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Ensuring access to primary, secondary, and
tertiary prevention interventions
Adapted from: POPPHI. Planning tool for expanding access to active management of the
third stage of labor (AMTSL): A guide for program managers and donors. Seattle: PATH;
2008.
Preventive interventions
By definition, primary prevention can help to avoid the development of a disease.
Primary prevention is difficult to achieve for pre-eclampsia because the cause is not well
understood and most factors associated with it are difficult to avoid or manipulate.
Nevertheless, the following interventions that can serve to prevent pre-eclampsia:
Table 1. Primary prevention interventions
Prevention
Intervention
Pregnancy outcome
Recommendation
Prevention of IUGR
Theoretically contributes to
primary prevention of preeclampsia (and IUGR) in the
next generation
Recommended
Family planning
Potential to reduce
pregnancies at risk for preeclampsia
Recommended
Pre-conceptual
prevention and/or
treatment of obesity
Potential to reduce preeclampsia
Recommended
Low-dose aspirin
Reduces pre-eclampsia
Reduces fetal or neonatal
deaths
Advise women with more
than one moderate risk
factor for pre-eclampsia to
take 75 mg of aspirin daily
from 12 weeks gestation
until the birth of the baby.
Calcium
supplementation
Reduces pre-eclampsia in
those at high risk and with
low baseline dietary calcium
intake
No effect on perinatal
outcome
Advise women at risk of
gestational hypertension
living in communities with
low dietary calcium intake,
to take 1 G of calcium daily
from 12 weeks gestation
until the birth of the baby.
Primary
Secondary prevention activities are aimed at early disease detection, thereby
increasing opportunities for interventions to prevent progression of pre-eclampsia. The
ability to prevent eclampsia is limited by lack of knowledge of its underlying cause.
Prevention has focused on identifying women with elevated blood pressure and/or
proteinuria, followed by close clinical and laboratory monitoring to recognize disease
progression. Although these measures do not prevent pre-eclampsia, they may be
helpful in preventing some adverse maternal and fetal sequelae associated with
symptoms and in preventing progression to eclampsia.
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Tertiary prevention focuses on the prevention of complications in women with preeclampsia. Reduction of maternal and fetal/newborn mortality and serious morbidity
depends on timely diagnosis and early referral. The three major interventions for
management of severe pre-eclampsia and eclampsia are: anti-convulsant therapy, antihypertensive treatment, and timed delivery of the baby.
Table 2. Tertiary prevention interventions
Prevention
Intervention
Anti-convulsive drugs
Magnesium
sulfate
Diazepam
Anti-hypertensive
drugs
Induction of labor
Pregnancy outcome
Recommendation
Reduces the risk of
eclampsia without any
substantive effect on longerterm morbidity and mortality
for the women or children
Recommend for women with
severe pre-eclampsia and
eclampsia
When compared to
diazepam, magnesium
sulfate was associated with a
reduction in the risk of
maternal death and in the
risk of recurrence of
convulsions.
When compared to
diazepam, magnesium
sulfate was associated with a
reduction in the risk of an
Apgar score <7 at 5 min and
in length of stay in a special
care baby unit (SCBU) >7
days.
Improves maternal outcome.
May permit prolongation of
the pregnancy and thereby
improve fetal maturity.
Acute falls in maternal
systemic blood pressure can
result in fetal compromise.
Improves maternal and fetal
outcome when carried out
according to
recommendations for severe
pre-eclampsia and eclampsia
Recommend if magnesium
sulfate is not available
Recommend if diastolic BP
110 mm Hg or more
Consider for women beyond
37 weeks’ gestation with
mild pre-eclampsia.
Recommend based on
severity of the disease,
gestational age, and
maternal and fetal condition
Critical elements to ensure availability of preventive
interventions
Each country will need to study the potential interventions to prevent and manage preeclampsia and eclampsia and then decide on which interventions to adopt. Once a
2
decision has been made on interventions to adopt, the following critical elements must
be in place to ensure access to the interventions:

