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Health care provider knowledge and routine management of pre-eclampsia in Pakistan Sheikh, Sana; Qureshi, Rahat N; Khowaja, Asif R; Salam, Rehana; Vidler, Marianne; Sawchuck, Diane; von Dadelszen, Peter; Zaidi, Shujat; Bhutta, Zulfiqar Sep 30, 2016

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RESEARCH Open AccessHealth care provider knowledge androutine management of pre-eclampsia inPakistanSana Sheikh1, Rahat Najam Qureshi1*, Asif Raza Khowaja1,2, Rehana Salam1, Marianne Vidler2, Diane Sawchuck3,Peter von Dadelszen4, Shujat Zaidi1, Zulfiqar Bhutta1,5 and the CLIP Working GroupAbstractBackground: Maternal mortality ratio is 276 per 100,000 live births in Pakistan. Eclampsia is responsible for one inevery ten maternal deaths despite the fact that management of this disease is inexpensive and has been availablefor decades. Many studies have shown that health care providers in low and middle-income countries have limitedtraining to manage patients with eclampsia. Hence, we aimed to explore the knowledge of different cadres ofhealth care providers regarding aetiology, diagnosis and treatment of pre-eclampsia and eclampsia and currentmanagement practices.Methods: We conducted a mixed method study in the districts of Hyderabad and Matiari in Sindh province,Pakistan. Focus group discussions and interviews were conducted with community health care providers, whichincluded Lady Health Workers and their supervisors; traditional birth attendants and facility care providers. In totalseven focus groups and 26 interviews were conducted. NVivo 10 was used for analysis and emerging themes andsub-themes were drawn.Results: All participants were providing care for pregnant women for more than a decade except one traditionalbirth attendant and two doctors. The most common cause of pre-eclampsia mentioned by community health careproviders was stress of daily life: the burden of care giving, physical workload, short birth spacing and financialconstraints. All health care provider groups except traditional birth attendants correctly identified the signs,symptoms, and complications of pre-eclampsia and eclampsia and were referring such women to tertiary healthfacilities. Only doctors were aware that magnesium sulphate is recommended for eclampsia management andprevention; however, they expressed fears regarding its use at first and secondary level health facilities.Conclusion: This study found several gaps in knowledge regarding aetiology, diagnosis and treatment ofpre-eclampsia among health care providers in Sindh. Findings suggest that lesser knowledge regardingmanagement of pre-eclampsia is due to lack of refresher trainings and written guidelines for management ofpre-eclampsia and presentation of fewer pre-eclamptic patients at first and secondary level health care facilities.We suggest to include management of pre-eclampsia in regular trainings of health care providers and to providemanagement protocols at all health facilities.Trial registration: NCT01911494Keywords: Community health services, Eclampsia, Health personnel, Pre-eclampsia, Community health worker,Pregnancy, Pakistan(Continued on next page)* Correspondence: rahat.qureshi@aku.edu1Division of Women & Child Health, Aga Khan University, Karachi, PakistanFull list of author information is available at the end of the article© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe 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.The Author(s) Reproductive Health 2016, 13(Suppl 2):104DOI 10.1186/s12978-016-0215-z(Continued from previous page)Abbreviations: CLIP, Community level intervention for pre-eclampsia; LHS, Lady health supervisor; LHVs, Ladyhealth visitors; LHWs, Lady health workers; LMIC, Low and middle-income countries; TBA, Traditional birthattendants; WHO, World Health Organization; WMO, Women medical officerPlain english summaryHigh blood pressure in pregnancy is one of the majorthree causes of maternal deaths in Pakistan. Different re-search studies have shown that health care providers havelimited knowledge regarding management of these pa-tients. In this study we explored knowledge of communityand hospital based health care providers regarding causes,complications and treatment of the disease. Doctors, LadyHealth Workers, Lady Health Supervisors and traditionalbirth attendants were