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Smith L, Therrien MS, Harley KG, Mbuyita S, Mtema Z, Kinyonge I, Tillya R, Mbaruku G, Miller S. Differences in Life-Saving Obstetric Hemorrhage Treatments for Women with Abortion Versus Nonabortion Etiologies in Tanzania. Stud Fam Plann 2019; 50:375-393. [PMID: 31506958 DOI: 10.1111/sifp.12101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Complications from unsafe abortion are among the major causes of preventable maternal morbidity and mortality, which may be compounded by delays and disparities in treatment. We conducted a secondary analysis of women with symptoms of hypovolemic shock secondary to severe obstetric hemorrhage in Tanzania. We compared receipt of three lifesaving interventions among women with abortions versus other maternal hemorrhage etiologies. Interventions included: non-pneumatic anti-shock garment (NASG) (N = 393), blood transfusion (N = 249), and referral to a higher-capacity facility (N = 131). After controlling for severity of disease and other confounders, women with abortion-related hemorrhage and shock had 78 percent decreased odds of receiving NASG (p < 0.001) and 77 percent decreased odds of receiving a blood transfusion (p < 0.001) compared to women with hemorrhage and shock from other etiologies. Our findings suggest that, in Tanzania, women with abortion-related hemorrhage received lower quality of care than women with other hemorrhage etiologies.
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Escobar MF, Suso JP, Hincapié MA, Echavarría MP, Fernández P, Carvajal J. Experience of combined use of a Bakri uterine balloon and a non‐pneumatic anti‐shock garment in a university hospital in Colombia. Int J Gynaecol Obstet 2019; 146:244-249. [DOI: 10.1002/ijgo.12872] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/28/2019] [Accepted: 05/24/2019] [Indexed: 11/09/2022]
Affiliation(s)
- María F. Escobar
- High Complexity Obstetric UnitDepartment of Gynecology & ObstetricsFundación Valle del Lili Cali Colombia
- Postgraduate DepartmentFaculty of Health SciencesIcesi University Cali Colombia
| | - Juan P. Suso
- Postgraduate DepartmentFaculty of Health SciencesIcesi University Cali Colombia
| | - María A. Hincapié
- Postgraduate DepartmentFaculty of Health SciencesIcesi University Cali Colombia
| | - María P. Echavarría
- High Complexity Obstetric UnitDepartment of Gynecology & ObstetricsFundación Valle del Lili Cali Colombia
- Postgraduate DepartmentFaculty of Health SciencesIcesi University Cali Colombia
| | - Paula Fernández
- Centro de Investigaciones ClínicasFundación Valle del Lili Cali Colombia
| | - Javier Carvajal
- High Complexity Obstetric UnitDepartment of Gynecology & ObstetricsFundación Valle del Lili Cali Colombia
- Postgraduate DepartmentFaculty of Health SciencesIcesi University Cali Colombia
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Escobar MF, Fernández Pérez PA, Carvajal JA, Burgos JM, Messa A, Echavarria MP, Nieto A, Montes D, Miller S, Hurtado DF. Impact of nonpneumatic antishock garment in the management of patients with hypoperfusion due to massive postpartum hemorrhage. J Matern Fetal Neonatal Med 2019; 33:3086-3090. [PMID: 30632844 DOI: 10.1080/14767058.2019.1568982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: The objective of this article was to compare hemodynamic and perfusion parameters as well as the clinical outcomes in critically ill patients with postpartum hemorrhage (PPH) who received treatment with a nonpneumatic antishock garment (NASG) as part of an intervention package, with a group of patients in similar conditions who did not receive an NASG.Methods: This observational study analyzed a historic cohort of 154 patients with PPH, secondary hypovolemic shock and signs of hypoperfusion who were admitted to this institution from 2012 to 2015. Group 1 (n= 77) was managed with NASG and Group 2 (n = 77) received interventions other than NASG. Hypoperfusion markers and maternal outcomes were compared in both groups.Results: Of 154 patients included in the analysis, 36.4% required a total abdominal hysterectomy (TAH) to achieve hemorrhage control, 98.2% of whom belonged to Group 2 and 1.8% to Group 1 (p = .001). The use of blood products was more common in Group 2 (p < .001), as was the administration of vasoactive agents. The mean number of days of hospitalization at the Obstetric High Dependency Unit (OHDU) was significantly lower in Group 1 and reached a statistically significant p value. Only two cases of maternal death occurred in Group 2.Discussion: The use of NASG in the management of PPH is a cost-effective strategy for patients with severe shock and signs of hypoperfusion and is optimal in a limited-resource scenario. In this study, the use of NASG was related to better outcomes in a statistically significant manner with better results regarding maternal outcomes such as uterine preservation and decreased transfusion requirements and hospital days.Conclusions: NASG, associated with the use of uterotonic agents and other strategies for PPH control, is a safe tool that helps reduce morbimortality in critically ill patients with PPH.
