Digital Health for Migrant Mothers Network: Maternal Care in Dadaab Camps

Lead Research Organisation: Newcastle University
Department Name: Geography Politics and Sociology

Abstract

Our Network entitled 'Digital Health for Migrant Mothers' establishes an innovative collaboration between the UN, African and UK-based academics, industry (African-based VR company 'Black Rhino') and midwives to explore how digital tools can be used to enhance maternal care for refugees within camp environments.

The UN has noted that despite improving global trends, maternal and neonatal mortality rates remain disproportionately high for women living in humanitarian settings, such as refugee camps. A central component in this challenge is the lack of trained midwifes with Combating these pressing challenges facing women's maternal health care has been strategically identified as part of the SDGs (5 & 3). Our project builds upon previous GCRF-funded research ('Birthing at the Borders' PI Bagelman) and addresses these challenges in one of the worlds' largest and longest-standing refugee camps: Dadaab camps in Kenya which borders Somalia.

The Dadaab camps currently host over 400,000 refuges (40% of reproductive age) where maternal morbidity and mortality is notably high (Gee et al, 2019). Our project proposes an innovative Network bringing together a diverse but coherent team to co-design a digital health response to the urgent challenges facing migrant mothers in an environment of protracted displacement. Our project is collaborative in nature, employing agile participatory modes of research rather than imposing models from above. Given the urgent need for midwives to have a more empowered role in the digital provision and education of maternal care our project will develop an engaged Network to explore the possibilities of 'training up' midwives, enhancing their digital literacy through the design of digital 'teaching toolkits' for midwifery education supported by UN.

Despite significant international funding spent on reproductive health in Dadaab, maternal and neonatal death rates are disproportionately high as compared to other hardship areas in the region (Gee et al, 2019). Research demonstrates that this discrepancy is due to a systemic disconnect in maternal care within the camp: while most refugee women rely on midwives (as they perceived to provide emotional, culturally-sensitive support) there are only few trained midwives available (Bagelman et al, forthcoming. See CV). Despite the key role that midwives play in supporting refugees in pre to post-natal care, midwifery training remains under-resourced and designed on an ad-hoc basis. While significant resources are earmarked for promoting digital learning and training for biomedical practitioners, midwifery-led health education platforms remain under-supported (WHO, 2016). In particular, digital health tools remain inaccessible to most midwives. For instance, while Virtual Reality (VR) have been well-established within biomedical communities as a productive mechanism for learning and teaching, midwives have little access to such tools. This digital gap is problematic for two main reasons: 1) the absence of digital technology underprivileges women in their ability to provide care 2) and directly impinges upon refugee women in camps who rely - sometimes exclusively - on midwives in receiving care.

In sum, our Network places primacy on African digital expertise, is gendered in its approach and centres those often marginalised in digital debates to promote an innovative, and agile response in emergency camp geographies.

Reference: Gee, S., Vargas, J. and Foster, A.M., 2019. "exploring the role of sociocultural context and perceptions of care on maternal and newborn health among Somali refugees in UNHCR supported camps in Kenya". Conflict and health, 13(1), p.11.

Planned Impact

Our 'Digital Health for Migrant Mothers Network' is vital in developing long-lasting, innovative and interdisciplinary collaborations to advance digital health in emergency camp environments. Our Network brings together key scholars and practitioners with expertise across the intersecting themes: refugee geographies, maternal care, digitality, humanitarian care. Too often these experts remain siloed and our Network addresses this problem. Vitally our Network includes end-users (midwives) and key partners (UN) in all conversations. See detailed 'pathway to impact.'

As an outcome of our Network we seek to design a proposal (to be submitted for second round of funding) which offers a research-led solution (comprising of 3 innovation activities) that will positively impact the DAC regions of Kenya and Somalia. Establishing our GCRF supported Network is a critical first step in the pathway for meeting our key three impacts listed below:

1. Co-design the first midwife-led 'teaching toolkits:' Using VR (virtual reality) this Network will bring together the UN, industry (African-based VR company) academics, practitioners and midwives to produce key simulated scenarios in emergency environments to better equip incoming practitioners. Each of our networking meetings supports this design (see pathway to impact).

