In her recent essay “Designing with Empathy,” Slow Space founder and architect Mette Aamodt writes, “Empathy is putting yourself in someone else’s shoes and feeling the emotions they feel.”
What if this “someone else” is a pregnant woman in Malawi, one of the world’s poorest countries? As an architect, how do you put yourself in that pair of shoes, in which she walked the long journey from her village to the district hospital in Kasungu, where she hopes to receive essential medical services that will give her a better chance of surviving childbirth?
Only slightly more than half of the children in this Southeast-African country are born under the care of a medical professional. Malawi has one of the worst maternal mortality rates in the world — 634 deaths per 100,000 live births (est. 2015).
The University of North Carolina (UNC) had already been working with Malawi’s Ministry of Health on a larger initiative to help address maternal mortality through medical practices and protocols. As part of the project, the Ministry had quickly and with very limited resources created a prototype maternity waiting home; a bare-bones rectangle, housing 36 beds and a small bathroom at its core. Outside, a small, unshaded space for washing laundry. They planned to build 130 more maternity waiting homes across the country, based on that model.
At the time, Boston-headquartered MASS Design Group (MASS) already had an office in Kigali, working on projects in Rwanda. The firm was invited to Malawi to contribute a design that could improve the mothers’ experience and help to mitigate that country’s unfathomably high maternal mortality rate. Women waiting until they are too close to labor for making the distance and women who had planned on giving birth at home in their village but encounter complications, far away from the nearest doctor, are at a particularly high risk. Thus, a maternity waiting home is a facility in the proximity of a hospital or health centre, where expecting mothers can stay toward the end of their pregnancy and await labor.
MASS Design Group’s mission is to design environments that promote health and dignity. The firm, founded as non-profit organization, aims to advance a movement that fosters public awareness of the way architecture can hurt or heal. Empathy in architecture, trying to understand the feelings of their design’s future users, is woven into the fabric of the firm. “It’s not just the Maternity Waiting Village for us that embodies empathy in design,” says Director Patricia Gruits, LEED. “That is really part of what we as a firm bring to all of our projects. We claim that entire process as an opportunity to ensure dignity and empathy across the continuum of design and construction.”
We claim that entire process as an opportunity to ensure dignity and empathy across the continuum of design and construction.
Before beginning to design, the MASS team traveled to the site of the future Maternity Waiting Village, set adjacent to Kasungu’s district hospital, where pregnant women from the surrounding villages came to deliver their babies. “We always start each project with what we call ‘immersion’,” Gruits notes. “It’s about immersing ourselves in the community, so we understand the needs, the context, any opportunities of the project — not sort of drop in a solution.”
It’s about immersing ourselves in the community, so we understand the needs, the context, any opportunities of the project — not sort of drop in a solution.
On his first site visit, her colleague Jean Paul Sebuhayi Uwase, design associate in MASS’ Rwanda office, was shocked to find these mothers under the rain, without shelter. Some stayed in tents, others slept outside under the trees. “What if this was my mother?” he remembers thinking. “For you to go through the experience of giving birth, you deserve to have this space that treats you well. That was pushing us to design, to go outside of the normal things, for this to be a special place for these mothers to give birth, but also a special space for people to change their mindset of not always delivering at their homes or in their villages.”
During the immersion, the MASS team quickly observed how social the Malawian women were, spending most of the time gathered together outside, sitting on the ground, around a tree in the shade or under the overhang of another building. The current prototype design clearly was not responding to the Malawian way of life.
Researching the setup of typical Malawian villages, the team found that even as younger generations start their own families, they all stay in the same area, near the houses of their parents and grandparents. The family life extends fluidly. “That creates a social cohesion within the family,” Uwase says. How could they recreate aspects of the mothers’ village life through design? By allowing empathy to influence their architecture. The common spaces in particular were designed to encourage gathering and interacting. “That creates a friendship that extends beyond the Maternity Waiting Village,” Uwase says. The hope for the Village is to encourage the women to carry on a social life and normal friendships. Gruits references the project’s main goal: “We really wanted to transform this maternity waiting experience from something that was seen as a negative experience for mothers, something that disempowered them, to something that was empowering.”
