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Piaggio D, Hyland S, Maccaro A, Iadanza E, Pecchia L. A 3D-printed condom intrauterine balloon tamponade: Design, prototyping, and technical validation. PLoS One 2024; 19:e0303844. [PMID: 38861495 PMCID: PMC11166290 DOI: 10.1371/journal.pone.0303844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/01/2024] [Indexed: 06/13/2024] Open
Abstract
Post-partum haemorrhage is among the main causes of (preventable) mortality for women in low-resource settings (LRSs), where, in 2017, the mortality ratio was 462 out of every 100 000 live births, over 10 times higher than for high-resource settings. There are different treatments available for post-partum haemorrhage. The intrauterine balloon tamponade is a medical device that proved to be a simple and cost-effective approach. Currently, there are several balloon tamponades available, with different design and working principles. However, all these devices were designed for high-resource settings, presenting several aspects that could be inappropriate for many lower-income countries. This paper presents the results of a preclinical study aiming at informing the design, prototyping and validation of a 3D-printed intrauterine balloon tamponade concept, contributing towards the United Nation's Sustainable Development Goal 3: Good health and Well-being. Frugal engineering concepts and contextualised design techniques were applied throughout, to define the design requirements and specifications. The performance of the final prototype was validated against the requirements of the UK National Health System (NHS) technical guidelines and relevant literature, measuring the water leak and pressure drop over time, both open air and in a approximate uterus model. The resulting prototype is made up of six components, some of which are easy to retrieve, namely a water bottle, a silicone tube and an ordinary condom, while others can be manufactured locally using 3D printers, namely a modified bottle cap, a flow stopper and a valve for holding the condom in place. Validation testing bore promising results with no water or pressure leak open air, and minimal leaks in the approximate uterus model. This demonstrates that the 3D printed condom-based intrauterine balloon tamponade is performing well against the requirements and, when compared to the state of the art, it could be a more appropriate and more resilient solution to low-resource settings, as it bypasses the challenges in the supply of consumables and presents a greener option based on circular economy.
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Affiliation(s)
- Davide Piaggio
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Scott Hyland
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Alessia Maccaro
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Ernesto Iadanza
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Leandro Pecchia
- School of Engineering, University of Warwick, Coventry, United Kingdom
- School of Engineering, Campus Biomedico of Rome, Rome, Italy
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Candidori S, Osouli K, Graziosi S, Zanini AA, Costantino ML, De Gaetano F. A novel low-cost uterine balloon tamponade kit to tackle maternal mortality in low-resource settings. Sci Rep 2024; 14:10004. [PMID: 38693193 PMCID: PMC11063067 DOI: 10.1038/s41598-024-60064-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/18/2024] [Indexed: 05/03/2024] Open
Abstract
The 3.1 target of the Sustainable Development Goals of the United Nations aims to reduce the global maternal mortality ratio to less than 70 maternal deaths per 100,000 live births by 2030. The last updates on this target show a significant stagnation in the data, thus reducing the chance of meeting it. What makes this negative result even more serious is that these maternal deaths could be avoided through prevention and the wider use of pharmacological strategies and devices to stop postpartum haemorrhage (PPH). PPH is the leading obstetric cause of maternal mortality in low- and middle-income countries (LMICs). Despite low-cost devices based on the uterine balloon tamponade (UBT) technique are already available, they are not safe enough to guarantee the complete stop of the bleeding. When effective, they are too expensive, especially for LMICs. To address this issue, this study presents the design, mechanical characterisation and technology assessment performed to validate a novel low-cost UBT kit, particularly a novel component, i.e., the connector, which guarantees the kit's effectiveness and represents the main novelty. Results proved the device's effectiveness in stopping PPH in a simulated scenario. Moreover, economic and manufacturing evaluations demonstrated its potential to be adopted in LMICs.
