Content note: includes childbirth documentation, hidden until you choose to view

Bachelor of Design graduation project · Product Design · 2017

An emergency delivery aid for the smallest clinic in rural India

Field research across Nashik district led me to design an emergency delivery aid for Sub Centres, supporting the squatting posture rural women already live in, so birth can work with gravity instead of against it.

Product Designer · Independent graduation project

Secondary research, interviews, field observation of live deliveries, clinician validation and ergonomics

Best Graduation Project award

Final jury, Bachelor of Design, 2017

Read the research

ROLE

Product Designer

Independent graduation project

CONTEXT

B.Des, Product Design

Graduation project, 2017 · Best Graduation Project award

FIELD

Nashik district, India

Sub Centres, PHCs and the Civil Hospital

RESEARCH

20 women · 5 clinicians

Interviews, plus live deliveries observed

The brief

An aid for the smallest workplace in Indian healthcare

AIM

Design an emergency delivery aid for the Sub Centre that supports the squatting posture for women in normal delivery.

The Sub Centre is the most peripheral contact point between a rural community and the primary healthcare system, a single room staffed by one male and one female multipurpose health worker. The aid had to serve that room, and a home delivery assisted by its staff.

Synopsis: aim, objective, goal, scope and delimitation, from my project deck

OBJECTIVES

PortableSafe deliveryLow costLess time-consumingErgonomically designed

Goal

Address the real needs of the Sub Centre and the staff who work in it.

Scope

Usable for delivering at home with the support of Sub Centre staff, and a guide to normal delivery that communicates with the support staff.

Delimitation

Rural areas of Nashik district, Maharashtra.

The problem

Most maternal deaths are preventable, and they happen furthest from care

Skilled care before, during and after childbirth can save the lives of women and newborns. Maternal mortality is highest among women in rural areas and poorer communities.

~830

women die every day from preventable causes related to pregnancy and childbirth

WHO maternal mortality factsheet, November 2016

99%

of all maternal deaths occur in developing countries

UNICEF, Maternal Health

27%

of maternal deaths are caused by severe bleeding, second only to pre-existing conditions (28%)

UNICEF, Maternal Health

70.2%

decline in India’s maternal mortality ratio, against a 44.7% global decline

Pradhan Mantri Surakshit Matritva Abhiyan

The starting point: daily life, environment, critical situations, habits and media for a pregnant woman in a rural village

The problem: causes of maternal death, and my research area of pregnant women, newborns and new mothers

Present scenario: the PMSMA scheme offers free antenatal check-ups on the 9th of every month

Understanding the situation: poverty, distance, lack of information, inadequate services and cultural practices

Healthcare delivery in India

Following the system down to the Sub Centre

Healthcare runs from central to state to local, and from tertiary hospitals down to primary care. At the very bottom sits the Sub Centre, where a rural woman first meets the health system.

Tertiary care

Regional and specialist hospitals

Secondary care

District and peripheral hospitals

Primary care

Health posts, Sub Centres, block and community health centres

Healthcare delivery system in India, from central planning to the Sub Centre in Nashik district

Focus area: the Sub Centre, its staff structure and its six service functions

Role of the healthcare providers: ASHA supervisor, ANM, ASHA and Aganwadi workers

ANM

Auxiliary Nurse Midwife. Multipurpose health worker who conducts home deliveries and is the first contact between community and health services.

ASHA

Accredited Social Health Activist. The bridge between the ANM and the village, bringing pregnant women in for check-ups. One per 1,000 people.

ASHA Supervisor

Visits monthly during vaccination and keeps the records of pregnant women and newborns, by hand.

Aganwadi worker

Works with children under 6, and visits homes to help mothers plan for their child’s growth.

Key users

Designing for the woman, and the people around her

Primary user

Pregnant women in rural areas.

Secondary user

Health service providers in rural areas: ANM, ASHA and Sub Centre staff.

Tertiary user

Gynaecologists and obstetricians.

