Utilization of maternal health care services and ownership and use of mobile phones among Indian women

INTRODUCTION

Despite significant improvements in healthcare provision and utilization in India, maternal and child health (MCH) remains a key area requiring public health intervention.^1-3 India had a maternal mortality ratio of 145 per 1,00,000 live births and an infant mortality rate of 30 per 1000 live births in 2017.⁴ Neonatal disorders, undernutrition, and iron deficiency feature in the top ten causes of premature death or disability despite decades of rigorous MCH research, policymaking, and programme implementation². With the increasing use of mobile phones across India, mobile health (mHealth) programs have been implemented to promote MCH services.^5,6 Despite criticisms that mHealth is an effective tool mainly for the relatively privileged socioeconomic classes, some evidence suggests that it could also be an effective innovation for improving the health of the underserved socioeconomically disadvantaged and rural populations of India.⁷ The ownership and use of mobile phones are key determinants of the success of mHealth interventions.⁸

A 2020 study found that the household ownership of mobile phones was positively associated with selected maternal and reproductive outcomes among Indian women.⁹ According to the latest World Bank report, one in five Indians is poor.¹⁰ Thus, the accessibility and affordability of mobile phones remain a concern when evaluating the effectiveness of mHealth interventions.¹¹ Notably, the cheapest mobile phones cost 500 Indian Rupees (INR) (about one day’s minimum wages for manual labour), while a smartphone could cost up to INR 1500.¹² While about 64% of the Indian population owns a mobile phone, most use basic versions that may not have the facilities to receive health intervention benefits, specifically targeting the illiterate population who are usually financially disadvantaged.¹³ Given the increasing deployment of mHealth in MCH programs targeting underprivileged populations and the unclear picture about the ability of such individuals to receive the benefits of such interventions, it is important to investigate the role of Indian women’s ownership/access to mobile phones in their healthcare utilization.⁶ To our knowledge, no study has examined this relationship in the Indian context. Therefore, we assess whether the ownership and use of mobile phones are associated with the utilization of antenatal care (ANC) and institutional delivery services by Indian women in the reproductive age group in both rural and urban areas.

Conceptual model

We constructed a conceptual model (Figure 1), based on social determinants of health framework and evidence from previous literature shows the socioeconomic status of Indian women is positively associated with the ownership of mobile phones and autonomy levels which are capable of enhancing knowledge about health-related topics and thereby increases utilization of health services.^14-18 The diagram shows various pathways explaining how ownership and use of the mobile phone can be linked to maternal health.

METHODS

Data source

We used data from the second round (2011) of the publicly available India human development survey (IHDS), a nationally representative survey of 42,152 households in 1503 villages and 971 urban neighborhoods across India. Interviews in each household covered topics related to health, economic status, fertility, gender relations, social capital among several others.¹⁹ These are the latest available nationally representative data that link mothers’ mobile phone use with their health outcomes.

Participants

We included ever-married women in the reproductive age group (n=39523) with data on whether they had received ANC or opted for an institutional delivery (n=13925). Observations with complete data on individual ownership of mobile phones and all covariates (12047) were included in the final sample for analysis using the individual ownership of mobile phones as the exposure variable. Missing data on mobility autonomy (783), access to mass media (220), civic participation autonomy (607), relationship with health workers (292) and cash in hand to spend (292) further reduced our analytic sample size. Observations with data on ownership of a mobile phone in their household, after excluding those missing data on covariates, formed the sub-sample for the analysis with household ownership of mobile phones as the exposure (n=10842). This analytic sample further excluded those missing data on mobility autonomy (983), access to mass media (481), civic participation autonomy (857), relationship with health workers (292) and cash in hand to spend (292). Finally, only those who responded

“yes” to the question of whether they owned a mobile phone (n=5548) were included in the analysis related to the access to subscriber’s messaging service (SMS) and mobile internet facility. Flowchart showing the inclusion criteria of study participants is depicted in (Figure 2).

Outcome variables

Our first outcome was an “ideal ANC” defined as a report of four or more antenatal care visits during the last pregnancy. A binary variable “ideal ANC” was created which was assigned the value ‘1’ if they reported four or more ANCs and ‘0’ otherwise. The second outcome was “institutional delivery” indicating whether they delivered their last baby at a health facility or not. Using the information on whether the participants reported giving birth to their youngest child at home or public/private facilities, we created a binary variable that denoted deliveries at any health facility as institutional delivery and others as not (0).

