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Mayrink J, Reis ZSN. Pre-eclampsia in low and middle-income settings: What are the barriers to improving perinatal outcomes and evidence-based recommendations? Int J Gynaecol Obstet 2024; 164:33-39. [PMID: 37329226 DOI: 10.1002/ijgo.14913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/08/2023] [Accepted: 05/17/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To discuss the points that still challenge low- and middle-income countries (LMICs) and strategies that have been studied to help them overcome these issues. METHODS Narrative review addressing 20 years of articles concerning pre-eclampsia morbidity and mortality in LMICs. We summarized evidence-based strategies to overcome the challenges in order to reduce the pre-eclampsia impact on perinatal outcomes. RESULTS Pre-eclampsia is the first or second leading cause in the ranking of avoidable causes of maternal death, and approximately 16% of all maternal deaths are attributable to eclampsia and pre-eclampsia. Considering the social and economic contexts, it represents a major public health concern, and prevention and early detection of pre-eclampsia seem to be a major challenge. Reducing maternal mortality related to hypertensive disturbances depends on public policies to manage these preventable conditions. Early and continuous recognition of signs of severity related to hypertensive disorders during pregnancy and childbirth, self-monitoring of symptoms and blood pressure, as well as preventive approaches such as aspirin and calcium, and magnesium sulfate, are lifesaving procedures that have not yet reached a universal scale. CONCLUSION This review provides a vision of relevant points to support pregnant women in overcoming the constraints to healthcare access in LMICs, and strategies that can be applied in primary prenatal care units.
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Affiliation(s)
- Jussara Mayrink
- Federal University of Minas Gerais, Department of Obstetrics and Gynecology, Belo Horizonte, Brazil
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Stefanovic V. International Academy of Perinatal Medicine (IAPM) guidelines for screening, prediction, prevention and management of pre-eclampsia to reduce maternal mortality in developing countries. J Perinat Med 2023; 51:164-169. [PMID: 34957729 DOI: 10.1515/jpm-2021-0636] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 11/30/2021] [Indexed: 11/15/2022]
Abstract
Approximately 800 women die from pregnancy or childbirth-related complications around the world every day, 99% of which occur in developing countries. In majority of cases deaths are related to pre-eclampsia and eclampsia. The purpose of new adjusted and simplified IAPM guidelines is specifically lowering maternal mortality by decreasing preventable deaths in developing countries (particularly in remote rural areas) by using rather cheap medicines used to control chronic and gestational hypertension, prevent pre-eclampsia in high-risk pregnancies and treat severe pre-eclampsia and eclampsia. IAPM guidelines should be implemented and evaluated in each developing country respecting specific problems, needs and resources. It is of essential importance to: 1. Identify specific high-risk pregnancies, 2. Commence timely appropriate ASA and calcium supplementation, 3. Organize basic antenatal care and adequate referral of pregnancies with early onset of pre-eclampsia to the appropriate institutions and ensure induction of labour in well-equipped delivery facility for women with near-term and term pre-eclampsia 4. Ensure magnesium sulphate availability to prevent severe pre-eclampsia and eclampsia-related maternal deaths, and 5. Identify specific barriers for implementation of these guidelines and correct them accordingly. Only by systematic implementations of these guidelines, we may have a chance to decrease the mortality of pre-eclampsia an its complications as a killer number one of mothers in developing countries.
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Affiliation(s)
- Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Eddy KE, Vogel JP, Zahroh RI, Bohren MA. Factors affecting use of magnesium sulphate for pre-eclampsia or eclampsia: a qualitative evidence synthesis. BJOG 2021; 129:379-391. [PMID: 34520111 PMCID: PMC9291451 DOI: 10.1111/1471-0528.16913] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- K E Eddy
- Gender and Women's Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia.,Maternal, Child, and Adolescent Health Programme, Burnet Institute, Melbourne, VIC, Australia
| | - J P Vogel
- Maternal, Child, and Adolescent Health Programme, Burnet Institute, Melbourne, VIC, Australia
| | - R I Zahroh
- Gender and Women's Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia
| | - M A Bohren
- Gender and Women's Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia
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Ooms GI, Kibira D, Reed T, van den Ham HA, Mantel-Teeuwisse AK, Buckland-Merrett G. Access to sexual and reproductive health commodities in East and Southern Africa: a cross-country comparison of availability, affordability and stock-outs in Kenya, Tanzania, Uganda and Zambia. BMC Public Health 2020; 20:1053. [PMID: 32620159 PMCID: PMC7333276 DOI: 10.1186/s12889-020-09155-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Access to sexual and reproductive health services continues to be a public health concern in Kenya, Tanzania, Uganda and Zambia: use of modern contraceptives is low, and unmet family planning needs and maternal mortality remain high. This study is an assessment of the availability, affordability and stock-outs of essential sexual and reproductive health commodities (SRHC) in these countries to inform interventions to improve access. METHODS The study consisted of an adaptation of the World Health Organization/Health Action International methodology, Measuring Medicine Prices, Availability, Affordability and Price Components. Price, availability and stock-out data was collected in July 2019 for over fifty lowest-priced SRHC from public, private and private not-for-profit health facilities in Kenya (n = 221), Tanzania (n = 373), Uganda (n = 146) and Zambia (n = 245). Affordability was calculated using the wage of a lowest-paid government worker. Accessibility was illustrated by combining the availability (≥ 80%) and affordability (less than 1 day's wage) measures. RESULTS Overall availability of SRHC was low at less than 50% in all sectors, areas and countries, with highest mean availability found in Kenyan public facilities (46.6%). Stock-outs were common; the average number of stock-out days per month ranged from 3 days in Kenya's private and private not-for-profit sectors, to 12 days in Zambia's public sector. In the public sectors of Kenya, Uganda and Zambia, as well as in Zambia's private not-for-profit sector, all SRHC were free for the patient. In the other sectors unaffordability ranged from 2 to 9 SRHC being unaffordable, with magnesium sulphate being especially unaffordable in the countries. Accessibility was low across the countries, with Kenya's and Zambia's public sectors having six SRHC that met the accessibility threshold, while the private sector of Uganda had only one SRHC meeting the threshold. CONCLUSIONS Accessibility of SRHC remains a challenge. Low availability of SRHC in the public sector is compounded by regular stock-outs, forcing patients to seek care in other sectors where there are availability and affordability challenges. Health system strengthening is needed to ensure access, and these findings should be used by national governments to identify the gaps and shortcomings in their supply chains.
