Matern Child Health J (2013) 17:11911198

DOI 10.1007/s10995-012-1105-9

Maternal and Fetal Outcomes After Introduction of Magnesium

Sulphate for Treatment of Preeclampsia and Eclampsia
in Selected Secondary Facilities: A Low-Cost Intervention
Jamilu Tukur Babatunde Ahonsi
Salisu Mohammed Ishaku Idowu Araoyinbo
Ekechi Okereke Ayodeji Oginni Babatunde

Published online: 7 September 2012

Springer Science+Business Media, LLC 2012

Abstract The aim of this study was to evaluate whether a

new low-cost strategy for the introduction of magnesium
sulphate (MgSO4) for preeclampsia and eclampsia in lowresource areas will result in improved maternal and perinatal
outcomes. Doctors and midwives from ten hospitals in Kano,
Nigeria, were trained on the use of MgSO4. The trained health
workers later conducted step-down trainings at their health
facilities. MgSO4, treatment protocol, patella hammer, and
calcium gluconate were then supplied to the hospitals. Data
was collected through structured data forms. The data was
analyzed using SPSS software. From February 2008 to January 2009, 1,045 patients with severe preeclampsia and
eclampsia were treated. The case fatality rate for severe preeclampsia and eclampsia fell from 20.9 % (95 % CI
18.723.2) to 2.3 % (95 % CI 1.53.5). The perinatal mortality rate was 12.3 % as compared to 35.3 % in a center using
diazepam. Introduction of MgSO4 in low-resource settings led
to improved maternal and fetal outcomes in patients presenting with severe pre-eclampsia and eclampsia. Training of
health workers on updated evidence-based interventions and
providing an enabling environment for their practice are
important components to the attainment of the Millenium
Development Goals (MDG) in developing countries.
Keywords Severe preeclampsia
Eclampsia

Maternal mortality
Millennium development goals

Magnesium sulphate
J. Tukur (&)
Department of Obstetrics and Gynaecology, Bayero University/
Aminu Kano Teaching Hospital, Kano, Nigeria
e-mail: jtukur@yahoo.com
B. Ahonsi
S. Mohammed Ishaku
I. Araoyinbo

E. Okereke
A. O. Babatunde
Population Council, Abuja, Nigeria

Introduction
As we approach 2015, there are several efforts at achieving
the Millennium Development Goals (MDG). The 4th MDG
is to reduce child mortality in children under 5 years old by
two-thirds while the 5th is to reduce maternal deaths by
75 % between 1990 and 2015 [1].
An area that has attracted attention is hypertensive disorders of pregnancy. Ten percent of women have high
blood pressure during pregnancy, and preeclampsia complicates 28 % of pregnancies. Ten to fifteen percent of
direct maternal deaths are associated with preeclampsia
and eclampsia [2]. The World Health Organization (WHO)
estimates that at least 16 % of maternal deaths in low- and
middle-income countries result from the hypertensive disorders of pregnancy, of which eclampsia is the primary
contributor [3].
Based upon the Eclampsia Trial Collaborative Group in
1995, the World Health Organization (WHO) recommends
Magnesium sulphate (MgSO4) for the treatment of severe
preeclampsia and eclampsia (SPE/E). The eclampsia trial
collaborative study compared regimens for treatment of
eclamptic seizures. Women treated with MgSO4 had 52
and 67 % lowered risk of recurrent seizures compared to
women who were treated with diazepam and phenytoin,
respectively. Maternal mortality was non-significantly
lowered in the women who received MgSO4 [4].
Despite the evidence of its effectiveness, the use of
MgSO4 has remained low especially in developing countries where it is incidentally needed the most [5].
Some of the reasons for the low availability and utilization of MgSO4 include the lack of guidelines on its use,
non-inclusion in many national essential drug lists, the
wrong perception that the drug is meant for use only at the
highest level of facilities (such as those with intensive-care

123

1192

facilities), lack of training of health workers on its use,

little incentive for pharmaceutical companies to commercialize the drug, and ready availability of pre-packaged
forms of less effective drugs [5, 6]. Other identified barriers
include a lack of procurement from governments, a lack of
demand by health workers, and lack of in-service training
on the use of MgSO4 [7]. There has been a call by the
WHO for the evidence on MgSO4s efficacy to be disseminated, the drug to be registered and made available in
all countries, the World Bank and other charitable organizations to fund the provision and distribution of treatment
kits and other international organizations to assist on
training frontline clinicians on how to use the drug [8].

