Attrition from care after the critical phase of severe pre-eclampsia and eclampsia: Insights from an intervention with magnesium sulphate in a primary care setting in northern Nigeria

Abstract

Background: Evidence has shown that Magnesium Sulphate (MgSo 4 ) is the gold standard for treating severe pre-eclampsia and eclampsia (SPE/E), and calls for its widespread use at all levels of health service delivery, including the primary care level. Objective: To determine if administering loading dose of MgSo 4 on pregnant women with severe preeclampsia and eclampsia at primary care level would improve maternal and fetal outcomes. Method: Two sets of Primary Health Care (PHC) facilities were identified; one served as experimental one and the other as control. The community health extension workers (CHEWs) and the community health officers (CHOs) at the experimental PHCs were trained to administer the loading dose of MgSo 4 for patients with SPE/E, in addition to other supportive treatments, before making a referral while the control PHCs did not give MgSo 4 , and neither administered diazepam as an alternative or no anti-convulsant at all, before making a referral to higher centers. Patients from the experimental and control facilities were prospectively monitored for fetal and maternal outcomes, namely maternal and fetal deaths, and for toxic effects of MgSo 4 in the experimental arm. Results: Of the 150 patients recruited, 82 (55%) were in the experimental group and 68 (45%) were in the control group. 90% of the patients in the experimental group defaulted after receiving the loading dose of MgSo 4 while the remaining 10% completed the referral process. 44% of those in the control group completed the referral process. There were 3 maternal and 3 perinatal deaths, all in the control group. No adverse outcome (maternal or fetal death) or toxic effect was recorded among the recipients of MgSo 4 . Conclusion: This study suggests that lower-cadre health care professionals at PHCs can administer the loading dose of MgSo 4 to SPE/E patients to improve maternal and fetal survival in critical states, without significant risk of adverse effects. However, the lack of compliance with referral processes remains a huge challenge.

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

“…Second, stakeholders reported that many patients who received a loading dose failed to complete the referral process to a higher level facility for delivery. This finding is consistent with other studies: in one study [17], 90% of women who received the loading dose did not complete the referral process.…”

“…However, many service providers interviewed maintained that the reason magnesium sulfate supply was never exhausted at the general hospitals was because health workers in the hospitals would only provide the loading dose of the drug, requiring patients to purchase the additional doses needed for treatment from the private sector (magnesium sulfate appears to be readily available through hospital pharmacies). According to one study conducted in 2013 [17], 62.2% of the cases required families of the women to purchase the drug for use after the loading dose.…”

Population Pharmacokinetic Modeling to Evaluate Standard Magnesium Sulfate Treatments and Alternative Dosing Regimens for Women With Preeclampsia

“…Although the regimen with only a 10g intramuscular loading dose seems unlikely to be successful, it is quite popular in low-resource settings and was associated with improved maternal and fetal survival in a study in northern Nigeria. 17 Systematic reviews of randomized studies (n = 4) 18 and nonrandomized studies (n = 5) 19 of various lower-dose or loading dose-only regimens in women with either preeclampsia or eclampsia were unable to identify differences in maternal and perinatal outcomes compared with standard regimens. However, definitive conclusions from either review could not be drawn because of the relatively sparse data evaluated.…”

Addressing barriers to quality of underutilized commodities and services for prevention and management of pre-eclampsia and eclampsia in Kenya

“…Innovative MNH training approaches, especially with high staff turnover and need re-train staff on site, have been proven to work 39,40,41 . Evidence shows that PHC workers, with training, can offer MgS04, especially if supported with functional referral systems 38 . Provider knowledge, competence, and confidence in managing PE/E can achieved be through such training approaches, and supportive supervision, for both lower and higher level facilities.…”