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Researchers and activists have expressed concerns over the lack of availability and nonuse of reversible, modern, contraceptive methods in India for decades. New attempts to increase access, availability, and acceptance of reversible contraceptives need to be developed, instead of relying solely on female sterilization. Mobile health (mHealth) initiatives may offer one way to serve underprivileged populations who face challenges in sexual and reproductive health (SRH) in countries such as India.
This study aimed to examine the outcome of an mHealth intervention for enhancing knowledge of, and practices related to, reversible contraceptives in rural Western India.
We implemented a nonrandomized controlled trial (before-and-after study in an intervention area and a control area) in the Indian state of Maharashtra. The intervention in this case was a mobile-based SRH helpline provided by a nongovernmental organization (NGO). Baseline and follow-up surveys were carried out in two government-run primary health center areas, one each in the intervention and control area, and 405 respondents were surveyed in the two rounds. An interview-based structured questionnaire suitable for a low-literacy environment was used to collect data. The effect of the intervention was estimated using logistic regression, adjusted for gender, by calculating robust standard errors to take into account the clustering of individuals by the area (intervention or control). In each regression model, the effect of intervention was estimated by including a term for interaction between the intervention area and the period before and after the intervention. The exponent of the regression coefficient of the interaction term corresponding to the period after the intervention, along with the 95% CI, is reported here. The odds ratio for the control village multiplied by this exponent gives the odds ratio for the intervention village. Calls received in the intervention were recorded and their topics analyzed.
The current use of reversible contraception (18% increase in intervention area vs 2% increase in control area; 95% CI) has seen changes. The proportion of respondents who had heard of contraception methods from an NGO rose in the intervention area by 23% whereas it decreased in the control area by 1% (95% CI). However, the general level of awareness of reversible contraception, shown by the first contraceptive method that came to respondents’ mind, did not improve. Demand for wider SRH information beyond contraception was high. Men and adolescents, in addition to married women, made use of the helpline.
A mobile helpline that one can confidentially approach at a time most convenient to the client can help provide necessary information and support to those who need reversible contraception or other sexual health information. Services that integrate mHealth in a context-sensitive way to other face-to-face health care services add value to SRH services in rural India.
In India, a few reproductive mobile health (mHealth) initiatives have been implemented [
With its population of 1.3 billion people, India has implemented the Indian family planning program, which relies heavily on female sterilization. Of currently married women, aged 15 to 49 years, 36% are sterilized whereas 11% use reversible modern contraception [
The use of reversible contraception remains abysmally low in India. Among the underlying structural factors are the generally low socioeconomic and educational standards [
Consequently, there is a need to provide personal counseling and information in a gender-sensitive manner, secure access to contraceptives and improve health care services, particularly among the socioeconomically underprivileged groups. Can mHealth assist in providing counseling and information and improve accessibility of contraception? Wireless phone subscribers in India reached a total of 998 million people by March 2018 [
This study explores gaps in SRH needs of rural, disadvantaged populations, and further examines the outcome of an mHealth intervention in enhancing knowledge and practice of reversible contraception to reduce the gap in rural Western India. An mHealth-based intervention on family planning is examined in a nonrandomized controlled trial (before-and-after study in an intervention area and a control area) in the Indian state of Maharashtra. The intervention was a project by a nongovernmental organization (NGO) offering mobile-based SRH helpline.
In terms of family planning, the Indian state of Maharashtra represents close to the average Indian situation. In the state, 51% of currently married women are sterilized whereas 11.5% use reversible modern contraceptive methods of which the condom is the most popular. Total unmet need for contraception is 9.7% [
Overall, two sufficiently similarly profiled districts, Thane and Nashik of Maharashtra, were chosen for the study. Although Thane is more urban than Nashik, the subdistricts where primary health center (PHC) areas were chosen for the data collection have a similar level of urbanization (77% in the chosen subdistrict within Thane and 78% in the chosen subdistrict within Nashik [
The intervention introduced a mobile helpline, combined with personal contact with participants by village health workers and with local distribution of contraceptives. The target population was married men and women in the age range of 15 to 35 years.
A toll-free helpline was available to villagers in the project area. A total of 12 gender-equal, frontline, field workers were responsible for communication and branding activities for the call center, and follow-up activities among targeted beneficiaries who sought the intervention services, using both interpersonal communication and mid-media activities (eg, street theater and wall paintings). The calls were attended by trained female and male paramedical staff, one of each, who were fluent in the local dialect. The helpline personnel recorded the received calls, specifically noting the main topic of discussion. This intervention complemented the regular governmental health care services available, and it took place from June 2015 to June 2016.
