Cost-effectiveness of the non-pneumatic anti-shock garment (NASG): evidence from a cluster randomized controlled trial in Zambia and Zimbabwe

Operational demonstration and process evaluation of non-pneumatic anti-shock garment (NASG) introduction to the public health system of Northern Province, Zambia

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.

CONCLUSIONS

A successful NASG demonstration took place over the course of 18 months in the existing health system of Northern Province, Zambia, suggesting that incorporation of NASG into the standard of care for obstetric emergency in the Zambia public sector is feasible and can be maintained without external support.

The effects of a peripartum strategy to prevent and treat primary postpartum haemorrhage at health facilities in Niger: a longitudinal, 72-month study

BACKGROUND

Primary postpartum haemorrhage is the principal cause of birth-related maternal mortality in most settings and has remained persistently high in severely resource-constrained countries. We evaluate the impact of an intervention that aims to halve maternal mortality caused by primary postpartum haemorrhage within 2 years, nationwide in Niger.

METHODS

In this 72-month longitudinal study, we analysed the effects of a primary postpartum haemorrhage intervention in hospitals and health centres in Niger, using data on maternal birth outcomes assessed and recorded by the facilities' health professionals and reported once per month at the national level. Reported data were monitored, compiled, and analysed by a non-governmental organisation collaborating with the Ministry of Health. All births in all health facilities in which births occurred, nationwide, were included, with no exclusion criteria. After a preintervention survey, brief training, and supplies distribution, Niger implemented a nationwide primary postpartum haemorrhage prevention and three-step treatment strategy using misoprostol, followed if needed by an intrauterine condom tamponade, and a non-inflatable anti-shock garment, with a specific set of organisational public health tools, aiming to reduce primary postpartum haemorrhage mortality.

FINDINGS

Among 5 382 488 expected births, 2 254 885 (41·9%) occurred in health facilities, of which information was available on 1 380 779 births from Jan 1, 2015, to Dec 31, 2020, with reporting increasing considerably over time. Primary postpartum mortality decreased from 82 (32·16%; 95% CI 25·58-39·92) of 255 health facility maternal deaths in the 2013 preintervention survey to 146 (9·53%; 8·05-11·21) of 1532 deaths among 343 668 births in 2020. Primary postpartum haemorrhage incidence varied between 1900 (2·10%; 2·01-2·20) of 90 453 births and 4758 (1·47%; 1·43-1·52) of 322 859 births during 2015-20, an annual trend of 0·98 (95% CI 0·97-0·99; p<0·0001).

INTERPRETATION

Primary postpartum haemorrhage morbidity and mortality declined rapidly nationwide. Because each treatment technology that was used has shown some efficacy when used alone, a strategic combination of these treatments can reasonably attain outcomes of this magnitude. Niger's strategy warrants testing in other low-income and perhaps some middle-income settings.

FUNDING

The Government of Norway, the Government of Niger, the Kavli Trust (Kavlifondet), the InFiL Foundation, and individuals in Norway, the UK, and the USA.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Utilization of Nonpneumatic Antishock Garment and Associated Factors among Obstetric Care Providers in Public Hospitals of Sidama Region, Hawassa, Ethiopia, 2022

Background

Nonpneumatic antishock garment is one of the newly emerging technology advances that reduce blood loss which is caused by obstetric hemorrhage and help women survive during delays to get definitive care. Over 80% of maternal mortality due to hemorrhagic shock may have been prevented if a nonpneumatic antishock garment had been utilized by an obstetric care provider. However, to the current knowledge, the utilization of nonpneumatic antishock garments is low and even no single study was conducted in the study area. Hence, we found that it is necessary to assess the magnitude and factors affecting the utilization of antishock garments among obstetric care providers in public hospitals of the Sidama region, Ethiopia, 2022.

Methods

A facility-based cross-sectional study design was employed among 403 obstetric care providers from June 15 to July 15, 2022. A two-stage sampling technique was applied; the data was collected by 5 trained BSc midwives using pretested and structured self-administered questionnaires. Data was entered into EpiData Manager version 4.6 and exported to Statistical Package for Social Sciences (SPSS) version 26 software. Bivariate and multivariable logistic regression analyses were used.

