Careables, a mixed community of people and organizations committed to the co-design and making of open, personalized healthcare for everyone. With the presented cases we reflect on the potential implications for post-pandemic local production of healthcare products and analyze them from a social innovation perspective. These global experiences are valuable indications of transformative innovations that can reduce dependencies from international supply chains and mainstream mass production.Makerspaces—informal shared spaces that offer access to technologies, resources and a community of peer learners for making—across the globe initiated a rapid response to the lack of medical hardware supplies during the global pandemic outbreak in early 2020 caused by the Corona virus (COVID-19). As our health systems faced unexperienced pressure, being close to collapsing in some countries, and global supply chains failing to react immediately, makers started to prototype, locally produce and globally share designs of Open Source healthcare products, such as face shields and other medical supplies. Local collaboration with hospitals and healthcare professionals were established. These bottom-up initiatives from maker networks across the globe are showing us how responsible innovation is happening outside the constraints of profit-driven large industries. In this qualitative study we present five cases from a global network of makers that contributed to the production of personal protective equipment (PPE) and healthcare-related products. We draw our cases from the experiences made in  Across However, this first aid response of the maker community does not go without friction, especially when dealing with critical medical equipment that needs to adhere to strict quality control and standards and represents a large business field for companies specialized in this area. One of the first instances of such a conflict appearing in international media was the case of a volunteer maker in Italy, who produced 3D-printed valves for life-saving Coronavirus treatments. The original manufacturing company refused to release the design files for the valves, forcing the volunteer maker to reverse-engineer the valve . The ethThe bottom-up initiatives from maker networks across the globe are currently showing us how responsible innovation is happening outside the constraints of profit-driven large industries. We are witnessing critical, socially responsible making these days and a professionalization of the maker-driven open hardware movement that is comparable to Open Source Software which is running the world nowadays. But is the maker community putting social interests before business interests? What effects will the Open Source hardware designs, that are currently being created and shared, have on the future of manufacturing? Will we see new collaborations across established industries and makers emerging? How will this affect society and especially the younger generation? These are just some of the emerging questions that science and technology studies in a joint effort of different disciplines still have to address.In this paper, we build on the experiences made during the COVID-19 pandemic by a small number of globally distributed makerspaces and fablabs. We aim to provide rich descriptions of the makers’ COVID-19 response and reflect on their potential wider societal implications in the future. The main objective of this study is to critically reflect from within the maker community on the crisis response actions taken, showing current challenges and limitations as well as offering a stimulus for further analysis of the transformative character of makerspaces. We have chosen a case study approach as in qualitative research the complexity of each case provides us with an important context for understanding the issue we are studying .Careables, a project dedicated to personalized open healthcare (www.careables.org). While these maker communities all vary in their COVID-19 response approaches, which we discuss in detailed case description, a focus group discussion revealed a series of commonalities amongst makers when it comes to scaling their activities, which we then related to the theories of social and transformative innovation theories.The five selected cases have previously been active in open healthcare practices and have been loosely connected via Bottom-up digital social innovations are on the rise, including in healthcare. Over recent years we have witnessed a growing number of grassroots solutions in do-it-yourself (DIY) healthcare, including the development of Open Source hardware and DIY practices which may counteract current healthcare supply shortages. Via Open Source approaches communities can collaboratively improve and co-produce new solutions, in consultation with public health authorities . InnovatThese community-led or civic innovations are responses to societal issues that cannot be met by our healthcare systems nor by industry. Careables, an initiative that is rooted in the context of personalized open healthcare development. It is a mixed community of people and organizations committed to the co-design and making of open, personalized healthcare for everyone driven by a set of underlying principles for responsible making. It started 2018 as a European funded innovation action under the Horizon 2020 program and has since grown to a worldwide community, mostly via a global network of social and technological innovators called Global Innovation Gathering (GIG). The Careables platformCareables encourages care receivers, healthcare professionals, and makers to join forces and to co-create tailor-made solutions designed for supporting and better suiting the care receivers’ needs.Closely related to these critical making properties is Further, the global network of fablabs recently launched Fab Care as a global initiative to support fablabs, makerspaces and hackerspaces which are working in assistive technologies, in creating personalized solutions for people with physical challenges to improve their quality of life.Beyond the civic-innovation character, we also see more and more established healthcare institutions, such as hospitals, therapeutic and care centers, starting to work with digital fabrication tools. In some hospitals, makerspaces are already part of their infrastructure . While tThese developments obviously bring legal and ethical issues to the table such as do-it-yourself solutions that may not always comply with medical standards and regulations. Problems may range, for example, from intellectual property law  to safety and specific laws for medical devices and PPE. Part of these problems arises, as in most cases product laws are aimed at large organizations rather than small entities. Makerspaces and these new forms of collaboration blur the classic hierarchical dichotomy between producers and consumers  and resuIn early 2020, when the COVID-19 pandemic had completely turned into the globally dominating health concern, bringing the health systems in many countries to their absolute limits, the reaction of the maker movement was instantaneous. Maker communities around the globe have been very active during the first wave of the COVID-19 crisis by responding to the shortage of PPE and other medical and healthcare-related products. One of the larger civic response communities is the Open Source Medical Supplies (OSMS)Careables community shifted its focus of activities from supporting DIY healthcare for people with disabilities to collecting, documenting and sharing information and Open Source solutions to fight COVID-19. The Careables COVID-19 collection currently includes around 50 Open Source hardware projects, ranging from different versions of face masks and shields to intubation boxes and door openers. In addition, background information and legal guidance on the responsible production and use of DIY products are shared with the maker community worldwide.The variety of PPE and medical supplies that have been produced in these collective networks are said to include around 50 different products, ranging from door openers, and ear savers to intubation boxes. These PPE serve as a means to reduce the spread of the virus following the available evidence that the virus is transmitted via air droplets when in close contact with infected persons and not air-borne. Therefore by providing equipment that supports frequent and effective handwashing or acts as disinfectants, helps preventing contact with droplets or helps avoiding contact with contaminated surfaces like door handles, an effective preventive measure is being taken especially in healthcare and community settings. The knowledge and research done by the OSMS global network have been documented and shared in case studies, community stories, a project library that gives access to many open designs, a map to find local response groups, and the Open Source Medical Supply Guide . Also, tAccording to a survey done by the Fabfoundation , which wNot only has the failure of global manufacturing supply chains accelerated the makers’ response; another important factor triggering the community action has been the financially underserved and fragile healthcare systems in many countries. In the United Kingdom an analysis of the maker response to COVID-19 pandemic by Overall, the maker COVID-19 response initiatives strongly relied on the sharing of open designs and a self-organized production and dispatchment of the DIY equipment, via online and social media . When a The volunteer-driven, self-organized activities of the maker community have significantly contributed to the response phase of the COVID-19 pandemic and also drew attention to the latent innovation potential of the general public . Since tsocially transformative, educationally useful and entrepreneurially promising. They offer capabilities for participation, deliberation and community development, which constitute their transformational and democratic potential. At the same time makerspaces also reproduce dominant values of society and the global economy, e.g., when they follow an open innovation agenda that tries to leverage the makers’ creativity for global manufacturing and following prevailing economic growth business models. Thus, we are witnessing contradictory developments of makerspaces, where we have open spaces aiming for democratic transformations next to spaces that adhere to traditional market-driven models  network volunteered to participate in this case study. They are listed as co-authors and are referred to in the following text as “case representatives,” sharing their insights and experiences through an interactive dialogue, guided by a self-reflection exercise and an online focus group discussion.As the overall methodology, a qualitative case study approach was chosen since it represents a versatile form of qualitative inquiry that is suitable for a comprehensive and in-depth investigation of complex issues and unclear boundaries . RepreseCareables project consortium. In the following list we introduce the representatives of the makerspaces who contributed to this article.-Brazil: Ricardo Ruiz Freire (Member of the GIG Supervisory Board)-Cameroon: Nadine Mowoh (Member of the GIG network)-Iraq: Nawres Arif (Member of the GIG Supervisory Board)-Italy: Enrico Bassi  and explain their decision. In the next step, a second dimension was introduced, the scale and interaction dimension, as an indicator for connectedness . This di-Do case representatives wish that their COVID-19 activities in the different countries scale from micro, to meso, to macro level?