Maternal and Fetal Outcomes After Introduction of MagnesiumSulphate for Treatment of Preeclampsia and Eclampsiain Selected Secondary Facilities: A Low-Cost Intervention

Jamilu Tukur • Babatunde Ahonsi •

Salisu Mohammed Ishaku • Idowu Araoyinbo •

Ekechi Okereke • Ayodeji Oginni Babatunde

Published online: 7 September 2012

� Springer Science+Business Media, LLC 2012

Abstract The aim of this study was to evaluate whether a

new low-cost strategy for the introduction of magnesium

sulphate (MgSO4) for preeclampsia and eclampsia in low-

resource areas will result in improved maternal and perinatal

outcomes. Doctors and midwives from ten hospitals in Kano,

Nigeria, were trained on the use of MgSO4. The trained health

workers later conducted step-down trainings at their health

facilities. MgSO4, treatment protocol, patella hammer, and

calcium gluconate were then supplied to the hospitals. Data

was collected through structured data forms. The data was

analyzed using SPSS software. From February 2008 to Jan-

uary 2009, 1,045 patients with severe preeclampsia and

eclampsia were treated. The case fatality rate for severe pre-

eclampsia and eclampsia fell from 20.9 % (95 % CI

18.7–23.2) to 2.3 % (95 % CI 1.5–3.5). The perinatal mor-

tality rate was 12.3 % as compared to 35.3 % in a center using

diazepam. Introduction of MgSO4 in low-resource settings led

to improved maternal and fetal outcomes in patients present-

ing with severe pre-eclampsia and eclampsia. Training of

health workers on updated evidence-based interventions and

providing an enabling environment for their practice are

important components to the attainment of the Millenium

Development Goals (MDG) in developing countries.

Keywords Severe preeclampsia � Eclampsia �Maternal mortality � Millennium development goals �Magnesium sulphate

Introduction

As we approach 2015, there are several efforts at achieving

the Millennium Development Goals (MDG). The 4th MDG

is to reduce child mortality in children under 5 years old by

two-thirds while the 5th is to reduce maternal deaths by

75 % between 1990 and 2015 [1].

An area that has attracted attention is hypertensive dis-

orders of pregnancy. Ten percent of women have high

blood pressure during pregnancy, and preeclampsia com-

plicates 2–8 % of pregnancies. Ten to fifteen percent of

direct maternal deaths are associated with preeclampsia

and eclampsia [2]. The World Health Organization (WHO)

estimates that at least 16 % of maternal deaths in low- and

middle-income countries result from the hypertensive dis-

orders of pregnancy, of which eclampsia is the primary

contributor [3].

Based upon the Eclampsia Trial Collaborative Group in

1995, the World Health Organization (WHO) recommends

Magnesium sulphate (MgSO4) for the treatment of severe

preeclampsia and eclampsia (SPE/E). The eclampsia trial

collaborative study compared regimens for treatment of

eclamptic seizures. Women treated with MgSO4 had 52

and 67 % lowered risk of recurrent seizures compared to

women who were treated with diazepam and phenytoin,

respectively. Maternal mortality was non-significantly

lowered in the women who received MgSO4 [4].

Despite the evidence of its effectiveness, the use of

MgSO4 has remained low especially in developing coun-

tries where it is incidentally needed the most [5].

Some of the reasons for the low availability and utili-

zation of MgSO4 include the lack of guidelines on its use,

non-inclusion in many national essential drug lists, the

wrong perception that the drug is meant for use only at the

highest level of facilities (such as those with intensive-care

J. Tukur (&)

Department of Obstetrics and Gynaecology, Bayero University/

Aminu Kano Teaching Hospital, Kano, Nigeria

e-mail: jtukur@yahoo.com

B. Ahonsi � S. Mohammed Ishaku � I. Araoyinbo �E. Okereke � A. O. Babatunde

Population Council, Abuja, Nigeria

123

Matern Child Health J (2013) 17:1191–1198

DOI 10.1007/s10995-012-1105-9

facilities), lack of training of health workers on its use,

little incentive for pharmaceutical companies to commer-

cialize the drug, and ready availability of pre-packaged

forms of less effective drugs [5, 6]. Other identified barriers

include a lack of procurement from governments, a lack of

demand by health workers, and lack of in-service training

on the use of MgSO4 [7]. There has been a call by the

WHO for the evidence on MgSO4’s efficacy to be dis-

seminated, the drug to be registered and made available in

all countries, the World Bank and other charitable orga-

nizations to fund the provision and distribution of treatment

kits and other international organizations to assist on

training frontline clinicians on how to use the drug [8].

