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Every year, millions of women die from heart disease, stroke and complications of diabetes, with the greatest number of deaths occurring in low-resource settings, such as parts of rural India. Dr Jane Hirst and Dr D Praveen lead the SMARThealth Pregnancy programme, which aims to help community health workers identify women at risk and manage their healthcare in order to reduce premature deaths

Our department includes The George Institute for Global Health UK (TGI). They seek to challenge the status quo in healthcare to find the best ways to prevent and treat non-communicable diseases (NCDs) and injury, and to influence policy and practice worldwide. A recent project is SmartHealth Pregnancy - a tablet-based clinical decision support system in antenatal and postnatal care for use by rural healthcare workers in India.

Identifying women at risk                   

Both type 2 diabetes and high blood pressure are directly linked to heart disease, but many women in rural India are unaware of this and never seek treatment.

Some of those at greatest risk are women who develop diabetes and high blood pressure during pregnancy. Women with high blood pressure in pregnancy are up to four times more likely to develop long-term high blood pressure. Women who have diabetes in pregnancy are seven times more likely to develop type 2 diabetes; up to 75% of Indian women with diabetes in pregnancy will develop high blood-sugar levels or type 2 diabetes within five years of giving birth.

Although these are well-known complications of pregnancy, women in rural India who experience them may not always be identified, due to a lack of access to healthcare, shortages of health workers, and uneven health services in rural communities. This means women at risk are unable to access postnatal preventive therapies or make positive lifestyle changes.

Using smartphone technology

Antenatal care presents an opportunity to engage with women who might otherwise fall through the gaps; check whether they have conditions such as diabetes and high blood pressure, which may put them at increased risk of developing heart disease, stroke and diabetes in future; and put in place measures that can help prevent this. The George Institute in India and Oxford is developing a smartphone-based system to help community health workers do just that.

Mobile technologies have the potential to revolutionise the delivery of essential healthcare, especially in rural populations where the majority of antenatal and postnatal care is delivered by low-skilled, community health workers. The George Institute has developed SMARThealth: a low-cost, smartphone-based system that supports clinical decision-making and improves the screening, detection and management of adults with chronic diseases in India.

With the participation of community health workers, The George Institute intends to adapt the SMARThealth system for antenatal and postnatal care, and train community healthcare workers and primary care doctors to use the new SMARThealth Pregnancy system. The institute will then evaluate the feasibility and acceptability of the platform to support frontline healthcare workers to identify and manage the care of pregnant women at high risk of future heart disease, stroke and diabetes, and ensure their life-long health.



Integrating care to promote life-long health

Recognising the importance of pregnancy as a key life stage for women’s health, and identifying and managing the risk factors for heart disease and stroke early, could help to reduce the complications associated with high blood pressure and diabetes during pregnancy, for both mothers and their babies. It could also reduce the number of women in rural India who go on to develop heart disease, stroke and diabetes after giving birth.

Traditionally, postnatal care has focused on reproductive health and care of the baby. A new, life-course approach to women’s health, which integrates the prevention of non-communicable diseases with existing maternal and primary healthcare, may reduce the transmission of disease risk from one generation to the next; lead to earlier and improved uptake of preventive treatment; and promote life-long health in women.

In time, SMARThealth Pregnancy could be scaled up within India, and implemented in many other countries which face similar healthcare challenges.

From 2019-2020, Dr Shobhana Nagraj led a pilot cluster randomised trial to assess feasibility and acceptability of SMART Health Pregnancy. The pilot study involved 4 primary health centres and 200 pregnant women in Andhra Pradesh and Haryana and demonstrated that this approach was acceptable for community health workers, primary care doctors and women. 

Between 2017-2021, funded by The Medical Research Council (UKRI), Dr Shobhana Nagraj has been completing her DPhil on the development and evaluation of a theory-informed complex intervention including mobile clinical decision support (SMARThealth Pregnancy) for community health workers in rural India to provide integrated care for high-risk pregnant women across pregnancy and the postpartum period in rural India. This work, conducted together with the George Institute UK and India, has built upon their existing SMARThealth system.  Between 2019-2020, Dr Nagraj was the project lead for a pilot cluster randomised trial of SMARThealth Pregnancy in two diverse districts of rural India, involving 200 pregnant women

The next phase of this research, supported by UKRI and led by Dr Jane Hirst, is a large 4-year cluster randomised trial that will begin in 2021. We aim to answer the question of whether a SMART Health Pregnancy approach can reduce women’s cardiometabolic risk in the years after birth.

Our team

Selected publications

Related research themes