Utilization of non-pneumatic anti-shock garment and associated factors for postpartum hemorrhage management among obstetric care providers in public health facilities of southern Ethiopia, 2020.

BACKGROUND: Delays in care have been recognized as a significant contributor to maternal mortality in low-resource settings. The non-pneumatic antishock garment is a low-cost first-aid device that can help women with obstetric haemorrhage survive these delays without long-term adverse effects. Extending professionals skills and the establishment of new technologies in basic healthcare facilities could harvest the enhancements in maternal outcomes necessary to meet the sustainable development goals. Thus, this study aims to assess utilization of non-pneumatic anti-shock garment to control complications of post-partum hemorrhage and associated factors among obstetric care providers in public health institutions of Southern Ethiopia, 2020.
METHODS: A facility-based cross-sectional study was conducted among 412 obstetric health care providers from March 15 -June 30, 2020. A simple random sampling method was used to select the study participants. The data were collected through a pre-tested interviewer-administered questionnaire. A binary logistic regression model was used to identify determinants for the utilization of non-pneumatic antishock garment. STATA version 16 was used for data analysis. A P-value of < 0.05 was used to declare statistical significance.
RESULTS: Overall, 48.5% (95%CI: 43.73, 53.48%) of the obstetric care providers had utilized Non pneumatic antishock garment for management of complications from postpartum hemorrhage. Training on Non pneumatic antishock garment (AOR = 2.92; 95% CI: 1.74, 4.92), working at hospital (AOR = 1.81; 95% CI: 1.04, 3.16), good knowledge about NASG (AOR = 1.997; 95%CI: 1.16, 3.42) and disagreed and neutral attitude on Non pneumatic antishock garment (AOR = 0.41; 95%CI: 0.24, 0.68), and (AOR = 0.39; 95% CI: 0.21, 0.73), respectively were significantly associated with obstetric care provider's utilization of Non-pneumatic antishock garment.
CONCLUSIONS: In the current study, roughly half of the providers are using Non-pneumatic antishock garment for preventing complications from postpartum hemorrhage. Strategies and program initiatives should focus on strengthening in-service and continuous professional development training, thereby filling the knowledge and attitude gap among obstetric care providers. Health centers should be targeted in future programs for accessibility and utilization of non-pneumatic antishock garment.

Introduction

Postpartum hemorrhage (PPH) is a substantial contributor to severe maternal morbidity, long-term complications, and disabilities as well as to several other severe maternal conditions commonly associated with more considerable blood loss, including shock and organ dysfunction. A woman suffering from PPH may die within two hours unless she receives immediate and prompt medical care [1, 2]. Globally, postpartum hemorrhage accounts for one-quarter of all maternal death and it is the leading cause of maternal mortality in low-income countries [1]. In Ethiopia, about 25% of maternal death are attributed to hemorrhage [3, 4].

The survival and health of both mother and fetus depend on the ability of families and communities to recognize and access care quickly in case of an emergency. For obstetric complications like hemorrhage, the window of opportunity to respond and save the life of the mother may be measured in hours [3]. Delays in receiving care have been recognized as major contributors to maternal mortality in low-resource settings. The non-pneumatic anti-shock garment (NASG) is a low-cost first-aid device that may help women with obstetrical hemorrhage survive these delays without long-lasting adverse effects [5-7].

The NASG is a simple neoprene and velcro device that looks like the bottom half of a wetsuit cut into segments. It can be used to treat resuscitate, stabilize and prevent further bleeding in women with obstetric hemorrhage. It comprises nine articulated segments that are wrapped sequentially around the legs, pelvis, and abdomen and closed with velcro. A foam ball over the abdomen provides additional compression. The NASG works by applying circumferential counter pressure, decreasing blood flow to the compressed area (abdomen, pelvis, and lower extremities), and enhancing blood flow to the heart, lungs, and brain. As blood flow increases to these core organs, the symptoms of shock are reversed [8].

The NASG can be applied by any healthcare professional after brief training, and it results in the reversal of hypovolemic shock stabilization of the patient for many hours, during transport, examinations, and delays in receiving definitive treatments such as blood, procedures, and surgeries. The NASG is the only device available to stabilize women with shock until definitive treatments can be given. If Intravenous (IV) fluids no longer flow, the veins are easier to find after placing the garment. Because hypovolemic patients may not have access to surgery and/or blood, the NASG can help maintain patients while awaiting definitive care [9].

Even with major advances in the prevention of PPH women are still dying [10]. The use of non-pneumatic anti-shock garments is recommended as a temporizing measure until appropriate care is available. The World Health Organization (WHO) recommends health facilities delivering maternity services should adopt formal protocols for the prevention and treatment of PPH and patient referral [1]. Clinton Health Access Initiative (CHAI) introduced the non-pneumatic anti-shock garment (NASG) in selected health facilities of Ethiopia in June 2011 to reduce complications due to pregnancy-related excessive bleeding. With the introduction of the NASG, there was a 79% reduction in maternal deaths due to postpartum hemorrhage [11].

Before and after studies conducted in different parts of the world revealed a 55% reduction in maternal mortality, 80% reduction in blood loss, emergency hysterectomy decreased from 8.9% to 4.0%, and severe adverse outcomes lessened from 12.8% to 4.1% due to the application of NASG [12-15]. Evidence-based information from randomized control trials also suggested faster recovery from obstetric shock, decreased maternal mortality, severe end-organ failure, and morbidity after the utilization of NASG [16-18]. The NASG is also suggested to have major implications for nurses and midwives attending or assisting in childbirth in low resource settings with delays in obtaining definitive therapy [9].

Postpartum hemorrhage is one of the most alarming and serious emergencies which health professionals may face at health centers and their prompt and competent action will be crucial in controlling blood loss and reducing the risk of maternal morbidity or even death by using low cost, effective, and lifesaving instrument (NASG). Most of the studies conducted before used a small sample size (60–112) [19-22]. Non-availability of NASG, working experience, age of participants, qualification, lack of skilled personnel, and not being aware of the existence of NASG were factors identified in the previous studies about knowledge and utilization of NASG [20, 22–25].

Notwithstanding the benefit of NASG for preventing complications of obstetric hemorrhage in low-income countries like Ethiopia, where almost all maternal mortality occurs and for which 25–28% of maternal mortalities are attributable to postpartum hemorrhage few studies have been conducted to assess the knowledge and practice of health professionals about the use of NASG. Thus this study aimed to assess obstetric care providers utilization of NASG for the prevention of complications from postpartum hemorrhage and associated factors in public health institutions of southwest Ethiopia.

Materials and methods

Setting and duration of the study

This study was conducted in public health facilities of Gamo, Gofa, Segen Areas People, and South Omo Zone, Ethiopia from March 15 –June 30, 2020. Gamo, Gofa, Segen Areas People, and South Omo area are administrative Zones in the Southern part of Ethiopia. Those Zones hosted different general and district hospitals that serve the community by providing preventive and curative services. There are five functional hospitals in Gamo Zone (Arba Minch General Hospital, Chencha District Hospital, Kamba District Hospital, Gerese District Hospital, and Selamber District Hospital), one hospital in Gofa Zone (Sawla District Hospital), two hospitals in Segen Areas People Zone (Karat District Hospital and Gidole District Hospital) and three hospitals in South Omo Zone (Jinka General Hospital and Gazer District Hospital). Regarding the health centers distribution, there are a total of 76 in Gamo zone, 56 in Gofa zone, 16 in Segen area, 12 in Konos zone, and 41 in south Omo.