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Affiliation(s)
- Gaby I Ooms
- Health Action International, Overtoom 60-2, 1054, HK, Amsterdam, The Netherlands.
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.
| | - Denis Kibira
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
- Coalition for Health Promotion and Social Development (HEPS-Uganda), Kampala, Uganda
| | - Tim Reed
- Health Action International, Overtoom 60-2, 1054, HK, Amsterdam, The Netherlands
| | - Hendrika A van den Ham
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
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Akbar MIA, Yoseph D, - A, Bachnas MA, Dachlan EG, Dekker GA, Ernawati. Magnesium intoxication in women with preeclampsia with severe features treated with magnesium sulfate. Hypertens Pregnancy 2020; 39:221-227. [DOI: 10.1080/10641955.2020.1754851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Muhammad Ilham Aldika Akbar
- Department Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
- Department Obstetrics and Gynecology, DR. Soetomo General Academic Hospital, Surabaya, Indonesia
- Department Obstetrics and Gynecology, Universitas Airlangga Hospital, Surabaya, Indonesia
| | - Daniel Yoseph
- Department Obstetrics and Gynecology, DR. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Aditiawarman -
- Department Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
- Department Obstetrics and Gynecology, DR. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Muhammad Adrianes Bachnas
- Department Obstetrics and Gynecology, Dr. Moewardi General Hospital, Faculty of Medicine Universitas Sebelas Maret, Solo, Indonesia
| | - Erry Gumilar Dachlan
- Department Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
- Department Obstetrics and Gynecology, DR. Soetomo General Academic Hospital, Surabaya, Indonesia
- Department Obstetrics and Gynecology, Universitas Airlangga Hospital, Surabaya, Indonesia
| | - Gustaaf Albert Dekker
- Department Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
- Department Obstetrics and Gynecology, Lyell-McEwin Hospital, The University of Adelaide, Adelaide, Australia
| | - Ernawati
- Department Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
- Department Obstetrics and Gynecology, DR. Soetomo General Academic Hospital, Surabaya, Indonesia
- Department Obstetrics and Gynecology, Universitas Airlangga Hospital, Surabaya, Indonesia
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Chikalipo MC, Phiri LK, Mndolo N, Mbiza CR, Khisi P, Golombe E, Bonongwe P, Chirwa EM, Maluwa A. Perception of Midwives Towards Magnesium Sulfate Use at Chatinkha Maternity Wing in Blantyre, Malawi: A Qualitative Study. Int J Womens Health 2020; 12:187-196. [PMID: 32256123 PMCID: PMC7090174 DOI: 10.2147/ijwh.s223029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 02/20/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Globally, magnesium sulfate (MgSO4) has been recognized as the drug of choice for preventing and controlling fits among women with severe pre-eclampsia and eclampsia, respectively. Improper use of magnesium sulfate has been reported globally. Therefore, actionable findings for improving magnesium sulfate use are needed. This study aims at understanding the views of midwives towards MgSO4 use to inform an intervention whose objective is to improve MgSO4 use among the midwives. Methods An exploratory qualitative study was conducted from July to September 2018. We conducted 10 in-depth interviews and a focus group discussion with midwives. All the interviews were audio taped and transcribed verbatim. Data were managed by NVivo version 10.0 and analyzed thematically. Results We identified one overarching theme: “Inadequate governing approaches on management of clients on MgSO4” with corresponding subthemes; in adequate preparation on magnesium sulfate administration; inconsistent formula, regimen and guidelines/protocols on magnesium sulfate use and lack of resources. Conclusion Midwives perceived MgSO4 use as a demanding activity due to inadequate training, inconsistent tools, and lack of resources. While periodic in-service training should be intensified to improve MgSO4 use, necessary resources should be provided, such as blood pressure machines, more midwives, and protocols.
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Affiliation(s)
| | | | | | | | - Patricia Khisi
- Ministry of Health, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Eunice Golombe
- Ministry of Health, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Phylos Bonongwe
- Ministry of Health, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | | | - Alfred Maluwa
- Malawi University of Science and Technology, Blantyre, Malawi
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Incidence of maternal near miss among women in labour admitted to hospitals in Ethiopia. Midwifery 2019; 82:102597. [PMID: 31862558 DOI: 10.1016/j.midw.2019.102597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 10/18/2019] [Accepted: 12/02/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To assess the incidence of maternal near miss and contributing factors among hospitals in Ethiopia. The study also assessed the ability of hospitals to provide signal functions of emergency obstetric care and its regional distribution. DESIGN A national dataset accessed from the Ethiopian Public Health Institute were analysed to assess the incidence of maternal near miss and mortality index among women admitted to hospitals with obstetric complications. SETTING Maternal health indicators including obstetric complications, maternal deaths and births conducted at all hospitals available in Ethiopia were included. MEASUREMENTS The maternal near miss incidence ratio, which is the number of near miss cases per 1,000 live births, and the mortality index were presented descriptively. Chi-squared test at p value ≤ 0.05 was used to assess the presence of significant regional differences of the provision of signal functions of emergency obstetric care. RESULTS In 2015, 78,195 women were admitted to hospitals with both the direct (68,002) and indirect (10,193) causes of maternal mortality. Of women who experienced the direct causes, 435 died which means there were 67,567 maternal near miss cases. In the same year, 323,824 live births were reported in hospitals, making the crude maternal near miss incidence ratio of 20.8% (9.1-38.8%) and mortality index of 0.64% (435/68,002) for the direct causes of maternal mortality. A significant regional variation was observed with regard to incidence of maternal near miss, mortality index and the provision of signal functions of emergency obstetric care. Administration of parenteral antibiotics was the most frequently practiced signal function of emergency obstetric care while blood transfusion was the least provided signal function. CONCLUSIONS In Ethiopian hospitals, the incidence of maternal near miss was unacceptably high. A significant regional variation was detected with regard to maternal near miss incidence ratio, mortality index and the provision of signal functions of emergency obstetric care. The Ethiopian government needs to work on equitable resource distribution and quality improvement initiatives in order to close the detected regional variations. IMPLICATIONS FOR PRACTICE The Ethiopian government needs to practice evidence-based maternal health strategies, including capacity building of the regional hospitals in order to improve the distribution of resources and quality of maternal health.