Exposure variables

Individual ownership of mobile phones, access to the Internet, and availability of texting facilities were the exposure variables of interest. We used data on questions asking whether or not participants, or their households, owned a mobile phone. We coded women as mobile phone owners and non-mobile phone owners, defined as women who did or did not have access to a mobile phone on their own (individual ownership) or in their household (household ownership). Similarly, we created binary variables indicating women with and without Internet access and women with and without SMS (simple texting) facility.

Covariates

We included the following covariates, details of categories are shown in (Table 1): age (continuous, in years), income (categorical), caste (categorical) household location (urban/rural) participant’s access to mass media (yes/no), number of children (continuous), whether they received financial assistance for childbirth or not (yes/no), women’s autonomy indicators such as mobility autonomy level (ordinal) and civic participation autonomy levels (ordinal), cash in hand for household expenditures, health decision making (categorical), health-related knowledge (categorical) and acquaintance with health workers (yes/no). Calculation of autonomy variables has been shown in (Table 2).

Statistical method

Demographic patterning in the ownership of mobile phones was described using frequency and percentages. This patterning in our sub-samples for each outcome was compared with the sociodemographic distribution in the larger ever-married women’s sample. Survey-adjusted logistic regression models adjusting for women’s autonomy, education, occupation, household location, household income, religion, caste and access to mass media were fit. Odds ratios (OR) and 95% confidence intervals (CI) are reported. We used STATA version 12.0 (StataCorp, Texas) to conduct data analysis, and set alpha at 0.05.

RESULTS

The description of the sub-sample for the analysis on individual ownership of mobile phones (n=12013) is shown in (Table 1). The sociodemographic characteristics of the other sub-samples were generally similar to the presented subset. The association; odds ratios (OR); 95% confidence intervals (CI) of ownership and use of mobile phones with access to MCH health services are shown in (Table 3). The mean age of the respondents was 29, and they had an average of 6.7 years of schooling. About 75% of them had at least some schooling. The sample was mainly from rural locations (67%) and overwhelmingly identified as Hindu (79.4%). Most reported occasional access to mass media. Only 20% of these mothers were formally employed. Our analytical sub-sample had a slightly higher representation of educated women but a slightly lower proportion of women with high mobility-autonomy than the larger ever-married women’s sample.

The unadjusted odds of having an ideal ANC were 1.5 times higher (OR=1.5; CI=1.35-1.62) among those who owned a mobile phone versus those who did not. However, this was no longer associated with both the outcomes after adjusting for socioeconomic status and women’s autonomy. In an interesting contrast, the women belonging to households that owned versus not owned a mobile phone had 1.2 times higher odds of reporting an ideal number of ANCs and 1.2 times higher odds of reporting an institutional delivery in fully adjusted models.

The unadjusted odds of having ideal ANC and institutional delivery were higher among those with SMS facilities. The association with having an institutional delivery remained significant in the fully adjusted model (OR=1.28; CI=1.06-1.55). Women with access to the Internet had eight times (8.10; 4.64 -14.11) higher odds of reporting an institutional delivery and three times higher odds of receiving four or more ANCs. Even after adjusting for all the covariates, the odds of having an institutional delivery were 3 times (OR=2.87; p=0.00) higher among those who had access to the Internet than those who did not.

DISCUSSION

Using data of 12,047 Indian mothers from a nationally representative survey, we found that household ownership of mobile phones was associated with a greater prevalence of receiving ideal ANCs and institutional deliveries while individual ownership of mobile phones was not. Accesses to the Internet or SMS facility were positively associated with completing the ideal number of ANCs and opting for an institutional delivery. These findings are especially notable as they are the first, to our knowledge, to shed light on the nuanced ways mobile phones might influence healthcare utilization among Indian women beyond merely owning a phone.

