In 2013, a service design team took on the challenge to develop a set of innovative tools to increase the demand and provision of quality maternity care at time of birth in facilities in Uganda and Nigeria. We started with a blank sheet of paper: using service design, any solution could be possible, as long as it would be rooted in needs of and co-designed together with women and their care providers.
In service design, we are interested in the complex interplay between people, places and products and how their relationships and interactions influence how a service is delivered and experienced. Services are the manifestation of a series of interactions between in a service provider and a service consumer, in our case healthcare providers and women in labour. We wanted to look at maternity care in Uganda and Nigeria through this lens of delivering and experiencing and better understand the perceptions and expectations which are shaped before, during and after the moment of giving birth and how these are related to quality of care.
During the design research and co-design activities ,we conducted with over 90 maternity service users, providers and stakeholders (i.e. pregnant women and new mothers, their husbands, mothers and mothers in laws, religious leaders, community health workers and TBAs, doctors, nurses and midwives), we identified many barriers for women to first demand and then receive quality of care, many of which are well known and well researched by the global health community: Lack of money, access to transport, knowledge, religious myths and beliefs, delay in decision making and power, disrespect and abuse to name a few. So what could a team of service designers possibly bring new?
Here are three moments from our journey of co-designing with healthcare providers and women:
Sometimes a picture needs a new frame to get seen
Instead of writing up our findings from the interviews and interactions with service providers and users, as designers we created visual narratives that would illustrate our key insights into a story-based format rather than a research report. We used metaphors and visual language to illustrate difficult topics and showcase how barriers of access to quality of care are interconnected.
When we met with health care providers and facility managers to share our findings and get buy in for our design project in the health facility, we were nervous to present our visual findings with the team. The facility management and country MOH representative engaged lively in a dialogue adopting immediately our metaphors and narratives to discuss topics such as disrespect and abuse in the facility. Instead of focusing on problems in the way we laid out the insights, we mapped out the opportunities for design, therefore allowed an open and constructive discussion, which inspired the whole team to think more about solutions than problems. Facility representatives and local health authorities requested our document after the meeting for their own communication and advocacy purposes.
Facilitating providers and users of services to encounter in new ways
Using a service design approach meant to bring healthcare providers and women together to jointly identify the needs, gaps and opportunities around demand and provision of better quality at time of birth. Throughout the process, we would engage intensively with women and healthcare providers to identify opportunities for design and then quickly prototype solutions and iterate them until a working model was found.
As part of the co-design process, we brought midwives and mothers together for a workshop to prototype tools for communication. At first women and midwives were in separate groups both working on the same task: Design a board that will be attached to the bed of the laboring woman. What information do you want to see there? Women designed a board that would say: “I’m feeling cold” or “I need a hug”, whereas midwives would put the standard clinical data on the board. When we brought the both groups together and asked to present their boards to each other, both parties were surprised about the difference in results. One midwife told us afterwards: “I rarely get to think about what a woman needs in the rush our work. All of us being just here as the women we are without titles and uniforms and roles, helped us to open our eyes towards each other in new ways. We should practice this more often.”
Letting service users and providers discover their empathy for each other through design based exercises created a nurturing ground for change and the co-designed solutions embodied this shared experience of empathy.
Telling a story that women and their families can relate to
One of the key insights we discovered throughout this project was that in countries with a strong culture of story telling, there was no powerful story being told about giving birth in a facility. Instead there were too many stories about why not to go ANC or deliver in a facility. We thought, how can we use design and tools to create a more positive and encouraging story for facility based birth?
A story from the neighbor about her birth experience can influence how a pregnant woman prepares, plans and sets expectations for her own delivery. What if these stories are all negative? In service design, we aim to capture these so called touch points or moments when users come in touch with service experiences. We then design aim to design a consistent story across all these touch points to support the setting of expectations, assist in preparation, planning and communication.
In the case of maternity care services in Uganda and Nigeria, this meant to develop a consistent message and service experience for the woman and her family, which starts at home, gets emphasized at Antenatal Care and finally continues in the facility. The service that was co-designed with women and healthcare providers is called “Better Beginnings” and is a service experience containing with three key tools to better support the woman’s transition from one phase in her journey to another.
The “Pregnancy Purse” is a portable case to be used at home to provide relevant information for women and their families throughout pregnancy and childbirth. The “Birth Board” is a healthcare provider tool, which visually communicates labor and childbirth process to woman visiting antenatal care. The “Family Pass” is a set of wearable passes for the pregnant woman, her birth companion and the newborn to facilitate communication of preferences for options of care to healthcare providers. All three tools are not only visually connected but carry the same messages and information about how to stay healthy during pregnancy in a format that is easily understood and accessible also for low literate women. Preferences and expectations are set and managed through these tools and the moments when they are being used.
Better beginnings aims to tell a positive story to women about how to ensure a healthy pregnancy at those key moments: at home, at ANC and at the clinic.
Read the journal article A service concept and tools to improve maternal and newborn health in Nigeria and Uganda