hossain_experience implementing pe e management program in nigeria

8/2/2019 Hossain_Experience Implementing PE E Management Program in Nigeria

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Saving Nigerian Mothers:Magnesium Sulphate for thetreatment of Severe Pre-eclampsia and Eclampsia

J Tukur*

B Ahonsi**A Karlyn**I Araoyinbo**

Presented at

Asia Regional Meeting onInterventions for Impact in

Essential Obstetric and Newborn Care

Presenting bySharif Mohammed Ismail Hossain

4-6 May, 2012

Dhaka, Bangladesh*Aminu Kano Teaching Hospital,Kano, Nigeria; **Population Council, Nigeria


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Introduction Eclampsia is a common cause of maternal deaths worldwideespecially in developing countries About 10% women have increased BP during pregnancy 2-8% pregnancies complicated by pre-eclampsia (PE) 10% pre-eclampsia carry on to eclampsia (E) 10-20% maternal deaths are associated with SPE/E (50,000) The Eclampsia Collaborative Trial and Magpie studies confirmed

the efficacy of MgSO4 in the treatment of severe preeclampsia(SPE) and eclampsia. It showed 52-67% lower recurrence of seizures/fits than those treated with diazepam

and phenytoin, respectively

58% prevents progression from SPE to E

Reduce maternal deathsWHO 2005, The lancet 1995, Khat et al 2006; Magpie trial 2002; ETCG 1995)


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Background: Nigeria and Kano StateCategory National Kano State (north-west

Nigeria)

State 37 -

Population 140m 9.4m (most populous)

MMR 545/100,000 live births 1,000/100,000 live births

TFR 5.7 7.3

CPR (modern) 10%


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Background: Maternal deaths due tosevere pre-eclampsia/eclampsia in Nigeria In north-west Nigeria

31.3-46.4 maternal deaths contributed by eclampsia

One study shows that 60% of the patients with eclampsia were78% of them were primigravida

In south and central Nigeria 34.4% maternal deaths contributed by eclampsia

In Nigeria, eclampsia is a common cause of maternal deaths Despite the evidences that Mgso4 prevents progression from SPEto eclampsia and reduce maternal deaths it was not universally

used in Nigeria

Adam et al 2003, Kullim et al 2009, Tukur et al 2007 and 2008, SGO 2004


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The study Population Council launched the study in Kano State (mostpopulous state) with support from MacArthur foundation Pre-post study in clinical setting without separate control group The study was approved by NIMR and Pop. Council IRB/ERRC


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InterventionsInterventions were provided to 10 secondary level hospitals: Training of service providers Developing Mgso4 clinical protocol Supplying and introducing Mgso4

Training 25 staff trained (a doctor and a midwife from each facility)

2-day training

1

st

day: lectures on evidence-based management of hypertensive disorders ofpregnancy, how to use Mgso4 and treatment of Mgso4 toxicity

2nd day: practical training at 25-bed eclamptic ward of MMSH, demonstration

of use of Sphygmomanometer and urinalysis for proteinuria, injection of Mgso4

and toxicity monitoring


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Intervention (cont) The trained staff returned to their hospital and conducted step-down training (trained 160 staff within 3 months) Developed Mgso4 clinical protocolKano State eclampsia protocol.docx Participants were supplied with:

Mgso4 patella hammer (to assess deep tendon reflexes) and

calcium gluconate (antidote of Mgso4 toxicity)

All 10 facilities (Kano, Bichi, Wudi, Gwarno, Rano, Minjibir,Tudun, Wada, Dogrewa, Rano and Rogo) commenced the use ofthe Mgso4 (Feb 2008- Jan 2009)

Kano is urban and all other facilities are rural
http://kano%20state%20eclampsia%20protocol.docx/http://kano%20state%20eclampsia%20protocol.docx/http://kano%20state%20eclampsia%20protocol.docx/http://kano%20state%20eclampsia%20protocol.docx/


