Most babies come into the world well equipped to cope with their new setting. Their lungs are primed to start breathing air, and to cry loudly. They wear a thick padding of baby fat to insulate against the relatively Arctic conditions outside the womb.
But for every nine babies who reach full term, one is born premature. The rate varies from country to country, but it adds up to 15 million premature births every year. It isn’t just that they’re early and small — these babies are not ready for life outside the womb some very crucial ways. Premature babies are at risk of lifelong handicaps and developmental problems, and even death.
Because babies born prematurely don’t have enough baby fat to maintain a constant body temperature. Precious calories that should be used to grow their lungs and brains and eyes are instead burned just trying to keep warm. If born before 37 weeks, their lungs may not be developed enough to hold their structure, making breathing labored and inefficient. More than half of babies develop jaundice soon after birth, as their circulatory system switches from routing blood through the umbilical cord to filtering blood through their own livers. But premature babies’ livers may not be developed enough to properly cleanse their blood, and this threatens brain development.
In rich countries, these conditions are routinely addressed. Babies who can’t keep themselves warm lay in climate-controlled incubators. Jaundiced babies receive prompt phototherapy, and constant positive air pressure (CPAP) machines maintain a steady flow of air into underdeveloped lungs.
But in much of the developing world, these therapies are not available, for fundamental reasons. Small national budgets, remote clinic locations, and limited or unpredictable electricity supplies make rich country solutions impractical or impossible. $20,000 incubators sit unused because the electricity is only on for a few hours a day. Too many jaundiced infants are squeezed under too few phototherapy units, cutting the therapy’s efficacy. A mother may need to return to her home village only a few days after giving birth, unable to stay in a clinic setting with her baby. The World Health Organization estimates that a million babies die each year due to complications of an early birth: 98% of them in the developing world. A baby born early in a poor country can face grim odds.
There is no finer investment for any community than putting milk into babies.
- Winston Churchill
But in an increasing number of these low-resource settings, Thrive Networks, an international development nonprofit, is using its Newborn Health program to tackle the special risks that premature infants face. In countries as varied as India, Vietnam, Uganda, Myanmar and Afghanistan, Thrive Networks is employing technologies and methods designed specifically for the conditions found in developing countries. By providing vital support to at-risk infants in their first few days, 450,000 babies have avoided the potentially fatal consequences of being born early and unprepared. Sarah Chynowith, PhD, is the Vice President of Thrive Health. As she says, “in the last few decades, a lot of progress has been made in improving womens’ health in the developing world. But newborn health has been largely neglected.” Thrive Networks employs innovative technology, thorough program implementation and rigorous self-evaluation to provide life-saving care for premature infants.
Alejandra Villalobos, Chief Development and Communications Officer, says that “technology alone isn’t sufficient. There has to be a plan for adoption, use, and uptake, or the program won’t be sustainable.” An integral part of the Thrive model is self-sufficiency. Over time, the local health care providers integrate Thrive methods into their existing newborn health programs, allowing Thrive Networks to reassign its resources to new settings.
I’ve got my love to keep me warm
In the last few weeks in the womb, babies pile on weight in the form of brown fat. Brown fat is a body fat designed specifically to be burnt maintaining body temperature at 98.6 degrees. Premature babies don’t have enough brown fat, and as they struggle to keep warm, development can lag or falter as calories are diverted from growth to heat.
In much of the developing world, unreliable electricity makes conventional incubators useless. And improvised solutions like heat lamps and coal stoves are bad approximates, providing too much or too little warmth.
In 2008, a group of Stanford design students were challenged to solve one of the shortfalls in neonatal care described above. Expensive donated incubators went unused in clinics where electricity and spare parts are difficult to obtain. Could the students design a technology to overcome this issue? Not only did they succeed, but their student project would mature to become two companies: Embrace Innovations, a for-profit business that formerly designed and manufactured the Embrace infant warmer, and Embrace, a non-profit aid organization that developed a program to put the infant warmers into use in developing countries.