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Affiliation(s)
- Maria Fernanda Escobar
- Department of Gynecology and Obstetrics, Fundación Clínica Valle Del Lili, Cali, Colombia.,Departament of Health Science, Faculty of Medicine, ICESI University, Cali, Colombia
| | | | - Javier Andrés Carvajal
- Department of Gynecology and Obstetrics, Fundación Clínica Valle Del Lili, Cali, Colombia
| | - Juan Manuel Burgos
- Department of Gynecology and Obstetrics, Fundación Clínica Valle Del Lili, Cali, Colombia
| | - Adriana Messa
- Department of Gynecology and Obstetrics, Fundación Clínica Valle Del Lili, Cali, Colombia
| | - Maria Paula Echavarria
- Department of Gynecology and Obstetrics, Fundación Clínica Valle Del Lili, Cali, Colombia
| | - Albaro Nieto
- Department of Gynecology and Obstetrics, Fundación Clínica Valle Del Lili, Cali, Colombia
| | - Daniela Montes
- Departament of Health Science, Faculty of Medicine, ICESI University, Cali, Colombia
| | - Suellen Miller
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy, School of Medicine, University of California, San Francisco, CA, USA
| | - David Felipe Hurtado
- Departament of Health Science, Faculty of Medicine, ICESI University, Cali, Colombia
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Mbaruku G, Therrien MS, Tillya R, Mbuyita S, Mtema Z, Kinyonge I, Godfrey R, Temu S, Miller S. Implementation project of the non-pneumatic anti-shock garment and m-communication to enhance maternal health care in rural Tanzania. Reprod Health 2018; 15:177. [PMID: 30340602 PMCID: PMC6194579 DOI: 10.1186/s12978-018-0613-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 09/26/2018] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
| | - Michelle Skaer Therrien
- University of California, San Francisco, School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Safe Motherhood Program, California, USA
| | | | | | | | | | | | - Silas Temu
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Suellen Miller
- University of California, San Francisco, School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Safe Motherhood Program, California, USA
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Escobar MF, Füchtner CE, Carvajal JA, Nieto AJ, Messa A, Escobar SS, Monroy AM, Forero AM, Casallas JD, Granados M, Miller S. Experience in the use of non-pneumatic anti-shock garment (NASG) in the management of postpartum haemorrhage with hypovolemic shock in the Fundación Valle Del Lili, Cali, Colombia. Reprod Health 2017; 14:58. [PMID: 28499381 PMCID: PMC5427550 DOI: 10.1186/s12978-017-0325-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 05/03/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this case series is to describe the experience of using the non-pneumatic anti-shock garment (NASG) in the management of severe Postpartum hemorrhage (PPH) and shock, and the value of implementing this concept in high-complexity obstetric hospitals. METHODS Descriptive case series of 77 women that received NASG in the management of PPH with severe hypovolemic shock from June 2014 to December 2015. Vital signs, shock index (SI), the lactic acid value and the base deficit were compared before and after NASG application. RESULTS Fifty-six (77%) women had an SI > 1.1 at the time shock management was initiated; 96% had uterine atony. All women received standard does of uterotonics. The average time between the birth and NASG applications was 20 min. Forty-eight percent of women recovered haemodynamic variables in the first hour and 100% within the first 6 h; 100% had a SI < 1.0 in the first hour. The NASG was not removed until definitive control of bleeding was achieved, with an average time of use of 24 h. There were no mortalities. CONCLUSIONS In this case series of women in severe shock, the NASG was an effective management device for the control of severe hypovolemic shock. It should be considered a first-line option for shock management.