The role of the helpline in the intervention’s theory of change (hindrances in dark arrows and intervention activities in white boxes).
The intervention was based on the theory of change in a situation, when a woman or a couple was motivated to delay or avoid pregnancy, as expressed in
The control site was a PHC area in Nashik, an adjacent district. This area was serviced by similar governmental maternal and health care services, including family planning services. For several years, there was a mother and child health program being implemented by an NGO, whose local village workers supported governmental services. Thus, both areas were served by governmental public health, assisted by NGO-based services that involved personal contact with the local people. In the control area, there was no mobile helpline comparable with the one in the intervention area.
The study was a quasi-experimental study, a controlled before-and-after study as described by Reeves et al [
An interview-based baseline survey was carried out from March to April 2015 in both the study areas to gather data on knowledge of, and practices related to, reversible contraceptive methods, needs related to SRH, and willingness to use mHealth services. The study design is shown in
Study design. SRH: sexual and reproductive health.
To assess the outcome of the mobile helpline on SRH, a follow-up survey was carried out from November to December 2016. The follow-up survey was conducted in both areas about 18 months after the introduction of mHealth-assisted SRH services in the intervention area. The influence of external activities and information, such as government services and media programs toward family planning, was hypothesized to be similar in both areas. An NGO working with issues related to SRH was present in both areas but a mobile helpline was promoted only in the intervention area. Wider socioeconomic confounders were controlled using the control area. Hence, any differences in SRH observed between the areas after the intervention were analyzed as related to the potential outcome of the helpline intervention.
The target sample size was 100 married men and 100 married women from each area. The intervention survey was intended to represent the area or cluster level and not the individual level, meaning that the study participants in the two survey rounds were not necessarily the same persons.
The sampling was carried out in two stages. A total of 10 villages (about 50% from each area) were randomly selected from each selected PHC using systematic sampling with a random start. A list of villages with a total population size of at least 500, which were arranged in ascending population sizes, served as the sampling frame from which sample selection was made. From each sampled village, 20 households were selected by a systematic sampling process using the left-hand rule, and 1 study subject was selected per household. If a household had more than 1 eligible subject, then one of them was chosen randomly. Trained research investigators were responsible for recruiting the study subjects. The inclusion criteria for selection of a subject were: age between 15 and 35 years, married, and lived permanently in the settlement. If the respondent was a visitor (eg, a daughter come down for delivery to her natal home or a visiting guest) then she was excluded from the study and the interview was terminated.
This study used an interview-based data collection method, a structured questionnaire which suits low-literacy environments. The primary measurements were knowledge and practice of family planning, current use of contraception, intent for further use, and any changes in these after the intervention. The questionnaire included background socioeconomic and demographic information, questions on mobile phone ownership and use, union status and hygiene practices; knowledge, attitude, and practice of family planning; children and decision making, current use of contraception, intent for further use, and a contraceptive tracking sheet showing dynamics of contraceptive use of the study subjects. The data collection tool was first developed in English and then translated into the local language Marathi. A 3-day intensive training program was organized for 14 interviewers. A team of interviewers always included both a man and a woman. The interviews were conducted in privacy in the local (Marathi) language.
The main issue examined was whether a mobile helpline would improve people’s awareness of reversible contraceptive methods, and as a result of this would the use of such methods increase? The awareness of reversible contraception was operationalized by the question:
The proportion of responses, other than female sterilization, was taken as a measure of awareness of reversible methods among the respondents. The respondents were also asked to give a list of all other contraceptive methods that they knew without being prompted. To examine the contraceptive prevalence and use of reversible methods, the respondent was first asked if she or he was currently doing anything to prevent or postpone her, or his wife’s, next pregnancy and then what they were currently doing to prevent it. The responses were coded as reversible methods (condom, oral contraceptive pills, IUCDs, and injectable contraceptives), permanent methods (female and male sterilization), and other methods (eg, withdrawal, abstinence, and herbs).
