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

Hirabai Koli’s aesculapian reports were normal—but she wasn’t happy.   

She had been monitoring her value implicit the archetypal 2 months of her pregnancy, and she amazed assemblage health-care idiosyncratic Suraiyya Terdale erstwhile she asked wherefore she wasn’t gaining more. (To support her information and backstage wellness information, Koli is being identified by a pseudonym.) 

“It was an unusual question—something I heard for the archetypal time,” says Terdale. She past remembers Koli saying, “Someone told maine that if the large mother’s value isn’t expanding fast, past it’s a miss child.” 

Over 13 years of helping hundreds of women with childbirth successful the Ganeshwadi colony of Maharashtra, India’s second-most populous state, Terdale had heard a batch of aesculapian misinformation, but ne'er this peculiar myth. Terdale is an accredited societal wellness activist, oregon ASHA—part of an all-women cadre of 1 cardinal assemblage health-care workers. Across India’s villages, 1 ASHA is appointed for each 1,000 people; they are liable for implicit 70 health-care tasks and marque nationalist wellness attraction accessible to radical from distant areas and marginalized communities. 

Experience told Terdale that countering Koli’s beliefs without discourse could backfire. “If you archer idiosyncratic they are wrong, past radical don’t listen,” she says.

Indeed, erstwhile Terdale told Koli that her knowing was unscientific, Koli wasn’t convinced. Instead, Koli asked if she knew of immoderate doc who could corroborate if it was a antheral fetus, adjacent though the Indian authorities banned prenatal sex-determination tests successful 1994 successful effect to the precocious complaint of abortions of pistillate fetuses.

So Terdale began doing the tricky enactment of probing wherefore Koli believed this. After respective rounds of trust-building conversations, Terdale learned that Koli was a unfortunate of home unit and intersexual maltreatment due to the fact that her archetypal kid had been female. “My in-laws taunt maine each time for giving commencement to a girl,” Koli told her. “It has been truthful traumatic that I won’t beryllium capable to past if it’s different miss child.” 

After, Koli’s requests to get a prenatal enactment determination became much frequent, and Terdale decided to crook to the astir accessible and discreet mode to assistance her: WhatsApp. She sent Koli “scientific videos of what decides the biologic enactment of a child,” but “none of it made consciousness to her,” says Terdale. “The videos were successful English, but I americium definite the animation helped to a definite extent.” After further integer and in-person interventions, Terdale was yet capable to person Koli she wasn’t liable for the enactment of the child.

Terdale is 1 of galore ASHAs crossed the state who are turning to WhatsApp arsenic a means to combat aesculapian misinformation and navigate delicate aesculapian situations, peculiarly regarding pregnancy. Even though ASHAs weren’t trained to bash this, are paid precise little, and are astatine the mercy of India’s mediocre health-care infrastructure, the attack has had amazingly bully results. In 2006, India’s maternal mortality complaint was 254 deaths per 100,000 unrecorded births, 1 of the highest successful the world. By 2020, ASHAs had helped slash the maternal mortality complaint by implicit 60%, to 96 per 100,000 unrecorded births. This is peculiarly significant, due to the fact that for a agrarian colonisation of 833 million, India lone has 763 functioning territory hospitals, with conscionable nether 27,000 doctors.

But the enactment of ASHAs tin beryllium arduous and sometimes dangerous. Even aft she changed Koli’s mind, Terdale inactive had to person her husband. 

“Even I was scared. He abused whoever questioned him,” Terdale recalls. His repeated unit to get a prenatal sex-determination trial was causing Koli tremendous stress; Terdale disquieted astir what helium would bash next. “To commencement a antheral child, radical scope retired to babas [faith healers] and quacks,” she says. 

So she utilized the aforesaid approach, attempting to link straight with Koli’s hubby and debunk sex-related misinformation via WhatsApp messages. He didn’t respond. Finally, a fewer days later, she mustered the courageousness to face him successful person. “He verbally abused maine and adjacent declared that nary substance what happened, helium wouldn’t carnivore immoderate aesculapian expenses if it were a girl,” she says.

Suraiyya Terdale, an ASHA since 2009, has saved the lives of hundreds of women by busting pregnancy-related misinformation done WhatsApp and her fieldwork.

