NEWBORN RESUSCITATION KIT FOR LOW-RESOURCE SETTINGS
MFA Degree Thesis, Advanced Product Design
2017
Result
Kanga consists of a supportive cradle and a transparent blanket. It enables the resuscitation space to be set virtually anywhere keeping mother and child close, so the caregiver does not have to make the choice between the mother and child’s care. It assists the midwife through resuscitation by giving feedback with lights, to help indicate when to ventilate or to keep ventilating. Simple instructions on the blanket guide the user through the steps as well as enhancing the signs of the baby’s wellbeing like chest rise.
By collecting information on the time to and duration of resuscitation, interrup-tions and the baby’s wellbeing – the sup-porting app can help to install a training culture through feedback on what to focus on during training.
infants born with breathing difficulties, thus helping save newborn lives.
Inspiration and Method
For designers a human centered approach is often a given. But having the chance to put this approach into a different cultural perspective and exploring experience de-sign for a low-resource-setting has proven to be an interesting quest.
By visiting four hospitals in rural and urban Tanzania and a close collaboration with Laerdal Global Health, experts on resuscitation and nurses from the neonatal intensive care unit at the Umeå hospital insights were created. By prototyping and quickly testing concepts it was possible to access the validity of the design concepts. The aim was to create a new approach and thinking on the time to resuscitation and the training around it. With the intent of creating an architecture of a project that could be further pursued by my collaboration partner.
The mobile resuscitation kit kanga.
Surviving the golden minute.
Time is life. One million babies die each year due to lack of oxygen at birth, 99% of them in low resource settings. The risk of death could be decreased by 16% for every 30 seconds reduction in time to ventilation (1.Ersdal, Mduma, Svensen, Perlman, 2012). Simple interventions can save many of these lives.
Kanga is designed to guide the caregiver during resuscitation, helping to reduce the time to ventilation, while enabling to keep the mother and baby close during this critical time. Observations of births and resuscitations in several hospitals in Tanzania, Norway and Sweden were essential to the design. Being onsite with mothers and caregivers, and collaboration with medical experts provided valuable insights that helped develop the Kanga solution.
The Kanga mobile resuscitation kit aims to streamline the process of resuscitating
17
insightful
WEEKS
OF HUMAN-CENTERED
DESIGN
abstract
kanga in a nutshell
“If you want to implement a product in the
non-profit space you have to make sure it
is based in scientific facts.”
Cenk Aytekin, Laerdal Global Health
Abstract Introduction Introduction Background Historical review Collaboration partner Literature summary Method Initial research
Sweden, Norway fact check Tanzania
Mental stages during resuscitation Personas
Conclusions on reseach Decision making Feedback possibilities Goals and wishes Concept and goals
Result
Design language Process
Cradle shape
6 concepts to role play Role play insights 5 into one & feedback Chrest rise indication Heart rate monitor Feedback
Sensing the baby Shaping
Making of The pattern The finished model
Final Design
Architecture of Kanga Flexible resuscitation space Steps to resuscitation Supportive cradle shape Smart reminders Low-tech guidance Training with Kanga Training culture
Reflections & conclusions References
Appendices
Time schedule Image from research
will lead to an enhanced focus on training and improvement of skills for both new health workers and those already practicing.
Which meant the solution to make resuscitation of newborns in developing countries faster, has not only to be considering the ease of use for the person operating it, but as well has to keep in mind the teaching aspect of any solution provided.
Therefore during this degree project, I was focusing on the immediate need of resuscitation, but intended to let the design decisions be influenced by the considerations about the learning curve and initial training period with the health workers.
Perlman, 2012, p.1-5)
Further more there had been indications showing, that for every ten seconds delay in cord clamping after
spontaneous breathing, there was a 20% less risk of death for the newborn. (3. Mduma et al, 2015)
The conclusion of the initial research was that there were no solutions on the market to speed up the resuscitation process. But what if we could start resuscitation instantly, without cutting the umbilical cord too early? What if the steps taken until the resuscitation of a child starts could be minimized?
Another question to ask was: whom are we addressing with this project? According to the anaesthetist at the Stavanger University Hospital Hege Ersdal, the project manager and principal investigator for the Safer births project*, most births and newborn resuscitation in low-income countries have been
conducted by midwives. Those on the other hand are not always available, therefore “other staff, such as anaesthetic nurses, student nurses and even ward attendants with no formal education” had to help mothers during the delivery, manage the newborn and the possible resuscitation needs of the child (4. Ersdal, 2015, p. 9-10).
The report Surviving the First Day by Save the Children International, suggested that the turnover rate in hospitals and
shortage of skilled “health workers of all types” (5. Save the Children, 2013, p.10) In collaboration with Laerdal Global
Health, this degree project on newborn resuscitation was the final part of my master’s education in Advanced Product Design at the Umeå Institute of Design, in Sweden.
During this project I focused on the steps taken, to assess and apply newborn resuscitation in developing countries. Looking at health facilities and the steps taken between birth and resuscitation with face mask ventilation. Babies with problems to breath can be saved with a few simple steps - which need to be taken fast. The first minute after birth is crucial. Known as the golden minute.
Here the caregiver has first to assess whether the newborn needs assistance to breath and initiate basic stabilization care, such as drying the baby, temperature management, suctioning, stimulation to breath, cord clamping and face
mask ventilation, if needed - while continuously observing the child (2. American Academy of Pediatrics, 2016). Unlike the recommended procedure where the umbilical cord is clamped after one to three minutes to provide extra blood flow to the baby, during
resuscitation the cord has to be cut instantly and the child has often to be brought to a separate unit to be resuscitated.
Studies published by the American Academy of Pediatrics had shown that “the risk for death increased 16% for every 30 seconds´ delay in initiating” bag mask ventilation (1. Ersdal, Mduma, Svensen,
introduction
*
The Safer Births project was a collaboration between Laerdal Global Health and mainly Tanzanian and Norwegian research institutions toresearch and innovate product solutions to increase competence and training of health workers, with the goal to increase newborn survival.(6 6. Safer Births, 2017)
Save the Children Save the Children is an international organization with 30 member organizations to which are globally set to improve the
rights of children and decrease child deaths for over 90 years. (7. Save the Children International, 2017)
Graphic made by Darja Wendel after the HBB action plan 2.0
newborn resuscitation
How might we provide a safe solution to improve time to resuscitation of
newborns while maintaining the mother´s dignity?