Study Setting
Nigeria is located in West Africa and is Africas most
populous nation with a population of 162.5 million people
[9]. The Nigerian Health system divides hospitals into
primary, secondary, and tertiary hospitals with referral
linkages between them. Patients with SPE/E are referred
from primary to secondary and tertiary health facilities for
management. Delays are common due to lack of transport,
bad roads, and sometimes lack of knowledge from the
patient and relations on the seriousness of the condition. In
addition, there is poor record-keeping of births, as they are
kept only at hospitals even though the NDHS showed that
only 35 % of deliveries take place in hospitals [10]. As
registration of births and deaths in the community are not
compulsory, health facility-based data are often all that is
available for research.
In addition, the federal system of government being
practiced in Nigeria divides levels of governance into three
distinct and independent entities, which are federal, state,
and local governments. Consequently, the health care
system is disintegrated along this model with tertiary
institutions being managed by the federal government,
secondary institutions by the state governments, and primary health care by the local government authorities, with
no formal connection between these levels of care [11]. As
a result, the care for pre-eclampsia and eclampsia, as for
other major obstetric emergencies, is not properly coordinated across these levels of service delivery. Furthermore,
the guideline of the Federal Ministry of Health in Nigeria
for managing eclampsia excludes lower-cadre service
providers in the management of the condition.
Nigeria has a high maternal mortality rate of 545 per
100,000 live births [10] with eclampsia as a major contributor. Studies in northern Nigeria showed that eclampsia
contributed 31.3, 46.4, and 43.1 % of all maternal deaths in
Kano [12], Nguru [13], and Birnin Kudu [14], respectively.
In contrast, eclampsia contributed 34.4 % of maternal

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Matern Child Health J (2013) 17:11911198

deaths in Enugu in southern Nigeria [15]. The differences

in the contribution of eclampsia to maternal deaths could
be due to the culture of early marriage in northern Nigeria
and also delays in accessing care.
Kano is one of the states in the northwest of Nigeria.
The last Nigerian National census showed Kano as being
the most populous state in the country with a population of
9,401,288 [9]. Kano has a maternal mortality ratio (MMR)
of over 1,000 per 100,000 and a relatively high total fertility rate of over seven births per woman, with 45 % of
adolescents aged 1519 having already begun childbearing
and a modern contraceptive prevalence rate of less than
5 % [10]. Kano state has 35 general hospitals, offering free
maternity care funded by the government.
In 2007, the Population Council secured funding from
the MacArthur Foundation for the project. This followed a
baseline survey that showed that the drug used for the
treatment of SPE/E in all the 35 general hospitals was
diazepam. The survey also reviewed data from three general hospitals (Bichi, Wudil, and MMSH) to determine the
contribution of SPE/E to maternal deaths and its case
fatality rate prior to the introduction of MgSO4. The
baseline survey data covered the period January 1, 2007 to
December 31, 2007.

Materials and Methods

The data collection for the project started on February 1,
2008 and ended on January 31, 2009. In January 2008, one
doctor and one midwife from each of ten selected general
hospitals were invited to Kano, the state capital for training. The hospitals were selected on the basis of geographic
spread across the state, population, and high burden of
maternal deaths. The hospitals were at Kano, Bichi, Wudil,
Gwarzo, Rano, Minjibir, Tudun Wada, Doguwa, Rano, and
Rogo. Apart from Kano, the rest were rural towns. Also
invited for the training were five officials of the Hospitals
Management Board.
The facilities were spread across the entire state with
Kano metropolis at the center. The distance from each
facility to Kano where advanced life support exists ranges
from 42 km (Wudil) to 165 km (Doguwa), but since these
facilities receive referral from their surrounding clustered
primary health care (PHC) facilities, the average distance
from a particular PHC to its referral facility ranges from 15
to 30 km.
For this study, a pregnant woman was defined as having
pre-eclampsia if she had high blood pressure in the second
half of pregnancy of 140 mmHg systolic or more and/or
diastolic blood pressure of 90 mmHg or more with proteinuria (at least 2? of proteinuria using urine dipstick).
Features of severe preeclampsia included features of

