Why does prenatal care not get the attention it deserves? In our country women and children dying for reasons that should never happen. Sometimes the circumstances are horrific and if only they had a little bit of antenatal information at the right time they would not have to die. These are systemic issues, and it is so expensive for the system when patients come in a dying state.
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Dr Aparna Hegde says that very early on she realised that if "I have to impact lives it is not enough to work in the hospitals. I have to go into the community and ensure that these risk factors are picked up early enough before it is too late and women and children get the end-to-end care that they deserve."
Her NGO named ARMMAN, founded in 2008, works towards advancing reduction in mortality and morbidity of mothers and children and Neonatal. Dr Aparna Hegde is a practising Urogynaecologist, a published researcher and TED Fellow. She was also named as Fortune’s 50 greatest leaders, one of the only two Indians and the only Indian woman on the list. ARMMAN also won a Google grant to run skilling programmes for 180, 000 ASHA (Accredited Social Health Activists) and 40,000 Auxiliary Nurse Midwives (ANMs). Aparna, however, shares that it took her five years to get her first funding.
There is a particularly disturbing case that was one of the triggers which led to the formation of ARMMAN. She narrates it us:
Aruna's Story
*Trigger warning: This article contains graphic details.
During my first three months of residency, there was this patient called Aruna. I was doing my emergency duty that day. Aruna had gone to Thane Civil Hospital, a suburb of Mumbai, during the initial days of her pregnancy. The antenatal clinics are so overburdened in our country that she perhaps never felt cared for and thus never went back to the hospital. In her fifth month of pregnancy, she developed gestational diabetes. If you have diabetes in the womb, generally the baby does not survive but her baby did. In the ninth month, when she went into labour she went back to the hospital. The nurse there didn't understand that there was a problem, so she proceeded with the delivery. The baby developed something called a “shoulder dystocia”. When you are exposed to so much sugar in the body (because the mother had diabetes) the body becomes huge and the head remains small so the baby’s head was delivered and the body remained stuck inside. The baby died immediately, now it was the question of saving the mother’s life.
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It took the nurse half an hour to get a doctor who could do a C-Section, however, there was no anaesthetist in the operation theatre. So they had to transfer the patient. It took another half an hour to get an ambulance. So, one-and-a-half hours after she came to Thane hospital, she started getting transferred to Sion hospital. It took another 1.5 hours through the horrific Mumbai Friday evening traffic to reach the hospital. She came to the Sion hospital and I was the rookie doctor. I remember the sight of opening her petticoat. There was this black bonny baby head sticking out of her vulva and her lower part was getting gangrenous. This is just before mobile phones came to India and I immediately rushed to get my seniors down. She was sinking and losing her consciousness because of the gangrenous situation.
My seniors came down and we tried to take the baby down from below and it was not possible, it was all jammed. So, we had to take her for a C-section. I was the junior-most doctor, the seniors started operating and they tried to take the baby out from above, and it was not possible, it was all jammed. So, the deed fell on me, I had to take a knife and behead the patient’s baby on the operation table. And because you cannot give a beheaded baby to the family, I had to take a needle and twine and stitch the baby’s head on the body. And then the mother died three days later."
How crucial is first information in pregnancy?
Dr Hegde feels what had happened was just because the patient didn’t know that you have to go and get yourself tested for diabetes in the fifth month of pregnancy. If only she had been given this information, and she had gone and got the blood test done, her life would have been saved, her child’s life would have been saved. And you can’t even blame her. She came to the hospital, but the system failed her.
Dr Hegde feels, you can’t blame the nurse either. She asks, "with the overcrowded clinics how are we going to take care of so many women?" She further elaborates, "Couple of times, I have looked at the patient’s paper and looked at my own handwriting. The patient would have come in the third month of pregnancy and when we told them to come again, maybe she had come. We failed her, maybe we didn’t counsel her enough, tell her about the signs of complications and when to access care. And these stories would really keep playing in my head in the nine years I spent in the hospitals before I left for higher studies. Nothing had changed, women and children were dying for the same reasons. So, I realised that I have to go one step earlier, pick up these risk factors much earlier, educate the women, train the health workers and that’s how ARMMAN was born."
You can listen to our conversation with Dr Aparna Hedge Here:
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How can technology help us in creating a scalable solution in prenatal care?
With Technology ARMMAN is now creating scalable and cost-effective solutions. Aparna says, “During my residency days in Mumbai, I saw closely how pervasive systemic problems lead to loss of lives of mothers and children which are completely preventable and given the scale of India’s problems, it is very important that you create scalable solutions that are designed for scale from day one. And technology allows you to do that. But we do not only adopt technology, it has to be tech plus touch.”
Technology has helped them reach women and health workers more often than traditional models. They are now in 19 states and with their programmes reaching over 26 million women and their children and have trained over 200,000 health workers.
ARMMAN runs free voice call services which send timed and targeted preventive care information weekly/bi-weekly directly to the phones of the enrolled women through their pregnancy and infancy in their chosen language and timeslot. Aparna says if you give someone four pieces of information at the beginning of their pregnancy, they are not going to remember it. It has to be given at the point of time you need it. These services are handholding the women.
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Technology As Empowerment
About empowerment, she says it is the very beginning of financial independence for women. Empowerment is agency, the ability to stand up to the patriarchal moulds of the family dynamics. She shares how a woman in Mumbai’s Andheri East decided to send her girl child to an English Medium school and picked up a job on the side, and bought herself a phone after she enrolled for these programmes.
Uptake of the technological skills among the women
About the uptake of the technological skills among the women Aparna says, “Women were initially very sceptical, these are women from pockets of rural poor, very young women from Uttar Pradesh, Bihar married off to men they don’t know. Away from their communities staying in these illegal settlements. They do not talk to anybody, even if they have a phone they would talk to their husbands or mother-in-law. And when suddenly the health worker comes to you and tells you are going to get this service, that someone is going to call you twice a week and give you information on pregnancy and infancy and handhold you through the whole process, they get scared because they have never spoken to strangers.”
Adding, “We were told that it is patriarchal and the husbands wouldn’t like anybody to talk to their wives, but once the women heard those voice calls it was like an elder sister handholding you. And nobody else cares about you so much of apathy, hospitals don’t care about you. Now they have a call centre where they can call up, there is a missed call system. Suddenly they felt taken care of. The uptake was so immediate. And many of the women who became our first beneficiaries then went on and enrolled other women.”
Dr Aparna Hegde is also one of the early winners of SheThePeople’s Digital Women’s Awards and was a jury member this year. Aparna feels that when platforms like SheThePeople pick up people early on in their journeys it gives “other people the confidence to bet on you.” Adding, “When you start organisations it is a very lonely journey to have a peer group of women supporting you is a big support is an extraordinary experience.”
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