Impact of ICTs on MDGs:
Improve the Maternal Health
Workgroup C|IE MiM – S2
Technology & Innovation Management
Dr. Israr Qureshi

Contents
Introduction: 3
Maternal Health and ICT Usage in India 5
Maternal Health Initiatives with Mobile Components 5
Commonalities and Improvements of Current ICT Solutions 6
How to Leverage ICTs in Accomplishing the MDG 9
Proposed Feasible ICT-Based Solution 10
Conclusion 15
References 18

Introduction:
Since the United Nations Millennium Declaration in September 2000, the Millennium Development Goal (MDG) of improving maternal health has unfortunately not made the progress it set out to (The United Nations, 2015, a). Many information & communications technology (ICT) improvements towards this initiative have been made since 2000, however there is still a large amount of maternal mortality before, during, and after pregnancy around the world.
The maternal health MDG was divided into 2 targets. The first target was to reduce the maternal mortality ratio by 75% between 1990 and 2015, however only 43% has been achieved so far (The United Nations, 2015:40-43). This maternal mortality statistic also reflects the eight million babies that die every year between the prenatal stage and the first week of life. Moreover, there is a large yearly amount of children left motherless that are statistically more prone to die during the first years after their mother has died (Unicef.org, 2015). The second target was to reach universal access to reproductive health by 2015. These results show even less progress as only 50% of pregnant women receive the minimum amount of four antenatal visits recommended during pregnancy (The United Nations, 2015:40). This percentage is even smaller in Southern Asia with just 36% of pregnant women receiving antenatal visits (See Exhibit 1) (The United Nations, 2015:43).
Governments, United Nation’s Children Fund (UNICEF), NGOs, and humanitarian foundations help local communities by informing women and their families about typical complications that can arise during pregnancy and birth processes, as well as providing nutrition and health resources. Access to this type of information is progressive in preventing a significant amount of maternal and child deaths. However, difficulty arises in bringing this information to rural regions of underdeveloped countries for many socioeconomic, demographic and geographic reasons.
An example of this difficulty is represented in India, the second most populous country in the world which accounts for nearly 20% of maternal deaths worldwide (UNFPA - United Nations Population Fund, 2012). Approximately 30% of daily worldwide births occur in India, and from all the under-five years old deaths, 53% occur in during the first month of life. In addition, nearly one out of two children under the age of 5 present either malformation or underweight (mPowering Frontline Health Workers, United Nations Foundation & Qualcomm® Wireless Reach™, 2014).
This paper will allude to the contributions ICT has made in India because of its high contribution to maternal deaths worldwide combined with its greater access to technology compared to other developing countries. In this way, India serves as a future model nation for other developing countries that may adopt technology similarly over time. After introducing current ICTs and their contributions to accomplishing the MDG in India, an evaluation of their commonalities and limitations will be addressed. From this evaluation, perspective on how ICTs’ benefits can be leveraged within the context of maternal health will be offered. Lastly, the trends discovered through the evaluation of MDG efforts will form the basis of finding a feasible ICT-based solution that will further improve maternal health within India. Findings from India can be extrapolated to other developing countries to provide framework in increasing global maternal mortality through ICTs.
Maternal Health and ICT Usage in India
By the second quarter of 2015, 981 million mobile subscribers were accounted for in India, reaching 78% of the country population (See Exhibit 2) (Baidya, 2015). Moreover, out of these 981 million mobile subscribers, 89.8% were active subscribers according to Visitor Location Register information (Baidya, 2015). In connection with this, almost 69% of India's total population lives in rural areas. Therefore, access to hospitals and health centers is reduced and most healthcare facilities India has do not meet adequate quality requirements (Gramvaani, 2013).
The relatively easy-to-use characteristics of mobile phones plus the high mobile penetration in India enables these devices to facilitate information based on health needs and services at an affordable cost for India’s rural population, which was unreachable in the past (Singh Mehta, 2013:2). Furthermore, telecom companies have targeted women in rural areas in the last years, bringing awareness about its potential benefits for information about health (BBC News, 2015).
Maternal Health Initiatives with Mobile Components
ICTs based on improving maternal health have entered rural India with services like mMitra, a free mobile voice call service providing information on preventive care and simple interventions to reduce maternal and infant deaths. mMitra partners with hospitals by registering women when they go for antenatal checkups and also making use of NGO’s to reach out to women in rural areas. They have a database of 145 individualized educational voice calls of 90-120 seconds based on the pregnancy state (Mmitra.org, 2015).
Similarly, the Kilkari project launched in 2013 with another voice messaging service that plans to operate nationwide. It informs women about required check-ups and vaccinations together with health-related advices depending on the pregnancy stage or age of the newborn child (Kumar, 2015).
