General gaps in healthcare come in many flavors: malfunctioning of a tool or process, the absence of a tool or process, lack of a shared mental model during clinical procedures, communication issues, system inefficiencies, awkward workflows, transportation, physical space challenges, healthcare disparities, security issues, etc. Designers working in the healthcare field are charged with organizing complexity or finding clarity in an often overwhelming and unfamiliar context. Designers in this field need to be attuned to finding patterns in their research, and be comfortable pruning and prioritizing information. Through this synthesis process, insights emerge and meaning is created.
Design is experienced as the synthesis of resources through the personal lens of the designer or design team, and as such, insights and solutions will be unique to the people who bring those pieces together.(2) Not surprisingly, we bring our whole self to synthesis work. For me, that means that I view and experience the world as a woman, I draw on my education, my cultural and religious background, my personal fascinations, my past trauma, joys, fears and general biases. As a mother, I carry a particularly empathetic lens to my field of study. Although my role is researcher, I am also a stakeholder in this arena we call “women’s health,” and am therefore committed to understanding the relationship between modern women’s healthcare and its impact on the mental and physical well-being of clinicians and patients. At a more granular level, I am particularly interested in the physical, emotional and social consequences of subpar or nonexistent design within the cadre of women’s healthcare.
Though the professional designer brings her whole self to a project, she is trained to check her ego at the door and attempt to step into the lives and emotions of the people she is studying through immersing herself in their environment. In this way designers practice empathic design, a human-centered approach that helps us create products, systems and services that harmonize with the people that use them. This effort requires the designer to be what I call, “rigorously present” when researching a healthcare challenge. I would argue that in order to produce thoughtful solutions in healthcare design, practitioners need to regularly observe procedures, protocols and human interactions in the context for whom they are designing. Only through direct observation, listening and in some cases hands-on training can we begin to identify problems with equipment, workflows or communication. (7)
I’ve selected three women’s healthcare scenarios I have encountered that illustrate opportunities to improve common clinical situations in the labor and delivery unit and emergency department. I will also share solutions to problems identified within each of these examples I have been working on for the past six years.
- Jen had just gone through 10 hours of labor and a level-4 episiotomy. Jen had requested an epidural, but the medication didn’t take. They tried a second time, but it still didn’t work. The worst part of this situation for Jen was that the nursing staff didn’t believe that her epidural wasn’t effective. When her baby’s heartrate started to plummet, her OB/GYN arrived. She made Jen sign a consent for an emergency C-section or episiotomy while Jen was in active labor. Jen chose an episiotomy. Her doctor used a vacuum assist to pull her baby through the vaginal canal due to a shoulder dystocia. It took approximately 30 minutes to sew up the laceration while she bonded with her baby. The next day Jen was in so much pain that her OB/GYN prescribed an opioid. Consequently, she became sleepy and didn’t have the energy to breastfeed. Because of Jen’s drug-induced exhaustion, her baby was given formula. The nurse brought in a maxi-pad stuffed with ice-cubes to help relieve the pain from the episiotomy, but the sharp edges of the ice cubes and the mess of the water melting in her underwear was very uncomfortable. Jen was sent home with an oral pain prescription, and a small aerosol bottle of lidocaine which lasted two days. Due to her perineal pain, Jen found that she needed to sit on one side of her bottom in order to breastfeed at home adding yet another challenge to caring for
her baby. If it wasn’t for the private lactation consultant she hired to come to her home, Jen admits she would have quickly given up on breastfeeding.
Pain and fatigue are the most common problems reported by women in the early postpartum period. Pain can interfere with a woman’s ability to care for herself and her infant. Untreated pain is associated with a risk of greater opioid use, postpartum depression, and development of persistent pain. Nonpharmacologic and pharmacologic therapies are important components of postpartum pain management. Because 81% of women in the United States initiate breastfeeding during the postpartum period, it is important to consider the drug effects of all prescribed medications on the mother–infant dyad. (1) Considering how important it is to prevent long term opioid use, I have been working on a proprietary OTC and prescription topical drug to reduce perineal pain and swelling, and improving on traditional cryotherapy available for the perineum such as ice-cube stuffed maxi-pads, or re-usable cold gel pads.
Perineal pain can negatively affect breastfeeding because holding and breastfeeding a baby often requires sitting. When sitting creates pain, it creates a barrier to providing one’s baby breastmilk. To give you an idea of how impactful breastfeeding is on national healthcare costs, a study in 2007 found that if 90 percent of U.S. families followed guidelines to breastfeed exclusively for six months, the United States would save $13 billion annually from reduced direct medical and indirect costs and the cost of premature death. (3) Breastfeeding also confers global environmental benefits; human milk is a natural, renewable food that acts as a complete source of babies’ nutrition for about the first six months of life.(4) Furthermore, there are no packages involved, as opposed to infant formulas and other substitutes for human milk that require packaging that ultimately may be deposited in landfills.(4) In other words, it’s worth it for everyone to help a new mother deal with postpartum pain so she can more effectively care for her infant.
Long-term perineal pain also affects the relationship a mother has with her partner. Sexual disfunction and pain during intercourse may linger for many months (and in some cases years) postpartum putting stress on intimate relationships.
- Kate arrived in the emergency department (ED) bleeding profusely between her legs. She was 7 weeks pregnant. This ED had only two rooms with proper OB/GYN examining beds, and both were occupied. Jen was taken into a small space separated by curtains with a standard flatbed examining table. The resident brought in a plastic bedpan and paper cover. He proceeded to set up the examining table by placing the bedpan upside down and laying the paper cover over it. He instructed her to position her pelvis on the bedpan so her pelvis was lifted. Kate weighed 180 lbs. She crushed the bedpan beneath her. The resident became impatient, removed the crumpled bedpan and rolled up a towel which he placed under her bottom. He proceeded with a pelvic exam in this way. Besides panicking about an imminent miscarriage, she was embarrassed by the bedpan incident and incredibly uncomfortable with a bloody lumpy rolled towel under her bottom.