In July, 2015, Embrace merged with Thrive Networks, an international NGO pioneering evidence-based programs and technologies in health, water and sanitation, and education for underserved populations in Asia and Africa. Within Thrive Health, the eponymous Embrace Infant Warmer joined a suite of technologies and programs that target neonatal care, treating thousands of babies each year. Central to their mission of providing vital care to premature babies is keeping them warm.
The Embrace Warmer, descendant of that Stanford student project, solves the problem of keeping infants warm without continuous electricity. The Warmer looks like a high-tech, infant-sized sleeping bag. The secret of the Embrace Warmer is not the sleeping bag, it’s the heating insert. Looking like a vacuum-sealed package of waxy soap bars, its power relies on a phenomenon that’s familiar to high school physics students: phase change.
Most people have encountered the strange power of phase change without realizing it. Fill a bucket with water, put a thermometer in it, and take it outside on a winter night in Vermont. You will see the temperature of the water fall steadily, until it reaches 32 degrees Fahrenheit. Once the water hits its freezing point, the temperature will stay pinned at 32 degrees until all the water has turned to ice, and only then will the thermometer start to fall again. In that bucket, a lot of energy gets exchanged while the temperature stays exactly the same: that’s phase change.
And if you had a substance that stayed at exactly 98.6 as it slowly changed from liquid to solid, you would have an ideal method of keeping infants warm. The Embrace’s heating unit is filled with a proprietary recipe of sustainably-sourced oils. It is pre-warmed briefly in an electric heater. The heating element is then slipped into a pocket sewn into the sleeping bag. The temperature of the mixture, and therefore the infant, stays perfectly steady for up to six hours. In fact, if the baby becomes too warm, the wax will reabsorb some of the heat from the baby. And unlike an incubator, the mother can take the Embrace Warmer home with her, a perfectly warmed cocoon for her baby.
Within Thrive’s Newborn Health Program, the Warmer is addresses a major gap in care: transporting newborns to and within health facilities. In many settings around the world, newborns are sent to the hospital by motorbike or oxcart, wrapped only in a blanket. But a blanket doesn’t provide enough warmth, putting the babies at risk for hypothermia-related complications and even death. The gold standard in developed countries is a transport incubator in an ambulance, but these are extremely rare in the developing world. Until now, no technology or device has successfully filled this global gap in care, and newborns continue to needlessly die as a result. Thrive is using the Warmer to tackle this issue.
And once the infant has grown large enough to maintain its own temperature, the Embrace can be reused. Before the sleeping bag itself wears out through months of continuous use, each $400 unit can serve up to 50 infants — at a fraction of the cost of a single conventional incubator.
This little light of mine, I’m gonna let it shine
Jaundice is a sign of serious health problems in adults, but in infants, it’s surprisingly common. 60% of all babies born will develop jaundice, and 90% of those babies recover on their own. The typical yellow pallor developed by jaundiced people is caused by a buildup of bilirubin in the body. In a healthy person, red blood cells are recycled by the liver as they wear out. Bilirubin is one of the byproducts of red blood cells as they break down, and is filtered out of the blood by a healthy liver.
Infants in the womb have their blood filtered by their mothers, via the umbilical cord. After birth, their circulatory system reworks itself, using their new livers for the first time to clean their own blood. During this transition, it is common for babies to show signs of mild jaundice, as their own liver function comes up to speed. But in 10% of jaundiced babies, their livers are not ready to remove this backlog of bilirubin, and without medical intervention, they face serious complications like cerebral palsy, deafness, or even death.
Fortunately, there is a simple therapy to treat jaundiced babies: phototherapy. When the infants are exposed to a bright blue light, the excess bilirubin in their blood breaks down into simpler compounds that pose no danger to the baby. The length of therapy varies, but can last as long as a week. The phototherapy device employed by Thrive Health, called the Firefly, is designed to be especially effective in challenging conditions.
