Safe Motherhood

The October 2013 Safe Motherhood newsletter is available now! Click here to view.

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What is Safe Motherhood?
The Safe Motherhood Initiative is a worldwide effort that aims to reduce the number of deaths and illnesses associated with pregnancy and childbirth. Ways to achieve safe motherhood include:

    • Skilled attendance at all births
    • Access to quality emergency obstetrical care
    • Access to quality reproductive health care, including family planning and safe post-abortion care

Why Safe Motherhood?
Maternal mortality is a major cause of death and disability among women of reproductive age. 500,000 women die every year from complications related to childbearing. Many more women are injured, some severely, from childbirth complications. Maternal mortality and morbidity adversely affect the health and welfare of children, families, and communities.

Where is Safe Motherhood relevant?
Maternal mortality is the leading cause of death for women of reproductive age in Asia and Latin America. It is the second leading cause of death for women in Africa. Causes of maternal mortality include:

    • Hemorrhage
    • Sepsis
    • Obstructed Labor
    • Complications of Abortion

Advances in Hemorrhage Prevention and Treatment
Hemorrhage is the leading cause of maternal mortality, but advances in the prevention and treatment of hemorrhage are being made and include:

    • Recognition of when normal blood loss of pregnancy becomes too much
    • Transportation and referral systems to get women from home or a primary health care center to emergency obstetric care
    • Active management of third stage labor
    • Use of uteronics for prevention and treatment of uterine atony
      • Misoprostol oral and/or rectal
      • Oxytocin
      • Oxytocin in Uniject
    • Non-pneumatic Anti-Shock Garment to treat shock, resuscitate, stabilize, and prevent further bleeding in women with ANY form of obstetric hemorrhage

The Non-pneumatic Anti-Shock Garment (NASG)

What is it?
The NASG is a simple neoprene and Velcro device much like the bottom half of a wet suit split down the middle.

How does it work?
When in shock, the brain, heart, and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs. The NASG reverses shock by returning blood to the vital organs. This will restore the woman’s consciousness, pulse, and blood pressure. Additionally, the NASG slows blood flow to the lower body and decreases bleeding.

How is the NASG used?
After a simple training session, anyone can put the garment on a bleeding woman. Once her bleeding has stopped, she can be safely transported from a home birth or primary health care center to a referral facility for emergency obstetrical care. 

Results of NASG studies

We have synthesized the findings from five NASG studies conducted at tertiary care facilities into a meta-analysis, a statistical method for examining and combining data from multiple studies.  These five NASG studies were:  Egypt (2006); Nigeria and Egypt combined (2010); Lusaka, Zambia and Harare, Zimbabwe combined (2012); Copperbelt, Zambia (2012); and the Pathfinder India RAKSHA implementation project (2012). (See reference list for full citations.)  Combining the data from these different studies in a meta-analysis provided a larger sample size, and thus greater statistical “power”. Having adequate statistical power means that the sample is big enough to avoid missing a real difference between the treatment (NASG) and the non-treatment groups because the sample size is too small.

In addition, by combining our results we examined how the NASG works over a range of countries, from relatively middle income settings with lower maternal mortality (Egypt) to very low resource settings with high maternal mortality (Copperbelt, Zambia), and from strictly monitored, highly trained researchers/clinicians (Egypt), to implementation projects with little research supervision (India).  All of the studies used a quasi-experimental design, which means that women were not randomized.  Four studies had a pre-intervention/intervention design, and in the India RAKSHA Project, clinicians either used the NASG or did not use it in the same facilities on similar patients.

The five studies included 3,561 women with severe obstetric hemorrhage and hypovolemic shock; 1,614 (45%) were treated with standard care PLUS the NASG and 1,947 (55%) received standard care only.  Of these 3,561 women, about one-third (n=1,227) of women were in the most severe shock, with evidence of decreased oxygen to their brain, heart and lungs.

The pooled results for all women showed a 38% decrease in mortality among women who received the NASG, while the reduction in mortality was even greater for those in the worst condition, at 63%.  Further, data from all studies demonstrated no safety issues from using the NASG.