Study design and population

Institution-based cross-sectional study design was employed among obstetric care providers. All health care professionals who were working in public health facilities of southwest Ethiopia were the source population. And all obstetric care providers who were working in public health facilities of southwest Ethiopia, where NASG is available for PPH management and fulfilled the selection criteria were the study population.

Inclusion and exclusion criteria

All obstetric care providers who were staff in the respective wards in each public health facility were included in this study, whereas those obstetric care providers on annual leave at the time of data collection were excluded from this study.

Sample size and sampling procedure

A single population proportion formula was used to estimate the sample size required for the study. The sample size calculation assumed the proportion (p), the estimated level of utilization of non-pneumatic antishock garment 52.2% [23], 95% confidence level, and margin of error of 5% which gave a sample size of 384. In consideration of a 10% non-response rate, the final sample size was 422 obstetric care providers. There are eleven fully functional hospitals in five Zones of Southern Ethiopia. All the hospitals were included in the study. Regarding the health centers, among the 113 health centers in the five zones, 25% (34) of the health centers were selected by a simple random sampling method. At first, the calculated sample size was proportionally allocated to each public health facility based on the number of obstetric care providers who were working in the respective facilities. Furthermore, a table of the random number was used to select each obstetric care provider based on proportions to get the desired sample size.

Data collection instruments and procedures

A self-administered semi-structured questionnaire was used to collect data from study participants. The data collection tool is developed by reviewing different kinds of literature and guidelines [8, 19–24, 26–32] and it consists of eight parts which include: socio-demographic characteristics, professional related characteristics, facility-related characteristics, contextual related characteristics, and health professional’s knowledge about NASG, health professional’s utilization of NASG, the attitude of health care professional NASG which had eight questions and the responses consist of five Likert scales which were strongly agree, agree, neutral, disagree, and strongly disagree.

Definitions and measurements

Utilization of non-pneumatic anti-shock garment

Measured based on the response to the question of whether the obstetric care providers used NASG for the management of postpartum hemorrhage at least one time [23].

Knowledge scale

The respondents’ score of total knowledge questions those who below 50% were graded as having poor knowledge while those who score greater than 50% from the provided knowledge questions were graded as having good knowledge [33].

Attitude scale

A Likert scale was created by presenting respondents with a series of negative and positive attitude statements with five possible responses. For negative statements, responses including agree, and, strongly agree, were labeled as “disagree”, disagree and strongly disagree were labeled as “agree”, and undecided responses were labeled as “neutral responses”.

Data processing and analysis

Data were analyzed using STATA version 16. Data were cleaned by running frequencies to each variable to check outliers, inconsistencies, and missed values. The outcome variable was utilization; those who utilized NASG were coded as “1” and those who did not utilize were coded as “0”. The assumptions for binary logistic regression were checked. Hosmer-Lemeshow statistic and Omnibus tests were done for model fitness. Variables with P < 0.25 in the bivariate analysis, and variables that were significant in previous studies were considered to select the candidate variables for the final model. Collinearity statistics (Variance inflation factor (VIF) > 10 and tolerance (T) < 0.1 were considered as suggestive of the existence of multi co-linearity. Adjusted Odds Ratio along with 95% CI was estimated to identify factors affecting obstetric care provider’s utilization of NASG. The P-value < 0.05 was considered to declare a result as statistically significant. Then simple frequencies, summary measures, tables, and figures were used to present the information.

Data quality management

Data collectors and supervisors were provided with a daylong intensive training on the techniques of data collection and components of the data collection tool. Before the actual data collection, the questionnaire was pre-tested on 10% of obstetric care providers in Wolayita Sodo Hospitals. Based on the findings from the pretest, ambiguous questions were amended. An ongoing formative checkup for completeness and consistency of responses was made by the supervisors daily.

Ethics consideration and consent to participate

Ethical clearance was issued from the Institutional Review Board of Arba Minch University. Permission was secured from the respective hospital and health center administrators. Moreover, written consent was obtained from each study participant before the commencement of data collection. Before obtaining the consent of each participant, a letter of support and approval to undertake the research in health facilities was obtained from managers in each public health facility. Privacy, as well as the confidentiality of participants, was asserted. In any case, their right to withdraw from the study at any time was assured.

Results

Socio-demographic characteristics of the study participants

A total of 412 obstetric care providers participated, yielding a response rate of 97.6%. The mean age and standard deviation of study participants were 27.77 ± SD 3.98 years old. Two hundred ninety-four (71.36%) of the obstetric care providers reside in urban areas (Table 1).

Table 1

Socio-demographic characteristics of obstetric care providers who participated in the study and were working in public health facilities of southern Ethiopia, 2020 (N = 412).

Variable	Frequency	Percent
Age in years
20–24	81	19.7
25–29	206	50
30–34	92	22.3
35–40	33	8
Sex
Female	268	65
Male	144	35
Marital status
Married	255	61.9
Single	148	35.9
Others *	9	2.2
Religious status
Protestant	195	47.3
Orthodox	195	47.3
Muslim	16	3.9
Catholic	6	1.46
Residency
Urban	294	71.4
Rural	118	28.6

Others * = divorced, married but living apart.

Out of the total respondents, 298 (71.12%) of the obstetric care providers were working in health centers. Of the total obstetric care providers, 150 (36.4%) had training about NASG. Two hundred fifty-four, (61.6%) of the obstetric care providers had protocols about the NASG in their respective facilities (Table 2).

Table 2

Provider and facility-related factors of the obstetric care providers in public health facilities of Southern Ethiopia, 2020.

Variable	Frequency	Percent
Profession
Midwifes	304	73.8
Nurses	51	12.4
Medical doctor	9	2.2
Integrated Emergency Obstetric Surgery	48	11.6
Educational level
Diploma	235	57
Bachelor degree	120	29.1
Masters	57	13.8
Years of experience
1–5 years	241	58.5
6–10 years	145	35.2
11 years and above	26	6.3
Unit of service
ANC	79	19.2
Family planing	22	5.3
Labour and delivery	210	60
GYN Opd	63	15.3
Postnatal	38	9.2
Facility type
Hospital	119	28.9
Health center	293	71.1
Protocol about NASG in the facility
Yes	254	61.6
No	158	38.3
Traning about NASG
Yes	150	36.4
No	262	63.6

Participants’ knowledge of non-pneumatic anti-shock garment

This study indicated that the majority (82.04%) of respondents had heard about NASG while 74 (17.96%) never heard it before. One hundred sixty-one (47.6%) of the respondents correctly mentioned that NASG has six parts. Regarding the type of pressure, NASG exerts when applied on a patient, half of the respondents correctly mentioned that circumferential pressure is applied. Regarding the contra-indication to the use of NASG, the majority (83.73%) of the respondents responded it shouldn’t be applied to the viable fetus (Table 3). Overall, about three-fourth (74.26%) of the obstetric care providers had good knowledge about NASG.

Table 3

Knowledge of NASG among obstetric care providers in public health facilities of southern Ethiopia, 2020.

