To determine the optimal vital sign predictor of adverse maternal outcomes in women with hypovolemic shock secondary to obstetric hemorrhage and to develop thresholds for referral/intensive monitoring and need for urgent intervention to... more
To determine the optimal vital sign predictor of adverse maternal outcomes in women with hypovolemic shock secondary to obstetric hemorrhage and to develop thresholds for referral/intensive monitoring and need for urgent intervention to inform a vital sign alert device for low-resource settings. We conducted secondary analyses of a dataset of pregnant/postpartum women with hypovolemic shock in low-resource settings (n = 958). Using receiver-operating curve analysis, we evaluated the predictive ability of pulse, systolic blood pressure, diastolic blood pressure, shock index, mean arterial pressure, and pulse pressure for three adverse maternal outcomes: (1) death, (2) severe maternal outcome (death or severe end organ dysfunction morbidity); and (3) a combined severe maternal and critical interventions outcome comprising death, severe end organ dysfunction morbidity, intensive care admission, blood transfusion ≥ 5 units, or emergency hysterectomy. Two threshold parameters with optimal rule-in and rule-out characteristics were selected based on sensitivities, specificities, and positive and negative predictive values. Shock index was consistently among the top two predictors across adverse maternal outcomes. Its discriminatory ability was significantly better than pulse and pulse pressure for maternal death (p<0.05 and p<0.01, respectively), diastolic blood pressure and pulse pressure for severe maternal outcome (p<0.01), and systolic and diastolic blood pressure, mean arterial pressure and pulse pressure for severe maternal outcome and critical interventions (p<0.01). A shock index threshold of ≥ 0.9 maintained high sensitivity (100.0) with clinical practicality, ≥ 1.4 balanced specificity (range 70.0-74.8) with negative predictive value (range 93.2-99.2), and ≥ 1.7 further improved specificity (range 80.7-90.8) without compromising negative predictive value (range 88.8-98.5). For women with hypovolemic shock from obstetric hemorrhage, shock index was consistently a strong predictor of all adverse outcomes. In lower-level facilities in low resource settings, we recommend a shock index threshold of ≥ 0.9 indicating need for referral, ≥ 1.4 indicating urgent need for intervention in tertiary facilities and ≥ 1.7 indicating high chance of adverse outcome. The vital sign alert device incorporated values 0.9 and 1.7; however, all thresholds will be prospectively validated and clinical pathways for action appropriate to setting established prior to clinical implementation.
Research Interests:
ABSTRACT Objective: To use a comparative cost-effectiveness approach with evidence from four countries to understand which facility level is most appropriate for implementing the non-pneumatic anti-shock garment (NASG) to decrease... more
ABSTRACT Objective: To use a comparative cost-effectiveness approach with evidence from four countries to understand which facility level is most appropriate for implementing the non-pneumatic anti-shock garment (NASG) to decrease maternal mortality associated with obstetric hemorrhage (OH). Methods: Two data sources were compared. We determined the cost-effectiveness of NASG application for women with hypovolemic shock from OH at the referral hospitals (RH) compared to standard of care within a two-phase intervention study of 6 RH in Egypt and Nigeria. To specify the cost-effectiveness of applying the NASG at the primary health clinic (PHC) level compared to the RH, we estimated random-effects models within a cluster-randomized control trial of 38 primary health clinics (PHC) in Zambia and Zimbabwe. Costs (blood transfusions, medications, etc.) and disability-adjusted life years (DALYs) were compared across the intervention scenarios. Results: The NASG was cost saving ($77-85 per woman in Egypt) or very cost-effective ($3-6 per DALY averted in Nigeria) when applied at the referral hospital level. Applying the NASG at PHCs instead of waiting until the RH was very cost-effective ($19 per DALY averted in Zambia). We were unable to ascertain if the NASG was cost-effective in Zimbabwe due to low number of maternal deaths. Cost savings were mainly due to reduced blood transfusions. Conclusion: For health systems with at least moderate clinical resource availability, the NASG is cost-effective or cost savings at the RH-level. Our evidence suggests that applying the NASG at the PHC is cost-effective for countries with a health system similar to Zambia.