1192

facilities), lack of training of health workers on its use,

little incentive for pharmaceutical companies to commercialize the drug, and ready availability of pre-packaged
forms of less effective drugs [5, 6]. Other identified barriers
include a lack of procurement from governments, a lack of
demand by health workers, and lack of in-service training
on the use of MgSO4 [7]. There has been a call by the
WHO for the evidence on MgSO4s efficacy to be disseminated, the drug to be registered and made available in
all countries, the World Bank and other charitable organizations to fund the provision and distribution of treatment
kits and other international organizations to assist on
training frontline clinicians on how to use the drug [8].

Study Setting
Nigeria is located in West Africa and is Africas most
populous nation with a population of 162.5 million people
[9]. The Nigerian Health system divides hospitals into
primary, secondary, and tertiary hospitals with referral
linkages between them. Patients with SPE/E are referred
from primary to secondary and tertiary health facilities for
management. Delays are common due to lack of transport,
bad roads, and sometimes lack of knowledge from the
patient and relations on the seriousness of the condition. In
addition, there is poor record-keeping of births, as they are
kept only at hospitals even though the NDHS showed that
only 35 % of deliveries take place in hospitals [10]. As
registration of births and deaths in the community are not
compulsory, health facility-based data are often all that is
available for research.
In addition, the federal system of government being
practiced in Nigeria divides levels of governance into three
distinct and independent entities, which are federal, state,
and local governments. Consequently, the health care
system is disintegrated along this model with tertiary
institutions being managed by the federal government,
secondary institutions by the state governments, and primary health care by the local government authorities, with
no formal connection between these levels of care [11]. As
a result, the care for pre-eclampsia and eclampsia, as for
other major obstetric emergencies, is not properly coordinated across these levels of service delivery. Furthermore,
the guideline of the Federal Ministry of Health in Nigeria
for managing eclampsia excludes lower-cadre service
providers in the management of the condition.
Nigeria has a high maternal mortality rate of 545 per
100,000 live births [10] with eclampsia as a major contributor. Studies in northern Nigeria showed that eclampsia
contributed 31.3, 46.4, and 43.1 % of all maternal deaths in
Kano [12], Nguru [13], and Birnin Kudu [14], respectively.
In contrast, eclampsia contributed 34.4 % of maternal

123

Matern Child Health J (2013) 17:11911198

deaths in Enugu in southern Nigeria [15]. The differences

in the contribution of eclampsia to maternal deaths could
be due to the culture of early marriage in northern Nigeria
and also delays in accessing care.
Kano is one of the states in the northwest of Nigeria.
The last Nigerian National census showed Kano as being
the most populous state in the country with a population of
9,401,288 [9]. Kano has a maternal mortality ratio (MMR)
of over 1,000 per 100,000 and a relatively high total fertility rate of over seven births per woman, with 45 % of
adolescents aged 1519 having already begun childbearing
and a modern contraceptive prevalence rate of less than
5 % [10]. Kano state has 35 general hospitals, offering free
maternity care funded by the government.
In 2007, the Population Council secured funding from
the MacArthur Foundation for the project. This followed a
baseline survey that showed that the drug used for the
treatment of SPE/E in all the 35 general hospitals was
diazepam. The survey also reviewed data from three general hospitals (Bichi, Wudil, and MMSH) to determine the
contribution of SPE/E to maternal deaths and its case
fatality rate prior to the introduction of MgSO4. The
baseline survey data covered the period January 1, 2007 to
December 31, 2007.

