 Okay, I'd like to introduce Dr. Shantanu Sharma. Shantanu Sharma is working as a public health specialist with the MAMTA Health Institute for Mother and Child, a not-profit organisation for four years. He's pursuing his PhD part-time from Lund University in Sweden. He has experience of academics, research, implementation and communication. Shantanu's graduation and his MD in community medicine from Delhi University and a degree of diplomat of National Board from the National Board of Examinations in India. He did a one-year diploma in health and family welfare management from a national institute in India. He has over 14 publications in peer-reviewed journals and is currently working on a maternal child health and nutrition project. He has been working with 15 teams across different states in India. He's engaged in building the technical competence and monitoring, evaluation skills of the staff and evidence generation of this intervention. He's worked as a medical officer for six months and is involved in training midwives since then. He won the second best poster and oral presenter award in two recent international conferences. He was part of the group working on post hoc evaluations of adolescent sexual and reproductive health projects and programmes at the World Health Organisation in Switzerland. So now I'd like to hand over to Shantanu and let's hear his really interesting presentation. Shantanu, you have the floor. Hey everyone and good morning, good evening and good afternoon for all of you who are joining us from different continents. So right now I'm in India and I have been working in Indian organisation as Chris has told before that I'm working with Mumpan Institute and also I'm... So presenting today, any connection with them? Okay. Shantanu, your sound is coming and going. I'm not sure if you're moving around in relation to your microphone or putting your hand in front of it but your sound was fading in and out then. Okay. So let me talk very briefly about Mumpan Health Institute for Mother and Child. So it's a not-for-profit institution which is based in New Delhi, India. And this institute has seen a journey of 28 years. It started as a small clinic in Delhi and now it's an institution of over 900 staff. The institute has reached to more than 100 districts across 20 states of India and some five developing countries in Asia which includes Bangladesh, Nepal, Indonesia and some countries in African continent as well. Four thematic areas that the institute primarily works on includes maternal, child and adolescent health, sexual and reproductive health, non-communicable diseases like diabetes, hypertension, cervical cancer, infectious diseases like tuberculosis, HIV, hepatitis B and C. And I primarily am working on maternal, child and adolescent health division in Mumpan at the moment. The institute has experience of working with over 10 academic institutions nationally and internationally including Lund University in Sweden, Karolinska Institute in Sweden, Oregon. Then it has also worked with King's College of London and in India it's also working with King's George Medical University, BHU and did some of the daily medical universities as well. Now the institute has also been working with over 14 development sector partners in the past and some of the corporates like CETA, DFIT, Global Fund, UNFPA, Ford Foundation. Yes, so that was an information about minds that have been working with. So let me start my presentation giving you a short background about the presentation. So we are celebrating this day on International Day of Midwives on 5th of May and everybody knows that midwives are corner store in health for all and what do we mean by health for all is that the midwives, if we talk about midwives and nurses globally nearly 50% of them they constitute the health workforce and they play a very critical role in health promotion, in disease prevention, in delivering primary care, community care and they are very critical in the delivery of essential health services and core to the strengthening and particularly they are important because they are reaching to those people who are hard to reach though they are reaching to the places where it's important. So that's why it's important to actually invest in midwives because they are the one who are giving us the last mile. India, yes, the second most public country in the world. It's also having a capacity of over 1,75,000 midwives and around a million other primary health workers. So in India, primary health workers, we call them as accredited social health activists, ashras and some Anganwadi workers, AWW. So we have huge cadre of health workers. If you look at the current midwife population ratio, it's around 1.3 per 1,000 population. If you look at nurses plus midwife population ratio, then it's somewhere around 2.1 and the WHO talks about, ideally should have somewhere between 3.8 to 4 per 1,000 population. We are still far behind the ideal target and we really need to work towards that. And in India, we have seen in the last five years, we have seen a lot of investment in midwives covering their primarily education on their performance and incentivization, the working enabling environment. Recently, in 2008, we have this guidelines on midwife education by government of India. And one of my colleagues in the morning must have talked about it, the recent guidelines because the guidelines focus on investing in midwives education, task shifting and building a curriculum which is based on ICM standard of essential competences for midwives. So this is what is