The Maternal Health Task Force’s most recent quarterly newsletter focused on pre-eclampsia/eclampsia and postpartum hemorrhage. And for good reason: they are the two leading causes of maternal deaths globally and deserve widespread attention.
In Kenya and Nigeria, hypertensive disorders such as pre-eclampsia/eclampsia are the leading cause of pregnancy-related deaths. In Bangladesh, Pakistan and Ethiopia, hypertensive disorders are among the top three causes. But despite the high fatality rate, deaths from pre-eclampsia/eclampsia are entirely preventable. Early detection, diagnosis and treatment are crucial for preventing mortality due to pre-eclampsia/eclampsia.
Pre-eclampsia is characterized by elevated blood pressure and increased protein in the urine after 20 weeks of pregnancy. A woman with pre-eclampsia can suffer from blurred vision, severe headaches and edema, and if her pre-eclampsia goes untreated, she has an increased risk of developing eclampsia, which can cause life-threatening seizures. Pre-eclampsia/eclampsia is also a risk factor for preterm and stillborn births, maternal kidney and liver problems and pre-eclampsia/eclampsia in future pregnancies.
The gold standard of treatment
Use of magnesium sulphate, the safest and most effective treatment for eclamptic seizures, requires delivery of the baby and placenta. Not without challenges, magnesium sulphate is the gold standard for managing eclampsia. However, its use indicates that either a woman’s elevated blood pressure was not detected early enough, or that it was detected but not properly managed in order to prevent progression to eclampsia. Early, regular high-quality antenatal and postnatal care that includes blood pressure screening, urinalysis and close monitoring is crucial. If a woman has elevated blood pressure or excess protein in her urine, she should receive appropriate treatment that controls the blood pressure, reduces the severity of pre-eclampsia and prevents eclamptic seizures and stroke.
The World Health Organization (WHO) recommends calcium supplementation in areas where dietary calcium intake is low or aspirin prophylaxis for women at risk of pre-eclampsia. To control high blood pressure, thereby reducing the likelihood of pre-eclampsia progressing to eclampsia, the WHO recommends antihypertensive drugs. Since pre-eclampsia/eclampsia can occur after delivery of the baby, the WHO also recommends that these treatments continue postpartum.
Barriers to implementation
We know that these treatments work. We also know the difficulty of implementing interventions in low-resource settings and among hard-to-reach populations.
While antihypertensive drugs are on most countries’ essential medicines lists, there may not be a dedicated budget line or supply chain mechanism that actually gets the drugs to the people who need them. Furthermore, many countries lack sufficient policies allowing primary facility providers to prescribe and dispense these treatments, and there may be a shortage of skilled providers who are knowledgeable about treatment methods and able to manage cases that require them.
There are also cultural barriers, which some might argue are the most difficult to overcome. In many settings women do not trust health facility providers. When a problem occurs, women in some communities might first seek care from a traditional healer and only visit a health facility if the problem persists or worsens. Furthermore, women living in low-resource settings may not have the financial means to travel a long distance to a health facility, pay for services and drugs upon arrival and then pay for the return home.
Looking toward the future
Despite these challenges, the international development and public health communities want to eliminate preventable maternal and newborn deaths and are dedicating funds to implementation research and advocacy. Clinical practice is more or less established in hospital settings worldwide. However, poor quality care inhibits early diagnosis, and national policies often restrict primary facility providers from prescribing and dispensing antihypertensive drugs. Ensuring that women with pre-eclampsia have access to necessary treatments is vital for preventing eclampsia and ultimately averting preventable maternal deaths.
For more information, please visit www.endingeclampsia.org
Read the most recent MHTF Quarterly highlighting pre-eclampsia/eclampsia.
Learn more about pre-eclampsia/eclampsia on the MHTF website.