The intervention’s potential influence on the use of contraception based on the level of knowledge on contraceptive methods and SRH, access to contraception, and acceptability of mHealth support for SRH, were analyzed. The effect of intervention was estimated using logistic regression, adjusted for gender, by calculating robust standard errors to take into account clustering of individuals by the area (intervention or control). In each regression model, the effect of intervention was estimated by including a term for interaction between the intervention area and the period before and after the intervention. The exponent of the regression coefficient of the interaction term corresponding to the period after the intervention, along with the 95% CI, is reported here. The odds ratio for the control village multiplied by this exponent gives the odds ratio for the intervention village. The difference between the proportions after and before for each area is also reported. All analyses were performed with the statistical environment R (a free software environment supported by the R Foundation for Statistical Computing) [
The study was conducted in accordance with the Declaration of Helsinki of 1975, as revised in 2000, as well as with all applicable legal regulations governing data collection in India. The data did not contain any biological specimens but instead consisted of data on individual experiences, practices, attitudes, and knowledge, in addition to personal socioeconomic and demographic information. Informed consent was obtained in writing from every study subject after the nature and possible consequences of the study were explained. Participation was voluntary. All respondents were married. In the event of a respondent being below 18 years of age, consent was taken from a parent or spouse to include the underaged respondent in the study, with complete details of the study given to them, in addition to reading out the verbal consent form to the respondent.
The study was implemented in relation to the activities of two local NGOs [
Descriptive characteristics (source: baseline and follow-up surveys in two public health center areas in Maharashtra).
Characteristics | Intervention area | Control area | ||
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Women | 103 | 100 |
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Men | 102 | 100 |
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Total | 205 | 200 |
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Women | 90 | 101 |
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Men | 88 | 101 |
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Total | 178 | 202 |
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Women | 26 (24-30) | 26 (22-30) | |
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Men | 29 (26-34) | 29 (26-33) | |
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Women | 27 (25-31) | 27 (23-31) | |
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Men | 30 (27-35) | 30 (27-34) | |
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Women | 19 (13-28) | 18 (14-30) | |
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Men | 22 (17-30) | 21 (16-29) | |
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Women | 19 (15-28) | 18 (12-28) | |
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Men | 23 (17-30) | 22 (18-29) | |
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Womenb | 87 (84.4) | 76 (74.5) | |
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Menb | 86 (84.3) | 90 (90.0) | |
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Scheduled tribes and scheduled castes | 132 (64.3) | 150 (75.4) | |
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Other backward classes | 45 (22.0) | 34 (17.1) | |
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Women | 87 (84.5) | 93 (93.0) | |
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Menc | 81 (79.4) | 86 (86.0) |
aAble to both read and write, according to own statement.
bInformation collected in baseline survey only.
cHaving at least one mobile phone in household.
A total of 405 married men and women aged 15 to 35 years participated in the baseline survey before the intervention, of which 200 were from the control area. Gender-wise distributions are presented in
The median age of men and women was 29 and 26 years, respectively, in both areas before the intervention. It was 30 and 27 years, respectively, during the follow-up survey (detailed descriptive tables are available in [
In both areas, the caste composition was characterized by a high proportion of socially disadvantaged populations. Both areas have atypically high proportions of tribal populations, and in the Thane district, the intervention area, the proportion is even higher than in Nashik. Scheduled caste (formerly called the untouchables) and scheduled tribe populations are the most disadvantaged social categories in India and their combined proportion was 64.3% (132/205) in the intervention area, and 75.4% (150/199) in the control area. In both areas, the main occupation was farming and unskilled labor. A majority of the respondents in both areas reported having access to a mobile phone, with only 21.6% (21/102) of men and 15.5% (16/103) of women reporting not having a mobile phone in the household in the intervention area, and even less in the control area, with 14.0% (14/100) of men and 7.0% (7/100) of women reporting similarly. The difference between the proportion of men (
The summary statistics of the survey responses (n [%] for men, women, and all) are provided in
Knowledge on contraceptive methods and sexual and reproductive health, access to contraception, and acceptability of mobile health support for sexual and reproductive health by study areas before and after the intervention (source: baseline and follow-up surveys, two primary health care areas in Maharashtra).
