Maternal and Child Health Journal

, Volume 17, Issue 7, pp 1191–1198

Maternal and Fetal Outcomes After Introduction of Magnesium Sulphate for Treatment of Preeclampsia and Eclampsia in Selected Secondary Facilities: A Low-Cost Intervention

Authors

    • Department of Obstetrics and GynaecologyBayero University/Aminu Kano Teaching Hospital
  • Babatunde Ahonsi
    • Population Council
  • Salisu Mohammed Ishaku
    • Population Council
  • Idowu Araoyinbo
    • Population Council
  • Ekechi Okereke
    • Population Council
  • Ayodeji Oginni Babatunde
    • Population Council
Article

DOI: 10.1007/s10995-012-1105-9

Cite this article as:
Tukur, J., Ahonsi, B., Mohammed Ishaku, S. et al. Matern Child Health J (2013) 17: 1191. doi:10.1007/s10995-012-1105-9

Abstract

The aim of this study was to evaluate whether a new low-cost strategy for the introduction of magnesium sulphate (MgSO4) for preeclampsia and eclampsia in low-resource areas will result in improved maternal and perinatal outcomes. Doctors and midwives from ten hospitals in Kano, Nigeria, were trained on the use of MgSO4. The trained health workers later conducted step-down trainings at their health facilities. MgSO4, treatment protocol, patella hammer, and calcium gluconate were then supplied to the hospitals. Data was collected through structured data forms. The data was analyzed using SPSS software. From February 2008 to January 2009, 1,045 patients with severe preeclampsia and eclampsia were treated. The case fatality rate for severe preeclampsia and eclampsia fell from 20.9 % (95 % CI 18.7–23.2) to 2.3 % (95 % CI 1.5–3.5). The perinatal mortality rate was 12.3 % as compared to 35.3 % in a center using diazepam. Introduction of MgSO4 in low-resource settings led to improved maternal and fetal outcomes in patients presenting with severe pre-eclampsia and eclampsia. Training of health workers on updated evidence-based interventions and providing an enabling environment for their practice are important components to the attainment of the Millenium Development Goals (MDG) in developing countries.

Keywords

Severe preeclampsiaEclampsiaMaternal mortalityMillennium development goalsMagnesium sulphate

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 2–8 % 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 facilities), lack of training of health workers on its use, little incentive for pharmaceutical companies to commercialize the drug, and ready availability of pre-packaged forms of less effective drugs [5, 6]. Other identified barriers include a lack of procurement from governments, a lack of demand by health workers, and lack of in-service training on the use of MgSO4 [7]. There has been a call by the WHO for the evidence on MgSO4’s efficacy to be disseminated, the drug to be registered and made available in all countries, the World Bank and other charitable organizations to fund the provision and distribution of treatment kits and other international organizations to assist on training frontline clinicians on how to use the drug [8].

Study Setting

Nigeria is located in West Africa and is Africa’s 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 deaths in Enugu in southern Nigeria [15]. The differences in the contribution of eclampsia to maternal deaths could be due to the culture of early marriage in northern Nigeria and also delays in accessing care.

Kano is one of the states in the northwest of Nigeria. The last Nigerian National census showed Kano as being the most populous state in the country with a population of 9,401,288 [9]. Kano has a maternal mortality ratio (MMR) of over 1,000 per 100,000 and a relatively high total fertility rate of over seven births per woman, with 45 % of adolescents aged 15–19 having already begun childbearing and a modern contraceptive prevalence rate of less than 5 % [10]. Kano state has 35 general hospitals, offering free maternity care funded by the government.

In 2007, the Population Council secured funding from the MacArthur Foundation for the project. This followed a baseline survey that showed that the drug used for the treatment of SPE/E in all the 35 general hospitals was diazepam. The survey also reviewed data from three general hospitals (Bichi, Wudil, and MMSH) to determine the contribution of SPE/E to maternal deaths and its case fatality rate prior to the introduction of MgSO4. The baseline survey data covered the period January 1, 2007 to December 31, 2007.