interviewed in groups and one toone in Sindh province. Along with interviews Lady HealthWorkers were also asked to fill a questionnaire to assesstheir competency and knowledge. Study found that com-munity based health care providers consider stress andphysical work load a cause of high blood pressure. Onlydoctors were aware of the first line medicine to treatsevere cases of high blood pressure in pregnancy but theywere concerned regarding the safety of drug to be used insmall health facilities. Regular trainings of care providersare required to improve their knowledge and practices todeal with pregnant women with high blood pressure.BackgroundPre-eclampsia is defined as development of new hyperten-sion in pregnancy along with significant proteinuria occur-ring after 20 weeks of gestation [1]. It is a multisystemdisorder that may affect the liver, kidney and clotting inpregnancy, as well as potential fetal growth restriction andpremature delivery [1]. Eclampsia is a complication ofpre-eclampsia defined as the new onset of grand malseizure(s) and/or unexplained coma during pregnancy orpostpartum in a woman with pre-eclampsia [2]. Eclampsiais responsible for one in ten maternal deaths, and claims2000 maternal lives every year, in Pakistan [3, 4].Several multicounty trials [5, 6] and systematic reviews[7] have proved that MgSO4 is an important agent in themanagement of severe pre-eclampsia and eclampsia. TheWorld Health Organization (WHO) stated that MgSO4is the first line drug for treatment of pre-eclampsia andeclampsia more than a decade ago [8] and Pakistan in-cluded MgSO4 in the national essential drug list in 2007[9]. However, these efforts have not translated into prac-tice and a large number of women continue to sufferfrom pre-eclampsia and eclampsia without receiving life-saving treatment.In Pakistan, the health care system is comprised ofboth formal and informal sectors. Formal system in-cluded public and private health facilities. Pakistan’spublic health system is centralised under the FederalGovernment and Provincial Health Ministries; and com-prises of primary, secondary and tertiary health centres.Primary care facilities include 5000 Basic Health Units,560 Rural Health Centres, 900 Maternal and ChildHealth centres and large number of dispensaries andfirst aid posts. Secondary level centres include 900Taluka and district level hospitals. Tertiary health care isdelivered through 30 teaching hospitals [10].Lady Health Workers (LHWs) and Lady HealthVisitors (LHVs) are deployed as community-based healthcare workers in the home and primary health centres[10]. Doctors and nurses are deployed at all levels ofhealth care facilities. The private sector consists of a fewaccredited tertiary level hospitals and a large number ofnon-accredited tertiary, secondary and primary clinicsand hospitals both in urban and rural areas. The infor-mal health care system is led by non-certified localhealth care providers, such as traditional birth atten-dants (TBA), spiritual healers, and Hakeems (practitionerof Unani/Greek medicine). The informal health care sys-tem is patronised by many as treatment is affordable,available within the local community, and in-line withtraditional and cultural beliefs [11].Studies from other low and middle-income countries(LMIC) reported that contrary to WHO guidelines, womenwere not regularly screened for high blood pressure duringantenatal care [12]. Literature from the developing worldhas also reported that various cadres of health careproviders (doctors, nurses, midwife, and community careproviders) have limited knowledge regarding screening andmanagement of pre-eclampsia [13–15].The limited knowledge of health care providers likelyplays a role in the slow reduction in maternal morbidityand mortality due to pre-eclampsia in developingcountries, such as Pakistan. Hence, we explored the know-ledge of different health care providers regarding pre-eclampsia and eclampsia and their current managementpractices in rural Sindh, Pakistan.Study areaThis study was conducted in Matiari and Hyderabad,which are two districts of Sindh province. Sindhi is themost common language of both districts. Hyderabad hasa population of 4.5 million of which 60 % live in urbanareas, it is second most urbanised district of Sindh afterKarachi [16]. Matiari district is located 250 km north ofKarachi, with a population of 