Barriers and Facilitators to Scaling Up the Non-Pneumatic Anti-Shock Garment for Treating Obstetric Hemorrhage: A Qualitative Study (original) (raw)
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Reproductive Health
Background: Obstetric hemorrhage (OH) remains one of the leading causes of maternal mortality, particularly in rural Africa. Tanzania has a high maternal mortality ratio, and approximately 80% of the population accesses health care lower level facilities, unable to provide Comprehensive Emergency Obstetric Care (CEmOC). The non-pneumatic anti-shock garment (NASG) has been demonstrated to reduce mortality as it buys time for women in shock to be transported to or to overcome delays at referral facilities. Methods: This report describes one component of an ongoing maternal health improvement project, Empower, implemented in 280 facilities in four regions in rural Tanzania. The NASG along with a Closed User Group (CUG) mobile phone network were implemented within the overall EmOC project. Simulation trainings, repeated trainings, and close hands-on supportive supervision via site visits and via the CUG network were the training/learning methods. Data collection was conducted via the CUG network, with a limited data collection form, which also included free text options for project improvement. One-to-one interviews were also conducted. Outcome Indicators included appropriate use of NASG for women with hypovolemic shock We also compared baseline case fatality rates (CFR) from OH with endline CFRs. Data were analyzed using cohort study Risk Ratio (RR). Qualitative data analysis was conducted by content analysis. Results: Of the 1713 women with OH, 419 (24.5%) met project hypovolemic shock criteria, the NASG was applied to 70.8% (n = 297), indicating high acceptability and utilization. CFR at baseline (1.70) compared to CFR at endline (0.76) showed a temporal association of a 67% reduced risk for women during the project period (RR: 0.33, 95% CI = .19, .60). Qualitative feedback was used to make course corrections during the project to enhance training and implementation. Conclusions: This implementation project with 280 facilities and over 1000 providers supported via CUG demonstrated that NASG can have high uptake and appropriate use for hypovolemic shock secondary to OH. With the proper implementation strategies, NASG utilization can be high and should be associated with decreased mortality among mothers at risk of death from obstetric hemorrhage.
Frontiers in Public Health, 2023
Background: Global maternal deaths have either increased or stagnated tragically. Obstetric hemorrhage (OH) remains the major cause of maternal deaths. Non-Pneumatic Anti-Shock Garment (NASG) has several positive results in the management of obstetric hemorrhage in resource-limited settings where getting definitive treatments are difficult and limited. Therefore, this study aimed to assess the proportion and factors associated with the utilization of NASG for the management of obstetric hemorrhage among healthcare providers in the North Shewa zone, Ethiopia. Methods: A cross-sectional study was conducted at health facilities of the north Shewa zone, Ethiopia from June 10th-30th/2021. A simple random sampling (SRS) technique was employed among 360 healthcare providers. Data were collected using a pretested self-administered questionnaire. EpiData version 4.6 and SPSS 25 were used for data entry and analysis, respectively. Binary logistic regression analyses were undertaken to identify associated factors with the outcome variable. The level of significance was decided at a value of p of <0.05. Results: The utilization of NASG for the management of obstetric hemorrhage among healthcare providers was 39% (95%CI: 34-45). Healthcare providers who received training on NASG (
2010
Background: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality and severe maternal morbidity. The Non-pneumatic Anti-Shock Garment (NASG), a first-aid lower-body compression device, may decrease adverse outcomes from obstetric hemorrhage. This article is the first to report the effect of the NASG for PPH. Methods: This pre-intervention/NASG study of 854 women was conducted in four referral facilities in Nigeria and two in Egypt between 2004-2008. Entry criteria were women with PPH due to uterine atony, retained placenta, ruptured uterus, vaginal or cervical lacerations or placenta accreta with estimated blood loss of ≥ 750 mL and one clinical sign of shock. Differences in demographics, conditions on study entry, treatment