Materials and Methods

The data collection for the project started on February 1, 2008 and ended on January 31, 2009. In January 2008, one doctor and one midwife from each of ten selected general hospitals were invited to Kano, the state capital for training. The hospitals were selected on the basis of geographic spread across the state, population, and high burden of maternal deaths. The hospitals were at Kano, Bichi, Wudil, Gwarzo, Rano, Minjibir, Tudun Wada, Doguwa, Rano, and Rogo. Apart from Kano, the rest were rural towns. Also invited for the training were five officials of the Hospitals Management Board.

The facilities were spread across the entire state with Kano metropolis at the center. The distance from each facility to Kano where advanced life support exists ranges from 42 km (Wudil) to 165 km (Doguwa), but since these facilities receive referral from their surrounding clustered primary health care (PHC) facilities, the average distance from a particular PHC to its referral facility ranges from 15 to 30 km.

For this study, a pregnant woman was defined as having pre-eclampsia if she had high blood pressure in the second half of pregnancy of 140 mmHg systolic or more and/or diastolic blood pressure of 90 mmHg or more with proteinuria (at least 2+ of proteinuria using urine dipstick). Features of severe preeclampsia included features of preeclampsia and symptoms of headache, blurring of vision, vomiting and/or epigastric pain. Most of the hospitals did not have adequate laboratory facilities to enable us to use laboratory markers to define severity. Any woman who fitted and had features of preeclampsia was defined as having eclampsia. However, across all the centers, severe preeclampsia and eclampsia were treated similarly. This involved administration of MgSO4, administration of hydralazine (where the diastolic blood pressure was 110 mmHg or more), fluid management and then the delivery of the patient through the fastest route. The latter involves a Cesarean section where the woman was not in labor and augmentation with oxytocin where the woman was already in labor.

Two sets of trainings were conducted for the providers. The first was the “Training of Trainers” (ToT) during which 25 trainers were trained on the use of MgSO4. The second was the step-down training conducted by the master trainers at their respective health facilities. Both trainings were similar.

The training was conducted over 2 days. The first day involved didactic lectures on evidence-based management of hypertensive disorders of pregnancy and how to use MgSO4 including the detection and treatment of toxicity. The participants were taught how to use MgSO4 by the intramuscular (IM) route. For the purpose of the training, the dose used was a loading dose of 4 g administered intravenously followed by 10 g administered IM (5 g in each buttock). This was followed by 5 g administered IM every 6 h until 24 h after delivery or the last seizure. Monitoring of toxicity was done by checking the deep tendon knee reflex before administering each dose of MgSO4.

To aid the training, a simple clinical protocol was distributed to the participants. The second day was used for a practical training at the 25-bed eclamptic ward of MMSH. There was a demonstration of the use of sphygmomanometer to detect hypertension and urinalysis for proteinuria. The participants practiced preparation of different dosages of magnesium sulphate and monitoring for toxicity. At the end of the training, the participants were supplied the initial stock of MgSO4 to take back to their hospitals, patella hammer (for early detection of toxicity), and calcium gluconate (the antidote for toxicity). The trained health workers returned to their hospitals and conducted step-down trainings. All the facilities commenced the use of the drug after the step down training.

Data was then obtained from the ten health facilities on the maternal sociodemographic characteristics, pattern of SPE/E, and the fetomaternal outcomes. The data was obtained by filling of structured forms by the attending health workers. Relevant information that was captured includes patients’ obstetrics demographic variables, fetal outcomes (dead or alive) including APGAR score at 5 min, maternal outcomes (dead or alive) including complications, number of seizures before presentation, recurrence of seizures while on MgSO4, distance traveled before presentation, time lapse from onset of seizures to presentation at facility, mode of delivery and complications of MgSO4 administration. The forms were collated monthly from the sites and analyzed at Kano. However, due to poor record keeping culture, obtaining high-quality data was a challenge and some data were missing. Data review meetings were held monthly at all the sites to encourage the health workers to fill the forms properly. The data collection improved over time.

The data were summarized with frequencies and percentages. The associations between the dependent variables (eclampsia CFR and infant perinatal mortality) and the independent variables were measured with odds ratio (95 % CI) using binary logistic regression. To obtain the significant correlates of the dependent variables while controlling for the effect of each independent variable, multivariate analyses were also conducted using binary logistic regression. The analyses were done with SPSS 15 for Windows (SPSS Inc., Chicago, IL, USA).