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Affiliation(s)
- María Fernanda Escobar
- Department of Gynecology and Obstetrics, Fundación Clínica Valle del Lili, Universidad ICESI, Cali, Colombia.
| | | | - Javier Andrés Carvajal
- Department of Gynecology and Obstetrics, Fellow of Intensive Care Unit, Fundación Clínica Valle del Lili, Cali, Colombia
| | - Albaro José Nieto
- Department of Gynecology and Obstetrics, Fundación Clínica Valle del Lili, Universidad ICESI, Cali, Colombia
| | - Adriana Messa
- Department of Gynecology and Obstetrics, Fundación Clínica Valle del Lili, Universidad ICESI, Cali, Colombia
| | - Sara Sofía Escobar
- Department of Health Sciences, Medicine School, Universidad ICESI, Fundación Clínica Valle del Lili, Cali, Colombia
| | - Angélica María Monroy
- Department of Health Sciences, Medicine School, Universidad ICESI, Fundación Clínica Valle del Lili, Cali, Colombia
| | - Angélica María Forero
- Clinical Investigation Centre, Department of Gynecology and Obstetrics, Fundación Clínica Valle del Lili, Cali, Colombia
| | - José David Casallas
- Clinical Investigation Centre, Department of Gynecology and Obstetrics, Fundación Clínica Valle del Lili, Cali, Colombia
| | - Marcela Granados
- Internal Medicine, Intensive Care Unit, Fundación Clínica Valle del Lili, Cali, Colombia
| | - Suellen Miller
- Safe Motherhood Programs, Department of Obstetrics, Gynecology & reproductive Sciences, Bixby Center for Global Reproductive Health and Policy School of Medicine, University of California, San Francisco (UCSF), San Francisco, USA
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Manandhar S, El Ayadi AM, Butrick E, Hosang R, Miller S. The Role of the Nonpneumatic Antishock Garment in Reducing Blood Loss and Mortality Associated with Post-Abortion Hemorrhage. Stud Fam Plann 2015; 46:281-96. [PMID: 26347091 DOI: 10.1111/j.1728-4465.2015.00030.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Maternal mortality attributable to post-abortion hemorrhage is often associated with delays in reaching or receiving definitive care. The nonpneumatic antishock garment (NASG), a low-technology first-aid device, has been shown to decrease blood loss and mortality among women experiencing hypovolemic shock secondary to obstetric hemorrhage etiologies. Women experiencing post-abortion hemorrhage face longer delays in receiving definitive treatment as a result of abortion-related stigma and lack of access to quality abortion care; thus the NASG has the potential to make an even greater impact within this population. We conducted a secondary analysis of data collected in Egypt, Nigeria, Zambia, and Zimbabwe in NASG trials, limiting our analytic sample to women who experienced post-abortion hemorrhage (n = 953). Blood loss significantly decreased when the NASG was added to standard hemorrhage management during the intervention phase, and there was a large, although not statistically significant, 52 percent decrease in mortality during the NASG phase. The results indicate that adding the NASG to post-abortion care among women experiencing severe hemorrhage and hypovolemic shock would decrease blood loss and mortality.
