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Availability and use of magnesium sulphate at health care facilities in two selected districts of North… Katageri, Geetanjali; Charantimath, Umesh; Joshi, Anjali; Vidler, Marianne; Ramadurg, Umesh; Sharma, Sumedha; Bannale, Sheshidhar; Payne, Beth A; Rakaraddi, Sangamesh; Karadiguddi, Chandrashekhar; Mungarwadi, Geetanjali; Kavi, Avinash; Sawchuck, Diane; Derman, Richard; Goudar, Shivaprasad; Mallapur, Ashalata; Bellad, Mrutyunjaya; Magee, Laura A; Qureshi, Rahat; von Dadelszen, Peter Jun 22, 2018

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RESEARCH Open AccessAvailability and use of magnesium sulphateat health care facilities in two selecteddistricts of North Karnataka, IndiaGeetanjali Katageri1, Umesh Charantimath2*, Anjali Joshi2, Marianne Vidler3, Umesh Ramadurg4, Sumedha Sharma3,Sheshidhar Bannale5, Beth A. Payne3, Sangamesh Rakaraddi6, Chandrashekhar Karadiguddi2,Geetanjali Mungarwadi2, Avinash Kavi2, Diane Sawchuck10, Richard Derman8, Shivaprasad Goudar2,Ashalata Mallapur1, Mrutyunjaya Bellad2, Laura A. Magee7, Rahat Qureshi9, Peter von Dadelszen7and the Community Level Interventions for Pre-eclampsia (CLIP) India Feasibility Working Group2,3,9From 2nd International Conference on Maternal and Newborn Health: Translating Research Evidence to PracticeBelagavi, India. 26-27 March 2018AbstractBackground: Pre-eclampsia and eclampsia are major causes of maternal morbidity and mortality. Magnesiumsulphate is accepted as the anticonvulsant of choice in these conditions and is present on the WHO essentialmedicines list and the Indian National List of Essential Medicines, 2015. Despite this, magnesium sulphate is notwidely used in India for pre-eclampsia and eclampsia. In addition to other factors, lack of availability may be areason for sub-optimal usage. This study was undertaken to assess the availability and use of magnesium sulphateat 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 12areas of Belagavi and Bagalkote districts of North Karnataka, India and included a survey of 88 facilities. Data werecollected 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 wasavailable in six out of 10 Primary Health Centres (60%), in all eight taluka (sub-district) hospitals (100%), five of eightcommunity health centres (63%) and both district hospitals (100%). Fifty-five of 60 private facilities (92%) reportedavailability of magnesium sulphate.Stock outs were reported in six facilities in the preceding six months – five public and one private. Twenty-five percentweight/volume and 50% weight/volume concentration formulations were available variably across the public andprivate facilities. Sixty-eight facilities (77%) used the drug for severe pre-eclampsia and 12 facilities (13.6%) did not usethe drug even for eclampsia. Varied dosing schedules were reported from facility to facility.(Continued on next page)* Correspondence: drumesh.charantimath@gmail.com2KLE Academy of Higher Education and Research’s J N Medical College,Belagavi, Karnataka, IndiaFull list of author information is available at the end of the article© The Author(s). 2018 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.Katageri et al. Reproductive Health 2018, 15(Suppl 1):91https://doi.org/10.1186/s12978-018-0531-6(Continued from previous page)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, standardformulations and recommendations of dosage schedules and training may help improve use; and decrease morbidityand mortality due to pre-eclampsia/ eclampsia.Trial registration: The CLIP trial was registered with ClinicalTrials.gov (NCT01911494).Keywords: Magnesium Sulphate, Availability, Health care facilities, Pre-eclampsia, Eclampsia, Karnataka, IndiaBackgroundPre-eclampsia and eclampsia are a leading cause of mater-nal mortality, contributing to 14% of maternal deathsworldwide [1]. Every day approximately 830 women die asa result of pregnancy complications all over the world and99% of these deaths occur in developing countries [2]. In2015, globally there were 303,000 maternal deaths; and45,000 (about 15%) of these were in India [3]. India hasfallen short of achieving the Millennium DevelopmentGoal of reducing the national maternal mortality ratio(MMR) to 109 by 2015. Despite a substantial reduction inmaternal deaths, the MMR of India stood at 174 per100,000 livebirths in 2015 [3]. It is now necessary to focuson the newly adopted Sustainable Development Goals tar-geted to reduce the global MMR to 70.Interventions targeting maternal deaths need to ad-dress