Policy:
-
National policy is in place to promote use of calcium and aspirin supplementation
for primary prevention of pre-eclampsia
-
National policy is in place for indications for induction of labor in women with preeclampsia and eclampsia
-
National policy is in place outlining appropriate anti-hypertensives to administer
in cases of severe pre-eclampsia and eclampsia
-


All skilled birth attendants are permitted to administer at least the first stat
dose for the treatment of severe pre-eclampsia and eclampsia

National policy is in place to promote the administration of the first stat dose
of anti-hypertensive medications in peripheral health care facilities prior to
transfer to a health care facility with operative capacity and physicians
National policy is in place to permit and promote magnesium sulfate as the firstline anti-convulsive medication

All skilled birth attendants are permitted to administer magnesium sulfate for
the treatment of severe pre-eclampsia and eclampsia

National policy is in place to promote the administration of a first IM dose of
magnesium sulfate and the first stat dose of anti-hypertensive medications in
peripheral health care facilities prior to transfer to a health care facility with
operative capacity and physicians
Provider:
-
-
-
Practice:

Percentage of women who receive magnesium sulfate for the treatment of
severe pre-eclampsia and eclampsia is increasing

Percentage of women receiving anti-hypertensives for the treatment of severe
pre-eclampsia and eclampsia is increasing

Percentage of pregnant women who receive calcium and aspirin
supplementation is increasing

Percentage of women whose labors are appropriately induced in cases of preeclampsia and eclampsia is increasing
Capacity building:

In-service training programs and pre-service education programs for
physicians, midwives and other health providers giving obstetric care include
screening for and prevention, identification, and management of preeclampsia and eclampsia

In-service training programs are available to train providers to educate
women and/or community-based health workers on danger signs for preeclampsia during pregnancy and the postpartum
Advocacy:

Champions are found who advocate for increasing access to magnesium
sulfate by promoting administration of a first dose by community-based
providers to pregnant women who begin convulsing in the home
3


