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Texting Like A State: mHealth and the first thousand days in South Africa

This article is part of the series:

What does making a new life look like from the perspective of a mobile phone?

For the phone of a woman using the public health care system in Cape Town, South Africa, in all likelihood involves a series of WhatsApp conversations with a partner, with friends and kin. The phone helps with “Googling” questions about health and childcare, maybe about shopping for things for the baby. Maybe it will take photos of a growing belly and of the preparations for the new family member. Maybe it will take no photos of this at all because the pregnancy remains hidden as long as possible. The phone will make calls and send WhatsApp messages about finding money for transport and maybe about finding childcare and getting time off to go to the clinic for checkups. And when the time comes, for getting to the Midwife Obstetric Unit (MOU) to give birth. There will be WhatsApp’ing though early labor, where the phone is the woman’s only companion in the ward, apart from the other birthing women. The phone might be the only thing that follows the woman into the labour ward, when the time comes to push. When the birth is over and the child is in its mother’s arms, the phone is there to take photos and send WhatsApp messages to let family and friends know that all is well.

In the last few years the mobile phones of pregnant women and new mothers in South Africa have become the site of something else too: the first national mHealth program in Africa. The South African Department of Health established a mobile phone health program aiming to improve maternal and child health in August 2014. The MomConnect program seeks to harness the potential of high rates of mobile phone penetration in South Africa to communicate to patients and build digital infrastructures in the public health care system, to ultimately deliver more efficient and “patient centered” services (Barron and Pillay 2016).

At a recent conference in Stellenbosch on the use of digital technologies for maternal and child health, one presentation seemed to capture the un-blighted optimism about the transformative power of mobile phones in health systems in developing countries with the title: “mHealth – The Promise.” Using digital media technologies and mobile phone networks is considered, by international donors and governments of poor countries alike, a pathway to a more efficient, flexible and cheaper health system (Haas 2016, Vital Wave Consulting 2009), though both researchers and practitioners are more cautious (Donner and Mechael 2012). From a mushrooming of pilot projects, governments are now bringing “mHealth to scale,” investing in national mobile health programs and apps for both patients and health professionals (Haas 2016).

During nine months of fieldwork in Cape Town, I sought to place these grand development promises in the context of everyday media use among pregnant women and new mothers. Paraphrasing James Scott’s famous work on statecraft (1998), the idea of “texting like a state” here gathers thematic fragments from my fieldwork, looking at some connects and disconnects in the intersection between mobile phones and maternal health in the public health system in Cape Town.

 

The Promise

MomConnect is owned by the South African Department of Health, “championed by the Minister of Health,” and run in partnership with over 20 public and private actors. Among these are the American company Johnson & Johnson, the South African Praekelt Foundation, telecommunications companies in South Africa, and an investment of close to eight billion dollars from the United States Agency for International Development. The aim of the program is to improve maternal health by sending informational text messages to pregnant women and new mothers according to their gestational age or the age of their child, and in turn registering them in a national patient database when they sign up for the messages. MomConnect also has an interactive feature through which users can submit questions to a help desk staffed by maternal health professionals. Here I focus on the text-messaging feature of MomConnect.

The promise of mHealth as it appears in MomConnect is about knowledge. The idea is that almost every citizen is within reach via the mobile phone, and that delivery of information changes perceived problematic “behaviors” of individuals, leading to better health outcomes for mothers and children (Barron and Pillay 2016). This theory about how to bring about change is also known as the Knowledge Attitudes Practice Model or Social and Behavior Change Communication Theory among the health professionals working with the program (as described in for instance Lamstein et al 2014 but see Neuhauser and Kreps 2003). These models about communication and knowledge positions the sender – the Department of Health – and the receivers – poor pregnant women and new mothers – in an unequal relation of power, in which the sender is perceived as the holder and giver of “knowledge” and the receiver as without “knowledge”. It further assumes that if receivers are given “knowledge” their attitudes and practices will change regardless of whatever else might be at stake in their lives. To explore further how this envisioned theory of change is enacted from the side of the health system, let us consider the kinds of messages sent to women in the MomConnect program.