Study Setting

Nigeria is located in West Africa and is Africa’s most

populous nation with a population of 162.5 million people

[9]. The Nigerian Health system divides hospitals into

primary, secondary, and tertiary hospitals with referral

linkages between them. Patients with SPE/E are referred

from primary to secondary and tertiary health facilities for

management. Delays are common due to lack of transport,

bad roads, and sometimes lack of knowledge from the

patient and relations on the seriousness of the condition. In

addition, there is poor record-keeping of births, as they are

kept only at hospitals even though the NDHS showed that

only 35 % of deliveries take place in hospitals [10]. As

registration of births and deaths in the community are not

compulsory, health facility-based data are often all that is

available for research.

In addition, the federal system of government being

practiced in Nigeria divides levels of governance into three

distinct and independent entities, which are federal, state,

and local governments. Consequently, the health care

system is disintegrated along this model with tertiary

institutions being managed by the federal government,

secondary institutions by the state governments, and pri-

mary health care by the local government authorities, with

no formal connection between these levels of care [11]. As

a result, the care for pre-eclampsia and eclampsia, as for

other major obstetric emergencies, is not properly coordi-

nated across these levels of service delivery. Furthermore,

the guideline of the Federal Ministry of Health in Nigeria

for managing eclampsia excludes lower-cadre service

providers in the management of the condition.

Nigeria has a high maternal mortality rate of 545 per

100,000 live births [10] with eclampsia as a major con-

tributor. Studies in northern Nigeria showed that eclampsia

contributed 31.3, 46.4, and 43.1 % of all maternal deaths in

Kano [12], Nguru [13], and Birnin Kudu [14], respectively.

In contrast, eclampsia contributed 34.4 % of maternal

deaths in Enugu in southern Nigeria [15]. The differences

in the contribution of eclampsia to maternal deaths could

be due to the culture of early marriage in northern Nigeria

and also delays in accessing care.

Kano is one of the states in the northwest of Nigeria.

The last Nigerian National census showed Kano as being

the most populous state in the country with a population of

9,401,288 [9]. Kano has a maternal mortality ratio (MMR)

of over 1,000 per 100,000 and a relatively high total fer-

tility rate of over seven births per woman, with 45 % of

adolescents aged 15–19 having already begun childbearing

and a modern contraceptive prevalence rate of less than

5 % [10]. Kano state has 35 general hospitals, offering free

maternity care funded by the government.

In 2007, the Population Council secured funding from

the MacArthur Foundation for the project. This followed a

baseline survey that showed that the drug used for the

treatment of SPE/E in all the 35 general hospitals was

diazepam. The survey also reviewed data from three gen-

eral hospitals (Bichi, Wudil, and MMSH) to determine the

contribution of SPE/E to maternal deaths and its case

fatality rate prior to the introduction of MgSO4. The

baseline survey data covered the period January 1, 2007 to

December 31, 2007.

Materials and Methods

The data collection for the project started on February 1,

2008 and ended on January 31, 2009. In January 2008, one

doctor and one midwife from each of ten selected general

hospitals were invited to Kano, the state capital for train-

ing. The hospitals were selected on the basis of geographic

spread across the state, population, and high burden of

maternal deaths. The hospitals were at Kano, Bichi, Wudil,

Gwarzo, Rano, Minjibir, Tudun Wada, Doguwa, Rano, and

Rogo. Apart from Kano, the rest were rural towns. Also

invited for the training were five officials of the Hospitals

Management Board.

The facilities were spread across the entire state with

Kano metropolis at the center. The distance from each

facility to Kano where advanced life support exists ranges

from 42 km (Wudil) to 165 km (Doguwa), but since these

facilities receive referral from their surrounding clustered

primary health care (PHC) facilities, the average distance

from a particular PHC to its referral facility ranges from 15

to 30 km.

