The Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials in Mozambique, Pakistan, and India: an individual participant-level meta-analysis

Development and validation of a risk prediction model for placental abruption in patients with preeclampsia

INTRODUCTION

To develop a validated risk prediction model for placental abruption in preeclamptic patients with singleton pregnancies firstly.

METHODS

Data from 1448 preeclamptic patients with singleton pregnancies who delivered between January 2013 and December 2022 were reviewed. Variables, including demographic characteristics, laboratory test results, comorbidities, and aspirin use were collected and analyzed. The preeclamptic patients were divided into a training set and a validation set according to the time of delivery. Logistic regression with a backward stepwise elimination method was used for variable screening and nomogram construction. The area under the receiver operating characteristic curve and calibration curve were used to evaluate its accuracy. Decision curve analysis and clinical impact curves were conducted to assess predictive performance.

RESULTS

Finally, 1448 preeclamptic patients were included. We collected 50 variables for further analysis. Multivariate logistic regression analysis revealed that severity, subtype, premature rupture of membranes, urinary casts, diastolic blood pressure, aspartate aminotransferase, serum potassium, and fibrin degradation product levels were predictors of placental abruption. These factors were used to construct the nomogram model, which showed good concordance and accuracy. The area under the receiver operating characteristic curve values of the training set and the validation set were 0.767 (95 % CI = 0.728-0.806, P < 0.001) and 0.800 (95 % CI = 0.728-0.872, P < 0.001). Calibration curves revealed significant agreement between the nomogram model and actual observations. Receiver operating characteristic curve analysis and decision curve analysis indicated that the nomogram had good predictive performance.

DISCUSSION

The prediction model can accurately estimate the risk of placental abruption in preeclamptic patients.

Identification of potential biomarkers associated with oxidative stress in the pathogenesis of pre-eclampsia

Pre-eclampsia (PE) is a multisystem pregnancy disorder characterized by placental and maternal endothelial dysfunction, and affects approximately 5% to 7% of pregnancies worldwide, leading to significant maternal and neonatal morbidity and mortality. Mounting evidence indicates that placental oxidative stress (OS) plays a critical role in the pathogenesis of PE. However, the specific mechanisms associated with OS during the occurrence and progression of PE remain largely unknown. Thus, we aimed to identify the key molecules associated with OS and explore their potential mechanisms in PE. Transcriptome data were downloaded from the Gene Expression Omnibus database, including 80 PE and 77 normal placental tissues. OS-related genes were identified using the Gene Ontology database. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analyses were performed to analyze the functions and pathways of the OS-related differentially expressed genes (OS-DEGs). Protein-protein interaction networks were constructed using the Search Tool for the Retrieval of Interacting Genes database, and hub genes were screened using molecular complex detection and CytoHubba. Finally, the diagnostic value and drug-gene interactions of the hub genes were evaluated. We identified 470 differentially expressed genes and 43 OS-DEGs. These genes were mainly enriched in OS-related biological processes, the HIF-1 and MAPK signaling pathways. Furthermore, 5 hub genes were identified: VEGFA, CCL2, mitogen-activated protein kinase 8 (MAPK8), HMOX1, and Cytochrome B-245 Beta Chain (CYBB). CYBB and MAPK8 had the highest diagnostic accuracies, with area under the curve values of 0.767 and 0.764, respectively. We predicted 43 potentially targeted drugs for PE treatment. CYBB and MAPK8 may be valuable biomarkers that mediate OS through multiple pathways to promote the occurrence and development of PE. We conclude from our study that OS has involvement in PE, and improved our understanding of OS-related molecular pathways in the pathogenesis of PE.

Pre-eclampsia challenges and care in low and middle-income countries: Understanding diagnosis, management, and health impacts in remote and developing regions

As an example of a low- and middle-income country (LMIC), India ranks pre-eclampsia among the top three causes of maternal mortality, following haemorrhage and infections. It is one of the primary concerns for maternal and perinatal health in LMICs. Many LMICs lack clear consensus and guidelines for the prevention, diagnosis, and management of hypertensive disorders in pregnancy, including pre-eclampsia. The International Society for the Study of Hypertension in Pregnancy 2021 guidelines address LMIC applications, offering customisable solutions. Atypical presentations of pre-eclampsia contribute to diagnostic delays, resulting in additional adverse maternal and perinatal outcomes. Implementing management strategies faces challenges in both urban and rural settings. Adapting global research involving local populations is imperative, with the potential for cost-effective adoption of international guidelines. Prevention, early diagnosis, and education dissemination are essential, involving healthcare providers and advocacy initiatives. Encouraging government investment in pre-eclampsia management as a public health initiative is important. This article explores socio-economic, cultural, and legislative factors influencing the management of pre-eclampsia in LMICs, addressing emerging challenges and potential partnerships for healthcare provision.

Global inequities in adverse pregnancy outcomes: what can we do?

