Scale-up of magnesium sulfate for treatment of pre-eclampsia and eclampsia in Nigeria

Scoping review of maternal and newborn health interventions and programmes in Nigeria

OBJECTIVE

To systematically scope and map research regarding interventions, programmes or strategies to improve maternal and newborn health (MNH) in Nigeria.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY CRITERIA

Systematic searches were conducted from 1 June to 22 July 2020 in PubMed, Embase, Scopus, together with a search of the grey literature. Publications presenting interventions and programmes to improve maternal or newborn health or both in Nigeria were included.

DATA EXTRACTION AND ANALYSIS

The data extracted included source and year of publication, geographical setting, study design, target population(s), type of intervention/programme, reported outcomes and any reported facilitators or barriers. Data analysis involved descriptive numerical summaries and qualitative content analysis. We summarised the evidence using a framework combining WHO recommendations for MNH, the continuum of care and the social determinants of health frameworks to identify gaps where further research and action may be needed.

RESULTS

A total of 80 publications were included in this review. Most interventions (71%) were aligned with WHO recommendations, and half (n=40) targeted the pregnancy and childbirth stages of the continuum of care. Most of the programmes (n=74) examined the intermediate social determinants of maternal health related to health system factors within health facilities, with only a few interventions aimed at structural social determinants. An integrated approach to implementation and funding constraints were among factors reported as facilitators and barriers, respectively.

CONCLUSION

Using an integrated framework, we found most MNH interventions in Nigeria were aligned with the WHO recommendations and focused on the intermediate social determinants of health within health facilities. We determined a paucity of research on interventions targeting the structural social determinants and community-based approaches, and limited attention to pre-pregnancy interventions. To accelerate progress towards the sustainable development goal MNH targets, greater focus on implementing interventions and measuring context-specific challenges beyond the health facility is required.

Factors affecting use of magnesium sulphate for pre-eclampsia or eclampsia: a qualitative evidence synthesis

Background

Hypertensive disorders account for 14% of global maternal deaths. Magnesium sulphate (MgSO₄) is recommended for prevention and treatment of pre‐eclampsia/eclampsia. However, MgSO₄ remains underused, particularly in low‐ and middle‐income countries (LMICs).

Objective

This qualitative evidence synthesis explores perceptions and experiences of healthcare providers, administrators and policy‐makers regarding factors affecting use of MgSO₄ to prevent or treat pre‐eclampsia/eclampsia.

Search strategy

We searched MEDLINE, EMBASE, Emcare, CINAHL, Global Health and Global Index Medicus, and grey literature for studies published between January 1995 and June 2021.

Selection criteria

Primary qualitative and mixed‐methods studies on factors affecting use of MgSO₄ in healthcare settings, from the perspectives of healthcare providers, administrators and policy‐makers, were eligible for inclusion.

Data collection and analysis

We applied a thematic synthesis approach to analysis, using COM‐B behaviour change theory to map factors affecting appropriate use of MgSO₄.

Main results

We included 22 studies, predominantly from LMICs. Key themes included provider competence and confidence administering MgSO₄ (attitudes and beliefs, complexities of administering, knowledge and experience), capability of health systems to ensure MgSO₄ availability at point of use (availability, resourcing and pathways to care) and knowledge translation (dissemination of research and recommendations). Within each COM‐B domain, we mapped facilitators and barriers to physical and psychological capability, physical and social opportunity, and how the interplay between these domains influences motivation.

Conclusions

These findings can inform policy and guideline development and improve implementation of MgSO₄ in clinical care. Such action is needed to ensure this life‐saving treatment is widely available and appropriately used.

Tweetable abstract

Global qualitative review identifies factors affecting underutilisation of MgSO₄ for pre‐eclampsia and eclampsia.

Global qualitative review identifies factors affecting underutilisation of MgSO₄ for pre‐eclampsia and eclampsia.

This article includes Author Insights, a video abstract available at https://vimeo.com/manage/videos/623192027

Linked article This article is commented on by LA Magee, p. 392 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16971.

Management of Preeclampsia, Severe Preeclampsia, and Eclampsia at Primary Care Facilities in Bangladesh

Program introduction, including cascade training, to screen for severe preeclampsia and eclampsia and initiate treatment with magnesium sulfate was somewhat successful. Challenges included inconsistent adherence to the national protocol, data quality, and some issues with supplies and equipment.