Materials and Methods

The data collection for the project started on February 1,
2008 and ended on January 31, 2009. In January 2008, one
doctor and one midwife from each of ten selected general
hospitals were invited to Kano, the state capital for training. The hospitals were selected on the basis of geographic
spread across the state, population, and high burden of
maternal deaths. The hospitals were at Kano, Bichi, Wudil,
Gwarzo, Rano, Minjibir, Tudun Wada, Doguwa, Rano, and
Rogo. Apart from Kano, the rest were rural towns. Also
invited for the training were five officials of the Hospitals
Management Board.
The facilities were spread across the entire state with
Kano metropolis at the center. The distance from each
facility to Kano where advanced life support exists ranges
from 42 km (Wudil) to 165 km (Doguwa), but since these
facilities receive referral from their surrounding clustered
primary health care (PHC) facilities, the average distance
from a particular PHC to its referral facility ranges from 15
to 30 km.
For this study, a pregnant woman was defined as having
pre-eclampsia if she had high blood pressure in the second
half of pregnancy of 140 mmHg systolic or more and/or
diastolic blood pressure of 90 mmHg or more with proteinuria (at least 2? of proteinuria using urine dipstick).
Features of severe preeclampsia included features of

Matern Child Health J (2013) 17:11911198

preeclampsia and symptoms of headache, blurring of

vision, vomiting and/or epigastric pain. Most of the hospitals did not have adequate laboratory facilities to enable
us to use laboratory markers to define severity. Any woman
who fitted and had features of preeclampsia was defined as
having eclampsia. However, across all the centers, severe
preeclampsia and eclampsia were treated similarly. This
involved administration of MgSO4, administration of
hydralazine (where the diastolic blood pressure was
110 mmHg or more), fluid management and then the
delivery of the patient through the fastest route. The latter
involves a Cesarean section where the woman was not in
labor and augmentation with oxytocin where the woman
was already in labor.
Two sets of trainings were conducted for the providers.
The first was the Training of Trainers (ToT) during
which 25 trainers were trained on the use of MgSO4. The
second was the step-down training conducted by the master
trainers at their respective health facilities. Both trainings
were similar.
The training was conducted over 2 days. The first day
involved didactic lectures on evidence-based management
of hypertensive disorders of pregnancy and how to use
MgSO4 including the detection and treatment of toxicity.
The participants were taught how to use MgSO4 by the
intramuscular (IM) route. For the purpose of the training,
the dose used was a loading dose of 4 g administered
intravenously followed by 10 g administered IM (5 g in
each buttock). This was followed by 5 g administered IM
every 6 h until 24 h after delivery or the last seizure.
Monitoring of toxicity was done by checking the deep
tendon knee reflex before administering each dose of
MgSO4.
To aid the training, a simple clinical protocol was distributed to the participants. The second day was used for a practical training at the 25-bed eclamptic ward of MMSH. There
was a demonstration of the use of sphygmomanometer to
detect hypertension and urinalysis for proteinuria. The participants practiced preparation of different dosages of magnesium sulphate and monitoring for toxicity. At the end of the
training, the participants were supplied the initial stock of
MgSO4 to take back to their hospitals, patella hammer (for
early detection of toxicity), and calcium gluconate (the antidote for toxicity). The trained health workers returned to their
hospitals and conducted step-down trainings. All the facilities
commenced the use of the drug after the step down training.
Data was then obtained from the ten health facilities on the
maternal sociodemographic characteristics, pattern of SPE/E,
and the fetomaternal outcomes. The data was obtained by
filling of structured forms by the attending health workers.
Relevant information that was captured includes patients
obstetrics demographic variables, fetal outcomes (dead or
alive) including APGAR score at 5 min, maternal outcomes

1193

(dead or alive) including complications, number of seizures

before presentation, recurrence of seizures while on MgSO4,
distance traveled before presentation, time lapse from onset of
seizures to presentation at facility, mode of delivery and
complications of MgSO4 administration. The forms were
collated monthly from the sites and analyzed at Kano. However, due to poor record keeping culture, obtaining highquality data was a challenge and some data were missing. Data
review meetings were held monthly at all the sites to
encourage the health workers to fill the forms properly. The
data collection improved over time.
The data were summarized with frequencies and percentages. The associations between the dependent variables
(eclampsia CFR and infant perinatal mortality) and the
independent variables were measured with odds ratio
(95 % CI) using binary logistic regression. To obtain the
significant correlates of the dependent variables while
controlling for the effect of each independent variable,
multivariate analyses were also conducted using binary
logistic regression. The analyses were done with SPSS 15
for Windows (SPSS Inc., Chicago, IL, USA).

