NeoNurture: the "Car Parts" Incubator
Of the four million babies worldwide who die in the first month of life, one million die on their first day. Preterm birth is attributed, either directly or indirectly, to at least 25 percent of neonatal deaths , and low birth-weight (LBW) newborns are at the greatest risk. About half of the worldwide total, or 1.8 million babies each year, die for lack of a consistent heat until they have the body fat and metabolic rate to stay warm.
The current recommended method of providing infant temperature regulation in resource-constrained settings is Kangaroo Mother Care (KMC), the practice of placing newborns directly onto the mother's chest. KMC has demonstrated benefits in terms of improved weight gain for preterm infants, earlier hospital discharge and higher breast-feeding rates. At the same time, KMC also has important limitations:
- If the mother either dies in childbirth (as one of the 529,000 maternal deaths annually worldwide), or is too ill after delivery, she is unable to provide KMC.
- The majority of mothers have other obligations that prevent them from being able to provide continuous KMC, such as other children and/or a job to which they must attend. If no one else is able to provide KMC, a baby sent home for this care may receive it inconsistently at best and therefore suffer the complications of hypothermia, including respiratory distress, acidosis, hypoglycemia and even death.
- Skin-to-skin contact is considered a culturally inappropriate violation of privacy in some areas that rely on KMC.
As a consequence, at-risk newborns in developing countries need a warm, clean environment in which to grow stronger. Incubators can also help provide millions of at-risk infants with shorter hospital stays and can enable infants who might otherwise have faced a lifetime of severe disability to experience full and active lives.
In many poor countries, the majority of children are born at home. Part of the challenge is that district hospitals in rural regions typicaly lack the training and resources to improve upon the care offered by traditional birth attendants.
Despite the benefits and need for this equipment, incubators are not available in most poor countries. Conventional incubators designed for industrialized markets can cost up to US$30K. Not only is this price tag prohibitive, even if purchased, the devices are of limited utility in rural clinics due to the ongoing cost and extensive training requirements both for their use and maintenance. According to a study conducted by the Engineering World Health group at Duke University, up to 98% of donated medical equipment in developing countries is broken within five years. 
Our interviews with clinical and maintenance staff at hospitals in India, Bangladesh, Nepal, Cambodia, Vietnam and Indonesia provided concrete evidence of the challenges associated with incubators. In South Asia, there exists little in the way of trained technical staff outside of major cities. Spare parts are difficult to locate in rural settings, forcing medical staff to forego regular maintenance. In several instances, DtM's research team found operating incubators in rural Nepal with air filters that had not been changed in over five years, when filters are meant to be changed every six months. In addition, many broken incubators go without repair for want of inexpensive parts. For example, we found a broken incubator in Katmandu that needed a specific US$0.60 fuse--a part the hospital technician hoped to find on his semiannual trip to Delhi.
Maintenance staff in rural clinics also highlighted an inconsistent rural power supply as a problem. Load-shedding, which occurs when utilities temporarily turn off power to their customers due to electricity supply shortages, leads to voltage spikes that can easily damage or destroy sensitive hospital equipment--including incubators. In our research, parts associated with the power supply were the most common repair item on incubators.
IMPACTS ON HEALTH AND WELFARE
The impact of reducing neonatal deaths reaches far beyond the short-term goal of saving lives. According to the World Health Organization (WHO), a reduction in infant mortality rates yields lower birth rates and higher economic growth . Because high fertility rates in many societies are due in part to high child and infant mortality rates, lowering mortality rates at an early stage has a lasting effect on society and impacts the decisions parents make later on in life.
In turn, families are able to invest more in the health, education and future of their children, enabling families to be more sustainable. The WHO Commission on Macroeconomics and Health states that "each 10 percent improvement in life expectancy at birth (LEB) is associated with a rise in economic growth of at least 0.3 to 0.4 percentage points per year, holding other growth factors constant."  There is, then, a tangible return on the investment made to promote healthy individuals in developing countries, beginning at birth.
Partnering the implementation of the incubator technology with improved training for rural healthcare providers can have a multiplier effect on community health. The presence of a "good" rural clinic, with an incubator and trained staff, can create a magnet for clinical deliveries, as opposed to home births. Families deciding to give birth in a clinic, rather than at home, will lead to the mother and the infant receiving better care and having a higher chance of a healthy outcome. An incubator designed for local conditions and resource constraints, coupled with a rigorous training program for rural clinicians and non-physician care providers, will transform infant and maternal health in India and around the world.
OUR DESIGN APPROACH
We began the infant incubator project with extensive field research, starting with facilities in the United States. Our question was: in a context where money is no object, what are the standards for care? We conducted interviews and observations with domain experts and caregivers at Children's Hospital in Boston, the Harvard Medical School, the Stanford Medical School and many local neonatal intensive care units (NICUs).
Next, we conducted similar interviews and observations in newborn care facilities in our target markets, including hospitals and rural clinics in India, Bangladesh, Nepal, Vietnam, Cambodia and Indonesia. Interview subjects included hospital directors and administrators, NICU medical staff, newborn parents and extended family members, as well as members of the hospital maintenance and cleaning staff. In this case, our goal was to understand how the nature of newborn care changed given severe resource constraints.
Our contention from the beginning was that the creation of a context-appropriate infant incubator was, above all, a design problem. Maintaining a consistent temperature inside a box is not a difficult engineering problem. The success of our project entirely depended on our ability to get the context details right--and in this, establishing empathy with our intended users was critical .
This approach meant answering questions like:
- What qualities of the developing country context necessitate a radical re-thinking of the incubator features and requirements?
- How might we adapt the definition of an incubator, meaning the product requirements and specifications, to better fit the technology to the local needs?
- Who will pay for the incubator, both its purchase and its ongoing maintenance, and what are their requirements?
