Part 1: Sending Visual Tools to Africa
Part 2: Adjusting images for Africa
Part 3: Stories from Africa

Part 4: Safe Passage to Motherhood 2010

One woman started teaching Home Based Life Saving Skills (HBLSS) in 2009 by training 15 people. One year later those 15 have reached 10,000 people.

But really, what does that mean? Did the people who heard about the program actually learn something that will make a difference? The over arching goal is to reduce infant and maternal mortality. The numbers are alarming, everywhere from 1-13 to 1-22 risk of dying in childbirth in Africa. Many of the deaths are from complications that can be treated if the risk is identified and the woman gets help.

Going to the clinic

One of the core teachings in the HBLSS training is identifying the signs that a mother needs some kind of assistance in her birth. Most women birth at home, so the clinic is a place where women go who need some skilled assistance.

The year before HBLSS, there were 53 births at the clinic.  There were 166 births in the clinic in 2009, 90 already in 2010.

There have been no maternal deaths in the last year. Up until then, there had been 2-3 a year.

Spreading the word to other villages

The Safe Passage to Motherhood (SPM) team knew the biggest challenges the trainers in Kenya were facing from the VisualsSpeak session they did with the group.

1. Transport
2. Umbrellas, rain boots, shoes
3. Bag for carrying materials
4. Money for transportation
5. Badges and uniforms

All of these things relate to spreading the training to nearby villages. The team in Bware walk to do their work. For hours. In all kinds of weather. Carrying all their materials and supplies. The villages they go have limited resources, so there were times they were not even offered food and water.

Given all of this, the SPM team needed to go to the places the group considered trained, and see what those communities really knew about how to offer assistance to birthing women. They set off walking to the remote sites.

What helped communities learn

The results from the communities were mixed. When the trainers went and simply talked about HBLSS and the steps people could take to assist in birth, people did not remember enough detail to be able to take effective action. When the trainers went several times to the community and did the interactive training that involved role playing the interventions, the information was remembered.

Similar to my experience training with a wide variety of people in the US, lecture didn’t stick and experiential learning did.

Balancing empowerment and effectiveness

There is a certain amount of power in standing before a group to impart knowledge. SPM saw that empowerment in the Bware trainers. Some of it is really important, and shows new levels of confidence. As developing educators, we also need to guard against putting too much emphasis on ourselves, and serve the groups we work with. I know at times I can feel almost lonely facilitating a particularly dynamic conversation. Everyone else is fully engaged and I almost step back to allow the space for it to happen.

The work continues

SPM brought a lot of information back from Bware that is still being tabulated and analyzed. I know there are a lot more stories coming. The group plans to continue working with Bware, but also dreams of working on projects in other part of the developing world. Like so many others, funding is what limits their abilities to do more. If you’d like to help, I’m sure they would put your donation to good use.

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Part 1: Sending Visual Tools to Africa
Part 2: Adjusting images for Africa

Part 3: Safe Passage to Motherhood 2010

The Safe Passage to Motherhood (SPM) team were met at the airport by Emily when they arrived in Kenya. Emily acted as a translator during training, and takes responsibility for much of the communication between Bware and Portland, OR. Annie is a midwifery student, and the boys are Maggie and Mari’s teens. Mari is a physician assistant and Maggie is a nurse midwife.

In Kenya with specific goals

The team was in Kenya to assess the results of the training they started the year before. They identified specific things to look at while they were there.

• Assess the number of communities and participants trained,
• Assess the quality of the ongoing training as they cascade down to more
  and more women
• Set mechanisms in place to track health outcomes in trained communities
• Understand barriers and challenges
• Determine ways to support the sustainability of the program
• Strengthen ties between youth and women leaders
• Increase the emphasis on education and prevention starting with the young and
  extending through child-bearing years

Beginning to gather data

The Home Based Life  Saving Skills (HBLSS) program includes keeping detailed records of training and births. The SPM team was thrilled to find that their contacts had kept detailed notes and tracked their progress.

On the wall behind Mari and Emily is a pyramid chart. Each trainer filled in information about how many people attended their training each month.

When the numbers were added up, there were 10,000 people who had heard about how to identify signs that a woman needed help birthing. With proper training, skilled attendants can recognize problems early and can intervene directly or stabilize the condition and help the patient reach specialized care.

One woman started spreading the word in 2009 by training 15 people. One year later, those 15 have reached 10,000 people.

Understanding Barriers and Challenges

Safe Passage to Motherhood is committed to working with the people in Bware to help them solve their own challenges. The process includes listening to stories of what they are already doing, identifying resources they can utilize or reassign, and partnering to learn skills that can make a difference. The organization here in the US operates on a shoestring, and the trainers are volunteering their time and medical skills. This is grassroots. People sharing knowledge to help one another.

There are real challenges to spreading the work. Money to get SPM trainers there, money to pay for supplies and transportation in Kenya, money to pay for the medical supplies. At the same time, the groups have been incredibly resourceful in how they spend the small amounts they do have. The goal is always to think about the sustainability of the approach.

What are the problems?

The first step to looking at  barriers and  challenges was to make a comprehensive list of things that had come up in the last year. Seventeen items were identified, the Kenyans picked the top five as the most important.

1. Transport
2. Umbrellas, rain boots, shoes
3. Bag for carrying materials
4. Money for transportation
5. Badges and uniforms

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6. Sickness
7. Work at home
8. No money for help
9. Food for trainers
10. Trainees being late
11. Equipment
12. Vacation from work
13. Cultural beliefs,
14. Different ages and belief systems
15. No light at night
16. New people at repeat trainings
17. Distance

Understanding more fully what this means

We created a set of VisualsSpeak images to be used specifically to deepen understanding of these challenges. The more the SPM team knew about what people meant when they said these things, the more effective they would be helping them come up with solutions.