the recent advances in midwife reeducation in India. Okay, so the second pillar that is there in my presentation is regarding the periconception window. Now periconception window, it includes the time which is proceeding including and following conception. So it includes preconception period as well. And why it is important to work on periconception care because there is a pressing need. If you look at the figure one in my subsequent slide, so these are some of the indicators that I collected from National Family Health Survey 2015-16. And if you look at those indicators, prevalence of underweight women with body mass index less than 18. So around 23% of women in India are underweight. And if you look, if you compare them, if you divide them into two different categories of those from 15 to 19 and those from 2024, you'll find that those in the late adolescence 15 to 19 years, this percentage is even higher around 42% of adolescent girls in the late adolescence are underweight. India at the moment is suffering from dual epidemic of again both communicable and non-communicable diseases. And also from underweight and obesity. So if you look at the prevalence of obesity, obese women with BMI more than 25, around 21% of women and girls in India are obese. If you look at the other indicators of periconception care, let's talk about the unmet needs for family planning. It's again high, it's around 13% for both spacing as well as limiting. And the use of any contraceptive in married women around 57% of married women, they are using contraceptive at the moment. Tobacco consumption is not pretty common in terms of percentage, but if you convert them into absolute numbers, definitely it's quite high. If you look at the prevalence of anemia, again, that's also a very important factor that we need to and that's what the country is also trying to achieve is to reduce anemia because it's highly prevalent among women and girls. It's around, so around more than 50% of women and girls in India are anemic at the moment. And not just that, even including physical violence. If you look at the percentage, around 27% of women have ever experienced physical violence since the age of 15 years. So this make, I'm coming back to my previous slides. So that makes a case for investing a lot on periconception care. And WHO in 2013, they did an expert level group meeting where in a lot of people from different organizations, including community-based organizations, including NGOs, they came and they put forward there that what should be a basic minimum package for periconception care in countries like LMI's like India, Bangladesh or Nepal. So if you look at this figure number two and you can see this, this was the preconception care packet that was proposed by World Health Organization in 2013. So they said that a minimum basic package should include services like family planning, vaccine preventable diseases, should address nutrition and micronutrient supplementation like folic acid supplementation, should work towards tobacco cessation, including secondhand smoke, should work towards reducing harmful environmental exposure and improving sexual health and behavior of young couples or newly married couples through screening, through counseling and treatment. So based on the limited resources and the financial support, the country can adopt, but there should be a minimum basic package that has been discussed. But yes, if the resources and finances, if they allow that the country can have an expanded package of investing more on mental health problems or intimate partner violence, preventing intimate partner violence, screening for genetic conditions, prevention of non-communicable diseases and so on. So coming back to my slide again on background, so this makes a case for preconception care and preconception care is an important in the intervention in countries like India and other Southeast Asian countries. Government of India in 2014 launched a reproductive maternal newborn child and adolescent health program, but somehow, but if you'll remember, if you read that document, you'll find that still in that package, the preconception care and young couples were not prioritized. So still, there's a lot of scope and there's a lot of need to address preconception or preconception care in Indian settings. The third of my pillar that I talk about in the intervention is mHealth. mHealth includes any kind of app. It's an area of multiple intervention which includes the use of mobile for various purposes like SMS or text messages for WhatsApp messages using of interactive voice response system. Yes, it has an advantage of reaching a wider population, hard to reach population. It's cost effective with time-efficient and also it reduces barriers to communication, which makes an effective use of technology as well. So I'm starting up with the project now. So that project that I'm going to discuss about, it was a 18 month long project which is supported by MacArthur and Baugh Foundation. And the overall aim of the project was to strengthen district health systems for mainstreaming preconception care within the content of care approach into the national program of RNCHA. So that we can see an improvement in maternal health outcomes of young married women. So this program was implemented by Mamta Health Institute for Mother and Child and it was evaluated by Population Council of India. We want to my next slide. So what were the objectives? It was the objective of this project was to develop a user-friendly ML tool which is interactive voice response system IVRS for