Key users: primary, secondary and tertiary

Field research

Twenty women in Mohadi village, Dindori

I interviewed pregnant women with a prepared questionnaire, covering age, income, education, family, media use, nutrition and where they delivered.

50%

were pregnant between the ages of 16 and 20

Age of pregnancy

60%

showed iron deficiency

Nutritional status

80%

live in joint families

Family support

90%

use a mobile phone, the strongest media channel

Role of media

40%

delivered in a Sub Centre (45% in a PHC, 15% at home)

Place of delivery

Analysis: age, income, education and family support

Observing birth

Watching how delivery actually happens

I studied squatting and lithotomy deliveries through live delivery documentation by Arogya Vidya (Dr. Shyam Ashtekar), then observed live deliveries myself at the Civil Hospital, Nashik.

Sensitive content in this section

These images document childbirth. Each one stays blurred behind a screen until you choose to view it. The sketches and findings beside them describe what I learned without the photographs.

SQUATTING POSTURE · DELIVERY IN A SUB CENTRE

Stages of delivery, and how the posture transforms with 1 trained nurse and 2 supports

Two poles take the push

Strong support from two poles helps the woman put all the pressure ahead.

Heels need somewhere to rest

The body presses forward onto the toes, so the heels need support to rest down.

Holding a pose is unbearable

One birth helper has to support her legs, because keeping them in one position for long is unbearable.

Three people around her

A trained nurse and two supports, one of them ready with everything the baby needs.

AFTER BIRTH, AND LITHOTOMY POSTURE · HOME DELIVERY WITH ASSISTANCE

After birth: the posture shifts to resting behind, the cord is cut and the baby is cleaned

Lithotomy (supine) posture: cervical dilation from 5 cm to full, then the placenta

ON FIELD · LIVE DELIVERY AT THE CIVIL HOSPITAL, NASHIK

My documentation at the Civil Hospital, and my storyboard analysis of a lithotomy delivery

Lying flat by default

Deliveries were conducted in the lithotomy position.

Two births at once

Staff attended two deliveries at the same time.

Nurses lean on interns

One trained nurse, supported by interns.

Hygiene breaks down

Fluid spreads across the table; the environment was unhygienic.

The insight

A posture rural women already live in

Minor observations: activities and habits in the squatting posture

Familiar

Women in rural areas are used to the squatting posture.

Everyday

Almost every daily activity happens in a squat, and it works as exercise.

Helps the baby descend

In pregnancy, practising squats helps the baby’s head move downward gradually.

Builds strength

The ability to squat increases strength, making a squatting delivery possible.

Validating the need

Comparing birth positions, then asking clinicians

I compared six birth positions, then took the squatting position to five clinicians in Nashik. Most rated it favourably, and each pointed to further design opportunities.

Squatting

Lithotomy / supine

Benefits

Gravity assists the baby’s descent, less pain, shorter labour, significantly more pelvic space and more efficient contractions.

The easiest position for the birth helper.

Drawbacks

Sometimes hard to assist.

More painful, forces the mother to push against gravity, lengthens the pushing stage and raises the risk of forceps or vacuum delivery.

Practised birth positions: squatting against lithotomy

Validating the identified need: position reviews and clinician responses

CLINICIANS CONSULTED

Dr. Vanashri Kulkarni (Janakalyan Rugnalay, Indiranagar) · Dr. Shyam Ashtekar (Arogya Vidya) · Dr. Chaudhari (Gokul Hospital, Pathardi Phata) · a retired gynaecologist with 60 years of experience · Dr. Sankhlecha (Saubhagya Hospital, Gangapur Road)

Opportunities they raised: an adjustable, comfortable delivery furniture, an aid for painless delivery, a digital partograph, a diet plate, an exercise kit and support for breastfeeding.

Medical groundwork

Learning the body before designing for it

To design for birth I first had to understand it: the terms, how pregnancy changes the body, the stages of labour and the ways a baby can be delivered.

~20 h

First stage: dilation

Latent phase around 12 hours, active phase around 6, transition around 2.