0.6 million. The area isThe Author(s) Reproductive Health 2016, 13(Suppl 2):104 Page 108 of 162largely agricultural and development indicators arerepresentative of rural Sindh [17] (Table 1).MethodsThe Community Level Intervention for Pre-eclampsia(CLIP) study is a cluster randomized trial which is beingconducted in two districts of Sindh Pakistan(NCT01911494). Before implementation of the trial, afeasibility study was conducted to evaluate barriers andfacilitators of providing emergency treatment incommunity to women who are at high risk of severepre-eclampsia. Lady Health Workers were chosen to de-liver this intervention to pregnant women as they are re-sponsible to provide antenatal care at home in ruralareas. Intervention package includes triage and screeningof pregnant women for risk of severe PE/E, administer-ing oral antihypertensive and MgSO4 (if required) andreferral. It was important to understand the existingpractices and knowledge of health care providers regard-ing PE/E. We evaluated health care providers involved inmaternal care whether they were community based(LHW, LHS, TBAs) or health facility based (Doctors).The feasibility assessment utilized mixed methods [18].and intervention implementation plan was modified ac-cording to the findings of the feasibility study.Qualitative componentThe qualitative research team organised the conduct offocus groups and interviews. Gender specific staff wasallocated with respect of local culture and tradition. Pro-ject staff were locally recruited and trained by a seniorfaculty and a social scientist with first-hand knowledgeand expertise in qualitative research. Each focus groupwas conducted in the local language by one facilitator,two note takers, an observer and all discussions wereaudio-recorded. Observers documented field notes tocapture verbal and non-verbal communication in sup-port of the documented text. In addition, the facilitatorscompleted a self-reflection after each session to describetheir thoughts and impressions to better contextualizethe data, as well as, to protect against self-bias. Qualitycontrol was ensured through random observation offocus groups by the field co-ordinator, and an audit-trailof 20 % of transcripts. The audit-trail process includedverifying content of transcripts with audio-recordings,and bi-weekly debriefing sessions with moderators andtranscribers. The field staff then transcribed the data inSindhi based on the audio recordings. The qualitativedata was analyzed in Sindhi using NVivo version 10[QSR, Doncaster Vic, Australia] to develop the themesand subthemes from an ethnographic approach.The desired number of FGDs and KIIs were deter-mined through response saturation and data collectionwas stopped when data saturation was reached at eachsite. Data Saturation was reached after 26 in-depth inter-views and seven focus groups discussions. Participantswere eligible if they consented to participate in studyand were available for at least 60 min for the interviewor discussion (Table 2).Quantitative componentEligible participants were identified with the help of localcommunity health workers and research medical officersduring health facility visits. Written consent was ob-tained from all participants prior to data collection.A self-administered questionnaire was completed by457 LHWs, all questions were designed using a Likertscale (strongly disagree to strongly agreeThe knowledgeof LHWs regarding pre-eclampsia was evaluated by a setof questions pertaining to their ability to identify dangersigns of hypertension and seizures in pregnancy. Theircurrent practice of referral and skills to administer drugswere also evaluated.This study received ethical approval from Ethics ReviewCommittee of Aga Khan University, Karachi, Pakistan;National Bioethics Committee of Pakistan and InstitutionalReview Board of University of British Columbia, VancouverCanada.ResultsAmong health care providers who participated, all wereproviding care to 3–5 pregnant women daily for morethan a decade, except one TBA and two doctors. Six outof nine women medical officers (WMO) were providingcare at the primary and secondary level public healthTable 1 Comparison of population characteristics of SindhProvince with country estimatesPopulationcharacteristicsProvincial estimates [28] National estimates [5]% of women receivedskilled antenatal care78 73% of