Research Interests:
Research Interests:
The leading cause of maternal mortality is hemorrhage, generally occurring in the postpartum period. Current levels of PPH-related morbidity and mortality in low-resource settings result from institutional, environmental, cultural and... more
The leading cause of maternal mortality is hemorrhage, generally occurring in the postpartum period. Current levels of PPH-related morbidity and mortality in low-resource settings result from institutional, environmental, cultural and social barriers to providing skilled care and preventing, diagnosing and treating PPH. Conventional uterotonics to prevent PPH are typically not available or practical for use in low-resource settings. In such deliveries, most often taking place at home or in rural health centers, underestimation of blood loss leads to a delay in diagnosis. Deficiencies in communication and transportation infrastructure impede transfer to a higher level of care. Inability to stabilize a patient who is in hemorrhagic shock rapidly results in death. To address these individual factors, we propose a continuum of care model for PPH, including routine use of prophylactic misoprostol or other appropriate uterotonic, a standardized means of blood loss assessment, availability of a non-pneumatic anti-shock garment, and systemization of communication, transportation, and referral. Such a multifaceted, systematic, contextualized PPH continuum of care approach may have the greatest impact for saving women's lives. This model should be developed and tested to be region-specific.
Research Interests:
Research Interests:
ABSTRACT
Research Interests:
Although policies exist to promote safe motherhood in sub-Saharan Africa, maternal health has not improved, and may be deteriorating in some countries. We hypothesized that the adverse effects of HIV/AIDS on maternity services may... more
Although policies exist to promote safe motherhood in sub-Saharan Africa, maternal health has not improved, and may be deteriorating in some countries. We hypothesized that the adverse effects of HIV/AIDS on maternity services may contribute to poor maternal health. We conducted a pilot study in Kisumu, Kenya to explore: 1) how concerns related to HIV/AIDS affect uptake of maternity services and 2) the effects of HIV/AIDS on maternity workers, obstetric practices, and the quality of care. In-depth interviews with 17 health workers, 14 pregnant or postpartum women, 4 male partners, and 2 traditional birth attendants, and structured observations of 22 births, were conducted at four health facilities. Results suggest that considerations related to HIV/AIDS adversely affect both uptake and provision of maternity services. Participants reported that fears of HIV testing, involuntary disclosure of HIV status to others including spouses, and HIV/AIDS stigma are among the reasons that women...
Objective: To assess the cost-effectiveness of non-pneumatic anti-shock garments (NASG) for obstetric hemorrhage in tertiary hospitals in Egypt and Nigeria. Methods: Results from published pre-intervention/NASG-intervention phase trials... more
Objective: To assess the cost-effectiveness of non-pneumatic anti-shock garments (NASG) for obstetric hemorrhage in tertiary hospitals in Egypt and Nigeria. Methods: Results from published pre-intervention/NASG-intervention phase trials for women in severe shock (mean arterial pressure (MAP)<60) were standardized for 1,000 women. Clinical data included frequencies of health outcomes (mortality, major morbidity, severe anemia), and interventions to control bleeding (uterotonics, blood transfusions, hysterectomies). Costs (2010 international dollars) included the NASG, training, and clinical interventions. Changes in cost, morbidity, mortality, and disability-adjusted life years (DALYs) were used to calculate incremental cost-effectiveness ratios (ICERs; cost per DALY averted) for each country and study phase. We examined hysterectomies for all etiologies and for intractable uterine atony only. Results: Women with severe shock who received the NASG had lower mortality and morbidity...
Objective: To use a comparative cost-effectiveness approach with evidence from four countries to understand which facility level is most appropriate for implementing the non-pneumatic anti-shock garment (NASG) to decrease maternal... more
Objective: To use a comparative cost-effectiveness approach with evidence from four countries to understand which facility level is most appropriate for implementing the non-pneumatic anti-shock garment (NASG) to decrease maternal mortality associated with obstetric hemorrhage (OH). Methods: Two data sources were compared. We determined the cost-effectiveness of NASG application for women with hypovolemic shock from OH at the referral hospitals (RH) compared to standard of care within a two-phase intervention study of 6 RH in Egypt and Nigeria. To specify the cost-effectiveness of applying the NASG at the primary health clinic (PHC) level compared to the RH, we estimated random-effects models within a cluster-randomized control trial of 38 primary health clinics (PHC) in Zambia and Zimbabwe. Costs (blood transfusions, medications, etc.) and disability-adjusted life years (DALYs) were compared across the intervention scenarios. Results: The NASG was cost saving ($77-85 per woman in E...