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Affiliation(s)
- Shila Manandhar
- Resident Physician at Kaiser Permanente Los Angeles Medical Center, California
| | - Alison M El Ayadi
- Assistant Research Scientist, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA 94158.
| | - Elizabeth Butrick
- Project Coordinator, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA 94158
| | - Robert Hosang
- Professor, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA 94158
| | - Suellen Miller
- Lecturer, School of Public Health, University of California, Berkeley
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Pileggi-Castro C, Nogueira-Pileggi V, Tunçalp Ö, Oladapo OT, Vogel JP, Souza JP. Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage: a systematic review. Reprod Health 2015; 12:28. [PMID: 25889868 PMCID: PMC4422609 DOI: 10.1186/s12978-015-0012-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 03/12/2015] [Indexed: 11/17/2022] Open
Abstract
Introduction Women with postpartum haemorrhage (PPH) in developing countries often present in critical condition when treatment might be insufficient to save lives. Few studies have shown that application of non-pneumatic anti-shock garment (NASG) could improve maternal survival. Methods A systematic review of the literature explored the effect of NASG use compared with standard care for treating PPH. Medline, EMBASE and PubMed were searched. Methodological quality was assessed following the criteria suggested by the Cochrane Effective Practice and Organization of Care Group. Guidelines on Meta-analysis of Observational Studies in Epidemiology were used for reporting the results. Mantel-Haenszel methods for meta-analysis of risk ratios were used. Results Six out 31 studies met the inclusion criteria; only one cluster randomized controlled trial (c-RCT). Among observational studies, NASG fared better than standard care regarding maternal mortality reduction (Relative Risk (RR) 0.52 (95% Confidence interval (CI) 0.36 to 0.77)). A non-significant reduction of maternal mortality risk was observed in the c-RCT (RR: 0.43 (95% CI: 0.14 to 1.33)). No difference was observed between NASG use and standard care on use of blood products. Severe maternal outcomes were used as proxy for maternal death with similar pattern corroborating the trend towards beneficial effects associated with NASG. Conclusion NASG is a temporizing alternative measure in PPH management that shows a trend to reduce PPH-related deaths and severe morbidities. In settings where delays in PPH management are common, particularly where constraints to offer blood products and definitive treatment exist, use of NASG is an intervention that should be considered as a policy option while the standard conditions for care are being optimized.
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Affiliation(s)
- Cynthia Pileggi-Castro
- Department of Pediatrics & Glide Technical Cooperation and Research, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil.
| | - Vicky Nogueira-Pileggi
- Department of Pediatrics & Glide Technical Cooperation and Research, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil.
| | - Özge Tunçalp
- UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland.
| | - Olufemi Taiwo Oladapo
- UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland.
| | - Joshua Peter Vogel
- UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland.
| | - João Paulo Souza
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900, Ribeirão Preto, SP, Brazil.
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Miller S, Belizán JM. A promising device to save maternal lives associated with obstetric hemorrhage: the non-pneumatic anti-shock garment (NASG). Reprod Health 2015; 12:26. [PMID: 25890128 PMCID: PMC4392860 DOI: 10.1186/s12978-015-0019-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 03/23/2015] [Indexed: 11/29/2022] Open
Affiliation(s)
- Suellen Miller
- Director Safe Motherhood Programs, University of California, San Francisco, School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, California, USA.
| | - José M Belizán
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Buenos Aires, Argentina.
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Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage. Int J Gynaecol Obstet 2014; 128:194-5. [DOI: 10.1016/j.ijgo.2014.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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El Ayadi AM, Butrick E, Geissler J, Miller S. Combined analysis of the non-pneumatic anti-shock garment on mortality from hypovolemic shock secondary to obstetric hemorrhage. BMC Pregnancy Childbirth 2013; 13:208. [PMID: 24237656 PMCID: PMC3834872 DOI: 10.1186/1471-2393-13-208] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 10/25/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Obstetric hemorrhage is the leading cause of maternal mortality, particularly in low-resource settings where women face significant delays in accessing definitive treatment. The Non-pneumatic Anti-Shock Garment (NASG) is a first-aid device to stabilize women in hypovolemic shock secondary to obstetric hemorrhage. Prior studies on the effectiveness of the NASG have suffered from small sample sizes and insufficient statistical power. We sought to generate a summary effect estimate of this intervention by combining data from all previous quasi-experimental studies. METHODS Five quasi-experimental studies that tested the NASG as treatment for hypovolemic shock secondary to obstetric hemorrhage at the tertiary care facility level were included in the analysis. We evaluated heterogeneity of effect across studies and calculated pooled odds ratios. We also conducted a subgroup analysis among women in the most severe condition. RESULTS Participant characteristics were similar across studies with some variation in hemorrhage etiology. Median blood loss was at least 50% lower in the intervention group than the control group. The pooled odds ratio suggested that NASG intervention was associated with a 38% significantly reduced odds of mortality among the overall sample, and a 59% significantly reduced odds of mortality among the most severe women. CONCLUSIONS The results from this combined analysis suggest that NASG intervention is associated with a reduced odds of death for women with hypovolemic shock secondary to obstetric hemorrhage. Further research should focus on application of the NASG at the community or primary health care level, and utilize a more robust methodology.