deliveries attendedby skilled birth attendant60 52% of population coveredby Lady Health Workers45 [29] 65 [30]Table 2 Health care provider interviews and focus groupsHealth care providers Method Total number ofinterviews/discussionsTotal numberof participantsWomen MedicalOfficer/GynaecologistInterview 9 9Lady HealthSupervisorInterview 10 10Traditional BirthAttendantInterview 7 7Lady Health Worker FocusGroup7 64The Author(s) Reproductive Health 2016, 13(Suppl 2):104 Page 109 of 162facilities. About 6 pre-eclampsia or eclampsia patients(range 0–100 in last 12 months) were received by (WMO)in last 12 months. TBAs did not report encountering anywomen with pre-eclampsia in the last year. According toLady Health Supervisors (LHS) on average 3 women withpre-eclampsia are reported to them per year by LHWs.Knowledge regarding pre-eclampsia aetiology andconsequencesHealth care providers of all cadres reported that anormotensive woman can develop hypertension later inpregnancy which can lead to problems for mother andbaby. Common reasons for pre-eclampsia mentioned bycommunity-based health care providers (LHW, LHS andTBAs) were stress of daily life which included burden ofcare giving, physical workload, short birth spacing andfinancial stresses.“She looks after the children and again she getspregnant. She has no such stamina (strength) to dealwith the problems and that is the reason she also getsirritated, sometimes because of children, sometimesbecause of family problems and sometimes cause isfinancial problems. She starts thinking lot and her B.Pstarts to rise up”. (Focus group with LHWs)In addition, anaemia was mentioned as a risk factor byalmost all community-based health care providers. Allparticipant groups, except TBAs, correctly identifiedcomplications of pre-eclampsia: antepartum haemor-rhage, premature delivery, stroke, brain haemorrhage,decreased fetal movements, and restricted fetal growth.Doctors, LHWs and their supervisors were aware thatseizures occur as a consequence of hypertension. Similarresult was found through survey of LHWs where 84.5 %(386/457) LHWs strongly agreed that seizure is a dangersign of pregnancy and 83.6 % (382) strongly agreed forbleeding as a danger sign. See Additional file 1: Table S2.TBAs were not aware of other harmful effects of diseaseand considered seizures to be directly related to stressand physical weakness.“One cause of seizures is that they are pregnant andthe other cause is that she is anemic and stressedout.”(Interview with a TBA)All health care providers were aware that pre-eclampsiacould result in miscarriage or death.“When blood pressure increases firstly it is dangerousfor the mother, the mother can also die, even the babycan die, it can affect the mother in anyway, she canhave paralysis, because of high blood pressureparalysis can occur.” (Focus group with LHWs)Diagnosis and referral of pre-eclampsiaKnowledge for identifying a patient with pre-eclampsiavaried greatly among different set of care providers.Doctors were the most knowledgeable group. They wereaware that hypertension and proteinuria constitutes pre-eclampsia and these women require regular monitoring.“If the woman is pre-eclamptic, we will tell them tovisit us every 15 days. She should get her blood pres-sure checked and she should take medicines on time.”(Interview with a WMO)Doctors working at first and second level health facil-ity reported refering patients to tertiary facilities Thereasons for referral of these patients included limitedavailability of support staff (nurses, midwives, LHVs),monitoring equipment and medicines required tomanage severe pre-eclampsia or eclampsia.“When she comes with eclampsia and if she is havingseizures then we refer her because in our health centrewe don’t have facility for C-section. If she is not in agood condition and is having seizures, we try to get herdelivery done soon as possible. If she is not able tohave normal vaginal delivery then we refer her.”(Inter-view with a WMO)LHWs and LHSs mentioned that they refer patients tohealth facilities if there are any danger signs during preg-nancy. Pregnant women are also reportedly referred ifthere is sudden increase in weight or oedema, reducedfetal movements, vertigo or blurred vision. This findingwas supported by quantitative assessment of LHWswhere 42.9 % (96) reported receiving trainings to identifycomplications in pregnancy and 51 % (233) mentionedtraining to refer and manage these patients. ManyLHWs (79 %; 361) reported referring pregnant womenin their routine practice. See Additional file 1: Tables S2and S3.