Variables	Frequency	Percentage
Heard of NASG (N = 412)
Yes	338	82
No	74	18
Knew NASG as it is used for preventing complications from PPH (N = 338)
Yes	254	75.1
No	84	24.9
Source of information (N = 338)
Health institution	265	78.4
School	76	22.5
Seminars	30	8.9
Internet	17	5
Printed material	5	1.5
Friends/colleagues	15	4
NASG looks like (N = 338)
*Bottom half of a suit	150	44.4
A gown	30	8.9
A trouser	158	46.8
NASG is made of (N = 338)
*Velcro	66	19.5
*Neoprene	78	23.1
I don’t know	194	57.4
Number of segments of NASG (N = 338)
Four	130	38.5
*Six	161	47.6
Nine	17	5
Five	30	8.9
Type of pressure NASG exerts when applied on a patient (N = 338)
*Circumferential	169	50.1
Direct	132	39.2
Counter	36	10.7
** Types of activities performed on a woman on Non-Pneumatic Antishock Garment© (N = 338)
Intravenous line	268	79.3
Vaginal surgery	173	51.2
Abdominal surgery	147	43.5
Transport to other facilities	235	69.5
** NASG removed when© (N = 338)
After stabilizing for 2hrs	212	62.7
When the hg is 7g/ dl or more and hematocrit of about 20%	179	53
Pulse rate less than 100 bpm	167	49.4
Diastolic bp 90mmhg or more	156	46.2
When the women is awake /stable	133	39.4
Bleeding <50ml/hr	111	32.8
Starting segment while applying NASG (N = 338)
Abdominal segment	60	17.8
* Lower or ankle segment	254	75.2
I don’t know	24	7.1
Starting segment while removing NASG (N = 338)
Abdominal segment	82	24.3
*Lower or ankle segment	219	64.8
I don’t know	37	10.9
Time interval to remove each segment (N = 338)
Each successively	93	27.5
* 15 minutes apart	177	52.4
1hr apart	44	13
I don’t know	24	7.1
Segment adjusted when a woman experiences difficulty breathing with the NASG (N = 338)
*Abdominal	229	67.8
Thigh	44	13
leg	39	11.5
I don’t know	26	7.7
** Contra-indication to the use of NASG© (N = 338)
Viable fetus	283	83.7
Dyspnea	250	74
Mitral stenosis	223	66
CHF	237	70.1
Pulmonary hypertension	227	67.2
Bleeding above diaphragm	230	68
How long the NASG can/should be used on a given patient (N = 338)
For two hours	120	35.5
For 48 hours	65	19.2
* Applied until the bleeding arrested	135	39.9
I don’t know	18	5.3
Knowledge
Good knowledge	303	74.3
Poor knowledge	105	25.7

©Multiple responses are possible.

*Correct response,

** all the options are the responses, hg: hemoglobin, bp: blood pressure, bbp: beat per minute, mmhg: millimeter of mercury.

Attitude about non-pneumatic anti-shock garment

Regarding the attitude of the respondents towards NASG, one hundred ninety-eight (48%) of the respondents disagreed that the use of anti-shock garment (NASG) is unnecessary especially in the center where there is a facility for blood transfusion. Around two-fifth, (39%) of the respondents agreed that the garment (NASG) is expensive, therefore not affordable (Table 4).

Table 4

Attitudes towards NASG utilization among obstetric care providers working in public health facilitates of southern Ethiopia, 2020.

Variables	AgreeNo (%)	Neutral	DisagreeNo (%)
The use of anti-shock garment (NASG) is unnecessary especially in the center where there is a facility for blood transfusion	172 (41.8)	42 (10.2)	198 (48)
There is no need for NASG, since it is not readily available	145 (35.2)	49 (11.9)	218 (52.9)
The garment (NASG) is expensive, therefore not affordable	160 (38.8)	47 (11.4)	205 (49.7)
The NASG application and removal require a lot of procedures that take time.	135 (32.8)	39 (9.5)	238 (57.8)
The NASG can transmit HIV to patients; hence it is not advisable to be used in a hospital setting	217 (52.7)	60 (14.6)	135 (32.8)
A NASG is only beneficial to people in rural areas/primary care settings	154 (37.4)	43 (10.4)	215 (52.2)
NASG is only meant to be utilized by doctors	232 (56.4)	49 (11.9)	131 (31.8)
NASG is ineffective in patients with cervical lacerations	184 (44.7)	49 (11.9)	179 (43.4)

Utilization of non-pneumatic anti-shock garment

Regarding the utilization of NASG by obstetric care providers, two hundred (48.4.2%) used NASG for postpartum hemorrhage management while 51.45% never applied NASG while managing a patient with postpartum hemorrhage. More than half (54%) of the respondents mentioned “Don’t know how to use it” as the reason for non-utilization (Table 5).

Table 5

Utilization of non-pneumatic anti-shock garment among obstetric care providers working in public health facilities of southern Ethiopia, 2020.

Variables	Frequency	Percentage
Used NASG for the management of PPH (N = 412)
Yes	200	48.54
No	212	51.46
Reason for non-utilization*(N = 212)
Didn’t know it was available	59	28.23
No patient needed it	37	17.70
Don’t know how to use it	115	54.07
Do you use NASG every time there is PPH(N = 200)
Yes	109	54.50
No	91	45.50
If not, when do you use it*(N = 91)
severe pph	54	59.34
shock	20	21.98
when other method fail	17	18.68

Overall, 48.4% (95% CI: 43.7, 53.4%) of the study participants had NASG for management of postpartum hemorrhage.

Factors associated with utilization of non-pneumatic antishock garment

Training on NASG, type of facility, attitude towards NASG, and good knowledge on NASG was significantly associated with obstetric care provider’s utilization of NASG after controlling for confounders in the multivariable model.

Obstetric care providers who received training on NASG were 3 times more likely to use NASG as compared to those who had no training (AOR = 2.92,95%CI: 1.74, 4.92).

Obstetric care providers who disagreed, and those who had a neutral attitude about NASG were 59% and 61% less likely to use NASG as compared to those who had a positive attitude, (AOR = 0.41, 95% CI: 0.24, 0.68) and (AOR = 0.39, 95CI: 0.21,0.73) respectively. The odds of the utilization of NASG among obstetric care providers who are working at hospitals were 1.81 times more likely to use NASG as compared to those who work at health centers (AOR = 1.81, 95%CI: 1.04, 3.16). Those who had good knowledge about NASG were 1.99 times more likely to use NASG (AOR = 1.99, 95% CI; 1.16, 3.42) (Table 6).

Table 6

Factors associated with the utilization of non-pneumatic antishock garment among obstetric care providers in public health facilities of Southern Ethiopia, 2020.

Variable	Utilization of NASG		COR (95%. C.I), P. Value	AOR (95% C.I), P-Value
	Yes	No
Age
20–24	40	41	0.8 (0.4, 1.3), 0.4	0.9 (0.4, 2.1), 0.8
25–30	90	116	0.6 (0.4, 0.9), 0.03	0.7 (0.4, 1.2), 0.2
>= 31	70	55	1	1
Year of experience in work
1–5 years	105	136	1	1
6–10 years	80	65	1.6 (1.1, 2.4), 0.03	1.3 (0.7, 2.1), 0.4
11 years and above	15	11	1.8 (0.8, 4.0), 0.2	1.06(0.5, 3.7), 0.9
Trend of staff motivation
Yes	81	56	1.9 (1.3, 2.8), 0.003	1.22 (0.71, 1.9), 0.5
No	119	156	1	1
Training on NASG
Yes	108	42	4.8 (3.1, 7.4), 0.001	2.9 (1.7, 4.2), 0.000*
No	92	170	1	1
Protocols about NASG
Yes	148	106	2.9 (1.9, 4.3), 0.000	1.3 (0.7, 2.1), 0.4
No	52	106	1	1
Attitude about NASG
Agree	96	67	1	1
Neutral	54	32	0.4 (0.2, 0.6), 0.001	0.4(0.2, 0.7), 0.003*
Disagree	64	101	0.5 (0.3, 0.7), 0.000	0.4 (0.2, 0.7), 0.001*
Type of facility
Hospital	162	131	2.6 (1.7, 4.1), 0.000	1.8 (1.0, 3.1), 0.034*
Health center	38	81	1	1
Knowledge on NASG
Good knowledge	165	138	2.6 (1.6, 4.17), 0.000	2 (1.7, 3.4), 0.012*
Poor knowledge	33	72	1	1

*Significant at P < 0.05.