Logistics (drugs and supplies):
-
Magnesium sulfate is on the Essential Medicine List; magnesium sulfate is the
first line drug for the treatment of severe pre-eclampsia and eclampsia and is
included in the Standard Protocols and Guidelines for management of severe preeclampsia and eclampsia
-
Anti-hypertensives for treatment of severe pre-eclampsia and eclampsia are
registered and on the Essential Medicine List for use to treat severe preeclampsia and eclampsia
-
Protocols are developed for quantification and storage of anti-convulsive and
anti-hypertensive drugs at all levels of the health care pyramid
Monitoring and Evaluation:
-
Treatment and outcome measures at the facility are included in national HMIS
and supervision tools
Table 3 provides an overview of the critical elements necessary to ensure access to
interventions to prevent and manage pre-eclampsia and eclampsia.
Table 3. Critical elements for expanding access to prevention and management
of pre-eclampsia and eclampsia
POLICY
Policies,
guidelines,
protocols,
standards in
place
Awareness &
endorsement of
national
expansion
PROVIDER
Standardized
pre- & inservice
training
Improved provider
knowledge, skills
& motivation
LOGISTICS (DRUGS & SUPPLIES)
Drug
logistics
in place
All women are
screened for
hypertensive
disorders in
pregnancy, labor
and childbirth,
and the
postpartum
All women with
hypertensive
disorders in
pregnancy, labor
and childbirth,
and the
postpartum are
identified and
correctly
managed
Reduced
morbidity and
mortality from
hypertensive
disorders in
pregnancy
Appropriate amount of
drugs procured,
appropriately stored, &
available
MONITORING/SUPERVISION
MIS & supervision system in place
4
Potential interventions to scale-up activities to prevent,
screen for, identify, and manage hypertensive disorders
in pregnancy
After identifying gaps, decision-makers / stakeholders will need to prioritize which gaps
to address, as more than one will likely be identified. Once gaps have been described,
the next step is to determine the cause of those gaps. The decision-makers /
stakeholders group will need to participate in an analysis to uncover the policy, provider,
drugs/logistics, and monitoring/evaluation factors that are impeding greater than 50%
coverage to activities for prevention, screening, identification, and management of
hypertensive disorders in pregnancy. The decision-makers / stakeholders group next
selects interventions that will address the causes discovered during the analysis.
During the implementation stage, stakeholders recruit additional expertise as needed,
assure organizational readiness, apply the interventions, and help enable and monitor
organizational change. Through monitoring and evaluation, stakeholders measure the
change in the gaps identified. Whenever possible, stakeholders develop an evaluation
method that can be integrated into workplace processes and remain in the workplace
after the interventions as a feedback device for workers and managers. The final
evaluation should re-measure the gaps and assess the extent to which they have closed
as a result of the interventions and to what extent interventions have led to increased
coverage of screening and treatment interventions for pre-eclampsia and eclampsia.
The following are potential interventions that could increase coverage. The interventions
chosen will need to respond to gaps identified by stakeholders.
Policy
1. Hold national and provincial meetings among policy/decision makers to inform
them about the following:
a. Importance of hypertensive disorders as one of the biggest maternal
killers
b. Community and health service factors influencing maternal and perinatal
outcomes
c. Importance of early and regular antenatal care and awareness about signs
and symptoms of pre-eclampsia, severe pre-eclampsia and eclampsia to
improve maternal and perinatal outcomes
d. Primary prevention of pre-eclampsia
e. Importance of early identification
f.
Effectiveness of magnesium sulfate
g. Importance of all birth attendants having the legal authority to provide at
least the first dose of anti-hypertensive and anti-convulsive medications
h. Importance of doing a national assessment in the country to understand
provider practice, barriers to appropriate screening and management of
pre-eclampsia, severe pre-eclampsia and eclampsia, etc.
i.
Importance of developing a strategy to expand access to screening and
management of pre-eclampsia, severe pre-eclampsia and eclampsia in the
country
5
j.
Importance of developing a strategy for reaching women who do not have
access to SBAs or give birth in the home
2. Develop national strategies to increase access to screening for and management
of hypertensive disorders in pregnancy:
a. Promote policies that deploy skilled birth attendants to rural areas
b. Support innovative strategies to offer screening and management of preeclampsia, severe pre-eclampsia and eclampsia to the greatest number of
women, including community-based interventions
c. Sensitize and educate all women, not only those who receive antenatal
care, about the benefits of antenatal care and danger signs for preeclampsia by working with community-based non-governmental
organizations (NGOs)
d. Promote financing schemes / health insurance plans that will reduce
economic barriers to seeking care during pregnancy, childbirth, and in the
postpartum period
3. Update policies to authorize all cadres of skilled birth attendants to provide at
least the first dose of anti-hypertensive and anti-convulsive medications for
management of severe pre-eclampsia and eclampsia
4. Update service delivery guidelines to include:
a. Primary prevention interventions
b. First-line anti-hypertensive medications
c. Magnesium sulfate for treatment of severe pre-eclampsia and eclampsia
Providers
1. Standardize in-service and pre-service training programs treating prevention,
screening, identification, and management of hypertensive disorders in
pregnancy in.
2. Promote the ongoing revision of policies, norms, and procedures to reflect
updated clinical information on prevention, screening, identification, and
management of hypertensive disorders in pregnancy
3. Update all skilled birth attendants’ knowledge and skills
4. Provide each public and private maternity with at least one copy of updated
service delivery guidelines / protocols
5. Develop a system for informing public and private providers about updates and
changes in protocols for prevention, screening, identification, and management of
hypertensive disorders in pregnancy
6. Develop a country training strategy that gives priority to front line providers who
are assigned to peripheral facilities
7. Develop alternate training strategies to reduce cost, increase effectiveness, and
increase access to training activities
8. Where needed, develop behavior change interventions to address the continued
lack of care even after skilled attendants have been updated on prevention,
screening, identification, and management of hypertensive disorders in
pregnancy
6
9. Link managers, pharmacists, and clinicians to ensure that supplies and drugs are
available to prevent and manage hypertensive disorders in pregnancy
10. Use lessons learned from other countries or other health zones to improve
practice of and access to prevention, screening, identification, and management
of hypertensive disorders in pregnancy
11. Promote a “collaborative approach” between health zones and countries
12. Develop and disseminate simple and adapted job aids for developing a birth
preparedness plan (including speaking to the importance of antenatal care,
danger signs during pregnancy, and giving birth with an SBA)
Logistics (Drugs and Supplies)
1. If necessary, revise essential medicine list to include magnesium sulfate as the
first line drug for the treatment of severe pre-eclampsia and eclampsia
2. If necessary, revise essential medicine list to include updated list of antihypertensive drugs for treatment of severe pre-eclampsia and eclampsia
3. Include central drug supply staff, pharmaceutical managers and pharmacists as
key partners in efforts to expand access to prevention, screening, identification,
and management of hypertensive disorders in pregnancy
4. Update pharmaceutical managers and pharmacists on anti-hypertensive and anticonvulsive drugs and the appropriate use and indications of these drugs
5. Update drug management policies for anti-hypertensive and anti-convulsive
drugs
6. Develop systems to ensure that there is quality data for adequate procurement
and distribution
7. Include an anti-hypertensive and anti-convulsive drug security plan in the RH
commodity security plan
8. Ensure adequate equipment at all health care facilities for screening and
identification of hypertensive disorders in pregnancy
Monitoring and Evaluation
1. Develop relevant indicators for monitoring and evaluating access to prevention,
screening, identification, and management of hypertensive disorders in
pregnancy
Minimum indicators

