A Policy Lab held in Sierra Leone brought together clinicians, researchers, key stakeholders from government and communities to collaborate in providing improved care and clinical outcomes for pregnant women with pre-eclampsia and their babies.
The Ministry of Health and Sanitation, the University of Sierra Leone in collaboration with King’s College London and Welbodi Partnership hosted a ground-breaking Policy Lab on 7th March 2023, in Freetown, to address the question “How can we improve timely detection and appropriate action in women presenting to health facilities with pre-eclampsia?”
Background:
Pre-eclampsia is the 2nd leading cause of Maternal death in Sierra Leone. It can also lead to stillbirth and growth restriction in the baby. There is no definitive treatment for pre-eclampsia except delivery. Timely detection, to enable appropriate action (anti-hypertensives, anticonvulsants & delivery), is critical in order to minimise adverse maternal outcomes.
However, diagnosis is challenging in low-income countries where blood pressure devices & other equipment is limited. Hence the need to develop new ideas and approaches to improve outcomes and strategise about implementable solutions.
Evidence:
• CRADLE vital signs alert (VSA) is an accurate, validated tool for measurement of blood pressure (BP) & heart rate (HR) in pregnant women, with a traffic light alert system to prompt further action.
• CRADLE-3 trial: Use of CRADLE VSA has been associated with reduced maternal mortality & morbidity, including eclampsia in Sierra Leone.
• CRADLE-4 trial: Planned early delivery improves maternal outcomes & significantly reduces stillbirth (by 75%) for women with late preterm pre-eclampsia (34 to 37 weeks’ gestation) in LMICs.
• Since the CRADLE 3 study when the CRADLE VSA device was first introduced to Sierra Leone in 2017, CRIBS has now achieved national scale up of the CRADLE device (the first country in the world to do so), with 4969 CRADLE devices distributed countrywide, 1386 health facilities targeted and 4853 healthcare workers trained. During this timeframe of less than 5 years, Maternal Mortality Ratio (maternal deaths per 100k live births) in Sierra Leone have reduced from 1120/100 000 to 443/100 000 (WHO data), which is lower than the West African average of 753/ 100 000. This represents one of the largest falls in the world.
• Cradle 5: CRIBS has now achieved national scale up of the CRADLE device in 1700 units, that allows for wide-spread accurate, systematic detection of pre-eclampsia.
Aim of the Policy Lab:
The overarching aim of the policy lab was to bring together researchers, clinicians, key representatives from government & communities to consider how the above research-based evidence can be translated into policy which leads to improved care and clinical outcomes of women with pre-eclampsia and their babies.
Who was there?
The 39 participants who attended the policy lab were a diverse group of stakeholders who interacted engagingly and added to the richness of the discussions. They included among others
• Government members, programme managers,
• NGO project leaders, and
• Academics (from University of Sierra Leone, King’s College London and Zambia (Minister of Reproductive Health and Professor of Obstetrics)
• Health care workers, including community health workers, nurses, midwives, clinical officers and senior obstetricians and paediatricians.
• Community representatives, including an Imam, Christian Religious leader, traditional healer, and civil society leaders.
The Policy lab workshop consisted of group discussions and feedback sessions which overflowed and continued long into the evening, as a result of the lively engagement, passion and commitment of the participants to the topics discussed. Groups devised tailored interventions as solutions to the policy lab questions, and these included (to name but a few):
1) A dedicated, specialised ‘Centre for Pre-eclampsia’ Care, to provide expert care to women suffering from the condition.
2) Public health education campaign, to integrate Pre-eclampsia education into school and university curriculums, after school clubs and religious forums.
3) Personal action points – to encourage each individual to take ownership of the problem.
Anticipated outputs:
The Policy Lab brief is to be shared with participants and used for widespread dissemination, with support from the KCL Policy Institute.
A technical working group, (consisting of 15 participants who signed up on the day) plans to develop and strategize on the way forward for selected interventions discussed at the lab.
There was also a commitment to create a publication in a peer reviewed journal.
Participants of the Policy Lab has this to say about the process:
“The group was dynamic and you had these multi-disciplinary and diverse groups. There were interesting conversations generated. People were focused. They didn’t want to leave their group discussions because there was a lot of interest. They have acknowledged that it was timely and important and will continue to work on it. Hopefully the momentum will continue.” – Sister Betty Sam, Lead Facilitator of the Policy lab, Midwife with Welbodi
“I am a religious leader and community stakeholder. This is my first time attending this kind of workshop. I learnt more about pre-eclampsia. It allows us to take it back to our community and large congregations so that our pregnant women and other community members are encouraged to attend antenatal care. This will reduce pre-eclampsia and maternal mortality. Our role as religious leaders is to compliment health services. After today I will take this information away and preach it at to church services” Reverend Daniel Sesay, local religious leader
“My thought is that it was a very good activity. What I think is important is to be concrete in the actions we want to take after the Policy Lab. One of the things that comes to mind is revise the existing policies on hypertension. With the new research available we should be able to improve outcomes. It should be taken away and put into action”. Dr Angel Mwiche, Director of Reproductive Health, Ministry of Health, Zambia
“I am bowled over by the untethered enthusiasm we witnessed today. There is a real passion to make a difference. I think what we achieved today will be the start of several initiatives.” Professor Andrew Shennan, KCL
“The policy lab brought together a diverse group of stakeholders who wouldn’t normally sit in a room and discuss maternal health or any other topics. Our 39 participants commented on this, and said that it was novel, and made them think about things from different perspectives. In fact, they complained that the group breakout sessions weren’t long enough. It was a privilege to share a day with such a motivated, spirited group of people, from different walks of life, but united in a common goal, to reduce maternal mortality from pre-eclampsia, the second leading cause of maternal death in Sierra Leone. Now the work begins, to translate the multiple policy lab outputs into sustainable clinical impact.” Dr Katy Kuhrt, KCL