GOLDEN
MINUTE
time to ventilation
1 million children die due
to birth asphyxia, this
number can be reduced
by providing affordable
products which enable
the caregiver to start
resuscitation as fast as
possible.
(1. Ersdal, Mduma, Svensen, Perlman, 2012, p.1-5)
Since every 30 seconds
delay in face mask
ventilation means 16 %
increase in death risk
for the infant.
(4. Ersdal, 2015, p. 9-10) ESSENTIAL CARE FOR EVERY BABY DRY CRYING? NOT CRYING BREATHING ? BREATHING ? CHEST MOVEMENT CALL FOR HELP VENTILATE IMPROVE VENTILATION CONTINUE VENTILATION DECIDE ON ADVANCED CARE BREATHING ? HEART RATE? CUT CORD CUT CORD KEEP WARM CLEAR AIRWAY STIMULATE CRYING KEEP WARM CHECK BREATHING
breathing
heart rate normal
Let us talk about the most dangerous day, almost everywhere on earth. The birthday. In 2013 one million neonatal deaths occurred at birth due to failure to initiate or sustain spontaneous breathing, according to an article published by Hege Ersdal, 2015 on Birth Asphyxia (4. Ersdal, 2015). The author as well pointed out that of all the neonatal deaths, 99 percent were located in low-income areas (4. Ersdal, 2015).
So it is not surprising that in September 2015 it was announced as part of the Millennium Development Goals 2030 to reduce neonatal mortality, since it had become one of the largest representatives of the total number in under the age of five deaths (8. United nations, 2015). Looking at it in another way: the day of birth is therefore also an opportunity to safe lives. According to the Surviving the
First Day report from 2013, from Save the
Children International, most of the deaths in newborns could be prevented by low-cost interventions (5. Save the Children, 2013). This report specified that 3 out of 4 newborns could be saved by providing “treatment of infections in pregnant women; access to low-tech equipment that can help babies breathe; clean cord care using chlorhexidine; prompt treatment of newborn infections; and basic education for mothers about the importance of proper hygiene, warmth and breast feeding for newborns” (5. Save the Children, 2013).
Birth asphyxia (the inability to initiate
or sustain spontaneous breathing) was believed to cause from 23% up to 30% of the neonatal deaths and lead to
neurodevelopmental disabilities in survivors.
Recent studies had shown that due to in-accuracy in assigning the Apgar score the above mentioned number on birth asphyxia could be as high as 60%. Followed by prematurity with 18% and low birth weight and congenital abnormalities being additional reasons (2. American Academy of Pediatrics, 2016). Making birth asphyxia the leading cause of death in newborn mortality. A number of factors played into this amount of deaths accredited to birth as-phyxia, like the training methods or the direction of the training towards the right target group (which are midwifes and sometimes even staff members with no official education), lack of basic
equipment and a failure to initiate the re-suscitation in time ( 8. Ersdal H, Mduma E, Svensen E, Sundby J, Perlman J, 2012). Health workers in low-income countries were not only understaffed, but the person attending the birth should as well feel confident enough to actually take the steps for resuscitation in a real life setting, which was not always the case. After a
Helping Babies Breathe training in
Tanzania a study was conducted. The outcome was the realization that without a constant training program, the us-age of suction devices or ventilation did not change, since the health worker did not feel confident enough to make the
necessary steps (2. American Academy of Pediatrics, 2016). Underlining the need of an understandable resuscitation device to provide help to make the right decisions as quickly as possible.
The graphics above is provided by *The Millennium Development Goals Report 2015, United nations (2015) and **Surviving the First Day, Save the Children Inter-national (2013). *** **** ** *
background
Each year around 1 million newborns die,
many of these deaths could be prevented with simple measures (4).
design opportunity
In low- income countries 99%
of the newborn deaths occur.
(4. Ersdal, 2015).
)
1 million children die on
their day of birth due to
birth asphyxia.
(2. American Academy of Pediatrics, 2016)
A device to enable faster and
qualitative administration of
face mask ventilation.
Health workers in health care facilities, midwifes,
student nurses, ward attendants (sometimes without
official medical education)
(4. Ersdal, 2015).WHERE?
WHY?
WHAT?
WHO?
The history of resuscitation dates back into the ancient times. As writings from Hippocrates mentioned intubation of the trachea to support breathing on humans or mouth to mouth resuscitation techniques to revive newborns in the old Testament.
The first resuscitation societies in Europe were founded in the late 18th century. Where many different suggestions on treatment were made, such as administer-ing warmth and mouth-to-mouth ventila-tion techniques but went on and suggested as well “rectal fumigation” with tobacco smoke and other questionable practices. In 1879 a french obstetrician named Gairal developed the first device for short term ventilation of newborns – called the “aerophone pulmonaire” (9. Dr. Aparna Chandrasekaran* & Dr Ashok Deorari, 2012). Followed by a foot operated device for long term ventilation of newborns, called the Fell-O´Dwyer device. Already in 1914 continuous positive airways pressure to resuscitate (CPAP) newborns was described by Von Reuss. In 1928 Henderson and Flagg recommended positive airway pressure, while it was open to debate whether to do so with a T-piece in combination with a mask or by endotracheal intubation.
Over the next decades devices such as Bloxsoms air lock or pressure chambers would be used to subject the infant to pressure and a higher percentage of oxygen, until it was found as effective as endotracheal ventilation in the 1960s. During experiments performed in Balti-more, James Elam and Peter Safar dem-onstrated the effectiveness of the “ head tilt, chin lift” airway opening as well as the
mouth-to-mouth resuscitation technique from 1954 to 1957.
In the same year of 1945 Henning Ruben invented the first self-inflating
resuscitation bag, a creation made of bicycle spokes and an anesthesia bag, which he developed further in the following years.
1953 Virginia Apgar published her work on “the re-establishment of simple, clear classification or ‘grading’ of newborn infants which can be used as a basis for discussion and comparison of the results of obstetric practices, types of maternal pain relief and the effects of
resuscitation”(10. O´Donnell, Gibson, Davis, 2006). Until today this score is used in delivery rooms.
Herbert Barrie described 1963 resuscita-tion guidelines, which used similar equipment then seen today.
In 1987 US experts in neonatology wrote the first NRP textbook on an “accepted” practice in newborn resuscitation. Since 1999, the Neonatal Subcommittee of ILCOR reconciled every five years whether changes to the then published “advisory statement summarizing international consensus on resuscitation of the newly born infant at the time” (10. O´Donnell, Gibson, Davis, 2006) should be made.