2. Integrate curricula into Kenyatta University's Dadaab Centre, which supports our Network (See Institutional Letter of Support). Building upon existing capacity of the Dadaab Centre, which provides refugee training, our Network will embed midwifery digital 'teaching toolkits' (by and targeted at refugee women) into midwifery training programs which will have double impact: a) provide refugee's transferable skills which will empower communities and enhance economic development within the region b) enhance community-based support for vitally needed midwifery care. At present there are no courses designed by refugee midwives, and no training which mobilises digital tools (such as VR). Our Network will have the impact of bringing the proven success of VR simulations (used widely across biomedical fields) to midwifery training - enabling trainee midwives to learn the particular challenges which occur on the ground in emergency contexts.

3. Embed curricula in Dadaab camp, to 'train-up' midwives. With our UN partners we will develop a plan to roll out the digital 'teaching toolkits' (comprising of VR simulations) in Dadaab camps - where there is a dearth of trained midwives providing essential service. These toolkits provide peer-to-peer learning: where midwives teach trainees.

It should be noted that an immediate impact of our Network will be that we enhance Somali refugee midwives' digital literacy. Such actors are often marginalised from digital learning. So too, this project positively impacts digital expertise already present in Africa by supporting and raising the profile of 'Black Rhino' (Nairobi-based VR partner working towards social justice in Africa). During our first proposed workshops we will also develop an element of peer-to-peer learning, employing an online knowledge share platform for midwives and trainee midwives. For this stage sharing will be focussed on Dadaab experiences, but in second stages will be extended to diverse emergency camp contexts.

As indicated my UN Secretariat Lisa Kurbiel (see Letter of Support) our Network is geared towards an urgent problem, and promises tangible positive impact. Kurbiel clearly summarizes the impact of our Network in the following way: "The project is sure to enhance the digital literacies of those who continue to be marginalized; moreover, this project will surely enhance the maternal care challenges we see riven across the global south."

Publications

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Bagelman J (2020) Birthing across borders: 'Contracting' reproductive geographies in Dialogues in Human Geography

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Schmid-Scott A (2020) Rural Geographies of Refugee Activism: The Expanding Spaces of Sanctuary in the UK in Revue européenne des migrations internationales

 
Title Birthing across Borders: maternal care in humanitarian contexts 
Description 12 minute Virtual Reality (VR) produced by Jen Bagelman with Black Rhino, refugee midwives and Indigenous midwives based in Dadaab. From the arid landscape of Dadaab, Kenya comes 'Birthing at the Borders,' an experience exploring questions of citizenship, displacement and birth. This VR engages these issues specifically as they pertain to Somali refugees living in Dadaab: one of the largest, and longest-standing camps in the world. This VR broaches intimate questions of reproductive health by following the daily lives of Indigenous midwives: women who are refugees themselves and who provide vital maternal care for other refugee women outside hospitals. The midwife (literally 'with woman' in Somali) stands alongside women during their birthing journeys, and holds critical insights into maternal care. This VR centres five Indigenous midwives who have - collectively - delivered thousands of babies. Relying on our team's established networks of trust with midwives, this VR takes audiences to an oft-overlooked geography: the intimate worlds of women giving birth in camps. Here midwives will explore the challenges of birth and reproductive health in emergency humanitarian context. The midwife-led stories in 'Birthing across Borders' are tinged with urgency, yet cast critically hopeful light on the informal maternal care the remains essential to displaced women. Relying on our team's established networks of trust with midwives, this VR takes audiences to an oft-overlooked geography: the intimate worlds of women giving birth in camps. Here midwives will explore the challenges of birth and reproductive health in emergency humanitarian context. They will explore creative forms of solidarities forged in and beyond the camps that are essential to the maternal health of refugee women. The midwife-led stories in 'Birthing across Borders' are tinged with urgency, yet cast critically hopeful light on the informal maternal care the remains essential to displaced women. 
Type Of Art Film/Video/Animation 
Year Produced 2021 
Impact This immersive storytelling experience (using VR) was powerfully used to create conversation across practitioners who do not often have an opportunity to engage: medical doctors, nurses, humanitarian workers and Indigenous refugee midwives. The VR led to (as evidenced by testimony gathered) 'deeper understanding' of the importance of Indigenous maternal care. It led to a series of conversations (audio, recorded) which were then embedded into the VR experience, and now used as a teaching tool in Kenyatta University's nursing program and UNHCR training 
URL https://www.youtube.com/watch?v=5ciY6DEaM5g&feature=youtu.be
 