 

The Messages

The first message available in MomConnect is in week five: “Congrats on your pregnancy! Your baby is just the size of a small seed but you can help your baby grow. Eat vegetables and fruit, don’t smoke or drink alcohol.” The message initiates a narrative about a welcome and wanted pregnancy, taking for granted the relations of mother-child-dyad as already existing and positive. It also personifies the embryo growing in the woman’s womb as a baby, and prescribes specific courses of actions for “mother” and “baby”. The imagery of an already formed human being the size of a grain, a human being in need of the mother’s help to grow into a full social person runs through the messages of the MomConnect program. Such a text message from the National department of Health suggests a state with a pronatalist political stance, and does not seem to consider the ambivalence and choices that many women (and their partners) face in early pregnancy, somewhat undermining women’s rights to abortion.

Altogether 162 messages of MomConnect (in 2015) are sent during pregnancy, the first year after birth, and in case of miscarriage, stillbirth or the loss of a baby. Fifty-three (one-third) of these messages encourage the reader to go to the clinic, either for regular appointments or if mother or baby are showing signs of illness. Descriptions of the size and abilities of the un-born fetus or born child are the second most prominent theme in the messages, followed by encouragement and information about breastfeeding. Other recurring themes are healthy eating, keeping oneself and the baby clean by washing hands, taking the prescribed medicine from the clinic and avoiding traditional and alternative medicines, and avoiding alcohol, smoking and illegal drugs. Saving money for transport to the hospital and shopping to prepare for the birth of the child are also part of the messages. Throughout the messages, the fetus is articulated as a baby with human features in need of the help, care and safekeeping of the mother: “Your baby is growing fingers! If you feel unwell, have a fever, bleeding or vomiting, go to the clinic to make sure you and your baby are safe” (Week 10 of pregnancy). Many of the messages, like this one, seems to have several concerns in mind: to congratulate the mother on “growing” her “baby” in a friendly way and at the same time managing the “risk” involved with pregnancy with encouragements to go to the clinic.

After birth, messages focus on breastfeeding and feeding, as well as on activities that helps the child develop: “Your baby loves the sound of your voice. She may stop moving when you speak. Talk and sing to her every day. Make eye contact and smile. She will smile back!” (Week 11 after birth). The conclusion of the messages at week 51 after birth instigates a new period of life:

“You have done a great job! Keep being a great mother to your sweet child. If you miss a period, you may be pregnant again. Go to the clinic for pregnancy care”. The baby has now become a child, and the mother has proved herself a capable mother. But motherhood is not without risks; another pregnancy may occur.

MomConnect functions primarily as a broadcast from a national, centralized database in the Department of Health directly to subscribers’ phones. But it also has a feedback option through which subscribers, via text messages, can report problems or abuse and ask questions about their own health and that of their offspring. In project reports based on the self-generated data of MomConnect, this feature has been used to translate messages or call for materials for local clinics.

The promise of mobile technology as envisioned by the public health professionals working by MomConnect, and the theories of change that underpin it, is that it puts the National Department of Health in direct “conversation” with expecting and new mothers all over the country. The 140 characters of the text messages tell subscribers stories about how to bring new life into the world, not merely nudging but hailing pregnant women to act and feel in particular ways towards their pregnancy. The careful crafting of messages to be relevant and meaningful across the cultural and lingual differences in South Africa is reported repeatedly in grey literature on MomConnect, suggesting that the texting state is self-consciously practicing what Stuart Hall would have called “encoding”. Hall conceives of (mass) mediated communication as series of “moments” rather than a causal, linear process (as above) in which “no one moment can fully guarantee the next moment with which it is articulated” (Hall [1973] 1999: 91). Encoding is the moment of production of phenomena into “message form” – something that can be mediated and communicated – with particular meanings and purposes. The encoding of MomConnect would then be a moment of the National Department of Health purposefully seeking to communicate messages whose meaning it thinks will be understood by the receivers. According to Hall, mediated messages are received by audiences in moments of “decoding” though which messages are given meaning within receivers’ life worlds, as well as the power relations framing the communication. That is, the message “sent” and the message “received” is not the same thing: rather communication is a series of relatively autonomous moments of social practice with uncertain outcomes. Hall’s aim to trouble the idea of commination as a “perfectly equivalent circuit” (ibid: 100) may be as relevant today as it was in 1973.