pre-eclampsia and eclampsia as it is the secondleading direct cause of maternal mortality, second onlyto haemorrhage [1]. Also, these conditions can result inmajor morbidity and residual complications which affectthe quality of life of the woman and her family and sig-nificant economic burden.Magnesium sulphate is the drug of choice for the pre-vention and treatment for the seizures of eclampsia [4].The Magpie trial established that women receiving mag-nesium sulphate versus placebo were 58% less likely tohave convulsions and it also led to a decreased risk ofplacental abruption. Follow-up studies of the partici-pants of the Magpie trial and their babies showed nolong-term harm or benefit to either [5–7]. A systematicreview of the Cochrane database in 2010 found thatmagnesium sulphate is better than phenytoin and nimo-depine in preventing convulsions and results in a non-significant decrease in maternal deaths [8]. Studies havealso proven that it prevents convulsions better whencompared to the other treatment regimens for eclampsialike the lytic cocktail regimen and diazepam [9, 10].The World Health Organization’s (WHO) list of essen-tial medicines and the Indian National List of EssentialMedicines (NLEM) 2015 identify magnesium sulphate asan essential commodity for maternal health [11, 12]. It isinteresting to note that the NLEM lists it under S and Tcategories which means that it should be available atsecondary and tertiary facilities, when in contrast, theIndian Public Health Standards (IPHS) Revised Guide-lines 2012, specifically the IPHS guidelines for primaryhealth centres (PHCs), state that magnesium sulphateshould be present in the labour room in the PHCs [13].The antidote to magnesium sulphate, calcium gluconateis listed on the WHO list of essential medicines and alsofeatures on the NLEM 2015 under categories P, S and T,implying that it should be present at the primary, sec-ondary and tertiary levels.The guidelines for skilled birth attendants in India rec-ommend that magnesium sulphate be administered incases of severe pre-eclampsia and eclampsia prior to re-ferral [14]. These guidelines are meant to guide the func-tioning of Staff Nurses (providing services at the primaryhealth centres and higher facilities), Auxiliary NurseMidwives (ANMs; providing services at the subcenters)and Lady Health Visitors (LHVs) who are in a supervis-ory capacity for the ANMs. The guidelines also recom-mend that magnesium sulphate be present in the kit forhome delivery and specify that the skilled birth atten-dants are permitted to use magnesium sulphate for botheclampsia and severe pre-eclampsia, and that arrange-ments for immediate referral should then be made [14].Providing the loading dose of magnesium sulphate willstabilize a woman for safe transport to a facility, which isbetter equipped to handle these complications. Despiteall the recommendations, use of magnesium sulphate isnot universal [15].There may be many reasons for the sub-optimal use ofmagnesium sulphate, such as a lack of knowledge, lackof familiarity with the drug, the large volume of the in-jection, apprehension of complications, widely varieddoses and dosage schedules that may be confusing;among others [15]. Though there are standard regimensdescribed in obstetric textbooks, there are concerns thatthe dose may be too large for the smaller built Indianwoman. Hence several modified regimens are followedin practice [16–19]. In addition to this, magnesiumsulphate may not be readily available in all settings [15].We undertook an assessment of health facilities in twodistricts of North Karnataka to note how they wereequipped in handling obstetric and neonatal care. In thisstudy, we report the availability and use of magnesiumsulphate at the facilities assessed.Katageri et al. Reproductive Health 2018, 15(Suppl 1):91 Page 70 of 126MethodsThis study was carried out in Belagavi and Bagalkote dis-tricts of North Karnataka. Karnataka is a south Indianstate with a MMR of 133/100,000 livebirths in 2011-2013as per the Sample Registration System. There are vast dif-ferences in health infrastructure and service delivery inthe districts of northern and southern Karnataka [20]. TheCLIP Feasibility Study was undertaken in 12 areas ofBelagavi and Bagalkote districts (six in each district) [21].The two adjoining districts are quite dissimilar, withpoorer health indices in Bagalkote district [20]. Before theCLIP Trial (NCT01911494), the 12-month FeasibilityStudy was undertaken to assess the context, and identifyany potential barriers and