Maternal and perinatal adverse outcomes in women with pre-eclampsia cared for at facility-level in South Africa: A prospective cohort study

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Study Justification:
This study aimed to investigate the maternal and perinatal outcomes of women with pre-eclampsia in low- and middle-income countries, specifically in South Africa. Pre-eclampsia is a significant contributor to maternal deaths, particularly in these countries. Understanding the clinical outcomes and risk factors associated with pre-eclampsia can help inform guidelines, research priorities, and policy decisions.
Study Highlights:
– The study included 1547 women with pre-eclampsia, with a focus on three tertiary facilities in South Africa.
– The main outcomes measured were eclampsia, kidney injury, and perinatal death.
– Among the women with pre-eclampsia, 16 (1%) died, 147 (9.5%) experienced eclampsia, four (0.3%) had a stroke, and 272 (17.6%) had kidney injury.
– Out of 1589 births, there were 332 (21.0%) perinatal deaths, with 281 (84.5%) being stillbirths.
– Of the 1308 live births, 913 (70.0%) were delivered before 37 completed weeks of gestation, and 544 (41.7%) were delivered before 34 weeks’ gestation.
– Teenage mothers and those with low body mass index (BMI) were found to be at the highest risk of eclampsia.
– The strongest predictor of kidney injury was the highest systolic blood pressure, while early gestation at admission was strongly associated with perinatal death.
Recommendations for Lay Reader and Policy Maker:
– The study highlights the high incidence of complications, perinatal death, and preterm delivery in women with pre-eclampsia referred to tertiary care in South Africa, even with access to interventions.
– Teenage mothers and those with low BMI are at a higher risk of eclampsia, indicating the need for targeted interventions and support for these vulnerable groups.
– The findings of this study can be used to inform guidelines for the management and care of women with pre-eclampsia, as well as shape the research agenda and policy decisions related to maternal and perinatal health.
Key Role Players:
– Healthcare providers: Obstetricians, midwives, nurses, and other healthcare professionals involved in the care of women with pre-eclampsia.
– Policy makers: Government officials, public health authorities, and policymakers responsible for developing and implementing policies related to maternal and perinatal health.
– Researchers: Scientists and researchers specializing in maternal and perinatal health, epidemiology, and public health who can further investigate the findings and contribute to evidence-based interventions.
Cost Items for Planning Recommendations:
– Training and education: Budget for training healthcare providers on the management and care of women with pre-eclampsia, including early detection, monitoring, and appropriate interventions.
– Equipment and supplies: Allocation of funds for necessary medical equipment, medications, and supplies required for the management of pre-eclampsia and its complications.
– Outreach and awareness campaigns: Budget for public health campaigns to raise awareness about pre-eclampsia, its risk factors, and the importance of early detection and timely care.
– Research funding: Investment in research grants to further investigate the causes, risk factors, and potential interventions for pre-eclampsia in low- and middle-income countries.
– Support services: Provision of resources for support services such as counseling, nutritional support, and social services for teenage mothers and women with low BMI who are at higher risk of eclampsia.

Background Hypertensive disorders of pregnancy contribute to 14% of all maternal deaths, the majority of which occur in low- and middle-income countries. The aim of the study was to describe the maternal and perinatal clinical outcomes of women with pre-eclampsia living in middle- and low-income countries. Methods The study was a prospective observational study of women with pre-eclampsia (n = 1547, 42 twin pregnancies) at three South African tertiary facilities. Using stepwise logistic regression model area under the receiver operating characteristic curve (AUROC) values, the association between maternal baseline and admission characteristics and risk of adverse outcomes was evaluated. Main outcome measures were eclampsia, kidney injury and perinatal death. Results In 1547 women with pre-eclampsia, 16 (1%) died, 147 (9.5%) had eclampsia, four (0.3%) had a stroke and 272 (17.6%) had kidney injury. Of the 1589 births, there were 332 (21.0%) perinatal deaths; of these, 281 (84.5%) were stillbirths. Of 1308 live births, 913 (70.0%) delivered < 37 completed weeks and 544 (41.7%) delivered < 34 weeks' gestation. Young maternal age (AUROC = 0.76, 95% confidence interval (CI) = 0.71- 0.80) and low Body Mass Index BMI (AUROC 0.65, 95% CI = 0.59-0.69) were significant predictors of eclampsia. Highest systolic blood pressure had the strongest association with kidney injury, (AUROC = 0.64, 95% CI = 0.60-0.68). Early gestation at admission was most strongly associated with perinatal death (AUROC = 0.81, 95% CI = 0.77-0.84). Conclusions The incidence of pre-eclampsia complications, perinatal death and preterm delivery in women referred to tertiary care in South Africa was much higher than reported in other low- and middle-income studies and despite access to tertiary care interventions. Teenage mothers and those with low BMI were at highest risk of eclampsia. This information could be used to inform guidelines, the research agenda and policy.

