1. Health intervention strategies to improve provider practice: A case study of magnesium sulfate use to treat (pre)eclampsia in Mexico American Public Health Association, 135th Annual meeting and Expo, 3-7 November 2007, Washington DC Marieke van Dijk, MD, Regional AssociateCo-investigators: Sandra García Karla Berdichevsky Rosanne Rushing Eileen Yam Patricio Sanhueza

2. Overview Maternal health in Mexico (Pre)eclampsia and magnesium sulfate Rationale for research 3 complementary studies Results Conclusions Next steps

3. Maternal health in Mexico High prenatal care coverage (86%) However, National MMR of 63,4 per 100.000 live births in the year 2005 (72,6 in 2000) Need for strengthening evidence-based obstetric practices Source: CONAPO 2005, WHO 2001

4. Maternal Mortality Ratio in Mexico, 2005 Low9.6 - 42.7* Medium 46.5 -73.4* High 73.5 - 128.2* Source: CONAPO, 2005 32 states 1,242 maternal deaths in 2005 32 states 1,242 maternal deaths in 2005

5. (Pre)eclampsia: leading cause of MM Pre-eclampsia: Multisystem disorder of pregnancy Raised bloodpressure Proteinuria Eclampsia: The occurence of one or more convulsions superimposed on pre-eclampsia

6. MgSO 4 included in national guidelines and national list of essential drugs (2005)

7. BUT NOT WIDELY USED!

8. Rationale for research Preeclampsia/eclampsia is leading cause of maternal mortality in Mexico Gap between official guidelines and use of recommended drug MgSO 4 Response to Millenium Development Goals

9. Three complementary studies

10. Review of maternal mortality charts in Mexico City (2005) Surveys on knowledge and use MgSO 4 in Mexico City In-depth interviews with key informants

11. Results

12. 1. Chart review Mexico City 167 maternal deaths in 2005 49 (pre)eclampsia-related deaths (29%) 28 occurred in a public hospital 9 occurred in a social security hospital (IMSS/ISSSTE) 10 occurred in a private hospital 2 occurred at the woman’s home

13. 1. Chart review Mexico City Drug(s) usedn Magnesium sulfate6 Magnesium sulfate and phenytoin8 Magnesium sulfate and diazepam1 Magnesium sulfate, phenytoin and diazepam2 Phenytoin3 Phenytoin and diazepam2 None of these drugs9 Total31 18 cases excluded because no chart available 17 cases use of MgSO 4 (55%)

14. 2. Surveys on knowledge and use MgSO 4 113 self-administered questionnaires with physicians in public hospitals in Mexico City 63% men, 47% women Gynecologists (61%), residents in gynecology (22%), general doctors (17%) 80% worked in a teaching hospital

15. 2. Reported drugs of preference Drug(s) usedPreeclampsiaEclampsia Magnesium sulfate79%46% Phenytoin17%31% Fenobarbital3%13% Other drugs (e.g. Diazepam) 1%10%

16. 3. Key informant interviews In-depth interviews with 11 key informants: Few gynecologists follow the national guidelines for (pre)eclampsia MgSO 4 is not widely used for (pre)eclampsia Higher level of use MgSO 4 in Mexico City compared to other states/rural areas

17. 3. Key informant interviews Barriers to use MgSO 4 : Drug-related barriers Fear of side-effects (respiratory depression) Intramuscular administration not possible Belief that if blood pressure is under control, MgSO 4 not necessary Preference for other drugs Treatments learned from their professors Own experience

18. 3. Key informant interviews Barriers to use MgSO 4 : Lack of knowledge on use MgSO 4 No time to update knowledge No access to evidence-based knowledge No adequate training in use MgSO 4 No teaching hospital; no contact with ‘academy’

19. Conclusions Many barriers for use of MgSO 4 Discrepancy between actual and self-reported use of MgSO 4 MgSO 4 more commonly used for severe preeclampsia compared to eclampsia Use phenytoin seems to be very common, either alone or in combination with MgSO 4

20. Next steps Research proposal under development for NIH (others), 2008 Documenting barriers systematically Designing and testing different intervention strategies

21. THANK YOU! mvandijk@popcouncil.org.mx Acknowledgements: MOH Mexico City Federal MOH: Centro Nacional de Equidad de Género y Salud Reproductiva – Cuitlahuac Ruíz, Ricardo Muñoz, Rufino Luna, Edgar Lezama, Maria Elena Reyes Population Council colleagues Ana Langer José Villar