Imagine that you are a nurse midwife, the only staff member in a busy primary health center in rural Nigeria. At least once per month a woman will arrive “pouring” blood and in shock from a postpartum hemorrhage, ruptured ectopic pregnancy, or complication of an unsafe abortion. By the time she reaches the health center, she is close to death, unconscious, and her vital signs are non-recordable. She needs surgery and a blood transfusion, but those services are only available at the referral hospital in the city, 3 hours away. She will not survive a transfer; there is nothing that you can do.
Now imagine that you are that same nurse midwife, but instead of being powerless to treat the woman in shock, you have access to the non-pneumatic anti-shock garment (NASG), a simple neoprene wrap that reverses shock. You apply the NASG and notice that her bleeding slows, and her eyelids begin to flutter. You call for transport and send the woman, now conscious, to the referral hospital to receive definitive care.
This second scene, in which nurses, midwives, ambulance drivers, traditional birth attendants, and community members can apply the NASG as a first–aid device for hypovolemic shock is becoming reality. A new article, published in the journal, “Non-Pneumatic Anti-Shock Garment (NASG), a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage: A Cluster Randomized Trial” provides clinical support that earlier application of the NASG, at the community level, can decrease mortality and severe morbidity secondary to obstetric hemorrhage by 46%. Women who received the NASG also recovered significantly faster from shock.
The cluster randomized controlled trial was conducted by the UCSF Safe Motherhood Program, San Francisco, CA; University Teaching Hospital, Lusaka, Zambia; and the UZ-UCSF Reproductive Health Collaborative in Harare, Zimbabwe. Thirty-eight primary health care centers were randomized to either having the NASG (intervention clinics) or not having the NASG (control clinics) to apply to hemorrhaging women in shock before transferring them to a referral hospital.
The analytic sample included 887 women. All women delivering at the PHCs received IM prophylactic oxytocin and treatment oxytocin. Women who did not receive the NASG at the PHC (control) received the NASG at the RH; thus, the study examined what difference earlier NASG application would have on maternal health outcomes. Previous studies in Nigeria and Egypt had already established that application of NASG at the tertiary facility significantly decreased maternal mortality by more than 50%.
There were several women who entered the study at an intervention clinic, but did not receive the NASG until they arrived at the referral hospital. Adjusting the analysis for these cases resulted in an even greater reduction in maternal mortality and severe morbidity at 61%. Statistical analyses were challenged by a lower than expected sample size, and the mortality and morbidity result was not statistically significant. However, the following factors support use of the NASG to reduce maternal mortality: 1) the large observed reduction in mortality and morbidity rates, 2) the fact that previous studies also noted statistically significant >50% mortality reduction, and 3) the absence of harmful effects from using the NASG. NASGs can help overcome fatal delays in transport, delays during transport, and delays in receiving quality CEmOC care in referral hospitals. Furthermore, according to a recently published cost-effectiveness study by Tori Sutherland and colleagues, the NASG is highly cost effective.
Thanks to collaborative efforts with Pathfinder International, which has incorporated NASGs into their Clinical and Community Actions for PPH Plusprograms globally, and to PATH, which developed quality standards for the garment and negotiated affordable manufacturing in India and China, the NASG is gaining acceptance. It is now used in over 16 countries, and this number is growing. In 2012, WHO and FIGO both included the NASG on their respective PPH management guidelines.
At the community or primary health care level there are currently no other tools that can stabalize women with hemorrhagic shock. The NASG buys time and enables more women to survive transport and referral. Thus, the NASG is an important component of a continuum of care approach for obstetric hemorrhage management.