~2 h

Second stage: pushing

From full dilation to birth, around 2 hours. This is where posture matters most.

1–2 h

Third stage: placenta

Delivery of the placenta, 1 to 2 hours.

Stages of delivery: dilation, pushing and the delivery of the placenta

Stages of pregnancy across three trimesters, 40 weeks from the last menstrual period

Changes in pregnancy: loosening pelvic ligaments, swelling feet and ankles, leg cramps and more

Types of delivery: vaginal, caesarean, vacuum extraction and forceps

Understanding the terms: healthcare, pregnancy and child delivery

Why squatting works

A new understanding of an old position

Squatting during the pushing stage opens the pelvis and gives the baby more room to be born, with gravity helping rather than resisting.

Up to 15%

larger pelvic outlet when squatting, compared with lying down

About 1 to 2 cm wider, from the positions research board

Angles

feet and knee placement changes the pelvis

Feet and knees forward widens the space between the sitting bones; turned out narrows it.

Heels

most people need something under their heels

Without ankle flexibility, a rolled towel or a book under the heels makes the squat possible.

Importance of the squatting posture, and the range of squat and semi-squat positions

A new understanding of an old position: foot placement and the baby’s travel through the pelvis

Existing products

Every table I found was built for lying down

I documented delivery furniture at Sub Centres in Mohadi and Dugaon, the PHC in Mohadi, the Civil Hospital, and Saubhagya and Gokul hospitals. None supported an upright birth.

Existing delivery furniture across seven facilities in Nashik

Analysis of the existing delivery table: a cut for examination and fixed hand grips

Lithotomy only

Built for a supine delivery, with 2 birth helpers and 1 doctor around it.

Steel, resin and raincoat cloth

A stainless steel bed, resin cushion and a mackintosh cover.

Fixed and heavy

One section, 1290 × 760 × 840 mm, with no adjustability and no portability.

From research to requirements

What the aid has to do

Each requirement traces back to something I observed in the field or heard from clinicians.

Something to push against

Handles or poles placed so she can drive all the pressure forward, as the two poles did in the Sub Centre.

Support for the heels

A surface for the heels to rest down while her weight shifts onto her toes.

Let the posture shift

From squatting during labour to resting back after birth, without moving her off the aid.

Room for three people

Access for a trained nurse and two supports, including space for the baby’s things.

Hygiene by design

Catch fluid directly below, so it does not spread across the surface.

Fit the Sub Centre

Portable, low cost and quick to set up, so it also works for an assisted home delivery.

Design brief

An aid for normal delivery in the squatting position

The aim: fewer complications, less pain and a shorter labour.

ESSENTIAL FEATURES

Easy to assist

Easy for a rural birth helper to operate and assist with.

Safe and quick to set up

Ready for delivery by one birth helper in the quickest possible time.

Reliable

Something a woman can depend on to deliver her baby.

Economical

Affordable for people in rural areas.

Ergonomic

Designed around her need for support and grips.

DESIRED FEATURES

Portable and lightweight

So an ANM worker can carry it to emergency home deliveries.

Simple to repair

Simple enough to be fixed in a rural area.

Visual research

Image boards for posture and for place

One board gathered how squatting birth has been supported across cultures and products; the other captured the rural life the aid would live in.

Visual board: squatting for labour and birth, past and present

Visual board: women’s daily life in rural Nashik

From posture to form

Drawing the body first, then the aid around it

Before sketching furniture, I drew the squatting body: its hip, knee, back and heel angles, and every point where it needed something to lean on or hold.

POSTURE STUDY

Study of the squatting posture: body angles, back and heel details, and how the position transforms

Back support

Helps her hold the right posture and prevents back pain.

Heel support

A raised block under the heels helps prevent tearing.

Five positions, one seat

Pushing and crowning, shifts for rest and stitches, then squat and rest after the placenta.

Angles to design to

I measured back angles between roughly 65° and 75° across supported squats.

