Early Experience of Expansion of use of Magnesium Sulphate in Nigeria

1. Early Experience of Expansion of use of Magnesium Sulphate in Nigeria J Tukur*, B Ahonsi**, A Karlyn**, I Araoyinbo** *Aminu Kano Teaching Hospital, Kano, Nigeria **Population Council, Abuja, Nigeria

2. Outline of presentation • Describe the introduction of magnesium sulphate to a state health system • Describe the results of the intervention • Discuss the results as well as challenges

3. Introduction • Eclampsia is a common cause of maternal mortality worldwide especially in the developing countries. • It is estimated that every year eclampsia is associated with about 50,000 maternal deaths worldwide, most of which occur in developing countries. • In Nigeria, eclampsia is a common cause of maternal mortality.  

4. Introduction • The Collaborative Eclampsia Trial in 1995 confirmed the efficacy of MgSO4 in the treatment of severe preeclampsia and eclampsia. • Women treated with MgSO4 had a 52% and 67% lower recurrence of convulsions than those treated with diazepam and phenytoin, respectively. • Use of MgSO4 in patients with severe preeclampsia reduced the risk of progression to eclampsia by more than half and reduced maternal mortality

5. Introduction • The MagPie Trial demonstrated that when magnesium sulphate was used in women with preeclampsia, there was a 58% lower risk of progression to eclampsia compared to those who had placebo. • Maternal mortality was also reduced in those who had magnesium sulphate

6. Availability of MgSo4 • Despite these evidences, the use of magnesium sulphate is still not universal in Nigeria. • In Nigeria, the drug was not widely available as at five to ten years ago but that has now changed.

7. Introduction • This presentation will describe introduction of magnesium sulphate in an area where it was not available and discuss the effects of its introduction to maternity services

8. Genesis • Presentation at SOGON Conference in 2007 • Population Council sought funding for the project from MacArthur Foundation • Project site was Kano: most populous state of Nigeria with population over 10 million, 44 LGAs, 35 General Hospitals, free maternity scheme

9. Methodology • A pilot survey was first conducted in January 2009 to determine the use of Magnesium sulphate in General Hospitals in Kano state. • It was being used occasionally in one of the hospitals (Murtala Muhammad Specialist Hospital) • Advocacy followed

10. Methodology • A training of trainer workshop was held in February 2008 in Kano. • All the participants were either doctors or midwives from 10 pilot general hospitals. • The intramuscular regime was chosen for its simplicity in monitoring while toxicity was monitored clinically. • Patella hammers and calcium gluconatewere supplied to all the centres. • Most of the participants physically sighted magnesium sulphate for the first time at the workshop. • A simple protocol for the use of magnesium sulphate was also developed.

11. Methodology • A total of 25 master trainers were trained at the first workshop. • The 25 master trainers later conducted step down trainings at 10 of the 35 general hospitals in the state. • With training, the drug was introduced in the 10 General Hospitals. • The seed stock was supplied through the project to the 10 hospitals via the State Hospitals Management Board • Within a period of three months, the master trainers trained 160 clinical providers through step down trainings conducted at the various health facilities.

12. Results • From February to December, 2008, a total of 1846 patients were treated with magnesium sulphate in the 10 general Hospitals • Majority (43.3%) of them were treated the Murtala Muhammad Specialist Hospital in the state capital. • The highest frequency was in the primigravida consisting of 1152 out of the 1846 (63.3%) patients.

13. Results • 1044 (57.7%) of the patients had antenatal care while 764 (41.4%) did not have antenatal care. Data was however missing in 38 (2.1%) of the patients • The mean time in hours before presentation was 8.4 while the mean no. of fits was 3.2. • Twenty-three (1.24%) of the patients were noted to have toxic effects of the drugs through clinical monitoring. • For these few cases, the drug was stopped and the antidote (calcium gluconate) administered. • There was no mortality or morbidity recorded from the toxic effects of the drug.

14. Results • Seventy-seven (4.1%) mothers died while 239 (12.9%) babies were delivered dead. • These deaths were recorded only in women who delayed before presenting to the health facilities. • The 77 mothers who died within the 12 months period of the project constituted 15.9% of the total 483 maternal deaths recorded in the 10 hospitals (including those from other causes). • A review of the 12 months period prior to the intervention revealed that eclampsia accounted for 268 (47.3%) of the 567 maternal deaths. • This demonstrated a reduction in attributable deaths from eclampsia by 66%.

15. Results • All the facilities reported periods of stock- out of magnesium sulphate at least once during the 12 months of the project. • As the project was not directly responsible for the supply of the drug to the health facilities, joint meetings of the medical officers in charge of the health facilities and the free maternity drugs committee were called to discuss the recurrent reports of stock-outs.

16. Results • By the tenth month of the project, the state government took over the purchase of the drug and continued thereafter. • The decision of the government resulted from the data that was generated from the project and positive comments from both health workers who use the drug and patient relations.

17. Discussion • The project was not about showing that magnesium sulphate works. • That has already been proven

18. Discussion • The project was about demonstrating the following: • Evidence based interventions could be introduced into ‘new areas’. • The project is sustainable: related to engagement of stakeholders • Introduction of evidence based interventions usually replicable

19. Discussion • Project left a crop of master trainers who have commenced knowledge transfer

20. Challenges • Stock-outs in a setting of free maternity scheme • Improving the quality of ANC • Delays by women in reaching health facilities

21. Thank you