Title Documenting Undocumented Motherhood 
Description This project uses a visual 'picture-book' to explore the challenges of birthing across borders. 
Type Of Art Creative Writing 
Year Produced 2021 
Impact This project which was featured in globally recognised outlet 'Briarpatch' (both online and physical production) led to media coverage (CBC) and contacts from migrant mothers, who we were able to sign-post for support. We are currently co-designing further visual picture books with these mothers, to create an entire curated collection for stage 2 of GCRF project. This is a vital analogue companion to our digital VR immersive story-telling exploration. Indeed, these analogue processes are part of the VR immersive storyboarding process that we developed - whereby mothers are given the opportunity to visually map out their experiences as a step towards rendering their stories in VR 
URL https://briarpatchmagazine.com/articles/view/baby-book-documenting-undocumented-motherhood
 
Description The most significant achievements of this award were
1) Training refugees living in Dadaab in VR technology: providing KU certification to these women who had minimal digital literacy at the start of our project
2) Enabling refugee women to produce their own VR immersive storytelling experience
3) Witnessing humanitarian workers (UN) and trainee midwives experience refugees' VR 'training toolkits' and documenting their learning experience at the SDG VR Festival
4) Developing a 'Handbook for VR in Humanitarian Contexts' to educate future users how to ensure more participatory, gender-inclusive methods for using VR in camps
5) Embedding refugee women's training toolkits into curricula at Kenyatta University

The objectives of our project were met
Exploitation Route 1) The findings will be taken forward in Stage 2 of the GCRF-UKRI call where we (Dr Bagelman, Dr Josephine) will co-lead a larger Refugee Maternal Health Network, addressing key SDG goals addressing maternal and neonatal morbidity, and the lack of training midwives in humanitarian contexts.

2) In the Stage 2 we will expand our refugee-led digital toolkits to 5 other emergency contexts. We have already developed these networks across East Africa, to 'scale-up' our refugee-led training toolkit

3) In our next stage we will be using VR but also expanding to mobilise other immersive storytelling tools, such as spatial audio.

4) Our findings from Stage 1 are already being used by: UN, Kenyatta University Nursing and Midwifery training programs
Sectors Creative Economy,Education,Healthcare

URL https://www.ncl.ac.uk/press/articles/latest/2021/02/refugeemidwives/?utm_source=twitter&utm_medium=social&utm_campaign=university-news-promotion&utm_content=refugeemidwives
 
Description Migrant Mothers: Digital Health network has produced three VR 'immersive storytelling' tools documenting refugee midwives and refugee mothers experiences in Dadaab refugee camps. This VR was selected by the UN Sustainability Development Goals (SDG) 'Global Change' festival, and featured in their speaker series. Here policy makers, humanitarian organizations commented reflected how this toolkit helped them better understand cultural challenges of providing care in camps - one of our primary goals. We produced a 'Humanitarian VR Handbook' which has been integrated into our UN partners' training protocols it has also been integrated into COL (Commonwealth of Learning) training package. Our VR has been integrated into Kenyatta University's nursing program, to train up future midwives.
First Year Of Impact 2020
Sector Creative Economy,Education,Healthcare
Impact Types Cultural,Societal,Economic,Policy & public services