A different approach has been taken by the Manthan Project, a governmental project promoting technical assistance on the improvement of maternal and newborn health. One of the initiatives they have launched is mSakhi, an interactive mobile phone application that provides critical maternal and newborn health information to frontline health workers—accredited social health activists (ASHAs)—and serves as an interpersonal counseling tool to support ASHAs’ interaction with women and communities. This interactive tutorial with a simple interface offers 153 key health messages on prenatal and delivery care, postpartum mother and newborn care, immunization, postpartum family planning, and nutrition using a combination of text messages, audio, and illustrations all contextualized with localized illustrations and dialects (Intrahealth.org, 2015).
Commonalities and Improvements of Current ICT Solutions
In assessing the current impact of ICTs aimed at improving the maternal health initiative, understanding how ICT benefits the people it aims to serve is critical in improving its strengths and limiting its weaknesses. Based on the aforementioned ICTs available, it can be surmised that there are three main pillars of benefit derived from ICTs to mothers, unborn children, and affected families: access to information, effective delivery of that information, and the synchronicity of the ICT with culture it serves.
Enabling access to information to those who need it is an area that ICT has the ability to affect change tremendously. Understanding the prevalence of people’s interaction with a particular ICT and the factors that limit this prevalence is where the bulk of effort should be placed when deciding to implement ICT. In India, women in geographically remote areas have the lowest utilization of maternal healthcare information, with rates of morbidity 2 to 3 times higher than urban India (Kashyap, 2009).
India’s recognition of this fact through their use of mobile ICTs among the already high amount of rural mobile users shows a valid attempt at giving maternal health access to the people affected the most, with the lowest amount of financial and administrative resistance. In delivering access of the ICT, technology implementation should be based on the landscape of current and potential ICT users in attempting to optimize user's ability to access the information. In India however, enabling access to maternal health information is not enough and thus the effective delivery of that ICT-based information to those who have access also needs to be considered.
India is an example of a country that is greatly limited in its ability to effectively deliver ICT-based maternal health information. Considering that over 40% of women in India under the age of 20 have children and the net attendance ratio for women in secondary schools is slightly below 50%, it is no surprise that recent findings show, “that rates of change in female literacy and maternal mortality ratios are negatively related” (Moore, Singh, Ram, Remez & Audam, 2009) (UNICEF, 2013) (Pillai, Maleku & Wei, 2013).
From this, only ICTs that reflect the lack of education and literacy among the majority of women with maternal health issues will be effective in accomplishing the maternal health MDG. In confirming this, studies have determined that “variables such as women’s literacy rates and proportion of deliveries attended by trained birth attendants were found to be far more effective predictors of maternal mortality than per capita income” (Pillai et al,. 2013). mMitra and mSakhi recognize this phenomenon. Rather than having ICTs to increase the amount of resources available to help reduce maternal mortality (which have higher barriers in India), they have ICTs that deliver native-language information with the aim of empowering the resources already available. This solution is not only more viable in its implementation, but more likely to succeed in its long-term effect generation to generation. This is mainly due to the fact that socio economic and resource factors fluctuate more over time than those created from the “bottom-up” approach of enriching a context and educating people about maternal health.
Lastly, there needs to be a high level of synchronicity between ICT and the culture it serves. The fit between the value provided by an ICT has to be parallel with the culture in the population it is serving. This is to say that an ICT that communicates blood toxicology to prospective mothers after a physician’s consultation would be very helpful in reducing maternal mortality in America while not helpful in India. Hemorrhage, infection, unsafe abortion, eclampsia, and obstructed labor are the five main diagnoses that contribute to over 70% of global maternal deaths, generating an almost 1 in 50 maternal morbidity rate for women in developing countries (Janes & Chuluundorj, 2004).
The most critical component of an ICT from this standpoint becomes reducing maternal-health in relation to these five diagnoses while simultaneously adhering to circumstantial and cultural limitations as well. ICTs designed to decrease maternal morbidity should focus on areas where this relationship can be positively exploited across the most amount of people, and represents a large limitation in addressing the maternal health MDG in developing countries.
How to Leverage ICTs in Accomplishing the MDG
ICTs can transform delivery of health education, help in behavior change communication, train health workers (ASHAs), and enable an overall health system’s management. In theory, using the commonalities of current ICTs that successfully increase maternal health and extrapolating them into various cultures should reduce the global maternal mortality ratio. Currently however, the maternal mortality ratio has only decreased by 43% as oppose to the 75% decrease proposed in 2000. Of course there are non-ICT factors that influence the maternal mortality ratio, but there may still be room for improvement when it comes to ICTs contribution in tackling the MDG goal.
