Health care provider knowledge and routine management of pre-eclampsia in Pakistan

Pre-eclampsia is defined as development of new hypertension in pregnancy along with significant proteinuria occurring after 20 weeks of gestation [1]. It is a multisystem disorder that may affect the liver, kidney and clotting in pregnancy, as well as potential fetal growth restriction and premature delivery [1]. Eclampsia is a complication of pre-eclampsia defined as the new onset of grand mal seizure(s) and/or unexplained coma during pregnancy or postpartum in a woman with pre-eclampsia [2]. Eclampsia is responsible for one in ten maternal deaths, and claims 2000 maternal lives every year, in Pakistan [3, 4].

Several multicounty trials [5, 6] and systematic reviews [7] have proved that MgSO₄ is an important agent in the management of severe pre-eclampsia and eclampsia. The World Health Organization (WHO) stated that MgSO₄ is the first line drug for treatment of pre-eclampsia and eclampsia more than a decade ago [8] and Pakistan included MgSO₄ in the national essential drug list in 2007 [9]. However, these efforts have not translated into practice and a large number of women continue to suffer from pre-eclampsia and eclampsia without receiving life-saving treatment.

In Pakistan, the health care system is comprised of both formal and informal sectors. Formal system included public and private health facilities. Pakistan’s public health system is centralised under the Federal Government and Provincial Health Ministries; and comprises of primary, secondary and tertiary health centres. Primary care facilities include 5000 Basic Health Units, 560 Rural Health Centres, 900 Maternal and Child Health centres and large number of dispensaries and first aid posts. Secondary level centres include 900 Taluka and district level hospitals. Tertiary health care is delivered through 30 teaching hospitals [10].

Lady Health Workers (LHWs) and Lady Health Visitors (LHVs) are deployed as community-based health care workers in the home and primary health centres [10]. Doctors and nurses are deployed at all levels of health care facilities. The private sector consists of a few accredited tertiary level hospitals and a large number of non-accredited tertiary, secondary and primary clinics and hospitals both in urban and rural areas. The informal health care system is led by non-certified local health care providers, such as traditional birth attendants (TBA), spiritual healers, and Hakeems (practitioner of Unani/Greek medicine). The informal health care system is patronised by many as treatment is affordable, available within the local community, and in-line with traditional and cultural beliefs [11].

Studies from other low and middle-income countries (LMIC) reported that contrary to WHO guidelines, women were not regularly screened for high blood pressure during antenatal care [12]. Literature from the developing world has also reported that various cadres of health care providers (doctors, nurses, midwife, and community care providers) have limited knowledge regarding screening and management of pre-eclampsia [13–15].

The limited knowledge of health care providers likely plays a role in the slow reduction in maternal morbidity and mortality due to pre-eclampsia in developing countries, such as Pakistan. Hence, we explored the knowledge of different health care providers regarding pre-eclampsia and eclampsia and their current management practices in rural Sindh, Pakistan.