Marianne Vidler

Oral antihypertensive therapy for severe hypertension in pregnancy and postpartum: a systematic review

Pregnant and postpartum women with severe hypertension are at increased risk of stroke and require blood pressure (BP) reduction. Parenteral antihypertensives have been most commonly studied, but oral agents would be ideal for use in busy and resource‐constrained settings.

Preeclampsia in Low and Middle Income Countries—Health Services Lessons Learned From the PRE-EMPT (PRE-Eclampsia–Eclampsia Monitoring, Prevention & Treatment) Project

The hypertensive disorders of pregnancy, in particular preeclampsia, matter because adverse events occur in women with preeclampsia and, to a lesser extent, in women with the other hypertensive disorders. These adverse events are maternal, perinatal, and neonatal and can alter the life trajectory of each individual, should that life not be ended by complications. In this review we discuss a number of priorities and dilemmas that we perceive to be facing health services in low and middle income countries as they try to prioritize interventions to reduce the health burden related to preeclampsia. These priorities and dilemmas relate to calcium for preeclampsia prevention, risk stratification, antihypertensive and magnesium sulphate therapy, and mobile health. Significant progress has been and is being made to reduce the impact of preeclampsia in low and middle income countries, but it remains a priority focus as we attempt to achieve Millennium Development Goal 5.

The feasibility of community level interventions for pre-eclampsia in South Asia and Sub-Saharan Africa: a mixed-methods design

BackgroundGlobally, pre-eclampsia and eclampsia are major contributors to maternal and perinatal mortality; of which the vast majority of deaths occur in less developed countries. In addition, a disproportionate number of morbidities and mortalities occur due to delayed access to health services. The Community Level Interventions for Pre-eclampsia (CLIP) Trial aims to task-shift to community health workers the identification and emergency management of pre-eclampsia and eclampsia to improve access and timely care. Literature revealed paucity of published feasibility assessments prior to initiating large-scale community-based interventions. Arguably, well-conducted feasibility studies can provide valuable information about the potential success of clinical trials prior to implementation. Failure to fully understand the study context risks the effective implementation of the intervention and limits the likelihood of post-trial scale-up. Therefore, it was imperative to conduct community-level feasibility assessments for a trial of this magnitude.MethodsA mixed methods design guided by normalization process theory was used for this study in Nigeria, Mozambique, Pakistan, and India to explore enabling and impeding factors for the CLIP Trial implementation. Qualitative data were collected through participant observation, document review, focus group discussion and in-depth interviews with diverse groups of community members, key informants at community level, healthcare providers, and policy makers. Quantitative data were collected through health facility assessments, self-administered community health worker surveys, and household demographic and health surveillance.ResultsRefer to CLIP Trial feasibility publications in the current and/or forthcoming supplement.ConclusionsFeasibility assessments for community level interventions, particularly those involving task-shifting across diverse regions, require an appropriate theoretical framework and careful selection of research methods. The use of qualitative and quantitative methods increased the data richness to better understand the community contexts.Trial registrationNCT01911494

Magnesium sulphate for the management of preeclampsia and eclampsia in low and middle income countries: a systematic review of tested dosing regimens.

OBJECTIVE To review systematically the magnesium sulphate (MgSO4) dosing regimens tested in low and middle income countries (LMICs) for women with preeclampsia (prevention) and/or eclampsia (treatment). DATA SOURCES We searched Medline, EMBASE, IPA, CINAHL, CDSR, and CENTRAL databases for relevant English language publications. STUDY SELECTION Our search yielded 753 publications, of which 26 (10 randomized controlled trials and 16 observational studies) evaluated MgSO4 for preeclampsia and/or eclampsia in World Bank-classified LMICs. DATA EXTRACTION Independent, by two authors. DATA SYNTHESIS Twenty-five studies were conducted in hospital settings and one in the community. Rates of eclampsia were usually < 5% (median 3.0%, range 0.0% to 26.5%) even when MgSO4 was administered for eclampsia. When dosage varied from the standard Pritchard or Zuspan regimens, almost all (n = 22) reduced the dose or duration of treatment, most commonly because of concerns about maternal safety, cost, or resource availability. Four trials of a loading dose only (4 g IV + 10 g IM) versus loading plus maintenance dosing of 5 g/4 hr IM found no difference in eclampsia recurrence (RR 1.64; 95% CI 0.48 to 5.65, n = 396). One study documented less eclampsia recurrence associated with community administration of a MgSO4 loading dose before referral to a care facility versus treatment in a care facility (RR 0.23; 95% CI 0.11 to 0.49, n = 265). CONCLUSION Use of MgSO4 for eclampsia treatment and prevention has been well-studied in LMICs, but concern remains about potential toxicity. Further studies are needed to identify the minimum effective dosage of MgSO4 for management of preeclampsia and eclampsia and whether MgSO4 loading can be safely administered in the community.