 
Description UNHCR Training on Indigenous Midwifery in Humanitarian Contexts
Geographic Reach Africa 
Policy Influence Type Influenced training of practitioners or researchers
Impact Training program provided a unique pedagogical suite, demonstrating the role that Indigenous midwives play in maternal are for refugees in Dadaab. UNHCR participants had not experienced maternal care from the perspective of these providers. At the end of the session UN participants noted they had become more informed about the valued role that midwives play in providing care, and left with practical steps in terms of how to reach out, and integrate these informal practitioners into medical care for refugee women during their pre to post-natal journeys.
URL https://twitter.com/TMwoma/status/1336959059581427714
 
Description Impact Funds Autumn 2020 Call
Amount £4,500 (GBP)
Organisation Newcastle University 
Sector Academic/University
Country United Kingdom
Start 12/2020 
End 07/2021
 
Title Immersive Storytelling Studio 
Description Too often Virtual Reality (VR) is an exclusive technological tool, used only by those with elite technical training. We developed a research method to enable participants with basic digital literacy to design and produce their own VR as well as adapt and have agency in terms of deciding which tools are used in the first place. Our methods particularly empower women and girls as digital content creators and designers of immersive technologies. We developed tangible and often analogy tools for user-generated VR. Our research has found immersive tools are not often designed with users in mind, nor adequately designed for emergency educational environments. For this reason, we find immersive tools remain underutilised. Our aim was to centre refugee midwives - in particular - in the development of technological innovation in order for these tools to be more directly relevant. To achieve this goal, we developed a method that involves three stages. First: We begin by initially benchmarking existing digital literacy. This includes asking about basic technological skills, such as the use of a smart phone. Second: implement a participatory research process whereby participants experiment with and identify what does and does not serve them in the existing immersive toolkits. Here we would develop a 'user journey' flowchart, documenting their expectations and use of the tools. Third, we co-produce a technological innovation led by participants themselves to adapt the existing immersive tools. This final stage culminated in a user-generated 'Immersive Storytelling Studio' (including not only VR tools but also spatial audio podcasting which are user-oriented). This new Studio is portable, carefully curated set of tools and multi-lingual training kits designed with participants. The agile Studio will be rolled out in other emergency contexts, to enable participants to more effectively communicate their experience and become empowered as knowledge producers. Through this participatory process, this project especially places emphasis on girls as producers - not just consumers - of immersive digital tools. 
Type Of Material Improvements to research infrastructure 
Year Produced 2021 
Provided To Others? Yes  
Impact Commonwealth of Learning has embedded our method in their AV/VR teaching. 
URL https://twitter.com/DigitalMaternal/status/1358086889513906183/photo/1
 
Description Commonwealth of Learning: VR digital handbook for emergency contexts 
Organisation Commonwealth of Learning (COL)
Country Canada 
Sector Charity/Non Profit 
PI Contribution Developed the first handbook for emergency contexts in collaboration with pedagogical experts at Commonwealth of Learning (COL)
Collaborator Contribution COL provided clear guidance on pedagogy and distribute our handbook for emergency contexts
Impact VR Handbook for Humanitarian Contexts
Start Year 2020
 
Description Interactive Maternal Health Training with Ministry of Health 
Organisation Ministry of Health
Country Zambia 
Sector Public 
PI Contribution Our team at Migrant Mothers reached out to the Ministry of Health, inviting them to participate in a workshop to experience our 'immersive storytelling' tools (VR by refugee women). After participating, Ministry of Health (specifically Mrs. Chowa Tembo Kasengele, Chief Nursing Officer Adolescent Health and Principle Investigator at LAMRN Zambia Stillbirth Project Lead, Ministry of Health, Headquarters) suggested a unique partnership whereby our team Migrant Mother share our resource with trainee midwives through LAMRN: a network dedicated to improving maternal health outcomes in Africa through increasing evidence-based practice in midwifery. LAMRN aims to support midwifery research, information sharing, networking and training activities in six countries in the region namely, Kenya, Malawi, Tanzania, Uganda, Zambia and Zimbabwe.
Collaborator Contribution Ministry of Health and LAMRN provided Migrant Mothers with a large pool of trainee midwives through their network. They enabled our team's VR to have a direct audience, educating future midwives in the importance of Indigenous practices. This was vital to reaching one of our intended goals: producing inter-cultural dialogue on maternal care to enable more wholistic practice desired by refugee women,.
Impact This is a multi-disciplinary collaboration, bringing together Indigenous midwives (refugees) with medically trained midwives, doctors, and refugee women.
Start Year 2020
 