- Who will use the incubator, and how much training and education will they have?
- Who will maintain the incubator, and what do they have for tools and training?
THE CAR-PARTS INCUBATOR
Our research lead us in a surprising direction. After seeing countless piles of discarded medical device donations behind every hospital we visited overseas, we started asking the question, "What does gets fixed?" This lead us to the following series of insights and design directives:
- Automobiles are one of the few technologies that are reliably repaired in rural communities. Is it possible to design an incubator such that, if you know how to fix a car, you can figure out how to fix this incubator?
- There are over 40,000 parts in a standard SUV, and the auto industry has the distribution channels necessary to deliver those parts to the most remote communities. Is it possible to make use of some of those auto parts in the incubator design, in order to take advantage of economies of scale and access to spares?
- To paraphrase Paul Hudnut at Colorado State University, Coke, cigarettes and car parts are three products you can find pretty much anywhere in the world. Given that the auto industry can deliver parts to the most remote communities, is it possible for the incubator to take advantage of their supply chain to deliver incubator parts?
Following these directives, as well as the list of product requirements sourced during prior art research, user interviews and observations and a survey of the technical literature lead us to our design: NeoNurture.
WHAT MAKES NEONURTURE BETTER?
NeoNurture takes advantage of an abundant local resource in developing countries: car parts and the knowledge of auto technicians. This incubator leverages the existing supply chain of the auto industry and the technical understanding of local car mechanics. Among other components, it uses sealed-beam headlights as a heating element, a dashboard fan for convective heat circulation, signal lights and a door chime serve as alarms, and a motorcycle battery and car cigarette lighter provide backup power during incubator transport and power outages.
NeoNurture uses accessible parts while also meeting the needs of the infant, health care workers, and those who maintain and clean the device. It is an incubator that anyone — whether living in the richest country or the poorest — will be comfortable using.
NeoNurture is composed of two distinct parts: the bassinet and the base. The bassinet is detachable from the base and a surrounding handle allows two people to easily carry the newborn up and down stairs and over uneven ground — important features in the context of a rural hospital where infants often need to be carried long distances between the delivery room and the newborn intensive care unit (NICU).
The bassinet houses all of the mechanical systems for the incubator. This allows the bassinet to wait in the delivery room, maintaining a constant-temperature environment until the newborn is ready for transport to the NICU.
The warming system functions by powering two sealed beam headlights which provide warmth through conduction (warming the mattress from below) and convection (a motor blower which brings in filtered outside air for warming or cooling). The body also houses a door chime and signal lights which alert healthcare workers when the temperature of the baby or the environment rises or falls out of range. NeoNurture has built-in power regulation to protect against voltage spikes which is the source of 95% of damage caused to donated incubators. This low cost addition is not standard in most US equipment. A motorcycle battery and 12 volt car charger serve as additional power sources during travel from a home to a clinic or from a clinic to the hospital.
The bassinet canopy opens along a single hinge, providing three-sided access to the newborn during medical procedures--a feature currently limited to only the most expensive incubator models. The side windows of the canopy also drop open, allowing single-side access to the newborn for routine changing and feeding, without losing all of the warm air inside the bassinet.
The base of the NeoNurture mates precisely with its body allowing the incubator to maintain a level position, as well as two positions tilting ten degrees to the left or right. Mattress tilt is an important feature in many incubators as it aids infants with acid reflux. By integrating mating curves into the base and body we have addressed this feature while eliminating the need for a costly, automated system to power the tilting action.
NeoNurture’s base also provides for sterilized storage space for blankets. Located in the back door of the base is the battery charger and such items as additional air filters. The 18” inflatable wheels are durable for uneven terrain and the front full-swivel casters can be easily locked when stationary. If this portion of the incubator needs to be lifted or transported, integrated hand-holds have been included on all four sides.
The incubator’s temperature is controlled through an interface that integrates analog and digital controls for ease of use and the potential for easy repairs. The analog dial provides feedback to the user and the digital temperature screen provides quick visibility.
Active in the development of newborn care technology for the poor since 2004, Design that Matters (DtM) has had the great fortune of working with a huge crowd of talented students, professional volunteers and domain experts in the development of Neonurture, the Car Parts Incubator. Partners in our infant incubator work have included Medicine Mondiale in New Zealand and the Center for the Integration of Medicine and Innovative Technologies (CIMIT) in Boston. The project has benefitted from the design insights and clinical expertise of health care experts at Children's Hospital, St. Elizabeth's Hospital, Brigham and Women's Hospital and the Harvard Medical School in Boston, as well as from first-hand observations and interviews with newborn health experts and caregivers in Nepal, India, Bangladesh, Cambodia, Vietnam and Indonesia.
The design of Neonurture is based on concepts and prototypes developed by faculty and student volunteers at MIT, the Rhode Island School of Design, Stanford University and the University of Arizona, and from the input of professional volunteers at IDEO and Boston-area contract engineering and design firms. The alpha prototype was built by RISD graduates Tom Weis, Mike Hahn and Adam Geremia, and the beta prototype was built by Tom Weis, Emily Rothschild, Huy Vu, Paul Sherwood-Berndt and Mike Donelly.
1. Lawn et all. Neonatal Survival 1: 4 million neonatal deaths: When? Where? Why? Lancet 2005;365:891-900 (PMID:15752534).
2. Malkin Robert A., Technologies for clinically relevant physiological measurements in developing countries. Physiological Measurement, 2007, 28 R57-R63
3. World Health Organization. Macroeconomics and Health: Investing in Health for Economic Development. World Health Organization, Geneva, 2001
5. Prestero, T., Better by Design: How empathy can lead to more successful technologies and services for the poor. MIT Innovations Journal. Feb 2010
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