Strengthening intrapartum and immediate newborn care to reduce morbidity and mortality of preterm infants born in health facilities in Migori County, Kenya and Busoga Region, Uganda: a study protocol for a randomized controlled trial

BACKGROUND

Preterm birth (birth before 37 weeks of gestation) and its complications are the leading contributors to neonatal and under-5 mortality. The majority of neonatal deaths in Kenya and Uganda occur during the intrapartum and immediate postnatal period. This paper describes our study protocol for implementing and evaluating a package of facility-based interventions to improve care during this critical window.

METHODS/DESIGN

This is a pair-matched, cluster randomized controlled trial across 20 facilities in Eastern Uganda and Western Kenya. The intervention facilities receive four components: (1) strengthening of routine data collection and data use activities; (2) implementation of the WHO Safe Childbirth Checklist modified for preterm birth; (3) PRONTO simulation training and mentoring to strengthen intrapartum and immediate newborn care; and (4) support of quality improvement teams. The control facilities receive both data strengthening and introduction of the modified checklist. The primary outcome for this study is 28-day mortality rate among preterm infants. The denominator will include all live births and fresh stillbirths weighing greater than 1000 g and less than 2500 g; all live births and fresh stillbirths weighing between 2501 and 3000 g with a documented gestational age less than 37 weeks.

DISCUSSION

The results of this study will inform interventions to improve personnel and facility capacity to respond to preterm labor and delivery, as well as care for the preterm infant.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03112018 . Registered on 13 April 2017.

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.

Beyond repair - family and community reintegration after obstetric fistula surgery: study protocol

Background

Obstetric fistula is a debilitating birth injury that affects an estimated 2–3 million women globally, most in sub-Saharan Africa and Asia. The urinary and/or fecal incontinence associated with fistula affects women physically, psychologically and socioeconomically. Surgical management of fistula is available with clinical success rates ranging from 65–95 %. Previous research on fistula repair outcomes has focused primarily on clinical outcomes without considering the broader goal of successful reintegration into family and community.

The objectives for this study are to understand the process of family and community reintegration post fistula surgery and develop a measurement tool to assess long-term success of post-surgical family and community reintegration.

Methods

This study is an exploratory sequential mixed-methods design including a preliminary qualitative component comprising in-depth interviews and focus group discussions to explore reintegration to family and community after fistula surgery. These results will be used to develop a reintegration tool, and the tool will be validated within a small longitudinal cohort (n = 60) that will follow women for 12 months after obstetric fistula surgery. Medical record abstraction will be conducted for patients managed within the fistula unit. Ethical approval for the study has been granted.

Discussion

This study will provide information regarding the success of family and community reintegration among women returning home after obstetric fistula surgery. The clinical and research community can utilize the standardized measurement tool in future studies of this patient population.

The Role of the Nonpneumatic Antishock Garment in Reducing Blood Loss and Mortality Associated with Post-Abortion Hemorrhage

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.

A cluster randomized controlled trial of the non-pneumatic anti-shock garment for obstetric haemorrhage: sub-analysis of the Zimbabwean Arm

Objectives

To determine whether earlier application of the Non-pneumatic Anti-Shock Garment (NASG) at clinic level compared to the referral hospital level reduces maternal morbidity and mortality and recovery time from shock due to severe Obstetric Haemorrhage (OH) and to determine the safety of the NASG when applied at clinic level.

Design

A cluster Randomized Controlled Trial (RCT)

Setting

Harare and Parirenyatwa Referral Hospitals (RH) in Harare and the twelve Harare City Council clinics that offer maternity care.

Subjects

Women who had suffered severe OH at clinic level and were being transferred to a Referral Hospital (RH).

Iterventions

The clinics were randomized into two groups. In the early NASG group eligible women were given the standard management for OH and had the NASG applied at the clinic level before transport to RH. In the control group, eligible women were given the standard management for OH at the clinic level, transferred to the RH, and received the NASG at the RH. All women received equivalent OH/hypovolemic shock management at the RH.

Main Outcome Measures

The main outcome measures were maternal mortality and morbidity, blood loss, recovery from shock and the occurrence of side effects whilst in the NASG.

Results

There were few maternal deaths and morbidities, and no statistically significant differences between the two groups were noted. Women in the early NASG group spent a statistically significant shorter time in the NASG at referral hospital level (OR 0.64, 95% CI 0.52 - 0.79, p < 0.001) and had a non-significant 40% faster recovery from shock (HR 1.39; 95% CI 0.98-1.97, p=0.07). There were no differences in reported side effects.

