Inspiring change in the birthing culture in Cyprus through the community building project Baby Buddy




As the educational platform Baby Buddy is impacting more and more new parents and babies lives here in Cyprus, every big venture has a story behind it. This one is a story spanning a period of over 2,5 years and the involvement of over 700 people. In fact, years before this new chapter of story was in the making, there have been many people contributing to the award-winning Baby Buddy app – led by the UK charity Best Beginnings – the parent of babybuddy.com.cy.

A conversation with two “parents” and leaders of the Baby Buddy Forward project, which developed the Cypriot Baby Buddy Nicos Middleton, (parent of two, second from the left) Scientific Coordinator of “Baby Buddy Forward”, BSc MSc PhD, Associate Professor, Health Sciences Research Methodology, Dean, School of Health Sciences, Cyprus University of Technology and Veronika Christodoulides, (parent of three, second from the right) CEO of Birth Forward and Project Manager of Baby Buddy Forward.


THE PROCESS

What’s the story behind Baby Buddy Forward?

Veronika: As an organisation which provides advocacy, support and education for families and professionals in regards to the various stages of planning, creating and growing a family in Cyprus, the first seed, the idea, of a joint educational platform for both pregnant couples/new parents as well as health professionals goes way back. I remember, we started discussing this prospect in autumn 2015 within the Birth Forward community. At the time, this sounded like a far away idea. We then looked into potential funding opportunities and identified the Erasmus Plus of the European Commission as a good match since they support such innovative adult education projects like we envisioned. As a new NGO, we were reluctant to apply as coordinator of such a big project so we focused our efforts on searching for potential partners with whom we could share this vision. It wasn’t long before we found the right people! I remember it was summer of 2016 when I attended an event organised by the School of Health Science at the Cyprus University of Technology in association with the Cyprus Breastfeeding Association. They were presenting their “BrEaST start in life” study which was the first study in Cyprus to depict the practices around breastfeeding and breastfeeding support for new mothers. I remember that day was really hot and I drove down from the cool mountains just for that presentation and I am so glad I did because I met similar-minded people, equally passionate about improving the birth culture and environment in Cyprus. This was a large interdisciplinary team of academics and clinicians, paediatricians, midwives and public health experts led by the School of Health Sciences at CUT and it was the perfect “match” with Birth Forward which also thrives on multidisciplinarity. We then started conversations over the summer and over another project Birth Forward was looking into (which never happened) we came in contact with Best Beginnings. The result was explosive. This is a Registered Charity of the UK with a big and inspiring vision to inform and empower parents and give every child a good start in life. Best Beginnings have an impressive track of digital resources and solutions. One of them is the original and multi-award winning Baby Buddy UK app which is the loving “parent” of Baby Buddy Cyprus. The contact came at the right time when Best Beginnings were also exploring ways to form international strategic partnerships. With Cyprus being the “stepping stone” for the first international trip of Baby Buddy, we added academic and SME partners from Greece and Germany to the conversation to spread the learning experience further and the partnership was in place.

Nicos: I also remember that day Veronika is talking about very well. It was like one of those “lightbulb” moments that you know will lead to something rewarding and meaningful. As health researchers, we often wonder about the practical impact of our research studies, and of course we always analyse the implications of our findings for future research, clinical practice or health policy and so on and make relevant recommendations. We teach our students and advocate for evidence-based practice and policy, that is clinical practice and policy that is based on research evidence. That same year, however, at the European Public Health Conference, I had another “lightbulb” moment. I had attended a round-table debate on the role of advocacy in public health research. That’s when I realised that the reason us public health researchers are often not as successful as we would like in bridging the practice -research gap is because we are thinking in the context of research-based policy and not policy-oriented research. That is, we take research to be the starting point in the hope that this will inform practice, instead of taking the actual practice or policy or system change we are hoping to achieve as a starting point and hence produce the research that will promote and encourage the conversation about practice and policy changes. Both the “BrEaST start in life” project and even more so “Baby Buddy” are good examples of such policy-oriented research projects, and I am personally grateful to all the people - core and extended Baby Buddy family - with whom we shared this rewarding journey together. The idea for Baby Buddy took shape and form as a three-year Participatory Action Formative Research project, and we handed in the application in March 2017. The funded part of the project started 2,5 years ago.