-If not, why not? If yes, under which conditions?The case representatives placed again their COVID-19 response initiatives on the respective x- and y-axes and discussed their positioning with the group. After this introduction the core discussion focused on two questions:One of the leading researchers facilitated the discussion, while the second one summarized the main aspects of the discussion on the Jamboard to visualize the key points discussed. The third researcher took additional notes. The discussion was moderated to make participants reflect on their cases and to gain themselves new insights into their specific situation. In qualitative research the researcher is not necessarily the invisible neutral, but may also contribute to a moral discourse and spark transformative processes . The onlThe analysis of the case studies is based on the self-reflection reports of the case representatives and the summary of the online focus group discussion. Qualitative content analysis according to The research material was analyzed through two iterative phases, from October 29, 2020 to November 11, 2020 by the three female researchers from the Center for Social Innovation, who also figure as the first authors of this manuscript. Data were analyzed both inductively and deductively in these two phases. Specifically, two forms of data analysis triangulation were carried out by the researchers to ensure a rigorous and robust approach . First, We are aware that this study is exploratory in nature and is giving a rich qualitative view on the reported cases, but is limited in its scope. This is the very nature of qualitative research. Engaging the case representatives in a reflective focus group discussion and being part of the authoring team might shed some doubt on the validity of this research. However, we believe that by doing so we have guaranteed the authenticity of the experiences and our findings are internally coherent. In particular the focus group discussion has helped to reflect on the constructs emerging from the first analytical phase and has allowed the three main researchers to capture data “from the inside” and gain a deeper understanding of the phenomena under discussion . This trThe following case descriptions represent summaries of the self-reflection reports while chapter 6 presents the results from the online focus group.The following five cases of maker responses to COVID-19 cover different perspectives and contexts. Some focus on their lab’s activities, some relate more on the national activities all together, and overall, they give a good representation of the diversity of actions encountered in makerspaces across the globe.The Brazilian Case Careables project and started to function as local hubs which connect local communities of persons with  healthcare needs, care givers, and public healthcare professionals with the community of makers and medical herbalists. With the outbreak of COVID-19, the activities of these local hubs, called Careables Olinda, completely shifted to producing PPE and other medical supplies in order to fight the pandemic. So far, they have produced around 7,000 face shield units out of which they donated around 5,000 pieces to different initiatives, to hospitals and health authorities in the Recife metropolitan area, cities in the countryside, and indigenous and Afro-Brazilian communities. The remaining products were offered via an e-Shop that was specifically set up for that purpose. The Brazilian fablabs partly relied on shared Open Source designs of face shields and adapted them to the local context. Besides, together with healthcare professionals, they developed an open-source model of an aerosol box integrated into local necessities to use at Intensive Care Units (ICU) and released it online. The aerosol box is used in the process of intubation and extubation of patients, to avoid the contact of aerosol sprays of patients with doctors. The product was validated with doctors from two different hospitals in the Metropolitan Region of Recife, who have experience in orotracheal intubation. In addition, a community including professors, medical students and designers from Casa Criatura was established to develop the product further and is, at the time of writing this manuscript, seeking certification and registration of a free patent, with the final aim of bringing the aerosol box to a global market.In Brazil, before the outbreak of the pandemic, four maker-oriented organizations had established collaborations with the Careables Olinda had a dialogue with the Secretary of Health of Olinda, who realized the importance of the maker community in the local production of PPE to keep up the city’s health system. Later, collaboration with healthcare professionals and hospitals started as ICU professionals approached the makers with a request for a better version of an aerosol box and jointly they defined the specifications. The relationship with the health sector has allowed Careables Olinda to review its area of activity and has expanded the scope of its inventiveness while at the same time it increased local awareness and knowledge about open-source, digital manufacturing and healthcare across the involved stakeholders, e.g., physicists, designers, healthcare professionals, makers. The local maker hubs also felt like being part of a bigger initiative, not only for the producers of PPE. Their communication campaign was a small part of a big operation by different sectors in the cities to suppress the virus and the cooperation with the Secretary of Health has already split over to other activities of open innovation, besides COVID-19.Partnerships and networks, local and global, played a crucial role in this case. Since the beginning of its activities, While the activities clearly showed valuable impact in reducing the curve of COVID-19 infections in the regions  and in promoting the social value of open innovation, the actors clearly recognize the negative impact of their actions. The enormous amount of plastic being produced, the considerable degree of pollution and carbon emissions related to the makers’ activities, coupled with the environmental problems of the local communities triggered a commitment for more sustainable practices in the future. Some of those have already started to emerge, such as the work with recycled plastic or the creation of a bio-fermentation lab to address the food scarcity in some local communities.Mboalab is a community biology lab in the central region Yaounde in Cameroon, comprising molecular biologists, biochemists, public communications specialists, microbiologists, and electro-mechanic technicians, who act as educators in the local community to empower the population with the skills to solve their health and environmental problems. During the COVID-19 pandemic outbreak, the lab tried to attack some of the local bottlenecks related to the sanitary situation. The information department at Mboalab accessed the latest information and recommendations from the World Health Organization (WHO), the Food and Drug Administration (FDA), and the Centers for Disease Control and Prevention (CDC), looking for simple formulae for making hand sanitizers and instructions for face masks designs. With their strategy to target the most vulnerable groups and communities  of the suburban community of Mbankomo, where the lab is located, they started their educational work. The lab team was able to prepare alcohol-based hand sanitizers that met the FDA recommendation with locally available components and started demonstrating simple formulae for producing hand sanitizers from cheap and readily available components from the local drug stores.The lab also produced face masks using appropriate local fabric and prototyped an automatic gel and water dispenser to limit the spread of the virus and encourage frequent washing of hands. Educational aspects were embedded in most activities of the lab. Through the use of the automatic gel dispenser the local population was taught about the importance of handwashing and how an effective hand washing exercise should be carried out. These sensitization sessions were also used to educate the population about the Coronavirus, its modes of transmission, ways of prevention–helping to do away with certain myths about the virus that circulated in the local community.Again, global networks were important to connect with other populations to share stories, knowledge, and approaches using platforms like Openair and Wikifactory. National and international collaboration was encountered in the search of testing kits, and by participating in the development and testing of simple, easy to replicate methods of fighting COVID-19 in resource constraint settings.In spite of all these efforts made, some challenges were encountered. Upscaling was an issue, due to a lack of funds. For instance, the automatic gel dispenser that was prototyped was intended to be kept in at least 10 major centers of the community to encourage frequent washing of hands and demonstrate an efficient hand washing practice. The general increase in prices of all essential and non-essential goods made life difficult for the common local population. The widely spread belief that Africans are naturally immune to the virus and that some concoctions can provide them stronger immunity and protect them from being infected was another hurdle. Part of the population also strongly believed and went about saying that the Coronavirus is not real and that it was only a scam or some “thing” created to deceive and control people’s lives.Given the sensitizations, training, and collaborations achieved during this period of the pandemic, the population, community biologists, and makers stand a chance of independently handling future pandemics or epidemics by confidently producing PPE or other materials that might be required to fight the pandemic. The approach is to educate and equip the population with the skills to be able to handle the crisis without depending on the government, non-profit-organisations, or foreign aiders.The maker space at Waag aimed to provide support in maker research, product development and prototyping during the first lockdown phase, teaming up with a nationwide group of Technical Universities, the TechMed Center (University of Twente), the police, the Royal Netherlands Army and national and global maker communities.In an attempt to better understand the needs within the medical field efforts were mostly dedicated to coordinating and backchanneling within the network. Via online meetings Waag functioned as a catalyst in bringing different maker groups together and has been connecting stakeholders that weren’t in contact or collaboration with each other. It was important to get an overview of products or prototypes that were needed most, but also looking into existing solutions or solutions that were being developed, and how Waag could be involved in this. One of the main concerns and also the main challenge for the Waag team was to ensure the safety of the PPE. Also, getting prototypes tested by certified bodies was difficult. Based on the experiences from other makerspaces in the Netherlands and internationally, door handles and face shields were mostly considered for production.In collaboration with the police Waag explored the prototyping of door handles, which police officers would use when entering an unknown building. Different production methods were explored to find an alternative for the prototype the police were using, which was 3D printed and consumed quite some time for large scale production. The team at Waag adjusted the model so it could be laser cut, and thus be produced at large scale in a short time. The prototype was tested and functional. However, within the police force few police officers wanted to use a door handle in their daily work. So, the adapted design was in the end not produced. Other products the fablab was experimenting with include a transparent face mask and a DIY respirator.There was a lot of media attention on the lack of PPE for healthcare professionals in the Netherlands. Waag reached out to the medical institutions within the Metropole region of Amsterdam to hear what their needs and wishes were, but in the end the first contacts ended in no specific request for further research or prototyping. Thus, the fablab at Waag started to produce face shields and opened a webshop to sell them at minimal costs to local healthcare professionals, organizations and people working in contact jobs, such as hairdressers, cleaning services, beauticians, nail salons etc. Local residential care organizations that were directly offered these face shields did not show any interest.Overall, the impact of Waag’s engagement has been mainly in coordinating and pushing the notion of maker skills towards other domains, rather than organizing and producing PPE. Building on a network of local, national and international organizations, Waag was able to push the added value of maker skills as a driving innovation force. However, when it comes to the production and distribution