SANKET JAIN

Over the adjacent month, Terdale persisted—sending the hubby videos astir the interaction of intelligence wellness connected the wide well-being of an expectant parent and fetus. She besides messaged him applicable quality reports. After a fewer weeks, she accrued the frequence of her messages.

He yet changed his mind, and stopped bothering Koli with the request for a antheral child. However, the harm was already done; she reported symptoms of depression.

Terdale continued to usage WhatsApp to counsel Koli each fewer days: “When I wasn’t allowed to participate their house, WhatsApp helped maine prevention her.”

When it comes to pregnancy, astir radical successful India trust connected the experiences of their friends oregon relatives for information, though “this experience-sharing becomes different potent mode of sharing misinformation, particularly erstwhile it’s not backed by science,” says Hemraj Patil, who has implicit a decennary of acquisition successful nationalist wellness and antecedently worked with India’s National Health Mission. 

When younger women are coerced by household into pursuing superstitions—about what foods they tin and can’t eat, oregon that they can’t bargain caller clothes, permission the house, oregon deterioration bangles successful the archetypal 2 trimesters—ASHAs counsel the large women and guarantee they person due science-backed wellness care. If blimpish parents halt ASHAs from entering their houses, the ASHAs tin usage WhatsApp to remotely enactment large women and past inquire elder doctors oregon different assemblage members to sojourn their homes. Notably, ASHAs are besides utilizing WhatsApp to make safer spaces for women done targeted radical channels, wherever women stock their idiosyncratic experiences and talk candidly successful ways they can’t anyplace else. 

ASHA Maya Patil notes the wellness conditions of a assemblage pistillate and her newborn.

SANKET JAIN

“Ever since ASHAs started utilizing WhatsApp to bust misinformation, I’ve seen a affirmative change,” notes Patil. Last year, the World Health Organization honored ASHAs with the Global Health Leader grant for their work connected covid and successful slashing India’s maternal mortality rate.

Koli is conscionable 1 occurrence story. After months of patiently counseling her, Terdale took her to the infirmary to springiness commencement successful aboriginal 2022. “It was a antheral child,” says Terdale. “The lawsuit was nary uncertainty challenging and risky, but I americium arrogant I could alteration someone’s caput and marque radical think.” 

Crucially, the effects of changing 1 caput are not restricted to a azygous family. “Whenever you participate someone’s location successful a village, you are not conscionable talking to that peculiar member, but besides the neighbors, sometimes the full community,” Terdale says with a laughter that implies the concepts of privateness and idiosyncratic abstraction stay a important situation successful India’s villages. 

Today, Terdale proudly says she is successful interaction via WhatsApp with implicit 60% of the women successful the villages she oversees. 

“We are health-care workers and anticipation for truthful galore people. How tin we fearfulness and fto them down?” Terdale asks. In galore Indian languages, ASHA means hope.

“I started noting down the WhatsApp fig of everyone successful the community”

When she became an ASHA successful 2009, Netradipa Patil, from Maharashtra’s Shirol portion successful occidental India, was instantly forced to grapple with pregnancy-related misinformation and superstitions. 

During her tract visits backmost then, Patil saw a fewer young women utilizing WhatsApp. “I started noting down the WhatsApp fig of everyone successful the community,” she says. “Every day, galore radical would nonstop ‘good morning’ wishes to me.” By sometime successful 2014, she started to think: if they were already connecting connected the messaging app, wherefore not tackle misinformation there, too? 

Such enactment would spell supra and beyond Patil’s occupation requirements. In 2005, the Indian authorities launched the National Rural Health Mission to amended maternal and babe health. Under this program, ASHA workers were appointed successful 18 states; by 2009, the programme had expanded to each 28 states. ASHAs, though, are technically volunteers and are not paid a fixed wage but alternatively person “performance-based incentives” for completing tasks. In Maharashtra, for instance, they are paid conscionable 1,500 Indian rupees ($18.50) for maintaining elaborate records of each assemblage subordinate and 250 rupees ($3.70) for 9 months of prenatal care for 1 diligent and for facilitating infirmary delivery. Payment is often delayed. 

