Although maternal mortality is shown to be declining, it is estimated that around 800 women die daily as a result of complications of pregnancy. 85% of this burden lies with Sub-Saharan Africa and Southern Asia, with all ten of the countries with the highest maternal mortality ratios being in Africa. Pre-eclampsia (defined as hypertension and proteinuria occurring during pregnancy) is associated with around 40,000 maternal deaths annually, with the vast majority of these also occurring in low and middle income countries. The World Health Organisation estimates that around 26% of severe maternal outcomes are associated with pre-eclampsia or eclampsia, making it the second leading cause of such outcomes. Pre-eclampsia is also associated with poor fetal outcomes, including fetal growth restriction, and intrauterine fetal death.
Restricted or under-staffed maternity services, particularly in rural areas with poor transport systems, mean that women may present late or infrequently to antenatal care. However, even when uptake of antenatal healthcare in low and middle-income countries is high, pre-eclampsia remains under-diagnosed. Given that urinalysis by dipstick has low specificity, early and accurate identification of at-risk women depends on regular and accurate blood pressure monitoring. However, training in the use of the technically challenging sphygmanometer is often lacking, and equipment may be lacking or defective.
Once pre-eclampsia is diagnosed (often at a late stage), skilled management is essential: currently this is timely delivery of the infant with trained professionals in attendance, preceded by seizure prevention and antihypertensive control. However, access to such care may be restricted by limited transport and referral options, particularly for poor women in rural settings. Although magnesium sulphate has been shown to be effective in the prevention of eclamptic seizures, it is yet to be used widely in many low and middle income countries. Access to antihypertensive medication may also have similarly limited availability. These are only temporising measures that reduce morbidity prior to delivery.
Efforts to reduce maternal morbidity and mortality due to the complications of pre-eclampsia in low and middle income countries are therefore based around improving primary care centres’ abilities to identify at risk women (especially by accurate blood pressure monitoring) which must be accompanied by improved access to medication and facilities where induction of labour and caesarean section can be carried out. This talk will discuss management strategies that could address pre-eclampsia associated morbidity and mortality, particularly in low and middle income countries. It will describe the evolution and implementation of the CRADLE Vital Signs Alert in a low income settings.