Based on commonalities in currently effective ICTs, improving the variety of ICT may be effective in widening the understanding of factors causing maternal mortality within developing countries. Within India, despite mobile-communication services being either oral or based on multimedia pictures... 10 per cent of [India’s] villages are not reached by any kind of mobile network. Issues like lack of digital infrastructure, mobile and broadband connectivity and digital literacy have to be addressed to enable an ICT revolution in health to kick off in India (Venkatram, 2015).
Due to reasons like this, having only one variety of ICT based solution is not the answer to maximizing efforts in reducing the maternal mortality MDG in developing countries. In the case of India, increasing mobile-based ICT effectiveness for this unique population of India would do nothing and thus new varieties of ICTs need to be considered if they are to further reduce the maternal health MDG. Currently, the most used ICTs in India aim to reduce pregnancy-based deaths and illnesses by providing information and resources to women once the woman becomes pregnant.
There are very few maternal ICTs in India whose points of contact are before the woman becomes pregnant. This is likely because the scope of such tasks exceed the abilities of popular ICTs such as mMitra, Kilkari and mSakhi, whose benefit can only be empirically significant in reducing the maternal mortality ratio if you are already pregnant. In totality, a lack of variety may be limiting ICTs in solving the MDG to its fullest potential.
Proposed Feasible ICT-Based Solution
The lack of variety in current mobile communications that are applied to the MDG in India notion that there may be room for improvement within the usefulness of ICT. For example, the usage of a voice call system towards reaching the MDG of maternal health helps women by informing them about antenatal care practices. However these systems only transmit information to the user, while mobile phones possess technical features that enable the possibility amplifying the impact of the service by using a bidirectional relationship between the user and the system.
Techno Brain, an African IT and Business Processes solutions company, has recently developed a unique Interactive Voice Response (IVR) Solution specifically designed for improving maternal healthcare solutions (NetHope Solutions Center, 2015). As mentioned, India would be the preferred market for the introduction of this feasible ICT solution in terms of product testing, overall impact, and mobile technology usage. The Interactive Voice Response technology used in mobile phones allows customers to interact with a database by touching the keypad of the telephone or by using speech recognition to acquire information and enter data into a database. IVR technology does not require human interaction over the telephone as the user's interaction with the database is predetermined by how the IVR system has been programmed (IVRS Development, 2007).
The main difference of using an IVR platform compared with previous systems is that IVR offers the option to collect data by telephone using automated and interactive scripts that make use of the push-button features of the device. In addition, even women with limited literacy would benefit because it is still based on voice-interaction. Nevertheless, this project would need an intermediary (ASHAs) between the system and the local women community in generating adoption of the technology. Thus, the role of ASHAs will be vital in this ICT’s implementation, as they are the first point of contact to promote usage and scale the initiative at the community level throughout India. This is due to the fact that ASHAs have the competency to explain the appropriate usage of technology systems to the women most in need of maternal health practices (Deloitte & GSMA Intelligence, 2014:31). Moreover, the use of this system can give more credibility and more robust information to ASHAs resulting into a more efficient delivery of messages and services to community households (mPowering Frontline Health Workers et al,. 2014).
The value proposition of the system is based on the collection of data which highlights the increasing importance of big data analytics. The amount of data collected from a call with a pregnant women, analyzed in the right way, can provide large amounts of actionable insights for finding solutions and increasing the efficiency of services related to solving the maternity health problem.
There are several third parties that could use this information; two of which are hospitals and health care centers, who could use this data to monitor and update pregnancy states and symptoms of pregnant women in urban and rural areas. This data would include that of remote villages in hard-to-reach areas with the benefit of not requiring hospital visits, which is a limiting factor in solving the MDG in rural areas. This data could also be used to automatically call expecting women regularly on their mobile phone and provide them personalized health related information based on the data captured to ensure that expectant women get relevant information and concrete steps to keep themselves and their babies healthy (NetHope Solutions Center, 2015).
Big data collected over time through a bidirectionally communicative ICT would enable hospitals and NGOs to optimize the utilization of their resources by monitoring trends across the country (Deloitte & GSMA Intelligence, 2014:18), and more specifically, provide stratified information about trends in rural areas that can be used to lobby governments to provide more resources. As mentioned, the major causes of maternal mortality that pertain to ICT in rural India are a shortage of healthcare skills and education (Kausar, 2005).
If ICT developers like IVR are able to consolidate the vast amounts of independent data that has been obtained by hospitals and NGOs through the use of big data, the resources used in managing healthcare skills and education can be more technically and geographically advantageous. The World Health Organization states that, “Many of the countries in greatest need of health metrics struggle to collect statistics on births and deaths. The epidemiological data collected in these countries are of variable reliability, have often only been collected at small sentinel sites and are rarely digitized” (Wyber et al., 2015).