of large numbers of products Waag was expecting more collaboration with large enterprises, which was not achieved. According to their experience commercial companies are reluctant to take up on the innovative designs and knowledge stemming from the maker communities.Finally, it is worth mentioning that the discussion within the national coordination group, including the Netherlands Royal Army, also touched upon the notion of distributed manufacturing. The idea of setting up a global network of decentralized production facilities, as an immediate response to a healthcare crisis, gained wider attention and will be further discussed in the future. Currently the network of fablabs mostly shares knowledge, skills and blueprints, but could it also be equipped to coordinate a large-scale production of e.g. PPE in the future?Science Camp, a maker space based in Basra, south of Iraq, is attached to the global maker movement and used to provide innovative solutions by implementing digital fabrication and DIY concepts, armed with the qualified industrial infrastructure. This space was among the first entities in the country that responded to the COVID-19 crisis with innovative solutions. Approximately 13,000 protective face shields were produced and distributed for free to the frontline medical staff and other main human resources who provide essential services for healthcare, security, delivery services, etc. In collaboration with local industry, local civil society, and academicians, a response infrastructure was set up taking care of e.g. monitoring the needs of PPE, providing raw materials, communicating with healthcare services, PPE production, PPE distribution, online digital statistics monitoring, and research and development. Medical staff highly appreciated the efforts done by the maker community and requested even more face shields and research into other types of PPE.The design and production process of PPE was adapted to the local context, using locally available raw materials, such as PET plastic sheets used in water packaging factories. Also, the design was adapted to be easy to assemble, with no need for gluing, stapling, or sewing. The digital fabrication techniques applied made the production process use a minimal number of raw materials, and fast, with high quality.All efforts were covered by voluntary contributions from all partners. The raw materials were a donation from the local water factory. The Iraqi government did, however, not support this type of community response and some international NGOs suggested converting the PPE production process into a business rather than a charity crisis response, which was not realized by the maker space due to ethical reasons.Apart from the financial challenges, the Iraqi maker space also encountered other difficulties, related to public administration and logistics. Travel permission forms to procure raw materials, machine maintenance, etc. were partly refused during national lockdown and bureaucratic barriers hindered the distribution of PPE via the official channels of the healthcare authorities.In addition to the high recognition in local and global media, the involved makers got experience in PPE production and legal aspects related to it as well as better insight into the use and availability of raw materials and resources locations. The fast response activities have also shown that the bottom-up social response can work independently from governmental or international aid organizations, avoiding potential conflicts between these organizations.Italy was Europe’s first and one of the most affected nations being hit by the COVID-19 pandemic. The country’s most efficient health systems in the Northern regions were about to collapse and hospitals were running out of supplies, including PPEs as well as essential parts for ventilators and other respiratory devices. Triggered by the initiative of a maker who provided a hospital with a 3D printer and helped to reproduce missing valves, the value of the maker community for the local health infrastructure became visible, and local supply chains of PPE for healthcare staff and other essential workers started to emerge.Make in ItalyCareables partner and specialized in working with the healthcare sector, was involved in the national coordination activities from the onset and contributed to overcoming the local medical supply shortage.Local coordination groups played an important role in the distributed production and supply chains. These groups were almost all volunteer-based, almost always within existing communities of people or fablab networks who were already used to working together. The first COVID-19 maker networks in Italy were regional, and they succeeded in responding to local needs as they evolved. This teamwork at local and regional levels paved the way for nationwide coordination across Italy. In the period of just a few days, three different initiatives emerged with similar and complementary objectives. One of those initiatives alone, Italy’s response to the health crisis wasn’t limited to the grassroots maker movement of hundreds of volunteers and fablabs. Many Italian companies worked closely with active makers, and in some cases, even helped the movement to take off. Also the educational sector was involved as the face shield production model was included in the training of high school students, initiated by the Maker@Scuola projectThe case in Italy has shown so far how new local collaborations for digital social innovations can be established. Because of the emergency, various hospitals contacted specialized studios, fablabs, small businesses and startups in order to develop new solutions together. Doctors have started to become co-designers, innovators and makers. In Italy, we find some isolated examples where these emergency-driven collaborations have turned into established collaborations where hospitals, doctors and therapists recognize the value and potential of digital fabrication tools and distributed local production. However, the organizational and structural details of cooperation between makerspaces and the public healthcare system in a more systematic way are still to be explored.In the following chapter the results from the focus group discussion with case representatives from Brazil, Cameroon, and Italy are presented.In a first step, focus group participants were invited to relate their Covid-19 activities to one of the levels of social innovation–the micro, meso, or macro level see . The twoAll three case representatives present during the focus group meeting stated that their COVID-19 related activities were in transition from micro to meso level. Thus, cooperation with other organizations became important to meet the social need and not only social but also economic objectives were addressed. The Italian case representative said to have acted on a meso level during the first wave of COVID-19, establishing networks between Italian fablabs and organizations in the need for fabricated health devices; but acted again on a micro level when the emergency situation stopped. Connections with political actors have been established but sustainable links are not in place yet. In the Brazilian case, first sustainable contacts were established with local politicians, who showed interest in the civic engagement taking place in Olinda. Also, the close cooperation with health professionals is still in place, after the first wave. In economic terms, the fablab sells individual face shields, fabricated in their fablab, or whole packages, where e.g., a company is donating 200 face shields. In the Cameroon case the activities were and still are closer to the meso level, as sustainable links to other organizations have been established, mostly related to the educational purpose of the lab.In a second step, the focus group participants discussed two key questions: 1) If they would wish for their COVID-19 activities to sustainably scale from micro, to meso, to macro level; and 2) if yes, under which conditions.All three case representatives shared the same opinion–that scaling their activities at least from the micro level to a more stable macro level is wished for, as there are people in the need of help and this need can be met by the production capacities in fablabs. However, scaling up should take place only under certain conditions and building on certain shared principles and values.Scaling up on the social innovation model should not resemble the scaling up in business terms. It was stated that companies tend to change when they scale, losing contact with local communities, introducing intermediate layers of management, and shifting the focus to financial aspects and maximizing incomes. The risk is that open innovation is not open anymore, but rather owned by a company, thus hindering the innovative groundwork that was originally aimed for by their inventors. So it’s fundamental to change the models of scaling up.Case representatives wish to scale the approach and spread the specific knowledge on how to co-design and produce  healthcare devices with digital fabrication tools. So training other fablabs in how to support health and care is key here, but also the training of local people–first regarding COVID-19 and how to best protect themselves, and second how to cooperate with and make use of fablabs to support their health and well-being.Participants aim for establishing connections and collaboration with other fablabs to scale responses to healthcare professionals and people in need. The Italian experience in this regard shows that creating structured networks of cooperation increases complexity. Fablabs are heterogeneous, have different underlying organizational models and specializations. So not every fablab would be able to produce medical equipment that might work properly in a hospital context. The question is how to deal with this complexity and also raises some doubts that strong networks might result in decreasing visibility and importance of the single node of this network.Careables Olinda stresses that working for other groups in the need of health and care, might be a good way to strengthen their approach while avoiding complex certification issues. In the Italian case, the emergency situation of the first COVID-19 wave gave room for certain legislative exceptions. Still, producing for hospitals requires meeting high quality criteria and demands for additional aspects like documentation, etc. In times of crisis, the official processes might be too long and exclusive to flexibly react to emergencies, so there is a call for more agile mechanisms that are established and tested beyond the times of crisis. It is wished for more flexibility to test the collaboration between medical institutions and local manufacturers to co-design and produce medical equipment below certain risks or costs. As mentioned above, working with and for disabled people, and offering COVID-19 support that is not medical equipment  are some of the suggested activity areas that can strengthen sustainable cooperation between local manufacturers and people and organizations in need of health and care devices. Alternative approaches to supporting health and care are key to spread the approach.Legislation issues have to be addressed carefully if medical equipment is the focus of digital fabrication. When producing healthcare products or medical equipment the main aim is to not produce more harm than good. In Cameroon, only certain institutions are allowed to produce medical equipment, thus Mboalab focused on producing products where no strict legislative measures need to be addressed, e.g., producing and making accessible proper disinfectants and providing the knowledge on how to protect oneself from COVID-19. In Brazil, legislation is more flexible, and the close cooperation with health personnel allowed the fablab in Olinda to successfully develop face shields used in medical organizations as well as an open-source model of an aerosol box. Nevertheless, Additionally, strong local nodes are key to spreading the approach. Working in the health and care sector requires at the one hand trust of people and a diverse set of local organizations, on the other hand it aims to successfully empower local people. Thus, establishing a network of local nodes that adapt to local contexts, link to local organizations