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Affiliation(s)
- Alison M El Ayadi
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 50 Beale Street, Suite 1200, San Francisco, CA 94105, USA
| | - Elizabeth Butrick
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 50 Beale Street, Suite 1200, San Francisco, CA 94105, USA
| | - Jillian Geissler
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 50 Beale Street, Suite 1200, San Francisco, CA 94105, USA
| | - Suellen Miller
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, 50 Beale Street, Suite 1200, San Francisco, CA 94105, USA
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Miller S, Bergel EF, El Ayadi AM, Gibbons L, Butrick EA, Magwali T, Mkumba G, Kaseba C, Huong NTM, Geissler JD, Merialdi M. Non-pneumatic anti-shock garment (NASG), a first-aid device to decrease maternal mortality from obstetric hemorrhage: a cluster randomized trial. PLoS One 2013; 8:e76477. [PMID: 24194839 PMCID: PMC3806786 DOI: 10.1371/journal.pone.0076477] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 08/21/2013] [Indexed: 11/24/2022] Open
Abstract
Background 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. Methods and Findings 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 intervention group. The intervention was associated with a non-significant 46% reduced odds of mortality (OR 0.54, 95% CI 0.14–2.05, p = 0.37) and 54% reduction in composite EAO (OR 0.46, 95% CI 0.13–1.62, p = 0.22). Women with NASGs recovered from shock significantly faster (HR 1.25, 95% CI 1.02–1.52, p = 0.03). No differences were observed in secondary outcomes or negative effects. The main limitation was small sample size. Conclusions Despite a lack of statistical significance, the 54% reduced odds of EAO and the significantly faster shock recovery suggest there might be treatment benefits from earlier application of the NASG for women experiencing delays obtaining definitive treatment for hypovolemic shock. As there are no other tools for shock management outside of referral facilities, and no safety issues found, consideration of NASGs as a temporizing measure during delays may be warranted. A pragmatic study with rigorous evaluation is suggested for further research. Trial Registration ClinicalTrials.gov NCT00488462
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Affiliation(s)
- Suellen Miller
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Eduardo F. Bergel
- Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
| | - Alison M. El Ayadi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Luz Gibbons
- Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
| | - Elizabeth A. Butrick
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Thulani Magwali
- Department of Obstetrics and Gynecology, University of Zimbabwe, Harare, Zimbabwe
| | - Gricelia Mkumba
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Christine Kaseba
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - N. T. My Huong
- The Department of Reproductive Health and Research of the United Nations Development Programme/United Nations Population Fund/United Nations Children’s Fund/World Health Organization/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Jillian D. Geissler
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Mario Merialdi
- The Department of Reproductive Health and Research of the United Nations Development Programme/United Nations Population Fund/United Nations Children’s Fund/World Health Organization/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
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Sutherland T, Downing J, Miller S, Bishai DM, Butrick E, Fathalla MMF, Mourad-Youssif M, Ojengbede O, Nsima D, Kahn JG. Use of the non-pneumatic anti-shock garment (NASG) for life-threatening obstetric hemorrhage: a cost-effectiveness analysis in Egypt and Nigeria. PLoS One 2013; 8:e62282. [PMID: 23646124 PMCID: PMC3640005 DOI: 10.1371/journal.pone.0062282] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 03/19/2013] [Indexed: 11/19/2022] Open
Abstract