Discussion

In this study, 48.5% (95%CI: 43.73, 53.48%) of the obstetric care providers had utilized NASG for the management of complications from postpartum hemorrhage. Training on NASG, type of facility, knowledge, and attitude on NASG were significantly associated with obstetric care provider’s utilization of NASG.

The magnitude of the utilization of NASG among obstetric care in the current study is in line with a study done in western Nigeria (52.2%) and higher than studies conducted in Jimma, Ethiopia (36.2%), Ibadan Nigeria (35%), Ondo-State, Nigeria (14.1%) [21, 23, 33, 34]. The possible explanation for this discrepancy could be due to a large number of public health facilities (11 hospitals and 34 health centers) included in the current study. Whereas the magnitude of the current study is lower than the study conducted in the northern part of Ethiopia [35]. This could be because the introduction of the instrument NASG in Ethiopia started in the northern part of the country in 2011.

Findings from this study revealed that training on NASG were significantly associated with the utilization of NASG. This finding is in line with studies done in Western Nigeria, and Jimma Ethiopia [23, 33]. This could be because the refreshment and subject-specific training provided at facilities paved a way for obstetric care providers to acquire the necessary information which enabled them on how to use the non-pneumatic antishock garment. In addition, those who had training will have fresh memory about NASG which will enable them to apply the instrument when the need arises. This emphasizes the necessity of new hire training at each facility for new employees on life-saving instruments like NASG. A study conducted elsewhere also emphasized the importance of training on job performance and also enhancing positive attitude [36]. Moreover, the provision of training is also positively associated with the satisfaction of professionals and the need to apply the new knowledge that has been acquired, it will help the professionals to believe that they have improved their professional competence and the quality of health care that they can provide [37].

In this study, obstetric care provider’s attitude was significantly associated with their utilization of NASG. Compared with providers with a positive attitude towards the NASG, providers with a negative and neutral attitude were 59% and 61% less likely to use the NASG, respectively. This finding is in line with studies conducted in two regions of Ethiopia [33, 35]. The possible explanation for this could be, positive attitude towards the instrument might be related to an interest in knowing and exploring the instrument which in turn would enable the obstetric care providers to use the instrument when the demand arises. In addition, the neutral or undecided attitude of obstetric providers may indicate that they may be inadequately informed about the use of NASG. This is important for programmers in this particular issue, it will be an entry into the knowledge of the range of uninformed obstetric care providers in the health care facilities. In contrary to this finding, a study from Ondo State Nigeria [31] reported a non-significant relationship between attitude towards NASG and professionals utilization of NASG. The possible reason for this could be due to methodological differences (having different sampling methods and procedures, the difference in the study setting, and the difference in computation of the attitude variable).

The current study revealed that knowledge about NASG is significantly associated with the utilization of NASG. This is consistent with studies conducted in Ondo State Nigeria, Western Nigeria, Northern Ethiopia, and Jimma Ethiopia [23, 31, 33, 35]. This could be due to the fact that the more knowledge the obstetric care providers have, the more confidence they will have to apply the NASG. Moreover, the use of the instrument is composed of different steps and precautions, so that those who had adequate knowledge will be able to use it efficiently and effectively. In contrary to the current study, findings from Bayelsa state Nigeria stated a non-significant association between professional’s knowledge and utilization of NASG [22]. The discrepancy could be due to the different types of obstetric care providers included in the current study, whereas only midwives were included in the other study. The other reason might be the difference in sample size used (the sample size in the current study is four-fold compared to this study conducted in Nigeria).

The current study revealed that facility type is significantly associated with the utilization of NASG. In countries like Ethiopia with limited resources, the distribution of basic facilities including NASG may not be even in hospitals and health centers. As was identified in the current study hospitals are more likely to use NASG than health centers. However, considering the delays and difficulties in accessing definitive care for postpartum hemorrhage management in different parts of the country, health centers should be targeted and addressed about the use of the NASG.

In this study, the year of experience, and age of the participants were not significantly associated with the use of NASG. The finding of this result is in agreement with the studies elsewhere [22, 23, 35].

The public health importance of this study is; postpartum hemorrhage, which is a leading cause of maternal death in developing countries including Ethiopia, its complications largely occur within a very narrow time window, lending themselves to very focused and targeted interventions. Successful management of postpartum hemorrhage will require a combination of approaches to expand access to skilled care and, at the same time, extend life-saving interventions. In low-resource settings, obstetric care providers have few resources with which to stabilize women with severe PPH. NASG reduces maternal mortality and morbidity by buying time and stabilizing women during delays in transport and receiving appropriate care. Knowledge of the NASG as a unique first-aid device with which to stabilize patients within the facility or while awaiting transport to a referral facility provides an increased ability to stabilize women in shock in primary care settings. With training obstetric care providers can stabilize hemorrhaging women with the NASG, preventing complications from postpartum hemorrhage. Therefore, determining the utilization status of NASG and different factors will enable the public policy to enforce the availability and utilization of the lifesaving and inexpensive instrument, thereby preventing devastating and life-threatening complications of postpartum hemorrhage.

Conclusions and recommendations

In the current study, roughly half of the providers use the NASG to prevent complications from postpartum hemorrhage. Training on NASG, type of facility, knowledge, and attitude on NASG were significantly associated with obstetric care provider’s utilization of NASG. Strategies and program initiatives should focus on strengthening in-service and continuous professional development training, thereby filling the knowledge and attitude gap among obstetric care providers. Health centers, which are mostly accessible by the majority of the rural Ethiopian community should be targeted in future programs for accessibility and utilization of NASG. Stakeholders and non-governmental organizations that are working on improving maternal health could use this opportunity to increase the accessibility of NASG, and build the capacity of obstetric care providers.

Data collection tool used for the study.

(DOCX)

Click here for additional data file.

Data set of the study.

(DTA)

Click here for additional data file.

27 Jul 2021

PONE-D-21-10132

Utilization of non-pneumatic anti-shock garment and associated factors for postpartum hemorrhage management among obstetric  care providers in public health facilities  of southern Ethiopia, 2020

PLOS ONE

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I appreciate the authors' work on this paper and the findings are interesting. As noted by the reviewers, a number of revisions are needed as well as editing for language and grammar. Please also make the data available to ensure compliance with PLoS One's open data policy.

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Reviewer #1: Partly

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: No

Reviewer #2: Yes

**********

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Reviewer #2: No

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Reviewer #1: Overall comment:

The aims of this study are valuable, and the authors’ recommendations for increasing the use of NASG by targeting primary health centers are a valuable message. However there are some issues in the reporting of the results and conclusions that should be clarified to reflect the data. In particular, the conclusion should recognize that the Ethiopian government and CHAI have achieved a significant victory if within a random sample of providers, nearly half are using the NASG for management of hypovolemic shock and PPH. Several other countries are working towards this goal but are not close to this achievement. Attention should also be paid to the interpretation of the scaled attitude data. The authors should be attentive to reporting this data in an objective manner. Otherwise, the authors’ conclusions appear sound and provide important feedback about the introduction of the NASG in Ethiopia.

