Community Workers Adopt Mobile Technology to Improve Maternal-Child Health


As world leaders get ready to meet in New York in September to set a new development agenda for the next 15 years, their discussions will likely focus on maternal and child health. A report published by the World Health Organization (WHO) last May 13, in fact, highlights that progress has been insufficient to improve mothers’ health and reduce child mortality.

800 women still die every day in the world from preventable causes related to pregnancy and childbirth, while less than one third of all countries have achieved or will meet the target of reducing child-death rate by two-thirds.

Although the Millennium Development Goals have helped address many important public health challenges, there is still the need to ensure the “world’s most vulnerable people have access to health services,” said Dr. Margaret Chan, Director-General of WHO, in a statement presenting the report.

Local solutions to a global problem

South Africa is a good illustration of these public health emergencies – and of possible solutions. In a country where 30 percent of pregnant women do not access prenatal care, more than 12 percent of the population live with HIV and around 40% of maternal deaths are HIV/AIDS-related, a number of initiatives show encouraging results.

A study published last October by the Philani Maternal, Child Health and Nutrition Trust together with the University of California, Los Angeles, and Stellenbosch University in South Africa found that repeated home visits by trained community health workers to neighborhood mothers led to significant health improvements both for mothers and children, including in the prevention of mother-to-child HIV transmission.

Trained and recruited by the Philani, these health workers – known as mentor mothers – provide a lifeline for families otherwise excluded from the reach of many public health services. In the past 7 years, they have brought healthcare interventions into the homes of tens of thousands of pregnant women and new mothers. They taught them how to rehabilitate underweight children and improve their chances of giving birth to healthy babies, helped obtain state welfare allowances, and assisted in the prevention of preventable illnesses.

Tablets for health workers

Mentor mothers’ work has now caught the attention of some professors at Stanford University (California) who have started a project in February to support them with sturdy tablets pre-loaded with education videos. These videos explain basic health and nutrition facts in a simple and intuitive way, with the aim of helping mentor mothers in their work of expanding access to health knowledge and improving health conditions.

Nomfusi Nquru, one of the twelve mentor mothers testing the project, cannot conceal her excitement about using these tablets. “It is something new and a chance to use technology that I do not get to use,” she said in an interview. “Mothers react excitedly to the videos and seem to pay careful attention to what is being said. Hearing lessons in a different way is something that catches the mothers’ attention and afterwards they ask questions on how to feed their children well and look after themselves in their pregnancies.”

The tablet project is the brainchild of Dr. Maya Adam, a lecturer at Stanford School of Medicine with years of experience in developing digital educational content. After running a successful online course on child nutrition followed by thousands of people around the world, she has now decided to use her experience to help mothers in the developing world. “When we first introduced the teaching tablets, it was quite amazing to see how quickly these mothers picked up the new technology” she says. “In a way we are bypassing the blockage in access to education at least in the short term and providing these women with the opportunity to access knowledge using the technology we have today.”

According to Adam, who has spent years as a volunteer at Philani during her medical school and undergraduate studies, recruiting successful mothers and training them to become community health workers “is a powerful model for passing on good health practices in a way that is sustainable because women are counseling within their own communities. They are not going anywhere and they are not coming in from somewhere else with a solution that will then disappear when they leave.”

Adam hopes that the tablets will facilitate the learning and accelerate the training of new mentor mothers. Initial feedback from the twelve mentor mothers seems to confirm her intuition: responding to a questionnaire prepared by Stanford University, they all reacted enthusiastically to the introduction of the tablets in their work.

“Community health workers can help bridge the gap, in the short term, between what we need in access to healthcare providers and what we have,” says Adam. “If we wait for access to education and healthcare in South Africa to catch up with the need for it in these under-resourced communities, we are going to wait for a long time. By using technology like the tablets we can accelerate that process in communities otherwise cut off from main infrastructures.”

Adam intends to start an evaluation of the project next year, but is already working on a more ambitious goal of creating an open access health promotion library for community outreach workers.

“That’s my dream,” she says. “We are now raising funds for additional tablets, each costing around $170 U.S. dollars, and preparing translations of the videos into Spanish and other languages to extend the reach of this project. The videos are all picture-based, so they can easily be translated and used in other countries. We have the technology, we have the equipment. If we can get support, we can really put our heads down and start creating a comprehensive, multilingual, open access library to promote the health of mothers and children everywhere.”

