When you’re talking to a female population of 49 million; 88.71% of which reside in rural spaces and 46.67% of which are illiterate; it is essential to understand that service delivery strategies should not be innocent of user behavior. Through extensive field work in Bihar (India), done over a span of 18 months, it has been observed that the system and the beneficiary, speak two different languages. A simple observation was in regard to the concept of time – while the system’s understanding of time is in obvious accordance to the globally accepted Gregorian calendar, the end user remains largely oblivious to the basic understanding of the very months in the Gregorian calendar. Needless to say, the repercussions are endless.

 

Complexity within the Healthcare System:
The maternal and child health care system, depends almost entirely on the woman’s understanding of time leading to self-mobilization, further aided by the fleet of Frontline Health Workers (FLWs) acting as external triggers. The interactions begin with the woman registering for pregnancy and end with the child’s complete immunization. We start at the very beginning, understanding how women register their pregnancy – In order to register a pregnancy and generate the Expected Date of Delivery (EDD) the system requires the woman to recollect the date of her Last Menstrual Period (LMP). It is essential to understand the woman’s psychology and factors that affect her during this stage of service delivery. It has been observed that women refuse to disclose the news of their pregnancy to FLWs while in its early stage, finding it inauspicious to talk of their pregnancy publicly. Since this leads the mother to register her pregnancy later than expected, when asked about her LMP the mother must recall the said date. Now, due to the lack of perceived importance of this otherwise vital information, and a skewed sense of the Gregorian Calendar, the beneficiary is unable to accurately trace back the exact date furthermore finding it difficult to communicate it in Gregorian terms.

Time and its Blurred Perceptions:
The quickest answer to the problem, is for the system to start adhering to the beneficiary’s concept of time, abandoning an otherwise alien Gregorian system. But this local concept of time that we’re referring to is never homogenous. A few may follow the Panchang calendar, while the rest a completely independent but accurate system. While interviewing an ASHA facilitator in Sheikhpura-Bihar (India), we were told that many Muslim ASHAs have trouble understanding the paksha (shuklha paksha-krishna paksha-poornima-amaavas) concept that many Hindu women refer to. While they themselves preferred quoting the position of the moon. We realised that even though the paksha concept too referred to the position of the moon, it was primarily the mutually incomprehensible nature of mere terminologies that created a false barrier in simple communication.

The Nexus:
The visually rich lunar calendar, when mashed with the Gregorian calendar produces something that is easily comprehended by both- an illiterate beneficiary and the healthcare system. An added feature that this visual calendar boasts of is the course corrective nature of design. In a scenario, where the beneficiary is clueless about what day she stands on, she can time to time course correct herself by simply observing the actual position of the moon and recognizing it on the calendar.

Menstrual Tracking:
In practice, these calendars are distributed to eligible couples within villages by the FLWs with clear instructions of use. The system demands the woman to accurately point out her LMP, hence we get her to start tracking her period regularly. Since LMP can never be predicted, the most effective way of tracking it is by simply tracking every menstrual period. Once every period is being marked by the mother on a very visual calendar, it allows her to understand her menstrual cycle as well.

“Their understanding of their mens (menstrual cycle) is such that they feel that unless their mens (menstrual cycle) ends on the same day every month then it is irregular.” – ASHA, Samastipur

 

Family Planning:
The basic understanding of her menstrual cycle by the mother in an otherwise family planning depleted environment proves to be an extremely rich proposition. The understanding of the menstrual cycle allows one to employ the Standard Day Method of contraception. With the simple identification of her fertility window, the calendar allows the woman to be in control of family planning. Additionally, the Standard Days Method is 95% effective (right behind condoms, which stand at 98%). In a country that contributes to 17.1% of global unwanted pregnancies, methods such as this, which work only by understanding user behaviour, could prove to be vital interventions.

Once the woman’s LMP is accurately marked by the FLW, it becomes easier for the system to predict her EDD (37 weeks of foetal maturity) allowing the FLW to predict and alarm the system in case of preterm labor.

“If the child is born two months before our estimated due date (EDD) (which happens often) then it completely negates whatever birth preparedness information we can possibly give to them.” – Kunal, CARE BHM , Singhia PHC Samastipur

 

PreTerm:
After correct identification of preterm using the calendar, measures can be taken to prevent foetal mortality. In India alone 300,000 infant deaths occur annually (the highest in the world), with 10% of India’s IMR being attributed to preterm deaths. With the simple administration of Antenatal Corticosteroids, 30% of such deaths can be averted.

The Calendar hence projects to impact issues such as period tracking, better birth preparedness, accuracy in data collection, early identification of preterm cases, and effective family planning. Monumental impact is rarely attributed to such low cost solutions. With the Calendar, as a leap towards that dream, the Lab continues to strive towards low-cost-high-impact solutions driving up public health standards globally.

 

The Patient Health Identity Tokens team is piloting a first of its kind ‘Shringaar Card: A Menses Tracking Tool for Rural Women’ in the district of Samastipur in Bihar (India). This tool will aid married beneficiaries in accurately tracking their menstrual cycle, enabling family planning while also nudging them to register their pregnancy at the earliest and avail services currently offered by the Public Health System in Bihar. To know more about this tool do write across to Adithya Prakash at adithya.prakash@cks.in and Atishay Mathur at atishay.mathur@cks.in