Suellen Miller

• PhD, CNM
• Professor (Full) at University of California, San Francisco

Introduction: Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality. A new clinical intervention (E-MOTIVE) holds the potential to improve early PPH detection and management. We aimed to develop and pilot implementation strategies to support uptake of this intervention in Kenya, Nigeria, South Africa, and Tanzania. Methods:...

Introduction Postpartum haemorrhage (PPH) remains the leading cause of maternal mortality and morbidity globally. Innovative PPH management tools have emerged using suction and sponge tamponade but currently lack substantial evidence. Broader understanding and collaborative research prioritisation are needed, especially in low-income and middle-inc...

Objective There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert’s consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and po...

Objective To demonstrate that successful health systems strengthening (HSS) projects have addressed disparities and inequities in maternal and perinatal care in low‐income countries. Methods A comprehensive literature review covered the period between 1980 and 2022, focusing on successful HSS interventions within health systems' seven core compone...

Background Female genital fistula is a traumatic debilitating injury, frequently caused by prolonged obstructed labor, affecting between 500,000-2 million women in lower-resource settings. Vesicovaginal fistula causes urinary incontinence, and other morbidity may occur during fistula development. Women with fistula are stigmatized, limit social and...

(Abstracted from N Engl J Med 2023;389:11–21) Postpartum hemorrhage (PPH) is a serious complication of childbirth, and delays in diagnosis and treatment can cause major complications or fatalities. One method of early detection is a blood-collection drape, possibly in conjunction with other tests and treatments.

Background Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challe...

OBJECTIVE: There are no globally agreed upon strategies on early detection and first response management of postpartum haemorrhage during and after caesarean birth. Our study aimed to develop an international expert's consensus on evidence-based approaches for early detection and first response management of PPH intraoperatively and postoperatively...

Background Female genital fistula, largely caused by prolonged obstructed labour, is treated by surgical repair. Preventing pregnancy for a minimum period post-repair is recommended to ensure adequate healing and optimize post-repair outcomes. Methods We examined contraceptive preferences and use among Ugandan fistula patients (n = 60) in the year...

BACKGROUND A female genital fistula, primarily caused by prolonged obstructed labor or after cesarean delivery in resource-limited countries, affects 500,000 to 2,000,000 women worldwide. Fistula is preventable with timely access to high-quality obstetrical care. Access to surgical repair of a female genital fistula has greatly increased over time....

Background: Delays in the detection or treatment of postpartum hemorrhage can result in complications or death. A blood-collection drape can help provide objective, accurate, and early diagnosis of postpartum hemorrhage, and delayed or inconsistent use of effective interventions may be able to be addressed by a treatment bundle. Methods: We cond...

Background. Female genital fistula is a traumatic debilitating injury, frequently caused by prolonged obstructed labor, affecting between 500,000–2 million women in lower-resource settings. Vesicovaginal fistula causes urinary incontinence. Other gynecologic, neurologic and orthopedic morbidity may occur during fistula development. Women with fistu...

Informal caregivers remain critical across the care continuum for complex and stigmatized conditions including female genital fistula, particularly in lower-resource settings burdened by underfunded health systems and workforce shortages. These caregivers often provide significant nonmedical support in both community and facility settings, without...

Background: Surgical repair has been found to have a transformative impact on the lives of women affected by female genital fistula, however, various physical, social, and economic challenges may persist post-repair preventing complete reengagement in relationships and communities. Nuanced investigation of these experiences is needed to inform pro...

Background Postpartum haemorrhage (PPH) is the leading cause of global maternal deaths, accounting for 30–50% of maternal deaths in sub-Saharan Africa. Most PPH-related deaths are preventable with timely detection and initiation of care, which may be facilitated by using a clinical care bundle. We explore influences on current PPH detection and man...

This study aimed to explore the firsthand experiences of informal primary caregivers of women with female genital fistula in Uganda. Caregivers that accompanied women for surgery at Mulago National Teaching and Referral Hospital were recruited between January and September 2015. Caregivers participated in in-depth interviews and focus groups. Data...