Results

A total of 394 (97.8%) health professionals participated in this study. Overall, 30.71% (95% CI: 26.4%, 35%) of the obstetric care providers had utilized nonpneumatic antishock garments for the management of postpartum hemorrhage. Training on the antishock garment (AOR = 4.183, 95% CI: 2.167, 8.075, p < 0.00), tertiary hospital (AOR = 0.355, 95% CI: 0.132, 0.952, p < 0.04), having protocol in the facility (AOR = 2.758, 95% CI: 1.269, 5.996), availability of NASG in the facility (AOR = 4.6, 95% CI: 1.603, 13.24), good knowledge (AOR = 2.506, 95% CI: 1.26, 4.984), and positive attitude (AOR = 2.381, 95% CI: 1.189, 4.766) were significantly associated factors. Conclusion and Recommendation. We found that less than one-third of the study participants have used the antishock garment in the management of postpartum hemorrhage in the current study. In addition to enhancing in-service and ongoing professional development training, it is preferable to insure the availability and accessibility of antishock in the facilities in order to close the knowledge and attitude gap among obstetric care providers.

Utilization of non-pneumatic anti-shock garment for the management of obstetric hemorrhage among healthcare providers in north Shewa zone, Ethiopia

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 (AOR = 3.3; 95%CI: 1.46-7.48), availability of NASG in the health facility (AOR = 9.17; 95%CI: 5.10-16.46), diploma (AOR = 2.63; 95%CI: 1.39-3.68), bachelor degree (AOR = 7.89; 95%CI: 3.1-16.29) and those healthcare providers who have a positive attitude toward utilization of NASG (AOR = 1.63; 95%CI: 1.14-2.82) were variables positively associated with the utilization of NASG.

Conclusion

In this study, almost two-fifths of healthcare providers used NASG for the management of obstetrics hemorrhage. Arranging educational opportunities and continuous professional development training for healthcare providers, providing in-service and refresher training, and making it available at health facilities may help healthcare providers to effectively use the device, thereby reducing maternal morbidity and mortality.

Review of investigational medical devices' clinical trials and regulations in Africa as a benchmark for new innovations

Medical technologies present a huge potential in improving global health playing a key role toward achieving Sustainable Development Goal 3 by 2030. A number of clinicians, innovators, business entities and biomedical engineers among others have developed a number of innovative medical devices and technologies to address the healthcare challenges especially in Africa. Globally, medical devices clinical trials present the most acceptable method for determining the risks and benefits of medical device innovations with the aim of ascertaining their effectiveness and safety as compared with established medical practice. However, there are very few medical device clinical trials reported in Africa compared to other regions like USA, UK and Europe. Most of the medical device clinical trials reported in Africa are addressing challenges around HIV/AIDS, maternal health and NCDs. In this mini review, we report about some of the published medical device clinical trials in Africa PubMed and Google Scholar and their associated challenges.

High impact health service interventions for attainment of UHC in Africa: A systematic review

African countries have prioritized the attainment of targets relating to Universal Health Coverage (UHC), Health Security (HSE) and Coverage of Health Determinants (CHD)to attain their health goals. Given resource constraints, it is important to prioritize implementation of health service interventions with the highest impact. This is important to be identified across age cohorts and public health functions of health promotion, disease prevention, diagnostics, curative, rehabilitative and palliative interventions. We therefore explored the published evidence on the effectiveness of existing health service interventions addressing the diseases and conditions of concern in the Africa Region, for each age cohort and the public health functions. Six public health and economic evaluation databases, reports and grey literature were searched. A total of 151 studies and 357 interventions were identified across different health program areas, public health functions and age cohorts. Of the studies, most were carried out in the African region (43.5%), on communicable diseases (50.6%), and non-communicable diseases (36.4%). Majority of interventions are domiciled in the health promotion, disease prevention and curative functions, covering all age cohorts though the elderly cohort was least represented. Neonatal and communicable conditions dominated disease burden in the early years of life and non-communicable conditions in the later years. A menu of health interventions that are most effective at averting disease and conditions of concern across life course in the African region is therefore consolidated. These represent a comprehensive evidence-based set of interventions for prioritization by decision makers to attain desired health goals. At a country level, we also identify principles for identifying priority interventions, being the targeting of higher implementation coverage of existing interventions, combining interventions across all the public health functions-not focusing on a few functions, provision of subsidies or free interventions and prioritizing early identification of high-risk populations and communities represent these principles.