Shortly after the announcement of the Millennium Developmental Goals 2015, the authors of the article Pinching,
electrocution, ravens’ beaks, and posi-tive pressure ventilation: a brief history of neonatal resuscitation mentioned the
lack of “evidence to evaluate” resuscita-tion recommendaresuscita-tions (10. O´Donnell, Gibson, Davis, 2006). “Neonatal resusci-tation is among the most important and commonly performed medical
interventions world wide. […]With the
exceptions of suctioning, and oxygen administration, trials of resuscitation interventions of sufficient power or scientific rigor have not been published. Only about 7000 infants have ever been recruited to trials evaluating any aspect of neonatal resuscitation, an intervention to which millions of infants are subjected annually” (10. O´Donnell, Gibson, Davis, 2006).
Insight
So one of the biggest challenges with the recommendations for resuscitation seemed to be the ability to prove the effectiveness or ineffectiveness based on evidence.
So when the Helping Babies Breathe program started in 2009 in Tanzania, important studies were made on newborn resuscitation. Including insights from Ersdal er al on the inaccuracy of the Ap-gar score mentioned before and still used to evaluate newborns wellbeing on five criteria (2. American Academy of Pedi-atrics, 2016 ). Those being Appearance, Pulse, Grimace, Activity,
Respiration scaled from zero to two (11. Wikipedia, 2017). The test is performed one and five minutes after birth and while a score of 7 and higher was considered normal, Ersdal et al reported in their study a 50% chance of asphyxiated infants with a Apgar score of ≥ 7 at 5 minutes, which was “unreliable high”(2. American Academy of Pediatrics, 2016). And connected often to the caregivers ability to grade the newborn correctly.
In summery the methods for resuscita-tion were still evolving and providing proof on the effectiveness of a procedure for resuscitation was complicated. There-fore the recommendations for newborn resuscitation get updated and it is about recognizing these updates early on to be able to adapt solutions which are working in synergy with the recommendations.
18th century
19th
century
2000 - present
(Resuscitation as divine intervention.)
Experimental stage:
- mouth-to-mouth
- tracheal tubes
- pinching
- electrocution
- ravens’ beaks
- cold water baths
(10 O´Donnell, Gibson, Davis, 2006)
*
The Apgar score was used since 1953, but recent studies showed that it´s
reliability is highly dependant on the caregivers accuracy and ability to
as-sess the baby. (2. American Academy of Pediatrics, 2016).
Ancient greece
0
100
800
200
900
300
1100
1600
400
1200
1700
500
1300
1800
600
1400
1900
700
1500
2000
Refined version of one of the first self
inflating face mask ventilators.
(10 O´Donnell, Gibson, Davis, 2006)
**
***
2015 & 2030 Millennium
Developmental Goal to
reduce neonatal deaths
resulted in an increase in
research projects on
neonatal resuscitation.
historical
An ancient problem and various ways
of solving it - a short summery.
cal]”. (12. Vossius C, Lotto E, Lyanga S, Mduma E, Msemo G et al, 2014)
But even after the trainings were completed the time to ventilation was significantly longer then the
recommended golden minute. So I was tasked to investigate the reasons for the delay in time to ventilation and to look for solutions to enable the care providers to initiate face mask ventilation on time.
The United Nations promoted the Helping Babies Breathe program as one of the ten
breakthrough innovations in oder to close the Millennium Development Goal 4 gab before 2015.
collaboration
Since Laerdal Global Health and the Helping Babies Breathe
program supported my master thesis, therefore this is a brief
introduction to both.
partner
L
aerdal Global Health is a non-profit company with the focus to reduce preventable deaths of mothers and newborns.They did so by supporting programs like the Helping Babies Breathe through cost- effective solutions, which were easy to use and adopted to a variety of cultures and settings.
The HBB program was “an evidence-based curriculum in basic neonatal care and resuscitation, utilizing simulation-based training to educate large numbers of birth attendants in low-resource counties” (12. Vossius C, Lotto E, Lyanga S, Mduma E, Msemo G et al, 2014).
The HBB program had shown great success within two years, with 47% decrease in early neonatal mortality in the first 24 hours and 24% less stillbirths. (13. Msemo G, et al, 2013).
The teachings put an “emphasis on the immediate application of basic steps such as drying, stimulation and suctioning” which – if applied in the golden minute – would lead to spontaneous breathing in about 90% of the cases and a reduction of fresh still births and the need for face
mask ventilation. (13. Msemo G, et al, 2013).
Birth Asphyxia – the inability to initi-ate breathing with face mask ventilation and an Apgar score below 7 were both after an before the implementation of the HBB program the most common cause of death. “It [was] likely that these infants were in state of prolonged secondary apnea as a result of complications dur-ing labor and unresponsive to FMV [face mask ventilation]. Strategies targeted at enhanced monitoring of the fetus during labor may have a potential impact on this group of infants”. (13 Msemo et al, 2013) The program consisted of a one day training of health care providers , some of which then trained afterwards regionally hospitals, dispensaries and health centers, while additionally providing on the job and refresher training to their colleagues.
The tools used to achieve the training were “a set of flip-over illustrations, an action plan, a neonatal simulator
[NeoNatalie, Laerdal Medical], and a suction device [Pinguin, Laerdal
Medi-HBB
PROGRAM
active in this areas
Tanzania
was one of the first countries
to implement the Helping
Babies Breathe program
Graphic made by Darja Wendel
16% risk of death
increase for every
30 seconds delay
in face mask
ventilation
(4. Ersdal, 2015, p. 9-10)Application of
resuscitation
methods is
dependent on
confidence level
of the caregiver.
(4. Ersdal, 2015)( saves time during resuscitation )
Heart rate is an
indicator on the
wellbeing of the
newborn.
Above 180 - newly asphyxiated baby Below 100 - most likely secondary asphyxia, you should initiate face mask ventilation as fast as possible (14. Dr. Linde, J. (2017, January 27).
Personal interview.)
summary
Key insights and things to be further investigated
literature
KEY INSIGHTS
essential to the project
CONSIDER
THINGS TO
method
2 weeks
4 x hospitals
Tanzania
was one of the first countries to implement the Helping
Babies Breathe program
Focus areas for the Helping Babies Breathe
program.
expert
interviewIndia
collaboration
partner
4 x
expert
interviews 1 x hospitalNorway
3 x
expert
interviews 1 x hospitalSweden
over
6
hospital visits
11 BIRTHS
22
INTERVIEWS
OBSERVATION & IMMERSION IN
4 COUNTRIES
fact check
“Time to ventilation is important, but if you don´t ventilate
correctly and the baby does not get any air, then it does´t
matter how long it took you to face mask ventilation”
Dr. Jørgen E. Linde To validate my initial literature research I
visited the hospital in Umeå for interviews with NICU nurses, Laerdal Global Health for expert interviews and assisted a pediatrician and midwife at the hospital in Stavanger.
99% of all neonatal deaths occur in low-resource settings (4. Ersdal, 2015). But why is the western world doing so much better?
In high-income countries such as Sweden or Norway a decline in the stillbirth rates was documented over the last three decades (15. Kidanto H et al, 2015). And the reasons for this decline were most likely the “focused prenatal and intrapartum care including risk identification, coupled with targeted treatment of obstetric complications” as well as the higher availability of educated health workers and recourses (15. Kidanto H. et al, 2015). And still – from my observations it seems like even most of the Norwegian or Swedish hospitals have trouble to resuscitate within the golden minute. Simple things like the walking distance from the resuscitation table to the delivery bed in Stavanger
hospital, took nearly one third of the golden minute. But in Sweden and Norway the equipment and the ability to prevent brain damage were more advanced and not available in low resource settings.
In countries like Tanzania time is life – even more so since the necessary equipment or knowledge to extend the time frame and maintain the baby afterwards are not always given.
But time on its own is not the only factor,
Dr. Jørgen E. Linde explained. The median time for the resuscitations observed in Tanzania was significantly longer then one minute, additionally the caregivers interrupted the facemask ventilation up to 5 times. During which the lungs collapsed and the caregiver had a harder time reflat-ing the lungs.
“Time to ventilation is important, but if you don´t ventilate correctly and the baby does not get any air, then it does not matter how long it took you until face mask ventilation” Dr. Jørgen E. Linde stressed the importance of timely and qualitative ventilation in an interview for my thesis (14. Dr. Linde, J. ,2017, January 27, Personal interview). Cutting the cord is one of the most time consuming activities during the resuscitation - taking 15 to 45 seconds. If we are assuming that for every 30 seconds delay in face mask ventilation there was a increase of 16% risk of death, then cord clamping before resuscitation meant a 8-24% increase of risk of death (16. Ersdal H., Mduma E., Svensen E., Perlman J., 2011). Research had shown the positive effect on newborns by risk of death or admission decreasing by 20% for every 10-second delay in cord clamping in healthy babies (4. Hege Ersdal et al, 2015).
“The American Academy of Pediatrics, like A.C.O.G., recommend(ed) waiting at least 30 to 60 seconds before cutting the cord, while the World Health
Organization advises waiting at least 60 seconds and the American College of Nurse-Midwives says to wait two to five minutes.” (17. Healthy Newborn Network, March 2, 2017).
“ There is no data showing delayed cord clamping helps newborns which need resuscitation, but I think that is as well because it is impossible to do qualita-tive ventilation on the mother or the bed. ” Dr. Hege Ersdal mentioned in an interview with me (18. Esdal H., (2017, 24 January), Personal Interview). Nether the less, research in this direction is being made.“Dr. Kattwinkel and colleagues at the University of Virginia are leading a randomized clinical trial at eight medical centers around the country to test whether it is safe and beneficial to resuscitate very pre-term babies with the cord still intact.” (17. Healthy Newborn Network, March 2, 2017). The HBB program was hinting at the ability to safe time with delayed cord clamping in their updated guidelines in 2017. Where it is left to the Facilities to decide the time to cut the cord, but the poster image showed cutting the cord after the face mask ventilation- implying delayed cord clamping and mentioning the aspect of the time reduction to face mask ventilation.
But my observations made me come to the conclusion that most facilities would not have the ability to perform delayed cord clamping due to their equipment or layout. In fact both Dr. Hege Ersdal and Dr. Jørgen E. Linde pointed out that they had not seen a well
functioning mobile resuscitation unit to enable delayed cord clamping in low resource settings. Which is due to the cost, accessibility of the delivery area and stability of such units.
Dr. Hege Langli Ersdal. Project Manager and Principal Investigator
for the Safer Births Project. Dr. Jørgen E. Linde. Medical Doctor under specialization in Pediatrics and currently working as a PhD fellow for Stavanger University Hospital at Haydom Lutheran Hospital in Tanzania.
my insights from Tanzania combined with the
insights from the conversations in Norway.
GOLDEN
MINUTE
initiation of face mask
ventila-tion within one minute with
continues ventilation until
newborn started breathing.
WHAT SHOULD HAVE HAPPENED
SIGNIFICANTLY
LONGER
time to ventilation was
ob-served in the hospitals were
Laerdal Global Health was
observing resuscitations.
WHAT WAS HAPPENING
taking longer because: - unnecessary suctioning
- insecurity/hope leading to longer stimulation
- time to resuscitation table
- understanding the babies well-being early on
- no regular training on the mannequin like recommended, instead
practicing supported supervision
INTERRUPTIONS/
NOT QUALITATIVE
VENTILATION
were observed. Instead of
continues ventilations, Dr.
Jør-gen E. Linde was observing up
to5 interruptions of face mask
ventilation, which caused a
collapse of the lungs with each
interruption and made it
harder to to inflate the lungs.
WHAT WAS HAPPENING
stopping to : - readjust face mask - stimulate
- check for breathing/ well being - suction
- open/close the blanket
time and quality of vantilation
have to go hand in hand.
TIME QUALITY
Sweden, Norway
her in the decision-making. But a second person is not always available or more qualified to give instructions then the person performing the resuscitation. So small behaviors like suctioning or stimulating longer then necessary, interrupting for mask readjustments, opening the chest area of the baby, suctioning or stimulation would need a reminder during resuscitation. What midwifes repeatedly mentioned was that the simulation training with the doll was ”different from a real baby” since there was no panic or stress in the training situation. The stress factor played a major role in translating the learned behaviors into action during a resuscitation. To enable the change in behavior, habits had to be trained.
The behavior model of B.J. Fogg (20. Dr. BJ Fogg, 2016), a behavior psychologist, showed that long term behavior change occurred not only with motivation, but through embedding triggers in the daily tasks to remind us of the behavior we are targeting. Therefore triggers became a structural part of my concept. On the following pages I mapped out additional influences on the midwifes behaviors during the resuscitation according to the structural, social and personal influences on behavior change.
further user feedback would be conducted.
Since reducing time to resuscitation was my objective, I started to analyze the most time consuming actions – but other aspects had to be added into the consid-eration, since they would influence the actions of the midwifes and the long term inpact.
For example, midwifes would walk extra distances to get to a warmer or - in their perception- a better suctioning machine and would even interrupt face mask ventilation to either see the chest rise or make sure the baby is kept warm. So the prioritization of actions was different then expected and the emphasis on time was not always given.
To resuscitate a baby without keeping it warm was likely to lead to hypothermia or other complications and should be avoided. Especially in the Muhimbili Hospital or Temeke – where fans were working over each of the delivery beds and the windows in the whole ward were open – warmth was an integral aspect of the resuscitation.
One of the key findings was that often the training mannequins were not used and instead supported supervision was more common. Were someone from the staff would stand by the midwife to support In a design process it is easy to assume
that change will happen – because the advantages of our design are so compelling to us. In reality, we struggle even with simple changes like - morning exercise, to loose weight. Doing it once is easy – keeping it up is hard. So what influences long term change and how could we enable caregivers to embrace it? Was it about making things easier? According to the psychologist Al Switzler (19. TEDx Talks, 2012), motivation was not all you needed to change behavior long term.
The change was depended on social, structural and personal influences, which then relied on your abilities and motiva-tion to act on them. Therefore making a long term behavior change depended not only on the caregiver, but on a whole infrastructure of interconnected aspects. If we applied this thinking to the insights from my research, this meant that by addressing aspects of this separately, it would lead to concepts which are only focusing on a fraction of the problem, the time to ventilation. Going in with the hypothesis that if all the aspects could be addressed, the design concept would have had a real potential to enable long-term change, I decided to focus on a user experience rather then just one focused solution. Even though the effectiveness of the concept would be only detectable if
Tanzania
the bigger picture
How to change behavior
GOLDEN
MINUTE
what influences the
time and quality of
resuscitations?
training culture
Is resuscitation a priority?
Trainings are done and valued?
Is positive feedback & support from
coworkers
layout & tools
Where are my tools?
How long do I have to walk?
What do I have to cut the cord with?
knowledge & emotions
Do I know what to do?
Do I feel confident in my decisions?
Did I perform well?
To keep a baby warm midwifes would
walk extra distance. Also the baby was being
laid under a fan- the moving air would cool
the baby out and could lead to hypothermia.
Fans were positioned over every delivery bed,
also all windows were opened.
Space is critical, not only did it often take a
long time to get to the resuscitation table, but
the table was not always ready and might
have been occupied by either equipment or
babies. Delayed cord clamping could not be
done with just a trolley since there is very
little work space around the bed.
STRUCTURAL
STRUCTURAL
In videos midwifes
were observed to open and close repeatedly
the chest area of the baby during
resuscitations. Interrupting resuscitation
because one midwife would be concerned
about the temperature of the baby and the
the other midwife needed to see the chest
rise to evaluate the quality of ventilation.
PERSONAL
warmth
space
Plastic bags used in
Sweden & Norway
to keep premature
babies warm. Plastic
keeps the babies
humidity and
temperature better
then cotton.
*
OPERATION THEATER
HAYDOM LUTHERAN HOSPITAL
3 shifts X 8 hours
midwifes per shift: 3-8 morning shift
5-8 evening shift I night shift 3-5
deliveries per year 5000 I day 13,7
resuscitation table X 6
referral hospital
DONGOBESH HEALTH CENTER
2 shifts X 12 hours
midwifes per shift: 1 during the day
2 during night shift (taking care of the
antenatal, postnatal and labor ward )
deliveries per year 450 I day 1,2
resuscitation table X 1
1 hour referral to Haydom for difficult cases
MUHIMBILI HOSPITAL
2 shifts X 12 hours
midwifes per shift: 4-5
deliveries per year 10 000 I day 27,4
resuscitation table X 2
1 hour referral to Haydom for difficult cases
referral hospital
TEMEKE HOSPITAL
midwifes per shift: 4-5
deliveries per year 20 000 I day 54,7
resuscitation table X 1
30 min. - 1 hour referral to Muhimbili
LABOR WARDLABOR WARD
LABOR WARD ANTENATAL WARD
30 min. - 1 hour referral time
1 hour referral STORAGE IN OTHER BUILDING approx. 10 sec. appr ox. 7 sec. appr ox. 5 sec. approx. 2 min. approx. 15-12 sec. approx. 1-13 sec. approx. 10-15 sec. approx. 12-25 sec. approx. 6-15 sec. approx.
4-10 sec. approx. 5 sec.
Bigger hospitals had the problem of a large
amount of patients and longer distances to
the resuscitation table. On the other hand,
midwifes in smaller health clinics had
sometimes to decide weather to stay with the
mother or help the baby, if the resuscitation
table was not in the same room.
STRUCTURAL
DRY CRYING? NOT CRYING BREATHING ? BREATHING ?
VENTILATE CUT CORD CUT CORD KEEP WARM CLEAR AIRWAY STIMULATE CRYING KEEP WARM CHECK BREATHING breathing not breathing
pr
im
ar
y a
pn
ea
se
co
nd
ar
y a
pne
a
HEART RATE KEEP WARM CLEAR AIRWAY STIMULATE“IF THE BABY HAS A HEART RATE ABOVE
100
WE BRING ITUP TO THE NICU, EVEN IF THE BABY IS NOT BREATHING.”
Except one hospital, of the ones I visited,
most did not have a training culture using
the resuscitation mannequin. Which could
correlate to the longer working hours at
those hospitals or the lack of
understanding what to train on or
what the caregivers were doing
right or wrong
The heart rate feedback
was misunderstood and
a not breathing baby was
brought up to the NICU
after it had a heart rate
above 100 beats per
minute
“Babies were born before
this training and turned out fine”
or “but I don´t need the training I
have been a midwife for a very
long time” were things I heard. It
is hard to evaluate your own
performance if you are under
stress.
STRUCTURAL
If a baby has a heart rate below 100 beats per
minute it is most likely in secondary apnea
and had been deprived from oxygen for a
longer period of time. Here, it is key to act
faster then normal. But in my observations
midwifes were not acting on the feedback
from the heart rate monitor and instead
seamed confused by the information
provided to them.
A resuscitation is a very
stressful situation and it is
hard to focus on different
stimuli during this time. The
midwife is in panic mode and
it is key to start the support
before they reach that stage.
Other forms of feedback
midwifes will be looking for
are color and muscle tone of
the baby as well as chest rise.
These factors could be
obstructed by the blanket.
PERSONAL
feedback
SOCIAL
situation like resusitation, the more reluctant are they were to act and instead performed actions that they felt more con-fident in - like stimulation or suctioning. Since both these actions are either simpler or are performed on more babies then face mask ventilation, those actions the caregivers feel more comfortable with. Also the lack of feedback on the perfor-mance made it hard for the caregiver to assess if they performed correctly or if other factors were the reason for the babies decline in their wellbeing. Which would lead to the wrong learnings. By supporting caregivers with feedback, theoretically an increase up to 42,6% of chances of survival could be possible. resuscitation and the fans above every
delivery bed would lead to a quick temperature and humidity loss. Leading to complications. But there was as well a second layer of delay.
The psychological influences.
The actions like additional suctioning or stimulation could be a result of insecurity on the steps to take and the realization that a resuscitation might be needed, leading to panic. Generally the midwifes referred to resuscitations as a stressful situation. It seemed that most of the delays on a psychological level occured either to misinformation of the correct steps to take or on the stress level of the caregiver. The closer an inexperienced caregiver approached an uncertain But what steps were taking the most time
and could be reduced?
Looking at it from a physical standpoint: Mostly it was the cord cutting and getting to a resuscitation table, most other aspects could be credited to either knowledge gaps or lack of feedback and confidence. So if we assumed we wanted to resusci-tate next to the mother to save time–how much time were we talking about? With the 15-45 seconds for cord cutting and additionally the 3-25 seconds to get to a resuscitation table, that would be up to or over a minute which could be saved. So if we would resuscitate next to the mother - would the problem be solved? The surface of the delivery bed could be too soft or too hard to efficiently perform
mental stages
during resuscitation
I work twelve hours in the hospital .I have a family as well you know
physical steps that take time emotional/ knowledge
steps that take time
16% risk of death increase for every 30 seconds delay in face mask ventilation (Hege Ersdal, 2013) CUT CORD (15 - could be up to 45 sec) 8-24 % increase readjusting face mask and head positioning suctioning/ stimulation breaks during ventilation extra assessment time on ventilation table (15 sec.) extra suctioning or ventilation while baby on mother checking for wellbeing/ baby breath-ing yet? INTERRUP-TIONS IN WORK FLOW
(second assessment on table or waiting who will do the resuscitation 15 sec. extra suctioning 5-10 sec extra stimulation 5-10 sec before on table. going back to suctioning, stimulation during ventilation 5X 7 sec.
= 0-80 sec.)
0-42,6% increase
delayed cord clamping
(even if you could delay cord clamping you need a surface and can´t always force it- so an open solution to different locations)
training new equipment
(introduction of new behavior and is that better then just a well trained person?)
PLACE ON AREA VENTI-LATION
(walk to area: 3- 25 sec. other babies: 5-10 sec. equipment: 5-10 sec. = 3- 50 sec.)
is it an area of ventilation if the equipment is not ready?? 1,6-26 % increase
(but first you have to understand you need the training!)
objective feedback afterwards
- What should I train on? - Mental support if something didn’t´t go right to reduce anxiety of doing resuscitation the next time. - Building understanding that the steps learned are correct even if it does not work out every time.
- In training mode: Did I really learn what I was supposed to? Learning the right steps correctly.
( Data collection can make the hand over to other depart-ments easier)
guidance during resuscitation
- Does the baby need this? Assessment help on steps to take and making decisions (- What is the correct next step?)
- Am I doing this right? Is it me or is the baby doing worse? (- Wellbeing of baby? Is it me or the baby and should I stop now? Is the baby doing better now?)
The SHY WORKER
The PRODIGY
The ROOKIE
The DO-GOODER
The VETERAN
The CHAMPION
The LONE WORRIER
The “SPECIALIST”
little experience
-1 year of experience.
-Went into midwifery because it is a well paid job.
-Gets insecure sometimes, but hides it by making jokes
-Has an 8 hours shift, but works night shifts and weekends as well. -Likes the independence he get´s in the ward.
-Knowledge on resuscitation in theory is good but lacks the experience.
- Has no children on his own. - Driven and outspoken. - Lives close by to the hospital.
- 1 year of experience.
- Wants to help people first and fol-lowed as well the advice of a relative to choose the profession.
- Does not like to speak up or be in the center of attention.
- Has no children yet but wants them in the future.
(has empathy for the mothers) - Works weekends and nights but does not feel comfortable without someone very experienced there. She follows other young midwifes. - Is more likely to “hand over” the resuscitation to someone with more experience.
- Has studied the steps but is afraid to do it on a living baby.
- 3 years of experience. - Decided to become a midwife during the nursing school when a mother she was supervising died due to complications. She decided to help mothers and children is important because “ they are our future”. - Is calm and friendly. - Has a child on her own.
- 12 hour shift and 2 hours commute home.
- Determined and open.
- Has knowledge and experience in the basic steps of resuscitation. - If something goes wrong it is hard to accept for her. ( struggles afterwards)
- 3 years of experience.
- Likes to help people, it makes her feel good about what she does. - Likes to be in the spotlight and recognition, since she wants to advance
- Social with good leading skills. - Gets stuff done, by organizing her-self as well as others around her. - 8 hours shift with a short commute. - Has no children on her own. - Likes to study and knows the HBB steps perfectly in theory and in practice
- Confidence in herself makes it hard to see what she might be doing wrong.
- 10 years of experience. - Has 3 kids on her own. - 12 hours shift and 2 hours commute.
- Believes in learning by doing. “A real baby is just different. I know all the steps”.
- Judges on experience what is good or not. “ We have been resuscitating babies before the HBB plan and they lived”
- Social, confident outspoken person. - Likes to teach and guide others. - Had a training in HBB, taught by other midwifes to her.
- 9 years of experience. - 2 kids on her own. -Patient and kind.
- Accepts some things as they are. - Is open for suggestions to try out new things.
- Her experience allows her to be calmer then the younger midwifes and she is good at assessing the situation
- 8 hour shifts, mainly during the day. - Likes to guide people if asked. - Is on top of the HBB plan in both experience and knowledge of the steps.
- The steps have become muscle memory.
- 14 years of experience.
- Works 12 hours shifts and is mostly by herself on shifts.
