Papers by Elizabeth Butrick
PLOS ONE, 2016
To determine the optimal vital sign predictor of adverse maternal outcomes in women with hypovole... more To determine the optimal vital sign predictor of adverse maternal outcomes in women with hypovolemic shock secondary to obstetric hemorrhage and to develop thresholds for referral/intensive monitoring and need for urgent intervention to inform a vital sign alert device for low-resource settings. We conducted secondary analyses of a dataset of pregnant/postpartum women with hypovolemic shock in low-resource settings (n = 958). Using receiver-operating curve analysis, we evaluated the predictive ability of pulse, systolic blood pressure, diastolic blood pressure, shock index, mean arterial pressure, and pulse pressure for three adverse maternal outcomes: (1) death, (2) severe maternal outcome (death or severe end organ dysfunction morbidity); and (3) a combined severe maternal and critical interventions outcome comprising death, severe end organ dysfunction morbidity, intensive care admission, blood transfusion ≥ 5 units, or emergency hysterectomy. Two threshold parameters with optimal rule-in and rule-out characteristics were selected based on sensitivities, specificities, and positive and negative predictive values. Shock index was consistently among the top two predictors across adverse maternal outcomes. Its discriminatory ability was significantly better than pulse and pulse pressure for maternal death (p<0.05 and p<0.01, respectively), diastolic blood pressure and pulse pressure for severe maternal outcome (p<0.01), and systolic and diastolic blood pressure, mean arterial pressure and pulse pressure for severe maternal outcome and critical interventions (p<0.01). A shock index threshold of ≥ 0.9 maintained high sensitivity (100.0) with clinical practicality, ≥ 1.4 balanced specificity (range 70.0-74.8) with negative predictive value (range 93.2-99.2), and ≥ 1.7 further improved specificity (range 80.7-90.8) without compromising negative predictive value (range 88.8-98.5). For women with hypovolemic shock from obstetric hemorrhage, shock index was consistently a strong predictor of all adverse outcomes. In lower-level facilities in low resource settings, we recommend a shock index threshold of ≥ 0.9 indicating need for referral, ≥ 1.4 indicating urgent need for intervention in tertiary facilities and ≥ 1.7 indicating high chance of adverse outcome. The vital sign alert device incorporated values 0.9 and 1.7; however, all thresholds will be prospectively validated and clinical pathways for action appropriate to setting established prior to clinical implementation.
ABSTRACT Objective: To use a comparative cost-effectiveness approach with evidence from four coun... more ABSTRACT Objective: To use a comparative cost-effectiveness approach with evidence from four countries to understand which facility level is most appropriate for implementing the non-pneumatic anti-shock garment (NASG) to decrease maternal mortality associated with obstetric hemorrhage (OH). Methods: Two data sources were compared. We determined the cost-effectiveness of NASG application for women with hypovolemic shock from OH at the referral hospitals (RH) compared to standard of care within a two-phase intervention study of 6 RH in Egypt and Nigeria. To specify the cost-effectiveness of applying the NASG at the primary health clinic (PHC) level compared to the RH, we estimated random-effects models within a cluster-randomized control trial of 38 primary health clinics (PHC) in Zambia and Zimbabwe. Costs (blood transfusions, medications, etc.) and disability-adjusted life years (DALYs) were compared across the intervention scenarios. Results: The NASG was cost saving ($77-85 per woman in Egypt) or very cost-effective ($3-6 per DALY averted in Nigeria) when applied at the referral hospital level. Applying the NASG at PHCs instead of waiting until the RH was very cost-effective ($19 per DALY averted in Zambia). We were unable to ascertain if the NASG was cost-effective in Zimbabwe due to low number of maternal deaths. Cost savings were mainly due to reduced blood transfusions. Conclusion: For health systems with at least moderate clinical resource availability, the NASG is cost-effective or cost savings at the RH-level. Our evidence suggests that applying the NASG at the PHC is cost-effective for countries with a health system similar to Zambia.
