Voice and Choice of Mothers: Health Decision-Making Dynamics Among Women in Urban India

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By: Lily W. Lee, President, ALMATA, Division of Avegen Pte Ltd.; Mark Allen, Director of Strategic Partnerships, Merck for Mothers; Sumiti Saharan, Design and Research Director, Avegen Pte Ltd.

On a global basis, incorporating patients’ voices as part of the health care ecosystem is now well accepted and widespread. Evidence shows that patient-reported outcomes can improve the patient’s quality of life, enhance patient-clinician communication, reduce emergency department use and play a role in shared decision-making. Patients can provide valuable insights for health care personnel to improve quality of care. The World Health Organization (WHO)’s Integrated People-Centred Health Services framework prioritizes holistic and compassionate health care. WHO has extended this concept to maternal health care as exemplified by its recent framework for measuring and improving quality of maternal and newborn health care in facilities worldwide.

Insight from women in New Delhi and Mumbai

What are women’s roles in the maternal health care decision-making process in settings like India? Are women’s voices heard by their family members and caregivers? How can women be empowered in maternal health care? What is the potential of digital technology in amplifying women’s voices? These are significant questions to ask in the context of India, a country with the world’s largest population of women in childbearing age. To answer these questions, the ALMATA team conducted baseline research and surveyed 500 women from New Delhi and Mumbai in 2017 across a range of socioeconomic classes who had at least a secondary education and used the internet at least once a month.

The survey showed that women’s voices and choices in health decisions need to be elevated in both families and hospitals. Factors like extended family structure and patriarchal culture may influence women’s active role in their own maternal health care. Almost all women surveyed reported that their husbands play a critical role in all maternal health decisions. For decisions with a clear financial implication like the choice of hospital for delivery, husbands were cited as the sole decision-maker by the majority of women; only 32% of the women surveyed reported having a say in deciding which health care provider to choose. Interestingly, the proportions of women who had a role in maternal health related decision-making were consistent across educational and economic status.

In the context of women’s interactions with doctors and hospitals, the survey showed that women may not always voice concerns and preferences with maternal health care providers. Among all socioeconomic groups, 36% of women said they did not discuss their preferences or express their concerns to health care providers. The primary reason for not discussing was not feeling comfortable. This relatively low agency was prominent in both lower-middle-class and middle-class groups.

Among women in our sample, use of the internet for general purposes was high across all social economic groups, with around 80% of all women using the internet several times a week. While there was high uptake of the internet as a tool for entertainment and social communication, the percentage using the internet as a tool for health care information varied depending on socioeconomic status. For example, 78% of women in the upper middle-income group, 45% of women in the middle-income group and only 3% of the women in the lower middle-income women reported using the internet for comparing hospitals for delivery more than once a week.

The survey results indicated that pregnant women and postpartum women have different behaviors related to using the internet for health information. The percentages of new mothers using the internet more than once a week in the upper middle-, middle- and lower middle-class groups were 72%, 49% and 20%, respectively. On the other hand, those percentages for pregnant women in the upper middle-, middle- and lower middle-class groups were much lower—at 24%, 3% and 0%, respectively. This likely reflects the motivation new mothers have to seek information related to the care of their newborn babies.

A digital platform to empower women in decision-making

Our study found two key reasons preventing women from using the internet to search for maternal health care information: lack of trust in accuracy of online content and lack of awareness. A mother can be empowered by the internet only if she can trust the content of a website as much as she trusts information from her social circle and doctors.

Armed with the insights from this research, ALMATA and Merck for Mothers have partnered to develop and launch a digital platform, Together for her Health* , that aims to serve the dual purpose of:

  1. Empowering women with awareness, voice and choice of their maternal health care. After delivery, women are invited to provide objective feedback on a set of WHO-defined set of nine Quality of Care (QoC) Indicators that have a clinical and respectful care impact, thereby giving women a voice in health care. The indicators are on-time admission, clean delivery environment, privacy during delivery, skin-to-skin contact, early breastfeeding, courtesy and respect, counselling about family planning, informing about danger signs and communication during labor. Pregnant women and family can use these reviews to make educated choices for their maternity care.
  2. Enabling hospitals and providers to make evidence-based quality improvement incorporating the voice of the women. Hospitals receive objective and actionable feedback on the nine QoC indicators, thereby creating a platform where they can identify areas needing improvement and improve their QoC.

In just over a year post-launch, we have collected over 16,000 reviews from women across Maharashtra and the Delhi region. In the coming year, we will be assessing the impact of this feedback and how the voice of mothers can drive improvement in QoC. Encouragingly, hospitals that repeatedly log in to the together platform to review their profile and QoC performance are showing preliminary signs of improvement in QoC performance.

Digital technology holds promise to make a positive impact in empowering consumers of health care and improving quality of care. It is important to develop systems and interventions that build trust and engagement with the stakeholders and to deliver tangible value to the end users and the health care system as a whole.

*This program is sponsored by funding from MSD, through MSD for Mothers, the company’s 10-year, $500 million initiative to help create a world where no woman dies giving life. MSD for Mothers is an initiative of Merck & Co., Inc, Kenilworth, N.J., USA.

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