For this study, a pregnant woman was defined as having

pre-eclampsia if she had high blood pressure in the second

half of pregnancy of 140 mmHg systolic or more and/or

diastolic blood pressure of 90 mmHg or more with pro-

teinuria (at least 2? of proteinuria using urine dipstick).

Features of severe preeclampsia included features of

1192 Matern Child Health J (2013) 17:1191–1198

123

preeclampsia and symptoms of headache, blurring of

vision, vomiting and/or epigastric pain. Most of the hos-

pitals did not have adequate laboratory facilities to enable

us to use laboratory markers to define severity. Any woman

who fitted and had features of preeclampsia was defined as

having eclampsia. However, across all the centers, severe

preeclampsia and eclampsia were treated similarly. This

involved administration of MgSO4, administration of

hydralazine (where the diastolic blood pressure was

110 mmHg or more), fluid management and then the

delivery of the patient through the fastest route. The latter

involves a Cesarean section where the woman was not in

labor and augmentation with oxytocin where the woman

was already in labor.

Two sets of trainings were conducted for the providers.

The first was the ‘‘Training of Trainers’’ (ToT) during

which 25 trainers were trained on the use of MgSO4. The

second was the step-down training conducted by the master

trainers at their respective health facilities. Both trainings

were similar.

The training was conducted over 2 days. The first day

involved didactic lectures on evidence-based management

of hypertensive disorders of pregnancy and how to use

MgSO4 including the detection and treatment of toxicity.

The participants were taught how to use MgSO4 by the

intramuscular (IM) route. For the purpose of the training,

the dose used was a loading dose of 4 g administered

intravenously followed by 10 g administered IM (5 g in

each buttock). This was followed by 5 g administered IM

every 6 h until 24 h after delivery or the last seizure.

Monitoring of toxicity was done by checking the deep

tendon knee reflex before administering each dose of

MgSO4.

To aid the training, a simple clinical protocol was distrib-

uted to the participants. The second day was used for a prac-

tical training at the 25-bed eclamptic ward of MMSH. There

was a demonstration of the use of sphygmomanometer to

detect hypertension and urinalysis for proteinuria. The par-

ticipants practiced preparation of different dosages of mag-

nesium sulphate and monitoring for toxicity. At the end of the

training, the participants were supplied the initial stock of

MgSO4 to take back to their hospitals, patella hammer (for

early detection of toxicity), and calcium gluconate (the anti-

dote for toxicity). The trained health workers returned to their

hospitals and conducted step-down trainings. All the facilities

commenced the use of the drug after the step down training.

Data was then obtained from the ten health facilities on the

maternal sociodemographic characteristics, pattern of SPE/E,

and the fetomaternal outcomes. The data was obtained by

filling of structured forms by the attending health workers.

Relevant information that was captured includes patients’

obstetrics demographic variables, fetal outcomes (dead or

alive) including APGAR score at 5 min, maternal outcomes

(dead or alive) including complications, number of seizures

before presentation, recurrence of seizures while on MgSO4,

distance traveled before presentation, time lapse from onset of

seizures to presentation at facility, mode of delivery and

complications of MgSO4 administration. The forms were

collated monthly from the sites and analyzed at Kano. How-

ever, due to poor record keeping culture, obtaining high-

quality data was a challenge and some data were missing. Data

review meetings were held monthly at all the sites to

encourage the health workers to fill the forms properly. The

data collection improved over time.

The data were summarized with frequencies and per-

centages. The associations between the dependent variables

(eclampsia CFR and infant perinatal mortality) and the

independent variables were measured with odds ratio

(95 % CI) using binary logistic regression. To obtain the

significant correlates of the dependent variables while

controlling for the effect of each independent variable,

multivariate analyses were also conducted using binary

logistic regression. The analyses were done with SPSS 15

for Windows (SPSS Inc., Chicago, IL, USA).

Results

The baseline survey involving three general hospitals

showed that there were a total of 1,233 patients with SPE/E

of whom 258 died giving a baseline CFR of 20.9 % (95 %

CI 18.7–23.2).

Twenty-five master trainers were trained at the initial

training of trainers at Kano. They then trained 160 health

workers (doctors, midwives, and community health

extension workers) through step-down trainings at the ten

health facilities. There was universal acceptance of the

change though few health workers resisted the change and

there were initial difficulties with calculation of doses.