Objective To assess the cost-effectiveness of a non-pneumatic anti-shock garment (NASG) for obstetric hemorrhage in tertiary hospitals in Egypt and Nigeria. Methods We combined published data from pre-intervention/NASG-intervention clinical trials with costs from study sites. For each country, we used observed proportions of initial shock level (mild: mean arterial pressure [MAP] >60 mmHg; severe: MAP ≤60 mmHg) to define a standard population of 1,000 women presenting in shock. We examined three intervention scenarios: no women in shock receive the NASG, only women in severe shock receive the NASG, and all women in shock receive the NASG. Clinical data included frequencies of adverse health outcomes (mortality, severe morbidity, severe anemia), and interventions to manage bleeding (uterotonics, blood transfusions, hysterectomies). Costs (in 2010 international dollars) included the NASG, training, and clinical interventions. We compared costs and disability-adjusted life years (DALYs) across the intervention scenarios. Results For 1000 women presenting in shock, providing the NASG to those in severe shock results in decreased mortality and morbidity, which averts 357 DALYs in Egypt and 2,063 DALYs in Nigeria. Differences in use of interventions result in net savings of $9,489 in Egypt (primarily due to reduced transfusions) and net costs of $6,460 in Nigeria, with a cost per DALY averted of $3.13. Results of providing the NASG for women in mild shock has smaller and uncertain effects due to few clinical events in this data set. Conclusion Using the NASG for women in severe shock resulted in markedly improved health outcomes (2–2.9 DALYs averted per woman, primarily due to reduced mortality), with net savings or extremely low cost per DALY averted. This suggests that in resource-limited settings, the NASG is a very cost-effective intervention for women in severe hypovolemic shock. The effects of the NASG for mild shock are less certain.
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Affiliation(s)
- Tori Sutherland
- University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Janelle Downing
- Philip R Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy, University of California San Francisco, San Francisco, California, United States of America
| | - David M. Bishai
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elizabeth Butrick
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy, University of California San Francisco, San Francisco, California, United States of America
| | - Mohamed M. F. Fathalla
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University Women's Health Center, Assiut, Egypt
| | | | - Oladosu Ojengbede
- Department of Obstetrics and Gynecology, University College Hospital, Ibadan, Nigeria
| | - David Nsima
- Department of Obstetrics and Gynecology, Katsina General Hospital, Katsina, Nigeria
| | - James G. Kahn
- Philip R Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
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Su LL, Chong YS. Massive obstetric haemorrhage with disseminated intravascular coagulopathy. Best Pract Res Clin Obstet Gynaecol 2012; 26:77-90. [DOI: 10.1016/j.bpobgyn.2011.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 10/19/2011] [Indexed: 10/15/2022]
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Fathalla MMF, Youssif MM, Meyer C, Camlin C, Turan J, Morris J, Butrick E, Miller S. Nonatonic obstetric haemorrhage: effectiveness of the nonpneumatic antishock garment in egypt. ISRN OBSTETRICS AND GYNECOLOGY 2011; 2011:179349. [PMID: 21845226 PMCID: PMC3154575 DOI: 10.5402/2011/179349] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Accepted: 06/22/2011] [Indexed: 11/25/2022]
Abstract
The study aims to determine if the nonpneumatic antishock garment (NASG), a first aid compression device, decreases severe adverse outcomes from nonatonic obstetric haemorrhage. Women with nonatonic aetiologies (434), blood loss > 1000 mL, and signs of shock were eligible. Women received standard care during the preintervention phase (226) and standard care plus application of the garment in the NASG phase (208). Blood loss and extreme adverse outcomes (EAO-mortality and severe morbidity) were measured. Women who used the NASG had more estimated blood loss on admission. Mean measured blood loss was 370 mL in the preintervention phase and 258 mL in the NASG phase (P < 0.0001). EAO decreased with use of the garment (2.9% versus 4.4%, (OR 0.65, 95% CI 0.24–1.76)). In conclusion, using the NASG improved maternal outcomes despite the worse condition on study entry. These findings should be tested in larger studies.