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Data collection and analysis Baseline information collected retrospectively from 3 facilitiesfor1 year (Jan 1, 2007 -Dec 31, 2007) A form developed and used to collect information from each

hospital (covers maternal socio-demographic characteristics,pattern of SPE/E and feto-maternal outcomes)

12 months data were collected monthly Two data review meetingswere organized with hospital staff SPSS was used for data entry and analysis Multivariate analysis was performed to determine the factorsassociated with SPE/E and its case fatality rate (CFR) Relative standard error (RSE) was used as a measure of an

estimated CFRs reliability and


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Baseline findings Baseline findings from 3 general hospitalsshows:

1233 mothers/patients took SPE/E services in the previous year

258 mothers died due to SPE/E

Case fatality rate (CFR) was 20.9%

Information on peri-natal mortality was not available

Used diazepam to manage the SPE/E patients


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Post-intervention findings: Socio-demographiccharacteristics of SPE/E patientsBasiccharacteristics

Severe pre-eclampsia(%)

Eclampsia(%)

Total(%)

Age

24 20.4 14.9 15.1

Missing 2.0 1.7 1.7Parity

Primigravida 61.2 60.3 60.4

1-5 26.5 35.2 34.8

>5 12.2 3.3 3.7

Missing 0 1.1 1.1

EducationNo 73.5 74.1 74.1

Primary 14.3 17.8 17.6

Secondary+ 10.2 6.3 6.5

Missing 2.0 1.8 1.8

N 49 996 1045


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Behavior for ANC and time needed toreach the hospital after seizures/fits

Time needed toreach hospital

Number of seizures/fits Total(%)0

(%)1-2

(%)3-4

(%)>4

(%)

1 hours 73.1 66.2 55.4 47.3 60.2

>1-3 hours 20.2 21.9 28.4 12.2 23.7

>3 hours 6.7 11.9 16.2 31.5 16.1

N 104 370 303 165 942*

Health seeking behavior for ANC Percentage

Taken ANC 55.9

Not taken ANC 44.1

N 1045

* Information was missing for 103 cases


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Outcomes of pregnancy, fetal & maternaldeaths after administration of MgSO4Outcomes Severe pre-eclampsia(%) Eclampsia(%) Total(%)

Pregnancy outcomes

SVD 53.1 76.7 75.6

CS 30.6 16.2 16.8

AVD 2.0 2.3 2.3Missing 14.3 4.8 5.3

Maternal outcomes

Dead 2.0 2.3 2.3

Alive 87.8 94.4 94.1

Missing 10.2 3.3 3.6

Foetal outcomes

Dead 4.1 12.8 12.3

Alive 81.6 83.6 83.5

Missing 14.3 3.6 4.1N 49 996 1045

SVD-spontaneous vaginal delivery; CS-caesarian section; AVD-assisted vaginal delivery


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Factors associated with eclampsia casefatality rate (CFR)Variables CFR (95% CI) AOR (95% CI)

Age

15-19 (ref) 1.5 (0.5, 2.6) 1.00

20 3.4 (1.8, 5.1) 1.46 (0.40, 5.42)

Parity

Primigravida (ref) 1.6 (0.6, 2.6) 1.00

1-5 2.9 (1.1, 4.6) 1.14 (0.31, 4.17)6 8.6 (0.8, 18.0) 4.99 (0.77, 32.22)*

Education

None (ref) 2.4 (1.3, 3.5) 1.00

Primary 2.9 (0.1, 5.7) 1.18 (0.23, 6.23)

Secondary /Higher 3.0 (1.1, 7.2) 1.00 (0.12, 8.25)

Number of seizures/fits before presentation

2 (ref) 1.3 (0.3, 2.3) 1.00

3 2.9 (1.3, 4.4) 2.19 (0.63, 7.55)