These challenges improved with time.

During the period of the project, a total of 49 severe pre-

eclampsia and 996 eclamptic patients were treated at the

ten hospitals. There were 22,502 deliveries during the same

period. Table 1 summarizes the socio-demographic char-

acteristics of the patients that had SPE/E. A majority

(51.5 %) of the patients were teenagers aged 15–19 years

old. About 60 % of the patients were primigravida and

more than two-thirds (74 %) had no formal education. All

the patients were married and the majority (71.0 %) were

in a monogamous relationship.

More than half (56.9 %) of the patients presented at the

health facilities in less than an hour of eclampsia episode,

while a few others (23.3 %) presented after 3 h or more. A

majority (81.2 %) of the patients had at least a seizure

before their presentation at the health facilities. Also, 584

(55.9 %) of the patients had antenatal care.

Matern Child Health J (2013) 17:1191–1198 1193

123

The commonest mode of delivery among the patients

was spontaneous vertex delivery (75.6 %), distantly fol-

lowed by caesarean section (16.8 %), assisted vaginal

deliveries (2.3 %) and some few missing data (5.3 %).

Table 2 shows the fetomaternal outcomes. The CFR for

the patients treated with magnesium sulphate was 2.3 %

(95 % CI 1.5–3.5) as 24 of the 1,045 patients died. The

perinatal mortality was 12.3 % (CI 10.4–14.5) as 129 of the

1,045 mothers delivered dead babies. The 5-min APGAR

score for 72.9 % of the babies was 7 or more.

Further analysis was done to determine factors associ-

ated with maternal mortality, as shown in Table 3. The

significant measures of association showed that the CFR

was five times significantly higher among the patients with

parity of seven or more children than among the nullipa-

rous and six times higher among the patients that had

recurrent seizures after the loading dose than among the

patients that had none.

Factors associated with perinatal mortality are shown in

Table 4. Perinatal mortality was significantly higher among

the patients that had three or more seizures before pre-

sentation than among those that had no seizures at

presentation; the prevalence significantly increased with

increasing number of seizures before presentation. Simi-

larly, perinatal mortality was about three times higher

among the patients that had recurrent seizures after the

loading dose than among those who had no recurrent sei-

zures and four times higher among the patients that had

assisted breech delivery than those that had spontaneous

vaginal delivery.

Discussion

The case fatality rate for SPE/E was reduced from 20.9 %

(prior to the intervention) to 2.3 % (after the intervention).

This finding shows that MgSO4 has a great role to play in the

reduction of maternal deaths. Reduction of deaths among

mothers treated with MgSO4 compared to those treated with

diazepam has been reported from a center in southeastern

Nigeria [16]. Promoting, disseminating, and implementing

use of magnesium sulphate has been recognized as the most

important action to reduce maternal deaths from eclampsia

[17]. However, what is more important is that it was

Table 1 Socio-demographic characteristics of the patients that received MgSO4

Basic characteristics Pre-eclampsia

(n = 49)

Eclampsia Total

(n = 1,045)Antepartum

(n = 322)

Intrapartum

(n = 430)

Postpartum

(n = 244)

(%) (%) (%) (%) (%)

Age (years)

15–19 19 (38.8) 161 (50.0) 254 (59.1) 104 (42.6) 538 (51.5)

20–24 19 (38.8) 94 (29.2) 137 (31.9) 81 (33.2) 331 (31.7)

25–48 10 (20.4) 62 (19.3) 35 (8.1) 51 (20.9) 158 (15.1)

Unknown 1 (2.0) 5 (1.6) 4 (0.9) 8 (3.3) 18 (1.7)

Parity

0 30 (61.2) 195 (60.6) 311 (72.3) 95 (38.9) 631 (60.4)

1–5 13 (26.5) 110 (34.2) 106 (24.7) 135 (55.3) 364 (34.8)

[5 6 (12.2) 15 (4.7) 11 (2.6) 7 (2.9) 39 (3.7)

Unknown 0 2 (0.6) 2 (0.5) 7 (2.9) 11 (1.1)

Educational status

None 36 (73.5) 237 (73.6) 311 (72.3) 190 (77.9) 77 (74.1)

