1. Women’s Health Academic Centre CRADLE Community Blood Pressure Monitoring in Rural Africa: cfaDetection of Underlying Pre-eclampsia Hezelgrave N, Irvine L, Radford S, Seed P, Edmunds S, Basira D, Chicwezveru K, Mazanhi P, Horst M, Shennan A Introduction  Hypertensive diseases in pregnancy are a significant cause of morbidity and mortality, particularly in the low resource setting (LRS).  Pre-eclampsia and eclampsia alone claim up to 50,000 women’s lives globally each year, with an estimated fetal case fatality of 7-25% in Africa.  Pre-eclampsia is frequently underdetected due to inadequate training in accurate BP measurements, complex or poorly functioning BP monitors.  We have previously developed and validated in pregnancy a BP device suitable for use in low resource settings  These have shown to acceptable and useful to healthcare workers in rural Tanzania in formative research  The CRADLE study aims to evaluate the introduction of this low cost, automated BP monitors into rural antenatal clinics and among community health workers.  The introduction of of automated blood pressure devices in rural health centers will increase the detection and referral of asymptomatic hypertension in pregnant women from 20 weeks gestation. This will be reflected in an increased mean BP in pregnant women presenting to a secondary referral centre Hypothesis.  International prospective longitudinal multi-centre pre- and post-intervention pilot study.  Population: antenatal (>20 weeks) who accessed care at referral site in Tanzania (Hospitali Teuli), Zimbabwe (Morganster Mission Hospital) and Zambia (Ndola Hospital).  Intervention: 20 validated microlife AS1-2 BP devices were distributed to 20 peripheral rural health clinics together with training in their use and guidelines on referral thresholds. Methods No significant difference was found between mean age gestation or parity of participants pre and post intervention  The CRADLE intervention was associated with a significant increase in mean diastolic blood pressure (dBP) (2.39 mmHg, p< 0.05, 95% CI 0.97- 3.8) representing a higher proportion of women referred with high BP from the community.  The CRADLE intervention was associated with a significant reduction in proportion of women seen in the central referral hospital who had previously never had a BP measured in their pregnancy (25.1% to 16.9%, OR 0.58, p< 0.001, CI 0.42- 0.79).  No significant difference was found between mean systolic blood pressure (sBP) (0.97mmHg, P= 0.274, CI -0.77- 2.71), nor proportion of women presenting with sustained BP >140mmHg systolic or 90mmHg diastolic (16.1%-17.1%, OR 1.08, p= 0.6, CI.79- 1.48). Results CountryPre- intervention Post intervention Zimbabwe302204 Zambia16497 Tanzania228246 Total694547 Table 1: Participant numbers per site  Data collection: Systematic BP’s (2 readings) were taken using the automated, validated in pregnancy BP device in the central referral site before and after them implementation of the BP monitors, with a time lag of 12 months to exclude seasonal variation in presentation.  Results were adjusted for age, parity and gestation using logistic regression  The CRADLE intervention was associated with a significant increase in both mean systolic (3.16 mmHg, p<0.05, CI 0.25-6.06) and dBP (4.73mm Hg, p<0.001, CI 2.40-7.06)  The CRADLE intervention was also associated with a significant increase in the proportion of women who had a sustained systolic BP of ≥140 or diastolic BP ≥90 (12.8% to 21.3%, OR 1.09, p=0.03, CI 1.06- 3.43). Zimbabwe Conclusions Equipping low-skilled community health providers with a novel BP device is feasible and widely accepted, resulting in a significant rise in mean dBP, a proxy for increased referrals fo hypertension from rural clinics. A cluster RCT to evaluate their effect, together with community management of pre- eclampsia, on maternal and fetal outcomes is planned The introduction of a cheap, automated BP monitor suitable for use in low resource settings into rural clinics/health posts has the potential to increase detection of pre-eclampsia and reduce perinatal and maternal mortality. This research was supported by The Gates Foundation Grand Challenges Explorations, Tommy’s Charity and the National Institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London.