- Email: [email protected]
Reducing eclampsia-related deaths—a call to action
Comment
use opportunities for optimising resource allocations and service deliveries through learning by doing.
4 5
*Eline L Korenromp, Jane Kengeya Kayondo
6
Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva CH-1214, Switzerland (ELK); Department of Public Health, Erasmus MC, University Medical Centre, Rotterdam, Netherlands (ELK); and UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, WHO, Geneva, Switzerland (JKK) [email protected]
7
8
We declare that we have no conflict of interest. 1
2
3
Mermin J, Were W, Ekwaru JP, et al. Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study . Lancet 2008; 371: 752–59. Corbett EL, Steketee RW, ter Kuile FO, Latif AS, Kamali A, Hayes RJ. HIV-1/AIDS and the control of other infectious diseases in Africa. Lancet 2002; 359: 2177–87. The Antiretroviral Therapy in Lower Income Countries (ART-LINC) Collaboration and ART Cohort Collaboration (ART-CC) groups. Mortality of HIV-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and high-income countries. Lancet 2006; 367: 817–24.
9
10
11 12
Rosen S, Fox MP, Gill CJ. Patient retention in antiretroviral therapy programs in sub-saharan Africa: a systematic review. PLoS Med 2007; 4: e298. Hawley WA, Phillips-Howard PA, ter Kuile F, et al. Community-wide effects of permethrin-treated bednets on child mortality and malaria morbidity in Western Kenya. Am J Trop Med Hyg 2003; 68 (suppl 4): 121–27. Gilks C, Vitoria M. Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach. 2006. http://www.who.int/hiv/pub/guidelines/artadultguidelines.pdf (accessed Jan 14, 2008). World Health Organization HIV/AIDS Programme. Task shifting to tackle health worker shortages. 2007. http://www.who.int/healthsystems/task_ shifting_booklet.pdf (accessed Jan 14, 2008). World Health Organization HIV/AIDS Programme, UNAIDS. Guidance on provider-initiated HIV testing and counselling in health facilities. 2007. http://whqlibdoc.who.int/publications/2007/9789241595568_eng.pdf (accessed Jan 14, 2008). UNAIDS. 2006 UNAIDS annual report. Making the money work. 2007. http://data.unaids.org/pub/Report/2007/jc1306_annualreport_en.pdf (accessed Jan 14, 2008). White Johansson E, Newby H, Renshaw M, Wardlaw T. Malaria & children: progress in intervention coverage. 2007. http://www.healthandmedia. org/downloads/malariaUnicef2007.pdf (accessed Jan 14, 2008). Feachem RG. The research imperative: fighting AIDS, TB and malaria. Trop Med Int Health 2004; 9: 1139–41. International AIDS Society. The Sydney Declaration: good research drives good policy and programming—a call to scale up research. 2007. http://www.iasociety.org/Default.aspx?pageId=63 (accessed Jan 14, 2008).
