Pakistani women are seeing working in a field on the eve of International Day of Rural Women on October 15, 2016 in Lahore. Image: Zaeem Awais/Canadian Press

Pregnant Women in Rural Pakistan Have an Unusual New Ally: Voicemail

Toronto hackers made a service that could save lives in rural Pakistan.

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Oct 26 2016, 1:00pm

Pakistani women are seeing working in a field on the eve of International Day of Rural Women on October 15, 2016 in Lahore. Image: Zaeem Awais/Canadian Press

Starting in January 2017, expectant mothers in rural Pakistan will be able to sign up for a voice message service that will give them simple healthcare tips over the course of their pregnancies, urging them to eat more iron, for example, or to get a certain vaccine.

This might sound ho-hum to people who live in the US and Canada, where many parents-to-be track every little aspect of their pregnancy through an array of gadgets and apps. But the picture is different in Pakistan, which has one of the highest infant mortality rates in the world—specifically, the highest rate of first-day deaths and stillbirths, at 40.6 per 1,000 births, according to a 2014 Save The Children report. Compare this to Canada, where approximately 2.5 per 1,000 births result in same-day deaths.

The Toronto natives behind this startup, which is called Ammi (the word translates to "mom" in Urdu), think that sharing a few simple tips could help. Women can opt in simply by providing their child's expected birth date. Using this information, the service will call the woman a few times a week with pre-recorded maternal healthcare tips, just one or two minutes long, in the form of a voice message. The service is available starting at pregnancy and ending one year after birth.

Ammi is the brainchild of Kamil Shafiq, 23, and Israa Nasir, 29, who were one of 15 teams from around the world at the Pakathon Global Finals held at the Aga Khan Museum in Toronto in November 2015. Pakathon Toronto is part of a global network, from New York to Islamabad, of people who hack for social good in their spare time. Shafiq and Nasir won the Toronto event.

"The idea is provide general health information to a population that wouldn't have access to it"

In September, the two moved to Lahore, Pakistan to work on Ammi for four months through the Invest2Innovate (I2I) Accelerator. They secured a grant for just over $16,000 CDN, through the UK Department for International Development, via I2I.

"The idea is provide general health information to a population that wouldn't have access to it," said Nasir.

Successful versions of this type of service already exist in other countries, according to Ammi's founders, but never took off in Pakistan. "Their content is not culturally sensitive. Our mission is to eradicate those cultural barriers," explained Shafiq, 23.

For example, a woman may receive a message describing body changes she can expect during the pregnancy, such as soreness in her breasts. However, the word "breasts" would be changed to "upper body" or more subtle language to suit a rural Pakistani audience.

Although many Pakistanis don't have reliable access to healthcare, 87 percent of households do have access to a cell phone, according to one 2012 report. Since there may be only one phone for a family, and not one for every individual woman, Ammi is being marketed as a family service. "The reality is that a man will likely see the messages first and pass on the information to his wife or family member," said Shafiq.

Israa Nasir. Image: Israa Nasir

Illiteracy is another hurdle, especially in rural areas. The total adult literacy rate in Pakistan is 80 percent for males between the ages of 15-24 and 67 percent for females percent for females in the same age range, according to UNESCO. That's why a voice message, as opposed to a text message, is vital to get the words across.

Although some aspects of the service may initially be free to the user, Ammi is not a charity. It is a business that hopes to generate revenue by charging users a small subscription-based fee. While the co-founders couldn't reveal to Motherboard exactly how much it will cost users, they are aiming for it to be around 0.15 CDN cents per month, or under $1 for the nine-month duration of pregnancy.

Another potential revenue stream is projected to come through data collection. "Over 60 percent of Pakistan is rural and, yet, there is very little data. If we have this giant list of phone numbers and locations, a lot of companies would be really interested in how to get products out to them, whether it's diapers or a low cost birthing kit," said Shafiq.

Consumers may have no idea their information is being used in this way.

Read More: A Pakistani Startup Is Trying to Banish Fake Prescription Drugs

The data can also help improve access to healthcare for communities that are typically overlooked. For example, it can help the government figure out where to open a hospital next. "Data can also help inform the healthcare infrastructure. There are a lot of folks who are outside the reach of a basic healthcare unit and that is something we will now know," said Nasir.

Kalsoom Lakhani, founder and CEO of I2I and a judge at the 2015 Pakathon Global Finals, said that Ammi's strength is that it is not "reinventing the wheel" but using an existing model and tailoring it to Pakistan. Another similar service, the Mobile Alliance for Maternal Action (MAMA), is a similar service delivers health messages to expecting mothers in developing countries through their mobile phones.

South African users receive pregnancy healthcare tips as well as advice for HIV-positive mothers

In fact, the information that Ammi plans to use is partially provided by MAMA. "The government of Punjab have come up with uniform guidelines about what information should be present and that is what would be available if you went into a hospital. We want to respect their guidelines and combine them with lots of different resources to create a comprehensive and relevant base of information for Pakistan," said Nasir.

MAMA has supported programs in Bangladesh, India, Nigeria and South Africa. The service has reached more than 7.5 million women and families with healthcare information. Collectively, the messages provided by MAMA are being used by more than 160 organizations in more than 54 countries, and they seem to be working. According to MAMA, the results have shown higher rates of exclusive breastfeeding, delivery in clinics and adherence to pre and post-natal care visits.

In South Africa, the service launched in 2013 and had amassed 500,000 users in two years. South African users receive pregnancy healthcare tips as well as advice for HIV-positive mothers, since over 40 percent of maternal deaths in the country are HIV and AIDS-related.

Another service, Zero Mothers Die, provides small cell phones to women in Ghana, Gabon, Mali, Nigeria and Zambia. The phones are free and allow women to receive SMS text messages with information about healthy pregnancy. The phones also come preloaded with calling minutes, free to use, to allow for calls to local healthcare providers in case of emergency.

The business model for Ammi has been tried and tested in many other countries. Its success in Pakistan will depend on the government, telecom companies, and healthcare providers working together, to the benefit of women and kids.

Correction: An earlier version of this piece mistakenly said that Pakistan has the highest infant mortality rate in the world. The piece has been updated.

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