Utilization of non-pneumatic anti-shock garment and associated factors for postpartum hemorrhage management among obstetric care providers in public health facilities of southern Ethiopia, 2020

BACKGROUND

Delays in care have been recognized as a significant contributor to maternal mortality in low-resource settings. The non-pneumatic antishock garment is a low-cost first-aid device that can help women with obstetric haemorrhage survive these delays without long-term adverse effects. Extending professionals skills and the establishment of new technologies in basic healthcare facilities could harvest the enhancements in maternal outcomes necessary to meet the sustainable development goals. Thus, this study aims to assess utilization of non-pneumatic anti-shock garment to control complications of post-partum hemorrhage and associated factors among obstetric care providers in public health institutions of Southern Ethiopia, 2020.

METHODS

A facility-based cross-sectional study was conducted among 412 obstetric health care providers from March 15 -June 30, 2020. A simple random sampling method was used to select the study participants. The data were collected through a pre-tested interviewer-administered questionnaire. A binary logistic regression model was used to identify determinants for the utilization of non-pneumatic antishock garment. STATA version 16 was used for data analysis. A P-value of < 0.05 was used to declare statistical significance.

RESULTS

Overall, 48.5% (95%CI: 43.73, 53.48%) of the obstetric care providers had utilized Non pneumatic antishock garment for management of complications from postpartum hemorrhage. Training on Non pneumatic antishock garment (AOR = 2.92; 95% CI: 1.74, 4.92), working at hospital (AOR = 1.81; 95% CI: 1.04, 3.16), good knowledge about NASG (AOR = 1.997; 95%CI: 1.16, 3.42) and disagreed and neutral attitude on Non pneumatic antishock garment (AOR = 0.41; 95%CI: 0.24, 0.68), and (AOR = 0.39; 95% CI: 0.21, 0.73), respectively were significantly associated with obstetric care provider's utilization of Non-pneumatic antishock garment.

CONCLUSIONS

In the current study, roughly half of the providers are using Non-pneumatic antishock garment for preventing complications from postpartum hemorrhage. Strategies and program initiatives should focus on strengthening in-service and continuous professional development training, thereby filling the knowledge and attitude gap among obstetric care providers. Health centers should be targeted in future programs for accessibility and utilization of non-pneumatic antishock garment.

Resource use decrease after implementation of care bundles for treatment of postpartum hemorrhage

OBJECTIVE

To evaluate whether the implementation of care bundles has an impact on resource utilization in the care of patients with postpartum hemorrhage (PPH).

METHODS

Retrospective, cross-sectional, observational study of 404 patients with stage II or greater PPH. Periods 2011-2014 and 2015-2017, before and after the introduction of care bundles, were compared. Billing reports were analyzed, and all services provided to treat these events were extracted. Use of resources within the two periods was computed.

RESULTS

The amount billed per episode decreased 18.66% from the first to the second period. Most PPH cases used fewer resources after introduction of care bundles. The greatest reduction was in the use of medications, with a decrease of charges by 56.3%. Diagnostic procedure charges decreased by 47.6% and consultation charges decreased by (37.7%).

CONCLUSIONS

The use of PPH care bundles may be associated with lower resource use and fewer interventions.

Applying the RE-AIM framework in a process evaluation of the introduction of the Non-Pneumatic Anti-Shock Garment in a rural district of Zimbabwe