Conclusion

Earlier NASG application at the clinic level was associated with faster recovery from shock in women who had suffered severe OH and appears safe to use.

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

BACKGROUND

Obstetric hemorrhage is the leading cause of maternal mortality, particularly in low resource settings where delays in obtaining definitive care contribute to high rates of death. The non-pneumatic anti-shock garment (NASG) first-aid device has been demonstrated to be highly cost-effective when applied at the referral hospital (RH) level. In this analysis we evaluate the incremental cost-effectiveness of early NASG application at the Primary Health Center (PHC) compared to later application at the RH in Zambia and Zimbabwe.

METHODS

We obtained data on health outcomes and costs from a cluster-randomized clinical trial (CRCT) and participating study hospitals. We translated health outcomes into disability-adjusted life years (DALYs) using standard methods. Econometric regressions estimated the contribution of earlier PHC NASG application to DALYs and costs, varying geographic covariates (country, referral hospital) to yield regression models best fit to the data. We calculated cost-effectiveness as the ratio of added costs to averted DALYs for earlier PHC NASG application compared to later RH NASG application.

RESULTS

Overall, the cost-effectiveness of early application of the NASG at the primary health care level compared to waiting until arrival at the referral hospital was $21.78 per DALY averted ($15.51 in added costs divided by 0.712 DALYs averted per woman, both statistically significant). By country, the results were very similar in Zambia, though not statistically significant in Zimbabwe. Sensitivity analysis suggests that results are robust to a per-protocol outcome analysis and are sensitive to the cost of blood transfusions.

CONCLUSIONS

Early NASG application at the PHC for women in hypovolemic shock has the potential to be cost-effective across many clinical settings. The NASG is designed to reverse shock and decrease further bleeding for women with obstetric hemorrhage; therefore, women who have received the NASG earlier may be better able to survive delays in reaching definitive care at the RH and recover more quickly from shock, all at a cost that is highly acceptable.

Access to transport for women with hypovolemic shock differs according to weeks of pregnancy

OBJECTIVE

To examine whether women with hypovolemic shock secondary to obstetric hemorrhage are transported to referral hospitals differently depending on weeks of pregnancy in Zambia.

METHODS

In a retrospective study, transport type, wait time, and transit time were assessed for women with obstetric hemorrhage and hypovolemic shock transported from 26 primary health centers to three referral hospitals during 2007-2012. A mean arterial pressure of less than 60 mm Hg was used to indicate severe shock. Women were split into two categories on the basis of the number of weeks of pregnancy (<24 weeks vs ≥24 weeks).

RESULTS

Overall, 616 women were included. Mode of transport differed significantly by group (P<0.001). 414 (93.0%) of 445 women at 24 weeks of pregnancy or more were transported by ambulance versus 114 (66.7%) of 171 women at less than 24 weeks. Among those in severe shock, 106 (93.0%) of 114 women at 24 weeks of pregnancy or more were transported in ambulances versus 26 (52.0%) of 50 women at less than 24 weeks (P<0.001).

CONCLUSION

Women at 24 weeks of pregnancy or more were given preference for ambulance transport even when signs of shock were equivalent. Policy-makers aiming to lower maternal mortality need to address transport issues regardless of the etiology of hemorrhage or week of pregnancy.

Combined analysis of the non-pneumatic anti-shock garment on mortality from hypovolemic shock secondary to obstetric hemorrhage

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.

Comorbidities and lack of blood transfusion may negatively affect maternal outcomes of women with obstetric hemorrhage treated with NASG

The Non-Pneumatic Anti-Shock Garment (NASG) is a first-aid device to reduce mortality from severe obstetric hemorrhage, the leading cause of maternal mortality globally. We sought to evaluate patient characteristics associated with mortality among a cohort of women treated with the NASG in Nigeria. Data on 1,149 women were collected from 50 facilities participating in the Pathfinder International Continuum of Care: Addressing Postpartum Hemorrhage project in Nigeria from 2007-2012. Characteristics were compared using the appropriate distributional tests, and we estimated multivariable logistic regression models to control for treatment received. There were 201 deaths (17.5%). Women who died were significantly more likely to have any co-morbidity (AOR 3.63, 95% CI: 2.41-5.48), ruptured uterus (AOR 2.79, 95% CI: 1.48-5.28), macerated stillbirth (AOR 2.96, 95% CI 1.60-5.48) and to have had 6 or more previous births, (AOR 1.53, 95% CI 1.11-2.12), after adjusting for treatment received. These results suggest certain maternal conditions, particularly the presence of another life-threatening co-morbidity or macerated stillbirth, conferred a higher risk of mortality from PPH. This underscores the need for multi-system assessment and a comprehensive approach to the treatment of women with pregnancy complications.

