Gaje Ganewa Photo: Chris de Bode/UNFPA

11 October 2007

KATSINA STATE, Nigeria — Dr. David Nsimma works quickly. His patient, Maryama Aliyu, is bleeding internally and slipping into shock. Pregnancy-related injuries are causing blood to seep away from her vital organs and pool in her lower body. If Dr. Nsimma does not find a way to staunch the flow of blood, Maryama's organs may fail, and she could die.

Just three months ago, a woman in her condition here at Katsina General Hospital in northern Nigeria would have had a poor chance of survival. Today, however, Dr. Nsimma looks calm, even confident. He and his colleague, Dr. Natalya Adamu, are fitting Maryama’s legs and waist into a thick blue neoprene outfit. Known as a non-pneumatic anti-shock garment, or ASG for short, this relatively simple but effective device is part of a study (see below) by the University of California and the University College Hospital in Ibaden, Nigeria with support from the MacArthur Foundation. And it may very well save Maryama’s life.

A relatively simple life-saving intervention

By applying pressure to the lower half of the body, the ASG prevents blood from concentrating in the lower half of the body and forces it upward, so it can nourish the heart, brain, lungs and other vital organs. In addition to warding off shock, this process keeps the patient stable while she waits for a blood transfusion.

Within the short few months of this intervention, we have seen dramatic results. --Dr. David Nsimma

“Within the short few months of this intervention, we have seen dramatic results,” says Dr. Nsimma, sitting down in his office at the hospital now that Maryama has stabilized. “In the past, we would lose these women.”

Nigeria, like much of sub-Saharan Africa, is a dangerous place to become a mother. The risk of dying in childbirth is a hundred times higher than what it is in most high-income countries. Each year, around 37,000 Nigerian women die bringing children into the world. That is more than 100 deaths a day from preventable causes.

These numbers reflect a lack of adequate obstetric care for women, a problem that the Nigerian Ministry of Health and UNFPA are working together to resolve. UNFPA has donated beds, medicines, surgical equipment and contraceptives to maternal hospitals and clinics throughout northern Nigeria. Thanks in part to advocacy work by UNFPA, maternal health services have been entirely free in Katsina State since 2004. This removes one of the greatest barriers to women obtaining proper obstetric care here in Nigeria, one of the 20 least-developed countries in the world.

A woman receiving treatment with the anti-shock garment at the General Hospital of Katsina. Photo: Chris de Bode/UNFPA

The work to help pregnant women does not stop at these preventive measures. One of the primary goals of the partnership is to enhance the ability of medical personnel to save the lives of women who are already experiencing an emergency situation, such as an obstetric haemorrhage. To do so, UNFPA supports the Emergency Life-Saving Skills Initiative (ELSSI). This course trains doctors and nurses working in the maternity units of hospitals and health centres in the proper handling of various obstetric emergencies. It includes a section on the use of the anti-shock garment, as well as on another important life-saving breakthrough: magnesium sulfate.

Another important breakthrough

Injections of magnesium sulfate are a highly effective treatment for eclampsia, a dangerous complication of pregnancy. Though its exact cause is unknown, eclampsia is both more common and more dangerous for women living in developing countries. The primary symptom of eclampsia is severe convulsions, known as eclamptic fits, which can occur before, during or after labour. The convulsions, in addition to the difficulties they present to a smooth delivery, can lead to either kidney or heart failure, both of which can be fatal to the mother. When injected, magnesium sulfate typically causes the convulsions to cease, stabilizing the mother and often allowing for safe delivery of the child. It also greatly speeds recovery time.

Nana Abdullahi, left, was saved by quick action from Dr. Idris Jamo and her sister Gaje Ganuwa, right. Photo: Chris de Bode/UNFPA

“We’ve seen that patients used to stay in the hospital for two to three weeks,” says Baba Samaila, UNFPA Adviser in Katsina. “Now, they are home in two to three days.”

Nana Abdullahi is a living example of the difference made by magnesium sulfate’s introduction to hospitals here. The 18-year-old mother of two had an eclamptic fit shortly after her most recent delivery. Nana’s sister, Gaje Ganuwe, managed to get her unconscious, convulsing sister to the hospital on the back of a motorcycle taxi.

“We were very scared. We thought it was a spirit,” says Gaje. “We were crying because we thought that she was going to die.”

Dr. Idriss Jamo, medical director of Kankia General Hospital, treated Nana. Dr. Jamo had completed the UNFPA-sponsored ELSSI training, and his hospital is equipped with magnesium sulfate. He promptly administered the drug, and the fit stopped. Nana was soon back at home with her children.

Without the injection, Dr. Jamo estimates the chances of survival in a case like Nana’s would have been only 60 per cent. Now the odds are much better.

“[Since] we began using magnesium sulfate,” he says, “we have lost only one patient.”

Demand outstrips supplies

For all their success, doctors and nurses do have one complaint about the new emergency materials: there are not yet enough to go around.

“It’s not enough,” says Dr. Jamo when asked about the quantity of anti-shock garments his hospital has on hand. “Some patients have to queue to wait for the next one. Sometimes we even have to take the ASG off one woman to put it on another.”

As the government and UNFPA bring these new interventions up to scale, these shortages should decrease. Yet the fact that new medical options have been so quickly integrated into treatment plans here is clear demonstration of how badly they were, and are, needed. Anti-shock garments and magnesium sulfate may have been unheard of in northern Nigeria a few months ago. But they have already become a life-saving necessity.

— Arthur Plews

Consolidating Evidence Before Scaling Up The anti-shock garment was introduced in Nigeria as part of a MacArthur-funded study carried out by the Women's Global Health Imperative at the University of California-San Francisco and the University of Ibadan. Pilot studies took place in Egypt, where the garment was used to keep women alive in busy urban hospitals while they waited up to 36 hours for a blood transfusion. Early results indicated that those treated with the garment lost half as much blood as those treated using standard methods, and the use of the garment saved more lives. In Nigeria, the study is focusing not only on hospital use but also on rural health care stations, where the suit is being tested as a first aid tool until women can be transported to better-equipped treatment facilities. Because the early results proved so promising, MacArthur has invested $400,000 to expand the study in Egypt in an effort to yield statistically significant evidence of the suit's effectiveness. If the study provides scientific proof that the garment works, MacArthur has plans to support scaled up use of the suit to the point where government agencies can incorporate it into standard health care. Rigorous studies like those underwritten by MacArthur are critical to convincing the medical establishment and gaining the imprimatur of global health organizations, says Suellen Miller, a professor of public health at the University of California-San Francisco who directs Women's Global Health Imperative's Safe Motherhood Programs and coordinates the anti-shock garment study. --excerpted with permission from MacArthur Newsletter: Winter 2007 Population and Reproductive Health