Family Planning: There’s an App for That

Photo of Midwife Ibu Suri at her private midwife center in Denpasar, Indonesia

DENPASAR, INDONESIA—An insubstantial door in the clinic of a Balinese bidan (midwife) is all that separates me from the drama of a delivery in progress.

Inside the adjacent room, a laboring mother is at 3 centimeters, midwife Ibu Suri reports at about 10 a.m.

For the next hour, a hush prevails over this meticulous and cheery compound tucked into a traffic-choked side street of Bali’s busy capital city. Suri, 70, bustles about the private facility she owns and manages with the help of a competent staff of eight midwives, including her two daughters, ages 42 and 30.

At 11:02 a.m., the quiet is shattered. A baby inhales, then wails, announcing its arrival to the world. 

After a couple minutes, silence again. 

I imagine the wrinkled infant rooting for the breast of her exhilarated and exhausted mother, finding comfort there.

It’s a sacred moment. I’m transported many miles and years away, back to my own daughter’s birth. Words fall short. Ironically, it is here and now, in a hot and humid hallway—far from the air-conditioned comfort of the Bali Nusa Dua Convention Center where the 2016 ICFP is underway—that that the essence of family planning crystallizes for me.

It means that every pregnancy is planned; every mother, treated with dignity; every baby, wanted, valued, loved.

Since 1967, Suri has welcomed over 7,000 babies to the world. An average of 32 are born every month here—with significant increases in February and September, she says, as these months occur 40 weeks after the two times a year in Bali when tradition holds that it is a particularly good time to marry.

Delivering babies takes up lots of Suri’s time and energy, but she has another passion, too. That is, providing women with the best family planning counseling and services.

Suri is a private practice midwife, proud of having earned the title of Bidan Delima in 2005. Bidan Delima is an accreditation program run by Ikatan Bidan Indonesia (Indonesian Midwives Association), which certifies midwives to provide family planning and reproductive health in accordance with WHO standards.

There are 456 Bidan Delma in Bali, she says.

This distinction ensures that she provides high-quality reproductive services. According to a menu in her office, she offers a range of contraceptive options, as well as ear piercing for newborns and counseling for couples (unscientific though it may be) about how to increase their chances of conceiving either a boy or girl.

Most of her clients come in asking for short-term contraceptive methods, including pills and injectables, she says. 

“However, we suggest for them to use IUD,” Suri adds.

IUDs are among the methods classified as long-acting reversible contraceptives. LARCs, for short. It’s an acronym getting lots of buzz at the 2016 ICFP, for lots of good reasons.

Here’s one: LARCs are highly effective. IUDs, for example, prevent more than 99% of pregnancies—rivaling success rates of sterilization. But LARCs, of course, have the distinct advantage of being reversible.

Here’s another: Improving the uptake of long-term methods of contraception is hailed as a key strategy for countries—notably Indonesia—to revitalize family planning programs and meet the Sustainable Development Goals (SDGs). If you envision this nation of about 17,000 islands covering an area of 1.9 million square miles and encompassing tens of thousands of far-flung villages, you quickly realize that it’s just not feasible for many women to trek to a midwife every month to get a pack of pills, or even every few months for an injectable.

For more women than are using them, long-term reversible methods are a no-brainer. Implants can provide protection for a few years, and IUDs for up to a decade (and sometimes longer). Still, most Indonesian women—likely the new mother in Suri’s delivery room—aren’t choosing these safe, easy ways to stall or prevent pregnancy, for a number of reasons. Even though an IUD could safely be inserted within the first 48 hours post-delivery, the new mom in the delivery room is unlikely to ask for one.  Most women rely on word-of-mouth, getting contraceptive advice—good and bad—from friends and family members; common misconceptions about IUDs include that women using them can get pregnant and the devices will get stuck in their babies’ heads.

Most women don’t have midwives are as savvy as Suri when it comes to counseling them about IUDs, and providing them with a full range of contraceptive methods. 