Results
The baseline survey involving three general hospitals
showed that there were a total of 1,233 patients with SPE/E
of whom 258 died giving a baseline CFR of 20.9 % (95 %
CI 18.723.2).
Twenty-five master trainers were trained at the initial
training of trainers at Kano. They then trained 160 health
workers (doctors, midwives, and community health
extension workers) through step-down trainings at the ten
health facilities. There was universal acceptance of the
change though few health workers resisted the change and
there were initial difficulties with calculation of doses.
These challenges improved with time.
During the period of the project, a total of 49 severe preeclampsia and 996 eclamptic patients were treated at the
ten hospitals. There were 22,502 deliveries during the same
period. Table 1 summarizes the socio-demographic characteristics of the patients that had SPE/E. A majority
(51.5 %) of the patients were teenagers aged 1519 years
old. About 60 % of the patients were primigravida and
more than two-thirds (74 %) had no formal education. All
the patients were married and the majority (71.0 %) were
in a monogamous relationship.
More than half (56.9 %) of the patients presented at the
health facilities in less than an hour of eclampsia episode,
while a few others (23.3 %) presented after 3 h or more. A
majority (81.2 %) of the patients had at least a seizure
before their presentation at the health facilities. Also, 584
(55.9 %) of the patients had antenatal care.

123

1194

Matern Child Health J (2013) 17:11911198

Table 1 Socio-demographic characteristics of the patients that received MgSO4

Basic characteristics

Pre-eclampsia
(n = 49)

Eclampsia

Total
(n = 1,045)

(%)

Antepartum
(n = 322)
(%)

Intrapartum
(n = 430)
(%)

Postpartum
(n = 244)
(%)

(%)

1519

19 (38.8)

161 (50.0)

254 (59.1)

104 (42.6)

538 (51.5)

2024

19 (38.8)

94 (29.2)

137 (31.9)

81 (33.2)

331 (31.7)

2548

10 (20.4)

62 (19.3)

35 (8.1)

51 (20.9)

158 (15.1)

Unknown

1 (2.0)

5 (1.6)

4 (0.9)

8 (3.3)

18 (1.7)

30 (61.2)

195 (60.6)

311 (72.3)

95 (38.9)

631 (60.4)

15

13 (26.5)

110 (34.2)

106 (24.7)

135 (55.3)

364 (34.8)

[5

6 (12.2)

15 (4.7)

11 (2.6)

7 (2.9)

39 (3.7)

Unknown

2 (0.6)

2 (0.5)

7 (2.9)

11 (1.1)

Age (years)

Parity

Educational status
None

36 (73.5)

237 (73.6)

311 (72.3)

190 (77.9)

77 (74.1)

Nursery

3 (6.1)

18 (5.6)

12 (2.8)

9 (3.7)

42 (4.0)

Primary
Secondary/vocational

4 (8.2)
4 (8.2)

40 (12.4)
24 (7.5)

68 (15.8)
23 (5.3)

30 (12.3)
12 (4.9)

142 (13.6)
63 (6.0)

Tertiary

1 (2.0)

2 (0.6)

2 (0.5)

5 (0.5)

Unknown

1 (2.0)

1 (0.3)

14 (3.3)

3 (1.2)

19 (1.8)

Married
(monogamous)

37 (75.5)

222 (68.9)

315 (73.3)

168 (68.9)

742 (71.0)

Married (polygamous)

12 (24.5)

99 (30.7)

114 (26.5)

76 (31.1)

301 (28.8)

Unknown

1 (0.3)

1 (0.2)

2 (0.2)