Utilization of maternal health care services and their determinants in Karnataka State, India

BackgroundKarnataka State continues to have the highest rates of maternal mortality in south India at 144/100,000 live births, but lower than the national estimates of 190–220/100,000 live births. Various barriers exist to timely and appropriate utilization of services during pregnancy, childbirth and postpartum. This study aimed to describe the patterns and determinants of routine and emergency maternal health care utilization in rural Karnataka State, India.MethodsThis study was conducted in Karnataka in 2012–2013. Purposive sampling was used to convene twenty three focus groups and twelve individual interviews with community and health system representatives: Auxiliary Nurse Midwives and Staff Nurses, Accredited Social Health Activists, community leaders, male decision-makers, female decision-makers, women of reproductive age, medical officers, private health care providers, senior health administrators, District health officers, and obstetricians. Local researchers familiar with the setting and language conducted all focus groups and interviews, these researchers were not known to community participants. All discussions were audio recorded, transcribed, and translated to English for analysis. A thematic analysis approach was taken utilizing an a priori thematic framework as well as inductive identification of themes.ResultsMost women in the focus groups reported regular antenatal care attendance, for an average of four visits, and more often for high-risk pregnancies. Antenatal care was typically delivered at the periphery by non-specialised providers. Participants reported that sought was care women experienced danger signs of complications. Postpartum care was reportedly rare, and mainly sought for the purpose of neonatal care. Factors that influenced women’s care-seeking included their limited autonomy, poor access to and funding for transport for non-emergent conditions, perceived poor quality of health care facilities, and the costs of care.ConclusionsRural south Indian communities reported regular use of health care services during pregnancy and for delivery. Uptake of maternity care services was attributed to new government programmes and increased availability of maternity services; nevertheless, some women delayed disclosure of pregnancy and first antenatal visit. Community-based initiatives should be enhanced to encourage early disclosure of pregnancies and to provide the community information regarding the importance of facility-based care. Health facility infrastructure in rural Karnataka should also be enhanced to ensure a consistent power supply and improved cleanliness on the wards.Trial registrationNCT01911494

Pharmacotherapy for Preeclampsia in Low and Middle Income Countries: An Analysis of Essential Medicines Lists

OBJECTIVE To determine the prevalence of drugs for comprehensive management of preeclampsia in national essential medicine lists (EMLs) in low and middle income countries (LMICs) METHODS We collected EMLs from the 144 LMICs identified by the World Bank through broad-based Internet searches and in collaboration with the World Health Organization. We identified therapies for hypertension, eclampsia, preeclampsia complications (e.g., pulmonary edema, thrombosis), preterm birth, and labour induction contained in the EMLs. RESULTS In 91 EMLs obtained from 144 LMICs, the most commonly listed parenteral antihypertensive therapies were verapamil (63.7%), hydralazine (61.5%), sodium nitroprusside (48.3%), and propranolol (39.6%). The most prevalent oral antihypertensive therapies were nifedipine (95.6%), methyldopa (93.4%), propranolol (90.1%), and atenolol (87.9%). For eclampsia/preeclampsia, magnesium sulphate was present in 84.6% of EMLs and calcium gluconate in 85.7%. For pulmonary edema, most EMLs (94.5%) listed oral furosemide, for thrombosis 92.3% listed heparin, for acceleration of fetal pulmonary maturity 90.1% listed parenteral dexamethasone, and for labour induction 97.8% listed oxytocin or a prostanoid (usually misoprostol, 40.7%). CONCLUSION EMLs of LMICs provide comprehensive coverage of preeclampsia pharmacotherapy. These EMLs may be used as advocacy tools to ensure the availability of these therapies within each country.

Determinants of health care seeking behaviour during pregnancy in Ogun State, Nigeria

