Telling stories for healthy pregnancies

In the Parinari district of Peru, the journey between a pregnant woman’s home and the nearest health centre involves at least an hour-long boat ride. And to get to an actual hospital, the trip is even more arduous – she would need to take two more boats and a bus.

In remote regions like Parinari, 80% of women give birth at home instead of making the trip to a health centre or hospital. These home deliveries often take place without help from a healthcare provider, leading to a maternal mortality rate that is higher in rural indigenous communities.

But difficult journeys like this are just one of many problems identified by Nuestras Historias, a research project led by Dr. Neha Limaye as part of a Fogarty Global Health Fellowship and in partnership with a pre-existing intervention named Mamas Del Rio. The project used digital storytelling to recognise the struggles of pregnant women, highlight potential solutions and demonstrate the health benefits of seeking care despite the challenges.

Beginning in 2015, the project produced a series of community-created videos addressing maternal health issues within 13 communities in Peru, and demonstrates how digital interventions can be a powerful public health tool to address community-specific problems and amplify local voices.

The community knows best

The Parinari district is a rural area of the Loreto region of Peru, with approximately 7,264 inhabitants. The communities are remote, only accessible by river, and most households do not have connections to running water or electricity.

Peru has been slowly improving its maternal health measures, but these riverine regions of the Amazon are being left behind, Dr. Limaye, the primary investigator of the project said. The infant mortality rate in Loreto is around 25.4 deaths per 1000 births, compared to a national average of 19.5.

To combat this health disparity, Dr. Limaye’s research team aimed to use mobile technology and video interventions to share information about maternal health. But after spending a month in the communities, Dr. Limaye realised that a lack of information was not the main obstacle to healthy pregnancies.

Many of the women had some understanding of prenatal health needs but faced other issues preventing them from accessing care. Many of these obstacles were specific to their unique situations - for example, they needed gas to power a boat for travel or were limited by an unsupportive family member. Any successful public health intervention would, therefore, need to understand and address the specific geographic and socio-cultural barriers to maternal health.

“All the determinants of health are local,” said Dr. Limaye. “The only way to really understand them is to ideally be from there, and if you’re not from there, try to understand what it’s like to be from there.”

The project shifted its focus on using narratives to motivate healthy behaviours amongst pregnant women. But to do so, the intervention needed to highlight solutions that were possible within the local context.

Creating a digital curriculum

To create videos highlighting these local experiences and solutions, the researchers engaged in a series of workshops and digital storytelling exercises. Attended by 17 community health workers and 10 women with pregnancy experience, the workshops were used to identify central themes in local maternal health.

In the first workshop, attendees were introduced to the project and taught to use a camera. They then had two weeks to take photos they felt represented their experience with pregnancy, responding to questions such as “what does a healthy pregnancy mean to you?” and “what are the barriers to a healthy pregnancy?” This method, named “Photovoice,” encouraged the participating women to express their personal experiences in their local context.

For example, one photo of a house was paired with the caption “this house can be compared to a mother...going through pregnancy alone, sad and abandoned with no one helping her.” Another participant took a picture of a bright orange tree to represent a mother who had made healthy prenatal choices and would eventually give birth to a healthy baby.

The key to encouraging participation was to facilitate, but not lead, said Dr. Limaye.

From the resulting discussions, the researchers were able to determine what the main roadblocks were that prevented the women from having healthy pregnancies such as lack of partner support, accessing vaccinations and more. The participants were then asked to think of personal stories that were relevant to these themes, matching the photos to elements of the story in a storyboarding exercise. The women then recorded themselves narrating the stories on mobile devices.

The research team then chose stories that related to the original themes identified by the Photovoice workshops. The last step was to test that the videos were acceptable and relevant to the rest of the community, which the team did by surveying over 60 women and 47 men, all of whom rated the digital stories as “good” or “excellent”.

The final result was a collection of seven community-created short videos that made up a ‘digital curriculum’. The videos covered the topics raised in the initial workshops and were loaded onto solar-charged tablets that could be used permanently in the community.

Community health workers were then trained to use the videos, showing them in maternal health sessions along with a set of discussion questions that demonstrated the value of healthy decisions.

As the digital stories were made by the community members, they were automatically reflective of the specific needs of the area. This meant that the information was coming from a trusted and reliable source, and was far more likely to bring about a shift in behaviour in the viewers of the project.

For Dr Limaye, this proves the inherent value of community-tailored interventions. “There is more of an understanding of the narrator, as they’re speaking in the exact same intonations of the voice of people in that region,” she said. If the team had put the videos together anywhere else, “they would be irrelevant”.

Digital storytelling and inclusive participation

The Nuestras Historias digital curriculum is still being used by the Mamas del Rio program and has since expanded to 84 communities, in partnership with the Regional Health Department of Loreto. But for Dr. Limaye, one of the key takeaways of the study was the potential of digital storytelling to give a voice to vulnerable communities.

“[Digital storytelling] is such a rich form of participation that doesn’t happen in a lot of other government meetings, and is a way to get people that are typically ignored to really participate,” she said.

In Parinari, many of the communities are male-dominated and women did not usually attend community meetings. But women who were not used to speaking out were able to use their own photos as a reference for their stories, enabling them to feel more comfortable communicating their personal experiences.

The success of this project demonstrates the potential of digital storytelling for inclusive public health interventions, especially in populations with lower literacy levels and limited access to electricity. — Ali Hunter

(Picture credit: Unsplash)