The Firefly was developed by Thrive Networks and Design That Matters, and is produced by the Vietnamese company, MTTS. It looks like a tiny, transparent bathtub suspended between two tanning bed lights. Unlike traditional phototherapy units which shine therapeutic light via ceiling-suspended fixtures, the Firefly bathes the infant in light from above and below. By shining from all angles, the Firefly reduces the time required for effective therapy by 40%, minimizing time spent in clinic. It is small enough to place in a mother’s bed, uses power-efficient LED lights, and, crucially for the countries where Thrive operates, is affordable.
All I need is the air that I breathe and to love you
Babies born before 37 weeks risk having underdeveloped lungs. And the earlier they are born, the higher that risk rises. Underdeveloped lungs lack surfactant — a slippery substance that keeps the lungs from deflating. Without therapy, these infants struggle to breathe, starving their bodies of oxygen. To make breathing easier, Continuous Positive Air Pressure is applied. Via a nasal cannula, a gentle, continuous pressure of air is sent into the infant’s lungs to keep the alveoli open. Alveoli are the tiny cavities in the lungs where the real work gets done: exchanging oxygen and carbon dioxide between the lungs and the bloodstream. For babies whose lungs aren’t fully developed, CPAP therapy can be the difference between life and death.
CPAP equipment in the developed world uses disposable medical supplies. Hoses, mouthpieces and other parts are sterilized, sealed in plastic, used once and discarded. And many CPAP machines are used in hospitals that have a facility-wide compressed air system, providing clean, dry air on tap. Additional equipment is used to add humidity to the compressed air, and a pulse-oximeter to monitor the level of oxygen in the patient’s blood.
But these CPAP systems fail in low-resource settings, where clinics are short on resources and disposable supplies can be prohibitively expensive. The MTTS CPAP was developed to address these needs. Their CPAP unit is self-contained, incorporating air compression, humidity and gas mixture in a single unit. All of the components of the CPAP are designed to be sterilized and reused, instead of relying on expensive disposable components. An improved CPAP unit, called the Dolphin, is currently being developed by MTTS and Thrive Networks, scheduled to launch in 2017.
The real questions are: Does it solve a problem? Is it serviceable? How is it going to look in ten years?
One factor in the success of Thrive and its medical devices is the tight feedback loop between the designers, the manufacturers, and users in the field. Luciano Moccia, Thrive’s Newborn Health Program Director, says
“What is really important is having the design done in country — the engineers that work and live in low resource countries are aware of the challenges and needs of the local hospitals, and can design devices that are truly appropriate. In addition, ease of manufacture is an issue.”
Local designers are better at spotting design features that can’t be manufactured locally, and can move quickly to implement practical solutions. The devices employed by the Thrive’s Newborn Health Program are all manufactured in the developing world. The Firefly phototherapy bed and Dolphin CPAP are produced in Vietnam by MTTS (Medical Technology Transfer and Services), a company devoted to producing cost-effective, innovative technology for newborns requiring intensive medical care.
Since 2005, Thrive has worked directly with designers at MTTS. They collaborate on design, pilot programs in the field, and large-scale distribution. In fact, there are members of Thrive Health staff who work out of the MTTS office in Hanoi, ready with feedback and input at any time.
Similarly, Embrace Warmers are manufactured in India, where, in an earlier incarnation, Embrace both made and distributed the Embrace devices as a single enterprise. As with Thrive in Vietnam, Embrace was able to get feedback, incorporate improvements to the device, and address local health regulations and practices effectively.
Natural forces within us are the true healers of disease
In order to be truly effective, the Newborn Health program has to get buy-in by the single most important stakeholder: pregnant women who will soon be mothers. Naturally, the narrative varies from country to country. But the message is the same: your premature baby doesn’t need to die. We can help you keep your child warm and well until they are out of danger. And one of the most effective tools used by the Newborn Health program involves no technology at all: Kangaroo Care.