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 18.7–23.2).

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 pre-eclampsia 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 15–19 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.
Table 1

Socio-demographic characteristics of the patients that received MgSO4

Basic characteristics

Pre-eclampsia (n = 49)

Eclampsia

Total (n = 1,045)

Antepartum (n = 322)

Intrapartum (n = 430)

Postpartum (n = 244)

(%)

(%)

(%)

(%)

(%)

Age (years)

 15–19

19 (38.8)

161 (50.0)

254 (59.1)

104 (42.6)

538 (51.5)

 20–24

19 (38.8)

94 (29.2)

137 (31.9)

81 (33.2)

331 (31.7)

 25–48

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)

Parity

 0

30 (61.2)

195 (60.6)

311 (72.3)

95 (38.9)

631 (60.4)

 1–5

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

0

2 (0.6)

2 (0.5)

7 (2.9)

11 (1.1)

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

4 (8.2)

40 (12.4)

68 (15.8)

30 (12.3)

142 (13.6)

 Secondary/vocational

4 (8.2)

24 (7.5)

23 (5.3)

12 (4.9)

63 (6.0)

 Tertiary

1 (2.0)

2 (0.6)

2 (0.5)

0

5 (0.5)

 Unknown

1 (2.0)

1 (0.3)

14 (3.3)

3 (1.2)

19 (1.8)

Marital status

 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

0

1 (0.3)

1 (0.2)

0

2 (0.2)

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.

The commonest mode of delivery among the patients was spontaneous vertex delivery (75.6 %), distantly followed by caesarean section (16.8 %), assisted vaginal deliveries (2.3 %) and some few missing data (5.3 %).

Table 2 shows the fetomaternal outcomes. The CFR for the patients treated with magnesium sulphate was 2.3 % (95 % CI 1.5–3.5) as 24 of the 1,045 patients died. The perinatal mortality was 12.3 % (CI 10.4–14.5) as 129 of the 1,045 mothers delivered dead babies. The 5-min APGAR score for 72.9 % of the babies was 7 or more.
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)

(%)

(%)

(%)

(%)

(%)

Apgar score at 5 min

 0

1 (0.2)

15 (4.7)

27 (6.3)

13 (5.3)

56 (5.4)

 1–6

0

11 (3.4)

32 (7.4)

7 (2.9)

50 (4.8)

 7

3 (6.1)

38 (11.8)

84 (19.5)

12 (4.9)

137 (13.1)

 8

21 (42.9)

105 (32.6)

138 (32.1)

39 (16.0)

303 (29.0)

 9

12 (24.5)

70 (21.7)

90 (20.9)

26 (10.7)

198 (18.9)

 ≥10

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)

Fetal outcome

 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)

Maternal outcome

 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)

Further analysis was done to determine factors associated with maternal mortality, as shown in Table 3. The significant measures of association showed that the CFR was five times significantly higher among the patients with parity of seven or more children than among the nulliparous and six times higher among the patients that had recurrent seizures after the loading dose than among the patients that had none.
Table 3

Factors associated with eclampsia CFR

 

CFR (95 % CI)

COR (95 % CI)

AOR (95 % CI)

Age (years)

 15–19 (ref)

1.5 (0.5, 2.6)

1.00

1.00

 ≥20

3.4 (1.8, 5.1)

2.27 (0.96, 5.35)

1.46 (0.40, 5.42)

Parity

 0 (ref)

1.6 (0.6, 2.6)

1.00

1.00

 1–5

2.9 (1.1, 4.6)

1.79 (0.74, 4.35)

1.14 (0.31, 4.17)

 ≥6

8.6 (0.8, 18.0)

5.66 (1.49, 21.59)

4.99 (0.77, 32.22)*

Marital status

 Married, monogamous (ref)

1.7 (0.7, 2.6)

1.00

1.00

 Married, polygamous

4.3 (1.9, 6.7)

2.67 (1.18, 6.01)

2.97 (0.82, 10.79)

Educational status

 None (ref)

2.4 (1.3, 3.5)

