When asked whether gender issues contribute to Nigeria's poor maternal mortality indices, Onyedikachi Nwizu, Program Officer for the OMOMi app, paused. As a single pregnant woman, she chose her words carefully, to reflect her personal experience. "Many times when I went for antenatal clinic, I had to deal with a number of 'Assistant Jesuses' passing judgement. The judging did not end even after delivery," she said.
Available data from the World Bank shows that in Nigeria, out of 100,000 deliveries, nearly one thousand pregnant women die. However, in several countries including Italy and Norway, their maternal mortality ratio is only 2 out of 100,000 deliveries. Analysis of global data showed Nigeria has the fourth highest maternal mortality ratio in the world. Only South Sudan, Chad and Sierra Leone have worse maternal outcomes than Nigeria.
According to the World Health Organisation (WHO), a high number of maternal deaths is often a reflection of inequalities in access to quality health services and highlights the gap between the rich and the poor. "The risk of maternal mortality is highest for adolescent girls under 15 years old and complications in pregnancy and childbirth are higher among adolescent girls aged 10-19 (compared to women aged 20-24)," says a statement from the WHO.
The global health organisation also directly connected maternal deaths to largely ignored gender inequalities that are deeply enshrined in religiously-held cultural beliefs. These, it said, predispose some women to death over others. "Women in less developed countries have, on average, many more pregnancies than women in developed countries, and their lifetime risk of death due to pregnancy is higher. A woman's lifetime risk of maternal death is the probability that a 15-year-old woman will eventually die from a maternal cause. In high income countries, this is 1 in 5400, versus 1 in 45 in low-income countries," WHO stated.
Tech to the Rescue?
From the use of spreadsheets to collate patient data in hospitals to machine learning to detect diseases early, technology, especially digital health, has found several opportunities to improve healthcare by easing tedious processes and improving precision and quality of service.
For maternal health, digital health isn't just about organising files, but is a means of addressing inequalities that disproportionately affect women, especially pregnant women, some of whom rely on tools such as the OMOMi app to have a better chance of carrying their pregnancy to full term and delivering safely without their lives or that of their newborn being put in danger.
With over 40,000 women on its platform, the OMOMi app was launched by MOBicure, who had also developed the myPaddi that provides young people with sexual and reproductive health information. The app aims to provide pregnant women and mothers with access to life-saving maternal and child health information, as well as access to doctors with the touch of a button. "There is a lot of wrong information out there and they are harming women who do not know where to get accurate information from," Nwizu said.
At primary health centres in Nigeria, antenatal clinics are held for pregnant women. In addition to the routine laboratory investigations and periodical ultrasound scans, the women are also educated on how to go about their daily lives, take care of their growing babies and prepare for delivery and beyond, among other things.
But when the baby is delivered, the new mother is bombarded with lots of advice from family members, friends and others close to them. Some of the advice is in stark contrast to the information provided by healthcare workers. Such advice is often taken and implemented largely because of the domineering and trusted status of the person giving the advice, such as parents, mothers-in-law and religious leaders, or lack of easy access to channels through which accurate and reliable information can be accessed, and has been verified by experts.
It was therefore not surprising that Nwizu found the chatbot function on the app to be the most intriguing and useful. "With the live chat feature, you can quickly get answers to the questions you may have. These answers are accurate and there is also the option of reaching out to doctors via the platform," she said. She noted that swift access to the right information can be lifesaving, not just during emergencies, but could also prevent a woman from doing anything that can harm her baby or herself.
From USSD to Apps
In digital health product development, for issues that are associated with inequalities including poverty, there is often a debate around the choice of platforms to roll out such services. Developers must grapple between ensuring as many individuals as possible can access the tool or ensuring those that access it have the best and complete experience that leverages the best technology. No one solution can solve all the problems of maternal mortality in Nigeria.
According to the Nigerian Communications Commission (NCC), Nigeria had over 200 million active mobile lines at the end of January 2021, but broadband subscriptions were less than 90 million. The implication of this is that solutions such as OMOMi that require internet service is inaccessible to many mothers who may benefit from the information being shared. However, for services that can be delivered via SMS and shortcodes, the potential reach could be greater.
Nwizu disclosed that OMOMi's journey started with Unstructured Supplementary Service Data (USSD), but it encountered several challenges including getting a fair price for the USSD and SMS services in addition to the platform's limitations that restrict the type of services that can be deployed.
The team behind the OMOMi app however came to terms with the fact that the service can best serve users of app-enabled devices which is why the app is now available on the Google Play Store for devices running on Android mobile operating system, and App Store for iOS devices. Through these platforms, and its backing from MSD for Mothers, OMOMi is able to unleash a wide array of tools to improve maternal outcomes. Currently, the app has 42,500 users, according to Dr. Charles Akhimien, MOBicure's Co-founder.
Innovating for Women
Considering the unlimited powers of digital health, more innovation targeting maternal health could significantly improve outcomes in Nigeria and other countries where many women still die during childbirth, than from other factors.
The rapid growth recorded in Nigeria's fintech sector can largely be attributed to the market potential and profitability of the sector. This attracted investors and encouraged innovators to come up with solutions to pertinent problems while generating revenue. But this is different for healthcare, especially maternal health, which is rarely seen in the public health context, as an avenue for social enterprise. The private sector can play a critical role in leveraging its capacity to support the government by putting in place interventions and sustainable models that improve maternal health outcomes.
Nwizu admitted this is an issue as OMOMi's revenue generation option is largely limited to users paying to interact with doctors through the service platform. She however noted that this should not discourage innovators as tackling maternal mortality will always be a social issue that will require support from development partners and government.
Partnerships for Women
The theme for International Women's Day 2021 is #ChooseToChallenge. A challenged world is an alert world and from challenge comes change. This year's goal is to celebrate women's achievements, raise awareness against bias and take action for equality.
Nwizu noted that partnerships are critical to ensure that a woman doesn't die while giving birth, and to improve maternal health indices in Nigeria. "Tools like the OMOMi app can help provide the much-needed data that government and other stakeholders can work with to improve outcomes and protect women from preventable deaths," she told Nigeria Health Watch.
She added that men should also be encouraged to be participating partners and take more active roles by being equally able to access information given to women on the OMOMi app, considering that they often have input and influence regarding the fate of a pregnant woman. Men need to play a greater role in providing care and support to their pregnant wives, in order to improve the pregnancy journey and maternal outcomes.
"The likes of OMOMi are working because of people and organisations who know that there is a problem and it is not a small one. What an irony -- losing life while giving life. We intend to do more work, more footwork to get more women on board -- not just to collect their voices but show them how it is done," she concluded.
This project is supported by funding from MSD, through MSD for Mothers, the company's $500 million initiative to help create a world where no woman dies giving life.