On a recent busy day at the Nyamhunga clinic, a patient arrived bleeding heavily. Due to staffing shortages, there was only one nurse on duty for a clinic that serves 8,880 Hurungwe Rural District residents.
The patient, Anne*, had miscarried at 20 weeks pregnant, but had not delivered the placenta. As a result, she was losing a significant amount of blood and was at risk of succumbing to shock if not stabilized quickly. The nurse determined Anne was suffering from postpartum hemorrhage and tried to insert an IV line to help stabilize her but could not find a vein due to blood loss. Undeterred, the nurse applied a non-pneumatic anti-shock garment (NASG) until emergency transportation arrived to take her on the more than 70 kilometer journey to the district hospital in Karoi.
Anne has a NASG applied as she waits for emergency transport to the hospital. Her photo is blurred to protect identity.
Postpartum hemorrhage is the largest cause of maternal mortality in Zimbabwe. It takes less than four hours from the onset of hemorrhage, on average, to die, but the condition can only be treated in hospital. This is especially problematic across many low- and middle-income countries where women often suffer delays in reaching and receiving emergency care at a hospital.
In Zimbabwe, ambulance and fuel shortages often mean that transportation is unavailable. Even if healthcare workers are able to secure an emergency vehicle, it can take hours to arrive. The resulting maternal deaths are made more tragic by the fact that they are largely preventable. This is why solutions such as the NASG are critical to help keep women alive and stable until they reach the hospital.
In 2019, CHAI was the first organization to partner with the Ministry of Health and Child Care (MOHCC) to inform the rollout and catalyze the scale-up of the NASG starting in Hurungwe District. The NASG is a low-cost and simple to use device that stabilizes women suffering from hemorrhage for approximately 36 hours while they are waiting to access higher levels of care. This compression wrap is lightweight, reusable, and simple to apply. While the NASG alone is not a treatment, it buys women essential time.
“I had not realized that this strange looking suit would preserve my life, but I stand as a testimony of the effectiveness of this garment.”
This was the case for Anne. Although the nurse called for an ambulance, one was not immediately available. She next arranged for public transportation which took an hour and a half to arrive. Had it not been for the NASG, Anne likely would have died while she waited. Instead, she was able to walk to the car when transportation arrived. She got to the hospital two hours later where she was treated and returned home within three days.
“I arrived at the clinic bleeding profusely, it was not easy,” said Anne. “I thought I was going to die. The nurse attended to me promptly and I watched sceptically as she applied this garment, wondering if she realized the severity of my condition.
“At the time I had not realized that this strange looking suit would preserve my life, particularly when the ambulance could not be dispatched immediately. But today I stand as a sure testimony of the effectiveness of this garment. As a survivor, it is my desire that every health facility in Zimbabwe be equipped with these life-saving garments.”
Contributing factors to high maternal mortality in Zimbabwe
The 2019 Multiple Indicator Cluster Survey [1], a UNICEF-supported international household survey to understand the well-being of women and children, reported that in Zimbabwe 462 women died per 100,000 live births in 2019—one of the highest rates in the world. Three major health complications—hemorrhage, sepsis, and eclampsia (dangerously high blood pressure)—drove these deaths [2], with postpartum hemorrhage accounting for 26 percent of maternal deaths among women of all ages[3]. Ensuring that women suffering from hemorrhage are treated quickly and efficiently is critical to saving lives.
In Zimbabwe, delays in decisions around seeking appropriate emergency care contributed to 41 percent of maternal hemorrhage deaths in 2018. Lack of appropriate equipment or other products at health facilities contributed to 30 percent of the deaths; 19 percent of deaths were due to lack of transportation between health care facilities; and 18 percent were due to a lack of transportation from home to a health facility. [4]
These delays are further compounded by poor road networks between primary health facilities and higher levels of care which are often poorly maintained, causing long travel times. In the current economic situation, the shortage of fuel has put an additional strain on the availability of emergency transport.
A ‘stop-gap’ measure, such as the NASG, is critical to saving the lives of women.
Integrating the NASG into existing protocols
Although the NASG has been proven effective in a variety of studies, including a randomized controlled trial (RCT) conducted in Zimbabwe and Zambia, there was limited understanding of how effective its use was in rural, low-resource settings.
Working with MOHCC and with the support of the Embassy of Ireland, CHAI helped introduce the NASG in 34 health facilities in the Hurungwe District in Mashonaland West Province and conducted a three-month evaluation to understand how the integration of the NASG into Zimbabwe’s obstetric emergency response within the public health system contributed to its reach, effectiveness, adoption, implementation, and maintenance.
Results of the evaluation showed the NASG was used in 90 percent of potential applications and that there were 50 percent fewer maternal deaths compared to the same time period a year earlier – including no deaths from postpartum hemorrhage. Anecdotally, health workers reported its ability to almost immediately reverse shock from obstetric hemorrhage.
The MOHCC, with support from CHAI, used the results of the study to enable the roll out of the NASG to the rest of the 176 facilities in the province, as well as five central hospitals. CHAI also supported the MOHCC and its partners to integrate NASG use into national protocols, guidance, and mentorship.
A ‘stop-gap’, such as the NASG, is critical to saving the lives of women.
This work came at a particularly useful time for Hurungwe District which had one functional ambulance at the time of the study (which was often non-functional and/or had no fuel). The introduction of the NASG gave health workers peace of mind as it reduced the urgency for transport to higher levels of care.
What’s next?
The work done in Zimbabwe will be an instrumental addition to the growing global body of evidence that the NASG is a life-saving addition to the obstetric toolkit.
At the same time, the introduction of the NASG in Hurungwe District and its subsequent roll out to the rest of the province is helping lay the groundwork for a national scale up.
Read more: PLOS ONE article on NASG introduction in a rural district in Zimbabwe
“The aim of the process evaluation was to understand how contextual factors of the process of integrating the NASG into the obstetric emergency response within the public health system in Zimbabwe contributes to its reach, effectiveness, adoption, implementation, and maintenance,” Dr. Bernard Madzima, the Director of Family Health at the time, told The Herald.
The MOHCC has since adopted the NASG as part of the package for management of third stage labor complications, which will be rolled out nationally in the coming months.
CHAI helped the government draft the national scaleup plan and prepare health workers on the ground with NASG trainings for maternity ward doctors and nurses, midwives, and Reproductive Health Officers in central hospitals.
Now, we need other development-oriented partners to assist and channel resources and support to the implementation of the garment nationally. Together we can continue to save lives, one woman at a time.
