Maternal Health Hackathon: Community-Led Design for Reproductive Justice in Arkansas

Participants from across the state were gathered to identify the root causes of the maternal health crisis and generate actionable visions for change

Bree McMahon
Assistant Professor
University of Arkansas

Alison Place
Assistant Professor
University of Arkansas

Since 2019, the maternal mortality rate in the United States has increased by more than 15%, according to the CDC. While the number of women who die during or after childbirth has fallen globally in recent decades, it has nearly doubled in the U.S. since 1987. In Arkansas, the maternal death rate is one of the highest in the nation. Arkansas also ranks fourth among states where a majority of women live in a maternal healthcare desert, with 37 counties that do not have a single OB/GYN. Furthermore, Arkansas has the highest teen pregnancy rate in the country and, since the Dobbs decision in June 2022, the fourth strictest anti-abortion laws in the country. The lack of access to providers coupled with laws that lead to forced birth has created a complex crisis of reproductive justice in the state, which disproportionately affects women who are poor, Black, and live in rural areas.  

Understanding the crisis of maternal health in the United States is difficult due to a lack of data, as well as a lack of access to data, because there is no national system for tracking maternal health issues, and laws and guidelines vary from state to state. In 2020, funded by a federal legislative proposal, the Arkansas Maternal Mortality Review Committee published findings that cited a distinct lack of data in the state as a key barrier to improving outcomes. In Arkansas, another significant challenge is the disparate and disconnected nature of birth worker communities. The experiences and perspectives of stakeholders vary widely, and there is a lack of collective understanding of the roots of problems or possible solutions. 

As designers, we explored how design can help untangle the complexities of birth and motherhood and dismantle the systems that perpetuate oppressive and manipulative practices. We were interested in how disparate stakeholders might provide valuable perspectives on this crisis, which could help to articulate a path forward. When it comes to complex systems, designers have a unique ability to approach issues from a collaborative mindset while also keeping in mind users and desirable (and undesirable) outcomes. 

Since 2022, we’ve teamed up with a group of researchers at the University of Arkansas with backgrounds in nursing, business, and design to generate various community-led design approaches to addressing the maternal health crisis. Inspired by the 2014 “Make the Breast Pump Not Suck!” Hackathon at the MIT Media Lab, we hosted the Arkansas Maternal Health Community Hackathon in 2023. Traditionally, hackathons are multi-day events attended by multidisciplinary professionals, such as programmers, designers, and engineers. While typical hackathons are rooted in patriarchal tech culture, feminist researchers and designers have recently co-opted them as participatory spaces for social change. With an emphasis on relationship-building and care, feminist hackathons lay the groundwork for a plurality of community-led solutions to complex problems that are equitable, sustainable, and inclusive.  

The Arkansas Maternal Health Community Hackathon was a free one-day event that brought participants from across the state together to identify the root causes of the maternal health crisis and generate actionable visions for change. The two primary goals of the hackathon were to start conversations and build connections, so we designed the event to make people feel comfortable and to accommodate a wide variety of needs. Nearly 100 people registered for the event, and 72 of them attended. Attendees included parents of all genders, birth workers, nurses, doctors, midwives, doulas, public health experts, legal experts, policymakers, journalists, designers, and artists. We were strategic in our promotion of the event, focusing especially on inviting people from rural areas of the state and practitioners with expertise in marginalized populations. Funding was provided to cover travel and lodging for attendees who came from other areas of the state.  

Programming was focused on clearly framing the maternal health crisis and providing opportunities for attendees to form deep connections and dialogues. The day’s events included two keynote speakers; an advocacy session on how to talk to legislators about maternal health; a documentary screening by Every Mother Counts, a national organization devoted to maternal health; a networking and storytelling space; a resource room; a pre-/post-natal yoga session; and free childcare. With the support of facilitated activities and an on-site makerspace, some participants formed teams to address specific problems related to maternal and infant health. Volunteer designers worked with practitioners and organizations to strategize ways to approach various problems and discuss possible outcomes. Projects completed as a result of the hackathon included promotional materials for a local midwife, information design about prenatal care options for a local hospital, screen-printed tote bags with home birth kits for a local midwife, and a strategy and prototype for a website for the women’s hospital. We captured the perspectives of attendees by inviting them to participate in a qualitative research study about the barriers to maternal health in the state. We also produced a short documentary about the event (link in PDF). 