“Vomiting more than 3 months, slowly oedema starts,headache, having fever, bleeding during pregnancythen in that condition we refer to heath facility.”(Focus group with LHWs)Focus groups with TBAs revealed that the elder TBAswere critical of orthodox medicines and vaccines, andconsider them harmful in pregnancy. Some of theseTBAs mentioned that they referred women for vertigoor pain, but that this is due malnutrition and anaemia.Few young TBAs participated, though they appeared tobe more aware of the serious consequences of hyperten-sion in pregnancy and the importance of early referral insuch cases.The Author(s) Reproductive Health 2016, 13(Suppl 2):104 Page 110 of 162“We tell them that you must go for monthly orfortnightly check-ups to any good health facility whichis in vicinity; go there and get your check-up.” (Inter-view with a TBA)TBAs commonly referred pregnant women when theyconsider vaginal delivery will be difficult (e.g. cephalo-pelvic disproportion, breech presentation) or when com-plications occur during delivery (obstructed labour, post-partum haemorrhage, decreased fetal movements). Theyalso referred women for seizures; this was done becausethey believed it delays descent/delivery of baby. It wasapparent from their responses that TBAs were not awareof the signs and symptoms of pre-eclampsia, and so re-luctant to refer patients unless safe delivery at home isnot possible,“Bone is short or large; (delivery) path is clear or not.Then we refuse to take case and advise them to get herto the hospital.”“When we see that the fetal movements have stopped(in woman having fits), I ask the attendants to arrangethe car quickly”. (Interview with a TBA)When referral is required, TBAs preferred private fa-cilities because they are perceived to be better equipped.On the other hand, LHWs referred women to nearesthealth facility.“We will tell them to take her to the nearest hospitalor clinic as soon as possible.” (Focus group with LHWs)Management of pre-eclampsiaThis study found huge gaps in the knowledge of treat-ment for pre-eclampsia among all cadres of health careproviders. Doctors were aware of use of antihypertensivedrugs for hypertension and MgSO4 as the first line foreclampsia but there were several misperceptions regard-ing the use of MgSO4. The most common misconcep-tion was fears of MgSO4 toxicity and the need for anintensive care unit for these women. The findingsshowed that doctors did not recognise the role ofMgSO4 in reducing risk of morbidity and mortality ifadministered earlier. Hence patients are referred to ahigher facility untreated or diazepam was given to con-trol seizures. Doctors also reported that there was noguidelines available treatment of pre-eclampsia, exceptone doctor who was working in a private secondaryfacility.“No (we do not use), because it (MgSO4) is not used atdispensary level.”“MgSO4 we don’t give here because we need a separatedoctor to manage it.”“We monitor the blood pressure, and try to refer theeclamptic woman to the Civil Hospital as early aspossible.” (Interview with a WMO)All doctors except one senior doctor, with greater than25 years of experience, expressed a desire to learn moreregarding the management of pre-eclampsia and arguedthere was a need for related guidelines. Participantsstated that they infrequently encounter pre-eclampsia;therefore, they are not confident in managing thesecases.Among community-based health care providers theknowledge was increasingly limited. None of the TBAsand very few LHWs had ever heard of MgSO4. AllLHWs were aware that hypertension and seizures needmedical treatment and women should seek care at healthfacility but could not name any medications whichshould be given. However, 131 (28.7 %) LHWs reportedthat they can measure BP and 30 (6.6 %) had a BP de-vice. See Additional file 1: Table S3. TBAs could notname antihypertensive medications, they could, however,describe their appearance (shape, colour or brand logo).TBAs mentioned that they do not treat hypertensivewomen themselves nor do they prescribe any medica-tion. However, they mentioned giving some of the medi-cines themselves which they might have learnt over timefrom interaction with doctors. In addition to medicinelow salt and low fat diet was advised by almost all TBAsand LHWs.