increasing preconception care service delivery in rural settings of India. Second objective was to build the capacity of midwives and primary health workers on preconception care counseling through IVRS. And third was to test the operational feasibility and acceptability of IVRS in rural settings of India through rigorous research methods. Now, so this project was implemented. As you can see in the map, this project was implemented in two states, one Rajasthan and Uttar Pradesh. So this Uttar Pradesh is somewhere in North India and in West of India, Rajasthan, Northwest. And so one district each in Rajasthan and Uttar Pradesh was selected. So it was Churu district in Rajasthan and Mozaffar Nagar in Uttar Pradesh. And two blocks within each district was selected and roughly 20 villages across. So it was around five villages in each block, summing up to 20 villages totally. And then we had enrolled some 36 midwives of the project, some 219 primary health workers, which include primarily accredited social health activists ashras and other health workers like Angarmadi workers, catering to a population of over 25,000 between 15 to 25 years and primarily the population was women. So the project had different phases of intervention. It included a pre-intervention phase, an intervention phase, an evaluation phase. So in the pre-intervention phase, we did some baseline assessment of the knowledge and skills of primary health workers. We developed a training module. So we have a different training module, one for the master trainers. So master trainers were auxiliary nurse midwives and lady health visitors. And we have one module for the primary health workers, that is accredited social health activists. And we developed this IVRS tool. So we have an IT partner that was Gramvani, which is now called Aniyan Dev. So Gramvani, they developed this IVRS tool. And I will show you in my subsequent slides the interface of IVRS as well. And we developed some baseline and line data collection tools. In the intervention phase, we build the capacity of midwives with the master trainers for primary health workers. And midwives further gave mentoring and supportive solution to primary health workers. In addition, we also did some awareness generation activities in the field. IVRS was rolled out, data was managed. And in the end line, we did some assessment of IVRS and increased the knowledge of its users. So if you look at this intervention flow chart, there are the Mamta Health Institute of Mother and Child. So we have an IT partner, Gramvani, the agency which developed the content for the IVRS. So with the help of IVRS, so we did this training on preconception and preconception care to midwives. So it was a cascade model of training where we trained these midwives on how to use IVRS and also what is preconception care. Because preconception and periconception care has not been addressed very well in countries like India. It's still in a very recent stage. So we did our training, we did that and the midwives further went and trained the primary health workers on how to use IVRS tool. There were some issues in, because as Roger's diffusion of model says that technology is not something that comes very automatically. You need to learn and eventually it's the practice over a period of time that gives you competency. So it's how they learned over a period of time how to use IVRS and these primary health workers, they further. So there were the two main functions of IVRS, that the IVRS was acting as a job aid for self-learning. I mean the primary health workers can call and learn a lot about counseling, about preconception care through IVRS and also the community and the women particularly from between 15-24 years. So they can also call and through IVRS to our center and then they can have their queries being addressed. So these primary health workers, they did health communication, health education through IVRS to these women and these women then they can call back IVRS and their calls were recorded. So I'll explain you the entire flowchart. So this is the interface in my subsequent, so yeah. So if you look at this slide, so this is how the interface of an IVRS looks like. So you have a welcome prompt and then if it's a, so in that welcome prompt they ask whether you are an archer, a primary health worker or you are a beneficiary or a young married woman. So if I say that yes, I am a primary health worker, so then I can, so they were further sections in the IVRS. So I can press one for frequently asked questions or there was some knowledge which infotainment sessions that I can actually listen to or there are something for improving my counseling skills. So whichever option I press, then I will be addressed whether you want to focus on preconception care, whether you want something on anti-natal or delivery care or something on postnatal care like this. And similarly for a beneficiary, it was whenever like the press one, if you press button like one, you frequently ask questions, press two for knowledge, infotainment like this. And further they ask you whether you want information, something that have preconception for anti-natal or postnatal and then they give you further information. So now, if I have some query that was not addressed through FAQ or Norgeant and I want to have my query being addressed, then I used to record my, I can record my question and that question will actually go back to my server, a central server and that will be taken up by a medical doctor and the medical doctor will call back and respond to the query that has been