During her fifth month of pregnancy, a young woman, without a smartphone that can download applications from an app store, received the following message: "Your baby now has regular periods of being awake and sleeping. You will notice more movements when your baby is awake."
The young woman couldn't afford books about pregnancy. She didn't know where to turn to for advice – the public healthcare system she was using only offered four antenatal visits during her entire pregnancy, and, as she was young and single, she wasn't comfortable discussing her pregnancy with older, more experienced people in the community.
The only internet access she had was through her feature phone, which is much cheaper than a smartphone, but costs more than a basic cellphone. Whereas a basic phone can only make phone calls and receive text messages, a feature phone can also access the internet and some instant messaging services, but not email and complex applications like smartphones.
Android or Apple apps can only be accessed using smartphones. As a result the young woman could not benefit from the apps that provide free health information.
She wasn't the only one. A report by Tomi Ahonen Consulting, an independent mobile strategy firm, estimates that 79% of South Africa's phones are not smartphones.
Wider access to free information
What the young woman's feature phone could do, however, was access the youth platform and free instant messaging service Mxit, which is used by over six million people across Africa.
She could sign up to Mxit Reach, an educational package offered on the Mxit platform with over one million subscribers, and access services such as Babyinfo, which provides subscribers with free basic day-to-day updates about their pregnancy through instant messages.
Through this, she was regularly updated with information about the stages of her pregnancy and tips such as: "If you are having trouble sleeping, try sleeping on your left side with a pillow between your legs."
All of the information was free. The only cost she had to cover was that of the internet connection on her phone.
"Babyinfo can be supplemented with other apps on Mxit Reach, such as the counselling apps, Angel and LoveLife [substance abuse and HIV counselling services respectively]. This is particularly helpful for mothers who may battle substance abuse, or have partners trying to overcome addiction," said Mxit Reach's Lea-Anne Moses-Magerman.
Over 100 mobile services in SA
Mxit Reach is not the only application on the market. Several other services, on Mxit and mobile sites, are available.
Hi4LIFE, for example, is a service, available through SMS, mobile websites and Mxit, that offers information about HIV. According to their website, hi4LIFE gives "South African women and their partners' access to up-to-date health information on HIV, pregnancy and baby health".
The initiative is co-ordinated by the organisation HIVSA with the financial support of the Elton John Aids Foundation.
According to a recent report by the Global Systems for Mobile Communications Association, a group of mobile operators and related companies devoted to supporting and standardising mobile phone systems, there are over 100 mobile health services, of varying sizes, focuses and quality, being offered in South Africa alone.
Mobile health, or mHealth, "refers to the use of mobile electronic devices and includes personal digital assistants (PDAs), mobile phones and smartphones for the practice of medical and public health," explained Maurice Mars from the University of Kwazulu-Natal's telehealth department.
Information crucial for teen moms
Access to information about their pregnancies is crucial for young mothers and can help to prevent complications or deaths, which are particularly high among younger pregnant women.
During a parliamentary briefing last year, Health Minister Aaron Motsoaledi said teenage girls account for 8% of South Africa's pregnancies. Yet 36% of maternal mortality cases (women dying during pregnancy, labour or within 42 days after having giving birth) occur among girls under 18.
One of the reasons for this figure is that many young women only access antenatal care – and therefore also life-saving information about their babies and themselves – well into their pregnancies.
"As soon as a woman knows she is pregnant she should go for a check-up but fewer than half of women go to the clinic before their 20th week of pregnancy [when it's sometimes too late to prevent complications]," said Nowinile Dube from the Anova Health Institute.
She said that this is often due to the misconception that if one is "not showing she is not pregnant enough".
Barbara Klugman, a maternal health expert from the University of Witwatersrand school of public health, said: "One part of this problem is that girls often don't know why it's useful to go to the clinic well in advance, but high-risk patients can be easily identified if they are assessed by a healthcare worker."
Klugman said that mHealth initiatives could contribute towards fulfilling the "information needs" of pregnant women, especially younger mothers, including accessing information that could help them to identify complications early, as well as about safe abortions and future contraception.
mHealth "holds promise"
At a mobile health conference last year, deputy director general at the health department Yogan Pillay said that mHealth "holds much promise" because of the high penetration of mobile technology in South Africa.
But he warned that "little is known about their efficacy or effectiveness". More research was needed so that developers would have a better understanding "of what works and why", he said.
In response, Moses-Magerman said Mxit Reach wants to expand its programmes and start an early childhood development application, which will be designed by occupational therapists and will aim to "incorporate daily activities that focus on providing support, education and inspiration for all caregivers".
An anonymous user on the application's public forum said: "[It] helped me so much. [I'm going] through a tough time [and] it helps me … if I have questions about pregnancy, I come here [and get my answers] … it helped me to know that I'm not the only one with problems." – Additional reporting by Amy Green
Koot Kotze is a fifth-year medical student at Stellenbosh University and was an intern at Bhekisisa in November 2013