OPTIMIZING CARE AND PATIENT EXPERIENCE OF PREECLAMPSIA IN LOW- AND MIDDLE-INCOME COUNTRIES-THE CASE OF GHANA

Abstract

Hypertensive disorders in pregnancy continue to be associated with severe adverse pregnancy outcomes in low resource settings despite recommendations and interventions instituted to reverse the trend. This thesis aimed to optimize the care and patient experience of preeclampsia in low resource settings. We defined a novel treatment regimen of magnesium sulfate which differed from the most widely accepted and practiced Pritchard regimen in most low resource settings. The Beyuo regimen has a shorter fixed maintenance duration of 12 hours from initiation of treatment. It does not depend on timing of delivery. The regimen is: Loading dose: IV 4 grams of MgSO4 and 10mg IM MgSO4 (5 gram in each buttock) given at the time of antepartum, intrapartum, or postpartum diagnosis of eclampsia or preeclampsia with Severe Features. Maintenance doses: IM 5 grams MgSO4 every 4 hours for a total of THREE doses over TWELVE hours starting at the time of diagnosis of eclampsia or preeclampsia with Severe Features This novel regimen was evaluated in an open label randomized control (Modified versus standard Pritchard regimen in Eclampsia Prophylaxis (MOPEP)) trial at a large tertiary hospital in Ghana, the Korle Bu Teaching Hospital. 1176 participants with preeclampsia with severe features (including 116 with an admission diagnosis of eclampsia) were randomized into the Pritchard regimen arm (n=584) and the Beyuo regimen arm (n=592). We found no difference in occurrence of seizure between the 24-hour group (n=9, 1.5%) versus the 12-hour group (n=5, 0.9%), (p=0.28, RR 0.55, 95% CI 0.19–1.64). Participants in the 12-hour group had a shorter period of inpatient admission and urethral catheterization, with fewer side effects from magnesium sulfate. We conclude that compared with 24 hours, 12 hours of intramuscular magnesium sulfate showed similar rates of seizures, with fewer side effects and shorter inpatient admission. We explored women’s knowledge, attitudes, and experiences with preeclampsia in Ghana in chapter 9. We used grounded theory to explore patients’ experience of preeclampsia and eclampsia in a low-resource setting. Postpartum women diagnosed with preeclampsia or eclampsia at Korle Bu Teaching Hospital in Ghana were interviewed with semi-structured and open-ended questions regarding participant understanding of their diagnosis of preeclampsia and eclampsia; counseling from their healthcare providers; and experiences with their delivery, monitoring, and treatment. A total of 45 women were interviewed, 88.9% with preeclampsia and 11.1% with eclampsia. Major themes identified include participants’ low general knowledge of their diagnosis, inadequate counseling from healthcare providers, and resulting emotional distress. Women desire more information regarding their diagnosis and associate their health-seeking behaviors with counseling they receive from healthcare providers. Women also acknowledge the systemic barriers that make patient care and counseling challenging for providers, especially in low- and middle-income countries. Our findings highlighted the global need for improved models of counseling and health education for women with pregnancies complicated by preeclampsia and eclampsia.