Neonatal survival is a persistent global challenge; in high-resource settings, technological innovation has led to dramatic improvements, but deaths during the first month of life still comprise more than 40 per cent of under-five mortality.
Preterm birth is now the second leading cause of child death; most premature babies are born in low-resource settings where the basic technologies and approaches that led to improved outcomes for neonates in high-resource settings are largely unavailable.
Without new approaches to innovation, existing global inequities in neonatal outcomes will persist. The challenge is to package well-known and simple scientific principles of newborn care into affordable strategies that are feasible to implement in resource-poor countries. Nowhere is this more important than in district hospitals, which represent a key frontier to improving neonatal care in low-resource settings; most are understaffed and poorly resourced.
There is an urgent need to innovate the ‘Nursery of the Future’, a comprehensive set of affordable, highly effective technologies to provide quality neonatal care in low-resource hospitals. Implemented together with a comprehensive training programme for clinicians, nurses and biomedical technicians, such technologies could help turn the tide on newborn survival.
Three causes of death accounted for almost three quarters of the 2.8 million neonatal deaths globally in 2013: complications of premature birth, intrapartum-related complications, and sepsis. The majority of neonatal illnesses in low-resource settings could be treated with a set of technologies that aim to: 1) provide adequate hydration and nutrition; 2) prevent and treat infections; 3) provide temperature stability; 4) provide breathing support when necessary; and 5) monitor for and treat neonatal jaundice.
A broad array of devices are available to meet these needs in well-resourced settings, but these neonatal technologies often do not reach the developing world because they are too expensive or have prohibitive infrastructure or personnel requirements. When technologies designed for high-resource settings are used in low-resource settings, they fail because of harsh environmental conditions, lack of routine maintenance, or lack of necessary consumables. As a result, in many low-resource settings, the diagnostic and therapeutic possibilities for neonates are comparable to what was available in the United States and Europe in the 1950s.
The Nursery of the Future requires health-care technologies that can be safely used and sustained in low-resource settings. The ideal neonatal devices will be: safe and effective; robust and rugged; simple to operate; not require a regular supply of consumables or batteries; not require regular maintenance; operate from a range of power sources; be affordable; have a minimum lifespan of daily operation for five years, and meet international regulatory standards.
A relatively small list of appropriate technologies could meet the clinical needs of the Nursery of the Future (Table 1).
Often these technologies are not available. A recent survey of eight Kenyan district hospitals was conducted to assess whether basic equipment was available to support newborn survival. Simple tools such as infant warmers, oxygen flow meters and serum bilirubin tests were available in less than half of hospitals surveyed.
Comprehensive technologies can improve outcomes. When special care units for newborns were established at district hospitals in India containing radiant warmers, phototherapy lights, oxygen concentrators, pulse oximeters and IV infusion pumps, case fatality rates declined in 75 per cent of facilities. However, repair and maintenance of equipment designed for high-resource settings was a major concern. When equipment broke, repair was often delayed, with equipment remaining out of service for periods ranging from one week to six months. Similarly, an assessment of phototherapy lights at 16 Nigerian hospitals found that the majority of lights tested did not provide adequate irradiance levels, and only one hospital had an irradiance meter.
A number of new neonatal technologies explicitly designed to function in low-resource settings are under development, including a mechanically powered pulse oximeter, clean birth kits, a low-cost bubble CPAP device to assist premature babies in respiratory distress, low-cost LED-based phototherapy lights and a low-cost infant warmer. In many cases, developers have designed appropriate technologies that provide equivalent technical performance as systems designed for high-resource settings at a ten- to hundredfold cost reduction. Further studies are needed to determine whether the clinical implementation of these appropriate technologies leads to improved clinical outcomes.
While encouraging, this piecemeal approach to developing appropriate neonatal technologies carries risks. Improving neonatal outcomes requires an integrated approach to care and health system strengthening. Similarly, innovation and implementation of the Nursery of the Future will require coordinated multi-disciplinary collaborations that engage paediatricians, biomedical engineers and the medical device industry. Based on technologies that are available or under development, we estimate that a complete Nursery of the Future for a district hospital serving a catchment area of 300,000 people could be installed for $5,000–$10,000, much less than the cost of one western-style ventilator.
“When technologies designed for high-resource settings are used in low-resource settings, they fail because of harsh environmental conditions, lack of routine maintenance, or lack of necessary consumables.”
Technological innovation is only the first step in the process. Implementation research is needed to understand which low-cost technologies are beneficial and cost-effective and how they can best be implemented in low- and middle-income countries. This will require a shift in the priority of funding agencies; less than 1 per cent of published neonatal research during the past decade is relevant to deaths in low-resource settings.
Finally, sustained delivery of effective technologies requires commercially viable business models. Unfortunately, the traditional research and development enterprise has failed to develop technologies that are designed, delivered and priced for resource-poor settings. At the same time, many promising appropriate medical devices developed in academic settings do not leave the laboratory.
Improving global access to neonatal technologies requires new partnerships for product design that emphasize early business planning, affordability, translation to scale of practical technologies and stronger technical and business education in low-resource settings. Funding streams should adapt to support such efforts focused around integrated packages of technology.