Background

Nepal is one of the world’s least developed countries where problems related to transportation, lack of education, lack of proper healthcare services and cultural beliefs restrict access to healthcare services for many.

Although the government of Nepal has been working to provide better healthcare services, Nepal is still among the countries with the highest maternal and neonatal mortality rates in the world.

Postnatal care (PNC) is a critical period of maternal care, as serious and life threatening complications for mother and newborn can occur in this period. Despite this, less than 20% of new mothers in Nepal attend the three postnatal checkups recommended to be carried out within the first week after delivery.

Outcomes and objectives

The aim of the master thesis was to put service design methodology for the developing world into practice.

We intended to carry out a design project from inspiration to implementation that met the needs of users in their own cultural and geographical circumstances. The project goal developed into raising awareness and knowledge about the importance of PNC in an effort to increase the PNC checkup rate in rural areas of Nepal.

It was found that a lack of autonomy, education, access to services, economic issues and strong cultural traditions prevented women, specifically in rural areas, from utilizing healthcare services during the postnatal period.

The project resulted in highlighting the importance of proper postnatal healthcare by co-creating and designing a new health service for postnatal home visits for women who are not able to access a health facility for postnatal checkups. The service includes a protocol for the visits, as well as a flipchart and brochure with visualizations of important information for the postnatal period, with the intention of educating the new mother and her family.

Target market

New mothers in rural areas of Nepal and their families.

Process

The project is based on service design methodology, in a foreign setting, and focuses on understanding the people who are being designed for. Therefore it was important to utilize conjoining methodologies based around empathy, like humancentered design and ethnographic design research.

Both desk research and in-field research were used to gain a deep understanding of the overall maternal health situation of Nepal, and of the future users of the solution. Co-creation and participatory design have been utilized to develop the solution together with the users and stakeholders. In-field, we met with over 50 participants, both users and experts who have taken part in interviews, user testing and feedback.

Research

Before carrying out the field visit to Nepal, we conducted a thorough review of literature related to the history, geography, culture, socio-economic conditions, the status of women in society and the reach of the current healthcare system in Nepal.

It was also useful to uncover what has been done previously in relation to women’s maternal health both in Nepal and in other developing countries.

The two main research tools used in-field were observations and interviews. During our two months in Nepal, we used both non-participatory observations like shadowing, and participatory observations such as labour simulation in a local village health post.

Observations were very helpful during the research as they enabled us to verify what we had learned from secondary research as well as to gain deeper understanding through visual proofs and first-hand experience.

Several interviews with experts were conducted to gather further background information and contextual data about Nepal, as well as to learn from their knowledge and experience within the field of maternal health. With future users, we conducted both unstructured and semi-structured interviews with the help from a translator.

The user interviews were conducted in hospitals, slum areas and in a rural village. The interviewees were mostly young women who were pregnant or who had recently given birth. We also interviewed husbands and some of the family-in-law of the women.

Analysis

During our last days in Nepal, we conducted a co-creative workshop with a local NGO that we collaborated with, and made a user journey map using the 10-minute method. This was to gain an uncritical overview of all information gathered regarding maternity in Nepal.

The 10-minute map was the beginning of the analysis. We then made a larger and more thorough user journey map, where we separated actions, needs, experiences, challenges, possibilities, touchpoints and persons, and connected them all through background information.

Furthermore, we sorted our large number of notes and collated the collected data. We made a stakeholder map, a value level map and value proposition as well as a service model canvas. We then identified patterns and major challenges which, combined with setting criteria, lead to narrowing down our scope to the postnatal period.

Ideation

After deciding on a focus area, we began the ideation phase with ‘How Might We’ questions. These served as a guide to generate creative solutions to each of the eight challenges we had chosen to focus on. We then began developing ideas, first by using a method called Crazy Eights, which helped us form our initial ideas and start thinking creatively.

We also wanted a large bank of ideas to broaden our perspective for possible solutions to choose from. We then had converging and diverging iterations of idea generations, by bundling the ideas and creating new ones based on combined ideas. We also used dot voting weighing the ideas we thought were most relevant.

To get more inspiration, we explored existing solutions and conducted comparative solution mapping. This enabled an overview of what has been done and had worked for similar types of projects.

The final ideation round was done with ideation sheets, a tool used to articulate and specify ideas. They were used to flesh out the five ideas with the most votes from the dot-voting by specifying the same aspects of all of them.

A reality check was then done to figure out which of the ideas had more potential to be a success in reality, and create a basis for the decision of which of the five idea sheets to continue develop. It lead us to two final ideas that we, and the local NGO in Nepal we collaborated with, thought were promising concepts.

Finally, we found it necessary to also verify the concept with experts with different backgrounds and experience to make sure it was suitable in the Nepalese context, and worth continuing to develop.

Prototype and testing

After positive response from the experts we resolved to create a new health service for postnatal home visits, targeting the issue of new mothers not being able to go to a health facility for the recommended PNC checkups. The overall idea was for these postnatal home visits to be conducted by a health promoter shortly after a woman has given birth. During the visits, the health promoter would follow a protocol including what to check for, and what to ask the new mother and her family about.