Introduction:

Eclampsia-related conditions are the second leading direct cause of obstetric deaths in Bangladesh. Efforts to prevent such deaths in low- and middle-income countries are increasingly focused on task shifting at the primary care level to enable frontline providers to screen and initiate treatment for women with preeclampsia, severe preeclampsia, and eclampsia (PE/SPE/E). The MaMoni Health Systems Strengthening project (funded by the United States Agency for International Development) implemented a magnesium sulfate intervention at primary care facilities in 4 Bangladesh districts in 2016 and 2017.

Methods:

The project trained frontline providers through a cascade approach from the national to the union level. A PE/SPE/E patient algorithm, digital blood pressure machines, and eclampsia kits with magnesium sulfate were supplied to service providers at each facility. We conducted a retrospective record review of facility-level data to assess the degree to which newly trained frontline providers adhered to a protocol that incorporated the use of magnesium sulfate for SPE/E in primary care settings.

Results:

In total, 283 women were found to have PE/SPE/E. Fifty-four percent were managed according to the protocol. The required supplies were present at each facility, but some issues existed with regard to availability and functionality of blood pressure apparatuses.

Discussion:

Challenges related to recordkeeping and service quality limited the analysis. Frontline providers need refresher trainings, ongoing supervision, properly calibrated blood pressure devices, and performance monitoring support in order to improve screening and management of PE/SPE/E in primary care facilities.

Quality of care in early detection and management of pre-eclampsia/eclampsia in health facilities in Afghanistan

Background

Afghanistan faces a high burden of maternal and neonatal morbidity and mortality. Hypertensive disorders of pregnancy, including pre-eclampsia and eclampsia (PE/E), are among the most common causes of maternal and neonatal complications. Hypertensive disorders of pregnancy can lead to fatal complications for both the mother and fetus. The 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment assessed quality of early detection and management of PE/E in health facilities and skilled birth attendants’ (SBAs) perceptions of their working environment.

Methods

All accessible public health facilities with an average of at least five births per day (n = 77), a nationally representative sample of public health facilities with less than five births per day (n = 149), and 20 purposively selected private health facilities were assessed. Methods included a facility inventory and record review, interviews with SBAs, and direct clinical observation of antenatal care (ANC), intrapartum care and immediate postnatal care (PNC), as well as severe PE/E case management.

Results

Most facilities had supplies and medicines for early detection and management of PE/E.

At public health facilities, 357 of 414 (86.2%) clients observed during ANC consultations had their blood pressure checked and 159 (38.4%) were asked if they had experienced symptoms of PE/E. Only 553 of 734 (72.6%) SBAs interviewed were able to correctly identify severe pre-eclampsia described in a case scenario. Of 29 PE/E cases observed, 17 women (59%) received the correct loading dose of magnesium sulfate (MgSO4) and 12 women (41%) received the correct maintenance dose of MgSO4.

At private health facilities, 39 of 45 ANC clients had their blood pressure checked and 9 of 45 (20%) were asked about symptoms of PE/E. Fifty-four of 64(84.4%) SBAs in private facilities correctly identified severe pre-eclampsia described in a case scenario.

Conclusion

Notable gaps in SBAs’ knowledge and clinical practices in detection and management of PE/E in various health facilities increase the risk of maternal and perinatal mortality. Continuing education of health care providers and increased investment in focused quality improvement initiatives will be critical to improve the quality of health care services in Afghanistan.

Anti-Angiogenic Tyrosine Kinase Inhibitors and Reversible Posterior Leukoencephalopathy Syndrome: Could Hypomagnesaemia Be the Trigger?

Reversible posterior leukoencephalopathy syndrome (RPLS), also known frequently as posterior reversible encephalopathy syndrome (PRES), is a characteristic acute neuro-radiology syndrome with clinical presentation that typically includes acute hypertension, seizures and other neurological symptoms and signs. Many patients with RPLS have (a history of) pre-existing hypertension and in receipt of diuretics. It is being diagnosed more frequently and in association with an increasing number of morbidities and medications. Drugs most frequently implicated are immunosuppressant drugs and anticancer agents, including a number of anti-angiogenic tyrosine kinase inhibitors (TKIs). Hypomagnesaemia is a frequent finding at presentation in RPLS patients, which is known to lead to or aggravate hypertension. Pre-eclampsia, a variant of RPLS, responds effectively to intravenous magnesium. Cyclosporin, tacrolimus and some TKIs that induce RPLS are also known to give rise to both hypertension and hypomagnesaemia. This raises an interesting hypothesis that hypomagnesaemia may play a contributory role in triggering RPLS in some patients by acutely raising the blood pressure further. Additional systematic studies are required to test this hypothesis. If the hypothesis is confirmed, hypomagnesaemia offers an effective target for risk mitigation and prevention of RPLS in patients identified at risk.