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