Furthermore, the health promoter would have a flipchart to show visualized information on, for example, correct care practices, exercises to prevent pelvic complications such as uterine prolapse, etc.

After deciding on a concept, a physical prototype was created to clarify the idea, to better communicate it and get feedback for improvement. We began with quick sketching for what to include. Once a rapid prototype had been developed, we built on that with further information a new mother and her family need to know, and continued to conduct more research.

Once we had determined the topics to be included in the flipchart we collected visual representations of these. We looked for different types of visualizations including illustrations, drawings and real-life pictures. We brought these on the second trip to Nepal to use as the main tools for a co-designing session of the service and flipchart with health staff at a rural health post and with the NGO.

The first user testing was conducted in collaboration with a health promoter from the NGO in Tasarpu, a small village in the Dhading District of Nepal. The prototype from the co-designing session with the health staff consisted of pictures and
drawings that the health staff had chosen.

The health promoter conducted home visits with new mothers, showing the prototype flipchart and testing what worked well and what needed improvements. We also had the opportunity to test with a husband and other family members who were at home at the time of our visit.

We revised the user tests, got feedback from both the health promoter and a local health worker, and co-developed the changes before a new iteration started. We then had more co-creation and co-designing sessions and continuously based
the development on user and expert feedback.

Outputs and impact

Local health volunteers are familiar with the inhabitants of their village, and will know when someone is pregnant. Therefore, they can follow when a woman in the village has given birth and pass this information over to the health promoter. On the
third and seventh day after delivery, the health promoter goes to the new mother to conduct a postnatal home visit.

The health promoter has a protocol and a kit for the visit, starting with a health screening and private conversation with the new mother.

They then continue with a health screening of the newborn. Next, they have an information session using the flipchart to inform the new mother and her family about important things to be aware of in the postnatal period.

Before leaving, the family are provided with an information brochure with the most important information from the session to keep in their home. The health promoter then goes back to the health post to report from the visit.

Cause and effect

Less than 20% of new mothers in Nepal receive the three recommended PNC checkups, often due to being physically unable to reach a health facility. There is also a lack of knowledge regarding the importance of PNC checkups and the many complications that can occur in the postnatal period.

The postnatal home visit service meets these challenges by approaching the users where they are. It emphasizes the importance of PNC and aims to spread awareness about it.

The solution has been verified with several Nepalese experts in maternal health in rural areas. They have confirmed that there is a need for such a solution, and they believe it is a good solution that can make an impact and help many women.

Scale of impact

Although there are not any results of the service in use yet, we witnessed its positive effects during the user tests. New mothers who participated were observed to have taken on knowledge that they did not have before. The new father who also participated learned about correct newborn care, and how to be more supportive of his wife. This suggests that the results of the full service in production can be even more impactful.

For the service to be implemented, it requires funding and an organization to maintain it. The NGO we have collaborated with have worked with maternal health issues in Nepal for years, and are very happy to begin a pilot of the new service.

With sponsors from the university a number of copies of the flipchart will be printed along with the information brochures to provide to new mothers and their families, and with funding from a Norwegian design company, the service will soon be started.

The scale of the impact has the potential for a wider, national reach according to the Nepalese experts we have been in contact with and the NGO we have worked with. It was confirmed to us that, if it works in Tasarpu, the village where the solution has been developed, it can work in most other rural areas of the country, potentially about 75% of Nepal.

Wider impact, other stakeholders

On the 17th of May 2019, the project was presented at a symposium organized by our university, and ICIMOD International Centre for Integrated Mountain Development. The symposium concerned how universities in collaboration with other stakeholders can work on the UN Sustainability Goals. Among many guests, the Norwegian embassy in Nepal and the NGO we’ve worked with were invited.

Our professor organized an official handover of the materials we have developed to the NGO, and presented the project to the audience at the symposium. The NGO was also given the opportunity to present themselves, our collaboration and the developed service.

The Norwegian Embassy in Kathmandu will also be provided with a copy of the flipchart that they can promote if and when working with maternal health issues. The flipchart and service concept can therefore now be distributed and upscaled
without our involvement.

Did impact match initial objectives?

The initial objective was to use service design to improve one or more aspects of maternal healthcare for women in Nepal. With the developed new service of postnatal home visits, challenges that a large number of new mothers face in Nepal are being met with a solution that can improve not just one aspect but can empower and strengthen the new mother in the postnatal period, as well as targeting the surrounding family to spread awareness about women’s health.

Conclusion

This project is about taking a step in the right direction for improving PNC for Nepalese women. If it can be used in collaboration with NGO’s, government, campaigns, etc., it can make a difference. There are other existing incentives and
strategies for improving maternal health and for PNC. That being said, change requires a joint effort, repetition and time.

As one of the local experts we talked with said: “no one NGO or person can take credit for a society’s behavioral change, but together, over time, they can each make a small influence that can lead to a larger change, making a difference for many.”