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Rawlins B, Plotkin M, Rakotovao JP, Getachew A, Vaz M, Ricca J, Lynam P, Kagema F, Gomez P. Screening and management of pre-eclampsia and eclampsia in antenatal and labor and delivery services: findings from cross-sectional observation studies in six sub-Saharan African countries. BMC Pregnancy Childbirth 2018; 18:346. [PMID: 30139342 PMCID: PMC6108136 DOI: 10.1186/s12884-018-1972-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 08/08/2018] [Indexed: 11/25/2022] Open
Abstract
Background Preeclampsia and eclampsia (PE/E) are major contributors to maternal and neonatal deaths in developing countries, associated with 10–15% of direct maternal deaths and nearly a quarter of stillbirths and newborn deaths, many of which are preventable with improved care. We present results related to WHO-recommended interventions for screening and management of PE/E during antenatal care (ANC) and labor and delivery (L & D) from a study conducted in six sub-Saharan African countries. Methods From 2010 to 2012, cross-sectional studies which directly observed provision of ANC and L & D services in six sub-Saharan African countries were conducted. Results from 643 health facilities of different levels in Ethiopia (n = 19), Kenya (n = 509), Madagascar (n = 36), Mozambique (n = 46), Rwanda (n = 72), and Tanzania (n = 52), were combined for this analysis. While studies were sampled separately in each country, all used standardized observation checklists and inventory assessment tools. Results 2920 women receiving ANC and 2689 women in L & D were observed. Thirty-nine percent of ANC clients were asked about PE/E danger signs, and 68% had their blood pressure (BP) taken correctly (range 48–96%). Roughly half (46%) underwent testing for proteinuria. Twenty-three percent of women in L & D were asked about PE/E danger signs (range 11–34%); 77% had their BP checked upon admission (range 59–85%); and 6% had testing for proteinuria. Twenty-five cases of severe PE/E were observed: magnesium sulfate (MgSO4) was used in 15, not used in 5, and for 5 use was unknown. The availability of MgSO4 in L & D varied from 16% in Ethiopia to 100% in Mozambique. Conclusions Observed ANC consultations and L & D cases showed low use of WHO-recommended practices for PE/E screening and management. Availability of MgSO4 was low in multiple countries, though it was on the essential drug list of all surveyed countries. Country programs are encouraged to address gaps in screening and management of PE/E in ANC and L & D to contribute to lower maternal and perinatal mortality. Electronic supplementary material The online version of this article (10.1186/s12884-018-1972-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Marya Plotkin
- Jhpiego, 1615 Thames Street, Baltimore, MD, 21231, USA.
| | | | | | - Maria Vaz
- Jhpiego Mozambique, Maputo, Mozambique
| | - Jim Ricca
- Jhpiego, 1615 Thames Street, Baltimore, MD, 21231, USA
| | - Pam Lynam
- Jhpiego, 1615 Thames Street, Baltimore, MD, 21231, USA
| | - Frank Kagema
- Kenyatta Referral and Teaching Hospital, Nairobi, Kenya
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Munabi‐Babigumira S, Glenton C, Lewin S, Fretheim A, Nabudere H. Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis. Cochrane Database Syst Rev 2017; 11:CD011558. [PMID: 29148566 PMCID: PMC5721625 DOI: 10.1002/14651858.cd011558.pub2] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND In many low- and middle-income countries women are encouraged to give birth in clinics and hospitals so that they can receive care from skilled birth attendants. A skilled birth attendant (SBA) is a health worker such as a midwife, doctor, or nurse who is trained to manage normal pregnancy and childbirth. (S)he is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes and behaviour of SBAs, and the extent to which they work in an enabling working environment, impact on the quality of care provided. If any of these factors are missing, mothers and babies are likely to receive suboptimal care. OBJECTIVES To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies. SEARCH METHODS Our search strategies specified key and free text terms related to the perinatal period, and the health provider, and included methodological filters for qualitative evidence syntheses and for low- and middle-income countries. We searched MEDLINE, OvidSP (searched 21 November 2016), Embase, OvidSP (searched 28 November 2016), PsycINFO, OvidSP (searched 30 November 2016), POPLINE, K4Health (searched 30 November 2016), CINAHL, EBSCOhost (searched 30 November 2016), ProQuest Dissertations and Theses (searched 15 August 2013), Web of Science (searched 1 December 2016), World Health Organization Reproductive Health Library (searched 16 August 2013), and World Health Organization Global Health Library for WHO databases (searched 1 December 2016). SELECTION CRITERIA We included qualitative studies that focused on the views, experiences, and behaviours of SBAs and those who work with them as part of the team. We included studies from all levels of health care in low- and middle-income countries. DATA COLLECTION AND ANALYSIS One review author extracted data and assessed study quality, and another review author checked the data. We synthesised data using the best fit framework synthesis approach and assessed confidence in the evidence using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether the factors identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in a related intervention review. MAIN RESULTS We included 31 studies that explored the views and experiences of different types of SBAs, including doctors, midwives, nurses, auxiliary nurses and their managers. The included studies took place in Africa, Asia, and Latin America.Our synthesis pointed to a number of factors affecting SBAs' provision of quality care. The following factors were based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they were not always given sufficient training during their education or after they had begun clinical work. Also, inadequate staffing of facilities could increase the workloads of skilled birth attendants, make it difficult to provide supervision and result in mothers being offered poorer care. In addition, SBAs did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues were seen to increase stress and to negatively affect family life. Some SBAs also felt that managers lacked capacity and skills, and felt unsupported when their workplace concerns were not addressed.Possible causes of staff shortages in facilities included problems with hiring and assigning health workers to facilities where they were needed; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of care; these included good-quality housing, allowances for extra work, paid vacations, continuing education, appropriate assessments of their work, and rewards.Skilled birth attendants' ability to provide quality care was also limited by a lack of equipment, supplies, and drugs; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce SBAs' morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for SBAs to refer women on to higher levels of care. In addition, women's negative perceptions of the health system could make them reluctant to accept referral.We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants' motivation, their decision-making abilities, and the quality of care. Skilled birth attendants' workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers. AUTHORS' CONCLUSIONS Many factors influence the care that SBAs are able to provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork and of trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to all of these factors.