There are some specific language edits and clarifications of the data that are needed for this manuscript to be ready for publication, which I have detailed below.

1. The data for this study is indicated as being fully available according to PLOS One’s guidelines. However some data has been simplified for analysis and is not available in its original form within the supplemental material. I have provided suggestions for how this could be corrected within the manuscript in comment #9.

2. Language:

a. Please correct the spelling of “professionals” in the abstract and throughout the text.

b. Please correct “settlement” to “establishment” in the abstract and throughout the text.

c. “nasg” should be capitalized NASG as an acronym throughout the text.

d. Authors should check spelling and capitalization throughout the text.

3. Line 40 “A significant proportion of obstetric care providers do not use non pneumatic antishock garment for preventing complications from postpartum hemorrhage.”

This is a subjective and possibly misleading statement, as the authors do not give a reference point for comparison. It would be more accurate to say “roughly half of providers are using the NASG,” and then go on to describe the reasons the authors would recommend that actions be taken to increase this proportion.

4. Line 81. Add period: “excessive bleeding. With the introduction…”

5. Lines 103-105 “Most the studies conducted before used a small sample size (60-112) [19-22] and in developed countries where maternal mortality is less than 64/100 000 [23-25]."

If the authors are referring to implementation studies (studies examining utilization), both parts of this statement are not accurate. Please refer to Mbaruku study was conducted with a sample size of 1,713 women in Tanzania, published in 2018.

https://pubmed.ncbi.nlm.nih.gov/30340602/

6. Line 234-235 Regarding the use of the NASG on patients with a viable fetus. This is perhaps not worth mentioning in this paper as this issue is not being explored in-depth. Conclusive studies have not been done to investigate safety of the NASG with a viable fetus, and the NASG can be considered for use when “there is no other way to save the mother’s life and both mother and fetus will die.” (https://www.nqocncop.org/forum/welcome-to-the-forum/complementary-role-of-non-pneumatic-anti-shock-garment-nasg-in-management-hemorrhagic-shock-in-obstetrics)

7. Line 238: Table 3

For the knowledge questions, the authors could consider indicating all the correct responses for the readers who may not have this information.

8. Line 248 “Over all, 245 (59.5%) of the respondts had unfavourbale attitude towards non neumatic antishock garment.”

This statement appears to be attempting to summarize the results of the 8 scaled attitude statements, and does not appear to be a sound conclusion. It's not clear how the number 245 was derived. If I understand the author’s interpretation, this statistic counts neutral responses as “unfavorable” rather than neutral. Please see the next comment for feedback on the interpretation of the Likert scale responses. This statement should be removed and replaced with information that is firmly rooted in the data, however I am not able to provide more guidance as not enough information about the attitude responses has been made available in the manuscript.

9. Table 4: Attitudes

Reporting Likert scale data can pose a challenge. The 5 point Likert scale used here allowed respondents to report a neutral or undecided response. However the authors have chosen to collapse the 5 possible responses into a binary variable, “favorable” or “unfavorable”. Collapsing 5 responses without differentiation is problematic. Characterizing neutral responses as negative can mislead the reader and impacts the authors’ interpretation.

“Undecided” responses are important within this context as they indicate the number of respondents who may feel insufficiently informed on the NASG. A respondent who feels uninformed about the NASG should be considered substantively different from a respondent who feels informed and has formed a negative attitude. The neutral response is in line with the “I don’t know” categories in Table 3. It is relevant and important for those who are programming activities on the NASG to know the scope of uniformed staff within the health facilities, and this information supports the authors’ conclusion that further training is required.

This data should be clearly presented to the readers. The authors should add at least 1 column to this table to show the neutral responses, or alter this table to include 5 columns, to reflect all possible responses to gain the full benefit of the Likert scale. Including the “strongly agrees” and “strongly disagrees” would add value to the authors ‘ work. This data can be represented in a table or a graph displaying all percentages. An example of clear representation of 5-point responses can be found in this article:

Haffer H, Schömig F, Rickert M, Randau T, Raschke M, Wirtz D, Pumberger M, Perka C. Impact of the COVID-19 Pandemic on Orthopaedic and Trauma Surgery in University Hospitals in Germany: Results of a Nationwide Survey. J Bone Joint Surg Am. 2020 Jul 15;102(14):e78. doi: 10.2106/JBJS.20.00756. PMID: 32675666; PMCID: PMC7431148.

In addition, I would recommend that “favorable” be changed to “disagree” and “unfavorable” be changed to “Agree” which are the standard convention in English.

These changes should ensure that readers do not misinterpret the important results in this table. These changes should also be reflected in Table 6, and discussed in the results.

10. Line 284 “substantiate” is not correct in this context. Sentence could read “The NASG has been proven effective as a tool to stabilize….”

11. Line 285 Replace “absolute” with “definitive.”

12. Line 311 “inception” The authors’ intention with this word is not clear. Possibly “initial” or “new hire trainings”?

13. Line 365 “A significant proportion of obstetric care providers do not use non pneumatic antishock garment for preventing complications from postpartum hemorrhage.”

Same correction recommended as line 40.

Reviewer #2: Please correct the grammar and some spelling errors in the manuscript. Please mention whether all the obstetric care workers in Southern Ethiopia have previously been offered training on how the NASG is used. Also mention whether refresher trainings are available. Also indicate whether the NASG is actually available at the institutions where the study was done. On page 13 please indicate the type of random sampling that was used to select the institutions that participated in the study. The title of Table 1 gives the impression that these are the socio-demographic characteristics of all obstetric care workers in the region. Better to title the table to indicate that these are the socio-demographic characteristics of only the obstetric care workers who participated in the study. On Table 2 under ''Professions'' what does ''Emergency surgery'' refer to? Is it referring to general surgeons? On page 18 (lines 229 to 231) what denominator was used to determine the proportion of respondents that knew that the NASG is made up of six parts? On Table 3 (page 19) was the third row from the bottom meant to say ''Transport to other facilities''? The type of questions in Table 4 and Table 5 ideally should not be asked of someone who says that they have never heard of the NASG. The denominators should exclude those who say that they have never heard of the NASG.

**********

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Reviewer #1: Yes: Michelle Skaer Therrien

Reviewer #2: No

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4 Aug 2021

Title: Utilization of non-pneumatic anti-shock garment and associated factors for postpartum hemorrhage management among obstetric care providers in public health facilities of southern Ethiopia, 2020

Authors:

Yordanos Gizachew Yeshitila (yordanos.gizachew@yahoo.com)

Agegnehu Bante (agegnehubante@gmail.com)

Zeleke Aschalew (zelekeaschalew@gmail.com)

Bezawit Afework (bezawitafework2010@gmail.com)

Selamawit Gebeyehu (emugebe.sg@gmail.com)

Responses compiled by: Yordanos Gizachew Yeshitila

On behalf of the authors

Responses to editor’s comment

Editor’s comments, suggestions and question are considered and carefully revised the manuscript as per the suggestions and comments. Thank you for the feedback. We have addressed each comment below and within the revised manuscript (tracked changes and clean version).