facilitators to the implementa-tion of CLIP.As a part of the CLIP Feasibility Study, facility assess-ment was undertaken to determine the capacity of facil-ities in the study area in the provision of maternal andnewborn health services, with a focus on care of womenwith pre-eclampsia and eclampsia. Medical officers, incharge of provision of care at primary health centres(PHC), were asked to identify and list the health carefacilities that women in their area frequent. In total, 88facilities were identified. The survey of the facilities wasundertaken between April and August 2013.The survey was carried out by trained medical profes-sionals from the research team from the same region,who underwent training for a day in the approach neces-sary for data collection. Those conducting assessmentswere predominantly clinicians; this provided importantbackground knowledge for successful completion of theforms. The primary obstetric care provider at each facilitywas approached for a one-on-one interview to provide ne-cessary information, with some fields being completedwith inputs from pediatric care providers, laboratory tech-nicians and review of institutional records. Consent wasobtained from the respondents before proceeding.A pre-structured questionnaire was used to documentthe responses received. The questionnaire recorded pre-liminary data about the name of the facility, location,person responding to the questionnaire, contact num-bers, type of facility, usual place of referral, catchmentarea and population served. It also included the numberof beds, availability of intensive care units, a comprehen-sive description of the available personnel, equipment,drugs and services, costs, transportation to and from thefacility, access to blood transfusion, and the volume ofpatients. Questions pertaining to additional training inmaternal and neonatal care were included in the format,as were those related to existence and use of facilityguidelines for the management of hypertensive disordersof pregnancy. Questions regarding hypertension inpregnancy, criteria used for diagnosis of mild and severepre-eclampsia, antihypertensive treatment, and use ofmagnesium sulphate were also asked. The majority ofthe questions in the survey tool were close-endedthough a few questions requested detailed answering.Data were directly recorded on to hard copies of thequestionnaire at the time of the interview. The question-naire used in this study has been added as an appendixto this paper (Additional file 1).All data were keyed into a locally developed Accessdatabase. The data were cleaned prior to analysis. Fre-quencies were run on all quantitative fields providingtotals, means and standard deviations.This study was approved by ethics review committeesat the University of British Columbia, Vancouver Canada(H12-00132) and KLE University, Belgaum (Ref No:MDC/IECHSR/2013-14/A-28) India.ResultsOf the 88 facilities, 28 were public and 60 were private.Table 1 provides a description of the facilities surveyed.The facilities assessed included 8 Community HealthCentres (CHC) out of the total 24 in the two districts(33%) as reported by the Health Management Informa-tion System of the Ministry of health and Family welfare;8 taluka hospitals out of the total 14 (57%), and boththe district hospitals (100%). The total number of privateobstetric facilities in the two districts could not be ascer-tained to determine the proportion assessed.All health care facilities with magnesium sulphate atthe time of assessment also reported access to the drugin the labour room. Data regarding stock outs in thepreceding 6 months were collected. While the majorityof the healthcare facilities did not report any stock outs,five public facilities did report stock outs at the time ofassessment, one reporting multiple instances in the pre-ceding 6 months. One private facility reported a stockout. One CHC and one private hospital reported havingno availability of magnesium sulphate at any time andhence there was no response to whether stock outs oc-curred. One PHC medical officer reported that they didnot wait for replenishment of stock through the govern-ment supply since it was not streamlined, and theybought the necessary supply through funds allocated tothe PHC. Table 1 shows the different categories of healthfacilities surveyed, availability of magnesium sulphate atthe time of assessment and stock outs in the preceding6 months.The availability of other essential obstetric medicationswas ascertained. There were differences in availability,with some