Reducing eclampsia-related deaths—a call to action Birth should be a time for celebration, but for more than half a million women every year—one a minute— pregnancy ends in death.1 99% of these deaths occur in developing countries, and, tragically, most are preventable.2 One of the most common, yet treatable, causes of maternal death is pre-eclampsia which, if untreated, can lead to seizures (eclampsia), kidney and liver damage, or death.3 About 63 000 women worldwide die every year because of eclampsia and severe pre-eclampsia, both of which are also associated with neonatal death.4 On the basis of high-quality evidence, WHO has recommended magnesium sulfate as the most effective, safe, and low-cost drug to treat these disorders.5 Although magnesium sulfate has been the standard treatment in developed countries for 20 years, less effective and higher-risk drugs (eg, diazepam and phenytoin) are still widely used in most developing countries. In response, EngenderHealth—an international reproductive-health organisation—and the University of Oxford brought together leading scientists, advocates, researchers, and representatives from WHO, UNICEF, international non-governmental organisations, and national health ministries from around the world to identify country-specific barriers and potential www.thelancet.com Vol 371 March 1, 2008
facilitating factors to the drug’s availability and use. Importantly, these global experts then developed a call to action that was issued at the Women Deliver conference held on Oct 18–20, 2007, in London.6 The group identified four main barriers to the use of magnesium sulfate. First, most low-resource countries do not have guidelines mandating the use of magnesium sulfate, and only about half of the world’s countries include magnesium sulfate on their national essential drugs list. Second, even if national guidelines exist, they might not be widely disseminated or mandatory. Third, in some countries, the use of magnesium sulfate is viewed as being appropriate only at highest-level facilities, such as those with an intensive-care unit, because of the perceived need for close monitoring of patients. Health workers are commonly not trained or authorised to administer magnesium sulfate, so they lack confidence and knowledge about the drug and its safety and efficacy. Fourth, eclampsia and severe pre-eclampsia affect few women compared with the number of people affected by other health-care problems, and magnesium sulfate is fairly inexpensive. These factors leave little incentive for drug companies to commercialise the drug. Finally, prepackaged doses of less effective drugs are readily available, but magnesium 705
Comment
Still Pictures
The printed journal includes an image merely for illustration
measures to ensure that efforts for the prevention and treatment of eclampsia and severe pre-eclampsia are commensurate with their health-care burden. These disorders not only kill mothers and newborn babies but also have a long-term effect on the health and wellbeing of those who survive. Scaling up the use of magnesium sulfate for treatment of eclampsia and severe pre-eclampsia will significantly advance the safe motherhood agenda and contribute to reaching the Millennium Development Goals by 2015. We therefore call for the addition of magnesium sulfate to essential drug lists, to ensure registration, universal availability, and appropriate use in all countries. *Ana Langer, José Villar, Katie Tell, Theresa Kim, Stephen Kennedy
Antenatal check in Bangladesh
sulfate comes in inconvenient packs of 500–1000 mL, when only 250 mL is needed. Magnesium sulfate is the only drug for which there is extensive and compelling evidence of efficacy, safety, and cost-effectiveness for treatment of eclampsia and severe pre-eclampsia.7,8 Despite the high mortality associated with eclampsia and severe pre-eclampsia (which is also associated with neonatal deaths9), magnesium sulfate is still unavailable in many health facilities in the settings where most deaths occur.4 Additionally, even where the drug is available, there are many barriers to its appropriate use (eg, resistance to use, fear of side-effects, lack of institutional protocols, lack of experience with the drug, or lack of awareness of its effectiveness and safety).4 Widespread availability and appropriate use of affordable, ready-to-use eclampsia treatment packs to give magnesium sulfate should be priorities for the reduction of the unacceptable burden of eclampsia and severe pre-eclampsia. These packs should be available in all settings to provide care to women with these life-threatening disorders. All health professionals (including midwives, family and emergency-room doctors, anaesthetists, nurses, medical officers, and pharmacists) need to be appropriately trained to treat women with eclampsia and severe pre-eclampsia and in the use of magnesium sulfate. Governments, donors, and all organisations concerned about women’s health are urged to take all necessary 706