The Health Equity Leadership & Exchange Network states that "health equity exists when all people, regardless of race, sex, sexual orientation, disability, socioeconomic status, geographic location, or other societal constructs, have fair and just access, opportunity, and resources to achieve their highest potential for health." It is clear from the wide discrepancies in maternal and infant mortalities, by race, ethnicity, location, and social and economic status, that health equity has not been achieved in pregnancy care. Although the most obvious evidence of inequities is in low-resource settings, inequities also exist in high-resource settings. In this presentation, based on the Global Pregnancy Collaboration Workshop, which addressed this issue, the bases for the differences in outcomes were explored. Several different settings in which inequities exist in high- and low-resource settings were reviewed. Apparent causes include social drivers of health, such as low income, inadequate housing, suboptimal access to clean water, structural racism, and growing maternal healthcare deserts globally. In addition, a question is asked whether maternal health inequities will extend to and be partially due to current research practices. Our overview of inequities provides approaches to resolve these inequities, which are relevant to low- and high-resource settings. Based on the evidence, recommendations have been provided to increase health equity in pregnancy care. Unfortunately, some of these inequities are more amenable to resolution than others. Therefore, continued attention to these inequities and innovative thinking and research to seek solutions to these inequities are encouraged.

Impact of mHealth interventions on maternal, newborn, and child health from conception to 24 months postpartum in low- and middle-income countries: a systematic review

BACKGROUND

Mobile health (mHealth) technologies have been harnessed in low- and middle-income countries (LMICs) to address the intricate challenges confronting maternal, newborn, and child health (MNCH). This review aspires to scrutinize the effectiveness of mHealth interventions on MNCH outcomes during the pivotal first 1000 days of life, encompassing the period from conception through pregnancy, childbirth, and post-delivery, up to the age of 2 years.

METHODS

A comprehensive search was systematically conducted in May 2022 across databases, including PubMed, Cochrane Library, Embase, Cumulative Index to Nursing & Allied Health (CINAHL), Web of Science, Scopus, PsycINFO, and Trip Pro, to unearth peer-reviewed articles published between 2000 and 2022. The inclusion criteria consisted of (i) mHealth interventions directed at MNCH; (ii) study designs, including randomized controlled trials (RCTs), RCT variations, quasi-experimental designs, controlled before-and-after studies, or interrupted time series studies); (iii) reports of outcomes pertinent to the first 1000 days concept; and (iv) inclusion of participants from LMICs. Each study was screened for quality in alignment with the Cochrane Handbook for Systematic Reviews of Interventions and the Joanne Briggs Institute Critical Appraisal tools. The included articles were then analyzed and categorized into 12 mHealth functions and outcome domain categories (antenatal, delivery, and postnatal care), followed by forest plot comparisons of effect measures.

RESULTS

From the initial pool of 7119 articles, we included 131 in this review, comprising 56 RCTs, 38 cluster-RCTs, and 37 quasi-experimental studies. Notably, 62% of these articles exhibited a moderate or high risk of bias. Promisingly, mHealth strategies, such as dispatching text message reminders to women and equipping healthcare providers with digital planning and scheduling tools, exhibited the capacity to augment antenatal clinic attendance and enhance the punctuality of child immunization. However, findings regarding facility-based delivery, child immunization attendance, and infant feeding practices were inconclusive.

CONCLUSIONS

This review suggests that mHealth interventions can improve antenatal care attendance and child immunization timeliness in LMICs. However, their impact on facility-based delivery and infant feeding practices varies. Nevertheless, the potential of mHealth to enhance MNCH services in resource-limited settings is promising. More context-specific implementation studies with rigorous evaluations are essential.

Advances in pathogenesis of preeclampsia

PURPOSE

Preeclampsia is a major cause of health problems for both pregnant women and unborn babies worldwide. However, the underlying causes of preeclampsia are not fully understood, leading to limited effective treatments. The goal of this study is to enhance our knowledge of its causes, devise prevention strategies, and develop treatments.

METHODS

We performed a systematic literature search. Six models regarding the pathogenesis of preeclampsia are discussed in this review.

RESULTS

This review focuses on the latest advancements in understanding preeclampsia's origins. Preeclampsia is a complex condition caused by various factors, processes, and pathways. Reduced blood flow and oxygen to the uterus and placenta, heightened inflammatory reactions, immune imbalances, altered genetic changes, imbalanced blood vessel growth factors, and disrupted gut bacteria may contribute to its development.

CONCLUSION

Preeclampsia is thought to result from the interplay of these factors.

Machine learning-enabled maternal risk assessment for women with pre-eclampsia (the PIERS-ML model): a modelling study

BACKGROUND

Affecting 2-4% of pregnancies, pre-eclampsia is a leading cause of maternal death and morbidity worldwide. Using routinely available data, we aimed to develop and validate a novel machine learning-based and clinical setting-responsive time-of-disease model to rule out and rule in adverse maternal outcomes in women presenting with pre-eclampsia.

METHODS

We used health system, demographic, and clinical data from the day of first assessment with pre-eclampsia to predict a Delphi-derived composite outcome of maternal mortality or severe morbidity within 2 days. Machine learning methods, multiple imputation, and ten-fold cross-validation were used to fit models on a development dataset (75% of combined published data of 8843 patients from 11 low-income, middle-income, and high-income countries). Validation was undertaken on the unseen 25%, and an additional external validation was performed in 2901 inpatient women admitted with pre-eclampsia to two hospitals in south-east England. Predictive risk accuracy was determined by area-under-the-receiver-operator characteristic (AUROC), and risk categories were data-driven and defined by negative (-LR) and positive (+LR) likelihood ratios.

