Even as many US states move towards outlawing abortion, a Muslim-majority country is doing exactly the opposite. In Pakistan, a small army of women is being mobilized to improve access to safe abortion and other family planning services. Known as ‘lady health workers’, the women, mostly based in rural areas and urban slums, aim to put anyone seeking an abortion in touch with a doctor, using an app easily downloaded onto a smartphone.

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Pandemic disruptions

“This online system is our lifetime need,” says Sajida Zafar, a lady health worker in the village of Pind Begwal, near Islamabad, Pakistan’s capital. “It provides us knowledge, guides us on patient care and solves our patients’ health issues, whether it is abortion or family planning.”

Credit: IPAS Pakistan

Naureen Ikram, a 25-year-old woman from Bhara Kahu, a suburb of Islamabad, contacted a lady health worker last year, when she developed complications in the second month of her pregnancy. Using the app, the worker put her in touch with a doctor who advised her to get an ultrasound. Ikram then visited the doctor with the test result, and was prescribed an abortion medication. “The doctor explained the issue over the phone, and we were able to take immediate steps,” she recalls.

Pakistan, with a population of 230 million, already has a high abortion rate. According to the Guttmacher Institute, which conducts research into sexual and reproductive health, Pakistan had 43 abortions for every 1,000 women between 15 and 49 years old between 2015 and 2019. That is more than three times the rate in the USA.

Abortion is legal in Pakistan but only to save a woman’s life or to provide necessary treatment during early pregnancy. The decision is left to healthcare providers, who often refuse to carry out the procedure owing to the social stigma that still attaches to it. Abortion care is costly and thus out of reach for most poor women. As a result, many Pakistanis resort to unsafe and criminal abortions, that sometimes prove to be fatal.

The disruption in sexual and reproductive health services during the COVID-19 pandemic exacerbated the lack of access to care. “When COVID-19 happened, I went from being a busy clinician to being confined to my home,” says Azra Ahsan, a gynecologist and technical consultant to the National Committee for Maternal and Neonatal Health, a government advisory body. “My pregnant patients were calling me up in desperate situations when they were refused admission and attention in hospitals.”

Community telemedicine

Pakistan ranks 79th out of 100 countries on the Inclusive Internet Index 2022, which measures the ability of citizens to use the internet. Pakistani women, in particular, often lack access to modern technology, so it is not surprising that the shift to online health services has been slow. According to the Mobile Gender Gap Report 2022, published by the Global System for Mobile Communications, there is a 33% gender gap for smartphone ownership and a 38% gender gap for mobile internet use (see chart).

In 2020, IPAS Pakistan, a nonprofit organization that seeks to improve access to safe abortions and contraceptives, teamed up with Sehat Kahani, a local telehealth platform, to introduce a hybrid telemedicine and community model that offers free contraception, safe abortion and other gynecological services. Lady health workers are at the center of the initiative, acting as intermediaries to put women in touch with doctors online.

Launched in 1994 by then-prime-minister Benazir Bhutto, the lady health workers program equips women from local communities with at least 8 years of school education to deliver basic healthcare services to underserved populations. The women play a particularly important role in the fields of reproductive, maternal, newborn and child health.

“Unfortunately, in our society, a family will take special care of a pregnant animal, but they don’t look after a pregnant woman in the same manner,” says Ibrar Hussain, district coordinator for a government reproductive and child health program in the Chakwal district of Punjab province. “For this reason, the program focuses on the health needs of women and children under 5 years.”

Each lady health worker in Chakwal monitors about 10–12 families, visiting their homes regularly, screening for malnourished children and identifying pregnant women who may need medical advice or hospital attention. All the workers reserve one room in their own home, which locals call the ‘health house’, where they provide counseling to women in the community and conduct weekly meetings with community leaders.

The workers report to a lady health supervisor, who typically has a graduate degree and is either directly recruited or promoted after serving as a lady health worker. The supervisor oversees from 12 to 25 workers and reports to the district coordinator, the role played by Hussain in Chakwal.

For the hybrid community telemedicine model, IPAS works with the government to recruit lady health workers who already have smartphones. “In Chakwal, we have selected 35–36 workers, mostly from urban clusters. This is because internet connectivity and digital literacy is better there,” explains Hussain.

IPAS trains the workers on referral mechanisms, counseling, abortion law and follow-up protocols. Telehealth provider Sehat Kahani provides training on how to use the app. Doctors participating in the Sehat Kahani network also undergo training on abortion medication and post-abortion care. Any woman seeking an abortion can contact a trained lady health worker in her community, who then connects her to a doctor using the Sehat Kahani app.