In fact, of more than 300,000 midwives in Indonesia, fewer than 40% are trained and certified to provide long-acting methods like implants and IUDs. Given that midwives provide nearly 75% of the contraceptive services in the country—mostly in the form of pills and injectables—it’s vital to the success of Family Planning 2020 and the SDGs that midwives get on board with LARCs.

Increased attention to the supply side of LARCs is essential. But strengthening midwives’ capacity and making LARCs more widely available and accessible is only one side of the equation. That’s why the government of Indonesia along with partners who promote family planning is addressing the demand side in a number of strategic ways—including one that’s particularly social.

SKATA, a new smartphone app demonstrated Wednesday at the 2016 provides reliable and comprehensive information about family planning directly to a huge target audience using technology they already have, explained SKATA program director Dinar Pandan Sari of the Johns Hopkins Center for Communication Programs.

The goal of SKATA’s parent program, called My Choice, is to increase the contraceptive prevalence rate (defined as women of reproductive age using a contraceptive) by 5% in 11 districts within four provinces by 2017.

The target audience, strictly speaking, is married women ages 20-35, Sari explained. But this doesn’t mean that adolescents can’t access it and learn lots from it—without any hassle or embarrassment.

SKATA is meant to engage users and their partners in an ongoing conversation about family planning through the life course, in the biggest, broadest sense. It addresses parenting issues and education for instance.  Of course, contraception is a centerpiece component. The app shows how, as a couple’s status evolves over time, their contraceptive methods can and should reflect those changes.

The aim is to increase an “informed demand,” Sari explained, adding, “Indonesians have a broad awareness of family planning but not deep knowledge or accurate information about a range of contraceptive methods.”

If SKATA achieves what it has set out to do, women in the near future will go to bidans already knowing all about the implant and IUD, and therefore start demanding LARCs—instead of passively relying on a bidan (who might not yet have the training or incentive to offer long-term methods) to tell her what method to use.

With 64 million smartphone users and 280 million mobile phones, Indonesia is particularly ripe for SKATA, a user-friendly, conversation-generating technological solution, says Radha Rajan, a DrPH candidate at the Johns Hopkins Bloomberg School of Public Health.

Rajan has been based in Jakarta since mid-September, and will remain until April, working with Sari for CCP. She is testing usability of SKATA at three sites across Indonesia: in East Jakarta, Central Java and North Sumatra. Earlier this month, she conducted in-person structured interviews with 36 brand new users of SKATA, recording their first impressions while downloading and using the app. In a month, she’ll follow up with them to document if and how they’ve continued to use the app and what they’ve shared with others about it.  

The focus of her dissertation is on factors that facilitate or inhibit engagement with mobile health interventions; the context being family planning, of course.

Rajan’s findings will inform a new, improved version of the app, Sari says; one that’s likely to be even more interactive. Although SKATA’s just recently been soft-launched, its creators are champing at the bit to refine it and come out with SKATA 3.0.

What’s the rush? With the year 2020 fast approaching, the Family Planning 2020 goal set at the 2012 London Summit looms front and center for conference attendees like Rajan and Sari. They’ve listened intently as the 2016 ICFP has offered up all manner of evidence that family planning can benefit not only the new mother and infant still bonding in the midwife’s delivery room, but indeed, the entire world.

They know there’s not a moment to waste.  You can bet your bidan on it. — Maryalice Yakutchik


The SKATA app is available for download on the Google Play and iOS App stores, as well as at www.skata.info.

 

Ed note: Global Health NOW correspondent Maryalice Yakutchik, with support from the Bill and Melinda Gates Institute for Population and Reproductive Health, is among the journalists reporting from Indonesia at the 2016 ICFP. Check back every day this week for exclusives from the conference: http://www.globalhealthnow.org/intl-conference-family-planning-indonesia-2016.html

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