The impact of the event was evident in the overwhelmingly positive feedback we received. We heard from dozens of participants during and after the event that it was incredibly meaningful for them to come together in a supported space to work toward addressing this enormous problem. Many said they would like the hackathon to be an annual event. We are excited by the relationships formed and the community built through this one event. With the feminist hackathon as a guide, we are continuing to build a model for participatory design with diverse communities to build coalitions in the uphill battle toward reproductive justice in the South.

This project was the 2023 Design Incubation Educators Awards winner recipient in the category of Service.

Bree McMahon is a designer and educator driven by examining complex topics through dialogical prompts that encourage conversation, critical perspective, and collective learning. She is an assistant professor of graphic design at the University of Arkansas School of Art and currently serves as the inaugural director of graduate studies for the Master of Design in Communication Design program. Her research is situated within design pedagogy and the state of the design discipline. After the birth of her first child, she established an additional research trajectory concerned with maternal health, health literacy, and storytelling for improving birth outcomes in the United States. Prior to teaching, she worked with start-ups, small businesses, and non-profits within her various communities across the country. She received her M.G.D. from North Carolina State University College of Design and previous degrees in graphic design and art history from Carthage College in Kenosha, Wisconsin.

Alison Place is a designer, educator, and researcher who works at the intersection of feminism and design to create spaces for critical making and radical speculation. She is the author of Feminist Designer: On the Personal and the Political in Design published by MIT Press in 2023. She is an assistant professor of graphic design at the University of Arkansas School of Art, where she also serves as the director of the graphic design program. She has held several leadership roles in the design community, including two terms on the AIGA Design Educators Community National Steering Committee, and has earned multiple national awards for her scholarship and creative work. Previously, she worked for more than ten years as a creative director and designer for nonprofit and higher education institutions. She earned an M.F.A. in experience design from Miami University of Ohio, as well as degrees in graphic design and journalism from the University of Cincinnati College of Design, Architecture, Art, and Planning.

Uttar Pradesh’s First Breastfeeding Cubicle

communication collaterals in the form of cubicle wall panels were co-designed and rigorously tested with a cohort of mothers from the target audience

Service Design Award Winner

Sarah Tanishka Nethan
Community Empowerment Lab 

Shatarupa Bandopadhyay (Former Art Fellow, Community Empowerment Lab)

Abdul Qadir (Graphic Designer, Community Empowerment Lab)

Aarti Kumar (CEO, Community Empowerment Lab)

Vishwajeet Kumar (Principal Scientist, Community Empowerment Lab)

Exclusive breastfeeding till six months has the potential to save ~8,20,000 babies. The State of Uttar Pradesh (U.P.) in India loses ~2,00,000 newborns annually, making it the global epicentre for newborn deaths. However, simple interventions like early initiation within 24 hours after birth and exclusive breastfeeding till six months aid newborn survival. But despite ongoing awareness and advocacy around the benefits of breastfeeding, the progress and uptake still remain low. The National Family Health Survey-4 (2015-16) reports that in U.P. only a quarter of infants were being initiated to breastfeeding within an hour of birth, and only a quarter continued to be exclusively breastfed till six months.

A 10-days design sprint and partnership with Uttar Pradesh State Road Transportation (UPSRTC) in 2019 led to U.P.’s first Breastfeeding Cubicle at a public bus station in the State’s capital, Lucknow. This project aimed at

a) Creating an enabling environment for breastfeeding within the bus station;

b) Communicating value around breastfeeding and respectful care for nursing mothers through Communication Design, thereby shaping behaviors; and

c) Reinforcing ideal behaviors around breastfeeding through nudges in the form of communication materials.

The approach of the participatory design was adopted, wherein the communication collaterals in the form of cubicle wall panels were co-designed and rigorously tested with a cohort of mothers from the target audience. Insights from consultations with key stakeholders within the health system and UPSRTC were also included throughout the design process. The Breastfeeding Cubicle is a safe haven for traveling mothers who want to nurse their infants in a public place like a bus station. The wall panels act as a catalyst to nudge mothers to breastfeed their baby, through the use of storytelling aided by contextually relevant illustrations.