Background: Postpartum haemorrhage (PPH) is the leading cause of maternal death globally. Most PPH deaths can be avoided with timely detection and management; however, critical challenges persist. A multi-country cluster-randomised trial (E-MOTIVE) will introduce a clinical care bundle for early detection and first-response PPH management in hospi...

Background: Female genital fistula, largely caused by prolonged obstructed labour, is treated by surgical repair. Avoiding pregnancy for a minimum period post-repair is generally recommended to ensure adequate healing, so contraceptive preferences and use are important for optimizing post-repair outcomes. Methods: We examined contraceptive preferen...

Resulting from prolonged obstructed labour, iatrogenic and traumatic aetiologies, female genital fistula in low-resource settings causes a significant physical and psychosocial burden. Social support is an important mechanism to build resilience to health challenges. This study aimed to understand the role of emotional, informational and tangible s...

The World Health Organization (WHO) recently published a new recommendation on the use of the uterine balloon tamponade for the treatment of post-partum hemorrhage. The recommendation that uter-ine balloon tamponade should be used only where there is already access to other postpartum hemorrhage treatments (including immediate recourse to surgery)...

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. When PPH occurs, early identification of bleeding and prompt management using evidence-based guidelines, can avert most PPH-related severe morbidities and deaths. However, adherence to the World Health Organization recommended practices remains a critical cha...

Objectives: This is a protocol for a Cochrane Review (qualitative). The objectives are as follows:. The overall aim of this qualitative evidence synthesis is to describe and explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with postpartum haemorrhage (PPH)...

Rapid dissemination of mobile technology provides substantial opportunity for overcoming challenges reaching rural and marginalized populations. We assessed feasibility and acceptability of longitudinal mobile data capture among women undergoing fistula surgery in Uganda (n = 60) in 2014-2015. Participants were followed for 12 months following surg...

The International Federation of Gynecology and Obstetrics (FIGO) is dedicated to the improvement of women's health and rights, the reduction of disparities in healthcare for women and newborns, and advancing the science and practice of obstetrics and gynecology. Marking 65 years of work to improve the wellbeing of all women, FIGO has renewed its co...

An amendment to this paper has been published and can be accessed via the original article.

Many obstetric fistula patients remain untreated or present late to treatment despite increasing surgical availability in Uganda. We explored women's perceptions of the cause of their obstetric fistula and their treatment seeking behaviours, including barriers and facilitators to timely care access. In-depth interviews and focus group discussions w...

Respectful maternity care is recommended by the World Health Organization and refers to care that maintains dignity, privacy, confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth. In this paper, we review the evidence of respectful maternity care and discuss con...

Objective To systematically develop evidence‐based bundles for care of postpartum hemorrhage (PPH). Methods An international technical consultation was conducted in 2017 to develop draft bundles of clinical interventions for PPH taken from the WHO's 2012 and 2017 PPH recommendations and based on the validated “GRADE Evidence‐to‐Decision” framework...

Complications from unsafe abortion are among the major causes of preventable maternal morbidity and mortality, which may be compounded by delays and disparities in treatment. We conducted a secondary analysis of women with symptoms of hypovolemic shock secondary to severe obstetric hemorrhage in Tanzania. We compared receipt of three lifesaving int...

( Am J Obstet Gynecol . 2018;219(2):162–168) Prevalence estimates for postpartum hemorrhage (PPH) vary in the literature from 1% to 10% of all deliveries with PPH responsible for >80,000 deaths worldwide in 2015. The most commonly accepted definition of PPH is based on the amount of blood lost after birth. The World Health Organization defined PPH...

Fistula-related stigma is common. The absence of a unifying conceptual framework prevents a nuanced understanding of the nature of fistula-related stigma, comparison across contexts and the ability to contrast with other stigmas. It also hinders intervention development. We conducted in-depth interviews or focus groups with 60 women who had undergo...

Objective: The objective of this article was to compare hemodynamic and perfusion parameters as well as the clinical outcomes in critically ill patients with postpartum hemorrhage (PPH) who received treatment with a nonpneumatic antishock garment (NASG) as part of an intervention package, with a group of patients in similar conditions who did not r...