“We aren’t paid well,” Patil notes, “but that has ne'er stopped america from redeeming lives.” 

Despite the accrued workload and the inadequate (or sometimes nonexistent) compensation for net charges, Patil decided to effort utilizing WhatsApp successful her work. “Before straight busting immoderate misinformation, I started posting wide bits of proposal from doctors regarding pregnancy,” she says. To her surprise, galore younger women replied to her idiosyncratic messages and adjacent thanked her.

Along with WhatsApp, ASHA workers besides trust connected books and articles to scope the astir susceptible and marginalized radical successful the community. Here, Maya Patil talks to a radical of migrant sugarcane cutters.

SANKET JAIN

She past experimented by tackling the superstition that if a pistillate reveals her gestation to immoderate health-care idiosyncratic successful the archetypal trimester, she volition look complications and beryllium astatine hazard of miscarriage. A fewer women challenged this—though galore supported her. 

Patil began spending respective hours a time responding to each the doubts and apprehensions of assemblage women. “It did instrumentality a batch of my time, but aft 2 weeks, I saw a pistillate agreeing,” she says. 

Patil, who is besides a national person of implicit 3,000 ASHAs, invited a fewer 100 workers from adjacent villages to sermon however to usage the technology. “I shared my acquisition of utilizing WhatsApp and asked ASHAs to commencement experimenting successful their communities,” she says. Many reported affirmative results, and their enactment picked up momentum successful 2017 erstwhile WhatsApp introduced a diagnostic to stock photos and videos arsenic a status.

The archetypal clip Patil posted a WhatsApp status—a motivational quote—she thought it was conscionable different distraction successful her agelong workday. An hr later, implicit 100 radical had seen it. Just earlier the 24-hour mark, astatine which constituent the presumption gets archived, implicit 500 radical had viewed it. 

For a fewer days, she shared inspiring messages successful Marathi and Hindi and remembers galore radical replying to accidental they recovered them helpful. That encouraged Patil to standard up her enactment from one-on-one texts, and it besides gave her a feeling of designation from her community. 

Netradipa Patil often takes photos of the informational posters successful Shirol's agrarian infirmary to stock with a WhatsApp radical oregon arsenic a status.

SANKET JAIN

Over the past 5 years, Patil has trained hundreds of ASHAs from antithetic states to usage WhatsApp to debunk mendacious information. 

Maya Patil, an ASHA from Maharashtra’s Kutwad village, says she’s noticed akin affirmative results aft utilizing WhatsApp. She’s been moving successful the tract for 13 years, and successful 2018 she met a pistillate successful her ninth period of gestation with falling hemoglobin levels who had precocious been diagnosed with anemia. She tried to link the pistillate to the applicable nationalist doctor, but the household wanted her to usage earthy methods to summation her hemoglobin levels.

Patil asked the large pistillate to commencement drinking pomegranate juice, which has been proven to summation hemoglobin levels, but her parent said pomegranate foodstuff causes kidney stones. Patil tried for respective hours to explicate the science, but the household wasn’t convinced, nor were they funny successful anemia medications.

As a habit, Patil had been taking photos of hundreds of determination paper articles addressing communal wellness misinformation that were written by doctors. In one, she recovered details astir the benefits of pomegranate seeds and juice. She sent the large pistillate the nonfiction successful a WhatsApp message. Then she recovered much applicable YouTube videos recorded successful Marathi, the woman’s language. After 10 specified messages, she yet had an impact; the household allowed the pistillate to travel her advice, and wrong 12 days, her hemoglobin levels had increased. 

They worked unneurotic for 3 weeks, and erstwhile the pistillate gave birth, it was a mean transportation with a steadfast newborn weighing six-and-a-half pounds.

Creating a safer abstraction for women

Though they had successfully addressed a large woody of misinformation implicit respective years, galore ASHAs were inactive seeing large women who were excessively frightened to speech astir their pregnancies for fearfulness of their in-laws and husbands. Even successful big, ASHA-led radical messages, galore men successful the assemblage responded with “ill-informed comments,” says Netradipa Patil, the ASHA national leader.

Maya Patil likewise laments the persistence of unsafe aesculapian accusation passed down by family. “The superior extremity of immoderate fake quality related to gestation is to marque women suffer,” she says. “Many older women accidental that they had suffered these rituals during their pregnancy, truthful wherefore should the adjacent procreation not look this?” 

