European Journal of Cardiovascular Medicine

Maternal mortality remains an alarming global health concern, particularly in low- and middle-income countries (LMICs), where obstetric hemorrhage stands as the leading cause of maternal deaths. According to the World Health Organization, nearly 800 women die each day due to preventable maternal complications, with postpartum hemorrhage (PPH) accounting for over 27% of these fatalities, especially in Sub-Saharan Africa and South Asia[1,2]. PPH, defined as a blood loss of ≥500 mL after vaginal birth or ≥1000 mL after cesarean section, often results in hypovolemic shock if not managed promptly and effectively[3,4].

The Non-Pneumatic Anti-Shock Garment (NASG) is an innovative, low-cost, first-aid medical device designed to stabilize women suffering from obstetric hemorrhage. Composed of neoprene and Velcro, the NASG applies circumferential pressure to the lower body, thereby shunting blood from the lower extremities to vital organs such as the heart, lungs, and brain[5,6]. This temporizing measure provides critical time for patients to be transferred to facilities capable of delivering definitive care, significantly improving survival outcomes[7].

Initially introduced in countries like Nigeria and Ethiopia, the NASG has demonstrated promising results. For instance, between 2013 and 2015, implementation of NASG in selected Ethiopian health facilities led to an 80% reduction in maternal deaths due to hemorrhagic shock[6,8]. Despite such success stories, adoption of NASG remains limited and inconsistent, often due to factors such as poor availability, lack of provider training, and limited awareness among healthcare workers[9].

Moreover, a study by Pileggi-Castro et al. highlighted that NASG usage can reduce mortality by up to 50% in severe PPH cases if applied early, especially in resource-limited settings[3]. However, barriers such as absence of institutional protocols, logistical challenges, and cultural hesitancies persist, leading to underutilization even in high-burden areas[10].

Given these discrepancies in implementation and outcomes, this systematic review aims to consolidate current evidence regarding the role of NASG in managing hemorrhagic shock due to PPH, with an emphasis on utilization patterns, effectiveness, and associated barriers and facilitators in low-resource settings.

This study is a systematic review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.

Eligibility Criteria

Studies were included based on the following criteria:

• Population: Women of reproductive age experiencing postpartum hemorrhage (PPH), and/or healthcare providers involved in the use of NASG.
• Intervention: Use of the Non-Pneumatic Anti-Shock Garment (NASG) in PPH management.
• Outcomes: Primary outcome was the effectiveness of NASG in reducing hemorrhagic shock, maternal morbidity, and mortality. Secondary outcomes included NASG utilization rate and associated influencing factors (e.g., training, knowledge, availability).
• Study Types: Observational studies (cross-sectional, cohort, case-control), interventional trials, and systematic reviews.
• Setting: Studies conducted in low- and middle-income countries (LMICs), particularly in resource-constrained healthcare settings.
• Language and Timeframe: Studies published in English up to May 31, 2023.

Exclusion criteria included:

• Conference abstracts, letters to the editor, commentaries, and expert opinions without original data.
• Studies not focused on PPH or not involving NASG.
• Non-human studies or simulations without clinical application.

Search Strategy

A comprehensive literature search was conducted in the following databases:
PubMed, Embase, Web of Science, Scopus, Google Scholar, Hinari, ScienceDirect, and African Journals Online (AJOL). The search terms used included combinations of Medical Subject Headings (MeSH) and keywords as follows:

("non-pneumatic anti-shock garment" OR "NASG") AND ("postpartum hemorrhage" OR "obstetric hemorrhage") AND ("utilization" OR "effectiveness" OR "shock" OR "maternal mortality") AND ("healthcare providers" OR "maternity care") AND ("developing countries" OR "Ethiopia" OR "Africa").

Boolean operators "AND" and "OR" were applied appropriately. Filters were applied to include only human studies and articles in English. Additional records were identified through manual screening of reference lists of relevant articles.

Study Selection Process

All identified citations were exported into EndNote X7 reference management software. Duplicates were removed, and two independent reviewers screened the titles and abstracts. Full texts were assessed for eligibility based on predefined inclusion criteria. Disagreements were resolved through discussion or consultation with a third reviewer.

