Timer to Prevent Post-Partum Hemorrhage

Post-partum hemorrhage (PPH) is the leading cause of maternal mortality in low-income countries. Administration of oxytocin immediately after birth is the most important strategy for PPH prevention, yet assessments around the world show that oxytocin is often administered late. We developed an “oxytocin timer” which reminds busy providers in low-resource facilities how long they have to administer oxytocin with beeps and a simple countdown display.  The timer uses minimal energy, can be charged with solar power, and costs less than $30. Providers activate it through the touch of their elbow, making it easy to use when attending deliveries alone. The device also registers time of birth, has extra timer functions for other clinical tasks, and records all data to be downloaded for additional analysis.  This simple device will improve quality of care and could save thousands of women’s lives each year if scaled to providers around the world.

Stark disparities exist in maternal mortality between low and high income countries –  462 per 100,000 live births in low-income countries compared to 11 per 100,000 live births in high-income countries. Post-partum hemorrhage (PPH) is the leading cause of maternal mortality and causes around one-quarter of global maternal deaths. In low-resource settings, prevention of PPH is particularly critical since many providers do not have the skills or supplies to effectively manage PPH, and it may be extremely challenging to refer patients to higher-level facilities given poor roads, lack of reliable transportation, and the monetary burden on families. Providers in rural facilities often attend deliveries alone and the health systems in which they work have limited resources to support them. Administration of oxytocin immediately after birth is one of the most reliable strategies for PPH prevention—studies have found it to cut the incidence of PPH roughly in half (Salati et al., 2019). Despite evidence of its effectiveness, assessments around the world consistently show that oxytocin is often administered late.  Providing training, to improve timely administration of oxytocin, has not shown to be particularly successful, and little attention has been paid to developing more effective interventions to ensure timely administration of oxytocin. 

In the commotion following a baby’s birth, 60 seconds feels shockingly short. We developed an “oxytocin timer” which reminds busy providers of their one-minute window to administer oxytocin with beeps and a simple countdown display. Since many providers attend deliveries alone and their hands are gloved and bloody, the timer is mounted on the wall and has large buttons that can be activated with the touch of an elbow. The provider activates the timer once the baby is delivered, which freezes that timestamp so providers can record it as the time of birth in clinical files once they are able.  The timer is designed for maximal energy efficiency and the battery can be recharged with solar power.  In addition to the timer function for oxytocin, the device includes the ability to set custom countdowns for other tasks such as monitoring contractions and performing malaria rapid tests, which expand the timer’s usefulness and impact beyond PPH.  A chip inside the device registers all usage data so that it can be downloaded for analysis.  Finally, the timer costs around $30 per unit thus making it accessible for wide scale use in low-resource settings. 

Our solution supports providers attending deliveries in under-resourced clinics, who in turn serve laboring women, in low and middle income countries.  In these settings, providers often work alone for long hours and must creatively manage life or death situations with minimal supplies. Our process for designing the timer involved these providers throughout. First, we conducted in-depth interviews with providers attending deliveries in rural clinics in Madagascar to understand their context and their challenges related to managing post-partum hemorrhage.  This gave rise to the idea of the timer, which we promptly tested through several weeks of interviews and role-plays with providers in their clinics to understand the utility of the timer and to iteratively improve its desirability and usability. During these tests, providers expressed enthusiasm for the idea and without prompting could explain how they would use the timer in their work. We made significant changes to the timer design based on their feedback, including the shape of the timer, its buttons, and several other key features. Additional implementation research would enable us to better understand the user experience and further enhance and improve the solution to meet providers’ needs in these resource-scarce settings. 

The majority of maternal deaths occur in low-income countries and postpartum hemorrhage is the leading cause of maternal death. Our solution seeks to improve service delivery by ensuring that all women are given oxytocin in a timely manner after birth. Expanding the workforce is not feasible in many settings and training is expensive and not always effective, thus, our solution seeks to improve quality of care with existing staff and materials in low-resource settings.  By improving timely administration of oxytocin in clinics around the world with this device, we can prevent many cases of post-partum hemorrhage and save many lives.

No direct competitor exists for our solution and, to our knowledge, this is approach which has not been tested. Trainings are the most common solution employed to increase timely administration of oxytocin and they are rarely effective. Our solution seeks to target the actual behavioral drivers underlying the lack of adherence of this clinical practice: limited attention, underestimation of time, and no feedback mechanisms on performance. Timers have been used for other clinical tasks, but not for oxytocin use, and our timer is designed specifically for the context of a delivery in a low resource facility (ex: button activation with the elbow, pre-programmed time windows, long battery life, solar chargeable, low cost, etc.).  All of these features make it an innovative solution to tackle an entrenched and important health challenge.

Our technology solution is a pre-programmed timer device with a chip which records all usage data. The technology is intentionally simple since low power usage and durability are critical objectives of the design given its intended context. The chip inside the timer can be removed in order to download data on to a laptop to understand how often the timer has been used and when, for which time windows, and how much time elapsed before oxytocin administration, among other potential analyses. Given challenges in data quality in many contexts, this new data source can provide critical information. 

Digital timers are a widely used and accepted technology. What is innovative about our solution is that it is pre-programmed with critical time windows for oxytocin and other clinical tasks, and its features are built to allow for ease of use during deliveries in low resource settings. These features were built through an iterative, co-creation process with providers in clinics in low resource settings.

Our theory of change is straightforward. Our final outcome is to decrease maternal mortality from postpartum hemorrhage. The evidence of the link between timely oxytocin administration and prevention of post-partum hemorrhage is strong. Thus, our intermediary outcome is to increase timely provision of prophylactic oxytocin after birth. We identify two behavioral mechanisms through which use of the oxytocin timer can improve timely provision of oxytocin after birth. First, the pre-set timer will reinforce the one-minute window in the mind of the providers, and secondly the timer will provide accurate, consistent feedback on adherence to this time window for the provider. We therefore hypothesize that use of the timer will, in turn, increase timely provision of oxytocin leading to fewer cases of post-partum hemorrhage and a decrease in maternal mortality. A key assumption in this theory of change is that providers will consistently use the timer. In order to ensure this assumption holds, we have been working closely with providers from the inception of the idea to ensure that it is desirable and feasible to use. The initial pilot test will be focused on implementation and usage of the device to ensure that the device is perceived as useful by providers and feasible to use consistently in the intended context. 

This is a new solution in the prototype stage and since it has not yet been implemented, it is not currently serving anyone. That said, a small-scale pilot test is planned in the upcoming months in Madagascar where it will be implemented in 10 clinics reaching about 13 providers and hundreds of women during the initial period. In one year we would hope to implement the solution in another 50 clinics in Madagascar thus reaching around 70 providers and close to 8,000 women over the first year period. In five years we hope to roll out to 1,400 clinics in Madagascar reaching close to 2,000 providers and more than a million women. We hope that the network and visibility of the MIT’s Solve challenge would provide opportunity to expand this innovation beyond Madagascar in the medium-term.

Over the next five years we plan on executing the testing, adaptation, and scale of the oxytocin timer together with the Madagascar Ministry of Health and our local partner project in Madagascar. The first phase is a small-scale implementation test to understand potential efficacy of the oxytocin timer in improving quality of care as well as the feasibility, acceptability, and desirability of the timer in the real-life implementation context. Our local partner project supports 1,400 basic health clinics across Madagascar and is interested in scaling the solutions to all of these clinics in collaboration with the Ministry of Health. After the initial implementation test, we would run a larger-scale efficacy trial to gather additional implementation learnings, particularly in how well the solution works in contexts different than the initial test, as well as the effectiveness of the solutions at greater scale. This second phase will also be critical to fully developing a plan for manufacturing the device at scale and to inform the longer-term business model of the product beyond Madagascar. The third phase will entail scaling within Madagascar and exploration of partnership opportunities to scale the product, together with Ministries of Health, in other countries. In order to understand what might be promising avenues for scale beyond our present partnership in Madagascar, we have already begun discussions with individuals who have scaled devices in similar settings and who are working on biomedical innovation within the oxytocin space.