asked. So you don't need to actually have, I mean you can record your query in IVRS and then that can be answered later on by a medical expert. So you don't need to have a 24 hour medical doctor in place for responding to a query. So if you look back again at this, so this is how, so if you look at the women, so women between 15, 24 years, so they can ask these questions, so if they need some expert advice, they can record their question and that question through the server will reach medical doctor and the medical doctor can again call back and answer the query of these women and this entire MIS, the management information system was recorded for our data management by the IT partner. So what are the major components? As I mentioned, the major components were the frequently asked questions section. It had some knowledge based infotainment, so which makes it more interesting learning. Some experts, like you can ask some questions and there was an expert advice available for primary health workers, counseling and skill development session were there and you also have an option to give your feedback. If suppose I did not like the some of the services of IVRS, no it is not working well, I need to change it. So of course there was an option to give your feedback and the feedback was again, it was received into the server by the IT partner and then they can make changes and adjustments accordingly. And this entire package was developed in the local language in Hindi. So that's about the IVRS and the interface with the users. And very, very important thing that I wanted to give that, what are the major components in preconception care that we addressed in our project? Most of we were addressing contraception that was delaying the first pregnancy. We were counseling, providing counseling for better nutritional support to reduce anemia. Third, you're also counseling for screening of pre-existing diseases like diabetes, hypertension or if they have some reproductive health problem. Then you're also providing some screening for reproductive plaque infections or sexually transmitted infections or HIV and some counseling related to substance abuse. So if you look at the evaluation design, so we did this pre-post intervention. Also we did, so we took one district each in Rajasthan and Uttar Pradesh and then we did purpose assembling for a primary health worker, sample size was 210 and for young women because we did this 360 degree approach of evaluation wherein we not only had this survey on the primary health workers but also evaluated our intervention from the beneficiaries perspective. If you look at the results now, so you can see the increase in knowledge of midwives from pre-test and post-test or baseline. If you look at see from 28% it increased to 47%. If you look at the increase in knowledge of primary health workers, pre- and post-training, so it increased from 22% to 38%. And if you look at the percentage of midwives and primary health workers which are providing comprehensive pre-conception care, so it increased from 17% at baseline to 34% at the end line. It was another, this slide shows you the utilization of IVRS by users. If you look at the left hand side, the uppermost box, you can see the counseling on different components. So pre-conception care was at risk most commonly around 228 calls were made for pre-conception care. 201 calls were made for antenatal and 96 calls were made for post-training. This shows that there is need for pre-conception care counseling in the community that we need to address. If you look at the right hand side and the upper box, you can see the users of different components of IVRS. So frequently asked questions were the most common calls were made on 600 calls were made for FAQs and some 3,400 calls were made for infotainment session. If you look at the left hand side down, the feedback and queries as I mentioned, so some one or two feedbacks were received and substantive queries were addressed. And total number of calls that were made by primary health workers around 3,148 calls were made and some 21,118 calls were made by young women. And initially in the initial phase of the project, the calls were not so much, as were some 100 calls, but eventually as the project just picked up the speed and the call rate increased from just 100-200 calls to over 460 calls and to over around 2,000 calls per month. So that was like from 100 to 400 to 3,000 calls. So that's how it picked up the speed, the number of calls. If you look at the next results, yes, the percentage of primary health workers that were providing subparic conception care to young women in basin and land to some, so you can see, so contraceptive costing to women increased from 95 to 98. It's already quite high, so the increase wasn't so much. Contraceptive costing to couples it increased from 9 to 17. Delay of first pregnancy advice to mother-in-laws it increased from 36 because the servers were also open to the family relatives of the young women, including husbands and mother-in-laws, so again it was used by them as well. Assisting in, assistance in accessing contraceptive it increased and some nutrition related advice was also given through IVRS. If you look at the next slide, you can see the percentage of young women who were seeking treatment, so seeking treatment for complications during pregnancy it increased around by 10%. Seeking treatment for complications during delivery it increased by some around like 15% and for newborn it increased by 3 to 4%. If you look at the next results, again the knowledge and practices of