title: Barriers and Facilitators to Scaling Up the Non-Pneumatic Anti-Shock Garment for Treating Obstetric Hemorrhage: A Qualitative Study.
abstract: BACKGROUND
  Obstetric hemorrhage (OH), which includes hemorrhage from multiple etiologies during pregnancy, childbirth, or postpartum, is the leading cause of maternal mortality and accounts for one-quarter of global maternal deaths. The Non-pneumatic Anti-Shock Garment (NASG) is a first-aid device for obstetric hemorrhage that can be applied for post-partum/post miscarriage and for ectopic pregnancies to buy time for a woman to reach a health care facility for definitive treatment. Despite successful field trials, and endorsement by safe motherhood organizations and the World Health Organization (WHO), scale-up has been slow in some countries. This qualitative study explores contextual factors affecting uptake.
  
  
  METHODS
  From March 2013 to April 2013, we conducted 13 key informant interviews across four countries with a large burden of maternal mortality that had achieved varying success in scaling up the NASG: Ethiopia, India, Nigeria, and Zimbabwe. These key informants were health providers or program specialists working with the NASG. We applied a health policy analysis framework to organize the results. The framework has five domains: attributes of the intervention, attributes of the implementers, delivery strategy, attributes of the adopting community, the socio-political context, and the research context.
  
  
  RESULTS
  The interviews from our study found that relevant facilitators for scale-up are the simplicity of the device, local and international champions, well-developed training sessions, recommendations by WHO and the International Federation of Gynecology and Obstetrics, and dissemination of NASG clinical trial results. Barriers to scaling up the NASG included limited health infrastructure, relatively high upfront cost of the NASG, initial resistance by providers and policy makers, lack of in-country champions or policy makers advocating for NASG implementation, inadequate return and exchange programs, and lack of political will.
  
  
  CONCLUSIONS
  There was a continuum of uptake ranging in both speed and scale. Ethiopia while not the first country to use the NASG has the most rapid scale-up, followed by Nigeria, then India, and finally Zimbabwe. Increasing the coverage of the NASG will require collaboration with local NASG champions, greater NASG awareness among clinicians and policymakers, as well as stronger political will and advocacy.
authors.affiliation: College of Global Public Health, New York University, New York, New York, United States of America.
authors.forename: Keely
authors.initials: K
authors.lastname: Jordan
authors.affiliation: Private Sector Healthcare Initiative, Global Health Group, University of California, San Francisco, United States of America.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Butrick
authors.affiliation: Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.
authors.forename: Gavin
authors.initials: G
authors.lastname: Yamey
authors.affiliation: Safe Motherhood Program, Bixby Center for Global Reproductive Health, University of California, San Francisco, United States of America.
authors.forename: Suellen
authors.initials: S
authors.lastname: Miller
mesh_terms: D005002:Ethiopia; D005260:Female; D006291:Health Policy / Q000191:economics / Q000331:legislation & jurisprudence*; D006801:Humans; D007194:India; D007743:Labor, Obstetric; D009549:Nigeria; D036801:Parturition; D011057:Politics; D006473:Postpartum Hemorrhage / Q000401:mortality / Q000473:pathology / Q000517:prevention & control*; D011247:Pregnancy; D011481:Protective Clothing / Q000191:economics / Q000600:supply & distribution*; D036301:Qualitative Research; D016019:Survival Analysis; D015030:Zimbabwe