Nursery 3 (6.1) 18 (5.6) 12 (2.8) 9 (3.7) 42 (4.0)

Primary 4 (8.2) 40 (12.4) 68 (15.8) 30 (12.3) 142 (13.6)

Secondary/vocational 4 (8.2) 24 (7.5) 23 (5.3) 12 (4.9) 63 (6.0)

Tertiary 1 (2.0) 2 (0.6) 2 (0.5) 0 5 (0.5)

Unknown 1 (2.0) 1 (0.3) 14 (3.3) 3 (1.2) 19 (1.8)

Marital status

Married

(monogamous)

37 (75.5) 222 (68.9) 315 (73.3) 168 (68.9) 742 (71.0)

Married (polygamous) 12 (24.5) 99 (30.7) 114 (26.5) 76 (31.1) 301 (28.8)

Unknown 0 1 (0.3) 1 (0.2) 0 2 (0.2)

1194 Matern Child Health J (2013) 17:1191–1198

123

introduced in an area where it was not previously available

and this can be replicated in other areas especially in

developing countries. This was a relatively easy intervention

involving training health workers and providing the neces-

sary tools for them to practice what they learned. Yet, it had a

huge impact in reducing maternal deaths. Introduction of

similar interventions in developing countries could help in

the attainment of the MDGs.

Despite the successful reduction in CFR for SPE/E,

there were several factors that were identified to be con-

tributory to the recorded deaths. Analysis of these factors

helps in further reducing maternal deaths. In this study,

most cases were seen in primigravida, especially teenagers.

This finding is similar to that from other studies [13, 14].

This group of patients need to be targeted in any program

aimed at preventing SPE/E. Antenatal care is an opportu-

nity for detecting preeclampsia through monitoring of

blood pressure and detection of proteinuria. There is a need

to improve the quality of the antenatal care. It is a common

scenario in the hospitals under the study to observe one or

two nurses conducting antenatal care to 200–400 patients

in a single day. Task-shifting has been advocated to miti-

gate the lack of health workers. Tasks can be delegated to

non-physician clinicians, medical assistants, nurses, and

community health care workers [18].

To prevent eclampsia, it is necessary to first diagnose

pre-eclampsia using routine blood pressure and urine pro-

tein testing of all women [19]. Those that have pre-

eclampsia can then be treated with anti-hypertensives and

delivered early. Antenatal care also presents an opportunity

for instituting current evidence-based, possibly preventive,

strategies to those at risk in the form of low-dose aspirin

and calcium supplementation. Aspirin is associated with a

10–19 % reduction in pre-eclampsia risk and a 10–16 %

decrease in perinatal morbidity and mortality [20]. At least

1 g of calcium supplementation is also associated with

reduction in preeclampsia in those with low dietary cal-

cium [21]. There is also a need for community health

education on the importance of antenatal care.

The finding also that most of the patients with eclampsia

had at least a seizure at home means there is a need to

educate the patients on warning symptoms of eclampsia

such as headache, blurring of vision, and epigastric pain.

Among those that had eclampsia, more deaths were

recorded in those of high parity ([7) and those who had a

seizure after the loading dose. These groups of patients are

those in whom there could be other underlying pathologies

apart from eclampsia. These characteristics are those of

patients in whom a clinical search needs to be conducted

for other underlying causes for the seizures. In these cases,

however, this was not done, due to a lack of facilities.

The stillbirth rate in this study was 12.3 % (CI 10.4–14.5).

Unfortunately, there was no baseline perinatal mortality for

comparison. However, the finding is much lower than the

35.3 % stillbirth rate reported from another center using

diazepam [22], even though other studies show that mag-

nesium sulphate has no impact on stillbirth rates [23]. The

factors associated with perinatal mortality were recurrent

seizures fits after the loading dose, those delivered by

assisted breach delivery than among the patients that had

Table 2 Clinical outcomes of the pregnancies after the administration of the MgSO4

Clinical outcomes Pre-eclampsia (n = 49) Eclampsia Total (n = 1,045)

Antepartum (n = 322) Intrapartum (n = 430) Postpartum (n = 244)

(%) (%) (%) (%) (%)

Apgar score at 5 min

0 1 (0.2) 15 (4.7) 27 (6.3) 13 (5.3) 56 (5.4)