young women as I told you it's a 360 degree approach wherein we analyze not only the benefit, not only the healthcare providers the knowledge and usage but also the beneficiary. So their knowledge and practices also increased related to periconception care so they know their right age of pregnancy so they use around 71% use any family planning method and around 86% think that yes, IVRS should be consumed during pregnancy and yeah. So this last slide from the results we say that 89% of family health workers reported that IVRS provided information on preconception care comprehensively 77% family health workers are able to clarify all queries from young women after using IVRS so they were able to address their queries around 90% of family health workers reported that their knowledge related to periconception care has been increased by the server IVRS and 99% family health workers reported that their skills have definitely improved after using IVRS so that's really encouraging and that's how the IVRS was accepted very well not that it addressed the because it was free of cost it was toll-free number free of cost they don't have to pay anything it was toll-free so affordability was not an issue access because it was available just a phone away and most of them have they don't need and most of these users did not need the smart phones it was simple phone that they could use so accessibility was not because they can simply just pick up the phone and call and give a call to a user and they can respond back as soon as possible so that was so accessibility affordability was addressed very well so the acceptability was quite high so if I summarize what I said just now that yes our intervention was very successful in sensitizing in building the capacity of midwives and primary health workers and the hand holding and mentoring support by midwives proved to be successful because that midwives in this survey they told that yes we receive a lot of mentoring support from medical officers and the primary health workers receive a lot of mentoring support from midwives in this entire intervention project on preconception care so that was really good and IVRS as an ML intervention it increased the outreach and use of peri-conception care services by young women so they had a lot of queries there so they were involved if you look at the way forward so yes IVRS gives you a promising approach that can be scaled up to do a real-time mentoring and counseling support to midwives and health workers where we can actually address peri-conception care and increase our reach to a large number of young couples because family planning, contraception is something that that India needs to address at the moment very importantly it's something that we need to really address it now and we need to try to integrate preconception care in the continuum of care and the RMNCHA program of the country it's very important and yes midwives because everybody knows that midwives play a critical role in delivering prevention and promotion services so it's very important that whatever we do that midwife should be a component of it and I just want to add one more thing that a lot of emphasis has and recently WHO has also released their digital guidelines I mean digital health guidelines and it's really important so they say that digital health will be able to address our challenges of distance, our challenges of access, poor management, insufficient training they will be addressing the challenges of infrastructure limitations and poor access to supplies so digital health is really important, M health is really important they will be able to address those challenges plus but very important thing that they will not be able to replace the fundamental component that still will be addressed by our health system, our health workforce, our leadership but yes they will complement the existing intervention so how important it is so this is thanks a lot and thanks for your support that you listened to my presentation so this is a picture that I can show you so one of our, this picture belongs to one of our training to primary health workers and one of our team members doing the training and then we found that yes people are actually using IVRS and they were just, so their information their access to information, right to information was just a call away. Thank you everyone, yes Chris, I'm done. Thank you very much Shantanu, that was really interesting and well for me as an XIT professional the mixture of the use of IT for such an important aspect of life and health is really good so does anyone have any questions for Shantanu? There will be a few thank yous I think for the moment Shantanu and then we'll see Shantanu, how do you deal with the connectivity? Connectivity Yes, internet connection Yeah, so internet connection was not a problem because it was more like a server you give a call there was a toll free number that was given you just dial that number and then the server will ask you what do you want, are you a primary health worker or are you a woman, young woman so then I need to just press one so you don't need a smartphone you don't need internet connection and if you have some query that needs to be answered by an expert you just simply record your message and then that will be recorded and that will go to the server and from the server it will reach the medical officer and the medical officer will again give you I mean he'll call you back and give you the answer so you don't need an internet or real time all you need is just a good connectivity with no internet as and in