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Affiliation(s)
- Sara Candidori
- Department of Mechanical Engineering, Politecnico Di Milano, Via La Masa 1, 20156, Milan, Italy
| | - Kasra Osouli
- Department of Chemistry, Materials and Chemical Engineering "G. Natta", Politecnico Di Milano, Piazza Leonardo da Vinci 31, 20133, Milan, Italy
| | - Serena Graziosi
- Department of Mechanical Engineering, Politecnico Di Milano, Via La Masa 1, 20156, Milan, Italy.
| | | | - Maria Laura Costantino
- Department of Chemistry, Materials and Chemical Engineering "G. Natta", Politecnico Di Milano, Piazza Leonardo da Vinci 31, 20133, Milan, Italy
| | - Francesco De Gaetano
- Department of Chemistry, Materials and Chemical Engineering "G. Natta", Politecnico Di Milano, Piazza Leonardo da Vinci 31, 20133, Milan, Italy
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Burke TF, Shivkumar PV, Priyadarshani P, Garg L, Conde-Agudelo A, Guha M. Impact of the introduction of a low-cost uterine balloon tamponade (ESM-UBT) device for managing severe postpartum hemorrhage in India: A comparative before-and-after study. Int J Gynaecol Obstet 2022; 159:466-473. [PMID: 35212417 DOI: 10.1002/ijgo.14156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the impact of introducing a uterine balloon tamponade (ESM-UBT) device for managing severe postpartum hemorrhage (PPH), mainly due to uterine atony, in health facilities in India on the rates of PPH-related maternal death and invasive procedures for PPH control. METHODS We used a quasi-experimental, difference-in-difference (DID) design to compare changes in the rates of a composite outcome (PPH-related maternal death and/or artery ligation, uterine compression sutures, or hysterectomy) among women delivering in nine intervention facilities compared with those delivering in two control facilities, before and after the introduction of ESM-UBT. RESULTS The study sample included 214 123 deliveries (n = 78 509 before ESM-UBT introduction; n = 47 211 during ESM-UBT introduction; and n = 88 403 after ESM-UBT introduction). After introduction of ESM-UBT, there was a significant decline in the rate of the primary composite outcome in intervention facilities (21.0-11.4 per 10 000 deliveries; difference -9.6, 95% confidence interval -14.0 to -5.4). Change in the rate of the primary composite outcome was not significant in control facilities (11.7-17.2 per 10 000 deliveries; difference 5.4, 95% confidence interval -3.9 to 14.9). DID analyses showed there was a significant reduction in the rate of the primary composite outcome in intervention facilities relative to control facilities (adjusted DID estimate -15.0 per 10 000 points, 95% confidence interval -23.3 to -6.8; P = 0.005). CONCLUSION Introduction of the ESM-UBT in health facilities in India was associated with a significant reduction in PPH-related maternal death and/or invasive procedures for PPH control.
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Affiliation(s)
- Thomas F Burke
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Poonam V Shivkumar
- Department of Obstetrics and Gynecology, Mahatma Gandhi Institute of Medical Sciences, Sewagram, India
| | - Preeti Priyadarshani
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Gorakhpur, India
| | - Lorraine Garg
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Agustin Conde-Agudelo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, US Department of Health and Human Services, National Institutes of Health, Bethesda, Maryland, USA
| | - Moytrayee Guha
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Brown School of Public Health, Providence, Rhode Island, USA
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Joshi BN, Shetty SS, Moray KV, Sachin O, Chaurasia H. Cost-effectiveness of uterine balloon tamponade devices in managing atonic post-partum hemorrhage at public health facilities in India. PLoS One 2021; 16:e0256271. [PMID: 34407132 PMCID: PMC8372914 DOI: 10.1371/journal.pone.0256271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 08/03/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Post-partum hemorrhage (PPH) is the leading direct cause of maternal mortality in India. Uterine balloon tamponade (UBT) is recommended for atonic PPH cases not responding to uterotonics. This study assessed cost-effectiveness of three UBT devices used in Indian public health settings. Methods A decision tree model was built to assess cost-effectiveness of Bakri-UBT and low-cost ESM-UBT alternatives as compared to the recommended standard of care i.e. condom-UBT intervention. A hypothetical annual cohort of women eligible for UBT intervention after experiencing atonic PPH in Indian public health facilities were evaluated for associated costs and outcomes over life-time horizon using a disaggregated societal perspective. Costs by undertaking primary costing and clinical parameters from published literature were used. Incremental cost per Disability Adjusted Life Years (DALY) averted, number of surgeries and maternal deaths with the interventions were estimated. An India specific willingness to pay threshold of INR 24,211 (USD 375) was used to evaluate cost-effectiveness. Detailed sensitivity analysis and expected value of information analysis was undertaken. Results ESM-UBT at base-case Incremental Cost-Effectiveness Ratio (ICER) of INR -2,412 (USD 37) per DALY averted is a cost-saving intervention i.e. is less expensive and more effective as compared to condom-UBT. Probabilistic sensitivity analysis however shows an error probability of 0.36, indicating a degree of uncertainty around model results. Bakri-UBT at an ICER value of INR -126,219 (USD -1,957) per DALY averted incurs higher incremental societal costs and is less effective as compared to condom-UBT. Hence, Bakri-UBT is not cost-effective. Conclusion For atonic PPH management in India, condom-UBT offers better value as compared to Bakri-UBT. Given the limited clinical effectiveness evidence and uncertainty in sensitivity analysis, cost-saving result for ESM-UBT must be considered with caution. Future research may focus on generating high quality comparative clinical evidence for UBT devices to facilitate policy decision making.