Use of the non-pneumatic anti-shock garment (NASG) for life-threatening obstetric hemorrhage: a cost-effectiveness analysis in Egypt and Nigeria

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.

Nonatonic obstetric haemorrhage: effectiveness of the nonpneumatic antishock garment in egypt

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.

Positive effects of the non-pneumatic anti-shock garment on delays in accessing care for postpartum and postabortion hemorrhage in Egypt and Nigeria

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.

Assessing the role of the non-pneumatic anti-shock garment in reducing mortality from postpartum hemorrhage in Nigeria

BACKGROUND/AIMS

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality. The non-pneumatic anti-shock garment (NASG), a first-aid lower-body pressure device, may decrease mortality.

METHODS

This pre-intervention/NASG study of 288 women was conducted in four referral facilities in Nigeria, 2004-2008. Entry criteria: 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. t tests and relative risks with 95% confidence intervals were calculated for primary outcomes - measured blood loss and mortality. Multiple logistic regression analysis was performed to examine independent association of the NASG with mortality.

RESULTS

Mean measured blood loss decreased by 80% between 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% pre-intervention 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.

A comparison of objective biomarkers with a subjective health status measure among children in the Philippines

Large health surveys use subjective (self-reported) and objective (biomarkers) measures to assess heath status. However, the linkage or disparity of these measures has not been systematically studied in developing countries.

METHOD

Using data from the Philippine Quality Improvement Demonstration Study, QIDS, this study evaluated the associations between General Self-Reported Health Status (GSRH) and height, weight, hemoglobin, red blood cell folate, C-reactive protein, and blood lead levels. The authors modeled each biomarker as a function of GSRH controlling for socioeconomic status and selection effects. Changes in biomarkers and GSRH in children who had previously been hospitalized were also examined.

RESULTS

GSRH independently predicted hemoglobin, C-reactive protein, stunting, and wasting. GSRH did not vary significantly with folate deficiency and blood lead levels.

CONCLUSIONS

In addition to being a measure of overall child health status, GSRH may be a useful and inexpensive screening tool for identifying children that need further health testing.

Obstetric hemorrhage and shock management: using the low technology Non-pneumatic Anti-Shock Garment in Nigerian and Egyptian tertiary care facilities

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.

Assessment of clients health needs of two urban Native American health centers in the San Francisco Bay Area

A needs assessment was compiled from self-administered questionnaires completed by 796 clients at the Urban Indian Health Service clinics in San Francisco and Oakland, California. Data on the health disparities between Native Americans and Alaskan Natives and the rest of the U.S. population are limited. The data that exist, however, indicate that Native Americans continue to fare worse than the general population. This needs assessment reveals the same trend among a sample of clients of two Native American Health Centers in the San Francisco Bay Area and provides further information about the health needs and interests of the population currently attending these centers.

A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt

OBJECTIVE

To assess the impact of the non-pneumatic anti-shock garment (NASG) on maternal outcome following severe obstetric hemorrhage.

METHODS

A non-randomized pre-intervention/intervention study was conducted in 2 tertiary hospitals in Egypt from June 2006 to May 2008. Women with obstetric hemorrhage (estimated blood loss >or=1000 mL and/or >or=1 sign of shock [systolic blood pressure <100 mm Hg or pulse >100 beats per minute]) were treated with either a standardized protocol (pre-intervention) or a standardized protocol plus the NASG (intervention). The primary outcome was extreme adverse outcome (EAO), combining maternal mortality and severe morbidity (cardiac, respiratory, renal, or cerebral dysfunction). Secondary outcomes were measured blood loss, urine output, emergency hysterectomy, and (individually) mortality or morbidity. Analyses were performed to examine independent association of the NASG with EAO.

RESULTS

Mean measured blood loss decreased from 379 mL pre-intervention to 253 mL in the intervention group (P<0.01). In a multiple logistic regression model, the NASG was associated with reduced odds of EAO (odds ratio 0.38; 95% confidence interval, 0.17-0.85).

CONCLUSION

The NASG, in addition to standardized protocols at tertiary facilities for obstetric hemorrhage and shock, resulted in lower measured blood loss and reduced EAO.