FINDINGS

Of 8843 participants, 590 (6·7%) developed the composite adverse maternal outcome within 2 days, 813 (9·2%) within 7 days, and 1083 (12·2%) at any time. An 18-variable random forest-based prediction model, PIERS-ML, was accurate (AUROC 0·80 [95% CI 0·76-0·84] vs the currently used logistic regression model, fullPIERS: AUROC 0·68 [0·63-0·74]) and categorised women into very low risk (-LR <0·1; eight [0·7%] of 1103 women), low risk (-LR 0·1 to 0·2; 321 [29·1%] women), moderate risk (-LR >0·2 and +LR <5·0; 676 [61·3%] women), high risk (+LR 5·0 to 10·0, 87 [7·9%] women), and very high risk (+LR >10·0; 11 [1·0%] women). Adverse maternal event rates were 0% for very low risk, 2% for low risk, 5% for moderate risk, 26% for high risk, and 91% for very high risk within 48 h. The 2901 women in the external validation dataset were accurately classified as being at very low risk (0% with outcomes), low risk (1%), moderate risk (4%), high risk (33%), or very high risk (67%).

INTERPRETATION

The PIERS-ML model improves identification of women with pre-eclampsia who are at lowest and greatest risk of severe adverse maternal outcomes within 2 days of assessment, and can support provision of accurate guidance to women, their families, and their maternity care providers.

FUNDING

University of Strathclyde Diversity in Data Linkage Centre for Doctoral Training, the Fetal Medicine Foundation, The Canadian Institutes of Health Research, and the Bill & Melinda Gates Foundation.

Transitioning from the "Three Delays" to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique

BACKGROUND

The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance.

METHODS

The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial.

RESULTS

Qualitative analysis of these maternal death narratives in both countries reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of care-seeking, to update the categories of seeking, reaching and receiving care.

CONCLUSIONS

There is a need to supplement the pioneering "Three Delays Framework" to include focusing on continuity of care and the "Four Critical Connection Points": (1) between the stages of pregnancy, (2) between families and health care workers, (3) between health care facilities and (4) between multiple care-seeking journeys.

TRIAL REGISTRATION

NCT01911494, Date Registered 30/07/2013.

Exploring Perceptions and Needs of Mobile Health Interventions for Nutrition, Anemia, and Preeclampsia among Pregnant Women in Underprivileged Indian Communities: A Cross-Sectional Survey

According to the National Family Health Survey of 2021, about 57% of women aged 15-49 in India currently suffer from anemia, marking a significant increase from the 53% recorded in 2016. Similarly, a study conducted in southern India reported a 32.60% prevalence of preeclampsia. Several community-based initiatives have been launched in India to address these public health challenges. However, these interventions have yet to achieve the desired results. Could the challenges faced by traditional healthcare interventions be overcome through a technological leap? This study assesses pregnant mothers' perceptions regarding mobile health interventions for managing anemia and preeclampsia. Additionally, the study captures their health awareness and knowledge. We conducted a survey with 131 pregnant mothers in three underserved villages in Jharkhand, India. Statistical analysis was conducted using the SEMinR package in R (Version 2023.06.0), utilizing the non-parametric partial least squares-structural equation modeling. We found that every household had at least one smartphone, with the respondents being the primary users. The main uses of smartphones were for calling, messaging, and social media. A total of 61% of respondents showed interest in a nutrition and pregnancy app, while 23.66% were uncertain. Regarding nutritional knowledge during pregnancy, 68.7% reported having some knowledge, but only 11.45% claimed comprehensive knowledge. There was a considerable knowledge gap regarding the critical nutrients needed during pregnancy and the foods recommended for a healthy pregnancy diet. Awareness of pregnancy-related conditions such as anemia and preeclampsia was low, with most respondents unsure of these conditions' primary causes, impacts, and symptoms. This study serves as a critical step towards leveraging technology to enhance public health outcomes in low-resource settings. With the accessibility of mobile devices and an apparent willingness to utilize mHealth apps, compounded by the pressing need for improved maternal health, the impetus for action is indisputable. It is incumbent upon us to seize this opportunity, ensuring that the potential of technology is fully realized and not squandered, thus circumventing the risk of a burgeoning digital divide.

The role of the pregnancy heart team in clinical practice

Significant maternal and fetal morbidity and mortality risk has been shown to be associated with cardiovascular disease in pregnancy. Several determinants, such as the increasing number of females with corrected congenital heart disease in reproductive age, a more advanced maternal age associated with cardiovascular risk factors, and a greater prevalence of preexisting comorbidities related to cardiac disorders such as cancer and COVID-19), lead to a higher incidence of cardiac complications in pregnancy in the last few decades. However, adopting a multidisciplinary strategy may influence maternal and neonatal outcomes. This review aims at assessing the role of the Pregnancy Heart Team, which should ensure careful pre-pregnancy counseling, pregnancy monitoring, and delivery planning for both congenital and other cardiac or metabolic disorders, addressing several emerging aspects in the multidisciplinary team-based approach.

Socioeconomic and epidemiological milieu of maternal death due to eclampsia in West Bengal, India: A mixed methods study

Background

West Bengal is experiencing an unanticipated risk of eclampsia among pregnant women and it persists as the leading cause of maternal mortality. This study aimed to investigate the predictors for maternal deaths due to eclampsia in West Bengal.

Methods

The study adopted retrospective mixed methods covering facility and community-based maternal death review approaches. Facility-based data were used for 317 deceased cases wherein the community-based review approach was used in 40 cases. An in-depth interview was also performed among 12 caregivers.

