How Indian health-care workers use WhatsApp to save pregnant women

Hirabai Koli’s medical reviews had been regular—however she wasn’t pleased.   

She had been monitoring her weight over the primary two months of her being pregnant, and she or he shocked neighborhood health-care employee Suraiyya Terdale when she requested why she wasn’t gaining extra. (To defend her security and personal well being info, Koli is being recognized by a pseudonym.) 

“It was an odd question—something I heard for the first time,” says Terdale. She then remembers Koli saying, “Someone told me that if the pregnant mother’s weight isn’t increasing fast, then it’s a girl child.” 

Over 13 years of serving to tons of of women with childbirth within the Ganeshwadi village of Maharashtra, India’s second-most populous state, Terdale had heard lots of medical misinformation, however by no means this specific fantasy. Terdale is an accredited social well being activist, or ASHA—a part of an all-women cadre of 1 million neighborhood health-care workers. Across India’s villages, one ASHA is appointed for each 1,000 individuals; they’re accountable for over 70 health-care duties and make public well being care accessible to individuals from distant areas and marginalized communities. 

Experience advised Terdale that countering Koli’s beliefs with out context may backfire. “If you tell someone they are wrong, then people don’t listen,” she says.

Indeed, when Terdale advised Koli that her understanding was unscientific, Koli wasn’t satisfied. Instead, Koli requested if she knew of any physician who may affirm if it was a male fetus, though the Indian authorities banned prenatal sex-determination assessments in 1994 in response to the excessive price of abortions of feminine fetuses.

So Terdale started doing the tough work of probing why Koli believed this. After a number of rounds of trust-building conversations, Terdale discovered that Koli was a sufferer of home violence and sexual abuse as a result of her first youngster had been feminine. “My in-laws taunt me every day for giving birth to a girl,” Koli advised her. “It has been so traumatic that I won’t be able to survive if it’s another girl child.” 

After, Koli’s requests to get a prenatal intercourse dedication grew to become extra frequent, and Terdale determined to flip to essentially the most accessible and discreet manner to assist her: WhatsApp. She despatched Koli “scientific videos of what decides the biological sex of a child,” however “none of it made sense to her,” says Terdale. “The videos were in English, but I am sure the animation helped to a certain extent.” After additional digital and in-person interventions, Terdale was lastly ready to persuade Koli she wasn’t accountable for the intercourse of the kid.

Terdale is one in every of many ASHAs throughout the nation who’re turning to WhatsApp as a way to fight medical misinformation and navigate delicate medical conditions, significantly concerning being pregnant. Even although ASHAs weren’t skilled to do that, are paid little or no, and are on the mercy of India’s poor health-care infrastructure, the method has had surprisingly good outcomes. In 2006, India’s maternal mortality price was 254 deaths per 100,000 dwell births, one of many highest on the earth. By 2020, ASHAs had helped slash the maternal mortality price by over 60%, to 96 per 100,000 dwell births. This is especially important, as a result of for a rural inhabitants of 833 million, India solely has 763 functioning district hospitals, with slightly below 27,000 docs.

But the work of ASHAs could be arduous and typically harmful. Even after she modified Koli’s thoughts, Terdale nonetheless had to persuade her husband. 

“Even I was scared. He abused whoever questioned him,” Terdale remembers. His repeated strain to get a prenatal sex-determination take a look at was inflicting Koli large stress; Terdale fearful about what he would do subsequent. “To birth a male child, people reach out to babas [faith healers] and quacks,” she says. 

So she used the identical method, making an attempt to join instantly with Koli’s husband and debunk sex-related misinformation by way of WhatsApp messages. He didn’t reply. Finally, just a few days later, she mustered the braveness to confront him in particular person. “He verbally abused me and even declared that no matter what happened, he wouldn’t bear any medical expenses if it were a girl,” she says.

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Over the following month, Terdale continued—sending the husband movies in regards to the affect of psychological well being on the general well-being of an expectant mom and fetus. She additionally messaged him related information reviews. After just a few weeks, she elevated the frequency of her messages.

He finally modified his thoughts, and stopped bothering Koli with the demand for a male youngster. However, the injury was already performed; she reported signs of melancholy.

Terdale continued to use WhatsApp to counsel Koli each few days: “When I wasn’t allowed to enter their house, WhatsApp helped me save her.”

When it comes to being pregnant, most individuals in India depend on the experiences of their associates or family for info, although “this experience-sharing becomes another potent way of sharing misinformation, especially when it’s not backed by science,” says Hemraj Patil, who has over a decade of expertise in public well being and beforehand labored with India’s National Health Mission. 