Reproductive Health, 2015
Obstetric fistula is a debilitating birth injury that affects an estimated 2-3 million women glob... more Obstetric fistula is a debilitating birth injury that affects an estimated 2-3 million women globally, most in sub-Saharan Africa and Asia. The urinary and/or fecal incontinence associated with fistula affects women physically, psychologically and socioeconomically. Surgical management of fistula is available with clinical success rates ranging from 65-95 %. Previous research on fistula repair outcomes has focused primarily on clinical outcomes without considering the broader goal of successful reintegration into family and community. The objectives for this study are to understand the process of family and community reintegration post fistula surgery and develop a measurement tool to assess long-term success of post-surgical family and community reintegration. This study is an exploratory sequential mixed-methods design including a preliminary qualitative component comprising in-depth interviews and focus group discussions to explore reintegration to family and community after fistula surgery. These results will be used to develop a reintegration tool, and the tool will be validated within a small longitudinal cohort (n = 60) that will follow women for 12 months after obstetric fistula surgery. Medical record abstraction will be conducted for patients managed within the fistula unit. Ethical approval for the study has been granted. This study will provide information regarding the success of family and community reintegration among women returning home after obstetric fistula surgery. The clinical and research community can utilize the standardized measurement tool in future studies of this patient population.
Studies in Family Planning, 2015
Maternal mortality attributable to post-abortion hemorrhage is often associated with delays in re... more Maternal mortality attributable to post-abortion hemorrhage is often associated with delays in reaching or receiving definitive care. The nonpneumatic antishock garment (NASG), a low-technology first-aid device, has been shown to decrease blood loss and mortality among women experiencing hypovolemic shock secondary to obstetric hemorrhage etiologies. Women experiencing post-abortion hemorrhage face longer delays in receiving definitive treatment as a result of abortion-related stigma and lack of access to quality abortion care; thus the NASG has the potential to make an even greater impact within this population. We conducted a secondary analysis of data collected in Egypt, Nigeria, Zambia, and Zimbabwe in NASG trials, limiting our analytic sample to women who experienced post-abortion hemorrhage (n = 953). Blood loss significantly decreased when the NASG was added to standard hemorrhage management during the intervention phase, and there was a large, although not statistically significant, 52 percent decrease in mortality during the NASG phase. The results indicate that adding the NASG to post-abortion care among women experiencing severe hemorrhage and hypovolemic shock would decrease blood loss and mortality.
Background: Obstetric hemorrhage (OH) is the leading cause of maternal mortality due to delays in... more Background: Obstetric hemorrhage (OH) is the leading cause of maternal mortality due to delays in obtaining Emergency Obstetric Care. Women die during transports to facilities or while awaiting appropriate care in facilities. One strategy for decreasing MMR from OH is a first aid device, the Non-pneumatic Anti-Shock Garment (NASG), a low technology compression suit. The NASG is being pilot tested in Kano, Nigeria. Objectives: To understand provider, patient and family perceptions of the NASG in order to enhance its acceptability and decrease delays in application. Methods: 10 focus groups of 134 health care providers (doctors, nurse-midwives, nurses, and staff) and 6 in-depth, individual interviews of patients who survived severe OH and shock and/or their family members, were conducted and analyzed using grounded theory. Results and conclusions: Providers agreed that the NASG was easy to use, improved management of OH, but was difficult to fold correctly, and was not always the firs...
Miller S, Butrick E, Turan JM, Ojengbede OA, Morhason-Bello IO, Galadanci H, Martin H, Fabanwo A, Solanke O, Awwal M, Ojengbede A, Hensleigh P (2007). The Anti-Shock Garment for Postpartum Haemorrhage in Nigeria. Journal of Midwivery & Women’s Health; 52(5):534 Journal of midwifery & women's health
International Journal of Gynecology & Obstetrics
Objective: To assess the cost-effectiveness of non-pneumatic anti-shock garments (NASG) for obste... more Objective: To assess the cost-effectiveness of non-pneumatic anti-shock garments (NASG) for obstetric hemorrhage in tertiary hospitals in Egypt and Nigeria. Methods: Results from published pre-intervention/NASG-intervention phase trials for women in severe shock (mean arterial pressure (MAP)<60) were standardized for 1,000 women. Clinical data included frequencies of health outcomes (mortality, major morbidity, severe anemia), and interventions to control bleeding (uterotonics, blood transfusions, hysterectomies). Costs (2010 international dollars) included the NASG, training, and clinical interventions. Changes in cost, morbidity, mortality, and disability-adjusted life years (DALYs) were used to calculate incremental cost-effectiveness ratios (ICERs; cost per DALY averted) for each country and study phase. We examined hysterectomies for all etiologies and for intractable uterine atony only. Results: Women with severe shock who received the NASG had lower mortality and morbidity...