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Affiliation(s)
| | - Claire Glenton
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
| | - Simon Lewin
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
- South African Medical Research CouncilHealth Systems Research UnitPO Box 19070TygerbergSouth Africa7505
| | - Atle Fretheim
- Norwegian Institute of Public HealthPO Box 4404, NydalenOsloNorwayN‐0403
- University of OsloInstitute of Health and SocietyOsloNorway
| | - Harriet Nabudere
- Uganda National Health Research OrganisationPlot 2, Berkeley Lane, EntebbeEntebbeUganda
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Kyei-Nimakoh M, Carolan-Olah M, McCann TV. Access barriers to obstetric care at health facilities in sub-Saharan Africa-a systematic review. Syst Rev 2017; 6:110. [PMID: 28587676 PMCID: PMC5461715 DOI: 10.1186/s13643-017-0503-x] [Citation(s) in RCA: 178] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 05/19/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Since 2000, the United Nations' Millennium Development Goals, which included a goal to improve maternal health by the end of 2015, has facilitated significant reductions in maternal morbidity and mortality worldwide. However, despite more focused efforts made especially by low- and middle-income countries, targets were largely unmet in sub-Saharan Africa, where women are plagued by many challenges in seeking obstetric care. The aim of this review was to synthesise literature on barriers to obstetric care at health institutions in sub-Saharan Africa. METHODS This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases were electronically searched to identify studies on barriers to health facility-based obstetric care in sub-Saharan Africa, in English, and dated between 2000 and 2015. Combinations of search terms 'obstetric care', 'access', 'barriers', 'developing countries' and 'sub-Saharan Africa' were used to locate articles. Quantitative, qualitative and mixed-methods studies were considered. A narrative synthesis approach was employed to synthesise the evidence and explore relationships between included studies. RESULTS One hundred and sixty articles met the inclusion criteria. Currently, obstetric care access is hindered by several demand- and supply-side barriers. The principal demand-side barriers identified were limited household resources/income, non-availability of means of transportation, indirect transport costs, a lack of information on health care services/providers, issues related to stigma and women's self-esteem/assertiveness, a lack of birth preparation, cultural beliefs/practices and ignorance about required obstetric health services. On the supply-side, the most significant barriers were cost of services, physical distance between health facilities and service users' residence, long waiting times at health facilities, poor staff knowledge and skills, poor referral practices and poor staff interpersonal relationships. CONCLUSION Despite similarities in obstetric care barriers across sub-Saharan Africa, country-specific strategies are required to tackle the challenges mentioned. Governments need to develop strategies to improve healthcare systems and overall socioeconomic status of women, in order to tackle supply- and demand-side access barriers to obstetric care. It is also important that strategies adopted are supported by research evidence appropriate for local conditions. Finally, more research is needed, particularly, with regard to supply-side interventions that may improve the obstetric care experience of pregnant women. SYSTEMATIC REVIEW REGISTRATION PROSPERO 2014 CRD42014015549.
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Affiliation(s)
- Minerva Kyei-Nimakoh
- Disciplines of Nursing and Midwifery, Centre for Chronic Disease, College of Health and Biomedicine, Victoria University, PO Box 14428, Melbourne, Victoria 8001 Australia
| | - Mary Carolan-Olah
- Disciplines of Nursing and Midwifery, Centre for Chronic Disease, College of Health and Biomedicine, Victoria University, PO Box 14428, Melbourne, Victoria 8001 Australia
| | - Terence V. McCann
- Disciplines of Nursing and Midwifery, Centre for Chronic Disease, College of Health and Biomedicine, Victoria University, PO Box 14428, Melbourne, Victoria 8001 Australia
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Wolf HT, Huusom L, Weber T, Piedvache A, Schmidt S, Norman M, Zeitlin J. Use of magnesium sulfate before 32 weeks of gestation: a European population-based cohort study. BMJ Open 2017; 7:e013952. [PMID: 28132012 PMCID: PMC5278293 DOI: 10.1136/bmjopen-2016-013952] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 12/19/2016] [Accepted: 01/05/2017] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The use of magnesium sulfate (MgSO4) in European obstetric units is unknown. We aimed to describe reported policies and actual use of MgSO4 in women delivering before 32 weeks of gestation by indication. METHODS We used data from the European Perinatal Intensive Care in Europe (EPICE) population-based cohort study of births before 32 weeks of gestation in 19 regions in 11 European countries. Data were collected from April 2011 to September 2012 from medical records and questionnaires. The study population comprised 720 women with severe pre-eclampsia, eclampsia or HELLP and 3658 without pre-eclampsia delivering from 24 to 31 weeks of gestation in 119 maternity units with 20 or more very preterm deliveries per year. RESULTS Among women with severe pre-eclampsia, eclampsia or HELLP, 255 (35.4%) received MgSO4 before delivery. 41% of units reported use of MgSO4 whenever possible for pre-eclampsia and administered MgSO4 more often than units reporting use sometimes. In women without pre-eclampsia, 95 (2.6%) received MgSO4. 9 units (7.6%) reported using MgSO4 for fetal neuroprotection whenever possible. In these units, the median rate of MgSO4 use for deliveries without severe pre-eclampsia, eclampsia and HELLP was 14.3%. Only 1 unit reported using MgSO4 as a first-line tocolytic. Among women without pre-eclampsia, MgSO4 use was not higher in women hospitalised before delivery for preterm labour. CONCLUSIONS Severe pre-eclampsia, eclampsia or HELLP are not treated with MgSO4 as frequently as evidence-based medicine recommends. MgSO4 is seldom used for fetal neuroprotection, and is no longer used for tocolysis. To continuously lower morbidity, greater attention to use of MgSO4 is needed.