Data Extraction

A standardized data extraction form in Microsoft Excel was used to collect the following details:

• First author and year of publication
• Country and region of study
• Study design and setting
• Sample size and population characteristics
• NASG utilization rate or clinical outcome (e.g., maternal death reduction)
• Associated factors (e.g., training, availability, knowledge level)

Quality Assessment

The Joanna Briggs Institute (JBI) Critical Appraisal Checklists were applied to assess the methodological quality of the included studies. For observational studies, criteria such as sampling method, data collection, outcome measurement reliability, and confounding adjustment were considered. Studies were categorized as low, moderate, or high quality. Only moderate-to-high quality studies were included in the final synthesis.

Data Synthesis and Statistical Analysis

A narrative synthesis was conducted for all included studies, and meta-analysis was performed using STATA v15.1 for studies reporting NASG utilization rates. A random-effects model was employed to account for between-study variability. Heterogeneity was quantified using the I² statistic, with values above 50% considered substantial. Publication bias was assessed through funnel plot symmetry and Egger’s and Begg’s tests. Sensitivity analyses were performed using leave-one-out methods.

Fig 1: PRISMA flowchart

Study Selection and Characteristics

A total of 847 articles were retrieved through electronic and manual searches. After removing duplicates and screening titles and abstracts, 47 full-text articles were reviewed for eligibility. Eight studies, encompassing a combined total of 2690 healthcare providers, met the inclusion criteria and were included in the final analysis. Fig 1

As shown in Table 1, the studies were conducted in various regions of Ethiopia: three from Amhara, and one each from Addis Ababa, Oromia, Sidama, Tigray, and SNNPR. All studies employed cross-sectional designs, with one using a mixed-methods approach. Sample sizes ranged from 220 to 422 participants. The utilization rate of the NASG varied widely, with the highest in Tigray (64.2%) and the lowest in Sidama (30.7%).

Pooled Utilization of NASG

The meta-analysis using a random-effects model estimated the overall pooled utilization of NASG among healthcare providers to be 43.2% (95% CI: 35.88–50.52; I² = 93.5%; P < 0.001), indicating significant heterogeneity. The forest plot (not shown here) visually demonstrated variability in utilization across regions, reflecting disparities in implementation and access.

Factors Associated with NASG Utilization

Three key factors were found to be significantly associated with NASG utilization (see Table 2):

• Training on NASG: Healthcare providers who received training were 43 times more likely to utilize NASG compared to those without training (OR = 5.43; 95% CI: 3.13–9.44; P < 0.001).
• Availability of NASG: Facilities where NASG was readily available had 78 times higher odds of utilization (OR = 7.78; 95% CI: 4.29–14.09; P < 0.001).
• Knowledge of NASG: Providers with good knowledge of NASG were 61 times more likely to use the device (OR = 4.61; 95% CI: 2.95–7.18; P < 0.001).

Sensitivity Analysis

A leave-one-out sensitivity analysis was conducted to assess the robustness of the pooled utilization rate. As illustrated in Table 3, the removal of any single study did not substantially alter the pooled prevalence, which ranged between 41.8% and 43.6%. This indicates that no individual study disproportionately influenced the overall estimate, thereby reinforcing the consistency of findings across diverse settings.

Table 1: Characteristics of Included Studies

Table 2: Associated Factors and Odds Ratios (OR) for NASG Utilization

Table 3: Sensitivity Analysis of NASG Utilization

This systematic review highlights the critical role of the Non-Pneumatic Anti-Shock Garment (NASG) in managing postpartum hemorrhage (PPH), particularly in resource-limited settings such as Ethiopia. The pooled NASG utilization rate of 43.2% suggests a moderate but suboptimal adoption of this life-saving intervention across the studied regions. Despite recommendations from international bodies like WHO and FIGO supporting NASG use for hypovolemic shock, its real-world implementation remains inconsistent.

The regional variability in NASG utilization—ranging from 30.7% in Sidama to 64.2% in Tigray—may reflect disparities in policy implementation, healthcare infrastructure, training quality, and supply chain management. Similar heterogeneity has been reported in other LMICs, such as Nigeria, where utilization varied from 14.1% to 46.4% across states [11–13]. A study from Tanzania also reported a low usage rate of 26.7%, primarily due to limited awareness and availability [14].

The three significant determinants of NASG utilization identified—training, availability, and knowledge—underscore practical barriers to widespread adoption. The odds of usage were more than five times higher among trained healthcare providers, aligning with findings from Malawi and Nigeria, where lack of training and operational guidance were reported as major limitations [15,16]. Similar associations have been seen globally; Jordan et al. emphasized that consistent, context-specific training dramatically improves NASG application competency [5].

