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Low-Tech Saves Lives

Jennifer Wilder

 

Like many Nigerian women, Jamila delivered her first baby at home, with the help of a traditional birth attendant. But following the birth, her uterus failed to contract and she began to bleed heavily. The birth attendant failed to recognize the severity of blood loss, and by the time Jamila reached the nearest primary health center, she was in shock and her life was in jeopardy.

Luckily, the health worker at the primary health center had been trained to use the non-pneumatic anti-shock garment to halt postpartum hemorrhage and reverse shock. Starting at the ankles, neoprene fabric is snugly tightened with Velcro straps around the legs, gradually moving up to the thighs and finally across the abdomen below the breasts, shunting blood to the heart, lungs and brain, restoring consciousness, pulse and blood pressure. Once stabilized, Jamilla was moved to the nearest district hospital, where she waited five hours for available blood replacement and a doctor.

The amazing non-pneumatic anti-shock garment is part of the continuum of care model -a comprehensive, low-tech package of interventions that addresses the causes of postpartum hemorrhage morbidity and mortality in low-resource settings. Put simply, the archetype works because it keeps the woman alive long enough to be transported and seek further treatment.

Nearly 536,000 women die annually from complications of pregnancy and childbirth. At least 25 percent of these deaths are the result of postpartum hemorrhage, which can be treated successfully by trained health-care providers using the continuum of care model.

The model was put into practice through a grant from the John D. and Catherine T. MacArthur Foundation to Pathfinder International and its partners* to address postpartum hemorrhage in India and Nigeria. Community support and well-trained providers who can implement the strategies are the crux of this model, which comprises of: management of labor, measuring blood loss, treating shock, and community education.

Active management of the third stage of labor has demonstrably reduced the number of postpartum hemorrhage cases caused by uterine atony by as much as 60 percent. To do so, three essential steps - the administration of an utertonic drug immediately following delivery, controlled cord traction, and massaging of the uterus - must be performed. Unfortunately many providers are either inadequately trained or do not implement all of the necessary procedures.

Recent studies have found misoprostal to be clinically effective as an uterotonic drug, offering a major breakthrough, as it can be administered orally and stored in poor facilities without refrigeration, a potential replacement for drugs that require injection and cold storage.

Failure to recognize the severity of blood loss is another big challenge. Providers are learning better methods for visual estimation, as well as the Kanga method, which uses pre-measured absorbent cloths that, when fully saturated, signal that blood loss is excessive. In Nigeria, providers are learning to use a plastic blood collection drape that is placed under the woman's body to capture and accurately measure blood. It is easy to use and effective, though in India, stringent regulations limit use and disposal of plastics.

Shock can also compromise a woman's life. In the continuum of care model, trained, skilled providers apply the non-pneumatic anti-shock garment as a first aid tool when a woman has gone into shock, and refer her immediately to a facility capable of providing emergency obstetric care. The garment can sustain a woman for many hours, saving those who must travel long distances for care, or wait for hours for blood or a doctor's availability.

If necessary, physicians provide surgery while the garment is still in place, or the garment can sustain a woman until she receives blood and is stable enough that it can be removed. Staff must be trained to remove it gradually, as improper removal can be fatal. Systems must be in place to safely clean and store it, and to ensure its timely replacement or return to the original facility. The garment has now been made available in varied sizes to fit women of different size and build.

Some women have been sustained by the garment successfully for more than 50 hours while awaiting access to a facility, a doctor or blood.

Resistance to facility-based deliveries remains a real challenge. As part of the model, community health workers, traditional birth attendants, health officials, and community leaders are all being trained to teach women and their families why skilled care is important and how to plan for possible emergencies. Facilities have been upgraded and schedules have been changed to keep them open 24 hours a day, while families are taught how to recognize danger signs and to trust in the availability of capable providers who are caring and respectful. Communities are also organized to make emergency transportation available to any woman in crisis, and community and religious groups are beginning to promote the donation of blood.

Status Review

In Nigeria, 31 facilities currently use non-pneumatic anti-shock garment, and of the more than 840 hemorrhage cases seen between August 2008 and January 2009, half of the women received the garment. Some women have been sustained by the garment successfully for more than 50 hours while awaiting access to a facility, a doctor or blood.

In India, project activities have started in Tamil Nadu, Maharashtra and Rajasthan, with additional work being negotiated in Bihar. In one district of Maharashtra alone, 90 facilities have been evaluated for upgrading and staff training. Because providers in most Indian primary health centers have limited capacity, Pathfinder concentrates on training and equipping secondary and tertiary facilities where most crisis cases first appear. Interest in the model is also growing among private sector doctors, who provide 30 percent of Indian deliveries.

What's Next?

Efforts are under way to scale up the continuum of care model in additional sites in Nigeria and India, and to replicate it in other countries, including Bangladesh and Peru.

The continuum of care model holds immense promise for women in developing countries, and has garnered significant interest among community members, health-care providers, and government representatives in several countries. The non-pneumatic anti-shock garment, in particular, has caught people's imagination and raised hopes; many call it a "miracle." However program staff must repeatedly remind providers and planners that the garment is only part of the solution; the first goal must be to prevent postpartum hemorrhage through the management of labor, and to ensure the availability of quality emergency obstetric care at facilities. The garment is only a miracle as long as it keeps women alive until they can receive treatment; once it is removed, the doctors must work their own miracles.

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Jenny Wilder is senior technical documentation advisor at Pathfinder International. Cathy Solter, Abdelhadi Eltahir, Habib Sadauki, Rekha Masilamani, Amy Coughlin and Susan Collins contributed to this article.

*Dr. Suellen Miller of the University of California, San Francisco and Dr. Stacie Geller of the University of Illinois at Chicago.