Community health workers' knowledge and practice in relation to pre-eclampsia in Ogun State, Nigeria: an essential bridge to maternal survival.

BACKGROUND: Pre-eclampsia is a leading cause of maternal and fetal morbidity and mortality worldwide. Early detection and treatment have been instrumental in reducing case fatality in high-income countries. To achieve this in a low-income country, like Nigeria, community health workers who man primary health centres must have adequate knowledge and skills to identify and provide emergency care for women with pre-eclampsia. This study aimed to determine community health workers' knowledge and practice in the identification and treatment of pre-eclampsia, as they are essential providers of maternal care services in Nigeria. METHODS: This study was part of a multi-country evaluation of community treatment of pre-eclampsia. Qualitative data were obtained from four Local Government Areas of Ogun State, in south western Nigeria by focus group discussions (N = 15) and in-depth interviews (N = 19). Participants included a variety of community-based health care providers - traditional birth attendants, community health extension workers, nurses and midwives, chief nursing officers, medical officers - and health administrators. Data were transcribed and validated with field notes and analysed with NVivo 10.0. RESULTS: Community-based health care providers proved to be aware that pre-eclampsia was due to the development of hypertension and proteinuria in pregnant women. They had a good understanding of the features of the condition and were capable of identifying women at risk, initiating care, and referring women with this condition. However, some were not comfortable managing the condition because of the limitation in their 'Standing Order'; these guidelines do not explicitly authorize community health extension workers to treat pre-eclampsia in the community. CONCLUSION: Community-based health care providers were capable of identifying and initiating appropriate care for women with pre-eclampsia. These competencies combined with training and equipment availability could improve maternal health in the rural areas. There is a need for regular training and retraining to enable successful task-sharing with these cadres. TRIAL REGISTRATION: NCT01911494 .

OS025. Placental malaria infection as a risk factor for hypertensivedisorders of pregnancy in malaria endemic regions: A systematic review and meta-analysis.

INTRODUCTION: Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal mortality in low and middle income countries (LMICs). HDP complicates pregnancy in many malarial endemic areas with the greatest burden in sub-saharan Africa. It has been suggested that there is a link between placental malaria infection (PMI) caused by Plasmodium falciparum and HDP. To our knowledge, a systematic review has never been conducted on the relationship between PMI and HDP and the modification of that relationship with parity. OBJECTIVES: 1. To critically assess the association between PMI and HDP among a general obstetrical population in malarial endemic regions 2. To evaluate if the relationship between PMI and HDP is modified by parity. METHODS: We conducted a systematic review for any study reporting on placental malaria and hypertension. A literature search based on a prospectively prepared protocol was conducted in PubMed Central and EMBASE until 06/09/2011. Additional data on parity of study participants in each study group was requested from corresponding authors of included studies by personal contact through email. Studies were assessed using the Newcastle-Ottawa Scale. The Cochrane Revman 5.1 software was used for statistical analysis according to standardised methodology. Risk Ratios with 95% confidence interval were calculated. RESULTS: Seven studies met our inclusion criteria [1-7]. These included cross-sectional, case control and observational studies. Six were in English and one was translated internally from French. One study [2] was further excluded because it did not represent a general obstetrical population. Our meta-analysis found no association between PMI and HDP in a general obstetric population in malaria endemic areas [RR of 1.00, 95% CI of 0.82,1.23]. Furthermore, we did not find that this relationship was modified by parity in two studies [RR (nulliparous) 0.92, 95% CI of 0.26,3.25)]. Events=women with HDP (). CONCLUSION: Although trends and associations have been reported in individual studies, we did not find a significant association between PMI and the risk of HDP. There is an apparent need for a large prospective cohort study to be conducted on PMI and the possible association with HDP.

OS032. Pharmacotherapy for pre-eclampsia in low and middle income countries: An analysis of essential medicines lists (EMLS).