- Has 4 kids herself.
- Kind, understanding and quiet character.
- Had the HBB training a while back but does not have the time to train. She has the experience, so she does not need to train all the time. - Went into midwifery because she wanted to help people.
- Has to prioritize in her tasks daily.
- 8 years of experience as anesthetist (or doctor)
- He does not have experience with the training on the newborn resusci-tation but get´s asked because he has knowledge about intubation etc. - Does not want to loose face and does not refuse when a younger midwife would ask
- Confident and outspoken. - Trusts the senior midwifes - Would train but the training is not part of his routine nor is it asked of him.
experienced
very experienced
not his/ her specialty
personas
of caregivers
understand what to train and what you actually are doing wrong
remember the learned during a stressful situation PREP ARAT ION ASSESS MENT ACTION DESICION ASSESSME NT DES ICION AC TION ACT ION AS SE SS M EN T DE SIC IO N ASS ESS MEN T CLE ANI NG EV AL UA TIO N UN DE RS TA ND DES ICI ON TRAINING controlled resuscitation area feedback & guidance
?
9,6% up to 50%
increase of risk of death
0% up to 42,6%
increase of risk of death
cord cutting
takes time (15-45 sec.)
tools available on mother, transport and table
guidance/feedback available on mother, transport and table
time to table
takes time (3-25 sec.)
other babies on table
reorganizing babies (5-10 sec.)
table used as storage
things are taking space, not prepared (5-10 sec.)
even experienced midwifes might
perceive the time they need to
resuscitation as far less then they
actually do. In my observations
sometimes the caregivers needed
significantly longer then the
golden minute to get to face mask
ventilation, but did not even
real-ize that they did. The perception
skewed due to stress and and
possibly panic.
The learning from this was to
create a bridge between trainings
and therapy, which are currently
treated as rather separate
catego-ries. To provide feedback on what
to train on and support during
the resuscitation to remember
the trained steps.
A early feedback and guidance of
the caregiver had the potential to
reduce stress and prevent the set
on of “panic mode”. Also since
the perception of time is hard for
most care providers, a solution
to track time form the beginning
would be valuable.
feel more secure during the
resuscitation, others might want
to know how they performed.
One of the midwifes I met
during research explained how
the death of a mother during
nursing school was the reason he
became a midwife- for him
un-derstanding why curtain actions
turned out a the way they did,
might be a big mental support
structure to continue
resuscita-tions and motivate training.
While other midwifes where
actively looking for a companion
during resuscitation, to get a
con-firmation of actions to take.
Signaling that a support
struc-ture, even a subtle one during
resuscitation could be very
beneficial to insecure caregivers.
A device that they are familiar
with and reminds them in the
right moments of their training,
could trigger behaviors learned
during training while performing
a resuscitation.
The understanding of how you
perform was not always given,
The more a caregiver is reluctant
to perform a task the more stress
and panic they experience during
resuscitation. To be able to
reduce this stress, one could
either support them (even
be-fore the real panic sets in, at face
mask ventilation) with feedback
or one could reduce steps they
have to take and therefore give
the the necessary time to
concentrate at the task at hand.
I decided to work towards a
combination of those steps to
push the envelope. Focusing on
a user experience rather then a
product. The question asked was
how behavior change could be
achieved to reduce time to
venti-lation and enable a qualitative
resuscitation. Keeping in mind
that every midwife is different
but making an immense afford
in their work - so the concept
should aim towards reducing
steps for them, but as well to
provide the information they
want. While some caregivers
might benefit from feedback to
conclusions
research
key insights and things to be further investigated
decision
making
blanket with neck stabilizer
cord cutting
takes time (15-45 sec.)
time to table
takes time (3-25 sec.)
other babies on table
reorganizing babies (5-10 sec.)
table used as storage
things are taking space, not prepared (5-10 sec.)
wall mounted
+
can get closer to bed
-where is the trolley
really tight places- no workspace
hospital layouts
big - storage is tricky
other babies or storage space
+
everything prepared
closer to bed
( delayed cord clamping?)
-comfort of mother
space on bed or mother
how to integrate into work flow?
keeping baby in place
transport
+
soft on mother
-surface too soft for resuscitation
space on bed or mother
keeping baby in place
transport
+
soft on mother
temperature control
resuscitation possible everywhere
baby secured for transport
opening airway
-
make sure it opens quickly
trolley
the workstation
soft blanket or cushion
+
a fixed place
rigid surface to resuscitate
-time to get there
hospital layouts
feedback & guidance 0% up to 42,6%
increase of risk of death
feedback from colleagues
feedback on phone remote competence
what should I train on?
tools available on mother, transport and table
guidance/feedback available on mother, transport and table tools available on mother, transport and table
guidance/feedback available on mother, transport and table AM I DOING THIS RIGHT?
From my observations it was clear to me that the circumstances for each hospital very a lot. Some midwifes are alone on a shift, while others are working in a team. A large number of Tanzanian midwifes had smart phones, most of them had a mobile phone. Which lead to the conclusion that feedback should be provided in a variety of ways. The decision to continue with a mobile
so-lution in the from of a blanket to keep the baby warm and fixed on the resuscitation area, with a rigid spine support was made after an analysis of the possible layouts and feedback needs.
Also a clear decision was made to keep the amount of extra components to a minimum to decrease extra work or distractions during the resuscitation. Keeping the focus where it should be, on the baby.
feedback
possibilities
provide as much actionable feedback as possible. Feedback - meaning case by case information instead of general informa-tion. Helping to understand what the areas of improvement for a facility or the individuals were, was essential to enable a training culture. To maintain it further a social platform was needed- a source of information that helped translating the information into actionable learnings. By providing both feedback on performance and guidance during therapy. Creating a close connection between them.
To analyze the feedback opportunities this graphic was created. To illustrate the different information streams resulting in a variation of feedback opportunities. The main questions caregivers might be interested in: What should I train on?, Was it something I did that went wrong or the babies condition? Did I do all the steps right? and Did I learn the steps correctly? were only ansered by guidance type 4. The main focus of this work was to
ASSESSMENT
BREATHING? CHEST RISE?