and the local community of people in need, is the basis of spreading digital fabrication for health and care.The COVID-19 emergency situation showed how powerful the network of local digital manufacturers can be in flexibly supporting societal needs. Focusing this power of the network to other aspects, like climate change, digital fabrication initiatives can play a key role in successfully supporting social innovation processes. Maker activities can in this regard catalyze the attention to a wider problem, e.g., the climate change and the scaling up should not take place at the cost of the environment. Thus, producing tons of plastics  should be critically reflected and alternative ways of more environmentally friendly production should be sought.The two main data collection instruments brought forward complementary findings. While the self-reflection reporting focused on describing the past and current experiences made during the COVID-19 response activities by the makers, the focus group discussion built on these experiences and reflected on future implications for the scaling of the makers’ grassroots initiatives. responsive behavior was strongly enabled by the commitment of local stakeholders on the one hand and the global connectedness on the other hand. By drawing from their local, national and global networks the actors in the makerspaces were able to get rapid access to design templates, material resources and distribution channels. Some of the connections with relevant stakeholders, such as medical staff or local politicians, proved to be rather fragile though. For scaling locally embedded maker activities that address local social needs a strengthening of networks, locally and globally, is important according to our cases.From the collected experiences we see how fast the maker community reacted during the health emergency by supplying local healthcare providers with urgently needed PPE and other medical devices. Such flexible in adapting to the local contexts. This resulted in localized designs, such as the Brazilian tropical face shield, which was a local adaptation of a German design, or the use of locally available materials, such as the Iraqi PET plastic sheet, which are usually used for water packaging. In the case of the Cameroon maker space the COVID-19 response activities included a strong educational aspect acknowledging the local need for more information about the virus. Next to the importance of education and training on maker skills, the cases also highlight the strong local embedding and connectedness to the local communities as essential for a flexible and fast response to pressing social issues. For a future scaling of maker space activities that respond locally to social needs established cooperation with local stakeholders has been identified as a key element.The COVID-19 response of the makers was also responsible practice from makers. Across the five cases we observe a strong sense of social responsibility. This has been manifested in acknowledgment of quality standards for healthcare products as well as the overall commitment to doing no harm and user safety. Clear guidelines and legal structures that allow responsible making are thus being requested based on the current experiences. When discussing ethical aspects, the case representatives also stress their growing awareness towards the need for ecologically sustainable maker practices.Another important aspect addressed in the self-reflection and the focus group discussion has been the awareness for a limitations of the approach. Their COVID-19 response activities were limited in terms of capacities, resources, and infrastructures. The makers thus recognize the boundaries of what can be achieved within their limited spaces. Collaboration with established businesses and governments should be envisioned for the future. This would allow for an effective response at a larger scale.Finally, the case representatives are aware of the A Network PerspectiveThe five cases represented in this study are located across three continents and are embedded in very different contexts, economically, politically, and socially. When the COVID-19 pandemic started to spread, these makerspaces took on the challenge of counteracting the PPE and medical device shortages. In their civic reactions to the failures of public healthcare procurement and shortages in the global supply chains, they all faced some similar challenges and new opportunities. In this analysis, we want to concentrate on four main perspectives that evolved during the analysis and turned out to be relevant when discussing the maker COVID-19 response activities in the theoretical frame of the three social innovation levels: social needs (micro level), societal challenges (meso level), and systemic changes (macro level).Working in translocal networks, referring to networks at local and global level, has been a critical aspect for the operation on the ground. We saw that reflected in all of the cases, with local networks playing a key role in all phases, from research and design to the production, testing and distribution of the provided COVID-19 response solutions. The established local networks and temporary partnerships include stakeholders from across the quadruple helix, namely academia, government, civil society, and industry. In addition, in most cases, the fast reaction from the makerspaces was only possible due to the global open sharing of PPE designs. Being globally connected offers access to a wide range of resources and is possible only in a culture of openness and sharing, which is propagated also by the Open Design and Open Hardware movements. The benefits of open networked collaborations become visible immediately in times of crisis, such as the COVID-19 pandemic. In social transformative innovation theory translocal networks are an important element contributing to empowerment . From th(2)A Value PerspectiveThe sustainability of the emergent translocal networks is however very fragile. The Italian case showed that highly efficient and quickly established networks might become loose when the emergency situation is over. For the networks to continue and possibly lead to a transformational change as described by An ethical commitment of the makerspaces becomes noticeable also in other aspects. When discussing ways to scale their practices a need for new types of business models and new value definitions was expressed. Transformative social innovations cannot be achieved by just applying existing innovation models and capabilities to issues of social concern . It need(3)An Educational PerspectiveWith the presented experiences we argue that environmentally and socially responsible making should be assigned additional value, next to the cost-benefit calculations dominating today’s business models and move to added value-oriented models. The case representatives in this study follow a community-driven approach, not a business-driven approach, which needs higher societal recognition. There are attempts to raise broader attention for the values of transformative social innovations in measurable terms, such as the Social Return on Investment (SROI), which is a performance measurement tool, demonstrating the social value enterprises generate. SROI is however an underused and undervalued practice despite being accepted as an internationally recognized measurement tool for social enterprise . For comMakerspaces are often characterized as spaces for collaboration, information sharing, reflection and learning . Inciden(4)A Legal PerspectiveAlso, learning between makerspaces and with and from other network partners, like health professionals, is key. We see knowledge exchange on a global scale that addresses overarching topics, like the exchange of certified, proven PPE instruction guides, guidelines on the design of co-creation processes, and the efficient use of digital fabrication tools. And we can identify contextualized knowledge that emerges in the diverse settings, like how to react to the local availability of material, how to adapt production processes to local contexts, how to address very specific local needs. Undoubtedly, the learning taking place in makerspaces leads to empowerment and resilience . As RattIn order for local manufacturing to become relevant at a systemic level, fundamental transformations of the underlying structures need to take place. In the context of open healthcare, current legal frameworks are one of the key structures that would require adaptation. As system changes are typically slow and require long-term thinking, makers are exploring the current boundaries in their support of the healthcare sector. Part of the current boundaries being explored by makers relate to the nature of the solutions they produce. In some states (e.g. in the European Union) the production of specific solutions–such as respiratory valves or breathing masks–requires complex processes and compliance documentation. These are necessary as the solutions qualify as medical devices and imply the respect of the relevant laws in the matter . As PearGood Samaritan Laws–which offer protection from liability for those whom they believe to be in peril, ill, or otherwise incapacitated - could set useful measures to counterbalance this dichotomy. This legal perspective could help reduce the barriers for companies and makers hindering the release of healthcare projects’ designs and their replication. The case of COVID19 opened new scenarios for the application of these laws. We are aware of the complexity of system innovation as they are “profound transformations in social systems”  by makers vis-a-vis the possible unintended negative consequences of such ethical acting. As a way forward, so-called systems”  and we bsystems”  and it wThe experience brought forward in our five contextually very different cases has shown how local production networks can function in times of emergency. Their local design, production, and distribution of PPE and other healthcare related products towards health professionals and the general population has proven to flexibly cover emerging needs and stand in for global manufacturers. Looking at the makers’ initiatives during the COVID-19 crisis from a social and transformative innovation perspective, we encounter a wish to scale from working on the social needs level to addressing wider societal demands and, in the future, even triggering systemic change. Networking and sharing knowledge and experiences across multiple actors are key with this aim. Representatives from the five cases stress the importance of emergent translocal networks for their COVID-19 response to happen, which include actors of the quadruple helix on local scale while exchanging and learning from each other globally.Scaling transformative practices of makerspaces is however envisioned only under certain circumstances and following a set of principles and values. A commitment towards openness and sharing, such as it is propagated by the open hardware movement, requires new forms of business and value models. Prototyping in the healthcare domain, with and for patients, people with disabilities, and other often vulnerable groups, requires an ethical commitment and legal backing in order not to produce more harm than good. Educational and environmental considerations likewise come into play. Empowerment through teaching and creating only solutions that address real personal problems or needs are core principles of responsible making. In the makers’ future endeavors towards co-designing and making open, personalized healthcare and establishing these processes as social innovations more social value propositions may be encountered, with implications for individuals, communities and society at large. While we notice signs of empowerment at individual and community level, we envision a strengthening of democratic processes at society level. Other scholars likewise speak about the democratic value of makerspaces, which they find in certain grassroots activities that address social issues e.g. . At the We have considered implications that go beyond the makers’ response to fighting COVID-19 from the experiences made in five contextually diverse settings. We are aware of the limitations of our study, but see reasonable generalization justified by the contextual heterogeneity of the cases covered, the strong embeddedness and connectedness of the case representatives (and co-authors) with the global maker community, and the similarities we have found on other documented cases, such as those documented by others. Our case-based snapshots resonate well with other documented experiences e.g. . Next to