and outcomes were examined. The Wilcoxon rank-sum test and relative risks with 95% confidence intervals were calculated for primary outcomes -measured blood loss, emergency hysterectomy, mortality, morbidity (each individually), and a combined variable, "adverse outcomes", defined as severe morbidity and mortality. A multiple logistic regression model was fitted to test the independent association between the NASG and the combined severe morbidity and mortality outcome. Results: Measured blood loss decreased by 50% between phases; women experienced 400 mL of median blood loss after study entry in the pre-intervention and 200 mL in the NASG phase (p < 0.0001). As individual outcomes, mortality decreased from 9% pre-intervention to 3.1% in the NASG phase (RR 0.35, 95% CI 0.19-0.62); severe morbidity decreased from 4.2% to 1%, in the NASG phase (RR 0.24, 95% CI 0.09-0.67). As a combination, "adverse outcomes," decreased from 12.8% to 4.1% in the NASG phase (RR 0.32, 95% CI 0.19-0.53). In a multiple logistic regression model, the NASG was associated with the combined outcome of severe maternal morbidity and mortality (OR 0.42, 95% CI 0.18-0.99). Conclusion: In this non-randomized study, in which bias is inherent, the NASG showed promise for reducing blood loss, emergency hysterectomy, morbidity and mortality associated with PPH in referral facilities in Egypt and Nigeria.
PloS one, 2013
Obstetric hemorrhage is the leading cause of maternal mortality. Using a cluster randomized design, we investigated whether application of the Non-pneumatic Anti-Shock Garment (NASG) before transport to referral hospitals (RHs) from primary health care centers (PHCs) decreased adverse outcomes among women with hypovolemic shock. We hypothesized the NASG group would have a 50% reduction in adverse outcomes. We randomly assigned 38 PHCs in Zambia and Zimbabwe to standard obstetric hemorrhage/shock protocols or the same protocols plus NASG prior to transport. All women received the NASG at the RH. The primary outcomes were maternal mortality; severe, end-organ failure maternal morbidity; and a composite mortality/morbidity outcome, which we labeled extreme adverse outcome (EAO). We also examined whether the NASG contributed to negative side effects and secondary outcomes. The sample size for statistical power was not reached; of a planned 2400 women, 880 were enrolled, 405 in the inter...
Reproductive Health
Background Non- pneumatic anti-shock garment is a unique, life -saving first -aid device made of neoprene and velcro, which is used for treatment of women with postpartum hemorrhage. Maternal mortality in the world still very high and postpartum hemorrhage is the leading cause of maternal mortality worldwide. Objective This study was aimed to assess the utilization of non-pneumatic anti-shock garment and associated factors for postpartum hemorrhage management. Methods Facility based cross-sectional studies design both quantitative and qualitative data collection methods were employed among 210 health care professionals and 10 key informants respectively. Bivariable and multivariable logistic regression was done to identify factors associated with non-pneumatic anti-shock garment utilization. Qualitative data was transcribed, translated and triangulated with quantitative findings. Results Seventy six (36.2%) of the respondents used non-pneumatic anti-shock garment in their hospitals ...
Nurses in low resource settings save mothers' lives with non-pneumatic anti-shock garment
MCN. The American journal of maternal child nursing, 2012
To discuss the role of nurses and nurse-midwives in preventing and treating postpartum hemorrhage (PPH) from uterine atony in developing countries and examine the role of a new device, the non-pneumatic anti-shock garment (NASG), in improving the outcomes for these patients. In this subanalysis of a larger preintervention phase/intervention phase study of 1,442 women with obstetric hemorrhage, postpartum women with hypovolemic shock (N = 578) from uterine atony (≥750 mL blood loss; systolic blood pressure <100 mmHg and/or pulse >100 beats per minute) were enrolled in two referral facilities in Egypt and four referral facilities in Nigeria. The study had two temporal phases: a preintervention phase and an NASG-intervention phase. Women with hemorrhage and shock in both phases were treated with the same evidence-based protocols for management of hypovolemic shock and hemorrhage, but women in the NASG-intervention phase also received the NASG. Relative risks (RRs) with 95% confid...
