Birth across the Borders: exploring contextual education as a catalyst for improved maternal health.

Lead Research Organisation: University of Ulster
Department Name: Sch of Nursing

Abstract

Families that lose a mother in pregnancy or childbirth face many challenges. They are left with a gap that can lead to a loss of income and poverty. It can cause a lot of family pressures, especially for girls are left to care for younger children and are not able to go to school. Many of these families come from communities that are already poor, with very little infrastructure and limited access to decent healthcare. This can cause a much higher risk of death, both for mothers and babies, especially in poor countries. Opportunities are more limited because families lack money and education.
Myanmar is a South East Asian country that has had many years of tension and conflict between the different people groups. Many of these groups live in remote mountainous areas where basic resources and infrastructure such as electricity are limited. There is often little healthcare in these areas with very few doctors, nurses or midwives to care for mothers and their families. One in 23 women in Eastern Myanmar either die or come close to death during pregnancy or childbirth. These challenges are all very typical in developing countries across the world today, but a lot can be changed with education that makes sense to mothers and families in their situations.

Working together with our local partners we intend to learn more about the specific challenges facing families in four regions of Myanmar. From this we will co-develop three education programmes which will be especially adapted for each region. One of these programmes will help families and communities understand the processes of pregnancy and birth, recognise what is normal, what is unusual and what is dangerous and to know what to do and where to go to get help. Our second programme will further train health workers to understand the different signs and symptoms that are dangerous in pregnancy and birth and find ways to help mothers in time to prevent complications. Poverty is very high in parts of Myanmar, so our third programme is for community leaders and local people to support them to start and grow businesses. This way families can afford to eat well and get good healthcare when they need it. Our project will focus on remote regions in Myanmar and together we plan to learn how to find ways to overcome the legacy of many years of poverty and conflict. This project will include staff from our universities in Northern Ireland and Thailand as well as local partners who come from or have been working in the region for many years.

Through this project we hope to help support the work of all our partners and improve education for mothers, families and communities. A key part of our project is making sure that the education they receive makes sense in their situations and includes their beliefs and customs leading to improved health, social and economic opportunities and accessible healthcare. We plan to share what we do with other organisations working in Myanmar who may also benefit from our research. Finally, it is hoped that our research will contribute to current policies and practices in partnership with the government of Myanmar and the ethnic health organisations.

Planned Impact

This maternal health education project is co-developed with local, national and international partners representing all beneficiary groups. It builds on partnerships consolidated over 5 years of international networking and research: a workshop with health professionals from Thailand and Myanmar, data collection from Karen State, Myanmar, and community and policy consultations. The project addresses maternal mortality and morbidity in remote, rural communities in Myanmar, with embedded sustainability, and potential for scale-up nation-wide and in other LMICS. Mode of delivery of educational interventions will be community and stakeholder led to ensure maximum benefits, with training of local members and support to promote learning and skills retention. The beneficiaries will be women, families, and communities in rural Myanmar and beyond, and the government departments, policy makers and organisations with responsibility for maternal health care.
Impact will effect: Women of childbearing age through enhanced pregnancy, birth and post-partum care; increased knowledge of pregnancy, birth (what's normal, what's unusual and what's dangerous); access to culturally relevant maternal health education; access to healthcare; decreased risk of pregnancy and birth-related illness and death; enhanced social and economic opportunity. Pathway: targeted educational interventions will lead to improved maternal health. Cascade benefit to siblings, families and communities challenging generational and gendered patterns of inequality. Fathers: increased support to equip fathers in their role in pregnancy, childbirth and parenting; skills to respond to obstetric emergencies; social and economic benefit and participation in sustainable community development. Pathway: timely antenatal and community education interventions. Siblings and Families: less educational disruption caused by caring responsibilities for younger siblings; increased access to education leading to increased life opportunities, lower risk of early motherhood and maternal complications; improved life choices, more equitable opportunity to engage in social and economic development. Pathway: timely maternal and community education interventions for parents and carers with local community members trained for sustainability. Community leaders:Increased understanding of maternal health; leadership development and enhanced understanding of models of social enterprise and sustainable community development. Pathway: educational interventions in maternal health and social enterprise at village tract level. Timely implementation for leadership with support from trainers on social enterprise strategies. Rural communities: enhanced contribution of women to sustainable community development; reduced social and economic burden, maximisation of community resources and realisation of social and economic potential; enhanced social cohesion; improved general health and well-being. Pathway: all educational interventions. Health workers in rural communities: Improved ability to enhance maternal health; recognition of their role within communities; challenge to potential gender discrimination associated with this mainly female role. Pathway: Community education and EMOC programme. Ministry of Health, Ethnic Health Organisations, Local NGOs: evidence of the barriers, risks and implications/realities of maternal health in rural areas. Greater awareness of effective interventions and their potential for roll-out/scale-up. A set of educational packages to promote maternal health. A template for effective practice, and evaluation. Pathways: reports for ethnic health organisations. Workshops to develop transferable skills to design and deliver further culturally and contextually relevant education packages to address health and development challenges/promote sustainable development in diverse ethnic populations in Myanmar. Delivery of interventions through regional training teams beyond project lifetime.