Abdominal B-ultrasound images of intrauterine pregnancy tissue residues were analyzed to discuss their diagnostic value. With the rapid development of computer technology and medical imaging technology, doctors are also faced with more and more medical image diagnosis tasks, and computer-aided diagnosis systems are especially important in order to reduce the work pressure of doctors. In recent years, deep learning has made rapid development and achieved great breakthroughs in various fields. In medical-aided diagnostic systems, deep learning has greatly improved the diagnostic efficiency, but there are no mature research results for abdominal B-ultrasound image recognition of intrauterine pregnancy tissue residues. Therefore, the study of liver ultrasound image classification based on deep learning has important practical application value. In this paper, we propose to give a CNN model optimization method based on grid search. Compared with the conventional CNN model design, this method saves time and effort by eliminating the need to manually adjust parameters based on experience and has an accuracy of more than 92% in classifying abdominal B-ultrasound images of intrauterine pregnancy tissue residues. The diagnosis of intrauterine pregnancy tissue residues by abdominal B-ultrasound can effectively improve the diagnosis and provide important reference for patients to receive treatment, which has high diagnostic value. Residual intrauterine pregnancy tissue is a residual appendage or detrusor that remains in the uterine cavity after termination of intrauterine pregnancy, which can cause recurrent vaginal bleeding or uterine infection, and is also an important cause of abortion or postpartum uterine bleeding and infection . AbdominMethods. Forty patients admitted to our hospital with suspected intrauterine pregnancy residues after delivery in mid- to late-term pregnancy underwent ultrasound examination, and those with abnormalities underwent surgical pathological examination. Results. The ultrasound images of the 40 patients in this group could be divided into mixed sonographic images (27 cases) and light-dot echo images (l3 cases), of which the conformity rate between mixed sonographic images and pathological diagnosis was 92 stone% (25/27), and the conformity rate between light-dot echo images and pathological diagnosis was 76% (10/13). Conclusion. Ultrasound imaging has a good diagnostic effect on the diagnosis of intrauterine pregnancy residues after delivery in mid- to late-term pregnancy and can accurately reflect the specific location, size, and relationship between the residues and the uterine wall while detecting intrauterine pregnancy residues. It is worthy to be widely promoted in clinical practice.The clinical characteristics of abdominal ultrasound images of intrauterine pregnancy residues after delivery in mid- to late-term pregnancy were studied and the diagnostic effect of ultrasound images was investigated. Intrauterine pregnancy residues are a major cause of postpartum hemorrhage in mid- to late-term pregnancies and are a complication of pregnancy that can lead to serious adverse outcomes. Ultrasound can effectively show whether there are pregnancy residues in the uterus, and if so, the test results can accurately reflect the specific location, size, and relationship with the uterine wall, providing clinicians with a more scientific, accurate, and detailed basis for judgment, thus avoiding the occurrence of bleeding and infection to the greatest extent possible.In this paper, we improve the method of CNN model design and propose a constraint-based grid search method to design CNN models, which integrates the balance between three different dimensional parameters of CNN models. The CNN obtained after grid search is able to compound and amplify three dimensional parameters by one variable at the same time and then obtain a CNN with the highest accuracy without tedious manual intervention, and the obtained CNN model has higher accuracy and smaller number of parameters compared with the previous chapter.Compared with the CNN model obtained by tuning the parameters, the experimental method in this paper has four main improvements: (1) the most intuitive is the model accuracy, and the final accuracy obtained in this paper is higher than 92%, and the accuracy is improved. (2) The balance of the three-dimensional variables of CNN depth, width, and input image size can improve the accuracy of CNN classification, and the subsequent experiments also show that the balance will not be destroyed with the CNN scaling. (3) In the experiments of this paper, Flops is introduced in the design of the CNN structure, and the model efficiency is fully considered. (4) The optimal performance of the CNN can be obtained by scaling up the CNN after the grid search, which avoids the complicated and tedious process of tuning the parameters. In order to deeply explore the value of abdominal B-ultrasound in the examination of intrauterine pregnancy tissue residues, this paper performs abdominal B-ultrasound examination on 66 patients with intrauterine pregnancy tissue residues who were included in this study in our hospital between September 2015 and September 2016.Medical imaging technology has made tremendous progress in the past decade or so, but in contrast, the development of computer-aided diagnosis-related technologies has been slightly delayed, especially in medical image analysis. With the development of deep learning in recent years, it has played a significant role in advancing medical image analysis. For example, image segmentation , image aIn the image classification, one of the most common tasks in medical image analysis, supervised learning is mainly used to train the model with annotated training datasets so that the model learns different image features corresponding to different classes of medical images, and after sufficient training, then it classifies unknown test data with high accuracy.In the task of classifying MRI images of the brain, Akl et al.  proposedFor the analysis of breast images, Ji and Kim  proposedIn analyzing images related to ocular region, Grossman et al.  used a d∗ 2 maximum pooling for feature extraction and finally used a long- and short-term memory network with 256 units, and the AUC of the final test result reached 0.83.To classify abdominal ultrasound images, Gatford et al. proposed a CNN-based multitask learning framework, in which 187,219 ultrasound images were used in the experiments, and the accuracy of their classification has been higher than that of a professional physician. The deep CNN model used in the article can automatically determine the severity of knee osteoarthritis. In their experiments, a pretrained network trained on ImageNet was used and then fine-tuned on the knee osteoarthritis dataset, and the final CNN model obtained was able to have good classification results. Inspired by the structure of VGG network, the authors used five convolutional layers, ReLU activation function, and 2 With the maturation of medical imaging technology, ultrasound has become the most common modality to examine fatty liver. The algorithm adopts manual extraction of the attenuation coefficient of the image and uses a mathematical statistical framework to detect fatty liver. Qayyum et al. proposed a “grayscale correlation grade” through regions of interest in multiple ultrasound images to indicate different fatty liver classes. Mihailescu et al. calculated the attenuation values from regions of interest and used a mathematical statistical framework to detect fatty liver. “Mihailescu et al. calculated attenuation values from regions of interest and used random forest to classify ultrasound images of intrauterine pregnancy. Vicas et al. used attenuation coefficients, fitting errors, etc., as feature sets and used SVM classifier to perform quantitative analysis of fatty liver. The principle of quantitative analysis used in this paper is to extract several features of ultrasound images in the gray-scale covariance matrix such as autocorrelation and signal-to-noise ratio and using logistic regression to determine the severity of fatty liver. The scatter coefficient of abdominal B-ultrasound images of intrauterine pregnancy tissue remnants can also be used to quantify the fat content of the liver.In all of the above methods, features of ultrasound images need to be extracted manually before performing classification experiments. CNNs have surpassed many traditional algorithms in the current field of computer vision tasks. Therefore, for ultrasound in utero pregnancy ultrasound image classification, CNN can be considered for the classification task. CNN does not require complex and tedious feature extraction process like the traditional methods in the previous literature and can learn texture features directly by convolutional operations and then perform classification, but currently CNN-based recognition methods have not been fully applied to ultrasound in utero pregnancy ultrasound images.The scaling of the CNN model does not change the specific computational operations such as convolution, pooling, or normalization in the CNN but mainly changes the depth and width of the model and the size of the fatty liver image size. Therefore, it is crucial to have a fully trained baseline CNN network, which is the basis for the later CNN model scaling and directly related to the performance of the CNN model after scaling.m, and the increase of its accuracy may be limited by adjusting a single parameter of the model, so it is important to balance different dimensional parameters of CNN to improve the efficiency of CNN.However, some current studies have shown that there is often a certain coupling relationship between the width and depth of CNN models Optimization of the CNN model using a grid search-based approach starts with determining a well-trained CNN baseline model. Then, a grid search is performed to determine an optimal CNN given the maximum number of parameters, and a formula is proposed to balance the relationship between the parameters of each dimension of the CNN during the search process. Finally, the searched CNN model is scaled up and the accuracy is improved.In The design process of CNN models needs to pay attention to the computational resources required for training, because in the actual application process, many embedded devices often have limited computational power. Lightweight network models are also becoming a hot topic of research. Some lightweight networks are more accurate than structures with a large number of parameters, but require less computational power, and these network models are more practical in practical engineering applications.In this experiment, image size is added as a factor to explore the relationship between the three dimensions of network width, depth, and the size of the input image. Empirically, the larger the image size is, the more layers it may need to increase the perceptual field of the model, and also the larger the width to capture more detailed feature information on the image. In the process of deep learning research, many CNN models with very large number of parameters have emerged. Although they can achieve very good models, they cannot provide large enough computational resources to meet the requirements in practical application scenarios and usually reduce the number of parameters of the model at the expense of accuracy through methods such as model compression.At present, the criterion used more often in research to evaluate the arithmetic power required for CNN models is Flops. The complexity of a model can also be judged by Flops, and for a certain convolutional layer of CNN, it is calculated as shown in the following equation:There are various methods of model scaling; ResNet models can be scaled down to ResNet-18 or scaled up to ResNet-200; WideResNet and MobileNet can scale the model by width. The width and depth of the CNN model play a very important role in the expressiveness of the CNN model, as