1.00

1.00

 Primary

2.9 (0.1, 5.7)

1.20 (0.40, 3.59)

1.18 (0.23, 6.23)

 Secondary/higher

3.0 (1.1, 7.2)

1.26 (0.29, 5.55)

1.00 (0.12, 8.25)

Antenatal care

 Attends (ref)

1.8 (0.7, 2.9)

1.00

1.00

 Does not attend

3.3 (1.6, 5.1)

1.91 (0.84, 4.35)

0.57 (0.15, 2.13)

Number of fits before presentation

 ≤2 (ref)

1.3 (0.3, 2.3)

1.00

1.00

 ≥3

2.9 (1.3, 4.4)

2.26 (0.85, 6.01)

2.19 (0.63, 7.55)

Distance (km) traveled before presentation

 <1 (ref)

2.1 (0.6, 3.5)

1.00

1.00

 ≥1

2.2 (1.1, 3.3)

1.08 (0.45, 2.60)

0.26 (0.05, 1.33)

Time (h) before presentation

 <1 (ref)

1.5 (0.5, 2.5)

1.00

1.00

 ≥1

3.1 (1.4, 4.7)

2.10 (0.89, 4.96)

2.95 (0.63, 13.66)

Recurrent fits after administering the loading dose

 No (ref)

1.8 (0.9, 2.6)

1.00

1.00

 Yes

9.2 (2.1, 16.3)

5.54 (2.10, 14.58)

7.65 (1.62, 36.03)*

Mode of delivery

 SVD

1.8 (0.9, 2.7)

0.78 (0.25, 2.39)

0.77 (0.19, 3.09)

 CS (ref)

2.3 (0.1, 4.5)

1.00

1.00

 AVD

4.2 (4.0, 12.3)

1.86 (0.20, 17.36)

2.58 (0.16, 41.52)

Condition

 Pre-eclampsia (ref)

2.3 (2.2, 6.7)

1.00

1.00

 Eclampsia

2.4 (1.4, 3.4)

1.05 (0.14, 7.97)

0.59 (0.04, 8.94)

Total ampoules of MgSO4 received

 ≤6

2.6 (0.3, 4.9)

1.87 (0.56, 6.22)

1.16 (0.18, 7.56)

 7–17

3.0 (1.4, 4.6)

2.08 (0.78, 5.53)

1.13 (0.25, 5.01)

 18 (ref)

1.5 (0.3, 2.7)

1.00

1.00

COR crude odds ratio, AOR adjusted odds ratio

* Significant at p < 0.05

Factors associated with perinatal mortality are shown in Table 4. Perinatal mortality was significantly higher among the patients that had three or more seizures before presentation than among those that had no seizures at presentation; the prevalence significantly increased with increasing number of seizures before presentation. Similarly, perinatal mortality was about three times higher among the patients that had recurrent seizures after the loading dose than among those who had no recurrent seizures and four times higher among the patients that had assisted breech delivery than those that had spontaneous vaginal delivery.
Table 4

Factors associated with perinatal mortality

Factors

Perinatal mortality  % (95 % CI)

Adjusted OR (95 % CI)

Marital status

 Married monogamous

10.6 (8.6, 13.1)

1.00

 Married polygamous

16.3 (12.4, 21.1)

1.17 (0.72, 1.92)

Antenatal care

 Attends

10.1 (7.8, 12.9)

1.00

 Does not attend

14.6 (11.5, 18.3)

0.88 0.55, 1.42)

Recurrent fits after MgSO4 loading dose

 No

11.4 (9.5, 13.6)

1.00

 Yes

27.7 (17.3, 40.2)

2.64 (1.25, 5.54)*

Mode of delivery

 CS

8.5 (4.8, 13.7)

1.00

 SVD

12.4 (10.2, 15.0)

1.24 (0.65, 2.36)

 ABD

29.2 (12.6, 51.1)

3.48 (1.12, 10.91)*

Number of fits before presentation

 0

3.7 (1.0, 9.1)

1.00

 1–2

10.4 (7.6, 14.1)

3.02 (0.90, 10.20)

 3–4

13.4 (9.9, 17.9)

3.69 (1.09, 12.48)

 ≥5

17.9 (12.4, 24.5)

5.70 (1.63, 19.93)*

Time before presentation (h)

 <1

9.7 (7.5, 12.5)

1.00

 ≥1

16.3 (13.0, 20.2)

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

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 introduced in an area where it was not previously available and this can be replicated in other areas especially in developing countries. This was a relatively easy intervention involving training health workers and providing the necessary tools for them to practice what they learned. Yet, it had a huge impact in reducing maternal deaths. Introduction of similar interventions in developing countries could help in the attainment of the MDGs.