This scenario is an excellent example of a clinical work-around that addresses a lack of proper equipment (GYN exam tables). In this case, the work-around (plastic bedpan) failed, leading to a second work-around (the rolled towel). Imagine being Jen, confronted with the reality that she might be in the process of losing her fetus, and in parallel of this panic, experiencing unnecessary humiliation and confusion by this subpar examination process. The clinician, frustrated by his lack of resources ends up performing a less effective exam due to visibility issues (the angle of the patient was suboptimal) and the stress of the patient. Zooming out from the physical and emotional impact on the patient and clinician, using plastic bedpans to perform emergency pelvic exams as well as pelvic exams in any L&D unit that does not have enough GYN beds, creates an enormous amount of bio-waste that costs the hospital money to manage and increases their carbon footprint. Our maternal/neonatal safety lab at Stanford is developing a re-usable pelvic exam cushion and custom disposable paper cover that can be employed in low-resource clinics and hospitals to perform safe and effective pelvic exams on a standard flat exam table. The original idea came from doctors at the University of Arizona with whom we are co-creating this product. Although we have already conducted simulation studies with standardized patients, ED doctors and OB/GYN doctors, A clinical study with real patients in the ED will be commencing at two hospital sites the beginning of 2019.
- Maria has just given birth to preterm twins. One of her babies had passed away and the other was at her side sleeping. Clearly distraught by her loss, Maria, a Spanish speaker, was too distracted to focus on the pediatrician’s breastfeeding advice. Unfortunately, the doctor did not speak Spanish, and proceeded to speak louder and slower in English thinking her patient might understand at a higher volume. Maria was supposed to be hand-expressing her colostrum for the remaining preterm twin–too young to latch onto her breast. The doctor handed her a plastic spoon and taught the hand-expression technique by placing her hands on Maria’s body, demonstrating the breast hold and movement for initiating lactogenesis. Maria was uncomfortable with having the doctor’s hands on her body but was afraid to show her emotions. She was unable to collect anything until the pediatrician left her room. Maria managed to collect a spoonful of colostrum, but accidentally spilled it on the floor. Distraught, she tried again having no idea how much colostrum she was expected to collect. When the nurses came back to take her baby for tests in the NICU, the absence of her baby made it much more difficult to collect her colostrum. Maria tried the hospital breast pump, but the suction was so strong it was painful, and the tiny drops she managed to pump stuck to the inside of the valve making it difficult to collect colostrum for her baby.
I observed this scenario while working on a product I co-invented called Primo-Lacto®. I was asked to bring Primo-Lacto® into a hospital as an intervention for this mother. Breastfeeding, hand expression and pumping are all learned behaviors, and not something that a woman and her baby should “naturally” know how to do. Half the battle is the will to keep trying even after it seems like no amount of hand or pump expression will work. Often, with persistence a mother will succeed in expressing her colostrum for her baby even if her newborn is preterm.
In this case, the product intervention, Primo-Lacto® had a positive effect on this mother and was subsequently tested on 67 additional mothers in a clinical study. (9) The product is thoughtfully designed to communicate quantity expectations, and securely routes colostrum (whether by hand-expression or pump expression) directly into a sterile syringe that can be capped and stored easily. Products can drive behavior, and in the case of a new mother trying to feed her preterm baby, the impact of success is immense for both the mother/infant dyad’s long-term health. By default hospital costs are reduced due to less readmissions.
Products have the power to influence feelings of safety. Physical and emotional safety are inextricably embedded in the patient experience, yet this connection may be overlooked in some inpatient birth or ED settings. Clinicians should be mindful of how the birth or ED environments and their behaviors in it can affect a woman’s feelings of safety during birth or emergency exams. Human connection is especially important during risk moments like these, which represent a liminal space at the intersection of physical and emotional safety. (8) Thoughtfully designed products for women is another component that can increase feelings of safety and morale.
As healthcare product designers, we must remember that the products, services and systems clinicians and patients utilize become the fabric of care in the hospital and in some cases at home, once discharged. Designers are the weavers of these solutions and should be cognizant of the emotional and physical costs a hospital’s value review board doesn’t necessarily understand upon product acceptance and acquisition. For the clinician, “cost” is what I define as the cognitive load she must bear while attempting to use a particular device or service to reach a desired outcome. For the patient, “cost” is the short and long term health consequences of using subpar products that do not support her physically or emotionally.
I tell my students that in order to make impactful change in healthcare through product design there seems to be four important components:
- Understand the culture and user you are designing for.
- Understand the ecosystem in which your product/system/service will live.
- Understand the potential barriers to adoption.
- Feel unusually curious and passionate by the problem you are studying.
I recently came across this quote from Gloria Dall’Alba:
“Learning to become a professional involves not only what we know and can do, but also who we are (becoming).”
A nugget of wisdom to carry for the mindful design professional. She reminds us that we must not forget ourselves and who we are becoming when immersed in our work. As a female designer, I am the first to admit that I couple my emotions about my research with my skills to create solutions I believe will be helpful to women, their babies and the clinicians that care for them. An often elusive piece of the design process, I believe a designer’s emotions about her subject of study is what ultimately drives an important idea to market. Human-centered product design has the power to influence the physical, emotional and social outcomes that affect women’s healthcare.