The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that can halt and reverse hypovolemic shock secondary to obstetric hemorrhage. The World Health Organization recommended the NASG for use as a temporizing measure in 2012, but uptake of the recommendation has been slow, partially because operational experience is limited. The study is a process evaluation of the introduction of NASG in a public sector health facility network in rural Zimbabwe utilizing an adapted RE-AIM, categorizing observations into the domains of: reach, effectiveness, adoption, implementation and maintenance. The location of the study was Hurungwe district, where staff members of 34 health facilities at primary (31), secondary (2) and tertiary (1) levels of care participated. We found that all facilities became skilled in using the NASG, and that the NASG was used in 10 of 11 instances of severe hemorrhage. In the cases of hypovolemic shock where the NASG was used, there were no maternal deaths and no extreme adverse outcomes related to obstetric hemorrhage in the study period. Among the 10 NASG uses, the garment was used correctly in each case. Fidelity to processes was high, especially in regard to training and cascading skills, but revisions of the NASG rotation and replacement operating procedures were required to keep clean garments stocked. Clinical documentation was also a key challenge. NASG introduction dovetailed very well with pre-existing systems for obstetric emergency response, and improved clinical outcomes. Scale-up of the NASG in the Zimbabwean public health system can be undertaken with careful attention to mentorship, drills, documentation and logistics.

Implementation project of the non-pneumatic anti-shock garment and m-communication to enhance maternal health care in rural Tanzania

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.

Global Emergency Medicine: A Review of the Literature From 2015

OBJECTIVES

The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a global audience of academics and clinical practitioners.

METHODS

This year 12,435 articles written in six languages were identified by our search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the gray literature. A total of 723 articles were deemed appropriate by at least one reviewer and approved by their editor for formal scoring of overall quality and importance. Two independent reviewers scored all articles.

RESULTS

A total of 723 articles met our predetermined inclusion criteria and underwent full review. Sixty percent were categorized as emergency care in resource-limited settings (ECRLS), 17% as EM development (EMD), and 23% as disaster and humanitarian response (DHR). Twenty-four articles received scores of 18.5 or higher out of a maximum score 20 and were selected for formal summary and critique. Inter-rater reliability between reviewers gave an intraclass correlation coefficient of 0.71 (95% confidence interval = 0.66 to 0.75). Studies and reviews with a focus on infectious diseases, trauma, and the diagnosis and treatment of diseases common in resource-limited settings represented the majority of articles selected for final review.

CONCLUSIONS

In 2015, there were almost twice as many articles found by our search compared to the 2014 review. The number of EMD articles increased, while the number ECRLS articles decreased. The number of DHR articles remained stable. As in prior years, the majority of articles focused on infectious diseases.

Barriers and Facilitators to Scaling Up the Non-Pneumatic Anti-Shock Garment for Treating Obstetric Hemorrhage: A Qualitative Study

Background

Obstetric hemorrhage (OH), which includes hemorrhage from multiple etiologies during pregnancy, childbirth, or postpartum, is the leading cause of maternal mortality and accounts for one-quarter of global maternal deaths. The Non-pneumatic Anti-Shock Garment (NASG) is a first-aid device for obstetric hemorrhage that can be applied for post-partum/post miscarriage and for ectopic pregnancies to buy time for a woman to reach a health care facility for definitive treatment. Despite successful field trials, and endorsement by safe motherhood organizations and the World Health Organization (WHO), scale-up has been slow in some countries. This qualitative study explores contextual factors affecting uptake.

Methods

From March 2013 to April 2013, we conducted 13 key informant interviews across four countries with a large burden of maternal mortality that had achieved varying success in scaling up the NASG: Ethiopia, India, Nigeria, and Zimbabwe. These key informants were health providers or program specialists working with the NASG. We applied a health policy analysis framework to organize the results. The framework has five domains: attributes of the intervention, attributes of the implementers, delivery strategy, attributes of the adopting community, the socio-political context, and the research context.

Results

The interviews from our study found that relevant facilitators for scale-up are the simplicity of the device, local and international champions, well-developed training sessions, recommendations by WHO and the International Federation of Gynecology and Obstetrics, and dissemination of NASG clinical trial results. Barriers to scaling up the NASG included limited health infrastructure, relatively high upfront cost of the NASG, initial resistance by providers and policy makers, lack of in-country champions or policy makers advocating for NASG implementation, inadequate return and exchange programs, and lack of political will.

Conclusions

There was a continuum of uptake ranging in both speed and scale. Ethiopia while not the first country to use the NASG has the most rapid scale-up, followed by Nigeria, then India, and finally Zimbabwe. Increasing the coverage of the NASG will require collaboration with local NASG champions, greater NASG awareness among clinicians and policymakers, as well as stronger political will and advocacy.