Availability and use of magnesium sulphate at health care facilities in two selected districts of North Karnataka, India

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Abstract

Background

Pre-eclampsia and eclampsia are major causes of maternal morbidity and mortality. Magnesium sulphate is accepted as the anticonvulsant of choice in these conditions and is present on the WHO essential medicines list and the Indian National List of Essential Medicines, 2015. Despite this, magnesium sulphate is not widely used in India for pre-eclampsia and eclampsia. In addition to other factors, lack of availability may be a reason for sub-optimal usage. This study was undertaken to assess the availability and use of magnesium sulphate at public and private health care facilities in two districts of North Karnataka, India.

Methods

A facility assessment survey was undertaken as part of the Community Level Interventions for Pre-eclampsia (CLIP) Feasibility Study which was undertaken prior to the CLIP Trials (NCT01911494). This study was undertaken in 12 areas of Belagavi and Bagalkote districts of North Karnataka, India and included a survey of 88 facilities. Data were collected in all facilities by interviewing the health care providers and analysed using Excel.

Results

Of the 88 facilities, 28 were public, and 60 were private. In the public facilities, magnesium sulphate was available in six out of 10 Primary Health Centres (60%), in all eight taluka (sub-district) hospitals (100%), five of eight community health centres (63%) and both district hospitals (100%). Fifty-five of 60 private facilities (92%) reported availability of magnesium sulphate.

Stock outs were reported in six facilities in the preceding six months – five public and one private. Twenty-five percent weight/volume and 50% weight/volume concentration formulations were available variably across the public and private facilities. Sixty-eight facilities (77%) used the drug for severe pre-eclampsia and 12 facilities (13.6%) did not use the drug even for eclampsia. Varied dosing schedules were reported from facility to facility.

Conclusions

Poor availability of magnesium sulphate was identified in many facilities, and stock outs in some. Individual differences in usage were identified. Ensuring a reliable supply of magnesium sulphate, standard formulations and recommendations of dosage schedules and training may help improve use; and decrease morbidity and mortality due to pre-eclampsia/ eclampsia.

Trial registration

The CLIP trial was registered with ClinicalTrials.gov ( NCT01911494).

Electronic supplementary material

The online version of this article (10.1186/s12978-018-0531-6) contains supplementary material, which is available to authorized users.

Related collections

Most cited references 17

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Status of Emergency Obstetric Care in Six Developing Countries Five Years before the MDG Targets for Maternal and Newborn Health

Charles A Ameh, Sia Emmanueli Msuya, Jan Hofman … (2012)

Background Ensuring women have access to good quality Emergency Obstetric Care (EOC) is a key strategy to reducing maternal and newborn deaths. Minimum coverage rates are expected to be 1 Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per 500,000 population. Methods and Findings A cross-sectional survey of 378 health facilities was conducted in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India between 2009 and 2011. This included 160 facilities designated to provide CEOC and 218 designated to provide BEOC. Fewer than 1 in 4 facilities aiming to provide CEOC were able to offer the nine required signal functions of CEOC (23.1%) and only 2.3% of health facilities expected to provide BEOC provided all seven signal functions. The two signal functions least likely to be provided included assisted delivery (17.5%) and manual vacuum aspiration (42.3%). Population indicators were assessed for 31 districts (total population = 15.7 million). The total number of available facilities (283) designated to provide EOC for this population exceeded the number required (158) a ratio of 1.8. However, none of the districts assessed met minimum UN coverage rates for EOC. The population based Caesarean Section rate was estimated to be <2%, the maternal Case Fatality Rate (CFR) for obstetric complications ranged from 2.0–9.3% and still birth (SB) rates ranged from 1.9–6.8%. Conclusions Availability of EOC is well below minimum UN target coverage levels. Health facilities in the surveyed countries do not currently have the capacity to adequately respond to and manage women with obstetric complications. To achieve MDG 5 by 2015, there is a need to ensure that the full range of signal functions are available in health facilities designated to provide CEOC or BEOC and improve the quality of services provided so that CFR and SB rates decline.