Publications

10 25 50
 
Title CMIC Survey 
Description Survey designed to collect data to understand the contextual and cultural factors influencing maternal health in remote areas. For mothers. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2019 
Provided To Others? Yes  
Impact This survey tool offers quantitative evidence across 4 domains of context; maternal health, infant health, health and cultural factors influencing maternal mortality. 
 
Title Semi-Structured Focus Group Schedule for Women 
Description The Focus Group schedule includes a set of interview schedules created to collect information on; -Women's pre-pregnancy life habits and patterns, their experience of pregnancy, where they sourced pregnancy information, health and life concerns for themselves and their babies, and their overall experience of childbirth. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2020 
Provided To Others? No  
Impact The findings from the focus group research tool demonstrates a complex tapestry of developmental challenges that impact maternal mortality. 
 
Description CHAD - Community Health and Development 
Organisation Community Health and Development
Country Myanmar 
Sector Charity/Non Profit 
PI Contribution Facilitation of the permission processes with local stakeholders and identification of ty data collection areas.
Collaborator Contribution CHAD (Community Health and Development) and will co-lead the project. They have and will facilitate future partnerships with ethnic health organisations. Local staff from these organisations will be trained in data collection methods, data analysis and will become the regional training teams for each area, building capacity not just within communities but also within the local organisations. Trainers will include medics, health workers and community development workers. These partners will work in conjunction with our team to identify and include communities in ethnic regions, liaise with ethnic health organisations, provide staff and expertise in the implementation of current and future projects through the scale up process with the ethnic health organisations and government departments.
Impact Ongoing permissions and Terms of Reference and Collaborations. Providing Cultural and community development expertise.
Start Year 2018
 
Description CMU - faculty of Nursing 
Organisation Chiang Mai University
Country Thailand 
Sector Academic/University 
PI Contribution The research team have built a professional relationship with colleagues in Chiang Mai University, which have aided the co-development of this project. Ulster University team members have made a number of visits to Chiang Mai university to facilitate this work and to build upon the partnership. Work in also underway to further strengthen this relationship with Faculty of Nursing at CMU and School of Nursing at Ulster University.
Collaborator Contribution Chiang Mai University have co-developed this project from the outset and provide valuable, transferable resources of regional, cultural and contextual knowledge and education. They will continue to guide this research through their leadership and partnership. The Faculty of Nursing have agreed a significant investment for the continuation of this project through staff and student involvement. Dr Chaloumsuk will co-lead the project and has played an active role in the development of this project to date. Contributions to this project include regional expertise and leadership for the duration of the project, support and expertise in the design, implementation and analysis of project activities, interventions and liaison with Yangon University of Nursing in conjunction with the research team.
Impact Number of reports from previous research work; Kernohan, G., Sinclair, M., Dornan, L. (2017) Birth across the Borders: A development study to explore maternal policy and practice in Thailand and Myanmar. University of Ulster. 11pp (BAB1) UIR? https://pure.ulster.ac.uk/admin/files/11648489/Dornan_2017_GCRF_BAB1FinalReport_v3.2.pdf https://drive.google.com/open?id=1qAQNZK_mJMhnp-xHsmg6tuu9cKUpEcr3 Kernohan, W.G., Sinclair, M., Dornan, L Chaloumsuk, N., Yimyam, S. (2018) Building Bridges to Improve Birth across the Borders: an in-depth study of maternal healthcare in remote and contested areas of Myanmar. University of Ulster. 9pp (BAB2) PURE? https://pure.ulster.ac.uk/admin/files/76838450/GCRF_BAB_2_Final_Report_V3.pdf https://drive.google.com/open?id=1jqFsUtr31dO4Cll2WjQZWd2XlwdBTZfC Kernohan, W.G., Sinclair, M., McCoy, J., Dornan, L., Chaloumsuk, N., Diyunugala , T., Nest, S., Gibbons, D., Ryan, M. (2019) Contextual Partnerships and Governance for Maternal and Infant Health Research in Myanmar. University of Ulster. 8pp (BAB3) https://pure.ulster.ac.uk/admin/files/76838646/Kernohan_83275R_Final_Report.pdf https://drive.google.com/open?id=18ZG5kAJJdPOXzO5diwcc8S9lq2nYZSOS Kernohan, G. Birth across Borders. Research Wisdom (2018) 5: 1,7,8 http://www.nurse.cmu.ac.th/web/userfiles/files/ResearchWisdom_April2018-NursingCMU-Final.pdf UIR? Memorandum of Understanding has been drafted and agreed between Chiang Mai University and Ulster University. Creation of CMIC Antenatal Survey
Start Year 2016
 