Designing a device is a new area for our organization, so we anticipate a learning curve as we investigate manufacturing options and more broadly navigate the commercialization space. We are cognizant of this weakness and have actively been engaging a range of individuals more knowledgeable in this area to inform our efforts and ensure we benefit from their learnings. Another challenge will be in identifying the right buyer to bring the product to scale. Our current partnership is supported by federal funding, but this is unlikely to be the right funding source to scale the product beyond Madagascar. We have started to explore different options including partnering with manufacturers of complementary products to conduct joint “sales” to Ministries of Health and partnering within the private sector in the case that there may be financial benefit by offering the timer together with oxytocin supplies. In the next five years, we plan on carefully investigating our scaling options and assembling a committee of knowledgeable stakeholders to help guide our strategy. 

Please see response above on how we will respond to the two key barriers identified. We would welcome the support of the Solve community in overcoming these challenges.

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3 full-time staff (for part of their time), 1 part-time staff, and 1 contractor currently work on our solution team. Our local partner project includes two key counterparts as does the Ministry of Health.

Our organization has developed innovations in more than 40 countries and has been operating for 10 years. Our solution team is multi-disciplinary covering engineering, human-centered design, behavioral science, epidemiology, and health policy and management. We have all worked extensively in developing and implementing innovations in low-resource settings and our team includes a staff member local to our initial geography, Madagascar. Our local partners have extensive experience working within the health system of Madagascar, particularly in the area of maternal health.

We currently partner with a range of different organizations, but specific to this solution we are partnering with the ACCESS project in Madagascar and the Ministry of Health of Madagascar. Both our counterparts from ACCESS and the Ministry of Health have been involved in the co-creation process, which led to the development of our prototype, and they are actively engaged in the initial implementation of the solution which is planned for later this year.

Our overall organizational business model is that of a non-profit in which we offer behavioral research and design support and technical assistance to funders, governments, and implementing organizations around the world with the support of private foundations or federal funding. For the oxytocin timer, we are considering a range of different models. At present, this work is supported by federal funding and federal funding is poised to support the scale-up of the solution within Madagascar. As mentioned previously in the application, a key component of the initial phases of work will be to develop a longer-term business model which is not solely dependent on federal funding since this is unlikely to be a sustainable source of funding long-term. We will continue to craft this strategy as we move beyond the prototyping phase.

The next few years will be supported with grant funding, however, for scale-up outside of Madagascar we plan on exploring other avenues. We are looking at the sale of our product through a number of potential channels including directly to Ministries of Health around the world, to manufacturers of complementary products, among other channels we might explore in the next phases of our work.

We are interested in Solve to belong to the network of innovators. We described a few barriers our solution faces related to understanding the pathway to commercialization, both in terms of manufacturing as well as in identifying the most viable revenue model long-term. We believe that belonging to the network would be very helpful for informing our long-term strategy and helping us overcome these hurdles. Additionally, the funding could help support the second phase of work which will be critical to the solution’s success.

In the realm of manufacturing, we are interested in gaining greater understanding as to the best avenues for manufacturing at scale in order to reach our intended geographies with a quality product at a low cost. On the revenue model side, we would be interested in exploring partnerships with other producers which employ a direct sales model to Ministries of Health as well as private companies which may be interested to integrate our oxytocin timer with their existing product suite.

Please see above.  We do not have specific names in mind.

Our solution is focused on supporting the work of the providers working in low-resource clinics around the world (the majority of whom are women) to ensure high-quality delivery care for the women they serve. No woman should die during childbirth and our solution is focused on making this a reality, while at the same time understanding the challenging circumstances under which providers work. We would use the prize money to support a second phase test of our solution to ensure that the solution is feasible to implement within other regions of Madagascar and makes a detectable difference in improving quality of care for women.

Our primary audience of our solution are health workers in low-resource clinics around the world.  Health workers in these settings have many competing demands and our solution is intended to support their work to make it easier to provide quality care. We worked closely with providers to understand their context to ensure that any solution developed was aligned with their needs. When we tested our timer solution with providers, they expressed great enthusiasm for having a timer which fits their working context and they played a key role in shaping its functionalities and features.  We would use the prize money to support a second phase test of our solution to ensure that the solution is feasible to implement within other geographies in Madagascar and makes a detectable difference in improving quality of care for women.