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Affiliation(s)
- H T Wolf
- Department of Obstetrics and Gynaecology, Hvidovre Hospital, Copenhagen University Hospital, Denmark
| | - L Huusom
- Department of Obstetrics and Gynaecology, Hvidovre Hospital, Copenhagen University Hospital, Denmark
| | - T Weber
- Department of Obstetrics and Gynaecology, Hvidovre Hospital, Copenhagen University Hospital, Denmark
| | - A Piedvache
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France
| | - S Schmidt
- Department of Obstetrics, University Hospital, Philipps University, Marburg, Germany
| | - M Norman
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - J Zeitlin
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France
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Sheikh S, Qureshi RN, Khowaja AR, Salam R, Vidler M, Sawchuck D, von Dadelszen P, Zaidi S, Bhutta Z. Health care provider knowledge and routine management of pre-eclampsia in Pakistan. Reprod Health 2016; 13:104. [PMID: 27719673 PMCID: PMC5056497 DOI: 10.1186/s12978-016-0215-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Maternal mortality ratio is 276 per 100,000 live births in Pakistan. Eclampsia is responsible for one in every ten maternal deaths despite the fact that management of this disease is inexpensive and has been available for decades. Many studies have shown that health care providers in low and middle-income countries have limited training to manage patients with eclampsia. Hence, we aimed to explore the knowledge of different cadres of health care providers regarding aetiology, diagnosis and treatment of pre-eclampsia and eclampsia and current management practices. METHODS We conducted a mixed method study in the districts of Hyderabad and Matiari in Sindh province, Pakistan. Focus group discussions and interviews were conducted with community health care providers, which included Lady Health Workers and their supervisors; traditional birth attendants and facility care providers. In total seven focus groups and 26 interviews were conducted. NVivo 10 was used for analysis and emerging themes and sub-themes were drawn. RESULTS All participants were providing care for pregnant women for more than a decade except one traditional birth attendant and two doctors. The most common cause of pre-eclampsia mentioned by community health care providers was stress of daily life: the burden of care giving, physical workload, short birth spacing and financial constraints. All health care provider groups except traditional birth attendants correctly identified the signs, symptoms, and complications of pre-eclampsia and eclampsia and were referring such women to tertiary health facilities. Only doctors were aware that magnesium sulphate is recommended for eclampsia management and prevention; however, they expressed fears regarding its use at first and secondary level health facilities. CONCLUSION This study found several gaps in knowledge regarding aetiology, diagnosis and treatment of pre-eclampsia among health care providers in Sindh. Findings suggest that lesser knowledge regarding management of pre-eclampsia is due to lack of refresher trainings and written guidelines for management of pre-eclampsia and presentation of fewer pre-eclamptic patients at first and secondary level health care facilities. We suggest to include management of pre-eclampsia in regular trainings of health care providers and to provide management protocols at all health facilities. TRIAL REGISTRATION NCT01911494.
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Affiliation(s)
- Sana Sheikh
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Asif Raza Khowaja
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
- Department of Obstetrics and Gynaecology, and the Child and Family Research Institute, University of British Columbia, Vancouver, V5Z 4H4 Canada
| | - Rehana Salam
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, and the Child and Family Research Institute, University of British Columbia, Vancouver, V5Z 4H4 Canada
| | - Diane Sawchuck
- Department of Research, Vancouver Island Health Authority, Victoria, V8R 1J8 Canada
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, St George’s, University of London, London, SW17 0RE UK
| | - Shujat Zaidi
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar Bhutta
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
- Program for Global Pediatric Research, Hospital for Sick Children, Toronto, M5G 2L3 Canada
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13
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Lotufo FA, Parpinelli MA, Osis MJ, Surita FG, Costa ML, Cecatti JG. Situational analysis of facilitators and barriers to availability and utilization of magnesium sulfate for eclampsia and severe preeclampsia in the public health system in Brazil. BMC Pregnancy Childbirth 2016; 16:254. [PMID: 27577571 PMCID: PMC5006565 DOI: 10.1186/s12884-016-1055-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/25/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Eclampsia is the main cause of maternal death in Brazil. Magnesium sulfate is the drug of choice for seizure prevention and control in the management of severe preeclampsia and eclampsia. Despite scientific evidence demonstrating its effectiveness and safety, there have been delays in managing hypertensive disorders, including timely access to magnesium sulfate. To conduct a general situational analysis on availability and use of magnesium sulfate for severe preeclampsia and eclampsia in the public health system. METHOD A situational analysis was conducted with two components: a documental analysis on information available at the official websites on the policy, regulation and availability of the medication, plus a cross sectional study with field analysis and interviews with local managers of public obstetric health services in Campinas, in the southeast of Brazil. We used the fishbone cause and effect diagram to organize study components. Interviews with managers were held during field observations using specific questionnaires. RESULTS There was no access to magnesium sulfate in primary care facilities, obstetric care was excluded from urgency services and clinical protocols for professional guidance on the adequate use of magnesium sulfate were lacking in the emergency mobile care service. Magnesium sulfate is currently only administered in referral maternity hospitals. CONCLUSION The lack of processes that promote the integration between urgency/emergency care and specialized obstetric care possibly favors the untimely use of magnesium sulfate and contributes to the high maternal morbidity/mortality rates.
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Affiliation(s)
- Fátima Aparecida Lotufo
- Department of Obstetrics and Gynecology of the University of Campinas School of Medicine, Campinas, Brazil
| | - Mary Angela Parpinelli
- Department of Obstetrics and Gynecology of the University of Campinas School of Medicine, Campinas, Brazil.
| | - Maria José Osis
- Sociologist and Full Professor of the Postgraduate Program on Obstetrics and Gynecology, University of Campinas School of Medicine, Campinas, Brazil
| | - Fernanda Garanhani Surita
- Department of Obstetrics and Gynecology of the University of Campinas School of Medicine, Campinas, Brazil
| | - Maria Laura Costa
- Department of Obstetrics and Gynecology of the University of Campinas School of Medicine, Campinas, Brazil
| | - José Guilherme Cecatti
- Department of Obstetrics and Gynecology of the University of Campinas School of Medicine, Campinas, Brazil
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Tran DN, Bero LA. Barriers and facilitators to the quality use of essential medicines for maternal health in low-resource countries: An Ishikawa framework. J Glob Health 2015; 5:010406. [PMID: 25969730 PMCID: PMC4416332 DOI: 10.7189/jogh.05.010406] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background An estimated 800 women die every day due to complications related to pregnancy or childbirth. Complications such as postpartum haemorrhage (PPH) and pre–eclampsia and eclampsia can be prevented by the appropriate use of essential medicines. The objective of this study was to identify the common barriers and facilitators to the availability and use of oxytocin, ergometrine, and magnesium sulfate (MgSO4) – essential medicines indicated for the prevention and treatment of PPH and pre–eclampsia and eclampsia. Methods We analyzed seven UNFPA/WHO reports published in 2008–2010. These reports summarized country–wide rapid assessments of access to and use of essential medicines for maternal health in Mongolia, Nepal, Laos, the Democratic People’s Republic of Korea (DPRK), the Philippines, Vanuatu, and the Solomon Islands. We used a “fishbone” (Ishikawa) diagram as the analytic framework to identify facilitators and barriers at four health–system levels: government/regulatory, pharmaceutical supply, health facility, and health professional. Results Common facilitators to the quality use of essential medicines for maternal health were observed at the government/regulatory and health professional level. A majority of countries had these medicines listed in their essential medicines lists. Awareness of the medicines was generally high among health professionals. Common barriers were identified at all health–system levels. First, standard treatment guidelines were not available, updated, or standardized. Second, there was an inadequate capacity to forecast and procure medicines. Third, a required MgSO4 antidote was often not available and the storage conditions for oxytocin were deficient. Conclusions The “fishbone” Ishikawa diagram is a useful tool for describing the findings of rapid assessments of quality use of essential medicines for maternal health across countries. The facilitators and barriers identified should guide the development of tailored intervention programs to improve and expand the use of these life–saving medicines.