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Affiliation(s)
- Mohamed M F Fathalla
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Assiut University Women's Health Center, P.O. Box 30, Assiut, Egypt
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Turan J, Ojengbede O, Fathalla M, Mourad-Youssif M, Morhason-Bello IO, Nsima D, Morris J, Butrick E, Martin H, Camlin C, Miller S. Positive effects of the non-pneumatic anti-shock garment on delays in accessing care for postpartum and postabortion hemorrhage in Egypt and Nigeria. J Womens Health (Larchmt) 2010; 20:91-8. [PMID: 21190486 DOI: 10.1089/jwh.2010.2081] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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 in-hospital. METHODS Pre/post studies of the NASG were conducted at hospitals in Cairo (n = 349 women), Assuit (n = 274), Southern Nigeria (n = 57), and Northern Nigeria (n = 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 (χ(2) = 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.
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Affiliation(s)
- Janet Turan
- University of California San Francisco, San Francisco, CA 94105, USA.
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Miller S, Fathalla MMF, Ojengbede OA, Camlin C, Mourad-Youssif M, Morhason-Bello IO, Galadanci H, Nsima D, Butrick E, Al Hussaini T, Turan J, Meyer C, Martin H, Mohammed AI. Obstetric hemorrhage and shock management: using the low technology Non-pneumatic Anti-Shock Garment in Nigerian and Egyptian tertiary care facilities. BMC Pregnancy Childbirth 2010; 10:64. [PMID: 20955600 PMCID: PMC2966449 DOI: 10.1186/1471-2393-10-64] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Accepted: 10/18/2010] [Indexed: 11/10/2022] Open
Abstract
Background Obstetric hemorrhage is the leading cause of maternal mortality globally. The Non-pneumatic Anti-Shock Garment (NASG) is a low-technology, first-aid compression device which, when added to standard hypovolemic shock protocols, may improve outcomes for women with hypovolemic shock secondary to obstetric hemorrhage in tertiary facilities in low-resource settings. Methods This study employed a pre-intervention/intervention design in four facilities in Nigeria and two in Egypt. Primary outcomes were measured mean and median blood loss, severe end-organ failure morbidity (renal failure, pulmonary failure, cardiac failure, or CNS dysfunctions), mortality, and emergency hysterectomy for 1442 women with ≥750 mL blood loss and at least one sign of hemodynamic instability. Comparisons of outcomes by study phase were assessed with rank sum tests, relative risks (RR), number needed to treat for benefit (NNTb), and multiple logistic regression. Results Women in the NASG phase (n = 835) were in worse condition on study entry, 38.5% with mean arterial pressure <60 mmHg vs. 29.9% in the pre-intervention phase (p = 0.001). Despite this, negative outcomes were significantly reduced in the NASG phase: mean measured blood loss decreased from 444 mL to 240 mL (p < 0.001), maternal mortality decreased from 6.3% to 3.5% (RR 0.56, 95% CI 0.35-0.89), severe morbidities from 3.7% to 0.7% (RR 0.20, 95% CI 0.08-0.50), and emergency hysterectomy from 8.9% to 4.0% (RR 0.44, 0.23-0.86). In multiple logistic regression, there was a 55% reduced odds of mortality during the NASG phase (aOR 0.45, 0.27-0.77). The NNTb to prevent either mortality or severe morbidity was 18 (12-36). Conclusion Adding the NASG to standard shock and hemorrhage management may significantly improve maternal outcomes from hypovolemic shock secondary to obstetric hemorrhage at tertiary care facilities in low-resource settings.
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Affiliation(s)
- Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, USA.
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Can the Non-pneumatic Anti-Shock Garment (NASG) reduce adverse maternal outcomes from postpartum hemorrhage? Evidence from Egypt and Nigeria. Reprod Health 2010; 7:24. [PMID: 20809942 PMCID: PMC2942803 DOI: 10.1186/1742-4755-7-24] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 09/01/2010] [Indexed: 11/21/2022] Open
Abstract
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.
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