Determining why magnesium sulfate is not used to prevent and treat pre-eclampsia and eclampsia can help identify strategies to improve access to this drug and reduce the risk of maternal mortality in Mexico.
Hypertensive disorders are one of the leading causes of maternal mortality in Mexico, accounting for 25% of deaths annually. Many of these deaths are caused by seizures associated with pre-eclampsia and eclampsia. The World Health Organization (WHO) recommends magnesium sulfate as the most effective, safe, and low-cost anticonvulsant treatment for severe pre-eclampsia and eclampsia. In 2006, the Mexican Ministry of Health recommended use of magnesium sulfate and added it to the national essential drug list. However, in practice the drug is often not used in accordance with the guidelines. The Population Council conducted research to determine how often magnesium sulfate is used to treat pre-eclampsia and eclampsia in Mexico, and to understand health providers’ reasons for non-use.
To establish a baseline of magnesium sulfate use prior to the 2006 update to Mexico’s technical guidelines, Council researchers reviewed medical charts of women who had died as a result of hypertensive disorders during pregnancy in 2005. They found that fewer than half of the women with either severe pre-eclampsia (38%) or eclampsia (48%) had been treated with magnesium sulfate.
Researchers also interviewed 13 maternal health experts to determine why providers might not use magnesium sulfate, even when it is medically indicated according to WHO guidelines. The experts cited four possible barriers to use:
- Lack of knowledge of the current treatment recommendations
- Resistance to changing regimens
- Fear of adverse effects (if administered incorrectly, magnesium sulfate can cause serious complications)
- Inadequate monitoring or supervision
In addition to this national-level baseline study, the Council examined magnesium sulfate use and barriers to use in Mexico City and in Oaxaca State. In Mexico City, researchers analyzed the files of 91 women who died of eclampsia from 2005 to 2007. Magnesium sulfate was prescribed in just over half (51%) of cases (another 15% of medical charts did not specify whether it had been prescribed).
In Oaxaca, the Council reviewed the medical records of 493 women with severe pre-eclampsia and eclampsia who were treated at public hospitals and survived, as well as 13 women who died. Interviews were also conducted with 84 physicians who provide obstetric services and with 14 other key stakeholders.
The Oaxaca medical record review and physician surveys indicated that half or more of women with severe pre-eclampsia (50%) and eclampsia (82%) received adequate antihypertensive medication, but use of magnesium sulfate was inconsistent. The barriers to use in Oaxaca mirrored those at the national level, including a tendency to use experience-based practices instead of evidence-based guidelines and a lack of supervision. Providers and stakeholders in Oaxaca, a relatively poor area of Mexico, also noted a shortage of human and material resources and inadequate referral mechanisms.
Mexican public health officials are using the Council’s research findings to identify potential strategies for increasing health care professionals’ awareness of, confidence in, and willingness to use magnesium sulfate to prevent pregnant women from dying of hypertensive disorders.