We really wanted to transform this maternity waiting experience from something that was seen as a negative experience for mothers, something that disempowered them, to something that was empowering.
The architect speaks of a local nurse’s vision for these women to come and learn a skill, so they can return to their villages not only with a healthy baby but with new potential and opportunities. Classes on gardening, nutrition, cooking and family planning are crucial to the program. “All of that is about really impacting and empowering her to make better and different life decisions that are right for her and her family.”
Empathy in architecture: Design for dignity
36 women sleeping in one big room was not the right answer to fostering solidarity. Based on their research on social interactions and social networks, MASS instead designed small huts that sleep four women each. Clusters of three huts surround a core of washrooms, showers and a laundry area 12 mothers share. A total of three clusters is complemented by a room for classes, several outdoor areas and a kitchen.
The local nurses and UNC saw additional opportunity to pair experienced mothers with first-timers, so they can coach each other along and answer questions. “There is now this much more communal approach to giving birth and to the pregnancy process,” Gruits says. Her colleague agrees: “The way it has been designed really helps to facilitate all of those relationships and connections.” The team even renamed their maternity waiting home Maternity Waiting Village, for its many chances to encourage relationship building through design.
The designers also had to address Malawi’s extreme climate of very strong rain seasons and very hot dry seasons. The mothers needed protection from the rain throughout the village, including covered walkways. But they also needed shaded areas where they would be protected from the sun. “So we really focused on the roof of the project,” says Gruits. “We looked at the roof to create those overhangs to shade and to protect from the rain.” Ample outdoor spaces now facilitate education programs and cooking classes or simply for the women to cook and gather together more comfortably.
What’s more, the mothers are typically accompanied by family members, who cook for them, keep them company and help them through the delivery process. So the designers doubled the number of toilets and added large benches under the overhangs. “If we couldn’t provide a bed for the guardians, at least we could provide protection from the rain and the sun,” Gruits says.
In the quest to combat maternal mortality beyond the Village, a key design objective had been to inspire the mothers to return to their villages and in turn encourage other pregnant women to make their way to the Maternity Waiting Village in Kasungu.
Building for a future
Malawi suffers from extreme deforestation, and high-quality building materials are hard to come by. “When you fire bricks, you use a lot of wood,” says Uwase. “So on this project, they were interested in us testing alternative building materials that would be more sustainable and would be solutions to combat deforestation.” The group implemented CSEBs — compressed stabilized earth blocks, which use very small amounts of cement and no firewood. Local laborers made the bricks onsite.
Uwase speaks passionately about the opportunity to train the local carpenters in reading technical drawings, and to influence them to think differently about materials. “Part of our model at MASS is that we are not just designing a building and dropping it off,” Gruits adds. “We train wherever we can, which not only ensures the stewardship or the repair or the maintenance of our own buildings but also that those same workers may go off and use that skill on another job and make more money.”
Uwase has returned to Kasungu three times since construction finished and women have moved into the Maternity Waiting Village he helped to build. One of the doctors told him that word-of-mouth is spreading about “one of the best places to wait when you are attending the maternity services.” If anything, too many mothers from the area surrounding Kasungu are coming. “It’s a good sign,” says Uwase. “It shows a response to one of the concerns we had when we studied the design, and how the design can change the mindset and attract more mothers. And that’s happening now, which makes me happy.”
More mothers are waiting
The MASS team knew from interviewing mothers beforehand that there would be more than 36 mothers at a time wanting to come. “There is a bigger demand for this Maternity Waiting Village,” Gruits notes. “Part of it being well designed is that we’ve been successful in encouraging more mothers to come, but we need more of these facilities to actually accommodate the demand.” The district hospital itself is currently adding on to their maternity ward. “It’s a huge success that they would invest in that infrastructure.”
The Malawian Ministry of Health is now considering implementing the MASS-designed Maternity Waiting Village prototype on a larger scale. “We’ve had conversations as well with NGOs and other leaders in Zambia and even in Uganda about maternity waiting homes,” Gruits says. “People are interested in using our model, and we see this as an opportunity for other countries that are also looking at maternity waiting villages as a solution to their maternal mortality issues.”