Results

One-third of maternal deaths occurred due to eclampsia, and this accounted for the leading cause of maternal deaths in West Bengal. A younger age, a primigravida or nulliparous status, absence of antenatal care (ANC), and residence in rural areas appeared to have the highest risk of developing eclampsia. The majority of pregnant women had an irregular antenatal check-up history, particularly during the second trimester of pregnancy. The rate of eclampsia-related maternal death was higher in women residing more than 49 km from the studied hospitals. Most of the deceased women were referred to three or more hospitals before their death. Gravidity, the number of ANC visits, the mode of delivery, and delays at different levels were significant confounders of death due to eclampsia. The risk of death due to eclampsia was two times higher among women without ANC and those who had a cesarean section than that in their counterparts.

Conclusions

Women in West Bengal have a high risk of preeclampsia and eclampsia resulting in maternal mortality and morbidity. Gravidity, the number of ANC visits, the mode of delivery, and delays in recognition of eclampsia contribute to the risk of maternal deaths. The establishment of separate eclampsia units, enhanced screening, and preventive and treatment procedures may optimize managing eclampsia.

A global view of hypertensive disorders and diabetes mellitus during pregnancy

Two important maternal cardiometabolic disorders (CMDs), hypertensive disorders in pregnancy (HDP) (including pre-eclampsia) and gestational diabetes mellitus (GDM), result in a large disease burden for pregnant individuals worldwide. A global consensus has not been reached about the diagnostic criteria for HDP and GDM, making it challenging to assess differences in their disease burden between countries and areas. However, both diseases show an unevenly distributed disease burden for regions with a low income or middle income, or low-income and middle-income countries (LMICs), or regions with lower sociodemographic and human development indexes. In addition to many common clinical, demographic and behavioural risk factors, the development and clinical consequences of maternal CMDs are substantially influenced by the social determinants of health, such as systemic marginalization. Although progress has been occurring in the early screening and management of HDP and GDM, the accuracy and long-term effects of such screening and management programmes are still under investigation. In addition to pharmacological therapies and lifestyle modifications at the individual level, a multilevel approach in conjunction with multisector partnership should be adopted to tackle the public health issues and health inequity resulting from maternal CMDs. The current COVID-19 pandemic has disrupted health service delivery, with women with maternal CMDs being particularly vulnerable to this public health crisis.

Exosomal MicroRNA-325 Enhances Trophoblast Migration and Invasion Through Downregulation of Lethal-7b and Upregulation of Forkhead Box Protein O1 Expression in Preeclampsia

We aimed to explore the mechanism by how microRNA (miRNA)-325 derived from marrow mesenchymal stem cell exosomes (MSC-exos) affects the trophoblast progression in preeclampsia (PE). RT-qPCR detected the level of miRNA let-7b and FOXO1 in the placenta tissue of PE patients. Functional experiment was performed to analyze the effect of FOXO1 inhibitor and let-7b mimics on cell migration, invasion and apoptosis through Transwell assay and TUNEL staining. The trophoblast cell was co-cultured with overexpressed-miR-325 MSC-exos to measure gene expression and cell progression. let-7b was highly and FOXO1 was lowly expressed in PE placenta tissue. let-7b directly targeted and inhibited FOXO1 expression. Importantly, as miR-325 was internalized by trophoblast cells through MSC-exos, MSC-exos overexpressing miR-325 inhibited let-7b expression in trophoblasts, up-regulated FOXO1 and activated AKT signaling pathway. Further, MSC-exos treatment promoted invasion and migration of trophoblast cell and inhibited apoptosis. In conclusion, miR-325 derived from MSC-exos promotes the invasion and migration of trophoblast cells in PE through inhibition of let7b and upregulation of FOXO1.

Role of GRK2 in Trophoblast Necroptosis and Spiral Artery Remodeling: Implications for Preeclampsia Pathogenesis

Impaired invasion of extravillous trophoblasts and severe oxidative stress manifest the poor placentation in preeclampsia, which is life-threatening and more than a hypertensive disease of pregnancy. Previous studies have reported that G protein-coupled receptor kinases (GRKs) play a key role in initiating hypertension and hypertensive renal damage, yet little evidence so far suggests a link between GRKs and preeclampsia-related hypertension. Here, we demonstrate GRK2 expression is significantly downregulated (P < 0.0001) in preeclamptic placentae compared to normotensive controls. Knockdown or inhibition of GRK2 in placentae caused insufficient arterial remodeling and elevated trophoblast necroptosis in vivo. These further induced preeclampsia-like phenotype in mice: hypertension, proteinuria, and elevated pro-angiogenic cytokines. By human extra-villous invasive trophoblast cell line (HTR8/SVneo cells), we revealed the knockdown or inhibition of GRK2 triggered excessive death with typical necroptotic characteristics: nuclear envelope rupture and the activation of RIPK1, RIPK3, and MLKL. Necrostatin-1, an inhibitor of RIPK1, is able to restore the survival of trophoblasts. Together, our findings demonstrated that insufficient GRK2 activity compromises spiral artery remodeling and initiates necrotic events in placentae, thereby leading to preeclampsia. These findings advance our understanding of GRK2 in the pathogenesis of preeclampsia and could shed light on a potential treatment for preeclampsia.

Implementation of the PIERS on the Move mHealth Application From the Perspective of Community Health Workers and Nurses in Rural Mozambique

Background:mHealth is increasingly regarded as having the potential to support service delivery by health workers in low-resource settings. PIERS on the Move (POM) is a mobile health application developed to support community health workers identification and management of women at risk of adverse outcomes from pre-eclampsia. The objective of this study was to evaluate the impact of using POM in Mozambique on community health care workers' knowledge and self-efficacy related to caring for women with pre-eclampsia, and their perception of usefulness of the tool to inform implementation.