Baby Buddy is a policy-oriented Action research project because it takes action in re-thinking our current practices in antenatal education and designing a “complimentary” model of care since the Baby Buddy platform functions as an educational resource for future parents as well as a valuable tool to support the educational role of health professionals. The various research activities included in the project were of a formative nature, meaning they aimed specifically at helping us shape the content, ensuring its relevance and suitability for parents in Cyprus. It is a participatory project as it employed through its various stages processes of co-creation with the health professional community (Midwives, Gynecologists, and Pediatricians) and parents-to-be/ new parents themselves. More information about the vision but also the aims, the structure and the research process in the project website: www.babybuddyforward.com


Veronika: The key values behind Birth Forward, to bring together parents, academics and professionals from many fields to provide international best practise and knowledge, so parents can make the right choices for them have been really nicely implemented in this partnership. Through the “Baby Buddy Forward” project Birth Forward steps a big step ahead in materialising it’s vision to create an informative culture in Cyprus that honors, respects and includes parents in the decision making process of creating and growing a family, while providing evidence based, multidisciplinary information.


When did BB launch? Veronika: The official launch event was planned for the 19th of March 2020. I returned from maternity leave with my 4 month old baby at the end of January, just to get everything ready on time. Our team put in weekend and night shifts. We had planned it as a whole day event with seminars, round-table discussions and workshops in the morning for mother and child health professionals and an official first public demonstration of the platform for the media and parents in the afternoon.

Nicos: We had planned for all our international partners to be there and participate in the activities. We were excited that Alison Baum, Founder and CEO of our partner organisation Best Beginnings would be there. Alison was such an inspiration personally to me and to all of us during these last three years with her vision and achievements. She has been awarded an OBE (Order of the British Empire) by the Queen of England for her contribution to society, and in particular in tackling social inequality. We were also particularly excited that Prof Sir Sabaratnam Arulkumaran, past President (2007-2010) of Royal College of Obstetricians & Gynaecologists UK and past President (2012-2015) International Federation of Obstetrics & Gynaecology was going to give the keynote talk on the topic of Respectful Maternity Care and the need for valid and timely information.


Veronika: The event was overbooked. We had to double the planned space to cover the interest...and then Covid19 came and a week before the event everything had to be postponed indefinitely. We are now exploring new ways to go forward a bit differently than planned, and adjusting also our own working not only from home which I did before but WITH home meaning for me working with 3 little kids interrupting, working nights or dividing the working slots in shifts with my husband.

Now for Baby Buddy doctors have started to send out emails to their clients to let them know about this valuable resource, we started to promote it more actively through social media… We are very grateful that we are reaching new couples hourly, hopefully soon reaching thousands.

Nicos: Yes, circumstances might not allow us to have the “big bang” event we had in mind followed by workshops with parents, health professionals and decision-makers all over the island. But, lets not forget that Baby Buddy is a digital resource and a digital solution. So, this “new reality” is particularly suited to Baby Buddy. So, we changed our strategy and we are now not aiming for a “big bang” launch but a steady ripple effect for spreading the word and reaching far larger numbers that we would be able to accomodate in our workshops in “physical space”.


Is BBF an app or a platform?

Veronika: It’s a webapp, meaning it is like an app but runs within your normal browser and you can access it from any device. And, it is totally free. You simply need an email address to register and create your own profile on the site. Once you set the due date or the day of birth, Baby Buddy will remember that and it will have a new «daily message» for you, adjusted to the stage of the pregnancy or age of the child every day.


Who is BB aimed at?

Nicos: Baby Buddy is an innovative webapp, the first of its kind in Cyprus, with information for pregnancy, birth & mother-baby care. It is your personal baby expert and above all your virtual knowledgeable and supportive friend (your buddy!) who will guide and support you through pregnancy. It is aimed towards pregnant couples and new parents and it covers the period from early pregnancy up until the first six months of the baby’s life. It is also a complimentary tool for all health professionals dealing with this target group to support them in their educational role. In addition, it is a rich resource to use in health professional education both in clinical training as well as in continuous education.

We all know that there is no scarcity of information on the internet about pregnancy and childbirth and we know from research studies that the use of the internet for information-seeking is very prevalent amongst pregnant women. We know that this is also true locally. At the same time, there is a lot of evidence in the literature to suggest that the quality of information on the internet is problematic, the information is not always appropriate or even accurate. There is one more paradox: we know from previous studies, and we now know that this is also true in Cyprus, that a lot of pregnant women avoid discussing information found on internet with their healthcare provider, yet, they tend to double-check the

information given by the healthcare provider on the internet. This wrong order of things is perplexing and indicative of the user-provider relationship. It might be that women may not feel comfortable or confident to discuss the information they retrieved on the internet with their health professional. It might be that health professionals may not provide sufficient time for discussion or think it is necessary, and more likely a combination of the two phenomena.