As the MomConnect program was implemented, two related issues seemed to make the promises of mHealth harder to keep. First, the technological infrastructure depends on busy, overworked health care workers to make the actual connection between MomConnect and expecting mothers. Second, those same people seem to define how subscribers understand, or decode, the text messages.

 

The Voice of Technology

To register fully with MomConnect, the pregnant woman must be “diagnosed” as pregnant in the public health system, and she must submit both her own national identification number and the number of the clinic. Because the woman cannot register fully on her own, clinic staff need to help patients with this. Speaking with community nurses and other health workers in Cape Town I learned that not all MOUs had taken up the program, despite public health facilitators presenting and introducing the service to managers and midwives at the clinic. Registration of users in the MomConnect database was experienced as a burden for nurses at some of the understaffed MOUs, and as beyond the scope of their professional duties. “Work is added … (by) this MomConnect. (…) It’s on top of other things,” one nurse reported (Wolf-Piggot and Rivet 2016: 7). Facility managers noted that it was “unfair” to give nurses further tasks, tasks not essential for the health of mother and her unborn child (Wolf-Pigott 2015). At some MOUs the community nurses would seek to enroll women in MomConnect while they were waiting to see a nurse in the antenatal ward. MomConnect depends on the staff at the MOUs to collaborate with the technical infrastructure of the program by “connecting” the phones of patients with the program. For this to happen, they must see the value of time spent registering their patients. This appears to be a challenge in a overburdened health system where nurses are torn between seeing as many patients as possible and correctly monitoring and diagnosing potentially fatal conditions in their patients.

The role of clinic staff in the kinds of connectivities established in MomConnect may be even more complex when it comes to how subscribers make sense of the messages. A central question is that of the “voice” of MomConnect, said one doctor who had worked with the program. When the subscribers read the messages, is the voice they hear in their head a friendly caring voice, or a shrill, patronizing one? The voice of the MomConnect program was essential for effecting behavioral changes in the women, he told me. He differentiated between the “tone” of messages, the wording and intentions put into the messages by the producers, and the “voice” of the messages heard by the receivers. If both the tone and the voice of the messages were not phrased just right, the mothers would not listen, and the messages would not change the behaviors of the mothers. The developers had worked closely with midwives, communication specialists and a range of other professionals to develop a set of messages that would be friendly and encouraging across cultures and languages in South Africa. MomConnect is available in South Africa’s 11 official languages, translated from the original set of English messages. The researchers working within the MomConnect program considered this use of “local knowledge” one of the strengths of MomConnect; it was designed with “local experts to make it compatible with the local South African context” (Sebregts et al 2016).

Yet the researchers discovered that the tone of text itself seemed not to be all that mattered to the receivers. Rather, they read the messages in “the voice” of the nurse who had helped them sign up for the program. The nurses were not only in material terms connecting patients to the infrastructure of the program; their voices became part of the messages themselves. The relationship between patients and caregivers, a relationship placed outside of the control of the carefully crafted MomConnect system, apparently circumscribes the system itself. “We can do everything and design everything, except for the thing that matters!” my friend exclaimed. Nurses and other frontline clinic staff mediate between MomConnect and the mothers the program seeks to connect with in curious ways. They are part of the MomConnect infrastructure, as the program does not function without them, but the owners and makers of the program see them as a difficult and mysterious element, beyond control.

 

Texting It In

Health professionals working with MomConnect noted that in the region of the more urban, cosmopolitan and affluent Western Cape, the program had not been taken up as enthusiastically as for instance in the poorer and rural Eastern Cape. At the local Cape Town office of a national NGO for reproductive health, the manager did not mince words when I asked her if she knew about MomConnect. “Bullshit!” she yelled. “It’s a total bullshit thing! Looks great on paper, looks great in high places and for international donors. But what is the outcome?! Does anyone on the ground even know what it is?” she asked. I wondered the same. I interviewed pregnant women and new mothers about their media habits. They had attended MOUs in areas that were formerly townships reserved for those classified as “Coloured” or “African” . Among the 52 mothers I talked to, one was enrolled in the MomConnect program. She enjoyed receiving the messages and felt they were inspiring. But then she turned to more pressing matters: difficult kin relations, cramped living situations, lack of employment, fear of personal violence. One other mother had tried to register with MomConnect and failed. Some said that they had heard about programs using the phone to support mothers, like WhatsApp groups. Though my study focused on the role of mobile phones in the everyday lives of pregnant women and new mothers, quite a few of the women we met did not have personal mobile phones. I talked to some of the people who had been developing and managing the program in the national Department of Health. One noted that though the market research showed that women were enthusiastic about the program, it appeared that despite the informational qualities of the text messages, there was no measurable change in users’ “knowledge” about pregnancy and childbirth (see also Lau et al 2014).