When youthful women are coerced by household into following superstitions—about what meals they will and might’t eat, or that they will’t purchase new garments, depart the home, or put on bangles within the first two trimesters—ASHAs counsel the pregnant women and guarantee they obtain correct science-backed well being care. If conservative mother and father cease ASHAs from getting into their homes, the ASHAs can use WhatsApp to remotely help pregnant women after which ask senior docs or different neighborhood members to go to their houses. Notably, ASHAs are additionally utilizing WhatsApp to create safer areas for women by way of focused group channels, the place women share their private experiences and converse candidly in methods they will’t anyplace else. 

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“Ever since ASHAs started using WhatsApp to bust misinformation, I’ve seen a positive change,” notes Patil. Last yr, the World Health Organization honored ASHAs with the Global Health Leader award for his or her work on covid and in slashing India’s maternal mortality price.

Koli is only one success story. After months of patiently counseling her, Terdale took her to the hospital to give start in early 2022. “It was a male child,” says Terdale. “The case was no doubt challenging and risky, but I am proud I could change someone’s mind and make people think.” 

Crucially, the results of adjusting one thoughts will not be restricted to a single household. “Whenever you enter someone’s house in a village, you are not just talking to that particular member, but also the neighbors, sometimes the entire community,” Terdale says with fun that means the ideas of privateness and private area stay a major problem in India’s villages. 

Today, Terdale proudly says she is in contact by way of WhatsApp with over 60% of the women within the villages she oversees. 

“We are health-care workers and hope for so many people. How can we fear and let them down?” Terdale asks. In many Indian languages, ASHA means hope.

“I started noting down the WhatsApp number of everyone in the community”

When she grew to become an ASHA in 2009, Netradipa Patil, from Maharashtra’s Shirol area in western India, was instantly compelled to grapple with pregnancy-related misinformation and superstitions. 

During her subject visits again then, Patil noticed just a few younger women utilizing WhatsApp. “I started noting down the WhatsApp number of everyone in the community,” she says. “Every day, many people would send ‘good morning’ wishes to me.” By someday in 2014, she began to assume: in the event that they had been already connecting on the messaging app, why not deal with misinformation there, too? 

Such work would go above and past Patil’s job necessities. In 2005, the Indian authorities launched the National Rural Health Mission to enhance maternal and toddler well being. Under this program, ASHA workers had been appointed in 18 states; by 2009, this system had expanded to all 28 states. ASHAs, although, are technically volunteers and will not be paid a hard and fast wage however somewhat obtain “performance-based incentives” for finishing duties. In Maharashtra, for example, they’re paid simply 1,500 Indian rupees ($18.50) for sustaining detailed information of each neighborhood member and 250 rupees ($3.70) for 9 months of prenatal take care of one affected person and for facilitating hospital supply. Payment is usually delayed. 

“We aren’t paid well,” Patil notes, “but that has never stopped us from saving lives.” 

Despite the elevated workload and the insufficient (or typically nonexistent) compensation for web expenses, Patil determined to attempt utilizing WhatsApp in her work. “Before directly busting any misinformation, I started posting general bits of advice from doctors regarding pregnancy,” she says. To her shock, many youthful women replied to her private messages and even thanked her.

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She then experimented by tackling the superstition that if a girl reveals her being pregnant to any health-care employee within the first trimester, she’s going to face issues and be vulnerable to miscarriage. Just a few women challenged this—although many supported her. 

Patil started spending a number of hours a day responding to all of the doubts and apprehensions of neighborhood women. “It did take a lot of my time, but after two weeks, I saw a woman agreeing,” she says. 

Patil, who can also be a union chief of over 3,000 ASHAs, invited just a few hundred workers from close by villages to talk about how to use the know-how. “I shared my experience of using WhatsApp and asked ASHAs to start experimenting in their communities,” she says. Many reported optimistic outcomes, and their work picked up momentum in 2017 when WhatsApp launched a function to share images and movies as a standing.

The first time Patil posted a WhatsApp standing—a motivational quote—she thought it was simply one other distraction in her lengthy workday. An hour later, over 100 individuals had seen it. Just earlier than the 24-hour mark, at which level the standing will get archived, over 500 individuals had seen it. 

For just a few days, she shared inspiring messages in Marathi and Hindi and remembers many individuals replying to say they discovered them useful. That inspired Patil to scale up her work from one-on-one texts, and it additionally gave her a sense of recognition from her neighborhood. 

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Over the previous 5 years, Patil has skilled tons of of ASHAs from totally different states to use WhatsApp to debunk false info. 

Maya Patil, an ASHA from Maharashtra’s Kutwad village, says she’s seen related optimistic outcomes after utilizing WhatsApp. She’s been working within the subject for 13 years, and in 2018 she met a girl in her ninth month of being pregnant with falling hemoglobin ranges who had just lately been recognized with anemia. She tried to join the girl to the related public physician, however the household needed her to use pure strategies to enhance her hemoglobin ranges.

