A promising device to save maternal lives associated with obstetric hemorrhage: the non-pneumatic anti-shock garment (NASG)

Preventable maternal mortality associated with obstetric hemorrhage is a human tragedy that mainly occurs in low and middle-income countries (LMIC). Massive blood loss leads to hypovolemic shock, which decreases blood flow and therefore oxygen to tissues in the heart, lungs, and brain. Women can rapidly develop disseminated intravascular coagulopathy, tissue anoxia, single or multiple organ failure, and death. Management and treatment of hypovolemic shock due to massive obstetric hemorrhage requires care at the tertiary or referral level, treatment varies dependent on hemorrhage etiology, but generally reversing shock requires not only uterotonics and IV fluids (sometimes available at primary health centers), but also blood transfusions and hemostatic surgeries, only available at Comprehensive Emergency Obstetric Care (CEmOC) facilities. The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid device that can buy time for women experiencing hypovolemic shock secondary to obstetric hemorrhage from any etiology. As such it buys time to overcome two of the three delays that contribute to maternal mortality in lower resourced settings [1]. The second delay is a delay in arranging transport and during transport from either home or lower level health care facilities to referral facilities, and the third delay is the delayed receipt of quality, comprehensive emergency obstetrical care at the tertiary facility. The NASG can mitigate both these delays [2]. In the article published within Reproductive Health ,t he authors, all international, maternal health researchers, are publishing the results of a systematic review of six studies on the NASG conducted in LMICs [3]. Four studies are quasi-experimental, pre-intervention/intervention design in Egypt [4,5], Nigeria [6], and Zimbabwe [7] and one was a non-randomized concurrent comparative study in India [8]. These studies were conducted at the tertiary level, and compared outcomes of women with hypovolemic shock treated with standardized hemorrhage/shock protocols with similar women treated with the same protocols, plus the NASG. One study, set in Zambia and Zimbabwe [9] was a cluster-randomized control trial (c-RCT) which compared outcomes for women who either received the NASG prior to transport from primary health care center to tertiary level with outcomes for women who received the NASG after arrival at the tertiary level. Systematic review and meta-analytic techniques were used to pool the results from the quasi-experimental studies. Use of these techniques is important when dealing with small samples and rare events. As the authors note, while maternal hemorrhage is a leading cause of maternal death, accounting for over 27% of all maternal deaths, and is associated with a huge burden of global disease; at the facility level life-threatening maternal hemorrhage and shock are rare events. Therefore, most studies use proxies for mortality or severe morbidity. This systematic review notes appropriately that these NASG studies are unusual in using mortality and severe morbidity as their direct outcomes. The findings of the review of the pooled 5 quasi-experimental studies have an overall sample size of 2,330 women with severe hemorrhage, and a statistically significant decrease in pooled risk ratio (RR) of maternal mortality of 48% (RR 0.52 (95% CI: 0.360.77)). The single c-RCT with a smaller sample size and rare event rate, showed a non-significant statistical reduction in mortality, RR 0.43 (95% CI; 0.14-1.33. Finding a greater than 50% reduction in mortality for any treatment