Sincerely,

Yordanos Gizachew Yeshitila , on behalf of the authors

Editors comment

Item 1:

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'

Response 1: Thank you dear editor, we have included all the three requested items

Item 2: When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response 2: Dear editor, we have gone through the manuscript, and revised it according to the PLOS ONE's style requirement

Item 3: We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

Response3: Dear editor, we have provided correct grant numbers for the awards we received for our study in the ‘Funding Information’ section on the electronic editorial manger section as well as on the manuscript. (However, our institution is not listed among the funders in the dropdown menu)

Item 4: in your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Response 4: Dear editor, we have provided the data availability statement as per the journal requirement on the electronic editorial manger data availability section

Item 5: Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Response 5: Dear editor, we have uploaded study’s minimal underlying data set as Supporting Information files

Item 6: Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Response 6: Dear editor, we have included captions for our Supporting Information files at the end of our manuscript, and updated any in-text citations to match accordingly

Item 7: I appreciate the authors' work on this paper and the findings are interesting. As noted by the reviewers, a number of revisions are needed as well as editing for language and grammar. Please also make the data available to ensure compliance with PLoS One's open data policy.

Response 7: Dear editor, thank you so much. We have gone through each and every concern and comments raised, and responded accordingly. We have also exhaustively worked on the editing for language and grammar

Reponses to reviewers

Reviewer’s comments and suggestions are considered and carefully revised the manuscript as per the suggestions and comments. I have addressed the requests and concerns raised by both the reviewers. I am very thankful to the potential reviewers for suggestions and comments, which substantially improved the manuscript

Response to reviewer 1

Item 1: The aims of this study are valuable, and the authors’ recommendations for increasing the use of NASG by targeting primary health centers are a valuable message. However there are some issues in the reporting of the results and conclusions that should be clarified to reflect the data. In particular, the conclusion should recognize that the Ethiopian government and CHAI have achieved a significant victory if within a random sample of providers, nearly half are using the NASG for management of hypovolemic shock and PPH. Several other countries are working towards this goal but are not close to this achievement. Attention should also be paid to the interpretation of the scaled attitude data. The authors should be attentive to reporting this data in an objective manner. Otherwise, the authors’ conclusions appear sound and provide important feedback about the introduction of the NASG in Ethiopia

Response 1: Dear reviewer, thank you for your insights and thank you so much for meticulous observation and comments which significantly improved the manuscript.

*We have considered and incorporated your suggestion on the interpretation of the scaled attitude data.

Item 2: The data for this study is indicated as being fully available according to PLOS One’s guidelines. However some data has been simplified for analysis and is not available in its original form within the supplemental material. I have provided suggestions for how this could be corrected within the manuscript in comment #9.

Response 2: Dear reviewer, we have provided the data as per your request.

(Page 14-15)

Item 3: Language:

a. Please correct the spelling of “professionals” in the abstract and throughout the text.

b. Please correct “settlement” to “establishment” in the abstract and throughout the text.

c. “nasg” should be capitalized NASG as an acronym throughout the text.

d. Authors should check spelling and capitalization throughout the text.

Response 3: Dear reviewer, we truly appreciate your suggestions and comments. We have incorporated each of them in the revised manuscript. The changes we made are presented on the revised manuscript with track change.

Item 4: Line 40 “A significant proportion of obstetric care providers do not use non pneumatic antishock garment for preventing complications from postpartum hemorrhage.”

This is a subjective and possibly misleading statement, as the authors do not give a reference point for comparison. It would be more accurate to say “roughly half of providers are using the NASG,” and then go on to describe the reasons the authors would recommend that actions be taken to increase this proportion

Response 4: Dear reviewer, we have corrected the sentences as per your suggestion.

Page 2, line 44-45 and page21, line 373-374

Item 5: Line 81. Add period: “excessive bleeding. With the introduction…”

Response 5: Dear reviewer, we have made the correction. Page 3, line 82

Item 6: Lines 103-105 “Most the studies conducted before used a small sample size (60-112) [19-22] and in developed countries where maternal mortality is less than 64/100 000 [23-25]."

If the authors are referring to implementation studies (studies examining utilization), both parts of this statement are not accurate. Please refer to Mbaruku study was conducted with a sample size of 1,713 women in Tanzania, published in 2018.

https://pubmed.ncbi.nlm.nih.gov/30340602/

Response 6: Dear reviewer, thank you for thorough review of our work.

The first part of the paragraph was intended to show those studies conducted on professionals knowledge and use of NASG, the references listed, and the sample size they used (in brackets) were Faiza et al (60), Kombo et al (100), Kolade et al (110), and Onasoga et al (112), however, for the second part of the statement as you have provided us with the references there are studies conducted in developing countries, where we were trying to show the studies from developed countries. So we removed the second part of the statement.

Item 7: Line 234-235 Regarding the use of the NASG on patients with a viable fetus. This is perhaps not worth mentioning in this paper as this issue is not being explored in-depth. Conclusive studies have not been done to investigate safety of the NASG with a viable fetus, and the NASG can be considered for use when “there is no other way to save the mother’s life and both mother and fetus will die.” (https://www.nqocncop.org/forum/welcome-to-the-forum/complementary-role-of-non-pneumatic-anti-shock-garment-nasg-in-management-hemorrhagic-shock-in-obstetrics)

Response 7: Dear reviewer, thank you again for your meticulous observation. It has been stated there is no absolute contraindication for use of NASG for PPH, However, regarding the use of NASG, as an indication, it is stated on pathfinder’s guideline that (page 87) “The NASG could be used to manage any condition where there is severe bleeding below the diaphragm. Our studies have documented use with all forms of obstetric hemorrhage, as long as the fetus is not viable in utero”

We would appreciate if you take look at the guideline

(https://www.pathfinder.org/publications/prevention-recognition-management-of-postpartum-hemorrhage-trainers-guide/

Item 8: For the knowledge questions, the authors could consider indicating all the correct responses for the readers who may not have this information.

Response 8: Dear reviewer, we have indicated the correct responses on the table with symbol and provided description for the symbols underneath the table.

Item 9: Line 248 “Over all, 245 (59.5%) of the respondts had unfavourbale attitude towards non neumatic antishock garment.”

This statement appears to be attempting to summarize the results of the 8 scaled attitude statements, and does not appear to be a sound conclusion. It's not clear how the number 245 was derived. If I understand the author’s interpretation, this statistic counts neutral responses as “unfavorable” rather than neutral. Please see the next comment for feedback on the interpretation of the Likert scale responses. This statement should be removed and replaced with information that is firmly rooted in the data, however I am not able to provide more guidance as not enough information about the attitude responses has been made available in the manuscript

Response 9: Dear reviewer, we are grateful for the comments and lesson on this specific issue, As you have emphasized, the neutral or undecided attitude of the professionals is another core aspect for future programmers and interventional projects on the area regarding NASG utilization.

*We have provided data on the neutral or undecided attitude aspect of the professionals (Page 14)

*The whole analysis was changed and interpreted again accounting for the neutral attitude (Page 16-17)

* We have also included under discussion part (Page9, line 320-339

Item 10: Table 4:

Attitudes

Reporting Likert scale data can pose a challenge. The 5 point Likert scale used here allowed respondents to report a neutral or undecided response. However the authors have chosen to collapse the 5 possible responses into a binary variable, “favorable” or “unfavorable”. Collapsing 5 responses without differentiation is problematic Characterizing neutral responses as negative can mislead the reader and impacts the authors’ interpretation.