Digital inclusion

“Sehat Kahani means ‘the story of health’,” says Sara Saeed Khurram, co-founder of the company and a former radiology specialist at Dow University of Health Science in Karachi. “My co-founder and I started the telehealth company for two reasons. First, to improve access to quality medical doctors, a service not easily available for more than half of our population. Second, to facilitate women doctors to start practicing medicine from their homes. This is crucial because while women comprise more than 80% of our health workforce, half of them do not work due to household responsibilities.”

Sehat Kahani runs three types of platform, each catering to a different segment of Pakistani society. One is a telehealth platform for low-income communities, where patients can visit a clinic and the nurse connects them to doctors online. The second is a helpline that enables patients to connect to doctors over the phone, in cases where they are unable to use the online platform. Finally, a mobile app is designed for urban smartphone users, where a patient can connect with a doctor directly. The mobile app is also used by lady health workers for the IPAS and Sehat Kahani initiative.

The company says it encrypts all personal information shared on the mobile app. “We are one of three companies in Pakistan that has conducted data breach audits and data security exercises by an ethical hacker company,” says Khurram. Consultations are not recorded, and the personal information management system is certified by the International Organization for Standardization (ISO).

Low bandwidth is an ongoing problem, but the district administration in Chakwal has been working with the provincial government to make internet services more easily available in rural areas. Today, every rural health center in Chakwal has an internet-enabled device, and every lady health worker has an Android phone. The administration has also collaborated with uPhone, a digital phone service, to provide the lady health workers with SIM cards containing a balance of 10 gigabytes.

If internet service is inadequate, a lady health worker can organize a phone consultation. After the consultation, she will often support the client by accompanying her to a local clinic for a surgical abortion or to a pharmacy for abortion medication. The health worker also does follow-up visits after an abortion procedure.

Trust and privacy

“Lady health workers have become the most trusted source of medical information in rural and poor areas,” says Ghulam Shabbir Awan, director of IPAS Pakistan. “They have given women the confidence to use online health services.”

For their part, the health workers say that the telehealth service has become indispensable to their work. “When doctors stopped seeing patients physically due to COVID-19, the app helped us connect with them virtually for abortion, contraception, sterilization and other services,” says Raheela Ajmal, a lady health worker in Pind Begwal, a village near Islamabad.

Nameeda Sabir, another lady health worker in the same village, expects that the online services will be needed long after the pandemic. “By minimizing the need to visit a clinic and paying doctors’ fees, the online system has helped in making abortion and other services less expensive for poor women,” says Sabir.

The telehealth service has not been without challenges. “While we are now able to consult doctors online, we still have to travel a long distance to purchase any medicine or visit a hospital. This is a problem,” says Ajmal, the health worker in Pind Begwal.

Hussain adds that “apart from problems with internet availability, lady health workers in my district have asked for some incentive, as using the app has increased their work burden.”

The community telemedicine model was initially put to the test in Islamabad and four districts in Punjab province, using a network of 22 doctors and 98 lady health workers. It has since expanded to six more districts across Punjab and Sindh encompassing about 50 doctors and 250 health workers.

Plans for expansion

IPAS and Sehat Kahani now aim to make the service available 24 hours a day, 7 days a week, introduce the English-language app to hundreds more lady health workers across the country, and expand its reach by adding Urdu and other local languages.

“As compared to physical visits to a clinic, the telehealth platform provides greater confidentiality,” says Awan. “Our latest data shows that women are confidently reaching out to tele-providers, not only for abortions but also other sexual reproductive health services, including antenatal, postnatal and pregnancy care.”

The IPAS and Sehat Kahani initiative is not the only example of the use of technology to improve access to sexual and reproductive health services in Pakistan. The Population Council, an international research and technical organization, and the National Committee for Maternal and Neonatal Health, a government advisory body, set up a phone helpline to connect women with gynecologists and obstetricians in tertiary hospitals during COVID-19.

“A telehealth service provides privacy. Healthcare facilities, especially public health facilities, are extremely crowded,” says Ahsan. “Women are shy and unable to talk about these things when there are other people around. In contrast, a telehealth service allows one-on-one interaction between doctors and patients.”

Ahsan says that telehealth services help maintain high standards among providers of medical services. “The difference between a licensed doctor and a quack is not very well understood in our communities,” she notes. “With telehealth services, women will be reaching out to qualified persons, and the advice that they receive will be evidence based.”

Yumna Usmani, a former consultant to the UN Development Program, sees vast potential for similar initiatives in other developing countries facing a digital divide. According to her, more governments should partner with telecom companies to provide free telehealth on their networks, or provide telehealth services at lower rates than their normal internet charges. “This can be implemented anywhere in low-income countries, especially in Africa where distances are long and people have to travel a lot,” she says.