Recurrent seizures/fits after administration of loading dose

No (ref) 1.8 (0.9, 2.6) 1.00

Yes 9.2 (2.1, 16.3) 7.65 (1.62, 36.03)*

* Significant at p


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Factors associated with eclampsia casefatality rate (CFR) contVariables CFR (95% CI) AOR (95% CI)Mode of delivery

CS (ref) 2.3 (0.1, 4.5) 1.00

SVD 1.8 (0.9, 2.7) 0.77 (0.19, 3.09)

AVD 4.2 (4.0, 12.3) 2.58 (0.16, 41.52)

Condition

Pre-eclampsia (ref) 2.3 (2.2, 6.7) 1.00

Eclampsia 2.4 (1.4, 3.4) 0.59 (0.04, 8.94)

Time needed to reach hospital

1 hours (ref) 1.5(0.5, 2.5) 1.00

>1 hour 3.1(1.4, 4.7) 0.26(0.05, 1.33)

ANC taken or not

Yes (ref) 1.8(0.7, 2.9) 1.00

No 3.3(1.6, 5.1) 0.57(0.15, 2.13)

* Significant at p


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Factors associated with perinatal deathsFactors Perinatal Mortality

% (95% CI)Adjusted OR

(95% CI)Recurrent seizures/fits after MgSO4 loading doseNo (ref) 11.4 (9.5, 13.6) 1.00Yes 27.7 (17.3, 40.2) 2.64 (1.25, 5.54)*

Mode of deliveryCS (ref) 8.5 (4.8, 13.7) 1.00

SVD 12.4 (10.2, 15.0) 1.24 (0.65, 2.36)AVD 29.2 (12.6, 51.1) 3.48 (1.12, 10.91)*

Number of seizures/fits before presentation to hospital0 (ref) 3.7 (1.0, 9.1) 1.001-2 10.4 (7.6, 14.1) 3.02 (0.90, 10.20)3-4 13.4 (9.9, 17.9) 3.69 (1.09, 12.48)5 17.9 (12.4, 24.5) 5.70 (1.63, 19.93)*

Time before presentation to hospital1hour (ref) 9.7 (7.5, 12.5) 1.001hour 16.3 (13.0, 20.2) 1.04 (0.65, 1.68)

*Significant at p


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Comparison of case-fatality rates atbaseline and during intervention periodPeriod All SPE/E

cases

(n)

Fatality dueto SPE/E

(n)

CFR(95% CI)

(%)

RSE(%)

Baseline 1233 258 20.9

(18.7, 23.2)

5.5

Intervention 1045 24 2.3

(1.5, 3.5)

20.2

CFR= Case-Fatality Rate

RSE= Relative standard error


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Overall post-intervention findings Post intervention findings from 10 hospitals shows:

1045 SPE/E patients treated in 12 months

996 eclamptic patients

49 severe pre-eclamptic patients

Mean time before presentation 8.4 hours

Mean no. of seizures/fits 3.2

Case fatality rate (CFR) was 2.3%

Perinatal deaths was 12.3%

Reduction of CFR by 42.4%

2.2% patients showed toxic effect of Mgso4 but had no fatality Intervention findings further confirm that teenage, primigravidity and low

educational attainment are risk factors for developing SPE/E


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Utilization of results By the 10th month of the project, the State Government took overthe purchase of the drug and continued thereafter State Government replicated the intervention in other 25 facilities A follow on projectis being continuing on injecting loading dose

of Mgso4 by field workers (CHOs and CHEWs) and then referralto higher level and focusing on averting eclampsia by ante-nataldetection of SPE and prompt treatment with MgSo4 and referral

The project demonstrated that: Evidence based interventions could be introduced into new areas

Engaging stakeholders can made a project sustainable

Introduction of evidence based interventions usually replicable


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Challenges Stock-outs in a setting of free maternity scheme (all the facilitiesreported periods of stock-out of magnesium sulphate at least once

during the 12 months of the project) Delays in reaching health facilities by the women


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Thank you

hossain_experience implementing pe e management program in nigeria

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