1–6 0 11 (3.4) 32 (7.4) 7 (2.9) 50 (4.8)

7 3 (6.1) 38 (11.8) 84 (19.5) 12 (4.9) 137 (13.1)

8 21 (42.9) 105 (32.6) 138 (32.1) 39 (16.0) 303 (29.0)

9 12 (24.5) 70 (21.7) 90 (20.9) 26 (10.7) 198 (18.9)

C10 3 (6.1) 26 (8.1) 32 (7.4) 63 (25.8) 124 (11.9)

Unknown 9 (18.4) 57 (17.7) 27 (6.3) 84 (34.4) 177 (16.9)

Fetal outcome

Dead 2 (4.1) 49 (15.2) 53 (12.3) 25 (10.2) 129 (12.3)

Alive 40 (81.6) 250 (77.6) 373 (86.7) 210 (86.1) 873 (83.5)

Unknown 7 (14.3) 23 (7.1) 4 (0.9) 9 (3.7) 43 (4.1)

Maternal outcome

Dead 1 (2.0) 9 (2.8) 8 (1.9) 6 (2.5) 24 (2.3)

Alive 43 (87.8) 289 (89.8) 420 (97.7) 231 (94.7) 983 (94.1)

Unknown 5 (10.2) 24 (7.5) 2 (0.5) 7 (2.9) 38 (3.6)

Matern Child Health J (2013) 17:1191–1198 1195

123

spontaneous vaginal delivery, and those that had seizures

before presentation. The first factor is also associated with

maternal deaths, which invariably affect the baby. Those

who had breech delivery had a higher mortality probably

because of the extra manipulation needed to deliver these

babies. Those mothers who had both breech presentation and

eclampsia were more likely to have an improved outcome

with a primary Cesarean delivery. The last factor implies

some delays from the mother before accessing care, in which

case the baby is invariably affected.

Table 3 Factors associated with eclampsia CFR

CFR (95 % CI) COR (95 % CI) AOR (95 % CI)

Age (years)

15–19 (ref) 1.5 (0.5, 2.6) 1.00 1.00

C20 3.4 (1.8, 5.1) 2.27 (0.96, 5.35) 1.46 (0.40, 5.42)

Parity

0 (ref) 1.6 (0.6, 2.6) 1.00 1.00

1–5 2.9 (1.1, 4.6) 1.79 (0.74, 4.35) 1.14 (0.31, 4.17)

C6 8.6 (0.8, 18.0) 5.66 (1.49, 21.59) 4.99 (0.77, 32.22)*

Marital status

Married, monogamous (ref) 1.7 (0.7, 2.6) 1.00 1.00

Married, polygamous 4.3 (1.9, 6.7) 2.67 (1.18, 6.01) 2.97 (0.82, 10.79)

Educational status

None (ref) 2.4 (1.3, 3.5) 1.00 1.00

Primary 2.9 (0.1, 5.7) 1.20 (0.40, 3.59) 1.18 (0.23, 6.23)

Secondary/higher 3.0 (1.1, 7.2) 1.26 (0.29, 5.55) 1.00 (0.12, 8.25)

Antenatal care

Attends (ref) 1.8 (0.7, 2.9) 1.00 1.00

Does not attend 3.3 (1.6, 5.1) 1.91 (0.84, 4.35) 0.57 (0.15, 2.13)

Number of fits before presentation

B2 (ref) 1.3 (0.3, 2.3) 1.00 1.00

C3 2.9 (1.3, 4.4) 2.26 (0.85, 6.01) 2.19 (0.63, 7.55)

Distance (km) traveled before presentation

\1 (ref) 2.1 (0.6, 3.5) 1.00 1.00

C1 2.2 (1.1, 3.3) 1.08 (0.45, 2.60) 0.26 (0.05, 1.33)

Time (h) before presentation

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

C1 3.1 (1.4, 4.7) 2.10 (0.89, 4.96) 2.95 (0.63, 13.66)

Recurrent fits after administering the loading dose

No (ref) 1.8 (0.9, 2.6) 1.00 1.00

Yes 9.2 (2.1, 16.3) 5.54 (2.10, 14.58) 7.65 (1.62, 36.03)*

Mode of delivery

SVD 1.8 (0.9, 2.7) 0.78 (0.25, 2.39) 0.77 (0.19, 3.09)