demonstrated in the experiments in the previous section. However, the model for classifying abdominal B-ultrasound images of intrauterine pregnancy tissue residues needs to be further investigated to obtain better efficiency and accuracy of the CNN model.Instead of scaling the model width or number of layers singularly by the control variables method, the experiments in this section use a composite scaling method to simultaneously scale the width and depth parameters and then observe the changes in model performance while adding the input image size as a factor. In In w on accuracy, which is the same as model depth d, same as different model widths obtained by multiplying w with different coefficients with the width of the baseline model. As the width w increases, Flops keeps increasing and the accuracy rate keeps rising, but the accuracy rate will gradually level off. The experiments for the size of the input image are shown in ∗ 20, 28 ∗ 28, 35 ∗ 35, and 40 ∗ 40, and the Flops increase as the size of the image size increases. When the image size is 20 ∗ 20, the accuracy rate is significantly lower compared with the accuracy rate of other experimental results, and the accuracy rate of the other three types of image sizes is basically the same with no significant changes.However, the accuracy improvement of this type of method is relatively limited, and the accuracy rate tends to stabilize after rising to a certain value, and then parameter adjustment to increase Flops does not improve the accuracy rate significantly. Therefore, these methods have some limitations.Single dimensional scaling can improve the accuracy of CNN models, but there are shortcomings and the improvement of model accuracy tends to flatten out. In this section, compound tuning of model parameters is used to explore whether there is a coupling relationship between different parameters and whether it is more effective than single dimensional tuning for CNN models to improve the accuracy of identifying ultrasound images of intrauterine pregnancy. Some studies have mentioned the relationship between depth and width of CNN models and have also tried to balance the width and depth of CNNs, but all of them require a lot of tuning based on manual experience. There is a certain coupling between different dimensions of CNNs such as width and depth. For images with higher resolution, a deeper network may be needed to extract deeper features, while a wider network may be needed to extract more different features.The above is based on the experience of tuning the parameters of the CNN model, and the simultaneous tuning of different dimensional parameters requires coordination and balance. To verify whether the CNN model for ultrasound image recognition of intrauterine pregnancy conforms to this basic hypothetical conjecture, the following experiments were conducted. The specific experimental results are shown in ∗ 28 and 35 ∗ 35 are used here. By combining the variables, and then conducting experiments to obtain the abovementioned graph of the relationship between Flops and accuracy, the accuracy rate is also gradually increasing with the increase of the computational volume, and the final accuracy rate is higher than that of the single dimensional scaling effect.In The main consideration of grid search CNNs is the balance relationship between the size of Flops and parameters. The goal of the grid search is to find the scalable CNN with the highest accuracy under the balance condition as well as the fixed Flops constraint.Yi= F1(X1), where i represents the i-th layer convolution, x1 represents the input of the i-th layer convolution, and K represents the convolutional layer output. The whole CNN model operation can be regarded asThe first is to clarify the CNN optimization objective combined with the computational volume Flops; for the CNN convolutional layer, assume a convolutional layer operation formula as hi and wi represent the size of the convolution kernel of the i-th convolution layer, and cj represents the number of convolution kernels, i.e., the width of the i-th layer. Unlike the previous CNN model structure design, this part does not change the convolutional computation part F1 but focuses on changing the model depth, width, or resolution size of the image and does not change the specific convolutional computation for.In the actual CNN model framework, there will be many convolutional layers, which basically share the same type of convolutional operations, so the whole CNN model can be reduced to the following formula:Here, for CNN model optimization under resource constraints, the main aspects include the following: (1) maximizing the CNN model accuracy, which can be expressed as the following equations:The constraints are mainly Flops and number of parameters. The CNN model searches for the optimal network structure under the constraints of certain Flops and model parameter size as shown in the following equations:In theory, the larger the number of CNN model parameters, the greater the computational power required for training, and the higher the accuracy rate will be gradually. The goal of the summary formula optimization is to traverse the search to the CNN model structure with the highest accuracy rate for classifying ultrasound images of intrauterine pregnancy under a fixed Flops constraint. CNN needs to fully take into account the Flops constraint, which mainly serves to narrow the parameter space in the grid search and determine the scalable CNN network model more quickly.Firstly, in order to verify the effectiveness of the model scaling method in this experiment, a comparison of the accuracy of the scaling method in this experiment with that of the scaling performed in a single dimension was first performed under the same Flops required for CNN. The three methods are increasing only the depth of CNN, i.e., the number of layers, increasing only the width of CNN model, and the method proposed in this experiment, compounding three dimensional parameters to expand the CNN model at the same time.As can be seen from the experimental results in α=1.5, β=1.71, and γ=1.25, and these three variable values correspond to a specific CNN structure.By the previous method of grid search, the values of the three parameters are determined based on the baseline CNN model The variable values of each dimension are obtained, and there will be decimal values in the calculation process, but the actual variable values should not be decimal values. At this time, the treatment is that the decimal values are rounded up and down, and then the accuracy of the two parameters corresponding to the CNN model is compared separately, and then it is determined which integer is taken. In In total, five scaling-ups were done for the grid-searched CNNs, because in the actual experiments, it was found that the accuracy growth of the models tended to level off and basically did not continue to increase when the scaling-up factor continued to increase. The Hops of the CNN models gradually increased, and the Flops of different CNN models were distributed in different intervals of the horizontal coordinates of In this paper, the proposed method based on grid search, which balances the parameters of each dimension of CNN, is more efficient and the accuracy of the model is higher with the same number of parameters.In this study, the clinical data of 40 postpartum patients with mid- to late-term pregnancy who came to our hospital from January 2014 to January 2015 were retrospectively analyzed. The age of the patients ranged from 22 to 41 years. The main postpartum symptoms included continuous or indirect vaginal bleeding, lower abdominal pain, amenorrhea, and elevated body temperature. In addition, 27 patients had irregular vaginal bleeding or amenorrhea, and 13 patients had lower abdominal pain and fever. The patients were routinely examined by transabdominal pelvic ultrasound. In the absence of vaginal bleeding and obvious signs of infection, transvaginal ultrasound can be combined with the examination.It is necessary to drink a lot of water before the examination. Only when the bladder is filled to a certain level can the uterus be squeezed from deep in the pelvis to the lower abdomen and the uterine cavity be observed with ultrasound. A combined supra-abdominal scan of the uterine adnexa was performed via the abdominal wall at the pubic bone, focusing on the changes in the uterine cavity and the endometrial echoes.This method does not require holding urine, and because it is close to the uterus and ovaries, the images are clear and have high resolution, making the results more accurate. However, it is not suitable for people with vaginal bleeding, such as menstrual periods or irregular vaginal bleeding. It is also not suitable for people with infectious diseases, such as vaginitis and sexually transmitted diseases. It should also be used with caution in cases of other cervical, vaginal, and vulvar diseases to prevent infection and bleeding.In the present group of 40 patients, ultrasound images showed mixed acoustic images (27 cases) and echogenic images of light clusters (13 cases), with a diagnostic compliance rate of 926% (25/27) and 76.9% (10/13). 40 cases showed an enlarged uterus with normal uterine morphology, indistinct endometrial lines, and homogeneous echogenicity of the myometrial wall. 40 cases showed inhomogeneous high, medium, and low echogenic light clusters in the uterine cavity. In 34 cases, the morphology was irregular, accounting for 80% of the cases, and the size was between 1 and 4 cm. All clusters were of varying echogenicity and irregular borders; in 6 cases, strong echogenicity was seen with acoustic shadowing. The residues were confirmed to be embryonic tissues and old blood clots, ranging from 20 to 2259 in volume, and the pathological examination was performed on degenerated necrotic meconium, and in 8 cases, there were fetal bones in the residues. After the treatment of uterine evacuation, 25 of the 40 cases had their vaginal bleeding stopped and pain relieved after 1 time evacuation; 12 cases had 2 times evacuation and 3 cases had 3 times evacuation until the uterine size returned to normal and there was no abnormal strong echo in the uterine cavity.The intrauterine pregnancy residues are a common cause of postabortion and late postpartum uterine bleeding or infection. The analysis showed that patients with mixed echogenic ultrasound diagnostic images had a higher diagnostic compliance rate because they had more residues in the uterine cavity, which provided a reliable basis for the treatment of uterine evacuation and also effectively prevented intrauterine infection. For patients with ultrasound diagnostic images of light cluster echogenicity, which is difficult to distinguish from blood clots, the compliance rate is reduced. For such patients, treatment with contraction agents and anti-inflammatory drugs can be performed first, and then curettage can be performed after failure, which avoids unnecessary trauma to the uterine cavity and minimizes the patient's pain.In summary, ultrasound testing can provide a more scientific and reliable clinical basis for accurate diagnosis of intrauterine pregnancy residues after delivery in mid- to late-term pregnancies and can also perform ultrasound-guided uterine evacuation for patients, effectively avoiding the blindness of previous surgery, improving the success rate of surgery, and reducing the occurrence of various complications, which is worthy of wide clinical use.Intrauterine pregnancy residue is a dangerous disease in obstetrics and gynecology, mainly caused by excessive curvature of the uterus. It is commonly seen in patients who have had a medication abortion at a long gestational age, in those who have undergone a poorly performed abortion, in those who have undergone an induction of labor in mid-pregnancy, resulting in adhesions between the fetal membranes and the placenta, and in those who have had abnormal changes in the morphology of the uterine cavity. Patients are prone to recurrent vaginal bleeding after the onset of the disease, which has a significant negative impact on the patient's health, so it is important to diagnose the patient promptly and accuratelyThe internal echogenicity is rougher. In addition, in patients with small pregnancy residues, one or more small substantive plaques can be observed in the mucosal layer of the uterine cavity. If the patient has a residual pregnancy tissue in the uterus along with fluid in the uterine cavity, the residue may be visualized as a ring, strip, or irregularly separated fluid-free area between the residue and the contralateral uterine wall, and the residue may appear as a pike, strip, mass, or peninsula or be flattened, with an echogenic image hyperechoic.It can be seen that the diagnosis of intrauterine pregnancy tissue residues by abdominal B-ultrasound can effectively improve the diagnostic results and provide important reference for the later treatment of patients, which has high diagnostic value.Abdominal B-ultrasound images of intrauterine pregnancy tissue residues were analyzed to explore their diagnostic value. With the rapid development of computer technology and medical imaging technology, doctors are also faced with more and more medical image diagnosis tasks, and computer-aided diagnosis systems are especially important in order to reduce the work pressure of doctors. In this paper, we propose to give a CNN model optimization method based on grid search. The method first determines a baseline CNN model and then optimizes it by approximate Flops per second, and for intrauterine, the accuracy of abdominal B-ultrasound image classification of pregnancy tissue remnants was over 92%. The diagnosis of intrauterine pregnancy tissue residues by abdominal B-ultrasound can effectively improve the diagnosis and provide important reference for patients to receive treatment, which has high diagnostic value.