Design Process:

The idea of having a Breastfeeding Cubicle at public bus stations was birthed by the sight of a mother struggling to nurse her infant in a busy bus station at Lucknow. The Managing Director of UPSRTC (Dr. Raj Shekhar) was taken aback to see the plight of the mother and decided to create a comfortable space for mothers to freely breastfeed their babies. Our team was commissioned to develop the wall panels for the cubicle, which was led by the designer.

Potential personas were mapped, based on insights gained from the Formative Research conducted as part of a Gates-funded grant to strengthen breastfeeding practices through Kangaroo Mother Care, as well as exploratory unstructured interviews with urban as well as rural mothers and Agrimaas (respectful care champions stationed at the Kangaroo Care Lounges in public health hospitals of Raebareli district). The Breastfeeding Support for Indian Moms (BSIM), a peer group on Facebook that aims at empowering mothers around breastfeeding was also used as a platform to gain an understanding of the “pains” and “gains” of breastfeeding i.e. common challenges faced by mothers and challenges specific to breastfeeding while traveling, from a larger sample set. Additionally, methods like role-playing and journey map were employed to build deep empathy and understand the current mental model of beneficiaries, along with a review of existing communication materials on infant nutrition. Insights obtained from all these activities helped frame certain guiding principles for the cubicle space as well as the communication materials to be used in it.

From the above, we learned that women who would avail the services of UPSRTC buses belong to middle and low-income families. Broadly, they can be categorized into:

• Mothers of babies younger than 6 months

• Mothers of babies older than 6 months

It was found that most mothers avoid traveling during the early months of the infant (less than 4 months). Therefore, our focus was on babies above 4 months which would include a mixture of breastfeeding infants as well as those on complementary feeding. As a result, one of the challenges for us was to bring a balance between information for these two types of infant categories in the existing architecture of the cubicle, with a major focus on reinforcing breastfeeding behavior. Messaging content for the communication materials in the form of wall panels were developed for the two categories of infants, with the common goal of calming down a hurried and anxious traveling mother in those 10-15 mins of the breastfeeding episode inside the cubicle.

On reviewing the existing communication materials, it was found that the tonality of the messaging was very instructive and direct. The desirable outcome (i.e. exclusive breastfeeding) was stated explicitly and contradicted the beneficiary community’s underlying socio-cultural reasoning. Therefore, our approach instead was to create a system that shifts behaviors and helps adopt ideal behaviors than merely changing them. A highly iterative process of co-designing and pretesting the prototypes with beneficiaries from seven public health facilities in U.P. was employed, along with inputs from health providers and UPSRTC stakeholders. During the pretesting, it was found that the shortlisted prototype version powerfully resonated with the beneficiaries and also affected their desire to not replace breast milk with other alternatives.

Project Outcome and impact

The above activities enabled the design and development of wall panels for the breastfeeding cubicle. In order to make it gender inclusive and balance any underlying gender connotations, the wall panels had a teal and fuchsia base. Principles of affect and salience biases were used to create a conversational and narrative-based messaging architecture and tonality. The messaging was framed as a dialogue between the mother-baby dyad, with the mascot (i.e. an infant) addressing key perceptions on breastfeeding through culturally grounded analogies, along with simple cartoon-style illustrations. Cues for messaging were taken from experiences shared by mothers during the interviews, which became instrumental in making it contextually relevant for the beneficiaries. In addition to this, a remote lactation tele-support system was also developed, wherein the nominee created the operational plan, call protocols, and a database.

U.P.’s first breastfeeding cubicle was inaugurated on 30th September 2019 by Shri. Ashok Kataria (Minister of State, Independent Charge for Transport). Data from pre-COVID times suggests that an average of five mothers used the Breastfeeding Cubicle every day, who found the space to be attractive as well as comfortable, and the messages to be intuitive. The wall panels have created a respectful and caring environment for severely resourced nursing mothers by nudging them towards the desired outcome of breastfeeding, without any imposition. Anecdotal evidence suggests that the vibrant color palette and illustrations grabbed the attention of most passers-by. Furthermore, the conversational tonality of the messages, especially the analogies, appealed to the beneficiaries’ cultural “sense”. With such a positive response, UPSRTC had also announced to scale this initiative across hundred bus stations in the State. However, the expansion has been on pause since early 2020 due to the pandemic, since all the resources across government bodies (including UPSRTC) have been directed towards COVID-19 relief efforts.