Method: An evaluation was conducted for health care workers in the Mozambique Community Level Intervention for Pre-eclampsia (CLIP) cluster randomized trial from 2014 to 2016 in Maputo and Gaza provinces (NCT01911494). A structured survey was designed using themes from the Technology Acceptance Model, which describes the likelihood of adopting the technology based on perceived usefulness and perceived ease of use. Surveys were conducted in Portuguese and translated verbatim to English for analysis. Preliminary analysis of open-ended responses was conducted to develop a coding framework for full qualitative analysis, which was completed using NVivo12 (QSR International, Melbourne, Australia).

Results: Overall, 118 community health workers (44 intervention; 74 control) and 55 nurses (23 intervention; 32 control) were surveyed regarding their experiences. Many community health workers found the POM app easy to use (80%; 35/44), useful in guiding their activities (68%; 30/44) and pregnant women received their counseling more seriously because of the POM app (75%; 33/44). Almost a third CHWs reported some challenges using the POM app (30%; 13/44), including battery depletion after a full day's activity. Community health workers reported increases in knowledge about pre-eclampsia and other pregnancy complications and increases in confidence, comfort and capacity to advise women on health conditions and deliver services. Nurses recognized the increased capacity of community health workers and were more confident in their clinical and technological skills to identify women at risk of obstetric complications.

Conclusions: Many of the community health workers reported that POM improved knowledge, self-efficacy and strengthened relationships with the communities they serve and local nurses. This helped to strengthen the link between community and health facility. However, findings highlight the need to consider program and systematic challenges to implementation.

Cardiovascular Deaths in Pregnancy: Growing Concerns and Preventive Strategies

There has been an increase in maternal deaths from cardiovascular disease in many countries. In high-income countries, cardiovascular deaths secondary to cardiomyopathies, ischemic heart disease, sudden arrhythmic deaths, aortic dissection, and valve disease are responsible for up to one-third of all pregnancy-related maternal deaths. In low- and middle-income countries, rheumatic heart disease is a much more common cause of cardiac death during pregnancy. Although deaths occur in women with known heart conditions or cardiovascular risk factors such as hypertension, many women present for the first time in pregnancy with unrecognised heart disease or with de novo cardiovascular conditions such as preeclampsia, peripartum cardiomyopathy, spontaneous coronary artery dissection. Not only has maternal cardiovascular mortality increased, but serious cardiac morbidity, or "near misses," during pregnancy also have increased in frequency. Although maternal morbidity and mortality are often preventable, many health professionals remain unaware of the impact of cardiovascular disease in this population, and the lack of awareness contributes to inappropriate care and preventable deaths. In this review, we discuss the maternal mortality from cardiovascular causes in both high- and low- and middle-income countries and strategies to improve outcomes.

Causes and circumstances of maternal death: a secondary analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials cohort

BACKGROUND

Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials.

METHODS

The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12-49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient.

FINDINGS

Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193-268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0·56 [95% CI 0·43-0·66]) or InterVA-5 (κ=0·44 [0·30-0·57]), and InterVA-4 and InterVA-5 (κ=0·72 [0·60-0·84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0·48 [0·38-0·58]), poor for physician review versus InterVA-5 (κ=0·36 [0·27-0·46]), and good for InterVA-4 versus InterVA-5 (κ=0·69 [0·59-0·79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0·04 [0·00-0·15]).

INTERPRETATION

Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths.

FUNDING

University of British Columbia (grantee of the Bill & Melinda Gates Foundation).

Pre-eclampsia

Pre-eclampsia is a multisystem pregnancy disorder characterised by variable degrees of placental malperfusion, with release of soluble factors into the circulation. These factors cause maternal vascular endothelial injury, which leads to hypertension and multi-organ injury. The placental disease can cause fetal growth restriction and stillbirth. Pre-eclampsia is a major cause of maternal and perinatal mortality and morbidity, especially in low-income and middle-income countries. Prophylactic low-dose aspirin can reduce the risk of preterm pre-eclampsia, but once pre-eclampsia has been diagnosed there are no curative treatments except for delivery, and no drugs have been shown to influence disease progression. Timing of delivery is planned to optimise fetal and maternal outcomes. Clinical trials have reported diagnostic and prognostic strategies that could improve fetal and maternal outcomes and have evaluated the optimal timing of birth in women with late preterm pre-eclampsia. Ongoing studies are evaluating the efficacy, dose, and timing of aspirin and calcium to prevent pre-eclampsia and are evaluating other drugs to control hypertension or ameliorate disease progression.

Role of community engagement in maternal health in rural Pakistan: Findings from the CLIP randomized trial

Background

Community-based strategies to promote maternal health can help raise awareness of pregnancy danger signs and preparations for emergencies. The objective of this study was to assess change in birth preparedness and complication readiness (BPCR) and pregnant women’s knowledge about pre-eclampsia as part of community engagement (CE) activities in rural Pakistan during the Community Level Interventions for Pre-eclampsia (CLIP) Trial.