In this “changing landscape” where the internet is a prevalent information source for women, studies internationally and locally suggest that women want to be reassured that the information is trustworthy and want direction to reliable pregnancy-related websites and other digital resources by their healthcare providers. So, health professionals need to engage with this new reality rather than ignore it, be aware of what’s out there, shortlist good quality web resources to suggest to their clients, such as Baby Buddy. Baby Buddy is an enhanced digital tool for their clinical and community practice...and it speaks five languages.


Why is BB needed here in Cyprus?

Nicos: Baby Buddy, I would say, is not needed just here in Cyprus but internationally. In fact, Baby Buddy Cyprus is the first attempt to internationalise an innovative digital population-level intervention developed in the UK by customising to a different health and socio-cultural system. Baby Buddy makes every moment in the journey to parenthood a “teachable moment” aiming to enhance parental health literacy while in parallel widen the reach to couples who would not normally benefit equally from current traditional arrangements.

WHO recommendations on antenatal care for a positive pregnancy experience refer to “Respectful maternity care”, which includes among other the need for good quality medical care with effective clinical practices but also relevant and timely information to support decision-making and psychosocial and emotional support. Traditional models of antenatal education are not as effective as we might like to think. This, together, with the unguided use of the internet for information which, we know, may produce negative feelings and stress,means we need to rethink the way we provide learning for new parents today.

Traditional approaches include (a) the conventional printed or electronic informational leaflets, which, nevertheless, beyond providing information on very specific and narrow range of topics, we know from research they are not always as effective as we might like to think, (b) the classic antenatal or birth preparation classes, which while invaluable we know that attendance is not always high, and (c) personal communication during appointments with the doctor, midwife or health care provider which, nevertheless, are commonly and understandably characterized by limited time.

With regards to the classes, there is no doubt that these can be extremely useful to future parents. The changes new couples experience in that period of life on all levels physically, emotionally, financially, in their value system etc is huge. Such classes are offered in all state hospitals but with restricted capacity while not every clinic in the private sector offers them. However, we know from research that only around one in three pregnant women in Cyprus participate in birth preparation classes. This is true internationally, and in some countries attendance is even lower. There are many reasons for that but we know that with availability, time, language and other barriers we may inadvertently maintain a system of unequal learning opportunities that excludes the people who need it the most, So we need to go where everyone is: online.

What kind of information do parents-to-be access and how reliable it is? Well it depends. We run a series of discussion groups with pregnant women and new mums parents from several cultural backgrounds about their education needs and information-seeking behaviour. The experience ranged widely from women who relied on their mother, friends or neighbours for information to women who read clinical guidelines and protocols in detail or called their doctors on a weekly basis. Some of the themes that emerged from the analysis of the focus group interviews are very indicative: The experience of self-navigating is quite common, but women may find themselves in parallel words of information which do not always converge. They often try to make sense through a process of “supplementing and filtering”, but seem to remain in a state of parallel “Doubt and “Faith”, whereas the relationship and good communication with their healthcare provider is viewed as important in resolving this.

Another really relevant aspect of adult education is timing. If I read something months before I actually need it, I might not pay attention or remember. So the information in Baby Buddy is tailor-made and distributed over the whole period of pregnancy until the baby is 6th month old. For instance, I will learn about a test that I need to have a couple weeks before it will be offered to me. Or, information about paid maternity leave or other social benefits and schemes is presented relatively early and then again later when I actually need to hand in the details to my employer and social insurance. Or, I will watch a video on introducing solids which should start at 6 months around the 5th month of the baby’s life. It is important to highlight that Baby Buddy does not only cover the medical aspects of care, but it addresses the transition to parenthood holistically, covering emotional needs and providing an “one-stop” source for available local resources and reliable international sites. For example, Baby Buddy will direct users to local antenatal or breastfeeding classes, the sites or informational material produced by other local organisations and bodies such as the National Breastfeeding Committee or the Cyprus Paediatric Society and others, or the sites to government offices where they will find application forms for maternity and paternity leave or other social benefits, .

