Council research on the use of proven interventions for preventing and treating pre-eclampsia and eclampsia, thereby reducing the risk of maternal mortality and morbidity.
Hypertensive disorders during pregnancy are the second leading cause of maternal mortality. Many maternal deaths and a considerable proportion of maternal morbidity are caused by seizures associated with severe 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. Several national health protocols recommend its use. But in practice, the drug often is not available at primary care levels or may not be used in accordance with guidelines.
The Population Council conducted research to improve availability and correct use of magnesium sulfate to reduce the possibility of women dying from seizures, especially in resource-poor settings.
Northern Nigeria: Increased Access to Magnesium Sulfate
Council research in Kano State, Nigeria assessed healthcare providers’ acceptance of magnesium sulfate, the training required and capacity-building support needed to introduce magnesium sulfate in hospitals, and the factors influencing referral of patients with eclampsia for treatment. On the basis of the assessment, the Council developed a curriculum for health service providers.
Results were significant. Training providers with the curriculum resulted in a 40% reduction in maternal mortality and a 68% reduction in the contribution of eclampsia to maternal mortality across the 10 sites where the project took place, successful task-shifting of magnesium sulfate provision in 40 primary health care facilities, and development of a national training manual on the care of pregnant women with eclampsia.
In collaboration with WHO, Jhpiego, and the Nursing and Midwifery Council of Nigeria, the Council developed and tested a national curriculum to provide pre-service training to nurses, midwives, and community health workers on managing pre-eclampsia and eclampsia with magnesium sulfate. As a result, 70 nursing and midwifery schools in Nigeria now provide such pre-service training, and the Nigerian Ministry of Health has updated the country’s health policy to allow community health extension workers to administer an initial dose of magnesium sulfate at primary health care facilities before referring patients to the hospital.
Other Council work includes addressing delays in transporting women who receive an initial dose of magnesium sulfate at primary health care facilities to hospitals, as well as problems that arise during transit, and training hospital-based doctors and midwives to conduct training on pre-eclampsia and eclampsia and use of magnesium sulfate at their facilities.
Mexico: Determining Reasons for Non-use of Magnesium Sulfate
In 2006, the Mexican Ministry of Health recommended use of magnesium sulfate to treat eclampsia and added it to the national essential drug list. However, in practice the drug was 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 identify health providers’ reasons for non-use.
To establish a baseline of magnesium sulfate use among health providers prior to the 2006 update to Mexico’s technical guidelines, Council researchers reviewed medical charts of women who 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 maternal health experts to determine why providers might not use magnesium sulfate, even when it was 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 physicians who provide obstetric services and with 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 drugs, but use of magnesium sulfate was inconsistent. Barriers to use in Oaxaca included 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.
Bangladesh: Enhancing Community-level Provision of Magnesium Sulfate
In Bangladesh, Council researchers collaborated with EngenderHealth and the Obstetrical and Gynecological Society of Bangladesh on the expansion of magnesium sulfate usage by task-shifting to community-level service providers, who can screen and detect pre-eclampsia and eclampsia and provide an initial dose of magnesium sulfate to eligible women before referring them to higher-level facilities.
The Council’s research findings are being used to increase access to magnesium sulfate to reduce maternal mortality and morbidity.
In Nigeria, Council research demonstrated a reduction in maternal mortality; increased women’s access to magnesium sulfate; resulted in successful task-shifting to primary health care workers, who now provide an initial dose of magnesium sulfate to women prior to referral to hospital for further management; and led to the development of a widely used national training manual and curriculum.
In Mexico, public health officials are using the Council’s findings to identify potential strategies to increase health care professionals’ awareness of, confidence in, and willingness to use magnesium sulfate to prevent pregnant women from dying of hypertensive disorders.
And in Bangladesh, Council research provided evidence on the best ways to expand provision of magnesium sulfate in communities.