A promising tool

Stanford University is the latest of a number of projects providing health workers with mobile technology. OpenSRP, for example, is a tablet-based open source platform that allows health workers to register and track the health of their entire clients.

“The use of mobile health technologies is a promising mechanism to ensure that we can better measure health outcomes in order to inform processes intended to improve health along the continuum of care,” says Dr. Lale Say, coordinator of the adolescents and at-risk populations team at the Department of Reproductive Health and Research of the WHO. “Digital technologies like those used in this project have proven valuable for both community members as well as the health workforce to gain access to quality information that can help make timely and well informed health decisions that can impact on the lives of mothers and their children.”

Why We Should Care About Adoption Rehoming

“A sick thing”. “Human trafficking in children”. “A gaping loophole with life threatening outcomes”. These are just few of the ways experts, legislators and judges have named unregulated private transfers of child custody, a practice referred to as re-homing.

Private re-homing occurs when adoptive parents transfer the custody of a child bypassing official channels. In such cases, parental authority is transferred with a simple Power of Attorney to non-family members.

Very often these people are perfect strangers whose parenting abilities have not been screened by child welfare authorities or, worse, have been judged so poor that their biological children have been taken away by child protection services.

According to an investigation published by Reuters in 2013, hundreds of children are victims of re-homing in the USA every year. 70 percent of them are children adopted from abroad.

“Rehoming can be an appropriate change of placement for a child if it is done with court approval and with home study that look at the needs of the child and the child’s best interests,” said Stephen Pennypacker, a senior child welfare expert and current President of the Partnership for Strong Families, in an interview.

However, the problem with private rehoming is that it is not done with that oversight and the necessary background screening on the prospective placement. “This can lead to some pretty horrific consequences for children that are moved under those circumstances,” Pennypacker said.

One such case happened in Arkansas in 2014, when a six-year-old girl was sexually abused by a man who had obtained her custody via a private re-homing procedure. The case received intense scrutiny only last February as the media reported that the adoptive father who gave the little girl away was a state legislator, Justin Harris.

Arkansas has since then passed two laws to prevent this practice, becoming the fifth state to have regulated it. A few other states are slowly discussing bills to this effect, while no federal law regulates it.

In a court decision in the State of New York last December, Judge Edward W. McCarty III defined the practice “unmistakably trafficking in children” and called on the Legislature to amend domestic law to prohibit this “unsavory and unsupervised practice”.

This judgment came to no surprise to Mary-Ellen Turpel-Lafond, British Columbia Representative for Children and Youth. “Rehoming sounds like a positive experience that is looking at the best interests of the child, but actually it simply transfers a child to another person without any required review by child welfare, family judges, or other officials. So it could be easily a cover for trafficking in children.”

Other child experts echo the concerns about the risks that unregulated re-homing poses to a child’s wellbeing, although they do not consider re-homing as trafficking because parents do not move children to exploit them, but to get rid of them. “All under the table dealing on children’s matters entails risks of exploitation,” said Michael Moran, INTERPOL Assistant Director, Human Trafficking and Child Exploitation, in a phone interview. “Unregulated re-homing creates opportunities for sex offenders. If loopholes exist, sex offenders will use them.”

Reasons that push parents to resort to private re-homing vary from case to case. The most common explanation given by parents engaging in such a practice is that they feel overwhelmed by the behavioral problems of their adopted children. They also claim that the support they receive from child welfare authorities to deal with difficult adoption cases is inadequate. In another case, parents may fear to be charged with child abandonment if they seek to transfer custody to the state. Financial considerations may also play a role because certain states accept taking a child under their custody only on the condition that parents pay for the child’s care until a new adoption takes place.

Some state and federal authorities have acknowledged these problems and are trying to address them. State legislation has been adopted in Arkansas to strengthen post-adoption services and allow parents to give children back to the state’s care if they have exhausted the available resources – although no definition of what these resources are is provided. At the federal level, the US President’s 2016 budget contains a proposal that would guarantee federal funding for prevention and post-placement services.

Whether such initiatives will suffice to prevent rehoming is an open question, though, in particular as the practice remains largely lawless in the USA. So far, only five states – Arkansas, Colorado, Florida, Louisiana, and Wisconsin – have adopted legislation to prevent re-homing. Five other states – Maine, Maryland, Nebraska, New York, and North Carolina – are discussing bills to this effect.

“This kind of regulatory void is enormously concerning,” said Jacqueline Bhabha, professor of the practice of health and human rights at Harvard School of Public Health. “Clearly, we need much tighter regulation and more supervising and support to families.”

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