“We give it (Aldomet) daily if BP is high. We advise ittwice a day or daily at night. The patient must eatdaily so that the patient’s blood pressure remainsnormal.” (Interview with a TBA)Only one TBA, who had 50 years of experience, re-ported giving alternative or traditional medicines (phakki)to control blood pressure.“We give 200, 250, grams Phakki, one spoon dailymorning she is advised to take.” (Interview with a TBA)Similar to doctors community-based providers haveseen few patients with eclampsia in their practice; there-fore, they were willing to learn more about the condi-tion, its risk factors, prevention and treatment.DiscussionThis study found gaps in knowledge among communityhealth care providers regarding causes of PE/E and itsmanagement. Health facility based care providers wereaware of the etiology and complications of the diseasebut there were misperceptions and limited knowledgeabout use of Magnesium sulphate.The Author(s) Reproductive Health 2016, 13(Suppl 2):104 Page 111 of 162Studies have reported a common community percep-tion that seizures of eclampsia are caused by supernat-ural forces [19] and the frequent use of herbal medicinedelays health care seeking [20]. Community based careproviders may not connect eclampsia and hypertension;however, none claimed to believe in evil charms orsupernatural causes for the seizures and use of alternatemedicine to treat eclampsia.Pre-eclampsia is a serious condition, but because ofthe relatively low prevalence of the disease careproviders had infrequent experience with these patients.This lack of exposure results in a reported lack of confi-dence in dealing with these patients. Pakistan hasincluded current global management principles of pre-eclampsia in skilled birth attendants and nurses trainings[21], but in this study health care providers expresseddesire for further training as they found currenttrainings insufficient. This finding is not consistent withBigdeli’s findings from Pakistan that health careproviders were satisfied with their training [14].Data from other LMIC showed a preference for diaze-pam in cases of eclampsia [22] but in this study onlytwo of the nine doctors mentioned regular use of diaze-pam. Despite prolific myths and fears related to MgSO4,no other drugs were preferred for treating eclampsia bythe providers interviewed. This finding is consistent withanother study on use of MgSO4 from Pakistan [14]. Thepreference for MgSO4 is very encouraging as use of di-azepam in eclampsia is harmful for both mother andbaby. Health care providers in this study commonlyreported referring women with pre-eclampsia andeclampsia prior to the administration of lifesaving treat-ment. Similar finding has been reported in literature[14]. Explanations for this practice in Pakistan and else-where were related to the misperception that MgSO4should only be used in tertiary level facilities [23]. Otherreasons MgSO4 was not administered were the lack ofwritten treatment and referral protocols. The lack ofclear guidelines to manage pre-eclampsia has been re-ported earlier as a barrier to health care provision at firstand secondary level [22].Other studies have also found that health care pro-viders at high level facilities had better knowledge ofpre-eclampsia [24, 25]. This might be due to more ex-posure of such cases and the availability of writtenprotocols.Strengths and limitationsSeveral studies have been published on barriers and fa-cilitators to use MgSO4 in LMICs [14, 15, 26, 27]. Thisstudy explores significant aspects of management of preeclampsia with respect to knowledge regarding disease,procedural ability, preference for use of drugs and clin-ical decision making of both skilled and unskilled careproviders. Qualitative methods gave an insight to themisperceptions related to the condition and its treat-ment as health care providers were free to express theirbeliefs, fears and experiences. TBAs are preferred birthattendants for many rural women so it was important toevaluate their level of understanding for the disease. Sofar literature published from Pakistan on PE/E manage-ment only assessed practice of skilled care providers.Limitation of the study is that it did not inquire partici-pants about management for severe pre-eclampsia andeclampsia