EngenderHealth, New York, NY 10001, USA (AL, KT, TK); and Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK (JV, SK) [email protected] We declare that we have no conflict of interest. This call to action is supported by: Jean Ahlborg (Asia/Near East Office, EngenderHealth, Thailand), Sanchita Baksi (Government of West Bengal, India), Hillary Bracken (Gynuity Health Projects, USA), Sylvia Deganus (Tema General Hospital, Ghana Health Service, Ghana), Lelia Duley (University of Leeds, UK), Bissallah Ahmed Ekele (Usmanu Danfodiyo University, Nigeria), Sandy Garcia (Population Council, Mexico), Anne Garrett (International Pre-eclampsia Alliance, USA), Julia Hussein (Immpact, University of Aberdeen, UK), Lennie Kamwendo (Association of Malawian Midwives, Malawi), Andrew Karlyn (Population Council, Nigeria), I P Kaur (Ministry of Health and Family Welfare, India), Matthews Mathai (WHO, Switzerland), Suneeta Mittal (All India Institute of Medical Sciences, India), Ricardo David Muñoz Soto (Ministry of Health, Mexico), Oladosu Ojengbede, (University of Ibadan, Nigeria), Friday Okonofua (International Federation of Gynecology and Obstetrics, Nigeria), Nkeiru Onuekwusi, (Federal Ministry of Health, Nigeria), Ann Phoya (Ministry of Health, Malawi), Malcolm Potts (University of California at Berkeley, USA) Mike Rich (Action on Pre-eclampsia, UK), Harshad Sanghvi (JHPIEGO, USA), Judith Standley and Nancy Terreri (UNICEF, USA), Vivien Tsu (PATH, USA), Meera Upadhyay (Lumbini Zonal Hospital, Nepal), and Jyoti Vajpayee (EngenderHealth, India). 1
2 3 4
5 6 7
8
9
Hill K, Thomas K, AbouZahr C, on behalf of the Maternal Mortality Working Group. Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. Lancet 2007; 370: 1311–19. Mahler H. The Safe Motherhood Initiative: a call to action. Lancet 1987; 1: 668–70. Duley L. Pre-eclampsia and the hypertensive disorders of pregnancy. BMJ 2003; 67: 161. Duley L. Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean. Br J Obstet Gynaecol 1992; 99: 547–53. World Health Organization. Mother-baby package: implementing safe motherhood in countries. Geneva: WHO, 1994. The Lancet. Women: more than mothers. Lancet 2007; 370: 1283. The Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet 1995; 345: 1455–63. The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002; 359: 1877–90. Sevene E, Lewin S, Mariano A, et al. System and market failures: the unavailability of magnesium sulphate for the treatment of eclampsia and pre-eclampsia in Mozambique and Zimbabwe. BMJ 2005; 331: 765–69.
www.thelancet.com Vol 371 March 1, 2008
use opportunities for optimising resource allocations and service deliveries through learning by doing.
4 5
*Eline L Korenromp, Jane Kengeya Kayondo
6
Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva CH-1214, Switzerland (ELK); Department of Public Health, Erasmus MC, University Medical Centre, Rotterdam, Netherlands (ELK); and UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, WHO, Geneva, Switzerland (JKK) [email protected]
7
8
We declare that we have no conflict of interest. 1
2
3
Mermin J, Were W, Ekwaru JP, et al. Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study . Lancet 2008; 371: 752–59. Corbett EL, Steketee RW, ter Kuile FO, Latif AS, Kamali A, Hayes RJ. HIV-1/AIDS and the control of other infectious diseases in Africa. Lancet 2002; 359: 2177–87. The Antiretroviral Therapy in Lower Income Countries (ART-LINC) Collaboration and ART Cohort Collaboration (ART-CC) groups. Mortality of HIV-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and high-income countries. Lancet 2006; 367: 817–24.
9
10
11 12
Rosen S, Fox MP, Gill CJ. Patient retention in antiretroviral therapy programs in sub-saharan Africa: a systematic review. PLoS Med 2007; 4: e298. Hawley WA, Phillips-Howard PA, ter Kuile F, et al. Community-wide effects of permethrin-treated bednets on child mortality and malaria morbidity in Western Kenya. Am J Trop Med Hyg 2003; 68 (suppl 4): 121–27. Gilks C, Vitoria M. Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach. 2006. http://www.who.int/hiv/pub/guidelines/artadultguidelines.pdf (accessed Jan 14, 2008). World Health Organization HIV/AIDS Programme. Task shifting to tackle health worker shortages. 2007. http://www.who.int/healthsystems/task_ shifting_booklet.pdf (accessed Jan 14, 2008). World Health Organization HIV/AIDS Programme, UNAIDS. Guidance on provider-initiated HIV testing and counselling in health facilities. 2007. http://whqlibdoc.who.int/publications/2007/9789241595568_eng.pdf (accessed Jan 14, 2008). UNAIDS. 2006 UNAIDS annual report. Making the money work. 2007. http://data.unaids.org/pub/Report/2007/jc1306_annualreport_en.pdf (accessed Jan 14, 2008). White Johansson E, Newby H, Renshaw M, Wardlaw T. Malaria & children: progress in intervention coverage. 2007. http://www.healthandmedia. org/downloads/malariaUnicef2007.pdf (accessed Jan 14, 2008). Feachem RG. The research imperative: fighting AIDS, TB and malaria. Trop Med Int Health 2004; 9: 1139–41. International AIDS Society. The Sydney Declaration: good research drives good policy and programming—a call to scale up research. 2007. http://www.iasociety.org/Default.aspx?pageId=63 (accessed Jan 14, 2008).