META ANALYSIS CONCLUSION:  At the tertiary hospital level, the NASG plus standard care significantly reduces mortality, especially for women in more severe shock. The Odds Ratio for mortality for all participants was OR 0.62, 95% CI 0.44-0.86, and OR 0.37, 95% CI 0.25-0.56 for the most severe cases.

Current trials of the NASG

A Randomized Cluster Trial is currently underway in three sites in Zambia and Zimbabwe. This research project started in 2007 with the objective of gathering high level evidence of the efficacy of the NASG when applied at the lowest level of the health care system the primary community health center, before transferring the woman to referral hospital. Results of this study are expected in 2013.

Bixby Center Safe Motherhood Projects

    1. NASG studies in Egypt, Nigeria, Zimbabwe, and Zambia
    2. Continuum of Care PPH Projects in Nigeria and India
    3. Millennium Development Villages in Ghana, Kenya, Ethiopia, Uganda, and Nigeria
    4. Comparison of two strategies for preventing PPH:  Secondary prevention vs. primary prevention with misoprostol at the community level

For more information on Safe Motherhood Programs or the NASG, please go to  

Safe Motherhood Publications

2012 Stenson, AL, Miller, S, Lester, F.  The Mechanisms of Action of the Non-pneumatic Anti-Shock Garment (NASG).  Book Chapter, Book Chapter, in International Federation of Obstetrics and Gynecology (FIGO) Book, Postpartum Hemorrhage:  New Thoughts, New Approaches, Editors: C. B-lynch, A. LaLonde, L. West. Sapiens Publications, UK. ISBN 978-0-9552282-7-8

2012 Miller S, Morris J, Fathalla M, Ojengbede O, Youssif-MM, Hensleigh, P.   Non-pneumatic Anti-Shock Garments: Clinical Trials and Results.  Book Chapter, in International Federation of Obstetrics and Gynecology (FIGO) Book, Postpartum Hemorrhage:  New Thoughts, New Approaches, Editors: C. B-lynch, A. LaLonde, L. West. Sapiens Publications, UK. ISBN 978-0-9552282-7-8

2012 Turan, JM, Hatcher, AH, Medema-Wijnveen, J, Onono, M, Miller, S, Bukusi, EA, Turan, B, Cohen, C. The Role of HIV-Related Stigma in Utilization of Skilled Childbirth Services in Rural Kenya: A Prospective Mixed-Methods Study. PLoS Med, 2012; 9(8): e1001295. doi:10.1371/journal.pmed.1001295

2011 Stenson, A., Lester, F., Meyer, C., Morris, J., Vargas, V., Miller, S. The Non-pneumatic Anti-Shock Garment: How Applier Strength and Body Mass Index Affect External Abdominal Pressure. Open Womens Health J, 2011;5, 33-7

2011 Morris, J., Stenson, A., Theiss-Nyland, K., Coelius, R., Tudor, C., Cuomu, M., Miller, S. Preventing Postpartum Hemorrhage: Comparing ZB11, a Traditional Tibetan Medicine, to Misoprostol. International Journal of Childbirth, 2011; 9(3):159-170

2011 Fathalla, MF, Youssif, MM, Meyer, C., Camlin, C., Turan, J., Butrick, E., Miller, S. Non-Atonic Obstetric Hemorrhage:  Effectiveness of the Non-pneumatic Anti-Shock Garment in EgyptISRN Obstet. Gynecol, vol 2011, article ID 179349; doi 10.5402/2011/179349

2011 Ojengbede, O., Galadanci, H., Morhason-Bello, IO, Nsima, D., Camlin, C., Morris, J., Butrick, E., Meyer, C., Mohammed, AI, Miller, S. The Non-pneumatic Anti-Shock Garment for Postpartum Haemorrhage in Nigeria. African Journal of Midwifery and Women’s Health, 5(3):135-9

2011 Coelius, R, Stenson, A, Morris, J, Cuomu, M, Tudor, C, Miller, S. The Tibetan Uterotonic Zhi Byed 11: Mechanisms of Action, Efficacy, and Historical Use for Post-Partum Hemorrhage. Evid Based Complement Alternat Med, vol 2012 article ID 794164, doi: 10.1155/2012/794164

