DESIGN IN ACTION:

HUMAN-CENTERED DESIGN FOR MATERNAL, NEONATAL, AND CHILD HEALTH ADAPTATIONS.

BACKGROUND

Motherhood is one of the most important life goals for many, if not all, married adolescent girls reached through Smart Start. On average, 10% of Smart Start clients are pregnant when they are mobilized, and access to maternal health services is critical to this portion of the intervention’s target population. Thus, the project recognizes the need to support them to access information and the agency needed to pursue healthy pregnancies. And, critically, to maintain continuity of care so that they can continue to act on their fertility preferences after birth.

The project intends to use Human Centered Design (HCD) to design an appropriate intervention to support married adolescent girls accessing the Smart Start intervention to pursue healthy pregnancies and utilize available maternal health services.

PROGRESS

Design Timeline

where we have been:

• Aligning on scope and design objectives.
• Getting appropriate human subjects research approvals.
• Exploring the lived experiences of adolescent girls along the MNCH continuum of care.

where we are going:

• Creating early solution designs based on the insights gathered on girls’ experience
• Testing these solutions for desirability in one or more rounds of rough prototyping.
• Pausing to reflect on the scope of these design and refine them.
• Test high fidelity designs for feasibility during a time of live prototyping.

In late 2021, a workshop (the Hard Problems Workshop) was conducted with a wide range of stakeholders to align on existing evidence, the context, and parameters of Smart Start’s current programming, as it relates to accommodating an MNCH adaptation. The workshop results led to the development of a design brief that articulates the prioritized problems and design objectives and serves as a guide throughout the design process. The overarching design objective for this HCD workstream is to adapt the current Smart Start intervention to support married adolescent girls with the knowledge, agency, and support they need to pursue healthy pregnancies.

THESE OBJECTIVES WERE DIVIDED INTO FOUR WORKSTREAMS:

While waiting for the protocol approval, the design team prepared to start insight gathering. In parallel, a design advisory group was established to guide the design team and provide feedback at critical stages of the design process. The group comprises MNCH experts from FMOH (the Maternal Health Team Leader and Technical Advisor), an MEL expert from the Ethiopian Midwives’ Association, a Gender Consultant from Kore Global, and the President of Partners in Expanding Health Quality and Access and Senior Technical Advisors from PSI Global. In addition, the wider A360 and RISE team members were consulted to provide their feedback and expertise.

INSIGHT GATHERING

On May 25, 2022, EPHI-IRB gave provisional approval to start data collection. Shortly after, an insight gathering was conducted in Ejersa Lafo district of the Oromia region.

In the insight-gathering phase, the A360 design team observed the lives of the target audiences and had a few interview sessions with them to understand their hopes and desires. This helped the team understand the challenges the target audience faces, and this deeper understanding sparked the inspiration for a new solution.

The insight gathering targeted a total of sixty-two participants, which included married adolescent girls (ages 15–24), husbands, mothers and mothers-in-law, community leaders, and health workers. Alongside traditional research methods, A360 used a Human-Centered Design approach. After the insight gathering, the Addis-based staff and the IDEO team collaborated to identify critical insights on a girl’s journey across the MNCH continuum of care.

THE KEY INSIGHTS IDENTIFIED WERE:

1. Limited planning among couples before pregnancy: Married adolescent girls see having a child as a way of solidifying their status in their household, influenced by societal pressure to prove fertility and their husband›s desire to secure the marriage. Couples are thinking about the end goal (having a child) rather than the process to get there (pregnancy and birth). Therefore, planning for the process is limited.

“Prenatal planning is not common…There is no planning except maybe educated people in our area. There is no discussion unless a couple is having trouble conceiving.”– Community member.

“She has to come for vaccination [ANC] so her child is safe. She must prepare the money, soap, cereals… she will prepare this after she finds out she is pregnant.”– Girl.

“After we got married, we talked about getting pregnant, having a baby, also discussed family planning, but I suggested we need to have the first one (first baby) so that we can prepare for the future.” — Husband.

2. Delayed confirmation & ANC attendance: There is a gap between when a married adolescent girl thinks she is pregnant and when she goes to confirm the pregnancy. Despite the girl’s, husband’s, and mothers’ separate suspicions about pregnancy, conversations about pregnancy do not start until there are physical indicators.

“I was afraid that my friends might talk behind my back, saying that I got pregnant as soon as I got married, went back to the clinic after a month to get vaccines [ANC care] and was fine after that, even the pain stopped.” — Girl

“At first, I did not hear about the pregnancy from her, just suspected from the symptoms such as nausea, just knew about it because I have seen it on people. I asked her, and she told me that she is pregnant.” — Husband.

3. Husbands’ knowledge and power: Husbands have the most power to decide on pregnancy and the care a girl receives. Though girls are involved in the discussion, husbands decide whether or not a girl seeks ANC and where she gives birth. A husband’s level of knowledge determines the amount of support a girl receives.

“Must trust the husband whether to give birth at home or at the clinic. Nowadays, it is not common to give birth at home, the husbands also suggest going to clinic, advise her not to stop checkups because HEWs advise them to. Even if he says no, she [the HEW] will not listen to him.” — Mother

“If we don’t consult the husband, he might get angry and may harm her, he may hit her on a bad place like her belly and cause harm.” — Girl

4. Mother’s & Mother-in-Law’s Influence: Mothers are also seen by girls as decision makers (jointly with husbands). Even though husbands still made the final decision, they often went to their mothers to understand what is expected and recommended. Though mothers-in-law did not participate in decision making, they were key sources of knowledge for husbands.