Despite the successful reduction in CFR for SPE/E, there were several factors that were identified to be contributory to the recorded deaths. Analysis of these factors helps in further reducing maternal deaths. In this study, most cases were seen in primigravida, especially teenagers. This finding is similar to that from other studies [13, 14]. This group of patients need to be targeted in any program aimed at preventing SPE/E. Antenatal care is an opportunity for detecting preeclampsia through monitoring of blood pressure and detection of proteinuria. There is a need to improve the quality of the antenatal care. It is a common scenario in the hospitals under the study to observe one or two nurses conducting antenatal care to 200–400 patients in a single day. Task-shifting has been advocated to mitigate the lack of health workers. Tasks can be delegated to non-physician clinicians, medical assistants, nurses, and community health care workers [18].

To prevent eclampsia, it is necessary to first diagnose pre-eclampsia using routine blood pressure and urine protein testing of all women [19]. Those that have preeclampsia can then be treated with anti-hypertensives and delivered early. Antenatal care also presents an opportunity for instituting current evidence-based, possibly preventive, strategies to those at risk in the form of low-dose aspirin and calcium supplementation. Aspirin is associated with a 10–19 % reduction in pre-eclampsia risk and a 10–16 % decrease in perinatal morbidity and mortality [20]. At least 1 g of calcium supplementation is also associated with reduction in preeclampsia in those with low dietary calcium [21]. There is also a need for community health education on the importance of antenatal care.

The finding also that most of the patients with eclampsia had at least a seizure at home means there is a need to educate the patients on warning symptoms of eclampsia such as headache, blurring of vision, and epigastric pain. Among those that had eclampsia, more deaths were recorded in those of high parity (>7) and those who had a seizure after the loading dose. These groups of patients are those in whom there could be other underlying pathologies apart from eclampsia. These characteristics are those of patients in whom a clinical search needs to be conducted for other underlying causes for the seizures. In these cases, however, this was not done, due to a lack of facilities.

The stillbirth rate in this study was 12.3 % (CI 10.4–14.5). Unfortunately, there was no baseline perinatal mortality for comparison. However, the finding is much lower than the 35.3 % stillbirth rate reported from another center using diazepam [22], even though other studies show that magnesium sulphate has no impact on stillbirth rates [23]. The factors associated with perinatal mortality were recurrent seizures fits after the loading dose, those delivered by assisted breach delivery than among the patients that had spontaneous vaginal delivery, and those that had seizures before presentation. The first factor is also associated with maternal deaths, which invariably affect the baby. Those who had breech delivery had a higher mortality probably because of the extra manipulation needed to deliver these babies. Those mothers who had both breech presentation and eclampsia were more likely to have an improved outcome with a primary Cesarean delivery. The last factor implies some delays from the mother before accessing care, in which case the baby is invariably affected.

The limitation of this study is that of missing data which arose from incorrectly filled forms or even failure to complete the forms in some cases. Also, the study assumes that all patients received the standard dosage of the drug as the health workers were taught in the training. As the health workers also fill the forms, our assumptions could be wrong. In addition, the study was conducted in an area where women prefer to deliver at home. It is possible that a majority of women with this condition are not reflected in this study, although there is a tendency that even such women will come to the hospital when complications such as SPE/E develop.

In conclusion, this study clearly shows that the introduction of magnesium sulphate usage for SPE/E using this low-cost replicable intervention had a positive impact on both maternal and fetal morbidity and mortality. The state government should make the project sustainable on withdrawal of donor support so that the patients can continue to reap the benefits.

Conflict of interest

None declared.

Copyright information

© Springer Science+Business Media, LLC 2012