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Tackling the second biggest killer of mothers
Harshad SanghviVice President & Medical Director, JhpiegoMonday 10 March, 2010, Bangkok, Thailand
Why an additional Focus on PE/E
PE/E related mortality shows little decline in more than 75% of low resource countries
Disease targeted efforts within broad maternal and newborn care efforts are bearing fruit : eg Postabortion care, PPH, Infection prevention
Interventions are possible at all levels of health care system and high levels of coverage is feasible even outside formal healthcare systems
Nepal Maternal Mortality Study 1998 & 2009Cause of death
1998 2009PPH 37% 19%
Eclampsia
14% 21%
Source: Nepal maternal mortality study 2008-9 preliminary findings
Strategies to consider including in country plans
Tertiary prevention: Treatment of severe preeclampsia ( prevent
eclampsia Treatment of Eclampsia
Secondary Prevention: detecting Preeclampsia and timely delivery
Primary Prevention
Seeking simple, inexpensive and effective solutions that reach all pregnant women
Managing Preeclampsia
Monitoring for effects of PE on Renal and other functions Fetal growth and well being
Detecting severe Preeclampsia Controlling high blood pressure Preventing Seizures : Deciding when to institute
Magnesium Sulphate therapy On confirming diagnosis of Severe Preeclampsia In the context of severe Preeclampsia once decision
to deliver has been made Timely Delivery / Care of term and preterm
infants Postpartum vigilance and care
Epsom Salts
Gardens: Help seeds germinate Make plants grow bushier Produce more flowers
Spas: Dissolved in a bath, Epsom Salt
Ease stress Create a happy, relaxed feeling Raise energy levels
On Mars: The existence of Epsom salts on
Mars was first suggested by the 1976 Viking mission and has since been confirmed by the Mars Exploration Rover as well as the Odyssey and Pathfinder missions
But sadly Epsom salt (Magnesium Sulphate) was not available for this woman who died of Eclampsia
Availability of magnesium sulfate & diazepam: Hospitals, health centers & posts in select countries
92%
100%
55%
84%
81%
91%
88%
100%
63%
100%
12%
56%58
%
86%
9%
62%
10%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Magnesium sulfate Diazepam Magnesium sulfate Diazepam
Hospitals Health centers / posts
Nicaragua 2001 Bolivia 2004 Lesotho 2004 Malawi 2004 Sudan 2005
Preventing Eclampsia in women with Severe PE: Prophylactic magnesium sulphate
Halves risk of eclampsia NNT 100, 95% CI 50 to 100
probably reduces maternal death appears safe for baby about a quarter of women have side
effects, largely unpleasant rather than serious
applies to dosage in these trials, with clinical monitoring
Lelia Duley et al
Results: Cost-effectiveness (95% CI)
43184324NNT
0.0235
(0.0147-0.0331)
0.0054
(0.0001-0.0110)
0.0031
(0-0.0082)Difference in risk of eclampsia
11
(9-12)
13
(7-17)
65
(26-86)Difference in total cost ($)
Low incomeMiddle incomeHigh income
0.03030.01470.0084Baseline risk
456
(301-779)
2 473
(402-21 015)
21 202
(3 407-NA)Cost per eclampsia averted ($)
0.23 0.630.63Relative risk
-2-4-20Difference in other costs ($)
1317 86Difference in costs related to treatment ($)
43184324NNT
0.0235
(0.0147-0.0331)
0.0054
(0.0001-0.0110)
0.0031
(0-0.0082)Difference in risk of eclampsia
11
(9-12)
13
(7-17)
65
(26-86)Difference in total cost ($)
Low incomeMiddle incomeHigh income
0.03030.01470.0084Baseline risk
456
(301-779)
2 473
(402-21 015)
21 202
(3 407-NA)Cost per eclampsia averted ($)
0.23 0.630.63Relative risk
-2-4-20Difference in other costs ($)
1317 86Difference in costs related to treatment ($)
Courtesy: Lelia Duley
Treating Eclampsia
Comparison between magnesium sulphate and diazepam: 5 trials 1236 women: comparison between magnesium sulphate and diazepam
More than 50% reduction in recurrence of convulsions RR 0.45 95% CI 0.35-0.58 For every 7 women treated with mgSo4 rather
than diazepam, I case of recurrent convulsions prevented
Reduction in maternal mortality RR 0.60 (0.36-1.00) Reduction in low apgar at 5 minutes RR 0.72 (95%
CI 0.55-0.94) Cochrane reviews
Choice of antihypertensive agents
Mild PE: up-to 109 Diastolic 24 trials, antihypertensives vs none
• RR of severe PE: 0.52 (95% CI: 0.41-0.64)• NNT is 9-17 to prevent 1 case of Severe PE
22 trials, comparison of drug• No clear differences between metyldopa and
labetolol, nifedipine • Consider cost
Severe PE:diastolic over 110, proteinuria No clear differences Hydralazine may have advantages due to low cost,
slightly better newborn outcomes
Cochrane reviews
Understanding the Magnitude of the Challenge: Prevailing Practices Survey
Prescribe progestagen agents for threatened abortion
63%
Use diazepam to control convulsions in eclampsia
48%
Never do ECV 57%
Do not use the partograph to monitor and manage labor
88%
Practice AMTS for “high risk” patients only 42%
Perform episiotomy in all primigravida 32%
Prescribe 5-7 days of antibiotics routinely for CS 59
Perform Cesarean section mostly under general anesthesia
65%
Do not wash hands before every vaginal exam in labor
72%
Sanghvi 2005
4300 interviews with mid career faculty 16 countries, Asia, Africa, LAC
Using the SBMR Quality Improvement process to address systems challenges
GuidelinesSupervision
Supplies
Dangerous Practices
Barriers to Access
Improving quality of Eclampsia Care: NESOG: professional associations playing a vital role
7 Govt SBA training sites (6 achieved 80%)
2 service sites (government hospitals)
6 private hospitals (1 achieved 80%)
4 medical colleges (3 achieved 80%)
3 PHCCs (1 achieved 80%)
Comparison of Scores among Different Level of Health Facility
0%
20%
40%
60%
80%
100%
Training sites Service Sites Private Hosp Medical College PHCC
Facilities
Scor
e
Baseline First Second
Results of a small grant fromACCESS/USAID
Treating Eclampsia: The Price of Delay
The sooner treatment starts, the better the survival rates
Treatment is relatively simple if instituted immediately Magnesium sulphate and antihypertensive,
delivery Delayed treatment, especially beyond 2 hours,
requires intensive care for shock, DIC, renal shutdown, respiratory failure, electrolyte disturbance, sepsis, pneumonia, and multi organ failure: Even in best centers, mortality is highCan we ensure immediacy of treatment where many births are
occurring at home and where skilled care is not available?