Outcome | Intervention area, n (%) | Control area, n (%) | |||
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Before | After | Before | After | |
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Men | 49 (48.0) | 76 (86.4) | 46 (46.0) | 85 (84.2) |
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Women | 72 (69.9) | 59 (65.6) | 72 (72.0) | 75 (78.9) |
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All | 121 (59.0) | 135 (75.8) | 118 (59.0) | 160 (81.6) |
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Men | 3 (6.1) | 16 (18.6) | 2 (4.8) | 2 (2.2) |
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Women | 3 (4.2) | 43 (47.8) | 0 (0.0) | 0 (0.0) |
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All | 6 (5.0) | 59 (33.5) | 2 (1.7) | 2 (1.2) |
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Men | 28 (59.6) | 5 (6.8) | 24 (52.2) | 38 (46.3) |
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Women | 22 (32.4) | 14 (21.9) | 43 (67.2) | 36 (48.0) |
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All | 49 (42.6) | 19 (13.8) | 67 (60.9) | 74 (47.1) |
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Men | 30 (29.4) | 54 (61.4) | 54 (54.0) | 25 (24.8) |
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Women | 59 (57.3) | 37 (41.1) | 69 (69.0) | 55 (57.9) |
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All | 89 (43.4) | 91 (51.1) | 123 (61.5) | 80 (40.8) |
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Men | 8 (26.7) | 22 (40.7) | 15 (27.8) | 14 (56.0) |
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Women | 14 (23.7) | 17 (45.9) | 26 (37.7) | 14 (25.5) |
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All | 22 (24.7) | 39 (42.9) | 41 (33.3) | 28 (35.0) |
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Men | 44 (56.4) | 88 (100.0) | 84 (95.5) | 88 (91.7) |
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Women | 100 (100.0) | 86 (95.6) | 75 (81.2) | 88 (94.7) |
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All | 144 (80.9) | 174 (97.8) | 159 (88.3) | 176 (93.1) |
aNGO: nongovernmental organization.
bFirst contraceptive method that comes to mind is a reversible method.
cUsing some method other than sterilization, that is, a reversible method.
dWilling to call a male or female health worker to anonymously ask about sexual problems.
The general level of awareness of reversible contraception, shown by the first contraceptive method that came to respondents’ mind being a reversible method, neither improved in the intervention area nor in the control area. On the contrary, fewer respondents in both areas mentioned a reversible method as the first method that came to their mind (decrease of 29% in the intervention area vs decrease of 14% in the control area). This means that, in the follow-up survey in both areas, it had become more common to mention female sterilization as the first method that came to mind. In the intervention area, the acceptability of contacting a helpline for SRH needs rose by 17% compared with the control area’s increase of 5%.
Odds ratios (95% CIs) for interaction between intervention area and period after intervention and mean change for intervention versus control area on knowledge and practice of sexual and reproductive health (source: baseline and follow-up surveys, two primary health center areas in Maharashtra).
Outcome | Odds ratio (95% CI) | Change (after and before), intervention versus control area |
Has heard of any contraception method | 0.85 (0.844-0.855) | 20 versus 23 |
Has heard of contraception method from NGOa | 14.203 (13.265-15.208) | 29 versus −1 |
Reversible method first mentionedb | 0.363 (0.36-0.366) | −29 versus −14 |
Uses contraception now | 3.207 (3.037-3.388) | 8 versus −21 |
Using reversible methodc | 2.053 (1.856-2.271) | 18 versus 2 |
Willing to call sexual health helplined | 6.038 (4.7-7.759) | 17 versus 5 |
aNGO: nongovernmental organization.
bThe first contraceptive method that comes to mind is a reversible method.
cUsing method of contraception other than sterilization or traditional method, that is, a reversible method.
dWilling to call a male or female health worker to ask anonymously about sexual problems.
In the intervention area, 274 individuals aged between 15 and 52 years made a total of 964 calls to the mobile helpline on issues pertaining to SRH. This meant that repeat calls averaged around 3.5 calls per client. The typical questions dealt with were as follows:
Information about family planning and contraceptive methods (their contraindications and side effects if any) and access to services (where, how far, and what cost): 31.0% (85/274) of calls.
Sexual health issues such as itching in genitals, concerns regarding masturbation, wet dreams, condoms access, and use: 43.0% (118/274) of calls.
Issues pertaining to maternal and child health (vaccination schedules, nutrition-related questions, and other related matters): 13.1% (36/274) of calls.
Menstrual health and hygiene: 13.1% (36/274) of calls.
Questions on masturbation, condoms, and symptoms in genitals were mainly from men, and questions on menstrual hygiene were from adolescent girls. Questions on family planning and other contraceptive methods, other than condoms, came mainly from married women.
Both the current use of contraception and the use of reversible contraception have increased in the intervention area compared with the control area. Contraceptive knowledge increased in both areas, whereas fewer people first mentioned a reversible method in the follow-up survey than in the baseline survey, in both areas. Thus, the study suggests that the mobile helpline has had a bearing on the practice of contraception, whereas there is less evidence of effect on knowledge.
This apparent lack of improvement in awareness of reversible contraceptives might relate partly to the measurement used for the awareness: whether the first method that came to a respondent’s mind was a reversible method. In India, the universal connotation of family planning is female sterilization, a permanent method, which might turn out to be slow to change. Other types of questions to measure awareness of reversible methods might have painted a different picture. Moreover, this growing awareness of female sterilization compared with reversible methods in the follow-up survey might reflect governmental health service campaigns for female sterilization which the health workers were discussing in the communities in the months just before the follow-up survey, leading to an influence on the answers in the survey.