CS (ref) 2.3 (0.1, 4.5) 1.00 1.00

AVD 4.2 (4.0, 12.3) 1.86 (0.20, 17.36) 2.58 (0.16, 41.52)

Condition

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

Eclampsia 2.4 (1.4, 3.4) 1.05 (0.14, 7.97) 0.59 (0.04, 8.94)

Total ampoules of MgSO4 received

B6 2.6 (0.3, 4.9) 1.87 (0.56, 6.22) 1.16 (0.18, 7.56)

7–17 3.0 (1.4, 4.6) 2.08 (0.78, 5.53) 1.13 (0.25, 5.01)

18 (ref) 1.5 (0.3, 2.7) 1.00 1.00

COR crude odds ratio, AOR adjusted odds ratio

* Significant at p \ 0.05

1196 Matern Child Health J (2013) 17:1191–1198

123

The limitation of this study is that of missing data which

arose from incorrectly filled forms or even failure to com-

plete the forms in some cases. Also, the study assumes that all

patients received the standard dosage of the drug as the health

workers were taught in the training. As the health workers

also fill the forms, our assumptions could be wrong. In

addition, the study was conducted in an area where women

prefer to deliver at home. It is possible that a majority of

women with this condition are not reflected in this study,

although there is a tendency that even such women will come

to the hospital when complications such as SPE/E develop.

In conclusion, this study clearly shows that the introduction

of magnesium sulphate usage for SPE/E using this low-cost

replicable intervention had a positive impact on both maternal

and fetal morbidity and mortality. The state government

should make the project sustainable on withdrawal of donor

support so that the patients can continue to reap the benefits.

Conflict of interest None declared.

References

1. United Nations. Millennium Development Goals. 2007 progress

report 2007, http://mdgs.un.org/unsd/mdg/default.aspx. Accessed

January 2011.

2. Duley, L. (2009). The global impact of pre-eclampsia and

eclampsia. Seminars in Perinatology, 33(3), 130–137.

3. Khan, K. S., Wojdyla, D., Say, L., et al. (2006). WHO analysis of

causes of maternal death: A systematic review. Lancet, 367,

1066–1074.

4. The Eclampsia Trial Collaborative Group. (1995). Which anti-

convulsant for women with eclampsia? Evidence from the col-

laborative eclampsia trial. Lancet, 345(8963), 1455–1463.

5. Tukur, J. (2009). The use of magnesium sulphate for the treat-

ment of severe pre-eclampsia and eclampsia. Annals of African

Medicine, 8, 76–80.

6. Langer, A., Viller, J., Tell, K., Kim, T., & Kennedy, S. (2008).

Reducing eclampsia related deaths: A call to action. Lancet, 371,

705–706.

7. Ridge, L. A., Bero, L. A., & Hill, R. S. (2010). Identifying bar-

riers to the availability and use of magnesium sulphate injection

in resource poor countries: A case study in Zambia. BioMedical

Central Health Services Research, 10, 340.

8. Sheith, S. S., & Chalmers, I. (2002). Magnesium for preventing

and treating eclampsia: Time for international action. Lancet,

359, 1872–1873.

9. National Population Commission. (2006). Population and hous-

ing census of the Federal Republic of Nigeria. Available from

http://www.population.gov.ng/images/stories/Priority%20Tables

%20Volume%20I-update.pdf (Accessed July 14th 2011).

10. National Population Commission (NPC) and ICF Macro. (2008).

Nigeria Demographic and Health Survey (NDHS). http://www.

measuredhs.com/pubs/pdf/GF15/GF15.pdf.