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Affiliation(s)
- Dan N Tran
- Department of Clinical Pharmacy, University of California, San Francisco School of Pharmacy, CA, USA ; World Health Organization Collaborating Centre on Pharmaceutical Research and Science Policy, University of California, San Francisco, CA, USA
| | - Lisa A Bero
- Department of Clinical Pharmacy, University of California, San Francisco School of Pharmacy, CA, USA ; Institute for Health Policy Studies, University of California, San Francisco, CA, USA ; World Health Organization Collaborating Centre on Pharmaceutical Research and Science Policy, University of California, San Francisco, CA, USA ; Charles Perkins Centre, Faculty of Pharmacy, University of Sydney, Sydney, Australia
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Tukur J, Ahonsi B, Ishaku SM, Araoyinbo I, Okereke E, Babatunde AO. Maternal and fetal outcomes after introduction of magnesium sulphate for treatment of preeclampsia and eclampsia in selected secondary facilities: a low-cost intervention. Matern Child Health J 2014; 17:1191-8. [PMID: 22956402 DOI: 10.1007/s10995-012-1105-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The aim of this study was to evaluate whether a new low-cost strategy for the introduction of magnesium sulphate (MgSO4) for preeclampsia and eclampsia in low-resource areas will result in improved maternal and perinatal outcomes. Doctors and midwives from ten hospitals in Kano, Nigeria, were trained on the use of MgSO4. The trained health workers later conducted step-down training at their health facilities. MgSO4, treatment protocol, patella hammer, and calcium gluconate were then supplied to the hospitals. Data was collected through structured data forms. The data was analyzed using SPSS software. From February 2008 to January 2009, 1,045 patients with severe preeclampsia and eclampsia were treated. The case fatality rate for severe preeclampsia and eclampsia fell from 20.9 % (95 % CI 18.7-23.2) to 2.3 % (95 % CI 1.5-3.5). The perinatal mortality rate was 12.3 % as compared to 35.3 % in a center using diazepam. Introduction of MgSO4 in low-resource settings led to improved maternal and fetal outcomes in patients presenting with severe pre-eclampsia and eclampsia. Training of health workers on updated evidence-based interventions and providing an enabling environment for their practice are important components to the attainment of the Millennium Development Goals (MDG) in developing countries.
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Affiliation(s)
- Jamilu Tukur
- Department of Obstetrics and Gynaecology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria.
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Chahal HS, St Fort N, Bero L. Availability, prices and affordability of essential medicines in Haiti. J Glob Health 2013; 3:020405. [PMID: 24363923 PMCID: PMC3868824 DOI: 10.7189/jogh.03.020405] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Haiti is the poorest country in the Western Hemisphere and faces numerous challenges, including inadequate medication access for its residents. The objective of this study was to determine the availability, prices, and affordability of essential medicines in Haiti and compare these findings to other countries. Methods We conducted a cross–sectional nationwide survey in 2011 of availability and consumer prices of 60 essential medicines in Haiti using a standardized methodology developed by the World Health Organization and Health Action International. The survey was conducted in 163 medicine outlets in four health care sectors (public, retail, nonprofit and mixed sectors). Medicine prices were expressed as ratios relative to the International Reference Price. Affordability was calculated by comparing the costs of treatment for common conditions with the salary of the lowest paid government worker and was compared to available data from four Latin American countries. Results For generic medicines, the availability in public, retail, nonprofit and mixed sectors was 20%, 37%, 24% and 23% of medications, respectively. Most of the available medicines were priced higher than the International Reference Price. The lowest paid government worker would need 2.5 days’ wages to treat an adult respiratory infection with generic medicines from the public sector. For treatment of common conditions with originator brands (OB) purchased from a retail pharmacy, costs were between 1.4 (anaerobic bacterial infection) and 13.7 (hyperlipidemia) days’ wages, respectively. Treatment of pediatric bacterial infections with the OB of ceftriaxone from a retail pharmacy would cost 24.6 days’ wages. Prices in Bolivia, Colombia, Mexico and Nicaragua were frequently lower for comparable medications. Conclusions The availability of essential medicines was low and prices varied widely across all four sectors. Over 75% of Haitians live on less than US$ 2.00 /day; therefore, most medication regimens are largely unaffordable. Inclusion of essential medications on the national formulary and working with organizations responsible for importing medications into Haiti, particularly drug donation agencies, are important first steps to increasing medication access.
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Affiliation(s)
- Harinder Singh Chahal
- Department of Clinical Pharmacy, University of California, San Francisco, Cal., USA ; Haiti Initiative, University of California, San Francisco, Cal., USA
| | - Nazaire St Fort
- Haiti Initiative, University of California, San Francisco, Cal., USA
| | - Lisa Bero
- Clinical Pharmacy and Health Policy, University of California, San Francisco, Cal., USA
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Kim YM, Ansari N, Kols A, Tappis H, Currie S, Zainullah P, Bailey P, van Roosmalen J, Stekelenburg J. Prevention and management of severe pre-eclampsia/eclampsia in Afghanistan. BMC Pregnancy Childbirth 2013; 13:186. [PMID: 24119329 PMCID: PMC3852136 DOI: 10.1186/1471-2393-13-186] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 10/10/2013] [Indexed: 11/23/2022] Open
Abstract
Background An evidence-based strategy exists to reduce maternal morbidity and mortality associated with severe pre-eclampsia/eclampsia (PE/E), but it may be difficult to implement in low-resource settings. This study examines whether facilities that provide emergency obstetric and newborn care (EmONC) in Afghanistan have the capacity to manage severe PE/E cases. Methods A further analysis was conducted of the 2009–10 Afghanistan EmONC Needs Assessment. Assessors observed equipment and supplies available, and services provided at 78 of the 127 facilities offering comprehensive EmONC services and interviewed 224 providers. The providers also completed a written case scenario on severe PE/E. Descriptive statistics were used to summarize facility and provider characteristics. Student t-test, one-way ANOVA, and chi-square tests were performed to determine whether there were significant differences between facility types, doctors and midwives, and trained and untrained providers. Results The median number of severe PE/E cases in the past year was just 5 (range 0–42) at comprehensive health centers (CHCs) and district hospitals, compared with 44 (range 0–130) at provincial hospitals and 108 (range 32–540) at regional and specialized hospitals (p < 0.001). Most facilities had the drugs and supplies needed to treat severe PE/E, including the preferred anticonvulsant, magnesium sulfate (MgSO4). One-third of the smallest facilities and half of larger facilities reported administering a second-line drug, diazepam, in some cases. In the case scenario, 96% of doctors and 89% of midwives recognized that MgSO4 should be used to manage severe PE/E, but 42% of doctors and 58% of midwives also thought diazepam had a role to play. Providers who were trained on the use of MgSO4 scored significantly higher than untrained providers on six of 20 items in the case scenario. Providers at larger facilities significantly outscored those at smaller facilities on five items. There was a significant difference between doctors and midwives on only one item: continued use of anti-hypertensives after convulsions are controlled. Conclusions Drugs and supplies needed to treat severe PE/E are widely available at EmONC facilities in Afghanistan, but providers lack knowledge in some areas, especially concerning the use of MgSO4 and diazepam. Providers who have specialized training or work at larger facilities are better at managing cases of severe PE/E. The findings suggest a need to clarify service delivery guidelines, offer refresher training, and reinforce best practices with supervision and reinforcement.
