Thursday, July 18, 2013

Using Technology to Improve Maternal  
Health in the Developing World
ATLAS Ph.D. student discusses PartoPen technology 
and issues surrounding Information and Communication 
Technology for Development (ICTD)
by Ira G. Liss

Each year, billions of dollars are spent on engineering and technology projects in underdeveloped regions around the world. Varied in approach and strategy, they usually share one overall goal – improve the lives, health and living conditions of people. To do this effectively requires careful planning and a deep understanding of conditions on the ground.

The Big Picture of Global Maternal Health
I spoke with ATLAS Institute Ph.D. student Heather Underwood, whose focus is healthcare and Information and Communication Technology for Development (ICTD). Her research paper, “The PartoPen: Using Digital Pen Software to Improve Birth Attendant Training and Maternal Outcomes in Kenya,” recently won first place in the 2013 Student Research Competition (SRC) of the Association for Computing Machinery (ACM).
Two medical students from the University of Nairobi use PartoPens to work on a partograph worksheet. One of PartoPen's pilot studies showed that its instructions and decision support made a significant impact on students' ability to correctly complete these worksheets.
Underwood designed the PartoPen, an interactive digital pen-based system, to work with an existing paper-based labor monitoring system, the partograph. Widely used around the world since the 1970s, the partograph was promoted by the World Health Organization (WHO) in 1994 when a large-scale study showed its effectiveness in improving birth outcomes in underdeveloped regions.

According to the WHO, almost 300,000 women die every year from pregnancy related complications, mostly in the developing world. Quoting Underwood’s paper, “Used correctly, the partograph provides decision support that assists in early detection of maternal and fetal complications during labor. Especially in rural clinics, early detection allows transport decisions to be made in time for a woman to reach a regional facility capable of performing emergency obstetric procedures.”

Improving Existing Technology 
Underwood embarked on her Ph.D. research with the goal of developing and applying technology that could make the existing partograph system easier and more efficient to use. By adding new technology to an older system, she hoped to improve health outcomes while maintaining the continuity of a paper system that’s been in place for decades.

PartoPen Specs
PartoPen shown with partograph paper form in the background.
The PartoPen system uses customizable software written by Underwood for the Livescribe 2GB Echo digital pen. It captures and synchronizes audio and handwritten text and digitizes handwritten notes into searchable and printable PDF documents. Pens use an infrared camera in the tip, activated when users press pen to paper. Its camera captures a pre-printed dot pattern (placed on the page by laser printer), which allows the pen to detect its location on the form. It can then interpret and use data to perform location-specific functions.

Better Understanding by Just Being There 
“There’s something indirect about introducing technology in a place where you don’t have basic needs fulfilled first,” Underwood said. “While the PartoPen is a useful tool, you need a lot of things in place before realizing its full benefits. Being at a hospital in Kenya gave me a better understanding of the whole picture.”

Before observing the maternity wards of the Kenyatta National Hospital in Kenya, Underwood studied the well-documented barriers to the partograph’s effectiveness: lack of training, complexity of the paper form and data interpretation issues.

Addressing this, Underwood’s PartoPen provided three key capabilities: user instructions, decision support and time-based reminders.

In the hospital where she conducted her research, she observed a major obstacle first-hand. “I went in focused on a very specific need and realized there are a million other needs. Understaffing is one of the biggest problems at Kenyatta National Hospital. There’s not enough nurses for the number of patients.
Underwood demonstrates the functionality of the PartoPen while a nurse midwife monitors a laboring patient and members of Kenya's media look on.

“I began to see why the paper forms were not being filled out. At Kenyatta, the nurses are well-trained and familiar with correct partograph use, but if a patient starts bleeding, everyone is focused on saving the patient. Understandably, completing paperwork is not the first priority.”

The Big Takeaway
“One of the key messages of ICTD as a field is the need to understand and work with the existing social and cultural factors when introducing a new technology,” she said. This is where partnerships come in. She now focuses on working with hospital and clinic staff to take ownership of their technology choices, that is, encourage those who work directly with maternal health issues to define their needs and shape technology to address those needs.

Underwood has found the process challenging. Hospital staffs are busy. Like most of us, they can be creatures of habit and resistant to going through the problem-solving learning curve necessary to achieve positive results.

Expanding Roles in Evolving Fields 
After spending 12 to 15 hours in labor wards on a daily basis, watching nurses work and women giving birth, Underwood gained understanding of the paper/data trail – where paper forms begin, how they are filed, what gets filled out and where the data goes.

“I began to see my work expanding into occupational workflow,” she explained, which involves examining the workplace and asking, how are things done? How can existing procedures be improved? She also found herself exploring ethnography – the study of customs, culture and cultural phenomena.

In addition, she’s come to realize that having a more formal healthcare background in these settings would be valuable. So she is now working towards a master’s degree in public health in conjunction with her ATLAS Ph.D.

“I never thought I’d be writing software for nurses in the labor wards of Kenya and studying public health. It’s this interdisciplinary aspect of ATLAS that allows me the flexibility and support to design and evolve my areas of study and address real needs as they come up.”

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ATLAS Institute offers a two-year Master of Science in Information and Communication Technology for Development (MS-ICTD) that includes three semesters in residence and a one-semester practicum – a hands-on internship with an organization engaged in ICTD efforts. To learn more, contact Ruscha Cohen, graduate program adviser at or visit

Learn more about the top graduate student award that Heather Underwood won in the ACM Student Research Competition Grand Finals,

Learn more about Heather Underwood’s research, 

The writer/interviewer Ira G. Liss is assistant communications director at ATLAS Institute, University of Colorado Boulder. He is also a musician, songwriter and performing artist. See his video artwork here,