Globally, severe pre-eclampsia/eclampsia (PE/E) is the second leading cause of maternal mortality. While PE (development of elevated blood pressure and protein in the urine during the second half of the pregnancy) is a relatively common disorder of pregnancy, if not detected and managed properly, it can progress to seizures (eclampsia), kidney and other organ damage, and ultimately death for both the mother and unborn child. Pregnant women in developing countries suffer disproportionately, where the risk of dying from severe PE/E is many times higher than that for a pregnant woman in a developed country.
Evidence-Based Interventions for PE/E
Examples of evidence-based interventions that MCHIP supported for the prevention and treatment of PE/E include:
- Calcium supplementation during pregnancy where calcium intake is low to reduce the risk of developing PE/E by up to 78% in high-risk groups, and even up to 41% in low-risk groups.
- Screening and early detection of PE through blood pressure measurement and simple urine protein detection at every antenatal care visit to improve prognosis by increasing opportunities for effective interventions to prevent progression of PE to eclampsia.
- Timely and effective management at the appropriate level of care to prevent maternal mortality associated with severe PE/E. Treatment includes:
– Use of MgS04 for the prevention and treatment of severe PE/E. MgSO4 is a lifesaving drug and the anti-convulsant of choice for women with severe PE/E. It reduces the risk of developing seizures or recurrent seizures by more than 50% compared to other drugs or no drugs.
– Anti-hypertensive therapy for severely elevated blood pressure; and
– Timely delivery.
Global Leadership
MCHIP helped to shape global thinking to make PE/E a priority maternal health intervention. Along with participation in global PE/E technical forums, MCHIP developed and disseminated tangible resource materials and publications, such as: an updated technical briefer on PE/E; technical resources in the PE/E toolkit; and a practical review article on the safety of magnesium sulfate for management of severe PE/E.
In-country Activities
MCHIP worked collaboratively from the global level to the country level to find practical and effective approaches to implement these evidence-based interventions. MCHIP provided global and regional leadership and knowledge promotion through participation in global PE/E technical forums with WHO and other global organizations, regional meetings in Africa and Asia, and the development and dissemination of resource materials and publications.
At the country level, MCHIP conducted two important and ongoing studies in its country programs to understand and scale up key maternal health interventions: 1) Quality of Care (QoC) Surveys to assess the frequency and quality of interventions to address direct causes of maternal and newborn deaths; and 2) Multi-country Analysis (MCA) to track the implementation progress of programs that target PPH and PE/E. These activities were closely linked with provider performance improvement interventions, such as competency-based training and ongoing innovative quality improvement activities that identify and address gaps in service delivery.
Results
MCHIP country programs used findings from the QoC surveys and MCA to identify gaps and develop action plans to address the gaps. As a result, in country programs where these actionable gaps were identified, steps were taken included:
- Policy and supply mechanism change to reduce MgSO4 stock outs at health facilities.
- Supply of Emergency PE/E kits (such as MgSO4, syringes and calcium gluconate) at each health facility to facilitate emergency intervention for PE/E.
- Competency-based training that includes standardized screening and detection of PE, management of severe PE/E, ongoing supportive supervision, on-the-job mentoring, and development of job aids to improve provider knowledge, skills and confidence.
- Policy change and training/quality improvement to allow task shifting, enabling lower level, frontline health workers to provide appropriate interventions to reduce maternal mortality due to PE/E.
- Inclusion of specific indicators of severe PE/E to better monitor quality of service delivery.
MCHIP also conducted a pilot study in Nepal on calcium supplementation for pregnant women distributed through health facilities during routine antenatal care to assess its coverage, compliance and effectiveness at preventing PE/E, and to inform scale up.