Marital status

The commonest mode of delivery among the patients

was spontaneous vertex delivery (75.6 %), distantly followed by caesarean section (16.8 %), assisted vaginal
deliveries (2.3 %) and some few missing data (5.3 %).
Table 2 shows the fetomaternal outcomes. The CFR for
the patients treated with magnesium sulphate was 2.3 %
(95 % CI 1.53.5) as 24 of the 1,045 patients died. The
perinatal mortality was 12.3 % (CI 10.414.5) as 129 of the
1,045 mothers delivered dead babies. The 5-min APGAR
score for 72.9 % of the babies was 7 or more.
Further analysis was done to determine factors associated with maternal mortality, as shown in Table 3. The
significant measures of association showed that the CFR
was five times significantly higher among the patients with
parity of seven or more children than among the nulliparous and six times higher among the patients that had
recurrent seizures after the loading dose than among the
patients that had none.
Factors associated with perinatal mortality are shown in
Table 4. Perinatal mortality was significantly higher among
the patients that had three or more seizures before presentation than among those that had no seizures at

123

presentation; the prevalence significantly increased with

increasing number of seizures before presentation. Similarly, perinatal mortality was about three times higher
among the patients that had recurrent seizures after the
loading dose than among those who had no recurrent seizures and four times higher among the patients that had
assisted breech delivery than those that had spontaneous
vaginal delivery.

Discussion
The case fatality rate for SPE/E was reduced from 20.9 %
(prior to the intervention) to 2.3 % (after the intervention).
This finding shows that MgSO4 has a great role to play in the
reduction of maternal deaths. Reduction of deaths among
mothers treated with MgSO4 compared to those treated with
diazepam has been reported from a center in southeastern
Nigeria [16]. Promoting, disseminating, and implementing
use of magnesium sulphate has been recognized as the most
important action to reduce maternal deaths from eclampsia
[17]. However, what is more important is that it was

Matern Child Health J (2013) 17:11911198

1195

Table 2 Clinical outcomes of the pregnancies after the administration of the MgSO4
Clinical outcomes

Pre-eclampsia (n = 49)

Eclampsia

Total (n = 1,045)

(%)

Antepartum (n = 322)
(%)

Intrapartum (n = 430)
(%)

Postpartum (n = 244)
(%)

(%)

Apgar score at 5 min

0

1 (0.2)

15 (4.7)

27 (6.3)

13 (5.3)

56 (5.4)

16
7

0
3 (6.1)

11 (3.4)
38 (11.8)

32 (7.4)
84 (19.5)

7 (2.9)
12 (4.9)

50 (4.8)
137 (13.1)

21 (42.9)

105 (32.6)

138 (32.1)

39 (16.0)

303 (29.0)

12 (24.5)

70 (21.7)

90 (20.9)

26 (10.7)

198 (18.9)

C10

3 (6.1)

26 (8.1)

32 (7.4)

63 (25.8)

124 (11.9)

Unknown

9 (18.4)

57 (17.7)

27 (6.3)

84 (34.4)

177 (16.9)

Dead

2 (4.1)

49 (15.2)

53 (12.3)

25 (10.2)

129 (12.3)

Alive

40 (81.6)

250 (77.6)

373 (86.7)

210 (86.1)

873 (83.5)

Unknown

7 (14.3)

23 (7.1)

4 (0.9)

9 (3.7)

43 (4.1)

Dead

1 (2.0)

9 (2.8)

8 (1.9)

6 (2.5)

24 (2.3)

Alive

43 (87.8)

289 (89.8)

420 (97.7)

231 (94.7)

983 (94.1)

Unknown

5 (10.2)

24 (7.5)

2 (0.5)

7 (2.9)

38 (3.6)

Fetal outcome

Maternal outcome

introduced in an area where it was not previously available

and this can be replicated in other areas especially in
developing countries. This was a relatively easy intervention
involving training health workers and providing the necessary tools for them to practice what they learned. Yet, it had a
huge impact in reducing maternal deaths. Introduction of
similar interventions in developing countries could help in
the attainment of the MDGs.
Despite the successful reduction in CFR for SPE/E,
there were several factors that were identified to be contributory to the recorded deaths. Analysis of these factors
helps in further reducing maternal deaths. In this study,
most cases were seen in primigravida, especially teenagers.
This finding is similar to that from other studies [13, 14].
This group of patients need to be targeted in any program
aimed at preventing SPE/E. Antenatal care is an opportunity for detecting preeclampsia through monitoring of
blood pressure and detection of proteinuria. There is a need
to improve the quality of the antenatal care. It is a common
scenario in the hospitals under the study to observe one or
two nurses conducting antenatal care to 200400 patients
in a single day. Task-shifting has been advocated to mitigate the lack of health workers. Tasks can be delegated to
non-physician clinicians, medical assistants, nurses, and
community health care workers [18].
To prevent eclampsia, it is necessary to first diagnose
pre-eclampsia using routine blood pressure and urine protein testing of all women [19]. Those that have preeclampsia can then be treated with anti-hypertensives and
delivered early. Antenatal care also presents an opportunity

