Background

Overview of challenges in LMIC

The Safe Motherhood Initiative, launched in 1987 and targeted towards improving emergency obstetric care, has made access to high quality obstetric care throughout pregnancy and immediately after childbirth, one of its priorities. Despite this, the absence of pre-conception care coupled with a lack of effective and universal antenatal care remains a serious challenge in LMIC. Many women with pre-eclampsia, particularly, at the community level are missed due to the lack of antenatal care. These women are more likely to develop serious complications resulting in maternal and perinatal morbidity and mortality.

Antenatal care utilization is around 68% in LMIC compared to 98% in high resource settings. The region of the world with the lowest levels of use is South Asia, where only 54% of pregnant women have at least one antenatal care visit. In the Middle East and North Africa, use of antenatal care is somewhat higher at 65% of pregnant women. In sub-Saharan Africa, generally the region with the lowest levels of health care use, 68% of women report at least one antenatal visit. These figures, however, show an improvement of around 20% in the last decade.

Not surprisingly, there is marked urban/rural differential in accessing antenatal care in LMIC. Whereas 86% of women in urban settings will have one antenatal visit, only 65% of women rural settings will have the same. For repeated antenatal visits, 61% of women in urban women report four or more antenatal visits compared to 39% of rural women.

when women do access care, there are three primary delays that lead to the increased incidence of maternal mortality due to pre-eclampsia: delays in triage, in transport, and in treatment. These delays occur at the community, primary health center, and hospital facility level respectively. There are a number of factors that lead to these delays: lack of financially feasible and accurate point-of-care diagnostics, inadequate means and/or routes of transportation and unavailability of appropriate treatment due to financial cost or lack of pharmaceutical support including barriers to registration and production.

There is also a current shortage of health care workers. The World Health Organization (WHO) has declared that there are 58 crisis countries facing an acute health care worker crisis. 36 of these countries are in sub Saharan Africa. In addition to the shortage of health care workers, inappropriate skill-mix is an issue. For example, in Bangladesh, there are around five physicians and two nurses per 10,000 people. The ratio of nurse to physician is only 0.4 to 1. Furthermore, there is an uneven distribution of qualified health care workers in urban settings compared to rural areas.

As in well resourced settings, at the facility level, the introduction and adoption of evidence-based clinical practice remains challenging. Currently, there is no clear policy or country specific standard of care for pre-eclampsia. Access to evidence and guidelines may be limited in LMIC due to financial cost. However, resources such as the WHO Reproductive Health Library (RHL) are free, available online and are particularly targeted for LMIC. RHL takes the best available evidence on sexual and reproductive health from Cochrane systematic reviews and presents it as practical actions for clinicians to take to improve health outcomes.

The adoption of evidence depends on whether the practice is consistent with the values, beliefs and current needs of the local medical team and the population it serves, as well the simplicity of the intervention or treatment, adaptability of the practice to local conditions. Magnesium sulfate (see section titled “ Treatment of Pre-eclampsia ”) is one such example, where despite robust evidence, the uptake of evidence based practice has been low due to multiple systemic barriers.

PRE-EMPT will develop strategies and solutions that are easily adoptable, financially feasible and targeted at the community level where the majority of pre-eclampsia related maternal mortality and morbidity occur. PRE-EMPT has an emphasis on task shifting and will focus on the role of community health workers (CHW) or lady health care workers (as they are known as in many countries) in the care of women with pre-eclampsia. Task shifting is discussed below. The gender of the CHW is very important as women themselves are more comfortable around female health care providers. Furthermore, it may be the societal norm to seek care from females rather than from male health care providers. A 2009 analysis of Demographic and Health Surveys from 41 LMIC found that nearly one quarter of women listed not having a female health provider as a reason that they did not go to a health facility to give birth.

The focus on the community level will also raise awareness and perhaps, counter the existing regional myths, beliefs and misinformation about pre-eclampsia. Most women who survive pre-eclampsia do not champion this issue due to the misconceptions that personal hygiene or sexual infidelities may have been the cause. The lack of champions hinders advocacy for pre-eclampsia.

PRE-EMPT will also collaborate with the WHO to develop, distribute, and implement evidence- based and culturally appropriate knowledge translation tools. This will be critical in reducing the burden of life-ending, life-threatening, and life-altering maternal and perinatal complications of pre-eclampsia and eclampsia. The knowledge translation tools that will be developed will be suitable for use at the community, primary health clinic, and hospital levels to improve evidence based clinical decision-making. Ultimately, these can be used to inform policy making at the professional association, government, and national service health care levels ( Table 1 ).

Overview of challenges in LMIC

The Safe Motherhood Initiative, launched in 1987 and targeted towards improving emergency obstetric care, has made access to high quality obstetric care throughout pregnancy and immediately after childbirth, one of its priorities. Despite this, the absence of pre-conception care coupled with a lack of effective and universal antenatal care remains a serious challenge in LMIC. Many women with pre-eclampsia, particularly, at the community level are missed due to the lack of antenatal care. These women are more likely to develop serious complications resulting in maternal and perinatal morbidity and mortality.

Antenatal care utilization is around 68% in LMIC compared to 98% in high resource settings. The region of the world with the lowest levels of use is South Asia, where only 54% of pregnant women have at least one antenatal care visit. In the Middle East and North Africa, use of antenatal care is somewhat higher at 65% of pregnant women. In sub-Saharan Africa, generally the region with the lowest levels of health care use, 68% of women report at least one antenatal visit. These figures, however, show an improvement of around 20% in the last decade.

