Experiences of a dedicated Heart and Maternal Health Service providing multidisciplinary care to pregnant women with cardiac disease in a tertiary centre in Namibia

Objectives: First, to describe the implementation process, benefits and challenges of a multidisciplinary service for pregnant women with cardiac disease in Namibia. Second, to assess pregnancy outcomes in this population. Methods: In a tertiary hospital in Namibia, a multidisciplinary service was implemented by staff of obstetric and cardiology departments and included preconception counselling, provision of antenatal care and reliable contraception. Management guidelines developed for high-income settings were used, since no locally adapted guidelines were available. A cohort study was performed to assess cardiac, obstetric and fetal outcomes. Included were pregnant women with cardiac disease, referred to this service between 1 August 2016 and 31 July 2018. Results: Important benefits of this service were the integrated approach, improved access to reliable contraception and insight into drivers of poor outcome. Several challenges with use of available guidelines were encountered, as contextual factors specific to lower-income settings were not taken into consideration, such as higher rates of infection or barriers to access care. The cohort consisted of 65 women. Cardiac disease was diagnosed for the first time in 16 (24.6%) women, of whom 11 had pre-existing cardiac disease. These women presented more often with heart failure than women with known heart disease (75.0% vs. 6.1%, RR 12.5, 95% CI 3.9–38.0). Five women died. Cardiac events occurred in twenty-two women of whom eight developed thromboembolic events and two endocarditis. The majority had no indication for prophylaxis, based on available guidelines. Fetal events occurred in 36 pregnancies. After pregnancy more than half of women (35/65, 53.8%) were using long-acting reversible contraception. Conclusions: Despite several barriers, it was possible to implement a multidisciplinary service in a high-burden setting. Cardiac and fetal event rates in this cohort were high. To improve outcomes the focus should be on availability of context-specific guidelines and better detection of cardiac disease. This study was performed at Windhoek Central Hospital, the tertiary public hospital of Namibia, serving a population of 2.3 million [22]. This facility has approximately 12,000 births per annum [22]. During the study period, the number of available obstetrician‐gynaecologists ranged from three to six. This was the only public health facility in the country with availability of consultant cardiologists (2), cardiothoracic surgeons (2) and cardiac technologists (2) and where transcutaneous cardiac interventions and cardiac surgeries were performed. At one regional hospital in northern Namibia (Oshakati), about 700 km from Windhoek, two cardiologists employed in the private sector provided cardiac care for patients that were referred to them. Patients presenting to any public health facility in Namibia pay a minimum fee (about US$ 0.65) for each healthcare visit and no additional costs are incurred for diagnostics or treatments including admissions, interventions or surgeries. Those living outside Windhoek in need of elective specialist care, such as a consultation at the cardiac outpatient department or admission for surgery, were transferred from district hospitals to Windhoek by a free bus service, once per week, provided by the Ministry of Health and Social Services. Reproductive health services, including contraceptive services, are free of charge. Most facilities had combined oral contraceptives and progestogen‐only injectables routinely available. The United Nations Population Fund made a once off donation of hormonal implants and intra‐uterine devices to the Ministry of Health and Social Services of Namibia in 2016 so these contraceptive devices were available at the study site and some other hospitals for the duration of the study. For this 2‐year prospective observational cohort study, all pregnant and postpartum women with cardiac disease referred to the HMH Service were included between 1 August 2016 and 31 July 2018. We included both women with cardiac disease diagnosed prior to conception, as well as those newly diagnosed during pregnancy or within 42 days postpartum. The HMH Service was a comprehensive service for women of reproductive age with cardiac disease. A multidisciplinary team provided antenatal, intrapartum and postpartum care for women with cardiac disease. Every 2 weeks this team, consisting of one or more obstetricians, cardiologist, sonographers, echocardiographers and anaesthesiologists, was available at the antenatal clinic. Guidelines on the management of cardiovascular diseases during pregnancy of the European Society of Cardiology of 2011 were adhered to, as no local or LMICs‐adapted guidelines were available at that time [17]. Based on clinical condition, severity of cardiac disease and obstetric history, each woman received an individualised management plan, which outlined the frequency of follow‐up visits, obstetric ultrasounds, maternal echocardiograms and birth plan. Information on postpartum contraception was provided during antenatal visits. Women who presented with newly diagnosed cardiac disease were scheduled for the earliest available clinic day if haemodynamically stable or assessed as inpatients if haemodynamically unstable. Maternal risk was assessed using the mWHO risk classification, which stratifies maternal cardiovascular risk into four classes: class I (no increased risk of maternal mortality and no/mild increase in morbidity) up to class IV (extremely high risk, pregnancy contra‐indicated) [17]. Risk stratification for cardiac disease not specifically mentioned in the classification was done by a consultant cardiologist (C. Hugo‐Hamman) and a physician (T. Auala) with extensive experience in cardiology. For women with an indication for anticoagulation, the vitamin K antagonist warfarin, unfractionated and low‐molecular‐weight heparin were available in the public health sector. If she presented early in the first trimester, a woman using warfarin was counselled about the option to change to low‐molecular‐weight heparins in the first trimester. However, dose adjustment with anti‐Xa