for instituting current evidence-based, possibly preventive,

strategies to those at risk in the form of low-dose aspirin
and calcium supplementation. Aspirin is associated with a
1019 % reduction in pre-eclampsia risk and a 1016 %
decrease in perinatal morbidity and mortality [20]. At least
1 g of calcium supplementation is also associated with
reduction in preeclampsia in those with low dietary calcium [21]. There is also a need for community health
education on the importance of antenatal care.
The finding also that most of the patients with eclampsia
had at least a seizure at home means there is a need to
educate the patients on warning symptoms of eclampsia
such as headache, blurring of vision, and epigastric pain.
Among those that had eclampsia, more deaths were
recorded in those of high parity ([7) and those who had a
seizure after the loading dose. These groups of patients are
those in whom there could be other underlying pathologies
apart from eclampsia. These characteristics are those of
patients in whom a clinical search needs to be conducted
for other underlying causes for the seizures. In these cases,
however, this was not done, due to a lack of facilities.
The stillbirth rate in this study was 12.3 % (CI 10.414.5).
Unfortunately, there was no baseline perinatal mortality for
comparison. However, the finding is much lower than the
35.3 % stillbirth rate reported from another center using
diazepam [22], even though other studies show that magnesium sulphate has no impact on stillbirth rates [23]. The
factors associated with perinatal mortality were recurrent
seizures fits after the loading dose, those delivered by
assisted breach delivery than among the patients that had

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Matern Child Health J (2013) 17:11911198

Table 3 Factors associated with eclampsia CFR

CFR (95 % CI)

COR (95 % CI)

AOR (95 % CI)

Age (years)
1519 (ref)

1.5 (0.5, 2.6)

1.00

1.00

C20

3.4 (1.8, 5.1)

2.27 (0.96, 5.35)

1.46 (0.40, 5.42)

0 (ref)

1.6 (0.6, 2.6)

1.00

1.00

15

2.9 (1.1, 4.6)

1.79 (0.74, 4.35)

1.14 (0.31, 4.17)

C6

8.6 (0.8, 18.0)

5.66 (1.49, 21.59)

4.99 (0.77, 32.22)*

Married, monogamous (ref)

1.7 (0.7, 2.6)

1.00

1.00

Married, polygamous

4.3 (1.9, 6.7)

2.67 (1.18, 6.01)

2.97 (0.82, 10.79)

Parity

Marital status

Educational status
None (ref)

2.4 (1.3, 3.5)

1.00

1.00

Primary

2.9 (0.1, 5.7)

1.20 (0.40, 3.59)

1.18 (0.23, 6.23)

Secondary/higher

3.0 (1.1, 7.2)

1.26 (0.29, 5.55)

1.00 (0.12, 8.25)

Antenatal care
Attends (ref)

1.8 (0.7, 2.9)

1.00

1.00

Does not attend

3.3 (1.6, 5.1)

1.91 (0.84, 4.35)

0.57 (0.15, 2.13)

B2 (ref)

1.3 (0.3, 2.3)

1.00

1.00

C3

2.9 (1.3, 4.4)

2.26 (0.85, 6.01)

2.19 (0.63, 7.55)

Number of fits before presentation

Distance (km) traveled before presentation

\1 (ref)

2.1 (0.6, 3.5)

1.00

1.00

C1

2.2 (1.1, 3.3)

1.08 (0.45, 2.60)

0.26 (0.05, 1.33)

\1 (ref)

1.5 (0.5, 2.5)

1.00

1.00

C1

3.1 (1.4, 4.7)

2.10 (0.89, 4.96)

2.95 (0.63, 13.66)

