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Had she lived in the United States, things might have turned out differently.

Weakened from anemia and multiple pregnancies, she might have made a phone call to the Planned Parenthood hotline to get a contraceptive method of her choice. If that method had failed, she might have gone back to Planned Parenthood or looked online at the provider list of the National Abortion Fund or joined the Auntie Network on Reddit, where helpful individuals (albeit unverified) offer lodging, food, even plane tickets to states where abortions are still possible.

As it happens, Sunita Devi (an assumed name) lives with her husband and four children in a single room in New Delhi, India. As she recounts to writer Sanskriti Talwar of Pari, Sunita learned of a government-endorsed injectable birth control method from her ASHA (Accredited Social Health Activist) and decided it was worth a try.

But at the community health center, the doctor pushed her to try a copper IUD, without giving her much time to decide. Afterwards, the side effects came quickly- excessive bleeding and discomfort, and a short while later, a lump in her stomach. She was pregnant again, with the IUD still inserted, doctors having turned down her many requests to remove it.

Her husband, who had been angry at learning about the IUD in the first place, told her to let whatever was meant to happen happen. But Sunita was certain another pregnancy would finish her. So she searched for facilities, the ASHA worker her only companion, till finally she found one willing to perform an abortion. Later, deprived of her original choice of contraception, she opted to get sterilized.

In her own words, her pregnancy was averted, but her dignity was lost.

We Have Many Digital Health Tools

If you work in global digital health or sexual and reproductive health, you might wonder how many other women like Sunita are out there. Upon finding out that there are likely many – 38% of married women in India get sterilized according to the latest National Family Health Survey data – you might also wonder how many digital health solutions are made for women in Sunita’s predicament.

At present, there are at least two types of digital health tools Sunita may have interacted with, directly or indirectly: direct-to-client tools such as chatbots, and job aids made for community health workers (CHWs).

When looking for examples of chatbots, from a variety of sources including a landscape review of sexual and reproductive health (SRHR) chatbots that Dimagi recently supported, we know that there are numerous chatbots with SRHR content created for LMICs. Many operate on channels like Facebook and WhatsApp, and are made for girls or women much younger than Sunita. Almost all center on telling the user what type of contraception is available to her, and where she might find it.

When looking for examples of community health worker applications, we can find numerous CommCare and other applications to help CHWs provide counseling messages for what types of contraception are available, then record, track and monitor the uptake of family planning methods.

But Sunita already knew the method she wanted. She knew where to get it. And she had the consistent support of her CHW, the ASHA worker. Despite all of that, Sunita was denied her method of choice by others with more power in the health system, then further denied the choice to have it removed.

Is there any digital health tool our sector has made that could have helped Sunita? I have yet to find one.

We Even Have Feminist Digital Health Tools

To be clear, the tools that already exist are valuable and important. The history of women’s health tells us as much. For centuries, from the time of Hippocrates, the health outcomes of women went ignored, their suffering attributed to hysteria, their symptoms unrecorded and unreported. And that we even know of this history is mostly thanks to literature from Western societies.

Then, at the turn of 21st century, along came technologies such as ODK, CommCare and others, that were used to record, track, and follow up on the health outcomes of women, that too in LMICs. Large international development organizations, small community-based organizations and a variety of actors in between used these tools to bring to light women’s health outcomes for governments, policy-makers and researchers. I’m admittedly biased, but from the lens of history, these might well prove to be some of the most feminist applications of technology.

So I don’t think the problem lies in a lack of intention to reach women like Sunita. I also don’t think the challenge lies in us not knowing that women like Sunita exist- even if we don’t know NFHS or similar data very well, our collaborators in the SRHR sector do.

Our Version of Feminism Is Not Global

I think the problem lies in how we want to see Sunita, as a woman of agency and autonomy. While we know that Sunita is not a fully empowered woman, too many of our solutions ignore this and presume she is. The content of so many chatbots (including a few I’ve helped make) appears to be geared specifically towards a girl or woman who is fully in control of her own life.