Methods

The CLIP Trial was a cluster randomized controlled trial that aimed to reduce maternal and perinatal morbidity and mortality using CE strategies alongside mobile health-supported care by community health care providers. CE activities engaged pregnant women at their homes and male stakeholders through village meetings in Hyderabad and Matiari in Sindh, Pakistan. These sessions covered pregnancy complications, particularly pre-eclampsia/eclampsia, BPCR and details of the CLIP intervention package. BPCR was assessed using questions related to transport arrangement, permission for care, emergency funds, and choice of facility birth attendant for delivery during quarterly household surveys. Outcomes were assessed via multilevel logistic regression with adjustment for relevant confounders with effects summarized as odds ratios and 95% confidence intervals.

Results

There were 15 137 home-based CE sessions with pregnant women and families (n = 46 614) and 695 village meetings with male stakeholders (n = 7784) over two years. The composite outcomes for BPCR and pre-eclampsia knowledge did not differ significantly between trial arms. However, CE activities were associated with improved pre-eclampsia knowledge in some areas. Specifically, pregnant women in the intervention clusters were twice as likely to know that seizures could be a complication of pregnancy (odds ratio (OR) = 2.17, 95% confidence interval (CI)  = 1.11, 4.23) and 2.5 times more likely to know that high blood pressure is potentially life-threatening during pregnancy (OR = 2.52, 95% CI = 1.31, 4.83) vs control clusters.

Conclusions

The findings suggested that a CE strategy for male and female community stakeholders increased some measures of knowledge regarding complications of pre-eclampsia in low-resource settings. However, the effect of this intervention on long-term health outcomes needs further study.

Trial registration

Clinical Trials.gov – INCT01911494.

Feasibility of task-sharing with community health workers for the identification, emergency management and referral of women with pre-eclampsia, in Mozambique

BACKGROUND

Maternal mortality is an important public health problem in low-income countries. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. There is limited evidence on the role of community health workers in the management of pregnancy complications. This study aimed to describe the feasibility of task-sharing the initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and document healthcare facility preparedness to respond to referrals.

METHOD

The study took place in Maputo and Gaza Provinces in southern Mozambique and aimed to inform the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial. This was a mixed-methods study. The quantitative data was collected through self-administered questionnaires completed by community health workers and a health facility survey; this data was analysed using Stata v13. The qualitative data was collected through focus group discussions and in-depth interviews with various community groups, health care providers, and policymakers. All discussions were audio-recorded and transcribed verbatim prior to thematic analysis using QSR NVivo 10. Data collection was complemented by reviewing existing documents regarding maternal health and community health worker policies, guidelines, reports and manuals.

RESULTS

Community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they have not been trained to manage obstetric emergencies. Furthermore, barriers at health facilities were identified, including lack of equipment, shortage of supervisors, and irregular drug availability. All primary and the majority of secondary-level facilities (57%) do not provide blood transfusions or have surgical capacity, and thus such cases must be referred to the tertiary-level. Although most healthcare facilities (96%) had access to an ambulance for referrals, no transport was available from the community to the healthcare facility.

CONCLUSIONS

This study showed that task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia were deemed feasible and acceptable at the community-level, but an effort should be in place to address challenges at the health system level.

Blood pressure thresholds in pregnancy for identifying maternal and infant risk: a secondary analysis of Community-Level Interventions for Pre-eclampsia (CLIP) trial data

Background

Blood pressure measurement is a marker of antenatal care quality. In well resourced settings, lower blood pressure cutoffs for hypertension are associated with adverse pregnancy outcomes. We aimed to study the associations between blood pressure thresholds and adverse outcomes and the diagnostic test properties of these blood pressure cutoffs in low-resource settings.

Methods

We did a secondary analysis of data from 22 intervention clusters in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials (NCT01911494) in India (n=6), Mozambique (n=6), and Pakistan (n=10). We included pregnant women aged 15–49 years (12–49 years in Mozambique), identified in their community by trained community health workers, who had data on blood pressure measurements and outcomes. The trial was unmasked. Maximum blood pressure was categorised as: normal blood pressure (systolic blood pressure [sBP] <120 mm Hg and diastolic blood pressure [dBP] <80 mm Hg), elevated blood pressure (sBP 120–129 mm Hg and dBP <80 mm Hg), stage 1 hypertension (sBP 130–139 mm Hg or dBP 80–89 mm Hg, or both), non-severe stage 2 hypertension (sBP 140–159 mm Hg or dBP 90–109 mm Hg, or both), or severe stage 2 hypertension (sBP ≥160 mm Hg or dBP ≥110 mm Hg, or both). We classified women according to the maximum blood pressure category reached across all visits for the primary analyses. The primary outcome was a maternal, fetal, or neonatal mortality or morbidity composite. We estimated dose-response relationships between blood pressure category and adverse outcomes, as well as diagnostic test properties.

Findings

Between Nov 1, 2014, and Feb 28, 2017, 21 069 women (6067 in India, 4163 in Mozambique, and 10 839 in Pakistan) contributed 103 679 blood pressure measurements across the three CLIP trials. Only women with non-severe or severe stage 2 hypertension, as discrete diagnostic categories, experienced more adverse outcomes than women with normal blood pressure (risk ratios 1·29–5·88). Using blood pressure categories as diagnostic thresholds (women with blood pressure within the category or any higher category vs those with blood pressure in any lower category), dose-response relationships were observed between increasing thresholds and adverse outcomes, but likelihood ratios were informative only for severe stage 2 hypertension and maternal CNS events (likelihood ratio 6·36 [95% CI 3·65–11·07]) and perinatal death (5·07 [3·64–7·07]), particularly stillbirth (8·53 [5·63–12·92]).

