Addressing Birth as a Process Instead of a Procedure: Our Q2 Research at AC4D

James Lewis, Meghan Corbett and Anna Krachey have been doing design research around pregnancy and child birth decisions over the last eight weeks at AC4D.

We became interested in doing research around pregnancy when we read about some surprising statistics in The New York Times. The United States has the highest cost in the world for both traditional, vaginal deliveries and cesarean sections. We have a low rate of the use of midwives and a high rate of C-Sections compared to many European countries. Yet, The US also has one of the highest rates of both infant and maternal death among industrialized nations. So, what is going on with pregnancy, labor and delivery in the US if it’s so expensive and the outcomes are not so great?

We did contextual inquiries with participants to learn about why there is this discrepancy in our birth procedures here in the US.  We talked to:

  • Expectant mothers
  • Public health workers
  • Mothers who had been pregnant as teens
  • A Doula
  • We visited a birth center
  • OB GYN office
  • Pregnant teens Social Workers

Our initial focus centered around how socioeconomics affect pregnancy and birth plan decisions, thinking that socioeconomics could be tied to access to information. As we dug deeper in our research, we realized that there is a pervasive sense of fear around birth in our culture, and we became very interested in how we could design to mitigate that.

After we talked to participants and took a million pictures and saw all of the pregnancy pillows and toy model pelvises in the entire world, we transcribed the interviews, and cut all of the statements into utterances (800 utterances, woah).  We slathered the wall with them, and got to work on synthesizing: separating utterances into categories and then making affinity groups (observations about human behavior) and then eating a whole bunch of peanut butter so that we could create some brain power to churn out INSIGHTS.  Insights are provocative statements that combine what we see in the research we’ve done with what we know as human beings with experience in the world.

Our over-arching take away from our research is that our culture sees birth as a scary, out of control thing that needs to be addressed as a procedure.  We’ve started to manage pain and fear instead of accepting that birth and labor is a hard and long completely do-able and natural process.  With that really heavy and provocative statement, we worked to refine and pare down our many insights into these three statements.

Insight #1: Taking care of a baby gives teen moms a sense of purpose and motivates them to take care of themselves.

By talking to a teen mother and a program administrator for pregnant teens, we were able to see a common trend that many teen moms seem to find a sense of purpose that they had been lacking up until that point.  We talked to Amy, a teen mother who moved to a new town and felt like she didn’t fit in with the students at her high school. Although she did very well in sports and was offered some scholarships, Amy told us that she didn’t feel compelled to take the SAT and go to college. Her lack of direction went unaddressed by her parents and she was basically left to her own devices.  Our research has pointed to sexual activity as a way many teens look to feel loved and supported. This was true for Amy who told us that she went through a very promiscuous period, trying to feel loved in the wrong ways. Amy thought her boyfriend was using protection when she got pregnant at 17.

As the reality of her situation sunk in, Amy made the decision to wait to tell her family and friends about the pregnancy. She knew that ultimately it was her responsibility to make the decision either way. Even though her family shamed her, she decided to keep the baby. She said “I [knew] this would give me a sense of purpose in that if I didn’t do anything else well, I knew I could be a good mom.”

Through our research we identified the second trimester through 6 weeks postpartum to be the critical period of time that this sense of purpose needs to realized. This is the time when childbirth gets strangely real for the teen and could lead to panic and further disconnection if they don’t get the support they need. Amy had a sense of direction, but her boyfriend walked out on her and she was forced to become a single teen mom. Rebecca, a program administrator for pregnant teens told us is that 80% of teen dads aren’t around after a year. This negatively affects the child and decreases the mother’s chance of overcoming a low-income potential.

One design idea we are considering is that soon-to-be teen fathers could be trained to be a “Daddy Doula” (birth coach) through a series of training videos and an on-demand doula skype service. Through this program, fathers would become informed of the physical and emotional challenges of birth that their partner endures and learn how they can best support and assist them during labor. Teen fathers would then be empowered to take an active, supportive role in the birth of their child. which would form a stronger connection between them. And teen mothers would feel supported through what could otherwise be a very overwhelming process.

Kim, a doula we spoke to supported this idea. She said “We give dads and partners lots of things to do, lots of little massage techniques and just encourage them to feel like they’re part of the process too because you need that support. No longer do dads have to just sit in the corner and hang out.”

This design idea was solidified by a recent conversation with our classmate Alex Wycoff. His wife had a baby just a few days ago and Alex mentioned that he felt empowered that he could actively advocate for his wife during labor because he had a sense of what the correct care should look like. This lead to his wife feeling more supported and less fearful that her pain would go unrecognized.

Our second insight addresses the fact that our birth culture in the US is not doing a good job accepting that birth and labor is a hard and long completely do-able and natural process and is instead focused on managing pain.   Mentally preparing and planning for the process of birth may mitigate the postpartum PTSD that seems to be happening because of this.

Insight #2: Birth plans and informed mothers act as preventive medicine against postpartum depression and trauma.