Description Earth Mission Asia 
Organisation Earth Mission
Country United States 
Sector Charity/Non Profit 
PI Contribution The research team have worked with EMA to build this partnership to enable the facilitation of the research on the ground in the different regions of Myanmar. EMA has contributed to the design and development of the data collection plan, the development of local partnerships and permissions with the ethnic health organisations in one region and consulted in the design of the data collection tools for associated work packages. Identification of ty data collection areas.
Collaborator Contribution Earth Mission Asia have co-led the preliminary research and development of this project from the outset in 2016. Through their health and community development networks they have co-developed and co-ordinated the data collection processes from the last two GCRF pump priming projects. They have facilitated further partnerships with key regional partners in Myanmar and will co-lead the projects. They have and will facilitate future partnerships with ethnic health organisations. Local staff from these organisations will be trained in data collection methods, data analysis and will become the regional training teams for each area, building capacity not just within communities but also within the local organisations. Trainers will include medics, health workers and community development workers. They will work in conjunction with our team to identify and include communities in ethnic regions, liaise with ethnic health organisations, provide staff and expertise in the implementation of current and future projects through the scale up process with the ethnic health organisations and government departments.
Impact CMIC survey and EMOC survey/focus group questions. Permissions processes and Terms of Reference with regional health organisations.
Start Year 2017
 
Description Partners Relief and Development 
Organisation Partners Relief and Development
Country United States 
Sector Charity/Non Profit 
PI Contribution Our research team have worked with Partners Relief and Development to foster relationships and facilitate the partnership working required to enable this research project to be undertaken in Myanmar. Partners R & D have facilitated in the development of local partnerships and permissions with the ethnic health organisations in two region and consulted in the design of the data collection tools for associated work packages. Identification of ty data collection areas.
Collaborator Contribution Partner Relief and Development have co-led the preliminary research and development of this project from the outset in 2016. Through their health and community development networks they have co-developed and co-ordinated the data collection processes from the last two GCRF pump priming projects. They have facilitated further partnerships with the key regionals organisations and will co-lead the projects. They have and will facilitate future partnerships with ethnic health organisations. Local staff from these organisations will be trained in data collection methods, data analysis and will become the regional training teams for each area, building capacity not just within communities but also within the local organisations. Trainers will include medics, health workers and community development workers. They will work in conjunction with our team to identify and include communities in ethnic regions, liaise with ethnic health organisations, provide staff and expertise in the implementation of current and future projects through the scale up process with the ethnic health organisations and government departments.
Impact Data collection tools for maternal health and social enterprise. Terms of Reference with regional partners. Employment of local staff with contracts.
Start Year 2017
 
Description Yangon University of Nursing 
Organisation University of Nursing Yangon
Country Myanmar 
Sector Academic/University 
PI Contribution Regional Partner providing academic support. Continued development of national permission (on hold due to COVID and the current political unrest)
Collaborator Contribution Providing Academic support and regional knowledge
Impact None to date
Start Year 2017
 
Description BAB Community Resilience and Maternal Health 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Undergraduate students
Results and Impact A presentation undertaken by one of the research team members detailing the Birth Across the Borders project to date.
Year(s) Of Engagement Activity 2020
 
Description Birth Across the Borders - Challenges and Lived Experiences of Women in Karen State 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Third sector organisations
Results and Impact Presentation was given by a research team member to ethnic organisations (Karen Department of Health and Welfare: KDHW) in Karen State, Myanmar to describe the research project we are undertaking and secure their support. Subsequent presentations gave updates on the work/research as it progressed.
Year(s) Of Engagement Activity 2018,2020,2021
 
Description Birth Across the Borders - Challenges and Lived Experiences of Women in Myanmar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Third sector organisations
Results and Impact Presentation was given by a research team member to ethnic organisations (Kachin Baptist Convention: KBC) in Kachin State, Myanmar to update them on the research project we are undertaking and secure their support.
Year(s) Of Engagement Activity 2021
 