Objective: To use a comparative cost-effectiveness approach with evidence from four countries to ... more Objective: To use a comparative cost-effectiveness approach with evidence from four countries to understand which facility level is most appropriate for implementing the non-pneumatic anti-shock garment (NASG) to decrease maternal mortality associated with obstetric hemorrhage (OH). Methods: Two data sources were compared. We determined the cost-effectiveness of NASG application for women with hypovolemic shock from OH at the referral hospitals (RH) compared to standard of care within a two-phase intervention study of 6 RH in Egypt and Nigeria. To specify the cost-effectiveness of applying the NASG at the primary health clinic (PHC) level compared to the RH, we estimated random-effects models within a cluster-randomized control trial of 38 primary health clinics (PHC) in Zambia and Zimbabwe. Costs (blood transfusions, medications, etc.) and disability-adjusted life years (DALYs) were compared across the intervention scenarios. Results: The NASG was cost saving ($77-85 per woman in E...
MCN. The American journal of maternal child nursing, 2012
To discuss the role of nurses and nurse-midwives in preventing and treating postpartum hemorrhage... more To discuss the role of nurses and nurse-midwives in preventing and treating postpartum hemorrhage (PPH) from uterine atony in developing countries and examine the role of a new device, the non-pneumatic anti-shock garment (NASG), in improving the outcomes for these patients. In this subanalysis of a larger preintervention phase/intervention phase study of 1,442 women with obstetric hemorrhage, postpartum women with hypovolemic shock (N = 578) from uterine atony (≥750 mL blood loss; systolic blood pressure <100 mmHg and/or pulse >100 beats per minute) were enrolled in two referral facilities in Egypt and four referral facilities in Nigeria. The study had two temporal phases: a preintervention phase and an NASG-intervention phase. Women with hemorrhage and shock in both phases were treated with the same evidence-based protocols for management of hypovolemic shock and hemorrhage, but women in the NASG-intervention phase also received the NASG. Relative risks (RRs) with 95% confid...
ISRN Obstetrics and Gynecology, 2011
The study aims to determine if the nonpneumatic antishock garment (NASG), a first aid compression... more The study aims to determine if the nonpneumatic antishock garment (NASG), a first aid compression device, decreases severe adverse outcomes from nonatonic obstetric haemorrhage. Women with nonatonic aetiologies (434), blood loss > 1000 mL, and signs of shock were eligible. Women received standard care during the preintervention phase (226) and standard care plus application of the garment in the NASG phase (208). Blood loss and extreme adverse outcomes (EAO-mortality and severe morbidity) were measured. Women who used the NASG had more estimated blood loss on admission. Mean measured blood loss was 370 mL in the preintervention phase and 258 mL in the NASG phase (P < 0.0001). EAO decreased with use of the garment (2.9% versus 4.4%, (OR 0.65, 95% CI 0.24-1.76)). In conclusion, using the NASG improved maternal outcomes despite the worse condition on study entry. These findings should be tested in larger studies.
PLoS ONE, 2013
The Non-Pneumatic Anti-Shock Garment (NASG) is a first-aid device to reduce mortality from severe... more The Non-Pneumatic Anti-Shock Garment (NASG) is a first-aid device to reduce mortality from severe obstetric hemorrhage, the leading cause of maternal mortality globally. We sought to evaluate patient characteristics associated with mortality among a cohort of women treated with the NASG in Nigeria. Data on 1,149 women were collected from 50 facilities participating in the Pathfinder International Continuum of Care: Addressing Postpartum Hemorrhage project in Nigeria from 2007-2012. Characteristics were compared using the appropriate distributional tests, and we estimated multivariable logistic regression models to control for treatment received. There were 201 deaths (17.5%). Women who died were significantly more likely to have any co-morbidity (AOR 3.63, 95% CI: 2.41-5.48), ruptured uterus (AOR 2.79, 95% CI: 1.48-5.28), macerated stillbirth (AOR 2.96, 95% CI 1.60-5.48) and to have had 6 or more previous births, (AOR 1.53, 95% CI 1.11-2.12), after adjusting for treatment received. These results suggest certain maternal conditions, particularly the presence of another life-threatening co-morbidity or macerated stillbirth, conferred a higher risk of mortality from PPH. This underscores the need for multi-system assessment and a comprehensive approach to the treatment of women with pregnancy complications.
PLoS ONE, 2013
Objective: To assess the cost-effectiveness of a non-pneumatic anti-shock garment (NASG) for obst... more Objective: To assess the cost-effectiveness of a non-pneumatic anti-shock garment (NASG) for obstetric hemorrhage in tertiary hospitals in Egypt and Nigeria.