Use of magnesium Sulphate and case fatality rate in eclampsia, Sadar hospital, Purulia, West Bengal, India, 2002 - 2006
19.12
11.36
8.16
7.79 7.57
0
20
40
60
80
100
120
2002 2003 2004 2005 2006
% o
f M
ag S
ulph
Use
d
0
5
10
15
20
25
Cas
e fa
talit
y ra
te
% of Magsulph use Case fatality rate
Trained46 MO, 55 Nursing Personnel
Experience With Single Dose of MgSO4 for Treatment of Eclampsia: DHAKA
A randomized trial with 401 patients comparing efficacy of loading dose alone versus standard regime
Outcome: Recurrent convulsion rate: 4.0% vs 3.5%. Case fatality rate: 4.5% vs 5.0%.
Conclusion: For majority of patients a single loading dose alone will suffice
Implications: This simplified treatment makes it possible to treat eclampsia even at home
Rashida Begum et al
Preventing Preeclampsia
xx x x
Almost 100 interventions tested in randomized trials
Calcium 65% Reduction in pre-eclampsia RR 0.35, (95% CI 0.20 to 0.60).
Aspirin
15% Reduction in Preeclampsia RR 0.85 (95% CI 0.78-.092)
Effects of calcium supplementation during pregnancy in studies with low baseline calcium intake populations
Relative Reduction (95%CI)
7 studies; 10154 women
• Hypertension
• Pre-eclampsia
• Maternal death or serious morbidity
• Perinatal death 14% (-6, 31)
53% (24, 71)
64% (30, 82)
20% (3, 35)
Cochrane review
Daily calcium intakeper capita in developing and developed countries (FAO,
1990)
Daily calcium intakeper capita in developing and developed countries (FAO,
1990)
REGION CALCIUM (mg)
WorldDeveloped countriesDeveloping countries
AfricaLatin AmericaNear EastFar EastOthers
472860346363499498352402
Mary Ellens’s Question: Iron distribution has largely failed so what makes you think that you can do better with calcium?
Of 60 major micronutrient supplementation programs (cost approx $1.3b) only 3 had a significant impact in reducing anemia in pregnancy. All three were CBD programs
Acceptability of Calcium tabs low : Women do not like swallowing large chalky tabs
Alternative calcium preps too expensive for large scale supplementation
Food-milk fortification not suitable in rural settings where most produce is home grown
Sanghvi, 2008:PEE position paper
Best question: How can we make calcium more affordable and acceptable
Planned solution
Sprinkles: Calcium phosphate salt (powder) in
Sachets Calcium sprinkled on main meal Tests on wide variety of Asian and African
staple meals show very little taste or texture or smell effect
Will cost $0.92 for 100 sachets Field trials , CBD, will start in Nepal 2010
Detecting Preeclampsia
Measuring BP: Significant training needed to do BP well Robust and maintained equipment Currently completely missing about 50%
women who do not receive antenatal care, Also missing an additional 15-30% who
attend ANC but do not have BP takenMeasuring urine protein
Urine dipstick tests quite pricey Boiling not feasible in high volume sites
Preliminary Design
Sanghvi, Crocker, Patent Pending
Towards detecting all PE that exists in a community
Sanghvi, Gauri, Shin, Patent Pending
Achieving Maximum Impact of reducing mortality from PE: From Household to Hospital
Preventing PE: Qualitative study to develop suitable educational message, and
identify best approach to distributing calcium Use existing Community health volunteer network for CBD of
calcium Monitor coverage, acceptability, safety, impact and program
effort/costDetecting PE:• Clinical detection of PE as standard AN service; monitor and
supported at all levels Operations research in community detection of PE• Strengthen referral centersTreating severe PE & Eclampsia:• Review and disseminate protocol for Magnesium sulphate, antiHt• Revise policy on who and where magnesium sulphate can be made
available• Ensure sufficient supplies and monitor • Monitor use of protocols in facilities
All the interventions I have outlined today have been in the cart for 20 years
Plan Assess Test Validate Manage Implement Monitor Document Scale up Institutionalize
Objectives Disease burden Results Resources Impact Coverage Quality of care Access Effectiveness Efficiency
As public Health professionals we are taught to or focus on:
Convince Persuade Negotiate Recruit Collaborate Co-opt Bypass Overcome Mobilize Broker Compromise
Advocacy Partnership Quid pro quo Coalition Opinion leader Gate-keeper Agendas Motivation Trust Priority Power
But Bringing About Major changes requires us to
Courtesy Steve Hodgins