Description Scaling-up Digital Health Across East Africa 
Organisation University of Warwick
Country United Kingdom 
Sector Academic/University 
PI Contribution Professor Vicki Squire collaborated on the project, providing contacts for stage 2 of the project scaling up to South Sudan.
Collaborator Contribution Professor Vicki Squire brought her expertise in asylum/migration to connect with MSF and UNHCR contacts in relevant camp settings necessary for stage 2
Impact Multi-disciplinary: political science/international relations/geography
Start Year 2021
 
Description "Digital Innovation Spotlight Event" with Foreign Commonwealth & Development Office Feedback Meeting 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact During this 'Innovation Spotlight' event we provided a demo of our preliminary VR (virtual reality) produced in Dadaab with refugee midwives. Members from FCDO provided feedback on our VR experience. This engagement activity was vital for us to reshape the final production. FCDO had particular suggestions that the VR could also be used to document humanitarian workers, which we will plan to do in the future.
Year(s) Of Engagement Activity 2021
 
Description 'Birthing Across Borders' podcast episode 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This podcast was presented to over 100 maternal health care practitioners, globally. The podcast directly addresses issues of decolonising health care - particularly as it pertains to pre to postnatal care in humanitarian contexts. The podcast concluded with an 'engagement' activity where listeners were encouraged to ask direct questions via Twitter chat. This session provided an opportunity to provide participants with further information. One participant noted that the podcast and discussion 'opened their eyes to Indigenous forms of maternal care' and 'prepared them better for humanitarian maternal care' they - as a junior doctor - were preparing to endeavour through MSF.
Year(s) Of Engagement Activity 2021
URL https://twitter.com/SanyuSisters
 
Description Digital tools for health in emergency contexts with Migrant Mothers 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact In this session Dr Josephine Gitome (Kenyatta University) and Dr Jen Bagelman (Newcastle University) discussed their project which brings together academics and UNHCR with midwives in Dadaab refugee camps to explore how immersive tools (VR) can be used to enhance health outcomes. This session was attended by students interested in digital tools, global displacement, and global health. As well, this presentation was attended by the HCR institute - and foundational to building a partnership for the second stage of funding.
Year(s) Of Engagement Activity 2021
URL https://www.eventbrite.co.uk/e/digital-tools-for-health-in-emergency-contexts-with-migrant-mothers-t...
 
Description Migrant Mothers: Digital Health Conference 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact This workshop brought together key stakeholders: UNHCR (Kenya), MSF (Kenya), Red Cross, Nursing and Midwifery School, and refugee midwives. 65 participants in total attended. Key members of the Migrant Mothers team presented papers (5) from fieldwork in Dadaab, and participants were encouraged to comment in 'break-out sessions' which added key aspects to our research. The main event was the 'VR Experience' where participants were given the opportunity to become immersed in Dadaab, from the perspective of Indigenous midwives, themselves refugees in Dadaab. Many of the participants, including Dr.Osman from Red Cross (Kenya) was 'not aware of the critical role that Indigenous midwives play in maternal care.' The VR created dialogue across the network of maternal care (from biomedical practitioners, to nurses) where dialogue is - in the words of one participant - 'not often possible.' The research team left with follow-up ideas in producing their next VR series for the project
Year(s) Of Engagement Activity 2021
URL https://twitter.com/DigitalMaternal/status/1356603583446323200/photo/1
 
Description Research feature in episode of Sanyu Sisters: Global Maternal and Newborn Health Podcast 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Our Network was interviewed for 'Sanyu Sisters: Global Maternal and Newborn health podcast' with over 1000 listeners, worldwide. This was followed with a 'twitter takeover' where audiences could ask questions, and respond to our research
Year(s) Of Engagement Activity 2021
URL https://anchor.fm/sanyusisters