Transcript Slide 1

Tackling the second biggest killer of
mothers
Harshad Sanghvi
Vice President & Medical Director, Jhpiego
Monday 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 & 2009
Cause of death
1998
2009
PPH
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
0%
84
1%0
%
62
%
55
56
%
%
%
88
%
10
%
%
58
60%
63
70%
81
90%
80%
92
100%
0
91 %
10 %
0
86 %
%
Availability of magnesium sulfate & diazepam: Hospitals,
health centers & posts in select countries
50%
40%
10%
0%
Magnesium sulfate
Diazepam
Magnesium sulfate
Hospitals
Nicaragua 2001
Bolivia 2004
9%
12
%
10
20%
%
30%
Diazepam
Health centers / posts
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)
High income
Middle income
Low income
65
(26-86)
13
(7-17)
11
(9-12)
Difference in costs related to
treatment ($)
86
17
13
Difference in other costs ($)
-20
-4
-2
0.0031
(0-0.0082)
0.0054
(0.0001-0.0110)
0.0235
(0.0147-0.0331)
Baseline risk
0.0084
0.0147
0.0303
Relative risk
0.63
0.63
0.23
NNT
324
184
43
21 202
(3 407-NA)
2 473
(402-21 015)
456
(301-779)
Difference in total cost ($)
Difference in risk of eclampsia
Cost per eclampsia averted ($)
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%
4300 interviews with mid career faculty
16 countries, Asia, Africa, LAC
Sanghvi 2005
Using the SBMR Quality Improvement
process to address systems challenges
Guidelines
Supervision
Dangerous Practices
Barriers to Access
Supplies
Improving quality of Eclampsia Care:
NESOG: professional associations playing a vital role
Comparison of Scores among Different Level of Health Facility
Baseline
100%
First
Second
80%
Score
 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%)
60%
40%
20%
0%
Training sites
Service Sites
Private Hosp
Facilities
Results of a small grant from
ACCESS/USAID
Medical College
PHCC
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
Can
we ensure immediacy
of treatment where
many organ
births are
occurring
at home
and centers,
where skilled
care is not
available?
failure:
Even
in best
mortality
is high
Use of magnesium Sulphate and case fatality
rate in eclampsia, Sadar hospital, Purulia,
West Bengal, India, 2002 - 2006
120
25
20
19.12
80
15
60
11.36
7.79
40
7.57
10
8.16
5
20
0
0
2002
2003
2004
% of Magsulph use
2005
Case fatality rate
Trained46 MO, 55 Nursing Personnel
2006
Case fatality rate
% of Mag Sulph Used
100
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:
 Case fatality rate:
4.0% vs 3.5%.
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
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)
x
x
x
x
Effects of calcium supplementation during pregnancy in
studies with low baseline calcium intake populations
7 studies; 10154 women
Relative Reduction (95%CI)
• Hypertension
53% (24, 71)
• Pre-eclampsia
64% (30, 82)
• Maternal death or serious morbidity
20% (3, 35)
• Perinatal death
14% (-6, 31)
Cochrane review
Daily calcium intake
per capita in developing and developed countries
1990)
REGION
World
Developed countries
Developing countries
Africa
Latin America
Near East
Far East
Others
(FAO,
CALCIUM (mg)
472
860
346
363
499
498
352
402
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
Best question: How can we make calcium
more affordable and acceptable
Sanghvi, 2008:PEE position paper
Planned solution
 Sprinkles:
 Calcium phosphate salt (powder) in
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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 taken
Measuring urine protein
 Urine dipstick tests quite pricey
 Boiling not feasible in high volume sites
Preliminary Design
Sanghvi, Crocker, Patent Pending
Sanghvi, Gauri, Shin, Patent Pending
Towards detecting all PE that exists in a community
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/cost
Detecting PE:
•
Clinical detection of PE as standard AN service; monitor and supported at all
levels

Operations research in community detection of PE
•
Strengthen referral centers
Treating 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
As public Health professionals we are
taught to or focus on:
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Plan
Assess
Test
Validate
Manage
 Implement
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Monitor
Document
Scale up
Institutionalize
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Objectives
Disease burden
Results
Resources
Impact
Coverage
Quality of care
Access
Effectiveness
Efficiency
But Bringing About Major changes requires us to
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Convince
Persuade
Negotiate
Recruit
Collaborate
Co-opt
Bypass
Overcome
Mobilize
Broker
Compromise
Courtesy Steve Hodgins
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Advocacy
Partnership
Quid pro quo
Coalition
Opinion leader
Gate-keeper
Agendas
Motivation
Trust
Priority
Power