20 June 2013

Zimbabwe: The Miracle Garment

TATENDA MUGARIRI is a lucky woman who has lived to tell her story. Only last year, she almost knocked heaven's doors only to find them heavily sealed. She had experienced pregnancy complications at six months and bled profusely. It was just not her time to die, thanks to an intervention, which many now call the miracle cloth, the non-pneumatic anti-shock garment (NASG).

Mugariri narrates her story.

"I was pregnant and had pre-term labour on December 12, last year.

"Since I was experiencing complications, I was transferred to Harare Hospital.

"I was in pain and lost a lot of blood. I started feeling dizzy, my brain started shutting down," she said.

The doctor who attended to her suggested that she uses the NASG which was on trial at the hospital.

"I felt better after the garment was strapped on my lower body. The bleeding stopped and everything went back to normal. Some doctors were shocked that I was still alive.

"Sadly, I had lost my pre-term baby. I could have died were it not for this garment," she said.

In many underprivileged societies and under- resourced health facilities, women like Mugariri and others die from pregnancy.

Those who unfortunately give birth at home without the assistance of a skilled attendant also die.

These women bleed heavily and may face long delays while a decision is made to seek care, organise transport, travel to the hospital and wait in the hospital for blood or surgery.

Many women do not survive because of the delays.

But with interventions like the NASG maternal deaths may decrease.

NASG is a low-technology, low-cost first aid device used to treat shock, resuscitate, stabilise and prevent further bleeding in women with severe bleeding.

It applies circumferential counter pressure to the lower body and uterus which increases circulating blood to the heart, lungs and brain and decreases the rate of blood flow in the abdomen and pelvis, thus decreasing blood loss.

Each garment costs US$60 and can be used up to 40 times.

Maintenance is easy as it only requires washing and bleaching.

In Zimbabwe, the pilot project is being run at Harare and Parirenyatwa hospitals and is donor funded.

Locally, the project is being run by the University of California San Francisco (UCSF) Safe Motherhood Programme, PATH and Pathfinder International in collaboration with the University of Zimbabwe.

It is sponsored by the Bill and Melinda Gates Foundation.

Preliminary results from randomised clinical trials to access the impact of utilising the garment at primary care facilities for transfer to tertiary care centres indicate a 50 percent decrease in mortality from severe obstetric haemorrhage.

Government officials said they will soon roll out the low cost, first aid tool as efforts to reduce pregnancy-related deaths and other complications intensify.

Speaking at a meeting for health technocrats held to disseminate information on the safety and effectiveness of the NASG in Harare recently, Health and Child Welfare secretary Dr Gerald Gwinji said Government welcomed all research to reduce pregnancy-related deaths and complications.

"My ministry is looking forward to working with the research team to roll out the NASG to all provincial and district hospitals and to all rural health centres in the country," Dr Gwinji said.

He said rollout of NASG should be accompanied by frequent and regular training of health workers on effective use of the device.

Dr Gwinji added that in the long run, the NASG should be incorporated into the curricula of nursing and medical staff.

He explained that once resources were available, Government would start the rollout to primary health facilities that include clinics, especially in rural areas. Severe bleeding (haemorrhage) is the second cause of maternal deaths after HIV and Aids accounting for about 14 percent of all deaths.

Haemorrhage leads to shock, marked by decreased oxygen in the vital organs; shock leads to multi organ dysfunction syndrome and death.

The maternal mortality ratio continues to increase from 725 per 100 000 live births in 2007 to 925 per 100 000 live births meaning at least 12 women die every day due to pregnancy-related complications.

Post-partum haemorrhage accounted for 14,4 percent of maternal deaths in the study.

Worldwide, haemorrhage usually accounts for 25 percent of maternal deaths annually.

"We are working hard towards meeting the objectives of the Millennium Development Goal 5 by the year 2015.

"This requires a reduction of maternal mortality by 75 percent compared to 1990 figures," he said.

Former WHO Director in the Department of Reproductive Health, Professor Michael Mbizvo, said the death of women in pregnancy should be a concern to everyone not just health personnel, but society.

He described it as a public health issue that deserves priority consideration.

"It has remained elusive to high impact intervention in our country as in other low- and middle-income countries as developing countries still account for 99 percent of the 278 000 annual deaths globally," he said.

Maternal health was one of the hot issues deliberated at the just ended 3rd Women Deliver Conference held in Kuala Lumpur, Malaysia, last month.

Addressing delegates at the conference, UCSF Director of the Safe Motherhood Programme Dr Sue Ellen Miller said the NASG saves lives if it is used.

She said Zimbabwean research findings released last month are impressive as they are in line with that of Nigeria and Egypt.

"In Egypt and Nigeria, in separate and combined analyses, findings showed that women treated with the NASG fared much better than women who were not treated with the NASG. Results showed significant reductions in blood loss, rate of emergency hysterectomy and incidence of morbidity and mortality.

"Other analyses found that the NASG additionally resulted in a more rapid recovery from shock, helped women overcome treatment delays, and had a similarly strong ameliorative effect on women in severe shock."

She added: "In a cost effectiveness study published in the Public Library of Science in 2013 that used data from Nigeria and Egypt, the non-pneumatic anti shock garment was highly cost effective, averting thousands of DALYs, or death, at a cost of around US$1,50/DALY averted or life saved.

"Now we are seeing the same results in Zambia and Zimbabwe at the primary care level."

Non-governmental organisation, PATH, Chief Strategy Officer, Amie Batson said such types of innovations and unique collaborations are the key to providing access to life saving solutions to women around the world.

"Post-partum haemorrhage is a killer, but it's also one of the few obstetric complications with proven, effective interventions like the NASG.

"To reduce costs, PATH experts are focusing on the costs of production, from raw materials through manufacturing, transport and delivery," she said.

Batson revealed that PATH's collaboration with manufacturers in India and Hong Kong has resulted in a four time reduction in price, while maintaining high standards of quality.

The United Nations Population Fund (UNFPA) Deputy Executive Director Kate Gilmore said the combination of UCSF researching the garment, Pathfinder implementing its use in their proven continuum of care approach, and PATH finding lower cost manufacturing shows the importance of creative and innovative partnerships.

"Maternal mortality is not intractable: Innovation and collaboration have vital roles to play as we all accelerate our efforts to ensure every pregnancy is safe, including in emergencies," she said.

President And CEO of Pathfinder International, Purnima Mane said the garment keeps women safe at every stage of pregnancy.

"Working in parts of the world where distance is the difference between life and death demands solutions that can begin in the community or the home, and keep women safe at every stage. The continuum of care approach, combined with the NASG does just that," Mane said.

Given the increasing results indicating effectiveness, in 2012, WHO released new recommendations that included the NASG for use in addressing post-partum haemorrhage until appropriate care is available. WHO also recommended that national guidelines should be reviewed to ensure the NASG is included.

Since 2002, the UCSF Safe Motherhood Program has focused on clinical trials and cost effectiveness research specifically on the non-pneumatic anti-shock garment in low resource settings. They have documented outcomes of over 4000 women in hypovolemic shock in Nigeria, Egypt and Zimbabwe.


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