BackgroundIn Nigeria, women too often suffer the consequences of serious obstetric complications that may lead to death. Delay in seeking care (phase I delay) is a recognized contributor to adverse pregnancy outcomes. This qualitative study aimed to describe the health care seeking practices in pregnancy, as well as the socio-cultural factors that influence these actions.MethodsThe study was conducted in Ogun State, in south-western Nigeria. Data were collected through focus group discussions with pregnant women, recently pregnant mothers, male decision-makers, opinion leaders, traditional birth attendants, health workers, and health administrators. A thematic analysis approach was used with QSR NVivo version 10.ResultsFindings show that women utilized multiple care givers during pregnancy, with a preference for traditional providers. There was a strong sense of trust in traditional medicine, particularly that provided by traditional birth attendants who are long-term residents in the community. The patriarchal c influenced health-seeking behaviour in pregnancy. Economic factors contributed to the delay in access to appropriate services. There was a consistent concern regarding the cost barrier in accessing health services. The challenges of accessing services were well recognised and these were greater when referral was to a higher level of care which in most cases attracted unaffordable costs.ConclusionWhile the high cost of care is a deterrent to health seeking behaviour, the cost of death of a woman or a child to the family and community is immeasurable. The use of innovative mechanisms for health care financing may be beneficial for women in these communities to reduce the barrier of high cost services. To reduce maternal deaths all stakeholders must be engaged in the process including policy makers, opinion leaders, health care consumers and providers. Underlying socio-cultural factors, such as structure of patriarchy, must also be addressed to sustainably improve maternal health.Trial registrationNCT01911494

Community perspectives on the determinants of maternal health in rural southern Mozambique: a qualitative study.

BackgroundMozambique has one of the highest rates of maternal mortality in sub-Saharan Africa. The main influences on maternal health encompass social, economic, political, environmental and cultural determinants of health. To effectively address maternal mortality in the post-2015 agenda, interventions need to consider the determinants of health so that their delivery is not limited to the health sector. The objective of this exploratory qualitative study was to identify key community groups’ perspectives on the perceived determinants of maternal health in rural areas of southern Mozambique.MethodsEleven focus group discussions were conducted with women of reproductive age, pregnant women, matrons, male partners, community leaders and health workers. Participants were recruited using sampling techniques of convenience and snow balling. Focus groups had an average of nine participants each. The heads of 12 administrative posts were also interviewed to understand the local context. Data were coded and analysed thematically using NVivo software.ResultsA broad range of political, economic, socio-cultural and environmental determinants of maternal health were identified by community representatives. It was perceived that the civil war has resulted in local unemployment and poverty that had a number of downstream effects including lack of funds for accessing medical care and transport, and influence on socio-cultural determinants, particularly gender relations that disadvantaged women. Socio-cultural determinants included intimate partner violence toward women, and strained relationships with in-laws and co-spouses. Social relationships were complex as there were both negative and positive impacts on maternal health. Environmental determinants included natural disasters and poor access to roads and transport exacerbated by the wet season and subsequent flooding.ConclusionsIn rural southern Mozambique, community perceptions of the determinants of maternal health included political, economic, socio-cultural and environmental factors. These determinants were closely linked with one another and highlight the importance of including the local history, context, culture and geography in the design of maternal health programs.