Time (h) before presentation

Recurrent fits after administering the loading dose

No (ref)
1.8 (0.9, 2.6)

1.00

1.00

9.2 (2.1, 16.3)

5.54 (2.10, 14.58)

7.65 (1.62, 36.03)*

SVD

1.8 (0.9, 2.7)

0.78 (0.25, 2.39)

0.77 (0.19, 3.09)

CS (ref)

2.3 (0.1, 4.5)

1.00

1.00

AVD

4.2 (4.0, 12.3)

1.86 (0.20, 17.36)

2.58 (0.16, 41.52)

Pre-eclampsia (ref)

2.3 (2.2, 6.7)

1.00

1.00

Eclampsia

2.4 (1.4, 3.4)

1.05 (0.14, 7.97)

0.59 (0.04, 8.94)

B6

2.6 (0.3, 4.9)

1.87 (0.56, 6.22)

1.16 (0.18, 7.56)

717

3.0 (1.4, 4.6)

2.08 (0.78, 5.53)

1.13 (0.25, 5.01)

18 (ref)

1.5 (0.3, 2.7)

1.00

1.00

Yes
Mode of delivery

Condition

Total ampoules of MgSO4 received

COR crude odds ratio, AOR adjusted odds ratio

* Significant at p \ 0.05

spontaneous vaginal delivery, and those that had seizures

before presentation. The first factor is also associated with
maternal deaths, which invariably affect the baby. Those
who had breech delivery had a higher mortality probably
because of the extra manipulation needed to deliver these

123

babies. Those mothers who had both breech presentation and

eclampsia were more likely to have an improved outcome
with a primary Cesarean delivery. The last factor implies
some delays from the mother before accessing care, in which
case the baby is invariably affected.

Matern Child Health J (2013) 17:11911198

1197

Table 4 Factors associated with perinatal mortality

Factors

Perinatal mortality % (95 % CI)

Adjusted OR (95 % CI)

Marital status
Married monogamous

10.6 (8.6, 13.1)

1.00

Married polygamous

16.3 (12.4, 21.1)

1.17 (0.72, 1.92)

Antenatal care
Attends

10.1 (7.8, 12.9)

1.00

Does not attend

14.6 (11.5, 18.3)

0.88 0.55, 1.42)

Recurrent fits after MgSO4 loading dose

No

11.4 (9.5, 13.6)

1.00

Yes

27.7 (17.3, 40.2)

2.64 (1.25, 5.54)*

CS
SVD

8.5 (4.8, 13.7)

12.4 (10.2, 15.0)

1.00
1.24 (0.65, 2.36)

ABD

29.2 (12.6, 51.1)

3.48 (1.12, 10.91)*

Mode of delivery

Number of fits before presentation

0

3.7 (1.0, 9.1)

12

10.4 (7.6, 14.1)

1.00
3.02 (0.90, 10.20)

34

13.4 (9.9, 17.9)

3.69 (1.09, 12.48)

C5

17.9 (12.4, 24.5)

5.70 (1.63, 19.93)*

Time before presentation (h)

\1

9.7 (7.5, 12.5)

C1

16.3 (13.0, 20.2)

1.00
1.04 (0.65, 1.68)

COR crude odds ratio, AOR adjusted odds ratio, CS Cesarean section, SVD spontaneous vaginal delivery, ABD assisted breech delivery
* Significant values at p \ 0.05

The limitation of this study is that of missing data which

arose from incorrectly filled forms or even failure to complete the forms in some cases. Also, the study assumes that all
patients received the standard dosage of the drug as the health
workers were taught in the training. As the health workers
also fill the forms, our assumptions could be wrong. In
addition, the study was conducted in an area where women
prefer to deliver at home. It is possible that a majority of
women with this condition are not reflected in this study,
although there is a tendency that even such women will come
to the hospital when complications such as SPE/E develop.
In conclusion, this study clearly shows that the introduction
of magnesium sulphate usage for SPE/E using this low-cost
replicable intervention had a positive impact on both maternal
and fetal morbidity and mortality. The state government
should make the project sustainable on withdrawal of donor
support so that the patients can continue to reap the benefits.
Conflict of interest

None declared.

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