The study found that contraceptive use (both reversible methods and sterilization combined) at the time of the survey increased in the intervention site whereas it fell in the control site. This decrease found in the control area is rather unusual and needs further examination. In addition, the latest National Family Health Survey [
In both the intervention and in the control areas, NGOs working with issues related to SRH were present along with the standard local governmental services. The two NGOs provide basic information and services related to maternal and reproductive health to the relatively underprivileged populations of the two areas. The main difference between the two areas was the presence and promotion of a mobile helpline on SRH only existing in the intervention area. The results show that the intervention building upon a mobile helpline on SRH was associated with the increased use of reversible contraception compared with the control area. Although awareness of family planning generally strengthened, the awareness of reversible methods did not increase in the intervention area more than in the control area. This would imply that the governmental services and information channels have increased local people’s awareness on female sterilization in both areas.
A review of studies dealing with the impact of interventions that aim at influencing knowledge, attitudes, beliefs, and discussions regarding family planning and in increasing contraceptive use found that impacts are often a result of programs that have considered the importance of varied approaches to reaching women and couples [
The helpline received acceptance in the intervention area so that a 17–percentage point rise in the acceptability of such service provided by an NGO in case of SRH problems was evident. Villagers and helpline customers had expressed their appreciation of the fact that they could call whenever it was a convenient time and place for them. Most rural families in the project area, as in much of India, share a phone so that it stays at home and many family members can use it [
A considerable proportion of the questions raised in the mobile helpline touched on sexuality and issues other than contraception. There is clearly a great need in the area to provide more general SRH services and information than only family planning services to the local population, as well as to men and adolescents. A comprehensive SRH approach works better than a narrow family planning approach in winning local people’s confidence, which is essential for sustainable results.
It was evident from the intervention that among rural, socioeconomically underprivileged populations, women and men have an unmet need for reversible family planning methods [
This study was a rare attempt to examine the outcome of an mHealth intervention by making use of a control area. However, the conclusions would have been stronger if the samples would have been larger and the time frame would have been longer. The outcome was assessed after only half a year after the end of the intervention, which makes it difficult to say much about the perseverance of the changes. Changes in perceptions take a longer time to emerge in a measurable form.
The apparent inconsistency in the intervention area findings, in that knowledge of reversible methods seems to have fallen but the use of reversible contraception nevertheless increased substantially, can point to the problems in the instrumentalization of knowledge on reversible methods. Relying on the first thing that comes to mind question may have rendered the study vulnerable to a government campaign on female sterilization. If another measure of knowledge on reversible contraception were used this apparent inconsistency might have disappeared. The study design was neither a true panel design (interviewing the same respondent both in the baseline and the follow-up surveys) nor purely a successive cross-sectional design. Of all the respondents in the follow-up survey in the intervention area, 85% had also been interviewed in the baseline, whereas this proportion was 50% in the control area, meaning that a larger proportion of respondents in the intervention than control area had been interviewed earlier. This unplanned asymmetry was an outcome of some unforeseen practical imperatives in the field study. However, this fact has had only a minor influence on the age range of the respondents that appears nearly similar in the follow-up survey in the two areas. We do not see any other logic behind how this partial asymmetry in study design would have significantly influenced the results of the logistic regression analysis. The intervention implemented in the study was a community-level intervention and not an individual-level intervention, as the entire villages were targeted by the intervention. This is the main reason why it does not make a difference if the baseline subjects differ from the postintervention subjects. We are interested in population-level changes, and these can be studied by having different subjects pre and postintervention.
intrauterine contraceptive device
mobile health
nongovernmental organization
primary health center
sexual and reproductive health
This study was funded by Kone Foundation’s generous support for which the authors present their gratitude. The authors thank two NGOs, U-Respect Foundation, Dr Arundhati Char and Ms Arti Kandala, Mumbai, Vachan and the team, and Nashik for their essential contribution in training and data collection and making the study possible. Special thanks are expressed to the field data collectors and office staff of the abovementioned NGOs that presented their invaluable contribution. The authors thank all the study participants who spared their time in answering to the surveys. The members of the Ethics Committee are thanked for evaluating the data collection procedures. They also thank Akranumero Ltd for providing a platform for storing the offline survey data.
SK was the main author and contributed to data analysis. MS was the principal investigator and contributed to the literature review. BJ contributed to data management and was responsible for creating a mobile app for the data collection. All authors participated in the designing of the study, content of research instruments, interpretation of results, and the writing process.
None declared.