INTRODUCTION: Pre-eclampsia is the second leading cause of maternal mortality in low and middle income countries (LMIC). Pharmacological management of pre-eclampsia has five major components including antihypertensive therapy for severe and non-severe hypertension, magnesium sulphate for prevention or treatment of eclampsia, treatment of pre-eclampsia-related end-organ complications, antenatal corticosteroids for acceleration of fetal pulmonary maturity given iatrogenic preterm delivery for maternal and/or fetal indications, and labour induction for such indicated deliveries. Essential medicines are defined by the World Health Organization (WHO) as "drugs that satisfy the health care needs of the majority of the population". Essential Medicines Lists (EMLs) detail these essential medicines within an individual country and support the argument that the medication should be routinely available. OBJECTIVES: To determine how many drugs required for comprehensive pre-eclampsia management are listed in national EMLs of LMIC. METHODS: We conducted a descriptive analysis of relevant drug prevalence on identified EMLs. We searched for the national EMLs of the 144 LMIC identified by the World Bank. EMLs were collected by broad based internet searches and in collaboration with the WHO. The EMLs were surveyed for therapies for the different aspects of pre-eclampsia management: hypertension (non-severe and severe with oral or parenteral agents), eclampsia, pre-eclampsia complications (e.g., pulmonary oedema, thrombosis), preterm birth, and labour induction. RESULTS: EMLs were located and reviewed for 58(40.3%) of LMIC. One or more parenteral antihypertensive agents were listed in 51(87.9%) EMLs. The most common agents were: hydralazine (67.2%), verapamil (58.6%), propranolol (39.7%) and sodium nitroprusside (37.9%); parenteral labetalol was listed by only 19.0% of EMLs. The most prevalent oral antihypertensive therapies listed were: nifedipine (96.6%, usually 10 or 20mg intermediate-acting tablets), methyldopa (94.8%), propranolol (89.7%), and atenolol (87.9%). Captopril, enalapril, hydrochlorothiazide and spironolactone were commonly listed. Magnesium sulphate for prevention and management of eclampsia was present in 86.2% of EMLs (and its antidote, calcium gluconate in 82.8%). To manage complications of pre-eclampsia, oral frusemide was listed in 94.8% of EMLs and parenteral heparin in 91.4%. Most EMLs listed parenteral dexamethasone (91.4%) for acceleration of fetal pulmonary maturity and oxytocin (98.3%) or a prostanoid (usually misoprostol, 39.7%) for labour induction. CONCLUSION: EMLs of LMIC provide comprehensive coverage of all aspects of recommended pre-eclampsia pharmacotherapy. These EMLs may be used as advocacy tools to ensure the availability of these therapies within each country.

PP088. Oral antihypertensive therapy for severe hypertension in pregnancy.

INTRODUCTION: The hypertensive disorders of pregnancy are among the leading causes of maternal mortality and morbidity. The vast majority occurs in low and middle income countries. It is widely accepted that women with severe hypertension are at increased risk of stroke and benefit from blood pressure (BP) reduction. Although traditionally, parenteral antihypertensive agents have been studied for treatment of severe hypertension in pregnancy, oral agents would be ideal for use in the community and in under-resourced settings. OBJECTIVES: To review the published evidence for the effectiveness of oral antihypertensive therapy for severe hypertension in pregnancy. METHODS: The following databases were searched (to May/11) for randomised controlled trials (RCT) of oral antihypertensive therapy for severe hypertension in pregnancy: MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews. Inclusion criteria were: severe hypertension [an inclusion criterion or average enrollment BP of: systolic BP ⩾160mmHg and/or diastolic BP ⩾110mmHg), use of oral or sublingual antihypertensive therapy in at least one of the treatment arms, and at least one relevant measure of maternal or perinatal outcome within a week of administration. Data were abstracted independently by two reviewers and discrepancies resolved by consensus. The Cochrane Revman 5.1 software was used for statistical analysis according to standardised methodology. RESULTS: We identified 14 eligible trials (796 women). Most compared oral/sublingual (SL) nifedipine 5-10mg (10 trials, 606 women, 8/10 trials specified capsule preparation), with either: intravenous (iv) hydralazine 5-20mg (6 trials, 282 women), oral nifedipine 10mg PA tablets (1 trial), oral prazosin 1mg (1 trial), iv labetalol (1 trial), or iv/intramuscular (im) chlorpromazine 12.5 (1 trial). Three trials (154 women) compared oral methyldopa (250-500mg initially) with either oral labetalol (100mg), atenolol (50-200mg) or kentanserin (80-120mg) (1 trial each). One trial (36 women) compared SL isosorbide 1.25mg with iv magnesium sulphate (4g iv then 1g/hr). No trials were identified that compared oral labetalol with either parenteral hydralazine or oral nifedipine. Nifedipine compared favourably with parenteral hydralazine with no differences seen in BP control or maternal or perinatal outcomes. Heterogeneity between trial results was seen within the oral/SL nifedipine vs. iv hydralazine subgroup in which one trial evaluated treatment success and side effects over 20min, and found that nifedipine was associated with relatively lower success and fewer side effects. The incidence of maternal hypotension in the nifedipine capsule arms of these trials was low (1/102, 3 trials), but hypotension was common in both arms of a trial of nifedipine 10mg capsule vs. 10mg PA tablet trial (i.e., 11/31 vs. 3/33, risk difference 26%, 95% CI7% to 46%). CONCLUSION: Given the available RCT data on which to base oral antihypertensive treatment of severe hypertension in pregnancy, the choice of antihypertensive agent may need to be driven by the availability of the drug, setting in which it is to be administered, and by whom. For facility use, the evidence supports oral nifedipine capsules.

