Raigad, Ratnagiri in Maharashtra; Delhi NCR; Bhopal, Indore, Dewas and Ujjain cities of MP; Varanasi in UP; Dalsingsarai in Samastipur district in Bihar; Jhalawar district in Rajasthan and Hubli in Karnataka. This rapid scale up of services throughout Mumbai and other cities has been possible through a successful partnership with 100 hospitals, 41 community based NGOs and 7000+ Sakhis enrolling women directly in the communities.
ARMMAN’s ﬁve-year expansion plan for mMitra includes enrolling 2.2 million women in ten major tier I and tier II cities and spreading across rural India.
Deepening the mMitra Program
|One stop Call Centre to answer all health queries of enrolled women through pregnancy until the child is five years in age.||Weekly / once a month customized calls to prevent malnutrition until the child is five years old.|
|Handholding through weekly voice reminders and call centre for HIV positive women until the child is 18 months of age to prevent vertical transmission of HIV / AIDS from mother to child.||Handholding through weekly / fortnightly calls through 8 months of treatment and rehabilitation process for mothers of children who have developed SAM (Severe Acute Malnutrition).|
ARMMAN is adding the following complimentary services in the future to oﬀer more holistic service to mMitra beneﬁciaries:
● mMitra Customized Malnutrition Program: Aims to prevent malnutrition and facilitate treatment of SAM children. One additional voice call (in addition to the once a week mMitra voice call) will be sent weekly from fourth month of infancy until the child is one year of age and then one voice call per month will be sent until the child is ﬁve years of age guiding the mother on nutrition issues. Mothers with children diagnosed as SAM will be handheld through the treatment and rehabilitation process through weekly/once in two weeks calls by trained call centre counselors.
● Call-Back Component for Health Queries: Trained call centre counsellors will answer health queries of enrolled women with the help of an evidence-based data bank of FAQs developed and vetted by expert doctors from FOGSI and IAP.● Customized services for HIV positive pregnant women: ARMMAN will oﬀer customized voice reminders, medication reminders and call centre services for symptom management to all HIV positive mMitra beneﬁciaries in Mumbai. The aim is to handhold them through the HIV/AIDS treatment process until the child is 18 months of age, to prevent vertical transmission of HIV/AIDS.