By Associate Professor Arul Chib, Director, Singapore Internet Research Centre Assisted by Megan Fernandes, Graduate Student, Wee Kim Wee School of Communication and Information, Nanyang Technological University
“Almost 800 women die every day due to complications during pregnancy and childbirth” (WHO, 2014). 99% of these deaths occur in developing countries. These grim statistics betray the state of maternal healthcare and the circumstances under which many mothers try to bring their children into the world. A great majority of these deaths could have simply been averted had there been some form of skilled healthcare or obstetric care available to these expecting mothers.
For instance, in Aceh Besar, Indonesia, where I focused on rehabilitation efforts post the 2007 Tsunami, the stark lack of basic infrastructure and facilities available to mothers was immediately apparent. In other projects in India, China, Nepal, Papua New Guinea and Thailand, I was met with similar circumstances – derelict hospital infrastructure, threadbare facilities and an inadequate number of staff, many of whom were under-trained.
With high issue salience in the international development agenda – for example, Millennium Development Goal 5 is devoted to improving maternal health by reducing the maternal mortality ratio and increasing universal access to reproductive care – there is admittedly a lot of effort going into alleviating the problem.
But working in such low resource environments has taught me that mere injection of infrastructure or financial resources will not remedy the issue at hand. The issue of maternal mortality, or for that matter any development related issue we are grappling with today, is more nuanced and multi-faceted.
In exploring the various ways the issue can be approached, the role of Information Communication Technologies (ICT) stands out sharply. The rate of uptake of ICT devices – especially the now ubiquitous mobile phone has been nothing short of disruptive. Put in a healthcare context, ICTs have immense potential to be harnessed. The adoption and use of ICTs to achieve positive outcomes in healthcare delivery across the world has already been documented.
In making the case for maternal healthcare, let’s look at what decades of experience say: it is advised that pregnant women be provided with comprehensive care in the form of regular gynecological visits during pregnancy, access to skilled birth attendants during delivery, etc. However, the realities on the ground in many developing nations present a sharp contrast. Rural healthcare systems in such regions are unable to make available formal and adequate reproductive care. Without many of the required in-house facilities available locally, rural dwellers in developing countries need to travel to distant urban locations for access to service and care. In many cases such travel is not affordable or feasible and what remains are rural mothers-to-be cut off from access to the world at a time when it is most needed.
But the ubiquitous mobile phone is slowly trying to bridge this distance.
Evidence is emerging on how local healthcare workers are using mobile phones to access information and expert advice from their superiors in other locations. Mobile phones seem to be conquering the rural-urban distance barrier in two ways: they bring the urban healthcare center closer home in the form of professional advice directly from the expert and they improve the skills of the local, rural healthcare worker enough to the point that she can then make those important decisions by herself when the opportunity arises next time around.
Revisiting the case of Aceh, where we administered a mobile healthcare (mHealth) intervention for midwives, I found that mobile phone use and appropriation by the local midwives benefitted the local healthcare system by allowing for greater time efficiency, greater access to expert advice and finally improved relationships between the midwives, the community and with doctors.
I often quote a particular incident narrated to me by a participating midwife from the intervention in Aceh to illustrate the immense promise of the mobile phone:
“It was a high risk delivery. I called Ms. A [fellow midwife] then I called Ms. B [senior midwife] … When the baby came out, he didn’t cry, he had asphyxia. We thought he was already dead. The blood was all over my mobile phone because I kept holding it. I called an ambulance. The mother was bleeding. Ms. A took the baby with her and went with the ambulance. Imagine if I handled that patient alone, probably both the mother and the baby would have died.”
Despite the powerful narrative, it serves to mention that the mobile phone in itself is no single panacea to the problem. The problems that technology interventions are usually designed to address are but infrastructural problems. Most of the discourse surrounding this field today is in that order. However, there exists a social layer to the structural problem and this is where we should be turning our energy and efforts as well.
For example, we witnessed a strong patriarchal streak that ran in the community – the village chiefs [all male] were loath to allow the midwives [the females] possession of the mobile phones. The midwives employed strategies to protect the social order–projecting the fact that the mobile phone was ‘not theirs’ in that they resorted to ‘forced sharing’ strategies wherein they thrust the phone to their sons or other members of the community in a bid to escape the attention and questions they could be faced with. We observed other social dimensions to the problem in the form of ‘hierarchies’ or so called ‘power distance’ issues between those higher up in the medical fraternity and those at the junior or more rural levels.
Such ‘social’ problems are bound to exist well after the ‘technological or infrastructural’ problems are solved. Unsurprisingly, ‘technological or infrastructural’ solutions’ sometimes create ‘social’ issues.
What is required are interventions that adopt a more holistic approach towards resolving developmental issues. This requires effective problem solving with an entire system working in tandem: participation from a policy maker to a grassroots worker, from a gender expert to governance experts as no single issue can be resolved uni-dimensionally. From the perspectives of donors and governments, the conversation has to shift from the quantum of funds allotted and spent to the effectiveness of the outcomes this allocation has brought about. On its part, the research fraternity which I represent can help by pursuing more action oriented research and engaging more effectively with policy makers on the results of such research.
Dr. Arul Chib, Associate Professor at Nanyang Technological University, and Director of the Singapore Internet Research Center, studies the adoption of technology for positive development outcomes and examines the impact of development campaigns delivered via a range of innovative information and communication technologies (ICTD or ICT4D), focusing on mobile phone healthcare systems particularly in resource-constrained environments of developing countries.
Dr. Chib is the recipient of the 2011 Prosper.NET-Scopus Award for the use of ICTs for sustainable development, and a fellowship from the Alexander von Humboldt Foundation. He is the General Conference Chair for ICTD2015, taking place in Singapore 15-18 Ma, 2015. More details on his work may be found here, here and here, Dr. Arul Chib can be reached at ARULCHIB@ntu.edu.sg or (+65) 65148390