And of course, two more aspects are really important: first, it is locally adjusted information and in a language everyone understands. There are global pregnancy apps available in English or plenty of books all referring to an English or American health system and culture. Some things are different in our health system, in our families and this resource is customised to Cyprus. In fact, the actual content covered is based on the topics that emerged from the research. In a series of studies, we have asked both health professionals and parents for their suggestions. Combining expertise and experience in this way, we shaped the content to address the real needs and expectations of parents-to-be in Cyprus. More than 700 health professionals and parents participated in some of the structured research activities in this co-creation process.



Who contributed to BB?

Nicos: The “Baby Buddy” partnership is a big family of institutions and people spanning three Univeristies and three non-governemental organizations across four European countries. The project is coordinated by the Department of Nursing, School of Health Sciences, Cyprus University of Technology. Locally, a large team of people, too many to list, both from the University as well as our local partner Birth Forward participated, each offering their special expertise in childbirth, pediatrics, language development, infant nutrition, mental health and so on. Basing our approach on a modified version of the co-creation model of our valued partner Best Beginnings, creator of Baby Buddy UK, it was important from the start to secure the support and participation of all relevant scientific bodies and associations here in Cyprus. This was very important as the principles underpinning the whole project are based on Participatory Action Research. It's an approach to listen to the collective intelligence, be guided by the expertise of health professionals and the lived experience of the parents themselves. Encouraging people to get involved in the co-creation process from the very beginning was a very important component of the project, as we wanted everybody involved to be part of the co-creation process, take co-ownership and of course pride in the result. We are very grateful that all responded positively to our call. So the Baby Buddy family includes the Cyprus Gynaecological and Obstetrics Society, the Midwives Committee of the Cyprus Nurses and Midwives Association, the Society for Perinatal Medicine, the Cyprus Paediatric Society, the Ministry of Health and the National Breastfeeding Committee as associated partners.

BABY BUDDY

What does BB offer?

Veronika: First of all, we should say that Baby Buddy was created by professionals and parents for parents! So you can trust it! All local material was created in consultation with the relevant scientific bodies in Cyprus, while the material we brought forward from Baby Buddy UK have been specifically selected for their relevance to local needs and priorities. All the information is based on evidence and best clinical practice. What’s more, it comes in small bits every day and it is presented in a friendly and supportive tone, in an easy-to-understand language, avoiding medical jargon. Baby Buddy is free to use and will be your virtual friend who will guide you through pregnancy and the first months of parenthood up to the 6th month of baby's life. Overall, the features are:

  • A new «daily message» with relevant information for the stage of pregnancy or age of the baby, every day

  • Over 200 short videos with experts from Cyprus and the UK offering advice on a particular topic as well as parents sharing their own experiences, practical tips and encouragement to help you look after yourself and your baby.

  • Over 400 Frequently Asked Questions with verified information

  • A Glossary of “what does that mean?” terms

  • Links to local websites of interest and hotlines

  • and verified external local or international sources for more information on particular topics

  • Encouragement with emotionally supportive messages and “you can do it” motivation

  • Suggested topics and specific questions you might want to discuss with your healthcare provides to help structure the conversation in your next appointment.

And all this is available in five languages: English, Greek, Turkish, Russian and Arabic.

Nicos: Other than the wealth of material, what makes Baby Buddy so special? The co-creation method: That it was created especially for parents in Cyprus! The information: That it is based on scientific evidence and best practices! The approach: That it doesn’t only aim to inform, but to empower and support the healthcare provider-user communication! The credentials of the partnership: That they can trust it!

How can BBF help users?

Veronika: First of all Baby Buddy walks along with the future mother (and the father) through this whole journey and offers information that is relevant to them at the right moment with the small daily messages. It will tell them about things they did not even think they should google but are really relevant to them. Or, the couple goes and sees a doctor and hears some term they don’t fully understand and can check in our “What does that mean?” or “Ask me” section with over 400 questions answered. Baby Buddy has over 200 short 2-3 min videos with parents and health professionals explaining things. There is an overall screening time of over 10 hours on a variety of topics such as pain management in labour, emotional well-being in pregnancy, the couple’s relationship, the importance of skin-to-skin in the first hour of baby’s life, how to latch on the baby to breastfeed, how to manage colic and other common conditions. Parents can also listen to parents sharing their experiences, for example, a mother drawing from her inner strength with the help of her partner to overcome the first challenges at home, or how to manage “unwanted advice” from everyone and anyone who has an opinion. Also, there are many videos about caring for a premature baby. This might only concern a small percentage but when you have a premature baby it is really challenging.