facilities reporting availability of one type of adrug in a category versus another (for example beta-methasone/dexamethasone, different antihypertensivesetc.) and some reporting availability of all the drugs. Allfacilities reported the availability of uterotonics, oxytocinin particular.Katageri et al. Reproductive Health 2018, 15(Suppl 1):91 Page 71 of 126Regarding the formulation of magnesium sulphateavailable, responses were collected from 29 facilities withmagnesium sulphate at the time of assessment. Of these,22 (6 public and 16 private) facilities reported carrying aconcentration of 50% weight /volume (w/v), three (onepublic and 2 private) reported having 25% w/v and four(one public and 3 private) reported having bothstrengths available. All ampoules were of 2 ml.Information on practices related to magnesiumsulphate usage was collected, including the use of mag-nesium sulphate in the management of severe pre-eclampsia (Table 2). Health care professionals from 68facilities responded that they did use it for managementof severe pre-eclampsia, and notably this included fivePHCs. Thirty-two providers reported differential dosingschedules for severe pre-eclampsia as opposed toeclampsia with differences in both the route and thedosage of magnesium sulphate used. Seventeen of the 68providers reported that they did not provide a mainten-ance dose in cases of severe pre-eclampsia. One privatepractitioner reported maintenance therapy with pheny-toin after the loading dose of magnesium sulphate forpre-eclampsia. All the PHCs and two private hospitalsusing magnesium sulphate reported immediate referralof patients with severe pre-eclampsia and eclampsia,without waiting for the maintenance dose.When asked about alternative treatment strategies ineclampsia in place of magnesium sulphate amongstthose using the drug, the majority of the providers men-tioned use of injection diazepam or phenytoin, but onlyin cases where magnesium sulphate failed. Only oneprovider mentioned that maintenance treatment wasroutinely provided with phenytoin.A notable observation was that 12 providers did not usemagnesium sulphate even for eclampsia. This included 4PHCs, 3 CHCs and 5 private facilities. Three of these 12facilities did report availability of magnesium sulphate atthe time of assessment. Four of the 12 providers men-tioned the use of injectable diazepam for eclampsia.Varied dosage schedules were reported, with 25 (3 publicand 22 private) of 68 providers reporting using standardPritchard or Zuspan regimens for severe pre-eclampsia,and 44 (13 public and 31 private) of 76 reporting use ofstandard Pritchard or Zuspan regimens for eclampsia. Thedosages reported were very varied, with most providerswho were not using standard regimens resorted to lowerdoses, some up to half of the Pritchard and Zuspan regi-mens. One obstetrician at a private facility reported the useof 2 g intramuscularly (IM) as the loading dose and 2 g IMtwice a day as the maintenance dose for eclampsia. Therewere also some unusual responses like 100 mg intraven-ously (IV) every 8 h; and 25% IM. The respondents in thesecases were not obstetricians by qualification but were stillthe primary obstetric providers in that facility. Interest-ingly, 10 providers said they determine the loading andmaintenance doses based on the patient’s condition.The availability of calcium gluconate, the antidote tomagnesium sulphate was asked for. Calcium gluconatewas not available in 12 facilities, including 8 which re-ported availability of magnesium sulphate (Table 3).DiscussionDespite the well-established superiority of magnesiumsulphate in the management of severe pre-eclampsia andTable 1 Facilities assessed, the availability of magnesium sulphate at assessment and stock outs in preceding 6 monthsType of facility Belagavi district Bagalkote District TotalN A S N A S N A SPublic facilities Primary Health Centre 9 5 2 1 1 0 10 6 2Community Health Centre 4 3 0 4 2 2 8 5 2Taluka Hospital 4 4 0 4 4 1 8 8 1District Hospital 1 1 0 1 1 0 2 2 0Private facilities 39 35 0 21 20 1 60 55 1All facilities 57 48 2 31 28 4 88 76 6N Number assessedA Magnesium sulphate available during surveyS Stock outs of magnesium sulphate in preceding six mothsTable 2 Facilities using magnesium sulphate for managementof severe pre-eclampsiaUse of MgSO4 for severe pre-eclampsiaYes Public 17Private 51Total 68No Public 4Private 4Total 8Never used MgSO4 for even eclampsia Public 7Private 5Total 12Katageri et al. Reproductive Health 2018, 15(Suppl 1):91 Page 72 of 126eclampsia, it continues