Along with ensuring safer childbirth, ASHA workers are besides liable for providing due postnatal wellness attraction to assemblage women. Here, Maya Patil explains however to instrumentality attraction of a newborn.

SANKET JAIN

So, successful 2018 and 2019, ASHAs started to signifier hyperlocal all-women WhatsApp groups. With a smaller radical of conscionable 15 to 20 large women and their adjacent female relatives, Netradipa Patil would absorption connected helping them recognize the technological aspects of care. “It was difficult, but easier than dealing with hundreds of radical successful 1 go.” After six months of trial runs, women successful the groups adjacent reported talking astir misinformation successful their households. 

Patil and respective different ASHAs person created aggregate groups; immoderate are constricted to a household and immoderate see full villages, others are meant lone for large women oregon lone for ASHA workers and their supervisors.

The topics of speech successful these groups present spell beyond wellness care; women stock their dreams for the future, oregon inquire ASHAs astir however they tin go financially autarkic oregon commencement tiny businesses. Many women besides sermon workplace exploitation and inquire ASHAs however to woody with it, oregon they inquire astir however to payment from authorities payment programs. These groups are peculiarly beneficial “when state is truthful restricted successful galore agrarian houses,” says Terdale. 

ASHAs accidental 1 of their astir important tasks is ensuring women aren’t abused for confronting accepted beliefs. Particularly successful cases of household conflicts, galore ASHAs usage precise cautious and circumstantial connection to pass with women. “Sometimes during fieldwork, we usage a codification connection [with patients], which often means that there’s immoderate household oregon aesculapian contented which needs to beryllium discussed personally,” Patil says. “We person been moving for implicit a decennary and person built a enslaved with everyone. None of this could person been imaginable if the assemblage members [didn’t] spot us.”

Patil recalls 1 peculiarly unsafe case. Saniya Makandar, a pistillate with a high-risk pregnancy, was successful an interfaith matrimony that wasn’t accepted by their families, and galore ASHAs wouldn’t enactment with her due to the fact that they “feared attacks from spiritual fanatics,” Patil says. (To support her safety, Makandar is being identified by a pseudonym.)

Patil had to physique spot with Makandar and guarantee her information during treatment, adjacent arsenic predominant household clashes and spiritual fights weighed connected her. Soon, Makandar opened up astir her precarious condition. She didn’t cognize if she’d received definite vaccines, and she reported swelling successful her legs, precocious humor pressure, utmost weakness, and adjacent suicidal thinking. Patil recovered that her hemoglobin level had dropped to 7 during a clip successful which it should person been 12 to 16 grams per deciliter. 

Terdale plays with Hirabai Koli's lad during a sojourn with Koli.

SANKET JAIN

Low hemoglobin during gestation remains a occupation crossed India, but successful Makandar’s case, misinformation made it much hard to address. Patil discovered that she was eating lone wheat flatbreads, owed to a section superstition that the fare was healthy. While Patil prepared a due fare illustration for her, visiting her location regular wasn’t feasible due to the fact that of the backlash Patil mightiness look from her ain Hindu community. So she decided, again, to crook to WhatsApp. “Every day, I started sending photos, videos, and articles connected what nutrient to eat.”

But conscionable addressing the wellness myths wasn’t enough. So each day, Patil followed up with elemental messages via WhatsApp, like, Are you feeling amended today? Or, Is determination thing you privation to share? 

Such questions from ASHAs person had a tremendous interaction connected galore women similar Makandar, who had ne'er opened up astir their pregnancies, oregon their families and futures, earlier they began sharing their problems with the ASHAs and women successful their WhatsApp groups. 

After 2 months of aggravated enactment with Patil, Makandar’s wellness improved, and she gave commencement to a steadfast babe via cesarean conception astatine the nationalist territory hospital. 

“A connection tin prevention someone’s life,” says Terdale, “and we spot it happening astir each day.” 

Sanket Jain is an autarkic writer and a documentary lensman based successful India’s Maharashtra state. His enactment has appeared successful much than 30 publications. He tweets astatine @snktjain.