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Preventing and Treating (Pre)Eclampsia

Research Overview

TRAction is currently funding a research study in Bangladesh exploring the effectiveness of a community-based intervention to address severe pre-eclampsia (SPE) and eclampsia cases. Mothers who experience eclampsia/pre-eclampsia receive an early loading dose of Magnesium Sulphate by trained community health providers before referral to hospitals.

Although the maternal mortality ratio (MMR) in Bangladesh has been substantially reduced over the past decade, SPE and eclampsia combined remain the second leading cause of direct obstetric deaths, and constitute 20 percent of all maternal deaths in Bangladesh.

Magnesium Sulphate is considered to be an appropriate and affordable treatment for pre-eclampsia. Two randomized control trials in Bangladesh have demonstrated that one-half of the standard doses of Magnesium Sulphate are sufficient to effectively control maternal convulsions. These two studies validated the local use of a lower dose regime compared to the international standard. The “Eclampsia working group in Bangladesh,” comprised of leading researchers and relevant policy stakeholders recommended incorporating the low dose regime for Bangladesh in the country’s national guidelines in 1997.

The efficacy of Magnesium Sulphate for treatment of pre-eclampsia and eclampsia has been demonstrated mostly through hospital based trials. Global efficacy and effectiveness trials at the community level to assess the role of magnesium sulfate in the prevention and treatment of eclampsia are rare. A number of studies in Bangladesh show case fatality rates in hospital to be very high, in the range of 64%-70%, and have been largely attributed to delays in referral (identification, decision making, and transport problems). Accordingly, community-based strategies to provide the loading dose of Magnesium Sulphate for SPE and eclampsia at the community, before referral to higher level facilities may be an effective emergency initiative in Bangladesh.

Study Location

Bangladesh: Habiganj

Research Objectives

Primary Objective: To identify and manage SPE and eclampsia cases at the community level prior to hospital referral through training and providing support to community based skilled health providers with injectable Magnesium Sulphate and other logistics (Oxidase strip to measure urine protein).
 
Secondary objectives include:
  1. To reduce eclamptic seizures through identification of severe pre-eclampsia and eclampsia cases, and management with a loading dose of Magnesium Sulphate at the community level in intervention areas.
  2. To compare the maternal and perinatal outcomes (i.e., maternal deaths, recurrent convulsion, renal failure, stroke, coma/unconsciousness, obstetric shock, asphyxia, still birth and perinatal death) in intervention and control groups.

Study Approach 

Researchers utilized a mixed methods approach and surveyed pregnant mothers who developed SPE and eclampsia in intervention and control areas to track outcomes and indicators. Pregnant women in the intervention areas received a loading dose by a health worker and were referred to hospital. In the control area, no loading dose was provided, and pregnant women were referred directly to a facility, which is consistent with the standard of care in Bangladesh. Focus group discussions were conducted with community health workers who provided mothers with the loading dose of Magnesium Sulphate, and with facility-based providers who were responsible for management of the referred women.
 

Key Results

A majority of the pregnant women with SPE/E were less than 30 years old. 35% vs 13% (intervention vs control) of the total cases were identified by community based providers. Case identification per provider ratio was highest by the MaMoni supported paramedics, followed by FWVs (14/Paramedic, 1.6/FWV and 0.2/CSBA).  88% of the identified cases (n=73) received loading dose (72% by community based providers and 16% by others).  45% vs 9% (intervention vs control) of the total cases were referred by community based providers for further management. Case referral per provider ratio was highest by the MaMoni supported paramedics, followed by FWVs (13.5/Paramedic, 1.1/FWV and 0.1/CSBA). ANC sessions – the golden opportunity to identify cases – were poorly conducted in terms of not following the standard procedures of measurement and proper record keeping. ANC counseling were also not up to the standard.

Lessons Learned

Community-based management of eclampsia and SPE is a necessary intervention to decrease adverse pregnancy outcomes. There are health system gaps in the community-based provision of maternal health care, especially in regards to community health worker provided antenatal care, with large variation in quality of care and services. Strategies to increase CHW performance and confidence include revising existing training programs to be more extensive and robust, and establishing management structures with higher quality monitoring and responsiveness.

Research into Action

This results of this study are directly informative for policymakers and program implementers who are seeking to raise the quality of community-based services to mitigate the mortality and morbidity resulting from eclampsia and SPE.
 

Implemented by

International Centre for Diarrheal Disease Research (icddr,b)

Principle Investigator: Dr. Nafisa Lira

 

Project Status

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