This project aimed at changing behavior of beneficiaries by reinforcing ideal behaviors to achieve the goal of breastfeeding. However, behavior change isn’t possible overnight. But what this initiative does is that it aids a gradual shift to achieving breastfeeding outcomes for such a critical social challenge in difficult terrain like U.P. through Communication Design. This initiative, therefore, acts as a stepping stone to achieving the larger goal of newborn survival in one of the toughest geographies in the world.

Sarah Tanishka Nethan is a Social Design Researcher working at the intersection of participatory design and Behavioral Science, and currently working as Lead, Family Planning & Reproductive Health at Vihara Innovation Network. Over the years, she has developed community-centric solutions across disciplines of public health (primarily Sexual and Reproductive Health; Maternal, Newborn and Child Health; and WASH), planetary health, gender, and education. An advocate for inclusion and Human-Centered Design, she is deeply passionate about building innovations at the confluence of local wisdom and Design that bridge the social-development equity gap within communities. Currently at Vihara, in addition to managing the FP-RH practice area, she is conducting a landscape analysis on measurement and evaluation within HCD+ASRH programs, with an aim to develop solutions for some pertinent challenges within this field. In the past, she has also worked on various multidisciplinary projects associated with the World Health Organization, Bill and Melinda Gates Foundation, UN Women, World Design Organization, Government of Uttar Pradesh (National Health Mission), and Stanford University, among others. She holds a B.Sc. in Fashion and Apparel Design from JD Institute of Fashion Technology, and Master in Design from National Institute of Fashion Technology, Mumbai.

Design Edu Today

The Design Edu Today podcast is a biweekly interview with design professionals discussing topics concerning the state of interactive design education at institutions of higher learning.

The Design Edu Today podcast is a biweekly interview with design professionals discussing topics concerning the state of interactive design education at institutions of higher learning. In order to help define interactive design for classroom instruction, guests are chosen based on their contributions—whether technical or theoretical—and leadership within the interactive design field. With the goal of diversity in experience and perspective, guests range from junior designers, to art/creative directors, studio owners both large and small, in-house or freelance designers, and everything in-between.

Launched in June 2015, the podcast’s initial goal was to discover the balance between instructing visual principles for digital design, such as flexible grids and screen-based typography and iconography, and instructing one of the core mediums of digital design: HTML, CSS and JavaScript. All of this must be accomplished in a limited number of credits within a graphic design program. Since the launch, the scope of the podcast has grown beyond its initial goal of finding this instructional balance to include broader research topics that include the overview of the entire process of interactive design, from the initial client meeting to final site launch. This expanded research also targets in depth discussions about each phase of the interactive design process, including information architecture, content strategy, user research, designing for performance, design workflow, and interactive prototypes.

Now over a year into the research project, the Design Edu Today podcast is a vast resource for design educators that includes over thirty episodes, complete with audio files, transcripts, and links to people, topics, and tools discussed during each episode.

Gary Rozanc is an assistant professor of graphic design at the University of Maryland, Baltimore County and the Education Director for AIGA Baltimore. Gary received his BA in Graphic Design from Cleveland State University and his MFA in Visual Communications from the University of Arizona. In May 2013, Gary was awarded the AIGA DEC Design Faculty Research Grant to uncover necessary competencies for entry level interactive designers to successfully transition from student to industry professional. As a result of this grant, Gary’s current research includes hosting the bi-weekly Design Edu Today podcast that discusses the current state of interactive design education at institutions of higher learning. Gary’s past research activities include identifying contextual methods of creating solutions through inquiry and problem-based learning, and his findings have been presented at international and national peer-reviewed conferences. Gary’s personal work ranges from responsive web design to letterpress.

Recipient of recognition in the Design Incubation Communication Design Awards 2016.