Administering Magnesium Sulfate to Treat Severe Pre-eclampsia and Eclampsia

Location

In Nigeria, the Population Council is involved in a project in which magnesium sulfate (MgSO4) has been administered for the treatment of pre-eclampsia and eclampsia. While pre-eclampsia and eclampsia are together one of the largest causes of global maternal mortality (accounting for 12% of all maternal deaths in developing countries on average), they are easily preventable conditions and inexpensive to treat. While the treatment is easily administered with proper training and supervision of health workers, the drug has been underutilized in the past because of lack of knowledge among health workers on its use. The Population Council saw this gap and in conjunction with the health management board in Nigeria, and sponsorship from the MacArthur Foundation, began introducing the use of magnesium sulfate in 10 secondary health facilities in Kano in 2007. The objectives of this study are threefold: 1) to assess provider acceptability of the use of MgSO4 to control convulsions in eclamptic women entering maternity wards; 2) to determine training needs and capacity-building support required to be able to introduce MgSO4 at tertiary and secondary hospital levels; and 3) to understand the factors that influence the referral of women with eclampsia to facilities.

The incidence of eclampsia ranges from 10 to 50 per 1,000 deliveries in developing countries, and severe cases of pre-eclampsia and eclampsia are very common in northern Nigeria, where they cause up to 40 percent of maternal deaths. Regional variation exists in the country: the incidence rate is 3%–9% in the north and approximately 1%–3% in the south. The insidious nature of the disease makes it life-threatening and eclampsia is usually asymptomatic until the woman's condition deteriorates, potentially progressing into severe pre-eclampsia or eclampsia without warning.

Pre-eclampsia and eclampsia are problems usually associated with a woman’s first pregnancy (primigravida). In northern Nigeria, this means that the majority of those affected are teenagers. Other predisposing factors in the Nigerian context include poor access to antenatal care, past history of pregnancy-induced hypertension, multiple pregnancy, molar pregnancy, diabetes mellitus, and renal diseases. In addition, social contributory factors include poverty, poor reproductive health care-seeking behavior, cultural perceptions of eclampsia, and lack of access to high-quality maternal services, including intrapartum care.

Magnesium sulfate is the best method for preventing and treating eclampsia. Upon confirmation of high blood pressure, a loading dose—an intramuscular and intravenous administration—is given to the pregnant woman. Subsequently, maintenance doses are administered at four hourly intervals.

The Council’s pilot program aims to increase the administration of MgSO4 at 10 hospital sites in Kano state, and to investigate other relevant variables involved in MgSO4 administration, such as training requirements and maternal behaviors and constraints affecting hospital attendance. The project supported the national Ministry of Health in the development of a training manual for the expansion of magnesium sulfate use, job-aids and posters of the treatment protocol for distribution in health centers, and the training of master trainers and focal persons in each facility. Most importantly, the project stimulated the supply of magnesium sulfate for health centers through the health management board (HMB).

The training curriculum developed for health service providers covers resuscitation, hypertension, convulsions, fits, child delivery, postpartum care for women who have developed eclampsia, and MgSO4 clinical pharmacology, including clinical indications of use, dosage, route of administration, contraindications, precautions, side effects, and toxicity. Training and refresher courses target all health care workers at the community and facility levels. This targeting is intended to build consensus and momentum for front line individuals to take the activity forward. Training and follow up activities at the facility lasted 10 months before the study ended and the intervention was extended to all secondary facilities in the State (from 10 to 36 facilities). The government of Kano now supplies magnesium sulfate as a free maternity drug. Results from the initial study have been remarkable, and MgSO4 has been hailed a "miracle drug.” (See the results tab for more information.)