to be used sub-optimally. In ourstudy, non-availability of magnesium sulphate was identi-fied at several facilities. In addition, stock outs were experi-enced at five public facilities and one private secondaryfacility in the preceding 6 months but in none of the ter-tiary health facilities. Calcium gluconate was available in86% of the facilities assessed but 8 facilities with availabilityof magnesium sulphate did not have calcium gluconate.It was found that the health facilities had differingstrengths of magnesium sulphate available, some report-ing both 25% w/v and 50% w/v. The facilities reportedvarying dosage schedules, some of which may not havethe required stabilizing action and may not optimallybenefit the patient.The availability of magnesium sulphate seemed to besimilar across the two districts in this study. However,there were more stock outs in the preceding 6 months inBagalkote when compared to Belagavi. Also, the stockouts were in the secondary level facilities in Bagalkote asopposed to primary health centres in Belagavi. Availabilityand use of magnesium sulphate across all levels of health-care is important for ensuring favourable outcomes.The fact that other essential medications for obstetrichealth were available at the facility and only magnesiumsulphate seemed to be missing, points to the fact that thesupply chain is generally functioning. Due importance isnot given to make magnesium sulphate available. The pro-viders at the public facilities do have funds to procure thedrug through other suppliers but have to maintain a watchon the stock to see that the supply is uninterrupted.The facilities assessed in this study were the ones mostoften used for delivery and it would be expected thatthese health facilities would have better logistics thanthose not providing regular obstetric services. It isprobable that this assessment does not represent allfacilities in the region, and that others may have pooreravailability and use of magnesium sulphate. The strengthof this study is that researchers were trained medicalprofessionals and hence had a better contextualization ofthe study. A limitation of this study is that the healthcare providers self-reported the availability and use ofmagnesium sulphate in the facilities they served. It wasnot physically ascertained as to how many ampouleswere present, whether the ampoules were within thedate of expiry, and whether magnesium sulphate wasused in the manner reported. Though the researchersencouraged practitioners to report actual practices, thefact that the researchers were fellow clinicians may haveinduced a bias to report favourably.A study assessing 279 health care facilities in eight dis-tricts of northern Karnataka in 2010 revealed that magne-sium sulphate was available in only 18% of PHCs, 48% ofhigher public facilities and 70% of private facilities [22]. Incomparison, the present study found that 60% of PHCs,72% of higher public facilities and 92% private facilities re-ported availability of magnesium sulphate at the time ofassessment. This difference may be because we selectivelysampled facilities providing regular obstetric services.A study from Maharashtra state, India assessing 44secondary and tertiary public health facilities in 2009-2010 found that 61% of facilities had no stock of magne-sium sulphate, with the stock-out position ranging from3 months to 3 years. The researchers ascertainedwhether they had the minimum of 50 ampoules recom-mended in the guidelines for CHCs and found that 20%facilities had less than the minimum recommended andalso that 11.4% of the assessed facilities did not haveenough ampoules to even provide the first dose to a sin-gle woman [23]. The stock outs in the present studywere much fewer, with only five of 28 public facilities(18%) reporting stock outs in the 6 months before thesurvey, again perhaps due to the convenience samplingused in this study. The quantity of drug available wasnot assessed in this study.Another study done in Nagpur, Maharashtra con-cluded that though senior gynaecologists favoured theuse of magnesium sulphate especially prior to referral,its use was limited due to lack of institutional policieson dosing, timing, indications and also due to limitedavailability, especially in tertiary care centres [24]. In thepresent study too, it was found that health care pro-viders did not have uniform policies on indications anddosing, even when the drug was available.A 2010 WHO study that assessed emergency obstetriccare across six developing countries, including India,found that