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Magnesium sulfate in eclampsia and pre-eclampsia: pharmacokinetic principles.

Ake T. Lu, C H Nightingale (2000)

Magnesium sulfate (MgSO4) is the agent most commonly used for treatment of eclampsia and prophylaxis of eclampsia in patients with severe pre-eclampsia. It is usually given by either the intramuscular or intravenous routes. The intramuscular regimen is most commonly a 4 g intravenous loading dose, immediately followed by 10 g intramuscularly and then by 5 g intramuscularly every 4 hours in alternating buttocks. The intravenous regimen is given as a 4 g dose, followed by a maintenance infusion of 1 to 2 g/h by controlled infusion pump. After administration, about 40% of plasma magnesium is protein bound. The unbound magnesium ion diffuses into the extravascular-extracellular space, into bone, and across the placenta and fetal membranes and into the fetus and amniotic fluid. In pregnant women, apparent volumes of distribution usually reach constant values between the third and fourth hours after administration, and range from 0.250 to 0.442 L/kg. Magnesium is almost exclusively excreted in the urine, with 90% of the dose excreted during the first 24 hours after an intravenous infusion of MgSO4. The pharmacokinetic profile of MgSO4 after intravenous administration can be described by a 2-compartment model with a rapid distribution (a) phase, followed by a relative slow beta phase of elimination. The clinical effect and toxicity of MgSO4 can be linked to its concentration in plasma. A concentration of 1.8 to 3.0 mmol/L has been suggested for treatment of eclamptic convulsions. The actual magnesium dose and concentration needed for prophylaxis has never been estimated. Maternal toxicity is rare when MgSO4 is carefully administered and monitored. The first warning of impending toxicity in the mother is loss of the patellar reflex at plasma concentrations between 3.5 and 5 mmol/L. Respiratory paralysis occurs at 5 to 6.5 mmol/L. Cardiac conduction is altered at greater than 7.5 mmol/L, and cardiac arrest can be expected when concentrations of magnesium exceed 12.5 mmol/L. Careful attention to the monitoring guidelines can prevent toxicity. Deep tendon reflexes, respiratory rate, urine output and serum concentrations are the most commonly followed variables. In this review, we will outline the currently available knowledge of the pharmacokinetics of MgSO4 and its clinical usage for women with pre-eclampsia and eclampsia.

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The Magpie Trial: a randomised trial comparing magnesium sulphate with placebo for pre-eclampsia. Outcome for children at 18 months

(2006)

Objective To assess the long-term effects of in utero exposure to magnesium sulphate for children whose mothers had pre-eclampsia. Design Assessment at 18 months of age for children whose mothers were recruited to the Magpie Trial (recruitment 1998–2001 ISRCTN 86938761), which compared magnesium sulphate with placebo. Setting Follow-up of children born at 125 centres in 19 countries across five continents. Population A total of 6922 children were born to women randomised before delivery at follow-up centres. Of these, 2271 were not included for logistic reasons and 168 were excluded (101 at a centre where <20% were contacted, 40 whose death or disability was due to a problem at conception or embryogenesis and 27 whose parent/s opted out). Therefore, 4483 children were included in follow-up, of whom 3283 (73%) were contacted. Methods Assessment by questionnaire, with interview and neurodevelopmental testing of selected children. Main outcome measures Death or neurosensory disability at age of 18 months. Results Of those allocated magnesium sulphate, 245/1635 (15.0%) were dead or had neurosensory disability at 18 months compared with 233/1648 (14.1%) allocated placebo (relative risk [RR] 1.06, 95% CI 0.90–1.25), and of survivors, 19/1409 (1.3%) had neurosensory disability at 18 months compared with 27/1442 (1.9%) (RR 0.72, 95% CI 0.40–1.29). There were no substantial differences in causes of death or in the risk of individual impairments or disabilities. Conclusions The lower risk of eclampsia following prophylaxis with magnesium sulphate was not associated with a clear difference in the risk of death or disability for children at 18 months.