PP164. Magnesium sulphate for prevention and treatment of eclampsia in low and middle income countries: Systematic review of tested regimens.

INTRODUCTION: Magnesium sulphate (MgSO4) is regarded as the most effective prophylactic and therapeutic agent for eclampsia. Although well studied and widely used in high income countries (HICs), MgSO4 is under utilized in low and middle income countries (LMICs) due to many factors including lack of adequately trained health care providers, supplies for administration, or the MgSO4 itself, in addition to fear of potential adverse effects. OBJECTIVES: To systematically review the dosing and effectiveness of MgSO4 regimens administered in LMICs to women with pre-eclampsia or eclampsia. METHODS: We searched Medline, EMBASE, IPA, CINAHL, CDSR and CENTRAL databases for English language randomized controlled trials (RCT) and observational studies of MgSO4 regimens administered in LMICs to women with pre-eclampsia or eclampsia. Two authors independently reviewed search results and extracted relevant data from eligible studies. No quality assessment was performed. RESULTS: Twenty two papers (7 RCT and 15 observational studies) from 12 LMIC met our inclusion criteria, of which 21 were conducted in hospital settings. Two studied MgSO4 for eclampsia prevention ,14 for eclampsia treatment and 6 studied MgSO4 for both. In 20 studies, both loading and maintenance MgSO4 dosing was administered, with intravenous (IV) or combined IV and intramuscular (IM) loading doses of 4-15g and IV or IM maintenance doses up to 2g/h. Five studies used only the IV route of administration, while the remainder coupled IV with IM administration. All studies were effective at preventing the initiation and/or recurrence of eclamptic seizures. One study of 265 women with eclampsia found that MgSO4 loading dose administration in the community (4g IV over 20min plus 3g IM in each buttock) before referral and administration of maintenance therapy in hospital was more effective in decreasing recurrent eclampsia compared with the standard practice of referral to hospital where the initial dose of MgSO4 was administered [RR of 0.23, 95% CI 0.11, 0.49]. The two studies of 4g IV plus 10g IM loading dose-only regimens did not show a significant reduction in eclamptic seizures compared with identical loading dose plus 5g/4h IM maintenance dose regimens [RR of 1.38, 95% CI of 0.23, 8.45]. However the combined sample size was small (N=180 women). CONCLUSION: In LMICs, most studies of MgSO4 for pre-eclampsia or eclampsia were conducted in high level health care facilities and administered MgSO4 by the IV route, at least in part. The one study of community administration of a MgSO4 loading dose showed this approach to be effective. There are limited data to support loading dose-only regimens.