Reducing eclampsia-related deaths—a call to action Birth should be a time for celebration, but for more than half a million women every year—one a minute— pregnancy ends in death.1 99% of these deaths occur in developing countries, and, tragically, most are preventable.2 One of the most common, yet treatable, causes of maternal death is pre-eclampsia which, if untreated, can lead to seizures (eclampsia), kidney and liver damage, or death.3 About 63 000 women worldwide die every year because of eclampsia and severe pre-eclampsia, both of which are also associated with neonatal death.4 On the basis of high-quality evidence, WHO has recommended magnesium sulfate as the most effective, safe, and low-cost drug to treat these disorders.5 Although magnesium sulfate has been the standard treatment in developed countries for 20 years, less effective and higher-risk drugs (eg, diazepam and phenytoin) are still widely used in most developing countries. In response, EngenderHealth—an international reproductive-health organisation—and the University of Oxford brought together leading scientists, advocates, researchers, and representatives from WHO, UNICEF, international non-governmental organisations, and national health ministries from around the world to identify country-specific barriers and potential www.thelancet.com Vol 371 March 1, 2008
facilitating factors to the drug’s availability and use. Importantly, these global experts then developed a call to action that was issued at the Women Deliver conference held on Oct 18–20, 2007, in London.6 The group identified four main barriers to the use of magnesium sulfate. First, most low-resource countries do not have guidelines mandating the use of magnesium sulfate, and only about half of the world’s countries include magnesium sulfate on their national essential drugs list. Second, even if national guidelines exist, they might not be widely disseminated or mandatory. Third, in some countries, the use of magnesium sulfate is viewed as being appropriate only at highest-level facilities, such as those with an intensive-care unit, because of the perceived need for close monitoring of patients. Health workers are commonly not trained or authorised to administer magnesium sulfate, so they lack confidence and knowledge about the drug and its safety and efficacy. Fourth, eclampsia and severe pre-eclampsia affect few women compared with the number of people affected by other health-care problems, and magnesium sulfate is fairly inexpensive. These factors leave little incentive for drug companies to commercialise the drug. Finally, prepackaged doses of less effective drugs are readily available, but magnesium 705
Comment
Still Pictures
The printed journal includes an image merely for illustration
measures to ensure that efforts for the prevention and treatment of eclampsia and severe pre-eclampsia are commensurate with their health-care burden. These disorders not only kill mothers and newborn babies but also have a long-term effect on the health and wellbeing of those who survive. Scaling up the use of magnesium sulfate for treatment of eclampsia and severe pre-eclampsia will significantly advance the safe motherhood agenda and contribute to reaching the Millennium Development Goals by 2015. We therefore call for the addition of magnesium sulfate to essential drug lists, to ensure registration, universal availability, and appropriate use in all countries. *Ana Langer, José Villar, Katie Tell, Theresa Kim, Stephen Kennedy
Antenatal check in Bangladesh