Description Birth Across the Borders - Challenges and Lived Experiences of Women in Myanmar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Third sector organisations
Results and Impact Presentation was given by a research team member to ethnic organisations (Regional Council Shan State: RCSS and Shan Health Department) in Shan State, Myanmar to describe the research project we are undertaking and secure their support and collaboration.
Year(s) Of Engagement Activity 2021
 
Description Birth Across the Borders - The Story So Far 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Third sector organisations
Results and Impact One of our research team members presented an overview of our project to a Giving Circle made up of Business Women and women from third sector organisations. The Giving Circle secured £500 for the team to get a logo designed for use throughout the project.
Year(s) Of Engagement Activity 2020
 
Description Context Training and Mapping Exercise (Karen State, Myanmar) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Study participants or study members
Results and Impact 12 academics and other professionals (Research Project Advisory Committee) met to discuss the historical and political context of one of the key regions of Myanmar involved in the Birth Across the Borders Project. Members discussed the drivers for conflict in the region and worked to map the key Government, Ethnic Armed Organisations, Ethnic Health Organisations, NGO's and other parties who operation in this region in Myanmar.
Year(s) Of Engagement Activity 2021
 
Description Cost of Birth for Mothers in Remote Communities: When Evidence and Practice Don't Meet 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Presentation was given by a research team member to approx. 200 people.
Year(s) Of Engagement Activity 2018
 
Description Cultural and Contextual Research in Maternal Health 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Undergraduate students
Results and Impact One of the research team members gave an update on the Birth Across the Borders project to date to under graduate nursing students.
Year(s) Of Engagement Activity 2021
 
Description Doctoral Midwifery Research Society presentation - Birth Across the Borders: Cultural Research in Maternal Health 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact A presentation was given by a research team member at a Doctoral Midwifery Research Society Event, to an audience of health professionals and individuals from third sector organisations.
Year(s) Of Engagement Activity 2020
 
Description ESRC Learning From COVID: Partnership Working and Methodology event 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other audiences
Results and Impact Two members of the research team contributed to this event (as a Facilitator and Rapporteur) engaging with an academic audience of other researchers working on ESRC research projects during COVID.
Year(s) Of Engagement Activity 2020
 
Description Global Health Security: Adapting to the Challenge CPD Study Day 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Event hosted by the Royal College of Anaesthetists on Global Health Security and adapting to the challenge. Event was in association with MOD and attached a national audience.
Year(s) Of Engagement Activity 2020
 
Description ICM Dubai Conference - Realities of Modern Midwifery in Remote Communities in Myanmar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact Presentation was given by research team member to primary audience of nurses at an international conference.
Year(s) Of Engagement Activity 2018
 
Description Kings College London - International Fieldwork during a Pandemic: Co-Production and Ethics 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Over 80 researchers and academics met to discuss the challenges many researchers have faced due to COVID-19, which have encouraged them to innovate, and while there are many obstacles yet to be overcome, there have been positive experiences as well. The aim of the event was to share this knowledge and experience as well as to stimulate further dialogue and reflection.

It was a very informative session, with researchers sharing their experience in terms of;
- Applying for ethics/approvals;
- Co-production as a key aspect of research projects;
- Being open to the challenges faced, sometimes solutions lead to different / unique / unconsidered benefits to research;
Year(s) Of Engagement Activity 2021
 
Description RSM - You, me and PPE: The Challenges of Communicating in Lockdown 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact This event was a presentation 'You, me and PPE: The Challenges of Communicating in Lockdown, hosted by the Royal Society of Medicine. The event was focused on challenges to research of communicating during a pandemic.
Year(s) Of Engagement Activity 2020
 
Description Training Gateway - Myanmar Event 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Industry/Business
Results and Impact · All of the participants were open to ideas and possibilities about ways of joining our institutions, of developing ways of working together collaboratively
· A lot of the prospective partners had experience in social enterprise and in the field of business
· Business schools were well represented, looking for opportunities to link with UK universities
· We received several (3-4) offers of assistance and support and universities would be able to provide some useful ways of helping us move forward with our own research project (translation of documents, advice re: local setting, experience in launching social enterprise initiatives In Myanmar)
· Meetings being planned to see how or if any of this may help us in our own project
· Networking
Year(s) Of Engagement Activity 2021
URL https://www.thetraininggateway.com/case-studies/
 
Description UCD School of Psychology 'Creative Alternative Knowledge Exchange' 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact An invited guest lecture was delivered by Prof George Kernohan, entitled 'Knowledge Transfer: This Way - Helping you to navigate the research journey. Pulling out all the stops!' The aim of the event was to encourage graduate students to actively engage in dissemination and knowledge exchange.
Year(s) Of Engagement Activity 2020