Interpretation

In low-resource settings, neither elevated blood pressure nor stage 1 hypertension were associated with maternal, fetal, or neonatal mortality or morbidity adverse composite outcomes. Only the threshold for severe stage 2 hypertension met diagnostic test performance standards. Current diagnostic thresholds for hypertension in pregnancy should be retained.

Funding

University of British Columbia, the Bill & Melinda Gates Foundation.

Economic and cost-effectiveness analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials in India, Pakistan and Mozambique

Background

The Community-Level Interventions for Pre-eclampsia (CLIP) trials (NCT01911494) in India, Pakistan and Mozambique (February 2014–2017) involved community engagement and task sharing with community health workers for triage and initial treatment of pregnancy hypertension. Maternal and perinatal mortality was less frequent among women who received ≥8 CLIP contacts. The aim of this analysis was to assess the incremental costs and cost-effectiveness of the CLIP intervention overall in comparison to standard of care, and by PIERS (Pre-eclampsia Integrated Estimate of RiSk) On the Move (POM) mobile health application visit frequency.

Methods

Included were all women enrolled in the three CLIP trials who had delivered with known outcomes by trial end. According to the number of POM-guided home contacts received (0, 1–3, 4–7, ≥8), costs were collected from annual budgets and spending receipts, with inclusion of family opportunity costs in Pakistan. A decision tree model was built to determine the cost-effectiveness of the intervention (vs usual care), based on the primary clinical endpoint of years of life lost (YLL) for mothers and infants. A probabilistic sensitivity analysis was used to assess uncertainty in the cost and clinical outcomes.

Results

The incremental per pregnancy cost of the intervention was US$12.66 (India), US$11.51 (Pakistan) and US$13.26 (Mozambique). As implemented, the intervention was not cost-effective due largely to minimal differences in YLL between arms. However, among women who received ≥8 CLIP contacts (four in Pakistan), the probability of health system and family (Pakistan) cost-effectiveness was ≥80% (all countries).

Conclusion

The intervention was likely to be cost-effective for women receiving ≥8 contacts in Mozambique and India, and ≥4 in Pakistan, supporting WHO guidance on antenatal contact frequency.

Trial registration number

NCT01911494.

Impact of a maternal and newborn health results-based financing intervention (RBF4MNH) on stillbirth: a cross-sectional comparison in four districts in Malawi

BACKGROUND

Malawi implemented a Results Based Financing (RBF) model for Maternal and Newborn Health, "RBF4MNH" at public hospitals in four Districts, with the aim of improving health outcomes. We used this context to seek evidence for the impact of this intervention on rates of antepartum and intrapartum stillbirth, taking women's risk factors into account.

METHODS

We used maternity unit delivery registers at hospitals in four districts of Malawi to obtain information about stillbirths. We purposively selected two districts hosting the RBF4MNH intervention and two non-intervention districts for comparison. Data were extracted from the maternity registers and used to develop logistic regression models for variables associated with fresh and macerated stillbirth.

RESULTS

We identified 67 stillbirths among 2772 deliveries representing 24.1 per 1000 live births of which 52% (n = 35) were fresh (intrapartum) stillbirths and 48% (n = 32) were macerated (antepartum) losses. Adjusted odds ratios (aOR) for fresh and macerated stillbirth at RBF versus non-RBF sites were 2.67 (95%CI 1.24 to 5.57, P = 0.01) and 7.27 (95%CI 2.74 to 19.25 P < 0.001) respectively. Among the risk factors examined, gestational age at delivery was significantly associated with increased odds of stillbirth.

CONCLUSION

The study did not identify a positive impact of this RBF model on the risk of fresh or macerated stillbirth. Within the scientific limitations of this non-randomised study using routinely collected health service data, the findings point to a need for rigorously designed and tested interventions to strengthen service delivery with a focus on the elements needed to ensure quality of intrapartum care, in order to reduce the burden of stillbirths.

SMARThealth Pregnancy: Feasibility and Acceptability of a Complex Intervention for High-Risk Pregnant Women in Rural India: Protocol for a Pilot Cluster Randomised Controlled Trial

Introduction: India is in the process of a major epidemiological transition towards non-communicable diseases. Cardiovascular disease (CVD) is the leading cause of death in women in India. Predisposing independent risk factors include pregnancy-related conditions, e.g., hypertensive disorders of pregnancy (HDP) and gestational diabetes (GDM) - also associated with significant perinatal mortality and morbidity. Early identification, referral and management of pregnant women at increased risk of future CVD may offer opportunities for prevention. In rural India, Community Health Workers (CHWs) provide most antenatal and postnatal care. Innovative solutions are required to address integrated care for rural women during transitions between antenatal, postnatal and general health services. The George Institute's SMARThealth Programme has shown that CHWs in rural India screening non-pregnant adults for cardiovascular risk, using a decision support system, is feasible. Building on this, we developed a targeted training programme for CHWs and a complex system-level intervention that uses mobile clinical decision support for CHWs and primary care doctors to screen high-risk pregnant women. In addition to addressing HDP and GDM, the intervention also screens for anaemia in pregnancy. Methods/Design: A pilot study will be undertaken in two diverse rural districts of India: Jhajjar (Haryana) and Guntur (Andhra Pradesh). Two Primary Health Centre clusters will be randomised to intervention or control groups at each study site. The primary objective of this pilot study is to explore the feasibility and acceptability of the SMARThealth Pregnancy intervention. Secondary objectives are to estimate: (a) prevalence rates of moderate to severe anaemia, HDPs and GDM at the study sites; (b) referral and follow-up rates, and (c) mean haemoglobin and blood pressure values at the routine 6 week postnatal visit. A process evaluation will be conducted to explore the acceptability of the SMARThealth Pregnancy intervention for pregnant women and healthcare workers using qualitative methods. Discussion: It is anticipated that the findings of this pilot study will help determine the feasibility and acceptability of the SMARThealth Pregnancy intervention, and highlight how the intervention might be further developed for evaluation in a larger, cluster randomised controlled trial. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03968952.

