Attrition from care after the critical phase of severe pre-eclampsia and eclampsia: Insights from an intervention with magnesium sulphate in a primary care setting in northern Nigeria

Background: Evidence has shown that Magnesium Sulphate (MgSo_4) is the gold standard for treating severe pre-eclampsia and eclampsia (SPE/E), and calls for its widespread use at all levels of health service delivery, including the primary care level. Objective: To determine if administering loading dose of MgSo_4 on pregnant women with severe preeclampsia and eclampsia at primary care level would improve maternal and fetal outcomes. Method: Two sets of Primary Health Care (PHC) facilities were identified; one served as experimental one and the other as control. The community health extension workers (CHEWs) and the community health officers (CHOs) at the experimental PHCs were trained to administer the loading dose of MgSo_4 for patients with SPE/E, in addition to other supportive treatments, before making a referral while the control PHCs did not give MgSo_4, and neither administered diazepam as an alternative or no anti-convulsant at all, before making a referral to higher centers. Patients from the experimental and control facilities were prospectively monitored for fetal and maternal outcomes, namely maternal and fetal deaths, and for toxic effects of MgSo_4 in the experimental arm. Results: Of the 150 patients recruited, 82 (55%) were in the experimental group and 68 (45%) were in the control group. 90% of the patients in the experimental group defaulted after receiving the loading dose of MgSo_4 while the remaining 10% completed the referral process. 44% of those in the control group completed the referral process. There were 3 maternal and 3 perinatal deaths, all in the control group. No adverse outcome (maternal or fetal death) or toxic effect was recorded among the recipients of MgSo_4. Conclusion: This study suggests that lower-cadre health care professionals at PHCs can administer the loading dose of MgSo_4 to SPE/E patients to improve maternal and fetal survival in critical states, without significant risk of adverse effects. However, the lack of compliance with referral processes remains a huge challenge