Title: Use of the Human-Centered Design approach for a birth companion program in Dar es Salaam, Tanzania
Description: Human-Centered Design (HCD), sometimes referred to as Design Thinking, is increasingly gaining recognition as an approach that promotes people-centered care in global health. With its history embedded in the technical and engineering fields, HCD has potential to create interventions that are feasible and acceptable to program beneficiaries. Providing emotional and psychosocial support through the use of a birth companion of choice is associated with several significant clinical health outcomes as well as satisfying birth experiences. This intervention is recognized and recommended by the World Health Organization (WHO) as fundamental and is included in the WHO guidelines for improving quality care for women and their newborns. Despite all this background information, there is insufficient evidence on the factors influencing design and implementation of birth companion programs in people-centered ways in low- and middle-income countries (LMICs). The dissertation investigated the specific factors influencing implementation of a birth companion program in two health facilities in Dar es Salaam, Tanzania.

Additionally, the dissertation explored key learnings of Human-Centered Design as it was the approach utilized to design and implement a birth companion program in the two facilities. By understanding the factors influencing birth companion programs, as well as people-centered approaches such as HCD, it is hoped that the findings will provide important practice recommendations as well as inform policy and research. The dissertation used two data sets that employed qualitative design methodologies to meet its two broad objectives. The first data set was primary data collected to critique and reflect on the utility of the Human-Centered Design approach that was used to design and implement a birth companion program at Mwananyamala Referral Hospital and Tandale Health Center in Dar es Salaam, Tanzania. Data were collected using observations of design workshops, field notes, and face-to-face in-depth interviews as well as Zoom interviews of 13 participants including program staff, research team members, HCD experts, and providers who participated in the process.

These data were analyzed using Critical Systems Heuristics (CSH) for framework analysis as well as thematic analysis. The second data set was secondary data for a pilot study conducted by Averting Maternal Death and Disability (AMDD) that aimed to develop a birth companionship model that responded to the context and needs of women, considered health provider expectations and concerns, and adhered to and observed Tanzania’s health system requirements. Data were collected using in-depth interviews, focus group discussions, observations, and other project data such as meeting minutes, guided tours, influence maps, document review, and field notes. Data from this data set were analyzed using the Consolidated Framework for Implementation Research (CFIR) for framework analysis. No comparisons were made between the two facilities as the key findings that surfaced were similar across both facilities. However, the author made mention of the specific health facility where a key finding was more pronounced in one facility compared to the other facility.

Findings for the Human-Centered Design Approach were guided by the Critical Systems Heuristics framework. The findings showed that power dynamics exist across different stages during the HCD process, for example between local researchers and expatriate design experts. However, power differences were more pronounced in complex settings such as health facilities, especially between provider needs and those of women. Power dynamics were also seen between nurses and other providers such as doctors and facility heads, and these differences influenced important decision-making. These power imbalances stemmed from existing power hierarchies that are part of government-led entities such as the two facilities. The power asymmetry also stemmed from the providers’ responsibility to prioritize human lives and also to protect themselves against potential litigation, as birth companions become an eyewitness of the birth experience. In such environments, the execution of HCD is challenging and requires a lot of compromise.

Due to these and other provider concerns, providers became the primary co-designers of the birth models implemented at the facilities. However, HCD proved to be an approach that sparked creativity, enabling participants to realize their capacity to solve problems on their own without external influence or being told what to do. Findings for the factors influencing implementation were guided by the CFIR framework. Before program implementation, providers and women generally accepted the birth companion program and saw it as an important intervention to offer women needed non-clinical support such as providing food, supporting the mothers emotionally, and helping women exercise. However, there were general concerns from most stakeholders, especially providers, on limited space, proliferation of infections, and privacy and confidentiality violations by providers. During implementation, most of these concerns disappeared, as providers and women co-created a birth companion model that was feasible, acceptable, and low cost.

However, at Mwananyamala Hospital, space challenges continued, as the program implementers could only start with small numbers due to limited space. Space issues also manifested in other forms as birth companions could not be accommodated at night in the event of complications such as cesarean birth or admissions into the Neonatal Intensive Care Unit. Other key findings that emerged during implementation included poor communication networks, failure to engage other stakeholders, and lack of leadership engagement. The dissertation concludes by illustrating that implementation of a birth companion program in health settings such as Tandale Health Center and Mwananyamala Hospital is feasible, acceptable, and can be done without huge financial investments. There is a significant opportunity to adopt this model across Tanzania and in other settings with comparable contexts. What made this model feasible and acceptable is the Human-Centered Design approach that enabled a shift in the mindset of providers, sparked innovation, and allowed women and providers to develop their own solutions and test them out without imposition from the program planners.

The Human-Centered Design approach, therefore, offers opportunities to design and implement interventions that are acceptable to users and other key stakeholders on the frontlines, leading to potential increased use of the interventions. HCD should not, however, be viewed as an antidote to all complex public health challenges-but should be used as a guiding framework together with other participatory approaches that explore deeper into the complexities of the wicked problems pervasive in global health. The power dynamics it seeks to dismantle are sometimes difficult to disrupt due to other systemic variables that interplay within global health systems. Considerable efforts to locate where the power lies, what contributes to that hegemony, and how it can be reconfigured are necessary for the utilization of HCD. Application of HCD should prioritize the different contexts and evolve and adapt to suit the complexities within each context, yet at the same time maintain the major characteristics that separate it from other participatory approaches.