Social epidemiological research has consistently demonstrated that people with a low socioeconomic status are particularly at risk of diseases, health complaints and functional limitations, and die at younger ages than those with a higher socioeconomic status. Greater stresses and strains in the workplace, family and living environment are under discussion as possible explanations. Health-related behaviours, psycho-social factors and personal resources, which are important in coping with everyday demands, certainly also play a role. From a public health and health policy perspective, reducing these health inequalities is an important goal. Insights into developments and trends in health inequalities over time can contribute towards highlighting new and emerging problems, and can thus help identify possible target groups and settings for relevant interventions. At the same time, these insights provide a basis upon which the success of policies and programmes that have already been implemented can be analysed and measured. Against this background, this review examines how health inequalities in Germany have developed over the last 20 to 30 years and places its findings within the context of the latest international research in this field. Inequalities in health and life expectancy linked to socioeconomic status – also referred to as health inequalities – are a central issue in public health and health policy . These dAnalyses of social inequalities in health and life expectancy often distinguish between absolute and relative health inequalities. Absolute health inequalities are typically quantified using rate differences between the lowest and highest socioeconomic groups. In contrast, relative health inequalities are calculated using the rate ratios that exist between these groups. Research suggests that a reduction of absolute health inequalities occurs under a wider range of conditions than a reduction of relative health inequalities . If riskThe fact that social inequalities in living conditions and social inclusion are reflected in health and life expectancy has been sufficiently documented , 11, 12.Planning and implementing policies and programmes aimed at reducing health inequalities requires data and analyses that provide insights into how social inequalities in health and life expectancy develop over time. On the one hand, these insights are important because they help identify relevant developments at an early stage and can point to new or emerging problems. Moreover, they help to determine possible target groups and relevant settings for interventions. On the other hand, the careful analysis of trends and developments over time provides an essential basis upon which to assess and review policies and programmes that have already been implemented.Unlike in the UK, the US and Scandinavian countries, for a long time analyses of trends and temporal developments in health inequalities were only possible to a limited extent in Germany. This was due to the fact that the data varied in informative value and availability. In recent years the data has improved significantly, and this has opened up new research perspectives. This was supported by the establishment of the German national health monitoring system at the Robert Koch Institute (RKI), which in turn emerged from the German Cardiovascular Prevention Study (DHP) conducted in the mid-1980s and the German National Health Interview and Examination Survey 1998 (GNHIES98). Other health surveys and epidemiological studies, some of which have a narrower thematic focus, now enable more long-term observations to be made using data from repeated cross-sectional surveys, such as the Epidemiological Survey of Substance Abuse (ESA), the National Food Consumption Study (NVS) and the German Oral Health Study (DMS). The German Socio-Economic Panel (SOEP), the German General Social Survey (ALLBUS) and other social science surveys also provide additional databases. These are complemented by official statistics – in particular from the German microcensus and the European Statistics on Income and Living Conditions (EU-SILC) – as well as by data collected from social insurance agencies that are increasingly being used for epidemiological research and health monitoring.The aim of this review is to describe time trends in health inequalities in Germany over the past 20 to 30 years using published research findings. Moreover, this article also describes the dynamics that underlie these developments. For example, widening health inequalities may be related to the fact that positive developments are only or increasingly observed among population groups with a high socioeconomic status or a relatively advantaged social position. At the same time, negative developments among socially disadvantaged populations may explain why health inequalities are widening. This article focuses on the middle-aged population (25-to 69-year-olds), as developments in health inequalities in childhood, adolescence and old age require a separate consideration which takes the specificities of each life phase into account. The review begins by giving an outline of the research findings available for Germany, before placing these results within the context of the latest international research. However, due to the large number of studies focussing on time trends in health inequalities, this paper can only describe a selection of relevant examples.Analyses of time trends in health inequalities often refer to self-rated health, an indicator reflecting the subjective dimension of health and well-being. Longitudinal studies have shown self-rated health to be an independent predictor of the uptake of health services and further life expectancy , 24. AccAnother recent study that focused on the same observation period, but differentiated between population groups with different levels of education among 30- to 49-year-olds, reached a somewhat different conclusion . The stuFurthermore, some further analyses exist that are based on SOEP data, the majority of which point to an increase in social inequalities in self-rated general health. For example, although an analysis of data on the working-age population (aged 18 to 59) found a significant deterioration in the general health of unemployed men between 1994 and 2008, it did not identify any significant changes among part-time and full-time working men. In the same manner, an increase in the initial difference between these groups was observed. Unemployed women also tended to provide a worse self-rating of their general health than women in part-time or full-time employment; however, the study found no evidence of a change in these differences over time , 28. TheA further study based on SOEP data collected between 2001 and 2011 examined the temporal development of self-rated general health in relation to material deprivation. Data on material deprivation was obtained using eleven standard items ranging from the ownership of a colour TV, a car and home furniture to the home environment, financial reserves and the ability to pay bills on time. This data suggests that the differences in self-rated health between people with a low and high material standard of living have increased between 2001 and 2005; by contrast, a reduction was observed for 2006 to 2011 .Only limited conclusions can be deduced about time trends regarding social inequalities in the prevalence of chronic diseases in Germany. One of the few available studies uses data from the RKI’s health surveys to analyse time trends in educational differences in the prevalence of diabetes mellitus among 25- to 69-year-olds. The study found a significantly higher prevalence of known diabetes among women and men with low levels of education, compared to those with middle and high levels of education during both observation periods (1990 to 1992 and 1997 to 1999). However, the extent and pattern of these inequalities remained largely consistent over time . A folloA further analysis focused on time trends in social inequalities in cardiovascular diseases among 40 to 79-year-olds, also based on data from the RKI’s health surveys. The results show a slight decrease in the prevalence of major cardiovascular diseases  among women for the observation period 1997 to 1999 and 2008 to 2011; no significant change was observed among men. When the data was stratified by socioeconomic status, the study identified a slightly higher prevalence among women and men with a low socioeconomic status than among those with a higher socioeconomic status. No temporal change in the socioeconomic differences in the prevalence of major cardiovascular disease was observed among women. As such, although a general decline in prevalence was observed among all socioeconomic groups, the differences between the socioeconomic groups remained largely unchanged. In contrast, a widening in the range of these socioeconomic inequalities was observed among men. A decrease in prevalence was observed among men with a high socioeconomic status, but remained unchanged among the other socioeconomic groups .SOEP data can be used to analyse time trends in inequalities in the prevalence of physical pain. Between 1994 and 2014, there was a slight increase in the proportion of women and men aged 25 to 69 who were always or often afflicted by physical pain during the four weeks preceding the survey. This increase occurred to a similar extent across all income groups. Consequently, the extent of these health inequalities has remained largely constant over time.A further study based on SOEP data, which investigates the development in subjective health-related quality of life among 30- to 49-year-olds , came toTwo recent studies provide information about developments over time regarding social inequalities in people’s health-related behaviour. These are based on data from the German Health Update  and the German Telephone Health Survey 2003 (GSTel03) that preceded it , 35. TheThe second study focuses on changes in educational differences in sporting activity . As withStudies have also been published on time trends in social inequalities in the prevalence of overweight and obesity , 36, 37.Results regarding social inequalities in mortality and life expectancy play a central role in the scientific and political discussion of health inequalities . Only a Data from the German Statutory Pension Insurance Scheme (DRV) was used to analyse developments over time in regard to social inequalities in further life expectancy from the age of 65 years. Differences in terms of income level (earnings points) and occupational status were examined over an observation period from 1995/1996 to 2007/2008. The study found that social inequalities in further life expectancy have increased . AlthougThe