Beruflich Dokumente
Kultur Dokumente
DOI 10.1007/s10995-012-1105-9
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 disorders of pregnancy. Ten percent of women have high
blood pressure during pregnancy, and preeclampsia complicates 28 % 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 disorders 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 countries where it is incidentally needed the most [5].
Some of the reasons for the low availability and utilization 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
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Study Setting
Nigeria is located in West Africa and is Africas 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 primary 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 coordinated 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 contributor. 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
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1192
Study Setting
Nigeria is located in West Africa and is Africas 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 primary 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 coordinated 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 contributor. 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
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1193
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 18.723.2).
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 preeclampsia 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 characteristics of the patients that had SPE/E. A majority
(51.5 %) of the patients were teenagers aged 1519 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.
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1194
Pre-eclampsia
(n = 49)
Eclampsia
Total
(n = 1,045)
(%)
Antepartum
(n = 322)
(%)
Intrapartum
(n = 430)
(%)
Postpartum
(n = 244)
(%)
(%)
1519
19 (38.8)
161 (50.0)
254 (59.1)
104 (42.6)
538 (51.5)
2024
19 (38.8)
94 (29.2)
137 (31.9)
81 (33.2)
331 (31.7)
2548
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)
30 (61.2)
195 (60.6)
311 (72.3)
95 (38.9)
631 (60.4)
15
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
2 (0.6)
2 (0.5)
7 (2.9)
11 (1.1)
Age (years)
Parity
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
Secondary/vocational
4 (8.2)
4 (8.2)
40 (12.4)
24 (7.5)
68 (15.8)
23 (5.3)
30 (12.3)
12 (4.9)
142 (13.6)
63 (6.0)
Tertiary
1 (2.0)
2 (0.6)
2 (0.5)
5 (0.5)
Unknown
1 (2.0)
1 (0.3)
14 (3.3)
3 (1.2)
19 (1.8)
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
1 (0.3)
1 (0.2)
2 (0.2)
Marital status
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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
1195
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)
(%)
(%)
1 (0.2)
15 (4.7)
27 (6.3)
13 (5.3)
56 (5.4)
16
7
0
3 (6.1)
11 (3.4)
38 (11.8)
32 (7.4)
84 (19.5)
7 (2.9)
12 (4.9)
50 (4.8)
137 (13.1)
21 (42.9)
105 (32.6)
138 (32.1)
39 (16.0)
303 (29.0)
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)
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)
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)
Fetal outcome
Maternal outcome
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1196
Age (years)
1519 (ref)
1.00
1.00
C20
0 (ref)
1.00
1.00
15
C6
1.00
1.00
Married, polygamous
Parity
Marital status
Educational status
None (ref)
1.00
1.00
Primary
Secondary/higher
Antenatal care
Attends (ref)
1.00
1.00
B2 (ref)
1.00
1.00
C3
1.00
1.00
C1
\1 (ref)
1.00
1.00
C1
1.00
1.00
SVD
CS (ref)
1.00
1.00
AVD
Pre-eclampsia (ref)
1.00
1.00
Eclampsia
B6
717
18 (ref)
1.00
1.00
Yes
Mode of delivery
Condition
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1197
Marital status
Married monogamous
1.00
Married polygamous
Antenatal care
Attends
1.00
1.00
Yes
CS
SVD
1.00
1.24 (0.65, 2.36)
ABD
Mode of delivery
12
1.00
3.02 (0.90, 10.20)
34
C5
C1
1.00
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
None declared.
References
1. United Nations. Millennium Development Goals. 2007 progress
report 2007, http://mdgs.un.org/unsd/mdg/default.aspx. Accessed
January 2011.
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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), 153159.
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), 8184.
14. Tukur, J., Umar, B. A., & Rabiu, 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), 164167.
15. Onakewhor, J. U., & Gharoro, E. P. (2008). Changing trends in
maternal mortality in a developing country. Nigerian Journal of
Clinical Practice, 11(2), 111120.
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, 125132.
17. Tsu, V. D., & Shane, B. (2004). New and underutilized technologies to reduce maternal mortality: Call to action from a
bellagio workshop. International Journal of Gynaecology and
Obstetrics, 85(Suppl 1), S83S93.
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