Placing the MomConnect program within its context of use, the mobile phones of South African women, diffuses the idea of a monolithic state working through a perfectly functioning infrastructure, prescribing how life should be shaped.

Thinking with James Scott’s work on statecraft and the logics of great utopian social engineering schemes, what do grand infrastructural projects of development look like in the 21st century? MomConnect is not a grandiose project in terms of visible, physical structures, but the use of digital media technologies are forms of statecraft, seeking to effect change in the groups of citizens considered at once the most vulnerable and the most valuable – pregnant women and their infant offspring. Examining the intersection between media use and ideals of governance concerning mothers and infants that use the public health sector in Cape Town might help us to better understand the ideas that animate the relationship between social change and digital technologies and infrastructures in contemporary states in Africa.

 

Nanna Schneidermann is an anthropologist and postdoc in the research project MediAfrica at the Oslo and Akershus University College, and an affiliate of “The First Thousand Days” research group at the University of Cape Town. Her current research looks at intersections between digital media technologies and motherhood among poor and marginalized women in Cape Town, trying to understand ideas of change and transformation in the making of new lives, from texting states to WhatsApp’ing mother in laws.

 

References

Barron, P., & Pillay, Y. (2016). Using mobile technology to improve maternal, child and youth health and treatment of HIV patients. SAMJ: South African Medical Journal106(1), 3-4.

Donner, J., & Mechael, P. (Eds.). (2012). mHealth in Practice: Mobile technology for health promotion in the developing world. A&C Black.

Haas, S (2016). mHealth Compendium, Special Edition 2016: Reaching Scale. Arlington, VA: African Strategies for Health, USAID (link: www.africanstrategies4health.org.)

Hall, Stuart ([1973] 1980): ‘Encoding/decoding’. In: During, S. (Ed.). (1999). The cultural studies reader. Psychology Press. (‘Encoding and Decoding in Television Discourse’, 1973).

Lamstein, S.,T. Stillman, P. Koniz-Booher,A.Aakesson, B. Collaiezzi,T.Williams, K. Beall, and M.Anson. (2014). Evidence of Effective Approaches to Social and Behavior Change Communication for Preventing and Reducing Stunting and Anemia: Report from a Systematic Literature Review. Arlington,VA: USAID/ Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project.

Lau, Y. K., Cassidy, T., Hacking, D., Brittain, K., Haricharan, H. J., & Heap, M. (2014). Antenatal health promotion via short message service at a Midwife Obstetrics Unit in South Africa: a mixed methods study. BMC pregnancy and childbirth14(1), 284.

Neuhauser, L., & Kreps, G. L. (2003). Rethinking communication in the e-health era. Journal of Health Psychology8(1), 7-23.

Scott, J. C. (1998). Seeing like a state: How certain schemes to improve the human condition have failed. Yale University Press.

Seebregts, C., Barron, P., Tanna, G., Benjamin, P., & Fogwill, T. (2016). MomConnect: an exemplar implementation of the Health Normative Standards Framework in South Africa. South African Health Review2016(1), 125-135.

Vital Wave Consulting (2009) mHealth for Development: The Opportunity of Mobile Technology for Healthcare in the Developing World. Washington, D.C. and Berkshire, UK UN Foundation-Vodafone Foundation Partnership,

Wolff-Piggott, B., & Rivett, U. (2016). An Activity Theory Approach to Affordance Actualisation in mHealth: the Case of Momconnect. ECIS (Research Paper 108).

Wolff-Piggott, B. (2015). Towards an Affordance Perspective on mHealth Usage: A Clinic-Level View. In: Proceedings of SIG GlobDev Eighth Annual Workshop. (Vol. 26). Münster, Germany


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