Community perceptions of pre-eclampsia and eclampsia in southern Mozambique

BackgroundSub-Saharan Africa has the highest maternal mortality ratio at 500 deaths per 100,000 live births. In Mozambique maternal mortality is estimated at 249-480 per 100,000 live births and eclampsia is the third leading cause of death. The objective of this study was to describe the community understanding of pre-eclampsia and eclampsia, as a crucial step to improve maternal and perinatal health in southern Mozambique.MethodsThis qualitative study was conducted in Maputo and Gaza Provinces of southern Mozambique. Twenty focus groups were convened with pregnant women, partners and husbands, matrons and traditional birth attendants, and mothers and mothers-in-law. In addition, ten interviews were conducted with traditional healers, matrons, and a traditional birth attendant. All discussions were audio-recorded, translated from local language (Changana) to Portuguese and transcribed verbatim prior to analysis with QSR NVivo 10. A thematic analysis approach was taken.ResultsThe conditions of “pre-eclampsia” and “eclampsia” were not known in these communities; however, participants were familiar with hypertension and seizures in pregnancy. Terms linked with the biomedical concept of pre-eclampsia were high blood pressure, fainting disease and illness of the heart, whereas illness of the moon, snake illness, falling disease, childhood illness, illness of scaresand epilepsy were used to characterizeeclampsia. The causes of hypertension in pregnancy were thought to include mistreatment by in-laws, marital problems, and excessive worrying. Seizures in pregnancy were believed to be caused by a snake living inside the woman’s body. Warning signs thought to be common to both conditions were headache, chest pain, weakness, dizziness, fainting, sweating, and swollen feet.ConclusionLocal beliefs in southern Mozambique, regarding the causes, presentation, outcomes and treatment of pre-eclampsia and eclampsia were not aligned with the biomedical perspective. The community was often unaware of the link between hypertension and seizures in pregnancy. The numerous widespread myths and misconceptions concerning pre-eclampsia and eclampsiamay induceinappropriatetreatment-seeking and demonstrate a need for increased community education regarding pregnancy and associated complications.Trial RegistrationNCT01911494ResumoAntecedentesA África Subsaariana tem a taxa de mortalidade materna mais alta, com cerca de 500 mortes por 100.000 nascidos vivos. Em Moçambique a mortalidade materna é estimada em 249-480 por 100.000 nascidos vivos e a eclâmpsia é a terceira causa de morte. O objectivo deste estudo foi de descrever o que as comunidades entendem por pré-eclâmpsia e eclâmpsia, como uma etapa crítica para melhorar a saúde materna e perinatal no sul de Moçambique.MétodosEste estudo qualitativo foi realizado nas Províncias de Maputo e Gaza no sul de Moçambique. Vinte discussões em grupos focais foram organizadas com mulheres grávidas, parceiros e maridos, matronas e parteiras tradicionais, mães e sogras. Adicionalmente, dez entrevistas em profundidade foram feitas com praticantes de medicina tradicional, matronas e parteiras tradicionais. Todas as entrevistas e discussões foram áudio-gravadas, traduzidas da língua local (Changana) para Português e transcritas na íntegra antes da análise com QSR NVivo 10. Foi usada uma abordagem de análise temática.ResultadosAs condições de “pré-eclâmpsia” e “eclâmpsia” não eram conhecidas nestas comunidades; contudo, os participantes estavam familiarizados com hipertensão e convulsões na gravidez. Os termos ligados a conceitos biomédicos de pré-eclâmpsia eram tensão alta, desmaios e doença do coração; enquanto doença da lua, doença da cobra, doença de queda, doença de infância, doença de sustos e epilepsia eram os termos usados para caracterizar a eclâmpsia.Localmente, pensa-se que as causas de hipertensão na gravidez incluem maus tratos por parte dos sogros, problemas conjugais e excesso de preocupações. Em relação as convulsões na gravidez, acredita-se que sejam causadas por uma cobra que vive dentro do corpo da mulher. Os sinais de perigo que se pensa serem comuns as duas condições eram dor de cabeça, dor do peito, fraqueza, tonturas, desmaios, sudação e pernas inchadas.ConclusãoCrenças locais no sul de Moçambique em relação as causas, apresentação, resultados e tratamento da pré-eclâmpsia e eclâmpsia não estavam alinhadas com a perspectiva biomédica. A comunidade muitas vezes não tinha conhecimento da ligação entre a hipertensão e as convulsões na gravidez. Os numerosos e generalizados mitos e falsos conceitos relativos a pré-eclâmpsia e eclâmpsia podem levar a tratamento inapropriado – exigindo e demonstrando a necessidade de reforço na educação da comunidade em relação a gravidez e complicações associadas.Registo do ensaioNCT01911494

Maternal and Newborn Health in Karnataka State, India: The Community Level Interventions for Pre-Eclampsia (CLIP) Trial's Baseline Study Results.

Existing vital health statistics registries in India have been unable to provide reliable estimates of maternal and newborn mortality and morbidity, and region-specific health estimates are essential to the planning and monitoring of health interventions. This study was designed to assess baseline rates as the precursor to a community-based cluster randomized control trial (cRCT)–Community Level Interventions for Pre-eclampsia (CLIP) Trial (NCT01911494; CTRI/2014/01/004352). The objective was to describe baseline demographics and health outcomes prior to initiation of the CLIP trial and to improve knowledge of population-level health, in particular of maternal and neonatal outcomes related to hypertensive disorders of pregnancy, in northern districts the state of Karnataka, India. The prospective population-based survey was conducted in eight clusters in Belgaum and Bagalkot districts in Karnataka State from 2013–2014. Data collection was undertaken by adapting the Maternal and Newborn Health registry platform, developed by the Global Network for Women’s and Child Health Studies. Descriptive statistics were completed using SAS and R. During the period of 2013–2014, prospective data was collected on 5,469 pregnant women with an average age of 23.2 (+/-3.3) years. Delivery outcomes were collected from 5,448 completed pregnancies. A majority of the women reported institutional deliveries (96.0%), largely attended by skilled birth attendants. The maternal mortality ratio of 103 (per 100,000 livebirths) was observed during this study, neonatal mortality ratio was 25 per 1,000 livebirths, and perinatal mortality ratio was 50 per 1,000 livebirths. Despite a high number of institutional deliveries, rates of stillbirth were 2.86%. Early enrollment and close follow-up and monitoring procedures established by the Maternal and Newborn Health registry allowed for negligible lost to follow-up. This population-level study provides regional rates of maternal and newborn health in Belgaum and Bagalkot in Karnataka over 2013–14. The mortality ratios and morbidity information can be used in planning interventions and monitoring indicators of effectiveness to inform policy and practice. Comprehensive regional epidemiologic data, such as that provided here, is essential to gauge improvements and challenges in maternal health, as well as track disparities found in rural areas.