Number and percent of women screened for a hypertensive disorder in
pregnancy by skilled birth attendants

Number and percent of women at risk of developing pre-eclampsia who
received preventive doses of calcium / aspirin

Number and percent of women with identified severe pre-eclampsia or
eclampsia who received treatment with magnesium sulfate

Case fatality rate from severe pre-eclampsia and eclampsia
Other indicators that may be included

Number and percent of providers trained in prevention, screening,
identification, and management of hypertensive disorders in pregnancy
7

Number and percentage of districts providing only the stat initial doses of
magnesium sulfate and anti-hypertensive drugs

Number and percentage of facilities providing maintenance doses of
magnesium sulfate and anti-hypertensive drugs
2. Set a goal coverage for activities to prevent, screen for, identify, and manage
hypertensive disorders in pregnancy
3. Conduct a baseline assessment
4. Integrate documentation of prevention, screening, identification, and
management of hypertensive disorders in pregnancy into existing tools, medical
records, and registers:

BP, proteinuria, and use of anti-hypertensive and/or anti-convulsive drugs
is noted in patient’s chart and on partograph

BP, proteinuria, and use of anti-hypertensive and/or anti-convulsive drugs
is marked in the delivery book or log

Numbers of women with hypertensive disorders in pregnancy, numbers of
women receiving preventive interventions, and numbers of women treated
for pre-eclampsia and eclampsia are included in monthly reports
5. Integrate documentation of magnesium sulfate and anti-hypertensive drug
availability (stock-outs per year) into existing tools
6. Integrate documentation of state of BP machines and availability of urine testing
materials into existing tools
7. Integrate prevention, screening, identification, and management of hypertensive
disorders in pregnancy into existing supervisory tools (the supervision system
should include random observation of antenatal care to monitor quality of
screening and management of hypertensive disorders of pregnancy)
8. Use lessons learned to develop a plan to follow providers, and ensure an efficient
strategy of clinical and managerial support
9. Introduce quality assurance techniques to reinforce prevention, screening,
identification, and management of hypertensive disorders in pregnancy at health
care facilities
8