HEART RATE? TIME AFTER BIRTH
COLOR/ TONE? SECRETION/ MECONIUM? REACTION
THE BABY´S WELL BEING- TO AVOID INTERRUPTIONS
1. STEP BY STEP GUIDE (HBB PLAN ON
2. STEPS + TIME = A UNIVERSAL TIMED HBB PLAN (NOT CONSIDERING THE BABIES CONDITION)
3. STEPS + TIME + RECORDING ACTIONS = FEEDBACK ON PERFORMANCE AFTER-WARDS POSSIBLE BASED ON TIME AND ACTIONS TAKEN.
4 .STEPS + TIME + RECORDING ACTIONS + BABY´S WELLBEING (HEART RATE)= FEEDBACK ON PERFORMANCE AFTER-WARDS POSSIBLE AND REAL TIME ON CASE BY CASE.
REMEMBER THE STEPS
TIME SPENT ON STEPS
IS THE STEP NECESSARY QUALITY OF VENTILATION - DURATION OF VENTILATION - PACE OF VENTILATION - (VOLUME) - (LEAKAGE) SECOND OPINION -SUPPORTED SUPERVISION HELPING THE SYSTEM IF POSSIBLE
MENTAL SUPPORT HELPER TO MANAGE MOTHER AND CHILD
WHAT
SHOULD I
TRAIN ON?
YOU DID
WELL, THE
BABY WAS
JUST REALLY
SICK
DID I DO
EVERYTHING
CORRECTLY?
DID I LEARN
THE STEPS
CORRECTLY?
WHAT FEEDBACK
CAN I PROVIDE
AFTERWARDS?
WHAT GUIDANCE
CAN I PROVIDE?
WHY A SECOND PERSON
MIGHT BE GOOD TO
CONTACT:
(not always available, depending on shift and how busy the hospital is)
AM I DOING
THIS RIGHT?
TYPES OF
GUIDANCE
REDUCE TIME TO VENTILATION AND ANABLE A QUALITATIVE VENTILATION
TRIGGERS FOR
TRAINING
By providing feedback
MOBILE
To enable delayed cord clamping/
resuscitation close to the mother
WARMTH
Keeping the baby warm is part
of the resuscitation, to avoid further
complications
FEEDBACK
To help the caregiver though the whole
experience in order to safe time
SOCIAL
STRUCTURAL
PERSONAL
goals &
wishes
NURTURING TRAINING CULTURE THROUGH FEEDBACK
concept
layout
RESUSCITATION KIT
HIGH TECH LOW TECH
of overloading the product.
This decision was based on the
fact that a large amount of
mid-wifes had smart phones.
The aim was to build onto
available resources while being
still functional even if no
supporting devices would be
available.
guidance and a mobile solution,
a selection of concepts were to be
mocked up.
The initial assumption being that
the resulting product would be
some sort of mobile kit, which
then could be differentiated into
a high-tech version and a
low-tech version. Mainly
differentiat-ing in the feedback one would be
able to receive.
The low-tech and high-tech
as-pect stood in direct correlation
of ownership of a smartphone,
tablet or computer.
The choice was made to utilize
existing structures, to receive
ad-ditional information and
provid-ing guidance on trainprovid-ing instead
The goals and wishes are
reflecting the social, structural
and personal influences which
would be required to achieve long
term behavior change.
My focus will be on the physical
elements of the device, while
con-sidering the outer architecture of
the system. The aim was to create
a one to one model representing
the concept.
A video to visualize the concept
directions and to keep close
contact to experts during the
pro-cess, to ensure the direction of
the project to be actionable, were
tools I intended to use.
Building on a initial ideation
phase and analysis of different
ways of creating feedback,
concept
&goals
No one way solution, but a range of possibilities
results
friendly
translucent
soft bodies
To keep true to the design direction of Laerdal Global Health I decided to keep the main bodies white to be able to see dirt on them. Using color mainly to highlight functions or point to important features.
It was important to me that the Kanga would be seen as a part of the product portfolio and the resuscitation equipment. Using friendly, soft shapes was part of the design language, but were as well put in place for the safety of the newborn, to prevent injuries.
Therefore much of the shaping of the Kan-ga cradle and blanket were done though experiments and mock ups.
a smart Kanga helping the newborn to survive and giving little “messages” or feedback to the caregiver seems fitting. Each of the mothers brought with them colorful Kangas for their children to be welcomed in and so the Kanga design had to reflect a bit the traditional part of the blanket, while not overcrowding the design.
In correlation to that we had the clean, friendly and soft design of the Laerdal products. Where colors such as yellow or blue were only used for highlights. While the main bodies were white or used transparent or translucent silicon material.
The design language and the mood board, shows both the current design direction Laerdal Global Health had and the local impressions and influences I wanted the design of the Kanga be influenced by. Even the name Kanga stems from the Swahili word for warp around or blanket, worn by women and men and as well used to warp newborns in. The naming mak-ing it clear when or how to put the device into action and also to familiarize it to the users. Even though Kanga is not supposed to be used only Tanzania- this is where the idea of it took root.
Often a traditional Kanga would have messages people want to convey to oth-ers on them. So the metaphor of having
design
language
protect, enable, remind
To create the Kanga an approach of quick tests was necessary. Separate aspects of the project were tested in physical mock ups to come to a
conclusion, on which features would be helpful for a resuscitation.
Keeping true to the human centered approach each concept was acted out and later discussed with experts.
By starting my design process with focusing on the function instead of the styling, the product was shaped by feed-back throughout the process. Features before styling.
process
of failing quickly
build , design, test, repeat ....
neck support
Taking the assumption that adjusting the neck support under the stressful situation should not be beneficial for the midwife to
additionally worry about.
So lastly the decision was made to go with a soft, gradual designed neck support, which would be mostly targeted towards the smaller newborns, but which could still support a term baby.
After an initial consultation with Dr. Jørgen E. Linde - a Medical Doctor with specialization in Pediatrics - the conclu-sion was drawn that the whole surface on which the baby will lay would need to be cushioned, since newborns are not supposed to lay on a hard surface for an extended period of time.
Additionally the mock ups had a difference in softness- some of them where filled just with soft fibers, others had a blue hard foam in them and some where more flexible. In the end the deci-sion was made to stick to a non-flexible or adjustable neck support which was soft. The first feature to be tested was the neck
support cushion. The main incentive was to investigate if by supporting the head position of the newborn the opening of the airways and therefore the resuscitation could be performed faster.
And indeed the positioning of the airway on the resuscitation mannequins with cushions underneath the neck, proved to be up to double as fast, if tried out by an inexperienced person.
In this test round a term and a premature mannequin were used. The model with the smooth transition of the neck support to the cushion fit both sizes of newborns mannequins the best.
