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Expanding Use of Magnesium Sulfate for Treatment of Pre-eclampsia and Eclampsia

December 1, 2014

Pre-eclampsia/eclampsia is a serious condition that can develop during pregnancy, even in women with no risk factors. Although there is little understanding of what causes pre-eclampsia/eclampsia, there is an effective treatment for this condition which, if left untreated, can progress to coma and death. In 1994, the World Health Organization (WHO) recommended magnesium sulfate as the standard treatment for pre-eclampsia and eclampsia and within two years it was placed on WHO's Essential Medicines List. Despite its known efficacy, this inexpensive drug is often underutilized, in part because the diffusion of innovation takes time but also because of the service delivery challenges inherent to the use of magnesium sulfate—it requires a strong and effective referral system, often a challenge in under-resourced health systems. The underutilization of magnesium sulfate has been a recognized problem in Nigeria for some time; prior to 2007 there was almost no magnesium sulfate in the country.The significant contribution of pre-eclampsia/eclampsia to maternal mortality in Nigeria—along with the promise of magnesium sulfate as a solution—caught the attention of the John D. and Catherine T. MacArthur Foundation in 2005 when a program officer overheard a conversation between two Nigerian doctors who were lamenting the failure of a piece of equipment in their hospital laboratory that was used for manufacturing magnesium sulfate. Without it, one was saying to the other, they would have no supply of the drug to treat pre-eclampsia/eclampsia and no way to save women's lives. The Foundation decided to fund a series of grants to expand the use of magnesium sulfate for pre-eclampsia/eclampsia in Nigeria and, in 2014, commissioned an evaluation of that work. This case study describes the findings of the evaluation, including the challenges encountered while implementing the projects, the successes achieved, and existing opportunities for future scaling up of the services across the country.

Scaling up Access to Misoprostol at the Community Level to Improve Maternal Health Outcomes in Ethiopia, Ghana, and Nigeria

December 1, 2014

Over the past decade (2004–2014), the Population and Reproductive Health area of the MacArthur Foundation has focused on supporting projects aimed at reducing maternal mortality. In particular, it has supported efforts to use misoprostol to prevent postpartum hemorrhage, the anti-shock garment to aid in the treatment of hemorrhage, and magnesium sulfate to decrease deaths from eclampsia. In recent years, the Foundation has invested in a range of research and evaluation efforts to better understand these interventions, their effectiveness, and the extent to which successful pilot projects have been scaled up.In 2014, the Foundation commissioned the Public Health Institute to evaluate the grants it had made to increase community-based access to misoprostol for postpartum hemorrhage prevention in Ethiopia, Ghana, and Nigeria. Specifically, the Foundation was interested in documenting the models and approaches used and the progress toward scaling up the respective models in the three countries. Between June and November 2014, the evaluation team reviewed grantee reports, proposals, and the literature; interviewed key informants and global, national, and local stakeholders; conducted focus group discussions with local stakeholders; and made observations during site-visits in each country. From this the team produced case study reports relating to misoprostol use in each country. This report is a synthesis of those three case studies, highlighting the common findings across the projects, identifying differences, and interpreting the lessons learned for broader use and scale up of misoprostol at the community level in Africa and globally.