Earlier this week I finally got an opportunity to talk to my sister and niece via video chat. As I sat in my ‘office’ I watched them playing on the bed. Although the connection was poor I could easily make out my niece, in her green pajamas, jumping all over the place saying ‘Mausi’ and ‘Priya’ and ‘Purple.’ I sat watching my sister, now 8 months pregnant, sitting on the bed trying to calm my niece down, but also just enjoying the moment. She even stood up so I could see her 8-months-pregnant belly profile. Her belly protruded in her elastic band jeans and black cow neck top. Surprisingly, her pregnancy is still just all belly.
An hour later I found myself in front of another expecting mother, also 8 months pregnant, but the circumstances were quite different. I sat alongside an Accredited Social Health Activist (ASHA) and another colleague on a ripped tarp on the dirt floor in the middle of a moderately sized community of homes in rural Bihar. As huge cutter ants walked between us and flies buzzed around us we tried to help the ASHA use her new mobile phone application to ask the expecting mother a series of questions about her pregnancy. This 17-year-old, illiterate, woman barely said a word or showed her face. Rather her mother-in-law and other relatives shouted out answers for her. Soon our presence and the natural curiosity of the village resulted in a crowd of 6-7 women and 7-10 children. As the women squatted to listen to what we were doing the children stared at us with dripping noses.
As our session continued I started to get overwhelmed. I’m not sure if it was the little girl climbing on my back, the other little girl coughing on my arm, my fear of the cutter ants, the difficulty I saw the ASHA having, or the smell of cow dung. For a brief moment I thought to myself ‘if I were a different person, I don’t think I could handle this.’ The session went on for over an hour.
As the week continued, performing 3-4 home visits per day, two things became apparent. Firstly, I was becoming increasingly jealous of the women’s sarees. I realized that as these women squatted or sat on the ground the cloth of their sarees provided a barrier around their feet, shielding them from the bugs. The look of a pregnant woman in a saree is just so appealing. The bright colored cloth wrapped around her bellows out as it hits her stomach. Instead of making a ball of a stomach the way American clothes or a kurti would, the saree tucks in above the belly then balloons out and falls straight down creating a bucket around the woman. The most beautiful site was that of these women up against the green fields of rice and mustard seed flowers. Secondly, the village is FULL of children. Everywhere I looked there were children running around, playing with dirt, cuddling with baby goats, crying for their mothers, playing on the roofs, or sometimes, even walking away wearing my shoes. I realized that most of these kids were under the age of 10; any older and they would probably be working in the fields. How these women deal with so many young children each day is baffling to me. I guess there is comfort in the communal raising of children, but I know none of these children are getting the daily nutrition or education they need. I realized how important the family planning section of the ASHA’s mobile application really is and how challenging it will be for her to educate her community on the benefits of small family size.
I wondered what it must be like for an uneducated woman of the village to hear about introducing a foreign object like an inter-uterine device (IUD) into her body, or the idea of taking a daily pill to prevent pregnancy, or the idea of having tubal ligation surgery (TL) to take away a natural part of her womanhood. As I focused on what the ASHAs were telling the women about family planning I realized that there was a huge gap in education. While the most educated ASHAs knew about family planning methods many did not know about their administration, indications, complications, or side effects. I wonder what devastating events have occurred from improper use of family planning methods.
So what can we do? The current mobile application does highlight all these issues and prompts ASHAs to talk about complications, side effects, and indications, but how good are these prompts if the ASHA is not properly educated about them? It may be harmful to prompt ASHAs to give incomplete and sometimes inaccurate advice. By collecting data that continuously reports that an ASHA has ‘counseled about family planning methods’ we may be sending the wrong message to program managers who review the data if, in truth, the counseling was not up to par. While I want to believe that our partners can and will educate ASHAs further on family planning, it’s not always guaranteed. As a provider of open-source technology, we can only push for increased educational content within the mobile application itself and present honest feedback to our partners. Perhaps the benefit would be clearer if we worked only on education-based applications, but as a technology provider, would this restriction limit our potential for health impact?
Reena Gupta lives and works in India as a Dimagi Field fellow. Her work includes design, development, testing, and evaluation of CommCare mobile applications for use by ASHAs and other community health workers in rural India. To learn more about CommCare, please visit www.commcarehq.org. To learn more about the ASHA program, please visit About ASHA.