“Everyone might not be equal, but mothers are the ones to give most advice.” — Mother

“There are those that say that mothers used to give birth at home and use that as an excuse to keep a girl from going.” — Girl

5. Girls’ low knowledge & self-efficacy: Because pregnancy is seen as ‘normal,’ a girl’s concerns are disregarded, especially during her first pregnancy. Girls know they will not be taken seriously and do not feel empowered to seek care when they are pregnant unless they are encouraged by those with experience (sisters, friends, neighbors).

“Because they don’t have experience, if it’s their first child, they’ll be embarrassed, they won’t say anything.”– Girl

“I had pain on my left side. I did not do anything because I thought it would just go away.” She added, “There’s no one who will listen…because they’re not educated, they’ll tell me it’ll go away. “ — Girl

6. Partial picture of care needed during pregnancy: Girls and their influencers have limited understanding and clarity on the breadth of care needed and related health outcomes during pregnancy, including ANC.

“Since it’s said that if she doesn’t get what she’s craving, the baby will have a birth mark, he [her husband] will search and bring her what she wants.” — WDA, Oromia

“If she comes for ANC (follow up) she will come for her child’s vaccinations. When she comes for vaccinations, she will be counselled on Family Planning. Because of that, some girls do not come [for ANC] …They think, “why are they counselling us like this.”. Because they want to have children, they think, “this isn’t her [HEW’s] business.“ — Girl, Oromia

7. Feeling left out: Husbands and mothers are reluctant to support girl’s access to ANC and safe delivery services because they feel like outsiders in the delivery process and during ANC.

“We don’t usually think or feel like we’re needed when we go there, sometimes the doctors don’t even talk to us, we just sit there, we don’t feel like we’re needed there.” — Husband

“It’ll be better if she goes with me. I will not worry about where she has been and suspect her. I can see what she’s doing if we’re together.” — Husband

8. Importance of nutrition: ‘A balanced diet’/ nutrition is the one key aspect of pregnancy care that everyone agrees is important. But knowledge does not easily translate into action for girls who do not wish to be perceived as ‘selfish’ and couples who find a balanced diet ‘expensive’ or ‘inaccessible.

“A balanced diet — butter, beats, kale, tomatoes. eggs, milk, cheese, honey, chicken — if it is found, meaning if we can afford it. “– Girl, Oromia

“There are some customary practices that harm girls when they are pregnant. For instance, the girls do not eat when their husbands are away regardless of how long it has been and how hungry they are. They can go for long periods of time feeling hungry and that hurts their health in the long run” — HEW

9. Distance Of service: long distance to health facilities is a barrier both during ANC and delivery, so much so that sometimes Health Providers tell girls to prepare for a home birth.

“Since the clinic is far away, I gave birth at home.” — Girl

“The mother needs to get ready before giving birth, minimum need to prepare baby clothes, food…atemit (cereals), razor, clean clothes in case she gives birth at home or on the road. Red bathing equipment, prepare warm water with salt to sanitize and in malaria areas, need nets.” — MNCH Expert

10. Fear of facility delivery: Rumors and misconceptions result in fear of facility deliveries. Girls think some form of surgery and social discomfort is inevitable.

“To give birth at the health facility is to be touched inappropriately.” — Girl

“Women might be afraid to go to health centers to give birth because they are afraid that the doctors use knives and stitches. So many are afraid to give birth for their first born at the clinic, afraid of surgeries.” — Girl

11. Rushed Postpartum Family Planning (PPFP): PPFP is not discussed during pregnancy. Some girls may feel ambushed and pressured by providers and husbands to take a method without understanding their options.

“They told me [about FP] right when I gave birth. When we got back home, we decided. He told me to choose and take whichever method I wanted.” Then she added “My husband spoke to the HEW on the phone and decided. He told me to go to the Health Post to get take a 5-year method. I did not understand the method options.” — Girl.

“He will make the decision for her. He could push her to take family planning, even if she does not want to.” – Husband.

These insights were categorized into themes, which allowed us to understand what parts of the girl’s journey we should address. The insights and key challenges have guided the design team to develop solutions, prototyping, and testing opportunities.

These opportunities were formulated as ‘How Might We’ (HMW) questions. ‘How Might We” (HMW) questions are small but mighty questions that allow us to reframe our insights into opportunity areas and provide viable solutions to the problems identified during the insight gathering phase. For this process, we rephrased the key challenges with statements beginning with the term “How Might We” and containing different challenges or opportunities to help direct us, anchor our idea generation, and guide our focus towards the right problems to tackle and spark inspiration.

SOME OF THE ‘HOW MIGHT WE’ / GUIDING QUESTIONS DEVELOPED WERE:

The team then used the above opportunities to generate multiple solutions, products, and services that could solve our target audience’s problems. We then prioritized our most viable ideas and proceeded to the prototyping phase.

PROTOTYPING AND TESTING

The prototypes are categorized into the following two concepts:

1. Sacrificial concepts are early, raw, potentially flawed concepts made visual/physical and used as a medium for creating a reaction, response, and discussion among users and design teams. They are helpful when we still have big questions about our target audience that typical interviews have not been able to answer.
2. Rough prototypes are quick mock-ups of ideas using simple assets and materials designed to explain an idea better and spark discussion on what does and does not work. Rough prototypes are great at the beginning of ideation, and prototyping, to help bring a concept to life and solicit rapid feedback.

The team is currently working on the below concepts for the upcoming prototype testing.

NEXT STEPS

As we move closer to prototyping, we have built out these ideas in more detail. For each concept, we strip the idea down to reveal the most basic assumption — what must be true for the concept to work. We are now in the process of developing six concepts and building sacrificial and rough prototypes that would allow us to test our assumptions with girls and their key influencers rapidly. In the following months, we hope to test these prototypes in Oromia and SNNPR, synthesize our learnings and start to refine them for live prototype testing. We will feature the results of the prototyping and testing in our next edition.