The ability and safety of community-based health workers to safely initiate lifesaving therapies for pre-eclampsia in Ogun State, Nigeria: An analysis of 260 community treatments with MgSO4 and/or methyldopa

OBJECTIVES

To evaluate community-based health workers' ability to identify cases of hypertension in pregnancy, safely deliver methyldopa and magnesium sulphate and make referrals when appropriate.

STUDY DESIGN

This was part of Nigeria Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial (NCT01911494). Community-based Health Workers (CHW) recruited pregnant women from five Local Government Areas (clusters) and used mobile health aid for clinical assessment of pre-eclampsia.

MAIN OUTCOME MEASURES

The primary outcome was the number of adverse events that occurred after the administration of magnesium sulphate and/or methyldopa to pregnant women by CHWs.

FINDINGS

Of 8790 women receiving mobile health-guided care, community-based health workers in Nigeria provided 309 women with hypertension (4.2% of delivered women), and safely administered 142 doses of intramuscular magnesium sulphate. Community Heath Extension Workers (CHEWs) and nurses gave fifty-two and sixty-seven doses of intramuscular magnesium sulphate respectively, twenty-three doses were given by other health care workers (midwives, community health officers, health assistants). The high rate of administration by nurses can be explained by turf protection as well as their seniority within the health system. Also, CHEWs and nurses gave 124 doses of oral methyldopa and 126 urgent referrals were completed. There were no complications related to administration of treatment or referral.

INTERPRETATION

These findings demonstrate the ability of community-based health workers to safely administer methyldopa and intramuscular magnesium sulphate. The use of task-sharing, therefore, could drastically reduce the three delays (triage, transport and treatment) associated with high maternal mortality and morbidity in rural communities in low- and middle-income countries.

Prevalence and perinatal outcomes of non-communicable diseases in pregnancy in a regional hospital in Haiti: A prospective cohort study

Background

The prevalence of non-communicable diseases (NCDs) is rising in low and middle-income countries (LMIC). We aimed to report on the prevalence of NCDs in pregnancy and their associated perinatal outcomes in a regional hospital in Haiti.

Methods

We conducted the “Diabète et hYpertension Artéerielle et leurs issues MAternelles et Néonatales” (DYAMAN) prospective cohort study in a regional hospital in Haiti. Pregnant women presenting to care at 24-28 weeks were screened and treated for diabetes (DM) and hypertensive disorders of pregnancy (HDP) using setting-adapted protocols. Prevalence of NCDs and associated maternal-neonatal outcomes were described.

Results

715 women were included, of which 51 (7.1%) had DM, 90 (12.6%) had HDP, and 30 (4.2%) had both DM and HDP (DM/HDP). Of 422 (59%) women delivered in hospital, 58 (13.7%) had preeclampsia, including 5 (8.6%) with eclampsia. Preterm birth <32 weeks was more common in the HDP than the control, DM, and DM/HDP groups. More low birth weight babies (n = 20, 25.6%) were born to the HDP group than to the control (n = 20, 7.1%), DM (n = 1, 2.7%), and DM/HDP (n = 3, 12%) groups (P < 0.001). Macrosomia and hypoglycemia affected 5 (8%) neonates of women with DM. Perinatal mortality, affecting 36/1000 births, was mainly driven by maternal NCDs.

Conclusions

NCDs in pregnancy led to adverse maternal and perinatal outcomes. This study will help to prepare future refinements aimed at optimizing the management of NCDs in pregnancy in LMIC. Research is required to understand barriers to patient attendance at antenatal follow-up, treatment escalation for hyperglycemia, and in-hospital delivery.

Pregnancy Outcomes and Blood Pressure Visit-to-Visit Variability and Level in Three Less-Developed Countries

[Figure: see text].

Don't forget eclampsia in the efforts to reduce maternal morbidity and mortality

Hypertensive disorders are a leading cause of maternal morbidity and mortality worldwide. Despite advances in prevention and clinical management, women in low-resource countries continue to bear the burden of the sequelae of severe pre-eclampsia-eclampsia. Sustainable strategies to improve the care of women with hypertensive disease, to identify those at risk for hypertensive disease, and to reduce the risk of eclampsia will require partnerships between clinicians and health policy makers. Resources are needed to scale up healthcare access and infrastructure, establish evidence-based protocols for care, and ensure an adequate supply of equipment and drugs. Additionally, efforts for a sustained workforce of perinatal clinicians and staff trained in the assessment and management of hypertensive disease are needed. Effective postpartum care and monitoring are essential to prevent morbidity and mortality due to cardiovascular disease. Culturally appropriate strategies are needed to educate women and their families on the symptoms of pre-eclampsia to address delays in seeking care during pregnancy and postpartum. With targeted, sustained efforts and resources, eclampsia and its associated co-morbidities can be preventable.