Before they left for Kenya, I had a number of conversations with Mari about what prompt to use. She decided to use:

Find pictures that speak about a time you have succeeded at a challenge as a member of BUCHWA (the community health group that does the HBLSS training.)

What happened?

There was no hesitation with the VisualsSpeak process. The Kenyans were very comfortable with the images and process. There was no learning curve. Maggie reported,  “They are very metaphoric, it was like they had drawn the images themselves. We had no difficulty.”

Many of the stories that emerged were less about the challenges, and more about the empowerment. Stories about being lonely and only affecting their homes before learning all the skills, and now being a part of something bigger. Making a difference. Being someone.

Hierarchy is a large part of Kenyan culture. This is a poor rural village. There are not a lot of opportunities for women. The SPM team knew this, but until they heard all the stories, they didn’t realize how huge this was for the group. The uniforms and badges the Kenyans found so important? Very much about being part of, being someone special, being someone with knowledge.

The fifteen Bware United Community Health Workers Association (BUCHWA) members have shared information with 10.000 people. What has happened to them as a result of learning how to help others save the lives of women and babies may be even more profound.

Next up: More stories (and results) from Africa

Coming soon.

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Part 1: Sending Visual Tools to Africa

Part 2: Safe Passage to Motherhood 2010

The goal of using visual tools in Kenya was to encourage people to tell stories of their experience with the Home Based Life Saving Skills course, HBLSS they learned the year before. Maggie Alexander is the nurse midwife who trained the group the previous year. Mari Alexander  is a physician assistant who was on the assessment trip two years before. She is a VisualsSpeak customer who has used the tools in her mental health practice and in her work in diversity and inclusion training. The two of them were joined by their teenage sons and a midwifery student for the 2010 trip.

What images should we use?

The original VisualsSpeak tools are all photographs. While we worked hard to make them diverse, they are still a US designed tool, created for a professional market. We were nervous that rural Kenyans would not be able to relate to them. I’ve been working on new products that incorporate my paintings, and have a deck that we’ve been using in testing those products that we knew worked in the US and Europe.

I’ve also been working on a series of paintings for a storytelling deck. They have broad universal themes, and are the images in my online gallery. I plan to create a storytelling product as well as use these in other new decks.

We didn’t know which to pick, so we decided to send both, but with modifications.

Adding local images

The first deck is a mixture of 24 photographs, 12 illustrations, and 12 abstract paintings. We added 24 photographs Mari and Maggie had from Bware. Most of them were people, but there were also a few of the houses and landscape.

This deck is about the size of playing cards. We made one of those to use with the younger people, but had to enlarge them for working with the adults. We did this because most people do not have reading glasses (other than the gifts the group brings over) so they would have difficulty seeing the details of the images.

Brown is generic not diverse

We felt more confident about the storytelling images for a number of reasons. First, the Kenyans have a storytelling tradition. Second, my style has the flat patterned look of some of the textile work from the region.

When I did the original paintings, I made the people medium brown. As the group looked at them, they felt they were way too light. Especially considering how dark the Kenyans are. They also suggested making them more shades of brown to make the diversity clearer.

I altered many of the people images to be a variety of skin shades. Thanks to the wonders of Photoshop, this wasn’t too difficult. I printed out the images and laminated them. We put them in  zipper pouches handmade by a woman in our town, and sent them off with Maggie and Mari.

Other parts of the story:

Part 1: Sending Visual Tools to Africa

Part 3: Stories from Africa

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Safe Passage to Motherhood was heading back to Bware Kenya for the third time. On the first trip, they conducted an assessment of the community in relationship to maternal mortality. The second time, one midwife conducted a training in Home Based Life Saving Skills, a program designed by the American College of Nurse-Midwives for use in the developing world. The program teaches simple skills to the women in the community that save lives in childbirth.

Multiplying Effect

Maggie Alexander, a nurse-midwife from Oregon taught life saving skills to four lead trainers. Together they taught 12 more. That group taught 44 during the two weeks Maggie was  in Kenya.

During the next months messages arrived from Kenya about training hundreds of people. Then thousands. Women from a rural village. Without transportation. With very limited resources.

Excited Skepticism

Each time a report would arrive in the US, there was excitement. The program was working. People were learning skills to identify when a birthing mother was having potentially life threatening symptoms.

Then there was skepticism. Were they really reaching all those people. What did training really mean? Were people actually learning?

Going Back to Assess

The only way to really know what was happening, was to go back to Kenya. This time there was one midwife, one physicians assistant, and their two teen-aged boys and one midwifery student.

One problem. How were they going to get people to tell them what was really going on? They didn’t want to hear the stories people thought they should tell them. Culturally, it was not considered polite to talk about problems. Especially to guests who were coming to offer help.

Using Visuals to Get to the Real Story

People struggle to tell the story that really matters. Instead we tell stories that we are comfortable with, or ones that tell a flattering version of our part. Or the story we think the listener wants to hear.

When visuals become part of the mix, something else happens. Other memories get triggered. Less conscious aspects surface. You can talk about things that are awkward or hard to talk about because you are now talking about a picture. Not another person. All sorts of different stories surface.

Would the Images Work in Africa?

We know the VisualsSpeak tools work in many places in the world. We know they work with different backgrounds. But would they work in rural Africa? We weren’t sure. But we were willing to try.

Next parts of the story:

Part 2: Adjusting Images for Africa

Part 3: Stories from Africa

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