By Kanij Sultana
Every year in Bangladesh, between 5,000 and 6,000 women die from hypertensive disorders of pregnancy (HDP). Of those maternal deaths, between 1,000 and 1,200 are the result of undetected and unmonitored high blood pressure that progresses to eclampsia, the second leading cause (20%) of maternal mortality in the country. With timely and high-quality antenatal care (ANC), these deaths are preventable.
However, challenges exist for reducing these deaths – household and health system delays that inhibit timely identification, inadequately trained staff, lack of clear management strategies and clinical protocols for women with preeclampsia and eclampsia, delay in referrals of women with signs and symptoms of preeclampsia and eclampsia, and ineffective referral systems. Additionally, to date the focus has been on ensuring women suffering from severe preeclampsia and eclampsia have access to magnesium sulphate (MgSO4) to prevent and/or manage the convulsions. However little is done to manage the increased blood pressure – the main sign of preeclampsia and eclampsia.
The World Health Organization (WHO) recommends antihypertensive drugs – methyldopa, nifedipine, labetalol, and hydralazine are safe during pregnancy – and magnesium sulphate (mgso4) for preventing or treating pre-eclampsia and eclampsia (preeclampsia and eclampsia). The WHO also recommends task shifting to lower level cadres and states auxiliary nurse/midwives – the lowest cadre recommended – can prescribe antihypertensive drugs for severe hypertension when there is targeted and ongoing monitoring and evaluation, and that every health facility have adequate oral and intravenous antihypertensive drugs in the antenatal, and maternity units. (WHO 2012).
In Bangladesh, primary health care (PHC) providers can prescribe and administer a loading dose of MgSO4 for the management of women with severe preeclampsia and eclampsia prior to referring them to a higher-level facility. However, only doctors – posted at secondary and tertiary facilities – can prescribe antihypertensive drugs. Despite being the first point of contact, PHC providers are not able prescribe these life-saving antihypertensive drugs to pregnant or recently delivered postpartum women to manage their high blood pressure. Instead, they are mandated to refer women with high blood pressure to providers at higher-level facilities.
During a landscape analysis on preeclampsia in Bangladesh in 2015 it emerged that providers were not clear on which drugs (or the correct dose) were the best ones to prescribe to pregnant women suffering from hypertension.
As a result of these findings, the project is now assessing the feasibility of training PHC providers – who are nearer to where women live – to identify hypertensive disorders in pregnant women at PHCs, and provide a single dose of methyldopa to women with moderate to severe hypertension before referral to another facility. This drug, which is on the WHO and Bangladesh essential medicines list, is safe for pregnant women, affordable, accessible, has proven benefits, has been used for over 50 years to manage hypertension in pregnant women. Findings from the study are expected in early 2018.
National Institute of Population Research and Training (NIPORT), MEASURE Evaluation, ICDDR,B. 2012. Bangladesh Maternal Mortality and Health Care Survey 2010. Dhaka: NIPORT, MEAUSRE Evaluation, ICDDR,B.
Duley L, Henderson-Smart DJ, Meher S. 2006. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database of Systematic Reviews, (3):CD001449.*
Charlotte Warren, Sharif Hossain, Rahat Ara Nur, Kanij Sultana, Karen R. Kirk, and Amy Dempsey. 2016. Landscaping analysis on pre-eclampsia and eclampsia in Bangladesh. Dhaka: Population Council.
MCHIP, Prevention and management of pre-eclampsia and eclampsia: A reference manual for Health Care Providers, 2011
World Health Organization 2012. Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting.