Applying the RE-AIM framework in a process evaluation of the introduction of the Non-Pneumatic Anti-Shock Garment in a rural district of Zimbabwe

Abstract

The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that can halt and reverse hypovolemic shock secondary to obstetric hemorrhage. The World Health Organization recommended the NASG for use as a temporizing measure in 2012, but uptake of the recommendation has been slow, partially because operational experience is limited. The study is a process evaluation of the introduction of NASG in a public sector health facility network in rural Zimbabwe utilizing an adapted RE-AIM, categorizing observations into the domains of: reach, effectiveness, adoption, implementation and maintenance. The location of the study was Hurungwe district, where staff members of 34 health facilities at primary (31), secondary (2) and tertiary (1) levels of care participated. We found that all facilities became skilled in using the NASG, and that the NASG was used in 10 of 11 instances of severe hemorrhage. In the cases of hypovolemic shock where the NASG was used, there were no maternal deaths and no extreme adverse outcomes related to obstetric hemorrhage in the study period. Among the 10 NASG uses, the garment was used correctly in each case. Fidelity to processes was high, especially in regard to training and cascading skills, but revisions of the NASG rotation and replacement operating procedures were required to keep clean garments stocked. Clinical documentation was also a key challenge. NASG introduction dovetailed very well with pre-existing systems for obstetric emergency response, and improved clinical outcomes. Scale-up of the NASG in the Zimbabwean public health system can be undertaken with careful attention to mentorship, drills, documentation and logistics.

Operational demonstration and process evaluation of non-pneumatic anti-shock garment (NASG) introduction to the public health system of Northern Province, Zambia

“…Despite this gap among the study facilities, access to emergency transport for referral of patients was widely available, and this transportation was utilized to carry out NASG rotation, providing referring facilities with a clean NASG when they sent a patient wrapped in one. This lack of logistical challenge for NASG rotation relative to experience reported from other countries is worth noting [ 7 ].…”

“…A meta-analysis of observational studies showed a 48% mortality reduction among women who received the NASG, compared to the standard of care [ 6 ]. A process evaluation of the introduction of the NASG in public sector facilities in Zimbabwe showed healthcare workers were able to correctly use the garment after training and the public health system could afford to incorporate and maintain its use [ 7 ]. In cases of hypovolemic shock where a NASG was used, there were no maternal deaths and no extreme adverse outcomes, however, because the implementation period used in this evaluation was not of sufficient duration to estimate public health impact and was carried out in one country, a similar process evaluation of a longer period in a different geography enhances value of the literature on incorporation of NASG in LMIC maternity services.…”