Journal of Women's Health, 2011
Background: We examined whether the non-pneumatic anti-shock garment (NASG) ameliorates the effec... more Background: We examined whether the non-pneumatic anti-shock garment (NASG) ameliorates the effects of delays in transport to and treatment at hospitals for women with postpartum hemorrhage (PPH) and postabortion hemorrhage (PAH) and investigated the effects of NASG use on timing of delivery of interventions inhospital. Methods: Pre=post studies of the NASG were conducted at hospitals in Cairo (n ¼ 349 women), Assuit (n ¼ 274), Southern Nigeria (n ¼ 57), and Northern Nigeria (n ¼ 124). In post-hoc analyses, comparisons of delays were conducted using analysis of variance (ANOVA), and associations of delays with extreme adverse outcomes (EAO, mortality or severe morbidity) were examined using chi-square tests, odds ratios (ORs), and multivariate logistic regression. Results: Median minutes from hemorrhage start to study admission differed by site, ranging from 15 minutes in Cairo to 225 minutes in Northern Nigeria ( p < 0.001). Median minutes from study admission to blood transfusion ranged from 30 minutes in Cairo to 209 minutes in Southern Nigeria ( p < 0.001). Twenty percent of women with !60 minutes between hemorrhage start and study admission experienced an EAO without the NASG compared with only 6% with the NASG (w 2 ¼ 13.71, p < 0.001). In-hospital delays in receiving intravenous (IV) fluids and blood were more common in the NASG phase. Conclusions: Women with PPH or PAH in Egypt and Nigeria often face delays in reaching emergency obstetrical care facilities and delays in receiving definitive therapies after arrival. Our results indicate that the NASG can reduce the impact of these delays. Stabilization does not replace treatment, however, and delays in fluid=blood administration with NASG use must be avoided.
The Journal of Pediatrics, 2008
Objective Because little is known about its effects on cognitive function among children in less-... more Objective Because little is known about its effects on cognitive function among children in less-developed countries, we determined the impact of lead exposure from other nutritional determinants of cognitive ability.
Journal of Health Care for the Poor and Underserved, 2009
A needs assessment was compiled from self-administered questionnaires completed by 796 clients at... more A needs assessment was compiled from self-administered questionnaires completed by 796 clients at the Urban Indian Health Service clinics in San Francisco and Oakland, California. Data on the health disparities between Native Americans and Alaskan Natives and the rest of the U.S. population are limited. The data that exist, however, indicate that Native Americans continue to fare worse than the general population. This needs assessment reveals the same trend among a sample of clients of two Native American Health Centers in the San Francisco Bay Area and provides further information about the health needs and interests of the population currently attending these centers.
International Journal of Gynecology & Obstetrics, 2009
The mid-urethral tension-free vaginal tape sling has emerged as the gold standard to treat female... more The mid-urethral tension-free vaginal tape sling has emerged as the gold standard to treat female stress urinary incontinence (SUI). The transobturator approach was then developed to reduce risks of retropubic needle passage. Most recently, the mini-sling has been developed in attempts to place the sling without any needle passages through the abdomen or groin. The current study was conducted to report on the technique, safety and early efficacy of a single-incision mini-sling to treat female SUI. Methods: Women suffering from SUI were offered a single-incision approach to place a sub-urethral polypropylene mesh tape in a position similar to that of a transobturator sling without passage of needles through the groins. Retrospective data was collected on the first 61 patients that underwent the new MiniArc (American Medical Systems, Minnetonka, MN) single-incision sling at our specialty center in the United States. All patients had urodynamic proven SUI. Patient selection and concomitant procedures were determined by the senior authors at the center. The senior authors (RDM, JRM) were the primary surgeons in all cases. Procedures were completed under general, regional, or MAC anesthesia as determined by the surgeon. Results: Sixty-one patients underwent the Mini-arc single incision sling. 92% of patients had concomitant procedures for prolapse during the same setting. Average age was 58 years (range 26-84) and average LPP was 71.3. Average operative time for the sling procedure alone was short and average blood loss was 29 cc. There were no intra-operative complications. There was one postoperative adverse event secondary to urinary retention which was resolved by loosening of the sling under local anesthesia in an office setting. Significant urge symptoms were present in 55% of patients pre-operatively and only 14% post-operative (75% resolution of urge symtpoms). Overall cure rate at 12 months determined by physician and patient assessment in 58/61 patients was 91.4%. No patients suffered pain or dyspareunia secondary to the sling and no erosions or extrusions were reported. Conclusions: In this initial study, the MiniArc single-incision sling appears to be a safe approach to treat female SUI and the early clinical results are encouraging with 12 month cure at 91.4%. A multicenter US prospective trial is on-going.
International Journal of Gynecology & Obstetrics, 2012
International Journal of Gynecology & Obstetrics, 2012
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Papers by Elizabeth Butrick