Availability of the device emerged as a strong predictor, with nearly eight-fold increased usage when NASG was present in the healthcare facility. This finding is consistent with UNICEF’s global assessment in 2020, which reported that unavailability of NASG remains a key bottleneck in maternal emergency preparedness in low-income countries [17]. A study in southwest Ethiopia further confirmed that the general shortage of medical devices hampers NASG implementation even in referral centers [18].

Knowledge among providers was the third strong predictor of utilization, indicating that even where NASGs are physically available, their use is limited by insufficient provider confidence and familiarity. This is particularly crucial because NASG application is technically simple and can be taught effectively at all levels of care, including primary health centers and ambulance teams [19,20].

Despite the promise NASG holds, the implementation gaps observed in this review reflect a need for a more integrated and system-wide approach. Lessons from successful maternal health interventions suggest that mere policy endorsements are insufficient. Operational scale-up must involve consistent procurement, decentralized distribution, simulation-based training, integration into emergency obstetric protocols, and community-based birth preparedness programs [21-25].

The strength of this review lies in its adherence to PRISMA methodology and its focus on both utilization magnitude and associated factors. However, several limitations must be acknowledged. All included studies were from Ethiopia, limiting generalizability. Furthermore, the reliance on cross-sectional observational studies prevents causal inference, and the high heterogeneity (I² = 93.5%) suggests underlying variability not fully explained by the available data.

The findings of this systematic review underscore the substantial life-saving potential of the Non-Pneumatic Anti-Shock Garment (NASG) in managing postpartum hemorrhage (PPH), a leading cause of maternal mortality, particularly in low-resource settings. Despite being endorsed by WHO and FIGO, the overall utilization of NASG remains limited, with a pooled usage rate of only 43.2% across the reviewed studies in Ethiopia.

Critical enablers of NASG adoption include structured training, consistent device availability, and provider knowledge. Facilities equipped with NASGs and staffed by trained, informed personnel are significantly more likely to implement the device effectively during obstetric emergencies. The review also highlights that NASG can effectively address the second and third delays in the "Three Delays Model"—delays in reaching and receiving appropriate care—thus bridging a major gap in emergency obstetric management.

Recommendations

1. Policy Integration

Ministries of Health in LMICs should formally include NASG in national emergency obstetric care guidelines, birth preparedness programs, and maternal survival strategies.

2. Training Programs

Pre-service and in-service training for midwives, nurses, and doctors should mandatorily include NASG application techniques. Simulation-based hands-on training should be reinforced at primary and tertiary levels.

3. Supply Chain Strengthening

Governments and donors should ensure uninterrupted availability of NASGs in all levels of maternity care, especially in rural and under-resourced regions. Buffer stock and distribution networks must be optimized.

4. Monitoring and Evaluation

Utilization of NASG should be added as a performance indicator within maternal health programs. Routine audits and follow-up on usage during PPH cases can help monitor real-world adherence and identify implementation bottlenecks.

5. Community Engagement

Birth preparedness programs and community health workers should raise awareness about the availability and benefits of NASG to improve early demand and referral compliance in high-risk pregnancies.

6. Operational Research

More implementation studies are needed from diverse geographic and cultural settings to assess cost-effectiveness, long-term outcomes, and user acceptability. Randomized trials and cohort studies should complement observational data.

By systematically strengthening these components, healthcare systems can leverage the NASG’s full potential to reduce maternal deaths from hemorrhagic shock—an achievable target aligned with Sustainable Development Goal 3.1.