monitoring was not possible. The international normalised ratio was used to manage warfarin treatment. In Namibia, termination of pregnancy up to 26 weeks of gestational age is legally permitted for significant maternal conditions and certain fetal conditions. Because reported cardiac event rates are 19%–27% for women classified as WHO III and 40%–100% for women in mWHO IV, compared to 2.5%–5% for mWHO I and 5.7%–10.5% for mWHO II, the option of termination of pregnancy was included in the counselling for all women classified as mWHO III and advised for women classified as mWHO IV (if they presented before 26 weeks of gestation) [6]. The HMH Service followed up all women at 6 weeks and at 6 months after the end of pregnancy. On clinical indication, the follow‐up period was extended up to a year. Placement of long acting reversible family planning was offered directly after birth for women who had difficulties attending follow up visits and at 6 weeks after birth for all other women. If a HMH visit was not feasible for the woman, the 6‐month follow‐up was done by phone. At the last follow‐up visit, all women were referred to the Cardiology service. The HMH Service also provided preconception counselling at the cardiac outpatient department. All women of childbearing age were educated about their cardiac diagnosis, peripartum risk as determined by the mWHO risk classification and reliable contraception. A specifically designed patient information leaflet was provided to the women (Appendix S1). After counselling, the woman was seen by a doctor for her cardiac follow‐up and any further concerns were addressed. Women who opted for long‐acting reversible contraceptives (e.g., hormonal implant or intrauterine contraceptive devices) and who had no contra‐indication for these methods, could have them placed on the same day. These women were referred to the gynaecology department, as only doctors from this department had the expertise and equipment for placement of these devices. When the HMH Service was introduced, it was planned that these contraceptive devices would be placed by nursing staff of the cardiac outpatient department. This turned out to be unattainable due to an already high workload of these nurses and lack of training resources. Due to staff shortages across all departments the integrated HMH Service ended in June 2017 and cardiac and obstetric care was continued at the respective departments. Patient assessments and management were discussed in close communication between the departments and high‐risk women were discussed during multidisciplinary meetings. The provision of preconception counselling continued and long‐acting reversible contraceptives could be provided on the same day at the gynaecology department. There was no specific budget available for the HMH Service. All members of the HMH Service were employed by the Ministry of Health and Social Services and the HMH Service was part of their clinical duties. The patient information leaflet was printed by the United Nations Population Fund. Structured forms were developed for the HMH Service to record the women’s antenatal visits and maternal and fetal outcomes. Data collected included socio‐demographic characteristics, cardiac history, obstetric history, cardiac and obstetric outcome. All women were asked whether it was a planned or unplanned pregnancy and if continuation was desired. Primary outcomes were underlying cardiac diagnoses of women referred to the HMH Service, severity of cardiac disease, risk assessment based on mWHO classification and condition at first presentation based on the New York Heart Association (NYHA) class. Secondary outcomes were the incidences of cardiac, obstetric and fetal events. Cardiac event was defined as heart failure requiring admission or modifications in medication, thromboembolic event, new onset or exacerbated arrhythmia, endocarditis or a cardiac intervention during pregnancy or within 6 months after the end of pregnancy. Obstetric events that were documented included postpartum haemorrhage more than 1000 ml, pre‐eclampsia or eclampsia as defined by WHO [23]. Fetal event was defined as miscarriage or termination of pregnancy <26 weeks of gestation, stillbirth from 26 weeks of gestation or, if the gestational age was unknown, birthweight >1000 g and documented as either fresh or macerated in the medical file, premature birth <37 weeks gestation, small‐for gestational age birthweight (<10th centile), born alive with congenital anomalies or neonatal death (within 28 days after birth). Maternal death was defined as death of a woman while pregnant or within 42 days of termination of pregnancy or birth, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes [24]. Late maternal death was defined as the death of a woman from direct or indirect causes more than 42 days but less than 1 year after the end of pregnancy [24]. The association between events and several risk factors was assessed. Risk factors were selected when listed in the guidelines of the European Society of Cardiology or identified in studies from similar settings and present in at least 10% of our cohort [6, 16, 25]. Data analysis consisted of frequencies of demographic and clinical variables. Data were double entered and cross checked in Epidata version 3.1 and analysed with SPSS version 26. Continuous variables are presented as means with standard deviations and differences were assessed with student t‐test. Missing data regarding medical history were assumed to be ‘no’, whereas complete case analysis was used to handle missing data regarding outcome measures of the current pregnancy. Categorical variables are presented as percentages. Differences were assessed using chi‐square test or Fisher's Exact test when indicated and risk ratio (RR) and 95% confidence interval (CI) are presented. Statistical significance was assumed at a two‐sided value of p < 0.05. All results are presented in the tables and figures and therefore not published in a separate online database. We followed the STROBE reporting guidelines. This study was reviewed and approved by the ethics research unit of the Namibian Ministry of Health and Social Services, Reference 17/3/3 SH. Women were informed about the purpose of the cohort and verbally offered to opt out of her anonymous data being used for research purposes.