Patil requested the pregnant girl to begin ingesting pomegranate juice, which has been confirmed to enhance hemoglobin ranges, however her mom mentioned pomegranate juice causes kidney stones. Patil tried for a number of hours to clarify the science, however the household wasn’t satisfied, nor had been they excited about anemia drugs.

As a behavior, Patil had been taking images of tons of of regional newspaper articles addressing frequent well being misinformation that had been written by docs. In one, she discovered particulars about the advantages of pomegranate seeds and juice. She despatched the pregnant girl the article in a WhatsApp message. Then she discovered extra related YouTube movies recorded in Marathi, the girl’s language. After 10 such messages, she lastly had an affect; the household allowed the girl to observe her recommendation, and inside 12 days, her hemoglobin ranges had elevated. 

They labored collectively for 3 weeks, and when the girl gave start, it was a traditional supply with a wholesome new child weighing six-and-a-half kilos.

Creating a safer area for women

Though that they had efficiently addressed a substantial amount of misinformation over a number of years, many ASHAs had been nonetheless seeing pregnant women who had been too scared to speak about their pregnancies for concern of their in-laws and husbands. Even in huge, ASHA-led group messages, many males in the neighborhood responded with “ill-informed comments,” says Netradipa Patil, the ASHA union chief.

Maya Patil equally laments the persistence of harmful medical info handed down by household. “The primary goal of any fake news related to pregnancy is to make women suffer,” she says. “Many older women say that they had suffered these rituals during their pregnancy, so why should the next generation not face this?” 

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So, in 2018 and 2019, ASHAs began to type hyperlocal all-women WhatsApp teams. With a smaller group of simply 15 to 20 pregnant women and their shut femininefamily, Netradipa Patil would concentrate on serving to them perceive the scientific elements of care. “It was difficult, but easier than dealing with hundreds of people in one go.” After six months of take a look at runs, women within the teams even reported speaking about misinformation of their households. 

Patil and several other different ASHAs have created a number of teams; some are restricted to a family and a few embrace whole villages, others are meant just for pregnant women or just for ASHA workers and their supervisors.

The subjects of dialog in these teams now transcend well being care; women share their desires for the long run, or ask ASHAs about how they will develop into financially impartial or begin small companies. Many women additionally talk about office exploitation and ask ASHAs how to cope with it, or they ask about how to profit from authorities welfare applications. These teams are significantly useful “when freedom is so restricted in many rural houses,” says Terdale. 

ASHAs say one in every of their most vital duties is guaranteeing women aren’t abused for confronting conventional beliefs. Particularly in instances of household conflicts, many ASHAs use very cautious and particular language to talk with women. “Sometimes during fieldwork, we use a code language [with patients], which often means that there’s some family or medical issue which needs to be discussed personally,” Patil says. “We have been working for over a decade and have built a bond with everyone. None of this could have been possible if the community members [didn’t] trust us.”

Patil remembers one significantly harmful case. Saniya Makandar, a girl with a high-risk being pregnant, was in an interfaith marriage that wasn’t accepted by their households, and plenty of ASHAs wouldn’t work together with her as a result of they “feared attacks from religious fanatics,” Patil says. (To defend her security, Makandar is being recognized by a pseudonym.)

Patil had to construct belief with Makandar and guarantee her security throughout therapy, whilst frequent household clashes and spiritual fights weighed on her. Soon, Makandar opened up about her precarious situation. She didn’t know if she’d obtained sure vaccines, and she or he reported swelling in her legs, hypertension, excessive weak spot, and even suicidal considering. Patil discovered that her hemoglobin degree had dropped to seven throughout a time through which it ought to have been 12 to 16 grams per deciliter. 

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Low hemoglobin throughout being pregnant stays an issue throughout India, however in Makandar’s case, misinformation made it harder to handle. Patil found that she was consuming solely wheat flatbreads, due to an area superstition that the food plan was wholesome. While Patil ready a correct food plan chart for her, visiting her home each day wasn’t possible due to the backlash Patil may face from her personal Hindu neighborhood. So she determined, once more, to flip to WhatsApp. “Every day, I started sending photos, videos, and articles on what food to eat.”

But simply addressing the well being myths wasn’t sufficient. So daily, Patil adopted up with easy messages by way of WhatsApp, like, Are you feeling higher at present? Or, Is there one thing you need to share? 

Such questions from ASHAs have had an incredible affect on many women like Makandar, who had by no means opened up about their pregnancies, or their households and futures, earlier than they started sharing their issues with the ASHAs and women of their WhatsApp teams. 

After two months of intense work with Patil, Makandar’s well being improved, and she or he gave start to a wholesome child by way of cesarean part on the public district hospital. 

“A message can save someone’s life,” says Terdale, “and we see it happening almost every day.” 

Sanket Jain is an impartial journalist and a documentary photographer based mostly in India’s Maharashtra state. His work has appeared in additional than 30 publications. He tweets at @snktjain.