Not surprisingly, there is marked urban/rural differential in accessing antenatal care in LMIC. Whereas 86% of women in urban settings will have one antenatal visit, only 65% of women rural settings will have the same. For repeated antenatal visits, 61% of women in urban women report four or more antenatal visits compared to 39% of rural women.

when women do access care, there are three primary delays that lead to the increased incidence of maternal mortality due to pre-eclampsia: delays in triage, in transport, and in treatment. These delays occur at the community, primary health center, and hospital facility level respectively. There are a number of factors that lead to these delays: lack of financially feasible and accurate point-of-care diagnostics, inadequate means and/or routes of transportation and unavailability of appropriate treatment due to financial cost or lack of pharmaceutical support including barriers to registration and production.

There is also a current shortage of health care workers. The World Health Organization (WHO) has declared that there are 58 crisis countries facing an acute health care worker crisis. 36 of these countries are in sub Saharan Africa. In addition to the shortage of health care workers, inappropriate skill-mix is an issue. For example, in Bangladesh, there are around five physicians and two nurses per 10,000 people. The ratio of nurse to physician is only 0.4 to 1. Furthermore, there is an uneven distribution of qualified health care workers in urban settings compared to rural areas.

As in well resourced settings, at the facility level, the introduction and adoption of evidence-based clinical practice remains challenging. Currently, there is no clear policy or country specific standard of care for pre-eclampsia. Access to evidence and guidelines may be limited in LMIC due to financial cost. However, resources such as the WHO Reproductive Health Library (RHL) are free, available online and are particularly targeted for LMIC. RHL takes the best available evidence on sexual and reproductive health from Cochrane systematic reviews and presents it as practical actions for clinicians to take to improve health outcomes.

The adoption of evidence depends on whether the practice is consistent with the values, beliefs and current needs of the local medical team and the population it serves, as well the simplicity of the intervention or treatment, adaptability of the practice to local conditions. Magnesium sulfate (see section titled “ Treatment of Pre-eclampsia ”) is one such example, where despite robust evidence, the uptake of evidence based practice has been low due to multiple systemic barriers.

PRE-EMPT will develop strategies and solutions that are easily adoptable, financially feasible and targeted at the community level where the majority of pre-eclampsia related maternal mortality and morbidity occur. PRE-EMPT has an emphasis on task shifting and will focus on the role of community health workers (CHW) or lady health care workers (as they are known as in many countries) in the care of women with pre-eclampsia. Task shifting is discussed below. The gender of the CHW is very important as women themselves are more comfortable around female health care providers. Furthermore, it may be the societal norm to seek care from females rather than from male health care providers. A 2009 analysis of Demographic and Health Surveys from 41 LMIC found that nearly one quarter of women listed not having a female health provider as a reason that they did not go to a health facility to give birth.

The focus on the community level will also raise awareness and perhaps, counter the existing regional myths, beliefs and misinformation about pre-eclampsia. Most women who survive pre-eclampsia do not champion this issue due to the misconceptions that personal hygiene or sexual infidelities may have been the cause. The lack of champions hinders advocacy for pre-eclampsia.

PRE-EMPT will also collaborate with the WHO to develop, distribute, and implement evidence- based and culturally appropriate knowledge translation tools. This will be critical in reducing the burden of life-ending, life-threatening, and life-altering maternal and perinatal complications of pre-eclampsia and eclampsia. The knowledge translation tools that will be developed will be suitable for use at the community, primary health clinic, and hospital levels to improve evidence based clinical decision-making. Ultimately, these can be used to inform policy making at the professional association, government, and national service health care levels ( Table 1 ).

The role of task shifting

Given the shortages of the health workface and skill-mix imbalances, task shifting may be a promising strategy. Task shifting is defined as delegating tasks to existing or new personnel with either less training or narrowly tailored training. The primary objective of task shifting is to increase productivity and efficiency by increasing the number of health care services provided at a given quality and cost, or alternatively, to provide the same level of health care services at a given quality at a lower cost. Another objective of task shifting is to reduce the time needed to scale up the health force, as the personnel performing the shifted tasks require less training.

Tasks can be delegated to non-physician clinicians, medical assistants, nurses and community health care workers. CHW are lay members of communities who work within the local health care system and share ethnicity, language, socioeconomic status and life experiences with the community members they serve. They are an integral part of the health care force in many LMIC where they are employed to provide culturally appropriate health education and information, informal counseling and guidance on health behaviors. CHW also advocate for individual and community health needs and provide some direct services. For example, in Pakistan, CHW have been trained to promote antenatal care including the use of iron and folate in pregnancy and to promote breastfeeding.

The 2010 State of the World’s Mothers report states that female health care workers have a critical role in saving the lives of women, newborns and young children. It further states that relatively modest investments in female health workers can have a measurable impact on survival rates in isolated rural communities. The use of CHW in Nepal has resulted in more women accessing prenatal care, more trained birth attendance and a decline in maternal and perinatal mortality. In India, there is a team of 54,000 women community health volunteers who have been trained to dispense drugs, provide nutrition counseling, manage childhood illnesses, provide essential newborn care and identify danger signs that require prompt referral to a health care facility for proper treatment. This has resulted in reduction of the rural infant mortality rate from 85/1000 to 65/1000 in four years.

Outside of pregnancy, there is high quality evidence demonstrating the potential for task shifting as an important policy option. For example, randomized controlled trials have shown that there were no significant difference in patient assessment, drug recommendation, WHO clinical stage assignment and tuberculosis status assessment in HIV/AIDS patients receiving antiretroviral therapy from CHW in Kenya and Uganda.

However, a number of issues have also been raised with task shifting such as quality and safety concerns, professional and institutional resistance, and the need to sustain motivation and performance. One particular concern is that quality of care may decrease if CHW are given complex tasks. However, contextual factors like appropriate leadership, training and workplace infrastructure will be important in addressing this concern and determining the success of a skill-mix policy change.