“Undecided” responses are important within this context as they indicate the number of respondents who may feel insufficiently informed on the NASG. A respondent who feels uninformed about the NASG should be considered substantively different from a respondent who feels informed and has formed a negative attitude. The neutral response is in line with the “I don’t know” categories in Table 3. It is relevant and important for those who are programming activities on the NASG to know the scope of uniformed staff within the health facilities, and this information supports the authors’ conclusion that further training is required.

This data should be clearly presented to the readers. The authors should add at least 1 column to this table to show the neutral responses, or alter this table to include 5 columns, to reflect all possible responses to gain the full benefit of the Likert scale. Including the “strongly agrees” and “strongly disagrees” would add value to the authors ‘ work. This data can be represented in a table or a graph displaying all percentages. An example of clear representation of 5-point responses can be found in this article:

Haffer H, Schömig F, Rickert M, Randau T, Raschke M, Wirtz D, Pumberger M, Perka C. Impact of the COVID-19 Pandemic on Orthopaedic and Trauma Surgery in University Hospitals in Germany: Results of a Nationwide Survey. J Bone Joint Surg Am. 2020 Jul 15;102(14):e78. doi: 10.2106/JBJS.20.00756. PMID: 32675666; PMCID: PMC7431148.

In addition, I would recommend that “favorable” be changed to “disagree” and “unfavorable” be changed to “Agree” which are the standard convention in English.

These changes should ensure that readers do not misinterpret the important results in this table. These changes should also be reflected in Table 6, and discussed in the results.

Response 10: Thank you dear reviewer,

We have reviewed the article you suggested

(https://journals.lww.com/jbjsjournal/Fulltext/2020/07150/Impact_of_the_COVID_19_Pandemic_on_Orthopaedic_and.6.aspx

We have provided data on the neutral or undecided attitude aspect of the professionals (Page 14)

We have changed that “favorable” be changed to “agree” and “unfavorable” be changed to “disagree

Item 11: Line 284 “substantiate” is not correct in this context. Sentence could read “The NASG has been proven effective as a tool to stabilize….”

Response 11: Dear reviewer, we have revised it as per your suggestion, (Page 17, line 286)

Item 12: Line 285 Replace “absolute” with “definitive.”

Response 12: Dear reviewer, we have revised it as per your suggestion Page 17, line 287)

Item 13: Line 311 “inception” The authors’ intention with this word is not clear. Possibly “initial” or “new hire trainings”?

Response 13: Dear reviewer, the inception training were meant to be new hire training, as per your suggestion, we have corrected for clarity (Page 18, line 313)

Item 14: Line 365 “A significant proportion of obstetric care providers do not use non pneumatic antishock garment for preventing complications from postpartum hemorrhage.”

Same correction recommended as line 40.

Response 14: Dear reviewer, We have made the correction

Response to reviewer 2

Dear reviewer, thank you for your insights and thank you so much for meticulous observation and comments which significantly improved the manuscript.

Item 1: Please correct the grammar and some spelling errors in the manuscript.

Response 1: Dear reviewer, thank you. We have gone through the manuscript and made all the possible corrections. (changes can be found on the tracked version)

Item 2: Please mention whether all the obstetric care workers in Southern Ethiopia have previously been offered training on how the NASG is used.

Response 2: Dear reviewer, thank you. We have included obstetric care providers in health facilities where NASG is available, however weather they received training or not was one of the variable we assessed on table 2 (Page 10-11).

Item 3: Also mention whether refresher trainings are available

Response 3: Dear reviewer, same as to the above concern, we have included obstetric care providers in health facilities where NASG is available, however weather they received training or not was one of the variable we assessed on table 2 (Page 10-11).

Item 4: Also indicate whether the NASG is actually available at the institutions where the study was done.

Response 4: Dear reviewer, thank you. We have included obstetric care providers in health facilities where NASG is available, we have incorporated this under the method section, under subsection Study design and population (Page 6 line 132-133)

Item 5: On page 13 please indicate the type of random sampling that was used to select the institutions that participated in the study.

Response 5: Dear reviewer, thank you. We have indicated on page 6, line 146

Item 6: The title of Table 1 gives the impression that these are the socio-demographic characteristics of all obstetric care workers in the region. Better to title the table to indicate that these are the socio-demographic characteristics of only the obstetric care workers who participated in the study

Response 6: Dear reviewer, we truly appreciate your suggestion, we have revised the title as per your suggestion. (Page 9, line 210-211

Item 7: On Table 2 under ''Professions'' what does ''Emergency surgery'' refer to? Is it referring to general surgeons?

Response 7: Dear reviewer, we apologize for using the short version of the title. The profession is Integrated Emergency Obstetric Surgery, not general surgeons. We would appreciate if you visit the link for better clarification (https://ethiopia.unfpa.org/en/news/msc-programme-integrated-emergency-obstetric-surgery-launched

Item 8: On page 18 (lines 229 to 231) what denominator was used to

Response 8: Dear reviewer, we have used the denominator of 338 (those who heard about NASG) we have included the denominator for each question.

Item 9: On Table 3 (page 19) was the third row from the bottom meant to say ''Transport to other facilities''?

Response 9: Dear reviewer, thank you. Yes, it is mean to say ''Transport to other facilities''?, we have modified on the table

Item 10: The type of questions in Table 4 and Table 5 ideally should not be asked of someone who says that they have never heard of the NASG. The denominators should exclude those who say that they have never heard of the NASG.

Response 10: Dear reviewer, we are so much grateful for the suggestion, which we believe clear confusion for future readers. We have included the denominator for each question.

Submitted filename: Response to Reviewers.doc

Click here for additional data file.

7 Sep 2021

PONE-D-21-10132R1Utilization of non-pneumatic anti-shock garment and associated factors for postpartum hemorrhage management among obstetric  care providers in public health facilities  of southern Ethiopia, 2020PLOS ONE

Dear Dr. Yeshitila,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 22 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Catherine S. Todd

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

My thanks to the authors for undertaking this revision, which have improved the manuscript. In addition to the remaining critiques from the reviewers, please ensure the de-identified data set is included with the next revision, as required by the journal.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: No

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This revision has substantially addressed the issues that were raised in my comments as well as those of the other reviewer. I would like to thank the authors for their work to strengthen this paper. I have only minor corrections to recommends, otherwise I approve this paper.

1. Authors indicate in reply to the editors that the minimal data set is in the supporting information (Response 5 to the editor). In reviewing the supporting information, I noted only the tool used to collect the data, but did not find the original data. I believe this may remain to be addressed.

2. A comment: thank you to the authors for clarifying the reference on use with a viable fetus. Please note the Pathfinder document used as a reference is based on information from 2007, and has not been updated. It is considered out-of-date in light of several years of experience with the NASG in the field.

3. p.12 Velcro should have an asterisk as well, as the NASG is made of neoprene and velcro.

4. Line 238/239 The number is 198 and percentage is 48% of respondents disagreeing with the statement according to the table.

5. Line 240. The percentage is 39%, not 61% according to the table.

6. Line 295 "magnitude" (spelling correction)

Reviewer #2: There are still some concerns with the grammar. Please attend to the grammar or spelling errors in the following lines of the manuscript - 63, 67, 73, 75, 83, 95, 96 to 98 100, 105, 116, 131, 151, 159 to 160, 191, 198, 199, 207, 264, 279 and 373. Line 141 says the final sample size was 422 mothers? I think this is meant to read 422 health workers.

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Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

9 Sep 2021

Responses to editor’s comment

Dear editor, Thank you for the feedback. We have addressed comments and suggestions below and within the revised manuscript (tracked changes and clean version).