SUPPORT STUDY

ESSENTIAL PICK POINTS

1. Backrest

2. Hand grips

3. Support

4. Elevation for the seat

BRAINSTORMING

IDENTIFICATION · NEED

1. Portability

2. Grips

3. Support

4. Communication

MODIFICATION · DESIGN CHARACTER

1. Easy to clean

2. Frictional where needed

3. Light enough to carry

4. Sturdy

5. Material, form and structure

6. Stitching pattern

REPRESENTATION · APPROACH

1. Image board of existing product language

2. Postural study for supportive forms

3. Material palette

4. Study models

Brainstorming: identification, modification and representation

Ideation across three settings: institutional delivery, and home delivery with and without assistance

DIRECTION ONE

Framed chairs

Rigid frames built around a horseshoe seat, with side grips, upright poles to push against and trays to catch fluid.

Early forms: enclosing frames, grips and a horseshoe seat

Chairs with side grips, a front cut-out and a slide-out tray

Bent-frame and folding structures, and backrests shaped to the body

Folding planar concepts with upright grip poles

Bent-tube chair frames with sling seats and X-legs

Sling seats between grip poles, and cocoon forms that hold the body

DIRECTION TWO

Sculpted shells and folding forms

Moving away from furniture: pods and shells that cradle the body, then faceted forms that fold flat and open into a supported seat.

Idea 2, exploration 1: a wraparound seat with built-in grips

Idea 2: a flat square that folds up into a backrest and seat

DIRECTION THREE

Portable mats that fold, roll and carry

Designing for the ANM worker’s walk to a home delivery: panels and mats that lie flat, roll or fold into a bag, then rise into a backrest and supports.

Hinged and finger-jointed panels that fold into a seat

A flat mat with pop-up backrest and supports

Rolling mats with a frame, carried by the health worker

Rolls with a strap and a curved backrest

Curved wraps with grips that stand on their own

Wraps that open out, with grips and a pocket for supplies

Carryable folding shells with cut-out handles

STUDY MODELS

Testing the forms in paper, card, wire and cloth

Quick physical models to check how each direction folds, stands and supports.

Folding studies, and a flat mat with pop-up backrest and supports

Kraft paper slings and cloth wraps over a wire frame

Final concept

A shell that holds her in the squat

A curved, cushioned shell with a headrest, a supported seat and two upright grip poles to push against, built on a bent-tube frame.

Final concept renders, from top and front views

Final concept renders: the shell with its rolled side panels and grip poles

The final concept, empty and in use in the squatting position

Backrest and headrest

For rest between contractions, answering the back support from my posture study.

Two grip poles

Upright poles to push against, like the ones I saw used in the Sub Centre.

A supported squat

A low, cushioned seat that keeps her in the squatting position.

Curved, cushioned shell

The enclosing form wraps her body for support and privacy.

MATERIAL STUDY

Foams: polypropylene (PP), polyethylene (PE) and EVA

Sheets and fabrics: PP fabric, nylon fabric and PP corrugated sheet

CUSHIONING · PE foam

Cushioning, flexible and durable; resistant to bacteria, chemicals, grease, mould and oil.

STRUCTURE · PP corrugated sheet

Can be sterilised at high temperatures.

PADDING · PP foam and EVA

Lightweight, easy to cut and form, and resistant to water.

Prototyping

Built full scale, with local fabricators

I built the working prototype in a fabrication workshop: a bent steel frame first, then layered cushioning and upholstery.

Prototyping: the frame, the cushioning and the finished aid

01 · STRUCTURE

MS pipe and spring wire

Mild steel pipe bent into the frame, with spring wire joints and the two grip poles.

02 · CUSHIONING

Hitlon, foam and resin fabric

Hitlon and foam layers over the frame, covered in wipe-clean resin fabric.

03 · RESULT

A full-scale working aid

A wraparound seat with grip poles, ready to test the squatting posture at real scale.

Bachelor of Design graduation project, Product Design, 2017. Presented at my final jury, where it received the Best Graduation Project award. All research, field documentation, sketches and design are my own; sources for secondary data are credited on each slide.

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