areas like we selected Churu in Rajasthan and in Muzafranagar in Uttar Pradesh they have good phone connectivity, hello So, okay and what happened with these mothers or these girls that need to use these phones it was easy for them to use them It was easy, yes so we did a survey before we actually started the program that how many of them are actually using phones and we found that most of them have a phone either it was mobile or I mean the mobile without a smartphone or a normal phone that we have at our household so most of them had this phone so it wasn't a problem because either they were using their own phone mobile phone or they were using the mobile phone of their husbands so that's why I said at times it has happened that even the husbands are also calling because some of the times they have seen that preconception here in young married women was something that because a newly married woman in India is not allowed to approach a health worker very easily they're not allowed to interact with health workers easily because I mean there's a kind of system where mother-in-law try to over protect their daughter-in-law from interacting with health workers because they have this notion that they will go for contraception so their own queries are not easily addressed so this use of mobile form it was quite easy for them to just make a call and answer and I mean they have their queries being addressed so many of these women had their own mobile phones some of them used their mobile phones of their husbands as well so this made this accessibility as a barrier I mean it just addressed this accessibility as a barrier great thanks Shantanu I have a question for you what are the mHealth interventions under preconception care domain and what are the other ones that you're using yeah so thanks for that you asked this question now say in Manta so this is one of the project that Manta did in past but we had other projects like other that I'm working with is where we are using the other approaches of mHealth which includes a whatsapp texting so what we do is that we have in our community based intervention we have this whatsapp group of young couples so where in these young couples they are provided information on various upcoming information on contraception on upcoming information on some kind of infection coming in the community or regarding vaccination for example HPV human papillomavirus infection for preventing cervical cancer so often such kind of health information is circulated through whatsapp messages we even did this program through an SMS message because a smartphone is not available to everyone in rural areas so what we did is we just send them through our central server we send one liner, two liner messages in local languages of all the numbers that we had with us and then on like for example breastfeeding promotion or on contraception and keep them reminding about various health education messages so I mean digital health is the next I mean it's an era of using as much as possible with digital health because it's really promising because it addresses your accessibility barrier it is acceptable and mobile phones are like something that are I mean so commonly used by everyone including smartphones so this gives you very promising results Thank you very much Shantanu We've probably got time for maybe one or two more questions if anybody has another question It's interesting to see what you might call appropriate technology because in the UK National Health Service is trying to roll out the use of technology but it's completely different because of the nature of the UK technical environment so it's very interesting to see cutting edge technology but being used appropriately Exactly and if you have just one minute Chris I will also remind you because I am right now in Sweden and I have an eight month old child so you know she's undergoing immunization so vaccination so in Sweden I mean they invest a lot on this digital health so what we get that you know we get this reminders we had this visits to midwives so we have this scheduled visits to midwives so at times it happens that you are so much engaged in your world that you forget oh shit I had a meeting with midwife so what they have done is they register your mobile number and a day before 24 hours before your visit to midwife they send you a reminder message okay you have a scheduled appointment with the midwife okay and that gives you okay I have an appointment with the health care system there is an ambulance at the door I mean all the time I listen to this and it's a Yeah so that's really important because that gives you I mean a reminder and so they have a lot of interventions to mHealth in countries high income countries like Sweden remind us so again mHealth can be used for sending you reminders for immunization for your visits to midwives and also can give call like they have this my wife few months back when she was pregnant she was undoing labor pain so they have this toll free numbers where you can dial and call because every time you can't go and it's a false labor pain so you can call your midwife tell your symptoms and she can okay fine you don't need to come you can just handle it and if you still have any problem come over to me so it's how I mean it's so easy to use just a phone call away and I mean it's really interesting in countries like Sweden because high income countries they give you a lot of evidence for mHealth yeah okay I think we will leave it there I'd just like to say again thank you very much thank you for a very interesting presentation