relationship between social inequality and health or life expectancy can be determined at both the individual and the regional level. For example, it has been shown repeatedly at the regional , the district and municipal level that regions with a higher risk of poverty or higher levels of unemployment have lower average life expectancies . In ordeIn the UK, the US and Scandinavia, analyses of social inequalities in health and life expectancy have been possible for quite some time. As in Germany, self-rated general health is a commonly used indicator. Most of the existing studies conclude that social inequalities in overall health have remained largely stable over the past two to three decades or have increased slightly . In a reFindings on the temporal development of social differences in the prevalence of diabetes mellitus are available, for example, from the United States . Data frSocial inequalities in serious health conditions and diseases such as heart attacks and strokes , some ofThe results on time trends in social inequalities in functional limitations are also interesting. For example, an analysis of data collected by the European Social Survey for elderly people from 16 European countries shows that the prevalence of functional limitations decreased in most countries between 2002 and 2014. In the course of these developments, absolute and relative inequalities in the prevalence of functional limitations between different income groups have increased, which is particularly apparent in Ireland, the Netherlands and Sweden . SimilarWith regard to tobacco consumption, international studies concur with the results obtained for Germany: smoking is more prevalent and heavily practised among lower socioeconomic groups , 58. MorIn many countries, physical activity is more prevalent among socially advantaged groups than among lower socioeconomic groups , 64-66. The same study also analysed time trends in educational inequalities in obesity. However, in this case, the study identified a reverse trend: between 1990 and 2004, inequalities in obesity increased in only six states, whereas they declined in 36 others. This was mostly due to a stronger increase in the prevalence of obesity in the groups with higher levels of education over the observation period . AccordiIn comparison to Germany, the data for analysing time trends in health inequalities is far superior in many other countries. This is particularly true for data on mortality and life expectancy. In some countries, information concerning socioeconomic status, such as educational level and occupational position, is even recorded on death certificates – a practise that has been discontinued in Germany since 1972 , 74. In Looking at the mortality trends by cause of death, a more pronounced reduction in mortality can be observed among higher educational groups due to cardiovascular diseases and cancer, but also mortality due to other diseases (such as tuberculosis and asthma) and external causes of death (such as suicide and homicide) . AlcoholBreast cancer mortality also plays a special role in the specific causes of death and their social patterning. In contrast to the social gradient observed for most other causes of death, until the 1990s a higher level of breast cancer mortality existed internationally among high socioeconomic groups , 83. RecStudies that systematically differentiate between absolute and relative social inequalities in mortality show that health inequalities can increase and decrease during the same time period, depending on whether relative inequalities (rate ratios) or absolute inequalities (rate differences) are taken into account , 18. ForSocial inequalities in mortality are also reflected in social inequalities in life expectancies, so that time trends correspond closely with one another. Individual studies from Europe indicate that individuals from all socioeconomic groups have benefited from the general increased life expectancy in countries such as Denmark, Norway and the Netherlands; however, people in high socioeconomic groups have benefited more in terms of additional years of life expectancy compared to low socioeconomic groups . As a reEvery year, a large number of studies demonstrate that substantial social inequalities continue to exist in health and life expectancy in Germany and other countries. Since the data available at the national level has been steadily improving, it is now possible to study time trends in health inequalities in Germany. The studies undertaken so far either suggest that social inequalities in health and life expectancy in Germany have remained relatively constant over the last 20 to 30 years, or that they have increased.It is important to note that the results vary according to the respective socioeconomic indicator and health outcome used in each study, and according to the age group examined. Moreover, inconsistent results have sometimes been obtained from the same data. Most of the studies on trends in health inequalities in Germany examined self-rated general health, with a particular focus on SOEP data. The results suggest that although general health has improved over time, this has only been the case among the socially advantaged groups; moreover, strongly pronounced health inequalities tend to have increased further. The majority of these studies compare educational level and income groups. However, one study that compared unemployed people to parttime and full-time employees came to the same conclusions regarding these developments. However, the studies that focused on material deprivation do not quite fit this picture. An increase in inequalities in self-rated general health was reported between 2001 and 2005; however, it was followed by a decrease in the following years.Very few analyses are currently available for Germany when it comes to time trends in social inequalities in chronic diseases. The only available studies focus on diabetes mellitus and cardiovascular diseases. The results indicate that social inequalities remained relatively stable over time. Only one study reported an increase in social inequalities in cardiovascular diseases among men, which was attributed to the observed decline in cardiovascular diseases among men with a high socioeconomic status. In addition, the available studies on chronic pain and physical impairment related to health-related quality of life indicate that pronounced social inequalities continue to exist and have hardly changed over time.Health inequalities have also widened in terms of health behaviours and behavioural risk factors. This is particularly clear in relation to sporting activity, as the proportion of women and men who do not engage in any form of sport has clearly declined in the middle and high educational groups, and has remained largely unchanged among the lower educational group. With regard to men’s use of tobacco, positive developments such as the decline in smoking rates observed since the early 2000s have only been found among socially advantaged groups.Finally, the few available studies addressing developments in social inequalities in mortality and life expectancy in Germany suggest that health inequalities have widened rather than decreased. This is the case on both the individual and regional level. By the late 1990s, people living in districts that can be considered as socioeconomically advantaged in terms of the labour market, education and income had higher life expectancies at birth than those living in socioeconomically deprived districts. In recent times, these inequalities have increased further.The results achieved for Germany largely confirm the findings of the latest international research. Studies from the US, the UK and Scandinavia are particularly good examples. The superior data in these countries enables trends in health inequalities to be analysed over long periods of time. Most of the studies carried out in these countries show that, in regard to self-rated health, certain diseases and behavioural risk factors, social inequalities are repeatedly reproduced even over long periods of time and under changed framework conditions. In some cases social inequalities are increasing – for example, when a risk or prevalence rate among socially advantaged population groups declines faster and more rapidly than among socially disadvantaged groups. This phenomenon can be observed for tobacco consumption in many countries. Studies of the temporal development of social inequalities in mortality demonstrate that conclusions about whether social inequalities have diminished or increased may also depend on whether absolute or relative inequalities are being considered. The results from the US are remarkable, as they show that high income groups have registered a two- to three-year increase in life expectancy since the beginning of the 2000s, whereas people at the bottom end of the income scale have seen no significant increase in life expectancy whatsoever .Against the background of these national and international research findings, the reduction of health inequalities clearly remains an important policy objective. In this respect, a distinction can be made between measures aimed at improving and ensuring fairer social conditions and opportunities for social and economic participation – that is, measures that seek to tackle the underlying causes of health inequalities – and those that seek to directly improve health and to bring about a fairer distribution in opportunities for good health. On the one hand, this leads to a focus on measures aimed at combating poverty and social inequality as well as the strengthening of social integration; these measures need to be incorporated into various policy areas. The measures in question are far more comprehensive than simple state transfer benefits, which, by themselves, are not sufficient to guarantee people equal social participation. Moreover, these measures must also aim to improve people’s participation in education, reduce inequalities in educational opportunities, improve opportunities in the labour market for low-skilled workers, support and empower socially disadvantaged families, and reduce environmental pressures and risks that increasingly affect socially disadvantaged groups , 93.On the other hand, health policy needs to take action, not only in terms of medical and nursing care, but particularly in prevention and health promotion. In the context of medical and nursing care, it is important to note that socially disadvantaged groups have a greater need for health care due to their increased risk of chronic illnesses, disabilities and functional limitations. In addition, they also often have specific health care needs, for example due to multi-morbidities, mental co-morbidities or addiction. Finally, social disadvantaged people do not have the same financial capabilities to access medical services and goods that are not covered by the statutory health insurance .Prevention and health promotion are viewed as particularly important factors that can reduce health inequalities , 95. Couwww.gesundheitsziele.de) [Despite positive developments, such as the adoption of the Preventative Health Care Act (PrevG) which came into force in 2015  and the iele.de) , Germanyiele.de) , 102 andiele.de)  are furtiele.de) . Howeveriele.de) . Moreoveiele.de) .Experiences gained from countries such as the UK and Sweden show that reducing health inequalities is a task for the whole of society. It requires cross-sectorial determination that is focused on tackling the root causes , and highlights the importance of anchoring prevention and health promotion within all policy areas. Finally, experience has shown that reducing health inequalities is a long-term task, and that successful measures require a stable structural and legal framework as well as secure funding.Low socioeconomic status is associated with a higher risk of morbidity and premature mortality.In many respects, the extent of health inequalities has remained constant over the past 20 to 30 years.Increases in health inequalities can be observed, for example, with regard to sporting activity and life expectancy.The results for Germany largely correspond to the latest international findings.Reducing health inequalities is an important health policy objective and requires efforts on the part of society as a whole.