Journal of Women's Health, 2011
Background: We examined whether the non-pneumatic anti-shock garment (NASG) ameliorates the effects of delays in transport to and treatment at hospitals for women with postpartum hemorrhage (PPH) and postabortion hemorrhage (PAH) and investigated the effects of NASG use on timing of delivery of interventions inhospital. Methods: Pre=post studies of the NASG were conducted at hospitals in Cairo (n ¼ 349 women), Assuit (n ¼ 274), Southern Nigeria (n ¼ 57), and Northern Nigeria (n ¼ 124). In post-hoc analyses, comparisons of delays were conducted using analysis of variance (ANOVA), and associations of delays with extreme adverse outcomes (EAO, mortality or severe morbidity) were examined using chi-square tests, odds ratios (ORs), and multivariate logistic regression. Results: Median minutes from hemorrhage start to study admission differed by site, ranging from 15 minutes in Cairo to 225 minutes in Northern Nigeria ( p < 0.001). Median minutes from study admission to blood transfusion ranged from 30 minutes in Cairo to 209 minutes in Southern Nigeria ( p < 0.001). Twenty percent of women with !60 minutes between hemorrhage start and study admission experienced an EAO without the NASG compared with only 6% with the NASG (w 2 ¼ 13.71, p < 0.001). In-hospital delays in receiving intravenous (IV) fluids and blood were more common in the NASG phase. Conclusions: Women with PPH or PAH in Egypt and Nigeria often face delays in reaching emergency obstetrical care facilities and delays in receiving definitive therapies after arrival. Our results indicate that the NASG can reduce the impact of these delays. Stabilization does not replace treatment, however, and delays in fluid=blood administration with NASG use must be avoided.
BMC Health Services Research, 2023
Background A disproportionate burden of maternal deaths occurs in low-and middle-income countries (LMICs), and obstetric hemorrhage (OH) is a leading cause of excess mortality. In Zambia, most of maternal deaths are directly caused by OH. The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that uses compression to the abdomen and lower body to stop and reverse hypovolemic shock secondary to OH. We describe the process and experiences introducing the NASG into the Zambia public health system to encourage the development of national policies, clinical guidelines, and implementation plans that feature the NASG. Methods We conducted an observational study of NASG introduction to 143 public health facilities in Northern Province, Zambia, organizing observations into the five dimensions of the RE-AIM evaluation framework: reach, effectiveness, adoption, implementation, and maintenance. The NASG was introduced in August 2019, and the introduction was evaluated for 18 months. Data on healthcare worker training and mentorship, cases where NASG was used, and NASG availability and use during the study period were collected and analyzed. Results The NASG was successfully introduced and integrated into the Zambia public health system, and appropriately used by healthcare workers when responding to cases of OH. Sixteen months after NASG introduction, NASGs were available and functional at 99% of study sites and 88% reported ever using a NASG. Of the 68 cases of recorded OH where a NASG was applied, 66 were confirmed as clinically appropriate, and among cases where shock index (SI) could be calculated, 59% had SI ≥ 0.9. Feedback from healthcare providers revealed that 97% thought introducing the NASG was a good decision, and 92% felt confident in their ability to apply the NASG after initial training. The RE-AIM average for this study was 0.65, suggesting a public health impact that is not equivocal, and that NASG introduction had a positive population-based effect.
Gynecologic and …, 2010
tween phases. Women experienced 350 ml of median blood loss after study entry in the pre-intervention and 50 ml in the NASG phase (p ! 0.0001). Mortality decreased from 18% preintervention to 6% in the NASG phase (RR = 0.31, 95% CI 0.15-0.64, p = 0.0007). In a multiple logistic regression model, the NASG was associated with reduced mortality (odds ratio 0.30; 95% CI 0.13-0.68, p = 0.004). Conclusion: The NASG shows promise for reducing mortality from PPH in referral facilities in Nigeria.