Antananarivo, Madagascar — During a prenatal checkup late in her pregnancy, Holandrie Raharifara was dismayed to learn she had high blood pressure, a sign she may be at risk for a potentially life-threatening condition known as pre-eclampsia. The 33-year-old mother dutifully took the medicine prescribed to control her blood pressure — she lost her first child after a difficult pregnancy and wasn’t going to take any chances this time. A month later, when Holandrie felt her first labor contractions, she headed straight for the Mahambo health center.
Dr. Toky Raharimanana, the physician on call, examined Holandrie, found her blood pressure to be high and prepared to refer her to the closest hospital. But the baby came quickly — Holandrie gave birth to a healthy boy and then, despite receiving active management of third stage of labor, began bleeding heavily. To control the bleeding, Dr. Toky gave her an injection of oxytocin, the recommended treatment, massaged Holandrie’s uterus to help contract it and also squeezed the uterus between both hands (bi-manual compression of the uterus) as is recommended. The bleeding stopped, but the young mother wasn’t out of danger yet.
As Dr. Toky prepared to send her patient to the nearest hospital, Holandrie complained of a severe headache and nausea. The doctor took Holandrie’s blood pressure and it was higher than before. Suspecting severe pre-eclampsia because of her patient’s history, Dr. Toky took immediate action and administered the proper dosage of magnesium sulfate, the first-line drug to treat severe pre-eclampsia and eclampsia (PE/E), which are characterized by high blood pressure and protein in the urine and, in the case of eclampsia, convulsions.
Dr. Toky is among the 700 health care providers who have learned how to use this lifesaving drug during a training on pregnancy-related complications and emergency obstetric and newborn care sponsored by the U.S. Agency for International Development’s flagship global Maternal and Child Health Integrated Program (MCHIP). One of the leading causes of maternal death in Madagascar is eclampsia, and the MCHIP program targets it in their trainings.
As a result of Dr. Toky’s timely intervention, Holandrie survived and is now tending to her baby boy, Nomena, and his 9-year-old sister. But the outcome could have been very different. In the past, Dr. Toky said she attended other trainings on pregnancy complications that covered too much material in a short period of time. It wasn’t until this MCHIP training that she actually felt capable of using this drug.
In 2009, as part of its work with the Clinton Global Initiative, Jhpiego made a five-year commitment to strengthen prevention of maternal deaths from pre-eclampsia/eclampsia. MCHIP, with funding from USAID and through the leadership of Jhpiego, has recently released the second-year Global Status Report surveying countries’ progress in tackling this pregnancy-related condition as well as postpartum hemorrhage (PPH). The survey objective was to identify successes in expanding PE/E and PPH prevention and management in national programs and to target gaps and challenges that still need to be addressed. The survey showed that, while important drugs are more available, doctors and midwives sometimes lack the skills to use them.
In Madagascar, magnesium sulfate (MgSO4) is on the national essential medicines list as a first-line anticonvulsant for severe PE/E. Midwives are authorized to diagnose severe PE/E and administer an initial (loading) dose of magnesium sulfate. But the drug is available less than 50 percent of the time at public facilities that offer maternity services, and stock-outs occur often, impeding providers’ ability to treat the condition. When MgSO4 isn’t available, another drug, diazepam, is approved for use.
In MCHIP trainings, management of pre-eclampsia/eclampsia is an area of particular focus. Participants are checked on their ability to perform certain skills, including the administration of magnesium sulfate, explains Dr. Jean Pierre Rakotovao, who leads MCHIP in Madagascar. Staff provide training participants with highly visual job aids, which depict the flasks, syringes and dosages of the drug to be used. “Participants must then demonstrate how to mix and administer the drug, so they quickly learn that it is easy to master,” he adds.
Perhaps more important, participants take these job aids back to their sites and display them so their colleagues can also acquire this new knowledge and skill.
Dr. Toky admitted that before the MCHIP training, she and her colleagues gave mothers suffering from pre-eclampsia another drug because they feared they would give the wrong dosage of MgSO4. She said it was not uncommon to find unopened boxes of expired MgSO4 in health centers. MCHIP’s 2012 Global Status Report found that around the world, not all skilled attendants are authorized to use MgSO4 for severe PE/E, and comments from providers showed that their confidence using this anti-convulsant, even when authorized, remains a challenge.
MCHIP’s Dr. Rakotovao has advocated for increased availability and use of magnesium sulfate in discussions with health care officials and providers. Among the key local champions is Dr. Pierana Gabriel Randaoharison, the Head of Service at the busy Regional Hospital in Mahajanga on the north-west coast of Madagascar, and a professor at the nearby Faculty of Medicine.
In the birthing rooms at his hospital, Dr. Randaoharison has displayed MCHIP job aids, which illustrate the correct dosages of magnesium sulfate, to help give providers the necessary confidence. “Some of the midwives at our hospital who attended the MCHIP training have very good skills now — they will help to convince others at the hospital,” he says.
MCHIP also recently obtained assurances from collaborating partner United Nations Population Fund that in October 2012 they will supply this lifesaving drug to sites where MCHIP has trained about 700 doctors and midwives on its use. Through these tireless advocacy efforts, MCHIP is empowering both midwives and doctors like Dr. Toky to treat women and newborns with severe, life-threatening complications — helping to reduce both maternal and newborn deaths in Madagascar.