All she needs is a bit of information, the right information, and she is on her way. Similarly, the content and workflows of so many CommCare and other applications focused on family planning seem to assume that once a woman is talking to a healthcare provider, and the app is used to follow up with her, the process is complete, the goal achieved.

But Sunita’s story tells us that that is manifestly not the case. Her husband was angry when he found out about the birth control method. The doctors at the hospital refused to listen to her, time and time again. Had it not been for the help of her ASHA worker, she may have had to carry the pregnancy to term- against her will. She had to fight to exert every bit of bodily autonomy she could, every step of the way. Are the barriers Sunita faced any less real than the very real legal barriers to bodily autonomy women in the US now face?

Sunita is not yet the empowered, autonomous woman from an LMIC we so clearly want her to be. It might be necessary for us to stop presuming she is.  This may not sit well with our notions of feminism. But our feminism doesn’t match Sunita’s reality.

So where do we go from here?

How to Change Solutions for Women’s Lived Reality

1. We must expand our notion of human-centered design (HCD) to prioritize a DEI perspective

I worry that when we frame our discussions in the context of HCD, we are missing the much larger elephant in the room: power. We talk about DEI in our organizations frequently, we attend training sessions where we consider who has power and who doesn’t, yet why does this conversation not extend to how we design solutions?

The lack of power was Sunita’s chief impediment to accessing healthcare- it was not a lack of knowledge, nor was it the absence of a supportive CHW. If we design solutions that don’t take into account Sunita’s lack of power and address it head on, then what problem are we trying to solve?

2. We must expand our notion of feminism to incorporate an intersectional approach

If we focus all our efforts on designing solutions for Sunita alone, we aren’t going to help her. Her challenges stem from living in a home and a system where she doesn’t have as much autonomy as we’d wish for her to have. So we must seek different ways to reach her.

• Can we design chatbots for her husband to introduce him to the advantages of contraceptive methods, and to frame them in the context of his life, his financial and other realities?
• Can we design a game that helps Sunita and her husband engage in a fun, lighthearted way, that also nudges them to discuss what they want their family to look like?
• What about designing CommCare applications with role-play techniques for CHWs to help them practice having conversations with health providers, so that the ASHA in Sunita’s case could better advocate for her within the health system?

Spending resources on anyone other than Sunita might go against our feminist principles. But if our intent is to clear the path for Sunita to exert control over her own body, can we not put our principles aside for her sake? Is that not intersectional feminism at its core?

3. We must expand on the outcomes we report to funders

Reporting on metrics such as the “% of women reached” or the “number of women users” of any given solution is necessary and valuable. But we have to ask ourselves, are these metrics sufficient? Say we had metrics like “number of men whose minds were changed with counseling via CommCare”. Or even “% of women who reported improving their ability to negotiate with a health provider by using a role-play chatbot”. Would that not have helped Sunita more? And even if we don’t find these metrics in predetermined reporting templates, could we not advocate for different metrics?

We Have Intention, Now Show Action

If you hear the urgency in my voice, it’s borne of deep optimism for this sector. We have all the technology, we have the resources, and most importantly, it’s so evident that we have the intention to reach women like Sunita.

It may be encouraging for us to recall that a hundred years ago, the world was engaged in -and eventually won-  a different battle of rights for women, the right to vote. But the Suffragettes of England didn’t cross the ocean to simply tell their American sisters that women could vote or where to find the polling booth. No, they wrote letters and newspaper articles, held protests and crossed oceans to show other women how to get the vote, how to advocate for themselves, how to break the barriers they faced.

A hundred years later, women across the world are facing yet another battle, this time the battle over their bodily rights. What if we adopted the same approach in global digital health?

I’m optimistic but I’m worried too. I worry about what will happen if we don’t change our approach. What if no-one else is designing with Sunita’s experience in mind?

By Gayatri Jayal who designs chatbots for healthcare in LMICs