From talking to a doula about the mental game of birth, a mother who felt very prepared, and a mother who felt very out of control, we were able to begin to see how information and preparation really contributed to how in control a woman felt towards her birth experience.

When talking to Kim, the doula, she gave us a lot of perspective on what she considers some of the different “camps” of thinking around pregnancy, labor and delivery.  A lot of women’s birth plans ends up being “I trust my doctor.”, which is true, but they’re also so scared about the thought of a human exiting their body that they don’t actually even want to know what’s going to happen.  Those are the women that end up with birth trauma and feel totally bowled over by the process.  A lot of times new moms walk away from their birth experiences feeling like “what just happened?” Research is indicating that between 5% – 15% of postpartum depression is actually turning out to be PTSD (post traumatic stress disorder) from birth trauma and feeling out of control.  The media has constantly fed us images from popular films such as Knocked Up, in which the mother is screaming bloody murder, cursing the father, and seems completely terrified and out of control.  That’s what people think birth is.  People ask doulas all the time: is that what is going to happen to me?  Am I going to want to strangle the baby’s father during this process?  Kim has attended 65 births and has never experienced anyone laboring like that.  She says there’s just so much misconception around what birth experience is actually like.

Kim, a doula, shows us an educational video of a calm birth.

Tammy, pregnant with her second child, talked about feeling very prepared mentally and physically for a natural birth, and the response around her being very unsupportive and negative towards that decision. She designed her birth plan, which is a written record of what you would like to have happen during your birth process, to be an unmedicated vaginal birth.  She and her husband took a birth class where every couple went around and introduced themselves.  Tammy was last and was the only one to announce that she was planning a natural, unmedicated birth.  Everyone in the room looked at her like “wishful thinking.”  Her preparation later helped her deal with what ultimately wasn’t a great experience at the hospital, but her knowledge and commitment helped her stick to her natural birth plan.

Awareness and preparation empower women to better endure the physical and mental marathon of labor and delivery. It prepares them to handle the challenges that can occur. We are interested in designing in the area of mental and physical preparation and expectation of labor and delivery.

Our design idea around this is beginning to take shape.  The service of hiring a doula is not available to everyone and is often cost and circumstance prohibitive.   We are interested in a design that pervades mass media and begins to replace the negative images about birth that we have been fed through media.  Understanding that labor and delivery is an incredibly long and strenuous process, but one that the body is designed for, makes us believe that there could be some crossover in the way that one trains mentally for an endurance event like a marathon.   We propose an app concept that is pervades social media and provides visual stimulation and cues of peaceful, positive birth experiences.  There would also be a physical coach component that would provide manageable exercise that would facilitate connection with the body before the very intense process of labor occurs.  Both of these things would help mitigate fear and would promote confidence in birth.

Our third insight addresses the consequences that are happening because we address birth as a procedure.

The third insight from our research is that Hospitals and OBGYNs prioritize money and convenience over the patients well-being which leads to birth trauma and fear.

Consequently, alternative, more natural options have become unattainable because they are not covered by insurance.  We’re not saying OBGYNs don’t care about their patients or are just doing it for the money. What we do believe is that the medical system around labor and delivery incentivizes interventions like using pitocin, epidurals and c-sections. Birth becomes a procedure and women get lost in a mechanized system.

We think one of the ways to deal with that system is to make doulas regularly part of the process. Doulas not only act as coaches for women to deal with the physical and mental anguish women might experience during labor, but also as ambassadors. But when we spoke to Kim, an area Doula (birth coach), we heard that with all the expenses expectant parents have to deal with – Doulas are often left off the list.

Our design idea would be an online marketplace providing financing and business tools for Doulas and independent midwives. By getting the money out of the way, Doulas can focus on doing what they love. This would allow them to serve more clients and guide them through the labor and delivery process, as well as providing postpartum care. Adding more Doulas into the medical system could potentially decrease healthcare costs; for example by preventing unnecessary cesarean sections when vaginal delivery will do if a mother has assistance. When new parents have positive birth experiences and are able to process what is happening, they can be better caregivers for for their child.

Lily, who is expecting twins, launched a go fund me campaign to help with the piling costs of her pregnancy and delivery.

After 5 weeks of research, swimming through sense making of 800 utterances into 35 insights, we condensed those into 3 big rocks.  The statement that our culture sees birth as a scary, out of control thing that needs to be addressed as a procedure umbrellas our three primary insights. We have arrived at three spaces that we are interested in designing for and three concepts as initial solutions to these problem areas.

In the upcoming Quarter, we will be further understanding these spaces, choosing one idea, iterating on it much like we just did for 8 weeks with thermostats in Matt Franks’ rapid iteration class.  We will create a service blueprint to understand all of the moving parts of the idea and how they relate to each other as we did this quarter in Chris Risdon’s Service Design class.  We will apply all of these theories and methods that we have been learning to all of this research we have done to create a design idea that we are passionate about working on.  Totally what we signed up for.