Safe Motherhood


Check out the September 2011 Safe Motherhood Programs Newsletter!

Previous email updates are available here.


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
In the pilot Egypt study, bleeding of women who were suffering from various forms of obstetrical hemorrhage (e.g. ruptured ectopic pregnancy, post-abortion complications, post-partum hemorrhage) and were put in the NASG decreased by 50% as compared with women in the control group who did not use the NASG.

In pre-intervention/ NASG intervention studies in Nigeria and Egypt, n= 1442 women with obstetric hemorrhage (from all etiologies) and hypovolemic shock, measured blood loss was reduced by 50% (p<0.001), emergency hysterectomies were reduced from 8.9% to 4.0% (RR=0.44, 95% CI 0.23-0.86), morbidities were reduced from 3.7% to 0.7% (RR=0.20, 95% CI 0.08-0.50) and mortalities were reduced from 6.3% to 3.5% (RR=0.56, 95% CI 0.35-0.89). The Number Needed to Treat for benefit (NNTb) is 1 in 20 for avoiding an emergency hysterectomy, 1 in 34 for morbidity and 1 in 36 for avoiding a mortality.

A multiple logistic regression model of factors predictive of mortality and morbidity showed that women in a worse condition on study entry (MAP ≤60mmHg) had eight times the odds of mortality (aOR 8.42, 95%CI 3.13-22.66) relative to those with MAP >60. The NASG intervention was significantly associated with 55% lower odds of mortality (aOR 0.45, 95% CI 0.27-0.77). In the model for morbidity, women with MAP ≥60 had almost five times the odds of morbidity (OR 4.83, 95% CI 1.80-12.94) and women with a parity of >5 had over two times the odds of a morbidity. The NASG intervention was significantly associated with 80% lower odds of morbidity (OR 0.20, 95% CI 0.07-0.56). An analysis stratified by severity of condition as determined by MAP showed the NASG was significantly associated with reduced odds of death in women with MAP <60 (aOR 0.46, 95% CI 0.26-0.80) but not in women with MAP ≥60 (aOR 0.68, 95% CI 0.14-3.22).


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. To date, more than 3000 women have been treated with the NASG. 


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. Infectious diseases and maternal health in Kenya
    5. Peri-natal infections among pregnant women in Afghanistan
    6. Near-miss maternal mortality in Afghanistan
    7.  Uterotonics for Prevention of Postpartum Hemorrhage studies in Tibet
    8. 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 www.lifewraps.org.  

Safe Motherhood Publications

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. In Press

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.

2009 Miller, S. (as guest editor).  Cultural Humility is the First Step to Becoming Global Providers. Editorial column; Journal of Obstetric, Gynecologic and Neonatal Nursing (JOGNN) 38(1):92-3.

2009                Klein S, Miller, S, Thompson, F.  A Book for Midwives, 3rd Edition. Berkeley, CA:  Hesperian Foundation.

2009                Miller, S., Ojengbede, O, Turan, J., Morhason-Bello, IO, Martin, H., Nsima, D. A Comparative Study of the Non-pneumatic Anti-Shock Garment (NASG) for the Treatment of Obstetric Hemorrhage in Nigeria. IJGO 107(2):121-125.

2009                Samson, O., Nvarro, S., Khan, A., Hearst, N., Raine, T., Gold, M., Miller, S., Thiel de Bocanegra, H. Barriers to Adolescents’ Getting Emergency Contraception through Pharmacy Access in California: Differences by Language and Region. Perspect Sex Reprod Health 41(2):110-118.

2009                Haider, S., Todd, C., Ahmadzai, M., Rahimi, S., Azfar, P., Morris, J., Miller, S. Childbearing and Contraceptive Decision-Making amongst Afghan Men and Women: A Qualitative Analysis. Health Care Women Int 30 (10):935-53.

2009                Miller, S., Tudor, C., Thorsten, V., Nyima, Kalyang, Sonam, Lhakpen, Droyoung, Quzong, K., Dekyi, T., Hartwell, T., Wright, L., Varner, M. Randomized Double Masked Trial of Zhi Byed 11, a Tibetan Traditional Medicine, Versus Misoprostol to Prevent Postpartum Hemorrhage in Lhasa, Tibet. J Midwifery Womens Health 54:133-141.

2009                Le, P, Miller, S. Perinatal Health Communication Preferences among Women in Rural Tibet. J Obstet Gynecol Neonatal Nurs (JOGNN) 38(1):108-117.

2008                Miller, S. (as guest editor) Editorial: Responding to Women’s HIV and STI Risk in the Developing World. J Obstet Gynecol Neonatal Nurs (JOGNN) 37(5)586-7.

2008                Todd, CS, Isley, MM, Ahmadzai, M., Azfar, P., Atiqzai, F.,Smith, JM, Ghazanfar, SA, Strathdee, SA, Miller, S. Cross-sectional analysis of factors associated with prior contraceptive use among hospitalized obstetric patients in Kabul, Afghanistan. Contraception 78(3):249-56.

2008                Todd, C., Ahmadzai, M., Atiqzai, F., Miller, S., Smith, J., Ghazanfar, S., Strathdee, S. Seroprevalence and Correlates of HIV, Syphilis, And Hepatitis B and C Infection among Intrapartum Patients in Kabul, Afghanistan. BMC Infectious Diseases 8:119  doi:10.1186/1471-2334-8-119.