2011 Morris, J; Meyer, C; Fathalla, MF; Youssif, MM; Al-Hussaini, TK; Camlin, C; Miller, S. Treating Uterine atony with the Anti-Shock garment in Egypt. African Journal of Midwifery & Women's Health. 5(1):37-42 (January 2011)

2011 Lester F; Stenson A; Meyer C; Morris, J; Vargas, J; Miller, S Impact of the Non-pneumatic Antishock Garment on pelvic blood flow in healthy postpartum women. Am J Obstet Gynecol, In Press. DOI:10.1016/j.ajog.2010.12.054

2011 Fathalla MF, Youssif MM, Meyer C, Camlin C, Turan J, Morris JL, Butrick E, Miller S. Non-Atonic Obstetric Haemorrhage: Effectiveness of the Non-pneumatic Anti-Shock Garment in Egypt. ISRN Journal of Obstetrics and Gynecology, vol 2011, article ID 179349; doi 10.5402/2011/179349

2010 Ojengbede, O., Morhason-Bello, IO, Galadanci, H., Meyer, C., Nsima, D., Camlin, C., Butrick, E., Miller, S. Assessing the Role of the Non-pneumatic Anti-Shock Garment (NASG) in Reducing Mortality from PPH in Nigeria. Gynecol Obstet Invest. 71:66-72.

2010 Stenson, A., Kapungu, C., Geller, S., Miller, S. Navigating the Challenges of Global Reproductive Health Research. 2010 J Womens Health Nov;19 (11):2101-7.

2011 Turan, J; Ojengbede, O; Fathalla, M; Mourad-Youssif, M; Morhason-Bello, IO; Nsima, D; Morris, J; Butrick, E; Martin, H; Camlin, C;, Miller, S. Positive Effects of the Non-pneumatic Anti-shock Garment on Delays in Accessing Care for Postpartum and Postabortion Hemorrhage in Egypt and Nigeria. J Womens Health 20:1. DOI: 10.1089

2010 Miller, S., Fathalla, M., Ojengbede, O., Camlin, C., Mourad-Youssif, M., Morhason-Bello, IO, The Non-pneumatic Anti-Shock Garment for Obstetric Hemorrhage Stabilization in Egypt and Nigeria. BMC Pregnancy Childbirth, 10:64.

2010 Mourad-Youssif , M., Ojengbede, O., Meyer, C., Fathalla, M., Morhason-Bello, IO, Galadanci, H., Camlin, C., Nsima D., Al Hussaini., T, Butrick, E., Miller, S., Can the Non-pneumatic Anti-Shock Garment (NASG) Reduce Adverse Maternal Outcomes from Postpartum Hemorrhage? Evidence from Egypt and Nigeria. Reprod Health 7:24.

2010 Turan JM, Bukusi EA, Onono M, Holzemer WL, Miller S, Cohen CR. HIV/AIDS Stigma and Refusal of HIV Testing among Pregnant Women in Rural Kenya: Results from the MAMAS Study. 2010 AIDS Behav Online First, 9 September DOI 10.1007/s10461-010-9798-5.

2010 Sutherland, T., Meyer, C., Bishai, D., Geller, S., Miller, S. Community-based distribution of misoprostol for prevention of treatment of PPH: Cost effectiveness, mortality and morbidity reduction analysis. IJGO Mar 108(3):289-94.

2010 Browne, M., Jacobs, M., Miller, S. Perineal Trauma in Nulliparous Women Delivered at a Community Hospital: Reduced Risk in Births Attended by Certified Nurse-Midwives. J Midwifery Womens Health 55(3):243-9.

2010 Berdichevsky, K., Tucker, C., Martinez, Miller, S. Acceptance of a New Technology for Management of Obstetric Hemorrhage: A Qualitative Study from Rural Mexico. Health Care Women Int. 31(5):444-57.

2010 Miller, S., Fathalla, M., Youssif, M., Turan, J., Camlin, C., Al-Hussaini, T., Butrick, E., Meyer, C. A Comparative Study of the Non-Pneumatic Anti-Shock Garment (NASG) for the Treatment of Obstetric Hemorrhage in Egypt. IJGO 109, pp. 20-24.