Most of our findings generally corroborate the results of previous studies of mobile phone ownership and MCH outcomes in other low-to-middle-income countries, but few of them do not. A 2020 study using nationally representative data from India found that the household ownership of mobile phone was positively associated with selected maternal and reproductive outcomes among Indian women.⁹ However a 2016 Timor-Leste survey of 581 reproductive age women found that household mobile phone ownership was not associated with MCH related outcomes.²⁰

However, a 2014 randomized controlled trial with 2550 pregnant women in Zanzibar concluded that ownership of mobile phone was associated with better utilization of ANC.²¹ Our findings that access to SMS facility, and separately, access to the Internet, were positively associated with the outcomes are in line with previous evidence. For instance, several SMS-based MCH interventions currently being implemented in India were found to be effective.^22,23 Notably, our findings are about access to SMS facility and the Internet but not their actual use. While all mobile phones have the capability to receive SMS texts, only a subset of mobile phones used in India has Internet capability.

While it may appear to be counter-intuitive, the positive association of household ownership of mobile phones with the outcomes with no evidence of any influence of individual ownership might be expected in the Indian context. The household ownership of mobile phones may represent the involvement of other family members in exposure to the information that flows through mobile phones. Family members likely make decisions on behalf of the women in their households.²⁴ The low level of autonomy among most Indian women is further complicated by the gender divide in ownership and use of mobile phones in India. Previous research shows that autonomy levels of women in a patriarchal society such as India is low compared to men.²⁵ This may reduce women’s frequency of decision-making related to the purchase and utilization of digital services and normalise the involvement of men in the family in the decision-making process. Moreover, a woman owning a mobile phone may not be capable of using it to the fullest due to digital illiteracy or the lack of digital autonomy.^26,27 Indian women experience a significant disadvantage in employment status, wages, and social roles, increasing their risk of dependency on men.²⁵ Our finding regarding household mobile ownership is thus understandable in the Indian context, as also the lack of evidence related to individual mobile-ownership. One possible explanation for the health-promoting role of the ownership of mobile phones by women or their households could be any consequent increase in access to health-related information and health communication practices. This could also be explained by an increased ability to tap into social networks among women who either own or live in a household that owns mobile phones. Mobile phones have been shown to enhance the knowledge about self-care, child health and general health related topics among women and thereby can influence their decision-making capacity.^28,29

While a simple marker of individual ownership of mobile phones did not make a difference, access to SMS facility on women’s phones was associated with completing the ideal number of ANC and having an institutional delivery. This might be explained by the existence of several SMS-based health interventions, many of which were found to be effective.^22,23 While data constraints prevented us from studying SMS use, the evidence from previous studies that have measured SMS-facility practices among Indian women supports our finding.^22,23 Our finding might also reflect the better access to health information, health workers, family and friends due to Internet access, which likely further increase the probability of completing the ideal ANC and opting for an institutional delivery. Notably, SMS is a default facility in all mobile phones. Still, Internet access requires an opt-in with payment, suggesting that a history of access to the Internet may represent more active mobile phone users and potentially more proactive individuals leveraging such access. Taken together, our results suggest that the ownership and use of mobile phones are linked with better maternal healthcare utilization. In a country with an increasing emphasis on mHealth, especially in a post-pandemic scenario where face-to-face interventions may not be as feasible as earlier, there is a need to unpack the complex process underlying Indian women gaining access to mHealth services. Our findings, aligned with the findings of similar previous studies, support the hypotheses showcased in our conceptual model. Unavailability of data on the frequency of participants’ use of mobile phone services, and their autonomy in purchasing and using mobile phone and the Internet, prevented us from performing a nuanced analysis. Missing data was another limitation of this study. No causal claims are made due to the cross-sectional nature of the data. However, these are the only nationally representative data on the access to SMS and Internet among Indian women, therefore yielding a decent analytical sample size while allowing us to minimize confounding by adjusting for a range of relevant covariates. To our knowledge, this is the first study to investigate the potential health benefits of access to mobile phone Internet and SMS facility among Indian women at a time of increasing dependence on mHealth services.

CONCLUSION

mHealth interventions can be a powerful tool in low- and middle-income countries with a large population size and limited health workforce. The post-COVID-19 world may demand interventions which minimize direct contact but ensure better health outcomes. Our study sheds emphasises the importance of incorporating beneficiary-specific factors in designing mHealth interventions. The pathways linking access to, and use of, mobile services with healthcare utilization need an in-depth study to ensure effective planning, designing and implementation of mHealth interventions. mHealth interventions targeting women in India, especially the rural, low-income sub-group, are unlikely to be effective unless simultaneous efforts are made to increase access to, and autonomy in, mobile phone use.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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