This article has been published in Enabling Education Review 9
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Title: Life-saving lullabies: Using song in public health education in Zambia
Author: Reid, J
Publisher: EENET
Date: 2020

In this article, James introduces a research project led by Huddersfield University. It promotes inclusive, community-led approaches to accessible and sustainable public health education to reduce maternal and infant mortality and improve child development. Using songs to promote public health education and increase interaction between mothers and their children is part of a holistic approach to early childhood development and education.

The context
In Zambia in 2018, up to 15 women per week lost their lives in pregnancy due to preventable non-communicable causes. In May 2019, the president declared a public health emergency in Zambia. He called for ‘heightened interventions’ in maternal and child health (MCH) to ensure no woman or child dies, seeking new approaches to MCH that are sustainable and can be scaled up.

The reasons for maternal and infant mortality in Zambia are complex and involve a wide range of economic and social issues. These include significant differences between the services available in rural areas and urban centres, high rates of illiteracy, stigmatisation of unmarried pregnant women, and the availability of and distance to clinics. An important colonial legacy has also negatively affected the provision of MCH care. In the 1970s, various NGOs from the northern hemisphere sought to retrain traditional birth attendants (TBA) – women in the community who help pregnant women during pregnancy, especially when giving birth.

Although many TBA practices were inappropriate to the health and wellbeing of mothers and children, the desire to upskill TBAs ignored the intimate cultural, community and social aspects of their work. As a result, the intervention was only partially successful as the majority of TBAs did not complete their training and the sustainability of the programmes was affected by finite funding cycles and NGOs leaving the country.

Today, the cultural and social aspects of the TBAs’ work has been incorporated into Safe Motherhood Action Groups (SMAGs) so that MCH education continues to be provided in local communities, alongside clinical care, by local women, with local women. The Ministry of Health has contracted local NGOs, including St John Zambia, to develop the Mama na Mwana (mother and baby) project where volunteers are specifically trained to provide basic healthcare check-ups, advice and support. Nonetheless, recent gains in reducing the incidence of maternal and infant mortality have stalled.

Developing a local sustainable approach
The research team from Huddersfield University developed a partnership with St John Zambia, to define, develop and deliver a zero-cost, sustainable innovation strategy that could be scaled up. We wanted to start from an understanding of the everyday work of the MCH volunteers to avoid the colonising mistakes of the past. During 2019 we explored the work of the volunteers and clinical staff, all of whom were women, at two clinics in Lusaka in a one-day arts-based workshop,.

The workshop began with a discussion to assess the cultural and social efficacy of the ‘baby box’, a concept that is gaining interest globally as a tool for reducing maternal and infant mortality. We did not promote the box as appropriate. It is too expensive and the contents and design promote very specific notions of motherhood and ‘desired’ mothering practices that come from the global north. Instead, we explored how westernised practices compare to local experiences. The participants’ critiques of the baby box included it being made from inappropriate materials, it cannot be used to carry a sleeping baby, and it resembles a coffin!

Taking a context-appropriate approach
Following the women’s lead we explored items in everyday Zambian culture and practice. We considered using traditional chitenge – a piece of printed fabric – for communicating health messages in their design. The women identified 22 practical uses for chitenge as clothing, a blanket, a baby swaddle, a tablecloth and a wrapper for gifts. However, although the chitenge was culturally appropriate and ubiquitous, concerns emerged about the affordability and sustainability of using chitenge for health messaging, since the cloth may be produced and printed outside Zambia.

This led us to consider lullabies and songs instead. When women shared their experiences as mothers they mentioned singling lullabies and traditional songs to babies. We were also aware of an experience in Malawi where clinicians had taken to singing their new system of clinical standard operating procedures because their clinics lacked paper, ink and printers to print them out. By the end of the workshop, the St John volunteers began to develop songs that provided important health messages for pregnant women and new mothers.

During our later fieldwork 70% of young mothers we spoke to said they had sung contemporary, religious or made-up songs to their child. All the mothers agreed that they would enjoy singing to their child because it would be fun. We also know that singing can help build the relationship between mother and baby, and is highly correlated with good child development outcomes and mother and child mental health. This includes benefits to mother-child attachment, cognitive development, developing language and expressive capacities, and combatting post-natal depression. All of which benefit children’s later experiences in education.

Mothers and MCH volunteers were pleased to hear about the positives of singing to babies. They embraced the use of song as culturally appropriate, linked to traditional practices and because it can be shared within the community. They also accepted singing because they enjoyed making new songs together, felt empowered to share their experiences, and also found songs memorable, easy to pass on, and adaptable.

The volunteers have currently produced about 60 songs of various length and focus, they do this individually and in groups. One song, for example, is sung as a welcome to the new mothers as they arrive at the clinic, another is used to communicate the different services available at the clinic on different days. Shorter songs are used to inform new mothers of the benefits of breast feeding or their right to contraception.

The songs therefore, have become effective methods for communicating and learning important health messages. The next stage of our work is for the volunteers to create songs with young mothers and we hope to create a short documentary.

Adapting to Coronavirus
The adaptability of using songs was highlighted during the spread of coronavirus as the St John volunteers quickly, without cost, produced and performed songs focused on preventing the spread of the disease to women attending clinics. In September 2020, this frugal approach to inclusive public health education was awarded best in class for ‘social impact’ by Good Design Australia. The judges said it was:

“A really creative and well-designed solution… to produce a positive social and health outcome. The simplicity and very human nature of this solution to a deeply embedded cultural challenge is really inspiring.”

James Reid is a senior lecturer at Huddersfield University.