Baby Buddy will promote partner communication and will encourage couples to ask themselves: “How do you envision sharing the workload with your partner after the baby is born?”. It will also remind users of the importance of direct and open communication with their healthcare providers. Baby Buddy will encourage you to start a “Remember to ask” notebook, which you should take to your next appointment to help structure the conversation with the healthcare provider.


What languages is BB available in?

Nicos: Baby Buddy is available in English, Greek, Turkish, Russian and Arabic. We chose these languages as they largely reflect the demographic composition of maternity healthcare services in Cyprus. We believe in equal opportunities and access to timely and valid information should be available to everyone. It was particularly important to reach out to the population groups that are most in need but hard-to-reach, that traditional arrangements do not reach as effectively, and whose health outcomes can be usually improved the most. Often, non-Greek speakers may not speak English either, and there are few interpreters available in our hospitals. Using Baby Buddy, healthcare providers can reach out and surpass language barriers. The fact that the material is currently available in five languages particularly also highlights the transferability potential beyond the participating countries, to speakers of these languages across Europe and internationally. There might be a need to expand the range of languages in Baby Buddy in the future. For instance, during user-testing with our midwifery students at the University, they suggested that we should have also considered French or Spanish as this is commonly the only languages many Asian women speak comfortably other than their native language.


What feedback have you had so far?

Nicos: The feedback has been very positive from the very beginning and this was the most rewarding aspect of this project. As this was a participatory project, there have been many opportunities to engage with both health professionals and parents through the various stages of the co-creation process. All the health professionals we collaborated closely have highlighted the importance of this work and expressed their excitement about the prospect of using Baby Buddy in their practice. In some cases, this was in person and in other cases it was via participation in surveys.We are particularly grateful for the in-kind contribution of over 140 people - fellow academics, practicing health professionals, Birth Forward professional members and especially new parents - who participated in the various activities and/or feature in the videos. More importantly, the fact that all relevant professional associations and bodies have accepted our call to participate actively as associated partners in this project is in itself the best early-on indicator of the impact. In fact, there have been many positive side-effects. The co-creation process of Baby Buddy created a forum for interdisciplinary exchange and created a fertile ground for further collaborations. During the beta version user-testing phase, we had several opportunities to demonstrate Baby Buddy to future parents either in clinic visits or in organised pregnancy or mum and baby events, and the feedback was always positive. It is indicative that the number of registrations are increasing daily and we are certain that we will soon be reaching our first realistic target of 1000 users. With a cohort of less than 10000 births annually in Cyprus, this is already a high figure given that we haven’t been actively promoting due to the cancelation of the launch event.

Any other related information?

Veronika: Baby Buddy is to be used “along with” and not “instead of” other pregnancy support options. It is not supposed to replace personal contact and it is certainly not a replacement of the parenthood preparation class. One should never underestimate the importance of personal contact and the power of those small groups to create new friends with babies in similar ages. Peer support is extremely important over that period in life, creating lifelong friendships. Baby Buddy is a supplementary resource and in fact all Baby Buddy material is extremely helpful and can be used in antenatal classes for demonstration. More than three year planning went into Baby Buddy, and it is just a coincidence that the planned launch coincided with the start of this pandemic. Baby Buddy will be useful to so many couples for years to come. It is true that as a digital source of verified information based on research evidence and best clinical practice it is particularly suited in this new reality of social distancing and limited personal contact with health providers.


Furthermore, because all antenatal and parenthood classes around the island have been cancelled since the middle of March, we have gone beyond what we had originally planned. We have started online live webinars on birth preparation for pregnant couples with practising health professionals. In these sessions, experts will answer questions live and they will use Baby Buddy material to talk about their topic. The interest is huge, which we are trying to cover with more classes, not taking more than 100 couples at a time. The English series is starting on Monday 11th of May 8:30pm. Couples interested should email info@birthforward.com or contact us through our facebook site.


Additionally we have created a site https://www.birthforward.com/help-in-times-of-corona-crisis/ where we list the available services in Cyprus we know of relevant to pregnant couples. Our professional members offer support on breastfeeding, sleep, babywearing, and even physical or psychological support all available from home. Our experienced and trained mentors from our Parent2Parent program offer free one to one support to pregnant or new mums.

We also have a continuously updated weekly online live classes schedule including seminars and pregnancy yoga and pilates so the pregnant women who are all told to stay home can still stay healthy, fit and not isolated. (Questions by Alix Norman, Text by Nicos Middleton and Veronika Christodoulides)


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