Table S1. Description of physical and psychosocial health measures. Table S2. Psychosocial health indicators across study 12‐month study follow‐up, Unstandardised.

Objectives To explore trajectories of physical and psychosocial health, and their interrelationship, among women completing fistula repair in Uganda for 1 year post‐surgery. Methods We recruited a 60‐woman longitudinal cohort at surgical hospitalisation from Mulago Hospital in Kampala Uganda (Dec 2014–June 2015) and followed them for 1 year. We co...

Background Obstetric hemorrhage (OH) remains one of the leading causes of maternal mortality, particularly in rural Africa. Tanzania has a high maternal mortality ratio, and approximately 80% of the population accesses health care lower level facilities, unable to provide Comprehensive Emergency Obstetric Care (CEmOC). The non-pneumatic anti-shock...

The current definition of postpartum hemorrhage (PPH) is inadequate for early recognition of this important cause of maternal mortality, responsible for more than 80,000 deaths worldwide in 2015. A stronger definition of PPH should include both blood loss and clinical signs of cardiovascular changes after delivery, which would help providers to mor...

Background Obstetric fistula is a debilitating and traumatic birth injury affecting 2–3 million women globally, mostly in sub-Saharan Africa and Asia. Affected women suffer physically, psychologically and socioeconomically. International efforts have increased access to surgical treatment, yet attention to a holistic outcome of post-surgical rehabi...

Background The aim of this case series is to describe the experience of using the non-pneumatic anti-shock garment (NASG) in the management of severe Postpartum hemorrhage (PPH) and shock, and the value of implementing this concept in high-complexity obstetric hospitals. Methods Descriptive case series of 77 women that received NASG in the managem...

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity....

Female Genital Mutilation/Cutting (FGM/C) comprises different practices involving cutting, pricking, removing and sometimes sewing up external female genitalia for non-medical reasons. The practice of FGM/C is highly concentrated in a band of African countries from the Atlantic coast to the Horn of Africa, in areas of the Middle East such as Iraq a...

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 po...

Basic Demographic Information on Each Key Informant. (DOCX)

Code Book. (DOCX)

Interview Guide for Key Informant Interviews. (DOCX)

OBJECTIVE: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. STUDY DESIGN:We conducted secondary analyse...

Background: 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 rate...

To assess whether secondary prevention, which preemptively treats women with above-average postpartum bleeding, is non-inferior to universal prophylaxis. A cluster-randomised non-inferiority community trial. Health sub-centres and home deliveries in the Bijapur district of Karnataka, India. Women with low-risk pregnancies who were eligible for deli...

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 etiologie...

The death of a woman in pregnancy and childbirth is globally considered an individual tragedy and a human rights violation. Given the inequities in death that occur to marginalized, poor, and vulnerable women in low and middle income countries, there is no doubt that maternal death is a horrific injustice. However, the long term global burden of di...

To identify correlates of severe acute maternal morbidity (SAMM) in Kabul, Afghanistan. The present case-control study enrolled postpartum couples at four public maternity hospitals between September 2007 and December 2009. Eligibility was determined by: spousal consent; SAMM criteria from chart review for cases; and matching by age, parity, and ti...

Objectives: To determine whether earlier application of the Non-pneumatic Anti-Shock Garment (NASG) at clinic level compared to the referral hospital level reduces maternal morbidity and mortality and recovery time from shock due to severe Obstetric Haemorrhage (OH) and to determine the safety of the NASG when applied at clinic level. Design: A...

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While we believe that pre-eclampsia matters - because it remains a leading cause of maternal and perinatal morbidity and mortality worldwide - we are convinced that the time has come to look beyond single clinical entities (e.g. pre-eclampsia, postpartum hemorrhage, obstetric sepsis) and to look for an integrated approach that will provide evidence...

Recent evidence indicates that disrespectful/abusive/coercive service delivery by skilled providers in facilities, which results in actual or perceived poor quality of care, is directly and indirectly associated with adverse maternal and newborn outcomes. The present article reviews the evidence for disrespectful/abusive care during childbirth in f...