2008                Turan, J. M., Miller, S., Bukusi, E. A., Sande, J. and Cohen, C. R. (2008)'HIV/AIDS and maternity care in Kenya: how fears of stigma and discrimination affect uptake and provision of labor and delivery services, AIDS Care. 20(8)938 – 45.

2008                Geller, S, Adams, MG, Miller, S, A Continuum of Care Model for Postpartum Hemorrhage, International Journal of Fertility & Women's Medicine. 52(2-3)97-105.

2008                Miller, S, Tudor, C, Thorsten, V, Nyima, Sonam, Droyoung, Wright, L, Varner, M. Comparison of maternal and newborn outcomes of Tibetan and Han Chinese delivering in Lhasa, Tibet. J Obstet Gynaecol Res. 34(6)986-93.

2008                Turan, J, Bukusi, E, Cohen, C, Sande, J, Miller, S. Effects of HIV/AIDS on maternity Care Providers on Labor and Delivery Wards in Kenya. J Obstet Gynecol Neonatal Nurs (JOGNN) 37, 588-595.

2008                Miller, S, Martin, H, Morris, J. Anti-shock Garment in Postpartum Haemorrhage.  Best Pract Res Clin Obstet Gynaecol. 22(6) 1057-74. 

2007                Miller, S, Ojengbede A, Turan J, Ojengbede O, Butrick E, Hensleigh, P.  Anti-Shock Garments for Obstetric Hemorrhage. Current Women’s Health Reviews, 3(1):3-11.

2007                Miller, S, Tudor, C, Nyima, Thorsten, V, Sonam, Droyoung, Craig, S, Le, P, Wright, L, Varner, M. Maternal and neonatal outcomes of hospital vaginal deliveries in Tibet. Int J Gynaecol Obstet, 98:217-21.

2007                Miller, S, Butrick, E, Turan, J, Ojengbede, O, Morhason-Bello, IO, Galadanci, H, Martin, H, Fabamwo, A, Solanke, O, Awwal, M, Ojengbede, A, Hensleigh, P. The Anti-Shock Garment for Post-Partum and Post-Abortion Hemorrhage in Nigeria. Conference Proceedings: Abstracts from Research Forums Presented at the ACNM 52nd Annual Meeting J Midwifery Womens Health, 52(5):531-535.

2007                Miller, S, Turan, JM, Dau, K, Fathalla M, Mourad M, Sutherland, T, Hamza, S, et al. Decreasing Maternal Mortality from Hypovolemic Shock in Low Resource Settings: the Non-pneumatic Anti-Shock Garment (NASG). Global Public Health Journal, 2(2);110-24.

2007                Adams, V, Miller, S, Craig, S, Le, PV, Samen, A, Sonam, Nyima, Droyoung, Varner, M.  Informed Consent in Cross-Cultural Perspective:  The Case of Clinical Research in the Tibet Autonomous Region, PRC. Culture Medicine and Psychiatry, 31:445-472.

2007                Miller, S, Le, P, Craig, S, Adams, A, Tudor, C, Sonam, Nyima, Droyoung, Tshomo, M, Lhakpen, Varner, M. How to Make Consent Informed: Possible Lessons from Tibet. IRB: Ethics & Human Research, 29(6):7-14.

2006                Miller, S, Hamza, S, Bray E, Gipson R, Nada, K, Fathalla, M, Mourad, M, et al. First Aid for Obstetrical Hemorrhage: The Pilot Study of the Non-pneumatic Anti-Shock Garment (NASG) in Egypt. BJOG, 113(4):424-9.

2006                Miller, S, Turan, JM, Ojengbede A, Ojengbede, O, Fathalla, M, Morhason-Bello, IO, Mourad, M, Galandanci, H, Hamza, S, Awaal, M, Akinwuntan, A, Mohammed AI, McDonough, L, Dau, K, Butrick, E, and Hensleigh, P. The Pilot Study of the Non-pneumatic Anti-Shock Garment (NASG) in Women with Severe Obstetric Hemorrhage: Combined Results from Egypt and Nigeria. Int J Gynaecol Obstet, 94(S3):s43-s44.

2006                Tudor, C, Miller, S, Nyima, Sonam, Varner, M. Preliminary progress report: Randomized double blind trial of Zhi Byed 11, a Tibetan traditional medicine, versus misoprostol to prevent postpartum hemorrhage in Lhasa, Tibet. Int J Gynaecol Obstet, 94(S3):s27-s29.

2006                Miller, S, Hensleigh, P. Non-pneumatic Anti-shock Garment for Obstetric Hemorrhage. 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.

2006                Miller, S, Turan, JM, Ojengbede A, Ojengbede, O, Fathalla, M, Morhason-Bello, IO, Mourad, M, Galandanci, H, Hamza, S, Awaal, M, Akinwuntan, A, Mohammed AI, McDonough, L, Dau, K, Butrick, E, and Hensleigh, P.  The Pilot Study of the Non-pneumatic Anti-Shock Garment (NASG) in Women with Severe Obstetric Hemorrhage: Combined Results from Egypt and Nigeria. Evidence Based Interventions to Prevent Postpartum Hemorrhage: Translating Research into Practice, Goa, India, Conference Proceedings.