1. World Health Organization. Maternal mortality: Levels and trends 2000 to 2020. Geneva: WHO; 2023. Available from: https://www.who.int/publications/i/item/9789240068759
2. World Health Organization. Maternal Mortality Fact Sheet. Geneva: WHO; 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
3. Pileggi-Castro C, Nogueira-Pileggi V, Tunçalp Ö, Oladapo OT, Vogel JP, Souza JP. Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage: a systematic review. Reprod Health. 2015;12:28.
4. Miller S, Hamza S, Bray EH, Lester F, Nada K, Gibson R, et al. Non-pneumatic anti-shock garment (NASG), a First-Aid device to decrease maternal mortality from Obstetric Hemorrhage: a Cluster Randomized Trial. PLoS One. 2013;8(10):e76477.
5. Jordan K, Butrick E, Yamey G, Miller S. Barriers and facilitators to scaling up the non-pneumatic anti-shock garment for treating Obstetric Hemorrhage: a qualitative study. PLoS One. 2016;11(3):e0150739.
6. Geltore TE, Hadaro TS, Oshine W, Bekele M, Foto LL. Predictors of labor pain management among pregnant women in Ethiopia: A systematic review and meta-analysis. Womens Health (Lond). 2024 Jan-Dec;20:17455057241275442. doi: 10.1177/17455057241275442. PMID: 39245922; PMCID: PMC11382248..
7. Escobar MF, Füchtner C, Carvajal JA, Granados M, Miller S, et al. Experience in the use of non-pneumatic anti-shock garment (NASG) in the management of postpartum haemorrhage with hypovolemic shock in Colombia. Reprod Health. 2017;14(1):58.
8. Non-pneumatic Anti-shock Garment (NASG) Technical Bulletin. 2020. Available from: https://www.unicef.org/supply/media/5576/file/NASG-technical-bulletin.pdf
9. Akinyemi OO, Abiodun-Ojo OE, Owolabi BA. Factors influencing utilisation of non-pneumatic anti-shock garment in the management of Postpartum Haemorrhage among midwives in Ekiti State. Int J Public Health Pharmacol. 2022;7(3):22–30.
10. Breakthrough RESEARCH. Perception and use of NASG for PPH in Malawi. Washington DC: Population Council; 2020.
11. Onasoga O, Duke E, Danide I, Jack-Ide I. Midwives’ knowledge and utilization of NASG in reducing complications of PPH in Bayelsa state, Nigeria. Int J Reprod Contracept Obstet Gynecol. 2015;4(4):977–81.
12. Ohaeri BM, Ogbeye GB. Assessment of utilisation of NASG in PPH among midwives in Ondo State, Nigeria. Int J Caring Sci. 2017;10(1):327.
13. Oyedele M, Aina F, Dada S, Aina D. Knowledge and utilization of NASG for PPH management among midwives in Ogun State, Nigeria. Babcock Univ Med J. 2020;3(1):59–66.
14. Mbaruku G, Therrien MS, Tillya R, et al. Implementation project of the NASG and m-communication to enhance maternal health in Tanzania. Reprod Health. 2018;15:177.
15. Ademe BW, Tebeje B, Molla A. Availability and utilization of medical devices in hospitals, Southwest Ethiopia: a case study. BMC Health Serv Res. 2016;16:287.
16. Escobar MF, Füchtner C, Carvajal JA. NASG for PPH and hypovolemic shock in Colombia: practical experience. Reprod Health. 2017;14(1):58.
17. Miller S, Belizán JM. A promising device to save maternal lives associated with obstetric hemorrhage: the NASG. Reprod Health. 2015;12:26.
18. Magwali TL, Ndlovu M, Mafuva G, et al. Applying the RE-AIM framework to evaluate NASG in Zimbabwe. PLoS ONE. 2021;16(5):e0251908.
19. FIGO Safe Motherhood and Newborn Health Committee. Non-pneumatic anti shock garment to stabilize women with hypovolemic shock. Int J Gynecol Obstet. 2015;128(3):194–5.
20. Miller S, et al. NASG: Clinical trials and results. In: Comprehensive Textbook of Postpartum Hemorrhage. 2nd ed. London: Sapiens Publishing; 2012. p. 318–30.
21. Taye BT, Zerihun MS, Kitaw TM, et al. Utilization of NASG for obstetric hemorrhage among healthcare providers in North Shewa Zone. Front Public Health. 2023;11:1052885.
22. Yeshitila YG, Bante A, Aschalew Z, Afework B, Gebeyehu S. Utilization of NASG for PPH management in southern Ethiopia. PLoS ONE. 2021;16(10):e0258784.
23. Desta AA, Berhane M, Woldearegay TW. Non-utilization of NASG for PPH in Northern Ethiopia. Int J Womens Health. 2020;12:943–51.
24. Bekele M, Fikre R, Alelign Y, Geltore TE. Utilization of NASG in Sidama Region, Ethiopia. J Pregnancy. 2023;2023:6129903.
25. Ketema WG, Alemu G, Zewdie M, Tessema B. Knowledge and utilization of NASG in South Wollo Zone, Ethiopia. Obstet Gynecol Int. 2023;2023:8247603.