Background Obstetric hemorrhage is the leading cause of maternal mortality, particularly in low resource settings where delays in obtaining definitive care contribute to high rates of death. The non-pneumatic anti-shock garment (NASG) first-aid device has been demonstrated to be highly cost-effective when applied at the referral hospital (RH) level...

Objectives To compare the predictive value of the shock index (SI) with conventional vital signs in postpartum haemorrhage (PPH), and to establish ‘alert’ thresholds for use in low-resource settings.DesignRetrospective cohort study.SettingUK tertiary centre.PopulationWomen with PPH ≥1500 ml (n = 233).Methods Systolic blood pressure (BP), diastolic...

The development of early, accurate predictors for adverse maternal outcomes associated with obstetric hemorrhage may be useful as a trigger for initiating timely referral and resuscitation activities. Hemodynamic compensatory mechanisms mask abnormal values of traditional clinical indicators such as heart rate (HR) and blood pressure (BP) until wom...

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-...

Obstetric hemorrhage is the primary cause of maternal mortality worldwide, especially in lower-resource settings that are characterized by treatment delays [1]. The non-pneumatic anti-shock garment (NASG) is a first-aid device used to stabilize women in shock from obstetric hemorrhage until they can receive definitive care. The authors conducted a...

Objective: To examine whether women with hypovolemic shock secondary to obstetric hemorrhage are transported to referral hospitals differently depending on weeks of pregnancy in Zambia. Methods: In a retrospective study, transport type, wait time, and transit time were assessed for women with obstetric hemorrhage and hypovolemic shock transporte...

Postpartum hemorrhage (PPH) is the largest contributor to maternal mortality, occurring in between 1 and 5% of deliveries. Prophylactic uterotonics are widely recommended to prevent atonic hemorrhage. Rapid recognition of PPH and identification of hemorrhage etiology is essential to reduce mortality and morbidity. Treatment is etiology-specific and...

Obstetric hemorrhage is the leading cause of maternal mortality, particularly in low-resource settings where women face significant delays in accessing definitive treatment. The Non-pneumatic Anti-Shock Garment (NASG) is a first-aid device to stabilize women in hypovolemic shock secondary to obstetric hemorrhage. Prior studies on the effectiveness...

The Non-pneumatic Anti-Shock Garment (NASG), a first-aid device for obstetric hemorrhage (OH), has been shown to reduce blood loss and time to recovery from shock when applied at the referral hospital (RH) level. It is unknown whether women have better outcomes if they receive the NASG earlier in their course of care. In this analysis we evaluate r...

Obstetric hemorrhage is the leading cause of maternal mortality. Using a cluster randomized design, we investigated whether application of the Non-pneumatic Anti-Shock Garment (NASG) before transport to referral hospitals (RHs) from primary health care centers (PHCs) decreased adverse outcomes among women with hypovolemic shock. We hypothesized the...

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 facilit...

To assess the cost-effectiveness of a non-pneumatic anti-shock garment (NASG) for obstetric hemorrhage in tertiary hospitals in Egypt and Nigeria. We combined published data from pre-intervention/NASG-intervention clinical trials with costs from study sites. For each country, we used observed proportions of initial shock level (mild: mean arterial...

Description of methods for collecting input data, calculating cost-effectiveness, and performing sensitivity analyses. (DOC)

HIV prevalence among pregnant women in Kenya is high. Furthermore, there is a high risk of maternal mortality, as many women do not give birth with a skilled healthcare provider. Previous research suggests that fears of HIV testing and unwanted disclosure of HIV status may be important barriers to utilizing maternity services. We explored relations...

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 in...

Objectives: To assess if using a first-aid device, the Non-pneumatic Anti-Shock Garment (NASG), is harmful or protective for women at risk for or experiencing eclampsia (ARE) who have hypovolemic shock secondary to obstetric hemorrhage. Methods: Two non-randomized pre-intervention / NASG intervention parent studies were conducted in Egypt and Niger...

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 s...