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Based on the provided description, here are some potential innovations that could improve access to maternal health:

1. Telemedicine and remote monitoring: Implementing telemedicine and remote monitoring technologies can enable healthcare providers to remotely monitor pregnant women with pre-eclampsia, allowing for early detection of complications and timely interventions.

2. Mobile health (mHealth) applications: Developing mobile health applications that provide educational resources, reminders for prenatal care appointments, and personalized health information can empower pregnant women to take an active role in managing their health and accessing necessary care.

3. Community-based care models: Establishing community-based care models that bring maternal health services closer to women in low- and middle-income countries can improve access to prenatal care, early detection of complications, and timely referrals to tertiary facilities when needed.

4. Task-shifting and training programs: Implementing task-shifting programs that train and empower community health workers or midwives to provide basic prenatal care and monitor women with pre-eclampsia can help alleviate the burden on tertiary facilities and improve access to care in underserved areas.

5. Strengthening referral systems: Enhancing the existing referral systems between primary, secondary, and tertiary healthcare facilities can ensure seamless and timely transfer of pregnant women with pre-eclampsia to higher levels of care when necessary, reducing delays in accessing appropriate treatment.

6. Quality improvement initiatives: Implementing quality improvement initiatives at healthcare facilities, focusing on improving the management of pre-eclampsia and reducing adverse outcomes, can enhance the overall quality of care provided to pregnant women and improve maternal and perinatal outcomes.

These innovations have the potential to address the challenges highlighted in the study and improve access to maternal health for women with pre-eclampsia in low- and middle-income countries.
AI Innovations Description
Based on the study, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Implement targeted interventions for high-risk groups: The study found that teenage mothers and those with low BMI were at highest risk of eclampsia. To improve access to maternal health, healthcare providers and policymakers can develop targeted interventions specifically designed for these high-risk groups. This can include educational programs, counseling services, and specialized care plans to ensure early detection and management of pre-eclampsia in these populations.

By focusing on these high-risk groups, healthcare providers can provide tailored support and interventions to reduce the incidence of eclampsia and improve maternal and perinatal outcomes.

It is important to note that this recommendation should be further explored and developed in consultation with healthcare professionals, researchers, and policymakers to ensure its feasibility and effectiveness in the specific context of South Africa.
AI Innovations Methodology
Based on the study mentioned, here are some potential recommendations to improve access to maternal health:

1. Strengthening antenatal care: Implementing comprehensive antenatal care programs that include regular blood pressure monitoring, early detection of pre-eclampsia, and appropriate management can help reduce the incidence of complications.

2. Enhancing healthcare infrastructure: Investing in the improvement of healthcare facilities, particularly in low- and middle-income countries, can ensure that pregnant women have access to quality care, including emergency obstetric services.

3. Training healthcare providers: Providing specialized training to healthcare providers on the management of pre-eclampsia and other hypertensive disorders of pregnancy can improve the quality of care and reduce adverse outcomes.

4. Increasing awareness and education: Conducting community-based awareness campaigns to educate women and their families about the signs and symptoms of pre-eclampsia, the importance of early detection, and the need for timely medical intervention can help improve access to maternal health services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data collection: Gather data on the current state of maternal health access, including the incidence of pre-eclampsia, maternal and perinatal outcomes, and existing healthcare infrastructure.

2. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the reduction in maternal mortality, improvement in antenatal care coverage, and increase in the proportion of women receiving timely interventions.

3. Establish a baseline: Determine the current status of the selected indicators to establish a baseline against which the impact of the recommendations can be measured.

4. Model implementation: Use a simulation model, such as a mathematical or statistical model, to simulate the implementation of the recommendations. This could involve adjusting variables related to antenatal care coverage, healthcare infrastructure, healthcare provider training, and awareness campaigns.

5. Measure impact: Assess the impact of the simulated recommendations by comparing the indicators before and after the implementation. This can help determine the effectiveness of the recommendations in improving access to maternal health.

6. Sensitivity analysis: Conduct sensitivity analysis to evaluate the robustness of the results and identify potential uncertainties or limitations in the methodology.

By following this methodology, policymakers and healthcare stakeholders can gain insights into the potential impact of different recommendations on improving access to maternal health and make informed decisions to prioritize interventions.

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