only 53% of facilities with basic emergencyobstetric care (BEmOC) and 86% of facilities withcomprehensive emergency obstetric care (CEmOC) hadIM/IV anticonvulsants [25]. The study also indicatedthat public facilities were unable to provide emergencyobstetric care due to lack of good management systemsto ensure continuous availability of drugs and suppliesand emphasized the importance of strengthening thechain for procurement and distribution of basic drugsand equipment; and to improve skills of the providers toensure at least coverage of BEmOC [25]. In the presentstudy, in addition to the issues about availability ofmagnesium sulphate, we found that providers at 12Table 3 Non-availability of calcium gluconate by type of facilityType of facility Calcium gluconatenot availableCalcium gluconate notavailable but magnesiumsulphate availablePHC 2 0Taluka Hospital 1 1CHC 2 1Private 7 6Katageri et al. Reproductive Health 2018, 15(Suppl 1):91 Page 73 of 126facilities did not administer magnesium sulphate evenfor eclampsia despite three of these facilities reportingavailability. This emphasizes the need for knowledge andskill enhancement activities to improve usage practicesin addition to improving the supply chain.Even though the guidelines for skilled birth attendants[14] recommend that the ANM should administer mag-nesium sulphate for severe pre-eclampsia prior to refer-ral, the medical officers (who are qualified physicians) offive of the PHCs stated that they did not use magnesiumsulphate for severe pre-eclampsia and despite availabilityof magnesium sulphate, usage for even eclampsia wasnot universal. Familiarising health care professionalswith treatment recommendations, and building theircapacity and confidence could go a long way in optimiz-ing the administration of magnesium sulphate.There are standard regimens for the use of magnesiumsulphate, Pritchard, Zuspan and Sibai; as well as, manyother dosage schedules [16–19]. A systematic review ofthe studies evaluating these regimens in low- andmiddle-income countries was unable to establish the su-periority of any regimen and the lowest effective dose isnot agreed upon [26]. It was found in four studies thatthe administration of the loading dose only was as ef-fective as loading plus maintenance [26]. The varied dos-age schedules, however, confuse practitioners who maynot be familiar with magnesium sulphate. The strengthof the drug formulation also varies and achieving thecorrect dilution for IV administration may be prone toerror and confusion [27]. In the present study, we didfind that the health facilities had differing strengthsavailable and used many differing dosing schedules. It isimportant that there be a standard formulation and re-quirement for adherence to standard dosing schedulesto increase appropriate use and optimize action.Magnesium sulphate toxicity occurs very infrequently ifguidelines are followed during administration. In the eventthat it does occur, serious complications can usually beaverted by skipping the next dose. However, in rare in-stances, administration of calcium gluconate is requiredand may be lifesaving [28]. Hence, care should be taken toensure availability and train the providers in appropriateuse. A study in Lucknow, India in 2014 found that only33.3% Bal Mahila Chikitsalayas (health care facilities forwomen and children) which serve as first referral unitshad availability of calcium gluconate [29]. In our study,availability was found to be better with 86% facilitiesreporting the drug at the time of assessment.The Indian guidelines are conflicting, with the NLEMrecommending magnesium sulphate availability in thesecondary and tertiary facilities, the IPHS guidelines forPHCs recommending availability in the labour room ofthe PHCs; and the guidelines for skilled birth attendantsrecommending that it be available at the sub-center andeven in the home delivery kits [12–14]. Conflictingrecommendations of this nature need to be rectified toensure enhanced usage.The first step to encourage enhanced magnesiumsulphate use is that it should be available at all health carefacilities providing for obstetric patients, without anystock-outs. It is also essential to increase the providers’comfort and confidence in using this drug. All levels ofobstetric care providers need to be re-trained periodicallyin the benefits and use of magnesium sulphate.Observing the appropriate use of magnesium sulphateby senior obstetric providers may enhance uptake by theother health care providers like resident doctors, ANMsand staff