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Affiliation(s)
- Young Mi Kim
- Jhpiego/USA, an affiliate of Johns Hopkins University, 1615 Thames Street, Baltimore, MD 21231, USA.
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Knight HE, Self A, Kennedy SH. Why are women dying when they reach hospital on time? A systematic review of the 'third delay'. PLoS One 2013; 8:e63846. [PMID: 23704943 PMCID: PMC3660500 DOI: 10.1371/journal.pone.0063846] [Citation(s) in RCA: 159] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 04/04/2013] [Indexed: 11/13/2022] Open
Abstract
Background The ‘three delays model’ attempts to explain delays in women accessing emergency obstetric care as the result of: 1) decision-making, 2) accessing services and 3) receipt of appropriate care once a health facility is reached. The third delay, although under-researched, is likely to be a source of considerable inequity in access to emergency obstetric care in developing countries. The aim of this systematic review was to identify and categorise specific facility-level barriers to the provision of evidence-based maternal health care in developing countries. Methods and Findings Five electronic databases were systematically searched using a 4-way strategy that combined search terms related to: 1) maternal health care; 2) maternity units; 3) barriers, and 4) developing countries. Forty-three original research articles were eligible to be included in the review. Thirty-two barriers to the receipt of timely and appropriate obstetric care at the facility level were identified and categorised into six emerging themes (Drugs and equipment; Policy and guidelines; Human resources; Facility infrastructure; Patient-related and Referral-related). Two investigators independently recorded the frequency with which barriers relating to the third delay were reported in the literature. The most commonly cited barriers were inadequate training/skills mix (86%); drug procurement/logistics problems (65%); staff shortages (60%); lack of equipment (51%) and low staff motivation (44%). Conclusions This review highlights how a focus on patient-side delays in the decision to seek care can conceal the fact that many health facilities in the developing world are still chronically under-resourced and unable to cope effectively with serious obstetric complications. We stress the importance of addressing supply-side barriers alongside demand-side factors if further reductions in maternal mortality are to be achieved.
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Affiliation(s)
- Hannah E Knight
- Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Oxford, United Kingdom.
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Bigdeli M, Zafar S, Assad H, Ghaffar A. Health system barriers to access and use of magnesium sulfate for women with severe pre-eclampsia and eclampsia in Pakistan: evidence for policy and practice. PLoS One 2013; 8:e59158. [PMID: 23555626 PMCID: PMC3608621 DOI: 10.1371/journal.pone.0059158] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 02/12/2013] [Indexed: 12/02/2022] Open
Abstract
Severe pre-eclampsia and eclampsia are rare but serious complications of pregnancy that threaten the lives of mothers during childbirth. Evidence supports the use of magnesium sulfate (MgSO4) as the first line treatment option for severe pre-eclampsia and eclampsia. Eclampsia is the third major cause of maternal mortality in Pakistan. As in many other Low- and Middle-Income Countries (LMIC), it is suspected that MgSO4 is critically under-utilized in the country. There is however a lack of information on context-specific health system barriers that prevent optimal use of this life-saving medicine in Pakistan. Combining quantitative and qualitative methods, namely policy document review, key informant interviews, focus group discussions and direct observation at health facility, we explored context-specific health system barriers and enablers that affect access and use of MgSO4 for severe pre-eclampsia and eclampsia in Pakistan. Our study finds that while international recommendations on MgSO4 have been adequately translated in national policies in Pakistan, the gap remains in implementation of national policies into practice. Barriers to access to and effective use of MgSO4 occur at health facility level where the medicine was not available and health staff was reluctant to use it. Low price of the medicine and the small market related to its narrow indications acted as disincentives for effective marketing. Results of our survey were further discussed in a multi-stakeholder round-table meeting and an action plan for increasing access to this life-saving medicine was identified.
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Affiliation(s)
- Maryam Bigdeli
- Alliance for Health Policy and System Research, World Health Organization, Geneva, Switzerland.
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20
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An integrative review of the side effects related to the use of magnesium sulfate for pre-eclampsia and eclampsia management. BMC Pregnancy Childbirth 2013; 13:34. [PMID: 23383864 PMCID: PMC3570392 DOI: 10.1186/1471-2393-13-34] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 01/29/2013] [Indexed: 11/30/2022] Open
Abstract
Background Pre-eclampsia/eclampsia is one of the most common causes of maternal and perinatal morbidity and mortality in low and middle income countries. Magnesium sulfate is the drug of choice for prevention of seizures as part of comprehensive management of the disease. Despite the compelling evidence for the effectiveness of magnesium sulfate, concern has been expressed about its safety and potential for toxicity, particularly among providers in low- and middle-income countries. The purpose of this review was to determine whether the literature published in these global settings supports the concerns about the safety of use of magnesium sulfate. Methods An integrative review of the literature was conducted to document the known incidences of severe adverse reactions to magnesium sulphate, and specific outcomes of interest related to its use. All types of prospective clinical studies were included if magnesium sulfate was used to manage pre-eclampsia or eclampsia, the study was conducted in a low- or middle-income country, and the study included the recording of the incidence of any adverse side effect resulting from magnesium sulfate use. Results A total of 24 studies that compared a magnesium sulfate regimen against other drug regimens and examined side effects among 34 subject groups were included. The overall rate of absent patellar reflex among all 9556 aggregated women was 1.6%, with a range of 0-57%. The overall rate of respiratory depression in 25 subject groups in which this outcome was reported was 1.3%, with a range of 0–8.2%. Delay in repeat administration of magnesium sulfate occurred in 3.6% of cases, with a range of 0-65%. Calcium gluconate was administered at an overall rate of less than 0.2%. There was only one maternal death that was attributed by the study authors to the use of magnesium sulfate among the 9556 women in the 24 studies. Conclusion Concerns about safety and toxicity from the use of magnesium sulfate should be mitigated by findings from this integrative review, which indicates a low incidence of the most severe side effects, documented in studies that used a wide variety of standard and modified drug regimens. Adverse effects of concern to providers occur infrequently, and when they occurred, a delay of repeat administration was generally sufficient to mitigate the effect. Early screening and diagnosis of the disease, appropriate treatment with proven drugs, and reasonable vigilance for women under treatment should be adopted as global policy and practice.