A bidirectional ICT that uses the volume and variety capabilities of big data to reveal maternal health trends may incentivize NGOs, hospitals, and even academics, to alter the way they approach lowering maternal mortality. Through the information that such an ICT would provide, it could be possible to develop maternal health solutions that are more preventative in nature as opposed those like mSakhi and mMitra, which are more reactive in their approach. It cannot be forgotten that big data implementation comes with large initial infrastructure costs, interpretation requirements, security issues, and other fiscally constraining factors that especially affect developing countries. These factors represent the main barrier in implementing big data ICT in developing countries.
Despite initial setbacks, if ICT is to do more in contributing to lowering maternal mortality, it needs to consider the future of the context it operates in. In India, the implications of big data within the changing technological environment notion the acceptance of a more robust and communicative ICT. The future context of big data based ICT in maternal health translates into two phases which need to evolve, expand, and operate in tandem. The first phase would be to establish a widespread mobile communication network and the second to leverage the data emanating from these networks.
The increasing number of mobile phones globally indicates an area of development that India can most capitalize on. Considering its already high use of mobile communications technology, the growing tendency of 3G networks in rural and urban localities paint a positive picture in terms of growth and expansion of internet connectivity that can benefit maternal health (Sengupta, 2015). Integrating these two instruments of change (phone & internet) to form a fully functional communication network will greatly heighten the digital infrastructure, mobile and broadband connectivity, and digital literacy that currently limits rural regions of India from accessing and benefiting from ICT. The robustness of the maternal health information generated through this “internet revolution” will increase the effectiveness of current ICT solutions of maternal health and subsequently pave the way for further medical, political, or academic engagement.
Data on maternal health in India, although stratified by region, sometimes may not empirically represent the actuality of maternal health in particular rural communities. This trend can be seen in Healthcare Thought Leader Dr. Vikram’s analysis of healthcare in India, “when faced with large data sets that include various patterns and trends, traditional analysis procedures often fall inadequate. This is why more and more industries are increasingly moving towards Big Data, especially in the field of healthcare” (Taft, 2015). From this analysis, it would be beneficial for developing countries to invest in the development of data scientists, who are currently few in number (Phadnis, 2013). Data reception, monitoring, classification and cataloging based on the insights would initiate timely responses by third parties such as government and NGOs.
Conclusion
A more robust and bidirectionally communicative ICT that incorporates big data to leverage specific maternal health trends in rural areas of developing countries would benefit the continuation of lowering the maternal mortality ratio globally. Using India as an example, it can be seen that “considering the pace of MMR decline during 1997–2009, six out of the 15 most populous states have a fairly good chance of attaining India’s MDG 5 target level of ‘109’, albeit two–three years behind schedule (2017–2018)” (Reddy, Pradhan, Ghosh & Kash, 2012:10). Evidently, there is still work to be done in lowering the maternal mortality and ICT has and will continue to play a major role in contributing to its reduction. With the end of the United Nations Millennium Declaration time framework nearing, the main barriers to reducing maternal mortality are the lack of competent health workers during pregnancy/antenatal periods, and access to maternal resources. In parallel, the main barriers of current ICTs in improving these factors may be a lack of variety and the unidirectionality of independently collected data. If ICT is to contribute more in accomplishing this MDG, it will benefit developing countries greatly by generating data that is more specific to the MGD in rural areas and analyzing trends in this data in order to rally governments and NGOs to provide more access and more resources. The task of lowering global maternal mortality and providing more access to healthcare resources is laborious and accompanied with large financial and economic hurdles. But as technology becomes more adopted globally, so will the effectiveness of ICTs in their relation to saving mothers’ lives around the world.

Exhibit 1: Proportion of women aged 15-49 attended four or more times by any provider during pregnancy, 1990, 2000 and 2014

Source: Based on information presented by United Nations (2015). Millennium development goals report 2015. [S.l.]: United Nations Pubns. 41. Available at: http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf
Source: Based on information presented by United Nations (2015). Millennium development goals report 2015. [S.l.]: United Nations Pubns. 41. Available at: http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf

Exhibit 2: India’s Mobile Phone Subscribers (in Millions)
Source: Based on information presented by Baidya, A. (2015). Mobile Phone Subscribers in India. Available at: http://dazeinfo.com/2015/09/04/number-mobile-phone-subscribers-india-q2-2015-growth-airtel-vodafone-bsnl-broadband-trai/
Source: Based on information presented by Baidya, A. (2015). Mobile Phone Subscribers in India. Available at: http://dazeinfo.com/2015/09/04/number-mobile-phone-subscribers-india-q2-2015-growth-airtel-vodafone-bsnl-broadband-trai/

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