Sincerely,

Yordanos Gizachew Yeshitila, on behalf of the authors

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'

**Thank you dear editor, we have included all the three requested items

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

**Dear editor, thank you, we have gone tough the reference and made correction, we have showed the changes we made with highlight on the track version of the manuscript.

**We have also mentioned the changes we made to reference based on the suggestion from one of the reviewer on the cover letter

My thanks to the authors for undertaking this revision, which have improved the manuscript. In addition to the remaining critiques from the reviewers, please ensure the de-identified data set is included with the next revision, as required by the journal.

** Dear editor, we are grateful for the feedbacks. We have uploaded the de-identified data set which is used for the study.

Responses to the Reviewers' comment and question

Reviewer’s comments and suggestions are carefully considered and revised the manuscript as per the suggestions and comments. I have incorporated the suggestions and comments raised by both the reviewers. I am very thankful to the potential reviewers for suggestions and comments, which substantially improved the manuscript

Reviewer 1

Item 1: This revision has substantially addressed the issues that were raised in my comments as well as those of the other reviewer. I would like to thank the authors for their work to strengthen this paper. I have only minor corrections to recommends, otherwise I approve this paper

Response 1: Thank you dear reviewer for the feedback. We have incorporated your suggestion while revising the manuscript.

Item 2: Authors indicate in reply to the editors that the minimal data set is in the supporting information (Response 5 to the editor). In reviewing the supporting information, I noted only the tool used to collect the data, but did not find the original data. I believe this may remain to be addressed.

Response 2: Dear reviewer, we have uploaded the de-identified data set as per the inquiry. We apologize for not addressing the issue last time.

Item 3: A comment: thank you to the authors for clarifying the reference on use with a viable fetus. Please note the Pathfinder document used as a reference is based on information from 2007, and has not been updated. It is considered out-of-date in light of several years of experience with the NASG in the field.

Response 3: Dear reviewer, we truly appreciate your suggestions, for this specific inquiry we have replaced the reference with (Downing, J. et al) , DOI 10.1186/s12913-015-0694-6) although we didn’t mention it during our response last time. In addition please be informed that we have use other references together with pathfinder while developing the data collection tool including FIGO.

Item 4: . p.12 Velcro should have an asterisk as well, as the NASG is made of neoprene and velcro.

Response 4: Dear reviewer, we have corrected the sentences as per your suggestion. (Table 3)

Item 5: Line 238/239 The number is 198 and percentage is 48% of respondents disagreeing with the statement according to the table.

Response 5: Dear reviewer, thank you, we have made the correction. Page 14, line 245-246

Item 6: Line 240. The percentage is 39%, not 61% according to the table.

Response 6: Dear reviewer, thank you for your thorough review of our work. We have made the correction. Page 14, line 248-249

Item 7: Line 295 "magnitude" (spelling correction)

Response 7: Dear reviewer, thank you for thorough review of our work. We have made the correction. Page 18, line 303

Reviewer 2

Item 1: There are still some concerns with the grammar. Please attend to the grammar or spelling errors in the following lines of the manuscript - 63, 67, 73, 75, 83, 95, 96 to 98 100, 105, 116, 131, 151, 159 to 160, 191, 198, 199, 207, 264, 279 and 373.

Response 1: Dear reviewer, thank you. We have gone through the manuscript and made the correction as you pointed them out for us. We have made the changes on the track version of the manuscript

Item 2: Line 141 says the final sample size was 422 mothers? I think this is meant to read 422 health workers.

Response 2: Thank you dear reviewer, yes it health workers, we have made the correction accordingly.

Submitted filename: Response to Reviewers.doc

Click here for additional data file.

15 Sep 2021

PONE-D-21-10132R2Utilization of non-pneumatic anti-shock garment and associated factors for postpartum hemorrhage management among obstetric  care providers in public health facilities  of southern Ethiopia, 2020PLOS ONE

Dear Dr. Yeshitila,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Oct 30 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Catherine S. Todd

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

I thank the authors for their efforts to respond to reviewer comments. Despite this manuscript being revised twice, there remain considerable grammatical, formatting, and spelling errors that need to be addressed and corrected. Further, the non-pneumatic anti-shock garment (NASG) should be spelled out once and then the abbreviation used consistently through the remainder of the document. The manuscript would also greatly benefit from being made more concise - for example, the Introduction section states in three different places that postpartum hemorrhage is a leading cause of maternal mortality and gives the reasons for delayed care that lead to mortality. Please summarize this in one paragraph, describe the NASG in the next paragraph, discuss the introduction and use of NASG in Ethiopia briefly in a third paragraph and then state the gap in the evidence and the reason for the paper in the last paragraph. The Results section can similarly be abbreviated by removing double-reporting of proportions in the text that are also present in the tables. Simply summarize the most remarkable finding or two findings from each table and data not portrayed in tables. Please streamline the tables by only using one decimal place. Last, please streamline the Discussion section - the results should only be contextualized with the first paragraph summarizing the main findings. The current first paragraph re-states the Introduction - please remove this paragraph and simply summarize the main findings. Please take the time to carefully revise the manuscript before re-submission and consider engaging a professional editor who is a native English speaker.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

23 Sep 2021

Item 1: I thank the authors for their efforts to respond to reviewer comments. Despite this manuscript being revised twice, there remain considerable grammatical, formatting, and spelling errors that need to be addressed and corrected. Further, the non-pneumatic anti-shock garment (NASG) should be spelled out once and then the abbreviation used consistently through the remainder of the document. The manuscript would also greatly benefit from being made more concise - for example, the Introduction section states in three different places that postpartum hemorrhage is a leading cause of maternal mortality and gives the reasons for delayed care that lead to mortality. Please summarize this in one paragraph, describe the NASG in the next paragraph, discuss the introduction and use of NASG in Ethiopia briefly in a third paragraph, and then state the gap in the evidence and the reason for the paper in the last paragraph. The Results section can similarly be abbreviated by removing double-reporting of proportions in the text that are also present in the tables. Simply summarize the most remarkable finding or two findings from each table and data not portrayed in tables. Please streamline the tables by only using one decimal place. Last, please streamline the Discussion section - the results should only be contextualized with the first paragraph summarizing the main findings. The current first paragraph re-states the Introduction - please remove this paragraph and simply summarize the main findings. Please take the time to carefully revise the manuscript before re-submission and consider engaging a professional editor who is a native English speaker.

Response 1: Dear editor, we are very much grateful for the suggestions and comments which potentially improved our work.

• We have made all the corrections as per your suggestion (please kindly see the revised version with track change )

• We have exhaustively reviewed the manuscript and according to your recommendation, we engaged a professional editor (the changes made and are shown the revised manuscript with track change).

Submitted filename: Response to Reviewers.doc

Click here for additional data file.

6 Oct 2021

Utilization of non-pneumatic anti-shock garment and associated factors for postpartum hemorrhage management among obstetric  care providers in public health facilities  of southern Ethiopia, 2020

PONE-D-21-10132R3

Dear Dr. Yeshitila,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Catherine S. Todd

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

This manuscript is much improved and I thank the authors for their perseverance and attention to detail.

Reviewers' comments:

8 Oct 2021

PONE-D-21-10132R3

Utilization of non-pneumatic anti-shock garment and associated factors for postpartum hemorrhage management among obstetric care providers in public health facilities of southern Ethiopia, 2020

Dear Dr. Yeshitila:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Catherine S. Todd

Academic Editor

PLOS ONE