11. Kombe, G., Fleisher, L., Kariisa, E., Arur, A., Sanjana, P., &

Paina, L. et al. (April 2009). Nigeria health system assessment

2008. Abt Associates Inc.

Table 4 Factors associated with perinatal mortality

Factors Perinatal mortality % (95 % CI) Adjusted OR (95 % CI)

Marital status

Married monogamous 10.6 (8.6, 13.1) 1.00

Married polygamous 16.3 (12.4, 21.1) 1.17 (0.72, 1.92)

Antenatal care

Attends 10.1 (7.8, 12.9) 1.00

Does not attend 14.6 (11.5, 18.3) 0.88 0.55, 1.42)

Recurrent fits after MgSO4 loading dose

No 11.4 (9.5, 13.6) 1.00

Yes 27.7 (17.3, 40.2) 2.64 (1.25, 5.54)*

Mode of delivery

CS 8.5 (4.8, 13.7) 1.00

SVD 12.4 (10.2, 15.0) 1.24 (0.65, 2.36)

ABD 29.2 (12.6, 51.1) 3.48 (1.12, 10.91)*

Number of fits before presentation

0 3.7 (1.0, 9.1) 1.00

1–2 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)

C5 17.9 (12.4, 24.5) 5.70 (1.63, 19.93)*

Time before presentation (h)

\1 9.7 (7.5, 12.5) 1.00

C1 16.3 (13.0, 20.2) 1.04 (0.65, 1.68)

COR crude odds ratio, AOR adjusted odds ratio, CS Cesarean section, SVD spontaneous vaginal delivery, ABD assisted breech delivery

* Significant values at p \ 0.05

Matern Child Health J (2013) 17:1191–1198 1197

123

12. Adamu, Y. M., Salihu, H. M., Sathiakumar, N., & Alexander, R.

(2003). Maternal mortality in Northern Nigeria: A population

based study. European Journal of Obstetrics, Gynaecology and

Reproductive Biology, 109(2), 153–159.

13. Kullima, A. A., Kawuwa, M. B., Audu, B. M., Usman, H., &

Geidam, A. D. (2009). A 5-year review of maternal mortality

associated with eclampsia in a tertiary institution in northern

Nigeria. Annals of African Medicine, 8(2), 81–84.

14. Tukur, J., Umar, B. A., & Rabi’u, A. (2007). Pattern of eclampsia

in a tertiary health facility situated at a semi rural town in

Northern Nigeria. Annals of African Medicine, 6(4), 164–167.

15. Onakewhor, J. U., & Gharoro, E. P. (2008). Changing trends in

maternal mortality in a developing country. Nigerian Journal of

Clinical Practice, 11(2), 111–120.

16. Eke, A. C., Ezebialu, U. I., & Okafor, C. (2011). Presentation and

outcome of eclampsia at a tertiary center in South East Nigeria—

A 6-year review. Hypertension in Pregnancy, 30, 125–132.

17. Tsu, V. D., & Shane, B. (2004). New and underutilized tech-

nologies to reduce maternal mortality: Call to action from a

bellagio workshop. International Journal of Gynaecology and

Obstetrics, 85(Suppl 1), S83–S93.

18. Firoz, T. et al. (2011). Pre-eclampsia in low and middle income

countries. Best Practice & Research Clinical Obstetrics and

Gynaecology. doi:10.1016/j.bpobgyn.2011.04.002.

19. Goldenberg, R. L., McClure, E. M., McGuire, E. R., Kamath, B.

D., & Jobe, H. A. (2011). Lessons for low-income regions fol-

lowing the reduction in hypertension-related maternal mortality

in high-income countries. International Journal of Gynaecology

and Obstetrics, 113, 91–95.

20. Askie, L., Duley, L., Henderson-Smart, D., et al. (2007). Anti-

platelet agents for prevention of pre-eclampsia: A meta-analysis

of individual patient data. Lancet, 369, 1791–1798.

21. Hofmeyr, G. J., Atallah, A. N., & Duley, L. (2006). Calcium

supplementation during pregnancy for preventing hypertensive

disorders and related problems. Cochrane Database of Systematic

Reviews, CD001059.

22. Melah, G. S., Massah, A. A., & El Nafaty, A. U. (2006). Pregnancy

outcomes of women with eclampsia in Gombe, Nigeria. Interna-

tional Journal of Gynecology and Obstetrics, 92, 251–252.

23. Jabeen, M., Yakoob, M. Y., Imdad, A., & Bhutta, Z. A. (2011). Impact

of interventions to prevent and manage preeclampsia and eclampsia

on stillbirths. BioMed Central Public Health, 11(Suppl 3), S6.

1198 Matern Child Health J (2013) 17:1191–1198

123

Reproduced with permission of the copyright owner. Further reproduction prohibited withoutpermission.