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Affiliation(s)
- Beena Nitin Joshi
- Department of Operational Research, Indian Council of Medical Research - National Institute for Research in Reproductive Health, Mumbai, Maharashtra, India
| | - Siddesh Sitaram Shetty
- Regional Resource Hub for Health Technology Assessment, Indian Council of Medical Research - National Institute for Research in Reproductive Health, Mumbai, Maharashtra, India
| | - Kusum Venkobrao Moray
- Regional Resource Hub for Health Technology Assessment, Indian Council of Medical Research - National Institute for Research in Reproductive Health, Mumbai, Maharashtra, India
| | - Oshima Sachin
- Department of Health Research, Ministry of Health and Family Welfare, New Delhi, India
| | - Himanshu Chaurasia
- Regional Resource Hub for Health Technology Assessment, Indian Council of Medical Research - National Institute for Research in Reproductive Health, Mumbai, Maharashtra, India
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Shetty SS, Moray KV, Chaurasia H, Joshi BN. Cost of managing atonic postpartum haemorrhage with uterine balloon tamponade devices in public health settings of Maharashtra, India: an economic microcosting study. BMJ Open 2021; 11:e042389. [PMID: 33653747 PMCID: PMC7929829 DOI: 10.1136/bmjopen-2020-042389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Postpartum haemorrhage (PPH) is the worldwide leading cause of preventable maternal mortality. India offers free treatment for pregnancy and related complications in its public health facilities. Management with uterine balloon tamponade (UBT) is recommended for refractory atonic PPH cases. As part of health technology assessment to determine the most cost-effective UBT device, this study estimated costs of atonic PPH management with condom-UBT, Every Second Matters (ESM) UBT and Bakri balloon UBT in public health system of Maharashtra, India. DESIGN Health system cost was estimated using primary economic microcosting, data from Health Management Information System and published literature for event probabilities. SETTINGS Four public health facilities from the state of Maharashtra, India representing primary, secondary and tertiary level care were chosen for primary costing. OUTCOME MEASURES Unit, package and annual cost of atonic PPH management with three UBT devices were measured. This included cost of medical treatment, UBT intervention and PPH related surgeries undertaken in public health system of Maharashtra for year 2017-2018. RESULTS Medical management of atonic PPH cost the health system US$37 (95% CI 29 to 45) per case, increasing to US$44 (95% CI 36 to 53) with condom-UBT and surgical interventions for uncontrolled cases. Similar cost was estimated for ESM-UBT. Bakri-UBT reported a higher cost of US$59 (95% CI 46 to 73) per case. Overall annual cost of managing 27 915 atonic PPH cases with condom-UBT intervention in Maharashtra was US$1 226 610 (95% CI 870 250 to 1 581 596). CONCLUSIONS Atonic PPH management in public health facilities of Maharashtra with condom-UBT, ESM-UBT or Bakri-UBT accounts to 3.8%, 3.8% or 5.2% of the state's annual spending on reproductive and child health services. These findings can guide policy-makers to include PPH complication management in publicly financed health schemes. Economic evaluation studies can use this evidence to determine cost effectiveness of UBT in Indian settings.
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Affiliation(s)
- Siddesh Sitaram Shetty
- Regional Resource Hub for Health Technology Assessment in India, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, India
| | - Kusum Venkobrao Moray
- Regional Resource Hub for Health Technology Assessment in India, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, India
| | - Himanshu Chaurasia
- Regional Resource Hub for Health Technology Assessment in India, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, India
| | - Beena Nitin Joshi
- Department of Operational Research, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, India
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Conde-Agudelo A, Suarez S, Burke TF. Reply. Am J Obstet Gynecol 2020; 223:138-139. [PMID: 32109467 DOI: 10.1016/j.ajog.2020.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Agustin Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
| | - Sebastian Suarez
- Department of Internal Medicine, Boston Medical Center, 72 E. Concord St, E124, Boston, MA 02118.
| | - Thomas F Burke
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA
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