To identify correlates of severe acute maternal morbidity (SAMM) in Kabul, Afghanistan. The present case-control study enrolled postpartum couples at four public maternity hospitals between September 2007 and December 2009. Eligibility... more
To identify correlates of severe acute maternal morbidity (SAMM) in Kabul, Afghanistan. The present case-control study enrolled postpartum couples at four public maternity hospitals between September 2007 and December 2009. Eligibility was determined by: spousal consent; SAMM criteria from chart review for cases; and matching by age, parity, and time since previous delivery for controls (uncomplicated deliveries). Staff administered questionnaires to women and their husbands separately. SAMM correlates were analyzed with conditional logistic regression in models including (proximate) and excluding (distal) care factors. Among 285 case and 285 control couples, the most frequent SAMM diagnoses were obstructed labor (104 [36.5%]) and hemorrhage requiring transfusion (102 [35.8%]). In both models, SAMM was associated with the husband having more than one wife (distal: adjusted odds ratio [aOR] 48.6, 95% CI 5.4-436.5; proximate: 141.8, 3.5-5819.0), prior stillbirth(s) (distal: 16.2, 6.1-42.9; proximate: 8.0, 2.9-22.4), and complications in a prior pregnancy (distal: 5.4, 95% CI 2.5-12.1; proximate: 7.1, 2.5-20.4). In the proximate model, SAMM was associated with visiting another facility before hospitalization (aOR 7.5, 95% CI 3.1-17.9), male-reported planned home delivery (5.5, 1.5-20.0), and provider-determined care-seeking (4.8, 1.6-14.9). Planned home delivery and referral to multiple facilities or by providers are factors associated with SAMM that are potentially amenable to intervention in Afghanistan.
Research Interests:
Research Interests:
Antenatal syphilis control is an integral component of reproductive health policies in most countries. In many of these countries, however, the existence of a health policy does not automatically translate into an effective health... more
Antenatal syphilis control is an integral component of reproductive health policies in most countries. In many of these countries, however, the existence of a health policy does not automatically translate into an effective health programme. We argue that neglecting to take into account the perspectives of all stakeholders when planning programmes may be the reason that functional and sustained interventions for antenatal syphilis are lacking. Stakeholders may include health policy decision-makers, programme managers, service delivery personnel (on whom implementation depends), as well as the pregnant women, families, and communities who will most benefit from the intervention. We describe how to undertake a multilevel assessment in order to identify stakeholders, identify interlinked perspectives, and analyse these perspectives within the socioeconomic, cultural and political environment within which an intervention is designed to be delivered. Using this multidisciplinary approach...
Research Interests:
Research Interests:
ABSTRACT Objective: To determine whether the non-pneumatic anti-shock garment (NASG) reduces maternal morbidity and mortality from uterine atony. Method: Women with uterine atony (blood loss of ≥1000 ml) and one clinical sign of shock... more
ABSTRACT Objective: To determine whether the non-pneumatic anti-shock garment (NASG) reduces maternal morbidity and mortality from uterine atony. Method: Women with uterine atony (blood loss of ≥1000 ml) and one clinical sign of shock were enrolled in a pre-intervention phase (n=169) and an intervention phase (n=269) at two referral facilities in Egypt. Differences in demographics, condition on study entry, treatment, and outcomes were examined. Relative risks and 95% confidence intervals (CI) were estimated for mean measured blood loss, emergency hysterectomy, and extreme adverse outcomes (EAO)—a combination of morbidity and mortality. Results: in the intervention phase, mean measured blood loss was significantly reduced, emergency hysterectomy was significantly decreased, and there were fewer EAOs (11% to 3% in the NASG phase, relative risk=0.28, 95% CI: 0.12–0.63). A subgroup analysis of only women in severe shock demonstrated similar trends. Conclusion: The NASG shows promise for reducing blood loss, emergency hysterectomies, and EAO from obstetric haemorrhage-related shock due to uterine atony.