October 18, 2015

The Importance of Integration in Addressing the Triple Burden of Eclampsia/Pre-eclampsia

Written by Steve Hodgins, Senior Technical Adviser for Newborn Health, Save the Children

This post originally appeared on the Healthy Newborn Network Website.

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The Global Maternal and Newborn Health Conference being held in Mexico City marks an important watershed in global efforts to reduce the burden of preventable maternal and newborn deaths, bringing together what have been two fairly distinct technical communities to tackle their shared challenges in a post-MDG era. With movement towards a broader focus that embraces both mother and fetus/newborn, it’s an appropriate time to reflect on where we have allowed things to fall through the cracks and how we might do better. Pre-eclampsia and the life-threatening condition of eclampsia (seizures associated with this condition), constitute an important contributor to the burden of bad maternal-newborn outcomes which has not – to date – been addressed as effectively as it could be on a more integrated basis.

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In sub-Saharan Africa, 1 out of every 1,500 pregnancies ends in a maternal death attributable to eclampsia/pre-eclampsia; in South Asia the ratio is about 1 in 3,000 (calculated from Kassebaum 2014). The importance of the problem has been recognized within the maternal health community, largely through the emphasis it has placed on use of MgSO4 for care of women with eclampsia and severe pre-eclampsia (for example, as one of the EmOC signal functions).

However, though attention has not – to date – been drawn to this in major global-level newborn plans and reviews, eclampsia/pre-eclampsia makes an even more important contribution to perinatal mortality. According to data from a six-country WHO study (Ngoc 2006), eclampsia/pre-eclampsia is the primary obstetrical cause for up to 1 out of every 4 perinatal deaths (with similar proportions affected for stillbirths and newborn deaths). One could speculate that despite this huge contribution to the burden of preventable newborn deaths and stillbirths, this problem has been largely neglected by the newborn community because it is seen as falling under the responsibility of maternal health. On the maternal health side, as we’ve noted, there has been some serious attention to trying to ensure that when women arrive in hospital in a life-threatening state of eclampsia or severed pre-eclampsia that they’re appropriately treated with MgSO4. However, serious programmatic attention hasn’t extended much further. This represents an important missed opportunity to achieve better outcomes.

As Goldberg has documented (2011), in the United States in 1930 eclampsia-attributable mortality was at levels similar to the current burden in high mortality settings in Africa and South Asia. Over the following half-century (before introduction of MgSO4) such mortality was reduced by about 99%, with over 90% of that decline due to reduced incidence of eclampsia, which was achieved by early identification of pre-eclampsia (through routine ANC screening) and timely delivery. To date, this important lesson has not been widely applied in our program efforts.

If we want to take big chunk out of the wedge of maternal, newborn, and stillbirth mortality attributable to eclampsia/pre-eclampsia, maternal and newborn communities need to join forces and ensure a more comprehensive effort, including systematic early identification, timely delivery, and effective management of those cases that progress to a life-threatening state (including appropriate use of MgSO4).

References

Goldenberg R, McClure E, MacGuire E, et al: Lessons for low-income regions following the reduction in hypertension-related maternal mortality in high-income countries. Int J Gynaecol Obstet 2011, 113:91–95.

Kassebaum N, Bertozzi-Villa A, Coggeshall M, et al: Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014, 384(9947):980-1004.

Ngoc N, Merialdi M, Abdel-Aleem H, et al: Causes of stillbirths and early neonatal deaths: data from 7993 pregnancies in six developing countries. Bull WHO 2006, 84:699-705.

Say L, Chou D, Gemmill A, et al: Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014, 2(6):e323-333.