PATH

Recognizing formal and informal influences on care 

At the outset, we recognized that women receive care and advice from a wide variety of places during pregnancy. Our goal was to identify these information sources and understand which are influential, which act as barriers, and which come from formal (i.e., trained) vs. informal (i.e., untrained) health care providers. One key discovery that impacted our product design criteria aligned around providing a strong sense of authority. Pregnant women’s primary points of care are family members, traditional birth attendants who are largely untrained, and formal care providers who have approximately 2 days to 1 week of training.

In addition to this, pregnant women are seldom “in-charge” of their own health-related decision-making. These insights meant it was imperative that the diagnostic device provided authoritative and unambiguous evidence to women, their care providers and family members to seek treatment (see infographic below). It is only with this type of information that those involved would be willing to reconsider deeply ingrained cultural beliefs or take on overcoming barriers, such as treacherous road conditions, to seek formal care.

Finding the opportune time for intervention

No matter how perfectly designed the diagnostic tool was, we realized that if it wasn’t disseminated in a culturally acceptable way, widespread adoption would not follow. Through immersive research, we identified several factors that keep women from giving birth in clinics or hospitals, thus increasing the risk of infection for themselves or their babies. One of these cultural factors is the fear of “the evil eye” (a curse) that might be placed on a vulnerable newborn.

Fearing this, women deliver babies in their homes, or in the homes of traditional birth attendants. The often unsanitary conditions of childbirth and the low visibility in the environment, as well as the lack of training of caregivers, mean that labor can be extremely dangerous. We had to accept this strong bias towards giving birth at home and reframe this risky infection period in a way that would allow us to introduce the diagnostic tool, yet not threaten traditional beliefs.

Understanding acceptability within cultural context

We recognized that we could have the most impact by introducing the diagnostic during labor (see infographic above) and set out to ascertain the ideal form factor of the diagnostic. Collecting a specimen such as blood or urine might be most accurate, but would it be acceptable, and therefore, practiced? To learn about acceptability, we conducted scenario-based acceptability research with pregnant women, their mothers-in-law, husbands, and other people who influenced how they sought and received care.

We discovered that women were not comfortable self-administering diagnostics that require any type of specimen collection. They also did not trust birth attendants, family, and community members to collect specimens or to interpret test results. Not only did they worry about testing accuracy, but they were apprehensive of the possibility that gossip in the close-knit community would strip them of confidentiality.

From insights to solutions

After months of discovery-design-iteration cycles, we formulated product design criteria that would serve to inform the development of the infection diagnostic. Criteria included specifics about who should deliver the diagnostic and how it should be administered, given the location of use. For example, if formal providers have the opportunity to provide care, the diagnostic should provide on-the-spot diagnosis to help patients avoid additional trips and also be bundled with the frequently used “maama kits” women are familiar with. If the diagnostic is used at home with an informal provider, the diagnostic must provide authoritative evidence to seek further treatment, be administrable by patients themselves, and not be invasive.

We also explored several design concepts that met these design criteria. One concept is a fever patch that women would wear immediately after labor. The patch can detect a continuous fever over a 25-hour period, which is a signal of infection at such a vulnerable time. As women experience intermittent fevers during labor, the seriousness of a continuous fever is commonly ignored. The fever patch is a non-invasive measure that shows when the wearer has a fever by filling with a red pattern that spreads over the patch. It gives an authoritative, yet unambiguous signal to women and their untrained caregivers that immediate help should be sought.

We also explored two kinds of kits, the first is a pregnancy care kit, assembled at the manufacturer, that includes diagnostics for all points of care: during the first antenatal care visit, the follow-up, and the post-natal care visit. The kit can be customized based on regional factors. For example, an HIV diagnostic would be included in Uganda, but not Bangladesh. The kit also could give providers guidance for how to administer diagnostics, and also, as patients could see which diagnostics they should be receiving, they could hold providers accountable to administer them.

The second kit is a diagnostic kit (pictured below) that would be assembled by a provider within a clinic. We found challenges in trying to keep current records, so the diagnostic kit helps keep patient information and test results together. The kit also incorporates the current method of test distribution and procurement that occurs in clinical settings, and can be customized based on what is in stock at the clinic.