sulfate comes in inconvenient packs of 500–1000 mL, when only 250 mL is needed. Magnesium sulfate is the only drug for which there is extensive and compelling evidence of efficacy, safety, and cost-effectiveness for treatment of eclampsia and severe pre-eclampsia.7,8 Despite the high mortality associated with eclampsia and severe pre-eclampsia (which is also associated with neonatal deaths9), magnesium sulfate is still unavailable in many health facilities in the settings where most deaths occur.4 Additionally, even where the drug is available, there are many barriers to its appropriate use (eg, resistance to use, fear of side-effects, lack of institutional protocols, lack of experience with the drug, or lack of awareness of its effectiveness and safety).4 Widespread availability and appropriate use of affordable, ready-to-use eclampsia treatment packs to give magnesium sulfate should be priorities for the reduction of the unacceptable burden of eclampsia and severe pre-eclampsia. These packs should be available in all settings to provide care to women with these life-threatening disorders. All health professionals (including midwives, family and emergency-room doctors, anaesthetists, nurses, medical officers, and pharmacists) need to be appropriately trained to treat women with eclampsia and severe pre-eclampsia and in the use of magnesium sulfate. Governments, donors, and all organisations concerned about women’s health are urged to take all necessary 706
EngenderHealth, New York, NY 10001, USA (AL, KT, TK); and Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK (JV, SK) [email protected] We declare that we have no conflict of interest. This call to action is supported by: Jean Ahlborg (Asia/Near East Office, EngenderHealth, Thailand), Sanchita Baksi (Government of West Bengal, India), Hillary Bracken (Gynuity Health Projects, USA), Sylvia Deganus (Tema General Hospital, Ghana Health Service, Ghana), Lelia Duley (University of Leeds, UK), Bissallah Ahmed Ekele (Usmanu Danfodiyo University, Nigeria), Sandy Garcia (Population Council, Mexico), Anne Garrett (International Pre-eclampsia Alliance, USA), Julia Hussein (Immpact, University of Aberdeen, UK), Lennie Kamwendo (Association of Malawian Midwives, Malawi), Andrew Karlyn (Population Council, Nigeria), I P Kaur (Ministry of Health and Family Welfare, India), Matthews Mathai (WHO, Switzerland), Suneeta Mittal (All India Institute of Medical Sciences, India), Ricardo David Muñoz Soto (Ministry of Health, Mexico), Oladosu Ojengbede, (University of Ibadan, Nigeria), Friday Okonofua (International Federation of Gynecology and Obstetrics, Nigeria), Nkeiru Onuekwusi, (Federal Ministry of Health, Nigeria), Ann Phoya (Ministry of Health, Malawi), Malcolm Potts (University of California at Berkeley, USA) Mike Rich (Action on Pre-eclampsia, UK), Harshad Sanghvi (JHPIEGO, USA), Judith Standley and Nancy Terreri (UNICEF, USA), Vivien Tsu (PATH, USA), Meera Upadhyay (Lumbini Zonal Hospital, Nepal), and Jyoti Vajpayee (EngenderHealth, India). 1
2 3 4
5 6 7
8
9
Hill K, Thomas K, AbouZahr C, on behalf of the Maternal Mortality Working Group. Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. Lancet 2007; 370: 1311–19. Mahler H. The Safe Motherhood Initiative: a call to action. Lancet 1987; 1: 668–70. Duley L. Pre-eclampsia and the hypertensive disorders of pregnancy. BMJ 2003; 67: 161. Duley L. Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean. Br J Obstet Gynaecol 1992; 99: 547–53. World Health Organization. Mother-baby package: implementing safe motherhood in countries. Geneva: WHO, 1994. The Lancet. Women: more than mothers. Lancet 2007; 370: 1283. The Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet 1995; 345: 1455–63. The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002; 359: 1877–90. Sevene E, Lewin S, Mariano A, et al. System and market failures: the unavailability of magnesium sulphate for the treatment of eclampsia and pre-eclampsia in Mozambique and Zimbabwe. BMJ 2005; 331: 765–69.
www.thelancet.com Vol 371 March 1, 2008