Kangaroo Care is a way of holding a baby, that emphasizes skin-to-skin contact. The parent holds the naked baby upright against their chest. The baby’s back is covered by the parent’s shirt or a blanket, like of a joey in a mother kangaroo’s pouch. The skin-to-skin contact is a perfect means of keeping the baby warm. By spending hours each day in this embrace, the infant gets other benefits: more regular heart rate and breathing, better oxygen saturation, more sleep, faster weight gain, more successful breastfeeding. The stimulation of the parent’s heartbeat and breathing, their voice and touch, fuel healthy development. No modern technology could hope to be as effective as a method as old as motherhood.
Everyone designs who devises courses of action aimed at changing existing situations into preferred ones.
- Herbert Simon
All of the devices employed by Thrive benefit from thoughtful, effective, and far-sighted design. But the job of good design doesn’t end at the factory loading dock. The method to deliver devices from the manufacturer to the end user has to be designed. The program to train in-country doctors and clinicians to use the devices requires thoughtful design. And the program’s impact needs to be carefully and accurately measured and analyzed.
Although it is cheaper to move goods around the world than ever before, getting the medical devices Thrive uses to their destinations is not easy or cheap. Transport is expensive in many countries where Thrive operates. In the US, getting nearly anything delivered overnight is now commonplace. But transporting goods from, say, dockside Hai Phong in Vietnam, to a clinic in the interior of Uganda, is difficult and costly. The lack of infrastructure that leaves hospitals without electricity also means that local railways and roads are in poor repair. The best tool Thrive has to leverage against these systemic costs is through economies of scale. Thrive can mitigate the expense of transport and installation by implementing single, country-wide programs, instead of taking a piecemeal approach.
When Thrive starts a new program, there is generally a full year of work before therapy can start in earnest. They begin with proposals at the state level, for example, the Ministry of Health in Myanmar. Health ministries everywhere recognize that improving infant health improves the health and prosperity of the whole society. Local conditions vary, and Thrive has to design a program that closely matches the needs and resources of their target population. Alejandra Villalobos points out, “nothing is easy or clear cut” when bringing their newborn health program into a new country.
At the start, Thrive identifies a handful of Master Trainers — health professionals who already work in country. After learning about the Thrive methods and technology, these Master Trainers train their own teams. Because these Master Trainers are already familiar with the local health programs, government agencies, as well as local customs and traditions, they’re the best placed to design and adjust plans for implementing Thrive programs. As Luciano Moccia says, “Local Master Trainers are, at the end of the day, the best trainers for their own country.”
Master Trainers spread knowledge to other health care providers, until hospitals and clinics throughout the country are working from the same playbook. For example, in ten years of work in Vietnam, a half dozen Master Trainers have trained staff in 150 hospitals. Trainers from the Vietnam program then went on to train new Master Trainers in Laos. After receiving similar training, Khmer Master Trainers spread the Thrive mission throughout Cambodia. The Master Trainers in Myanmar learned their skills from Master Trainers in the Philippines.
It takes three to five years for Thrive’s Newborn Health Program to fully take root, depending on the setting. By then, Thrive devices are deployed across the country, and doctors, nurses and clinicians have received newborn health training. The program becomes self-sustaining, and local Trainers can move out to new territories to spread the technologies and methods championed by Thrive.
And Thrive Networks goes one step further than many other development agencies. Thrive carefully measures the effectiveness of their programs. Thrive undertakes program assessments, as well as research in collaboration with universities. By publishing findings in peer-reviewed journals, Thrive is able to demonstrate the efficacy of their programs. In fact, academic institutes and medical device developers have come to Thrive, hoping to leverage Thrive’s ability to deploy technologies and programs into low-resource settings. Thrive’s model of evidence-based development encourages all stakeholders to search for even more effective solutions.
The mission of Thrive Networks’ Newborn Health Program is a massive undertaking. Improving the odds for vulnerable infants born in low-resource countries requires developing appropriate technologies, training medical providers, providing ongoing support and monitoring. But for thousands of babies, born early and unprepared, and their families, Thrive is the difference between a tragedy and a hopeful future.