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Anson A, Ramay B, de Esparza AR, Bero L. Availability, prices and affordability of the World Health Organization's essential medicines for children in Guatemala. Global Health 2012; 8:22. [PMID: 22747646 PMCID: PMC3503802 DOI: 10.1186/1744-8603-8-22] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 06/13/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several World Health Organization (WHO) initiatives aim to improve the accessibility of safe and effective medicines for children. A first step in achieving this goal is to obtain a baseline measure of access to essential medicines. The objective of this project was to measure the availability, prices, and affordability of children's medicines in Guatemala. METHODS An adaption of the standardized methodology developed by the World Health Organization and Health Action International (HAI) was used to conduct a cross sectional survey to collect data on availability and final patient prices of medicines in public and private sector medicine outlets during April and May of 2010. RESULTS A subset of the public sector, Programa de Accesibilidad a los Medicamentos (PROAM), had the lowest average availability (25%) compared to the private sector (35%). In the private sector, highest and lowest priced medicines were 22.7 and 10.7 times more expensive than their international reference price comparison. Treatments were generally unaffordable, costing as much as 15 days wages for a course of ceftriaxone. CONCLUSIONS Analysis of the procurement, supply and distribution of specific medicines is needed to determine reasons for lack of availability. Improvements to accessibility could be made by developing an essential medicines list for children and including these medicines in national purchasing lists.
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Affiliation(s)
- Angela Anson
- Department of Clinical Pharmacy, University of California, San Francisco, CA 94143-0622, USA
| | - Brooke Ramay
- La Universidad del Valle de Guatemala, Vista Hermosa III, Guatemala City, Guatemala 01015
| | | | - Lisa Bero
- Department of Clinical Pharmacy, Institute for Health Policy Studies, University of California, San Francisco, CA 94118, USA
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Hill S, Yang A, Bero L. Priority medicines for maternal and child health: a global survey of national essential medicines lists. PLoS One 2012; 7:e38055. [PMID: 22675435 PMCID: PMC3365009 DOI: 10.1371/journal.pone.0038055] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 05/02/2012] [Indexed: 11/18/2022] Open
Abstract
Background In April 2011, the World Health Organization (WHO) published a list of “priority medicines” for maternal and child health based on 1) the global burden of disease and 2) evidence of efficacy and safety. The objective of this study was to examine the occurrence of these priority medicines on national essential medicines lists. Methods and Findings All essential medicines lists published since 1999 were selected from the WHO website collection. The most-up-to date list for each country was then selected, resulting in 89 unique country lists. Each list was evaluated for inclusion of medicines (chemical entity, concentration, and dosage form) on the Priority Medicines List. There was global variation in the listing of the Priority Medicines. The most frequently listed medicine was paracetamol, on 94% (84/89) of lists. Sodium chloride, gentamicin and oral rehydration solution were on 93% (83/89) of lists. The least frequently listed medicine was the children's antimalarial rectal artesunate, on 8% of lists (7/89); artesunate injection was on 16% (14/89) of lists. Pediatric artemisinin combination therapy, as dispersible tablets or flexible oral solid dosage form, appeared on 36% (32/89) of lists. Procaine benzylpenicillin, for treatment of pediatric pneumonia and neonatal sepsis, was on 50% (45/89) of the lists. Zinc, for treatment of diarrhoea in children, was included on only 15% (13/89) of lists. For prevention and treatment of postpartum hemorrhage in women, oxytocin was more prevalent on the lists than misoprostol; they were included on 55 (62%) and 31 (35%) of lists, respectively. Cefixime, for treatment of uncomplicated anogenital gonococcal infection in woman was on 26% (23/89) of lists. Magnesium sulfate injection for treatment of severe pre-eclampsia and eclampsia was on 50% (45/89) of the lists. Conclusions The findings suggest that countries need to urgently amend their lists to provide all priority medicines as part of the efforts to improve maternal and child health.
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Affiliation(s)
- Suzanne Hill
- Department of Essential Medicines and Pharmaceutical Policies, World Health Organization, Geneva, Switzerland
| | - Annie Yang
- Stanford Hospital & Clinics, Stanford, California, United States of America
| | - Lisa Bero
- Clinical Pharmacy and Health Policy, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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Barua A, Mundle S, Bracken H, Easterling T, Winikoff B. Facility and personnel factors influencing magnesium sulfate use for eclampsia and pre-eclampsia in 3 Indian hospitals. Int J Gynaecol Obstet 2011; 115:231-4. [PMID: 21930268 DOI: 10.1016/j.ijgo.2011.07.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 07/06/2011] [Accepted: 08/17/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To identify factors at the health facility and health professional levels that might hinder or facilitate the appropriate use of magnesium sulfate for the treatment of pre-eclampsia and eclampsia. METHODS Seven focus group discussions were conducted with a purposively sampled group of obstetricians/gynecologists, medical residents, and nurses at 3 hospitals in Nagpur, India. Data were collected on facility and drug availability, criteria for diagnosis and management of pre-eclampsia and eclampsia, attitudes about magnesium sulfate use, and perceived barriers to the treatment of pre-eclampsia and eclampsia. RESULTS Senior gynecologists seemed to encourage the use of magnesium sulfate, especially management prior to transfer to a higher facility. However, clinicians noted a lack of specific institutional guidelines on dose, timing, and indications, particularly in cases in which delivery was not imminent. In all facilities, service providers noted that their clinical care decisions were sometimes influenced by political and social factors, making management of eclampsia and pre-eclampsia cases difficult. Care was further challenged by limited drug availability, particularly at the tertiary-care center. CONCLUSION Limited drug supply and lack of specific institutional guidelines, equipment, and trained staff hinder the translation of evidence-based policy on magnesium sulfate into practice.
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