separately therefore the study cannot deter-mine the knowledge of health care providers for theprophylactic use of MgSO4 in severe pre-eclampsia.Future researches should explore ways to developeducational strategy and simple tools to empower firstand second level health care providers to be able to ap-proach obstetrical problems. This will help to expeditereferral in rural pregnant women and initiatingtreatment in homes in severe cases which require urgentmanagement even before referral. The curriculum forhealth care providers who are involved with pregnantwomen in communities should be reviewed and trainingshould ensure acquisition of competency for dealingwith obstetrical emergencies.ConclusionThis study reveals that even in presence of a nationalpolicy supporting pre-eclampsia programmes, providerslack confidence and/or competence in treating thesewomen. Gaps in the knowledge of aetiology, diagnosisand treatment of pre-eclampsia among all cadres ofhealth care providers were seen. Findings suggest thatlimited exposure to pre-eclampsia cases, the lack ofrefresher trainings and no written guidelines for man-agement of the disease are important factors leading toinadequate knowledge. We suggest inclusion of manage-ment of pre-eclampsia in regular training of all healthcare providers and to provide management protocols atall levels of health care. There is also need for strongadvocacy for use of MgSO4 as emergency treatmentbefore referral from first and secondary level health facil-ities for the best maternal and fetal outcomes.Additional filesAdditional file 1: Table S1. Baseline attributes of health care providers,Table S2. LHWs competency and skills to provide maternal health care,Table S3. Administrative and logistic support available to LHW toprovide maternal care. (DOC 44 kb)Additional file 2: Review reports. (PDF 431 kb)AcknowledgementsThis work is part of the University of British Columbia PRE-EMPT (Pre-eclampsia/Eclampsia, Monitoring, Prevention and Treatment) initiative supported by theBill & Melinda Gates Foundation. CLIP Working Group: Payne Beth, AinaOlabisi,The Author(s) Reproductive Health 2016, 13(Suppl 2):104 Page 112 of 162Chomiak Marianne, Dada Olukayode A, Drebit Sharla, Firoz Tabassum, GoudarShivaprasad, Kariya Chirag, Katageri Geetanjali, Lee Tang, Li Jing, Lui Man Sun,Makanga Tatenda, Ramadurg Umesh, Sharma Sumedha, Solarin Kunle, andMagee Laura A.DeclarationsThis article has been published as part of Reproductive Health Volume 13Supplement 2, 2016: Building community-level resilience for the case of womenwith pre-eclampsia. The full contents of the supplement are available online athttp://reproductive-health-journal.biomedcentral.com/articles/supplements/volume-13-supplement-2. Publication charges for this supplement were fundedby the University of British Columbia PRE-EMPT (Pre-eclampsia/Eclampsia,Monitoring, Prevention and Treatment) initiative supported by the Bill & MelindaGates Foundation.Authors’ contributionsRNQ was involved in the concept, design and execution of the study. Shealso contributed in writing and review of the manuscript; RAS, ARK, SZ wereinvolved in the design and execution of the study; data collection. SS andMV contributed to the writing of the manuscript. DS, ZAB and PvD madesignificant intellectual contribution to the entire study. All authors read andapproved the final manuscript.Competing interestsThe authors declare no potential conflicts of interest with respect to theresearch, authorship, and/or publication of this article.Peer reviewReviewer reports for this article are included in Additional file 2.Author details1Division of Women & Child Health, Aga Khan University, Karachi, Pakistan.2Department of Obstetrics and Gynaecology, and the Child and FamilyResearch Institute, University of British Columbia, Vancouver V5Z 4H4,Canada. 3Department of Research, Vancouver Island Health Authority, VictoriaV8R 1J8, Canada. 4Department of Obstetrics and Gynaecology, St George’s,University of London, London SW17 0RE, UK. 5Program for Global PediatricResearch, Hospital for Sick Children, Toronto M5G 2L3, Canada.Published: 30 September 2016References1. National Collaborating Centre for Ws, Children’s H. Hypertension inpregnancy: the management of hypertensive disorders during pregnancy.London: RCOG press; 2010. 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