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Author and article information

Contributors

Umesh Charantimath: drumesh.charantimath@gmail.com

Conference

Journal ID (nlm-ta): Reprod Health

Journal ID (iso-abbrev): Reprod Health

Title: Reproductive Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1742-4755

Publication date (Electronic): 22 June 2018

Publication date PMC-release: 22 June 2018

Publication date Collection: 2018

Volume: 15

Issue : Suppl 1 Issue sponsor : Publication of this supplement was funded by the University of British Columbia PRE-EMPT (Pre-eclampsia/Eclampsia, Monitoring, Prevention and Treatment) initiative supported by the Bill & Melinda Gates Foundation. The articles have undergone the journal's standard peer review process for supplements. The Supplement Editors declare that they were not involved in the peer review process for any manuscript on which they are an author. The conference was hosted by Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, J N Medical College, Belagavi, Karnataka, India.

Electronic Location Identifier: 91

Affiliations

[1 ]Department of Obstetrics and Gynaecology, S Nijalingappa Medical College, Bagalkot, Karnataka India

[2 ]ISNI 0000 0001 1889 7360, GRID grid.411053.2, KLE Academy of Higher Education and Research’s J N Medical College, ; Belagavi, Karnataka India

[3 ]ISNI 0000 0001 2288 9830, GRID grid.17091.3e, Department of Obstetrics and Gynaecology, , University of British Columbia, ; Vancouver, BC Canada

[4 ]Department of Community Medicine, S Nijalingappa Medical College, Bagalkot, Karnataka India

[5 ]Department of Pharmacology, S Nijalingappa Medical College, Bagalkot, Karnataka India

[6 ]Department of Anatomy, S Nijalingappa Medical College, Bagalkot, Karnataka India

[7 ]ISNI 0000 0001 2322 6764, GRID grid.13097.3c, School of Life Course Sciences, Faculty of Life Sciences and Medicine, , King’s College London, ; London, UK

[8 ]ISNI 0000 0001 2166 5843, GRID grid.265008.9, Global Affairs, Thomas Jefferson University, ; Philadelphia, USA

[9 ]ISNI 0000 0001 0633 6224, GRID grid.7147.5, Division of Women and Child Health, , Aga Khan University, ; Karachi, Sindh Pakistan

[10 ]ISNI 0000 0000 9878 7323, GRID grid.417249.d, Department of Research, Vancouver Island Health Authority, ; British Columbia, Canada

Article

Publisher ID: 531

DOI: 10.1186/s12978-018-0531-6

PMC ID: 6020005

PubMed ID: 29945665

SO-VID: 2f6315a3-19b2-428c-b51a-a85b5c7f2d08

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Conference name: 2nd International Conference on Maternal and Newborn Health: Translating Research Evidence to Practice

Conference location: Belagavi, India

Conference date: 26-27 March 2018

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ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: magnesium sulphate,availability,health care facilities,pre-eclampsia,eclampsia,karnataka,india

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ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: magnesium sulphate, availability, health care facilities, pre-eclampsia, eclampsia, karnataka, india

Availability and use of magnesium sulphate at health care facilities in two selected districts of North Karnataka, India

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Abstract

Background

Methods

Results

Conclusions

Trial registration

Electronic supplementary material

Related collections

Chinese Journal of General Practice

Most cited references 17

Status of Emergency Obstetric Care in Six Developing Countries Five Years before the MDG Targets for Maternal and Newborn Health

Magnesium sulfate in eclampsia and pre-eclampsia: pharmacokinetic principles.

The Magpie Trial: a randomised trial comparing magnesium sulphate with placebo for pre-eclampsia. Outcome for children at 18 months

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