nurses. However, they need to be exposed tothe use of this drug in a consistent manner. Standardiz-ing the strength and dosing schedules is essential; andguidelines for referral should be developed and enforced.Identification of non-compliant facilities could be doneby tracking referrals. Ascertaining the cause for devi-ation with corrective action and refresher training couldbe a solution to increase appropriate use. Cases ofeclampsia could also serve as triggers for evaluating thedelays and deficiencies in the health system and identify-ing and implementing potential remedial action.Future research could focus on the reasons for hesi-tancy for use of magnesium sulphate by obstetric pro-viders so as to inform the health system administratorsabout the steps necessary to increase usage.ConclusionThis study found that there were deficiencies in theavailability of magnesium sulphate in health care facil-ities that routinely cared for obstetric patients in northKarnataka. The public health facilities faced stock outsthough they could procure the drug through funds allo-cated to them. This shows a poor chain of coordinationbetween the suppliers, distributors and the users.Addressing contradictions in the Indian nationalguidelines regarding place of availability, indications foruse and cadre of health care professionals permitted touse magnesium sulphate is of prime importance.The indications for which magnesium sulphate was usedand the strength of drug available varied across facilities ofthe same type. Standardization of the drug formulationand familiarization with guidelines is important to ensureoptimal use of magnesium sulphate. In addition, identifi-cation of the factors preventing use; and trainings and re-fresher trainings to address these issues would increaseappropriate usage of magnesium sulphate.Despite a major reduction in the maternal mortality,the Millennium Development Goals of 2015 were notmet in India; nevertheless, positive action in this regardcould bring us closer to attaining the SustainableDevelopment Goals by 2030.Katageri et al. Reproductive Health 2018, 15(Suppl 1):91 Page 74 of 126Additional fileAdditional file 1: Questionnaire used in this study. (PDF 607 kb)AbbreviationsANM: Auxillary nurse midwife; BEmOC: Basic emergency obstetric care;CEmOC: Comprehensive emergency obstetric care; CHC: Community HealthCentre; CLIP: Community level interventions for pre-eclampsia; IM: Intramuscular;IPHS: Indian Public Health Standards; IV: Intravenous; LHV: Lady health visitor;MMR: Maternal mortality ratio; NLEM: National list of essential medicines;PHC: Primary health centre; SN: Staff nurse; w/v: Weight/volume; WHO: WorldHealth OrganizationAcknowledgementsThis study was undertaken as a part of the PRE-EMPT (Pre-eclampsia EclampsiaMonitoring Prevention and Treatment) grant awarded to the University ofBritish Columbia, a grantee of the Bill & Melinda Gates Foundation.CLIP Feasibility working group: Namdev Kamble, Amit Revankar, ZulfiqarBhutta, Sharla K Drebit, Chirag Kariya, Tang Lee, Jing Li, Mansun Lui, Asif RKhowaja, Domena K. Tu.FundingThis study was undertaken as a part of the PRE-EMPT (Pre-eclampsia EclampsiaMonitoring Prevention and Treatment) grant awarded to the University ofBritish Columbia, a grantee of the Bill & Melinda Gates Foundation. The fundingbody had no role in the design or conduct of the study or in the reporting ofthe results.Publication charges for this supplement were funded by the Universityof British Columbia PRE-EMPT (Pre-eclampsia/ Eclampsia, Monitoring,Prevention and Treatment) initiative supported by the Bill and MelindaGates Foundation.Availability of data and materialsThe datasets used and/or analysed during the current study are availablefrom the corresponding author on reasonable request.About this supplementThis article has been published as part of Reproductive Health Volume 15Supplement 1, 2018: Improving pregnancy outcomes - Proceedings of the2nd International Conference on Maternal and Newborn Health: TranslatingResearch Evidence to Practice. The full contents of the supplement will beavailable online at https://reproductive-health-journal.biomedcentral.com/articles/supplements/volume-15-supplement-1.Authors’ contributionsGK, UC and UR were involved in the preparation of the study materials, datacollection and prepared the manuscript. AJ, SB, SR, CK, GM, AK were involvedin data collection. RD, SG, SS, MV, AM, MB, DS, BP, LAM were responsible forprotocol preparation and overseeing the study. PVD and RQ were thePrincipal Investigators. All authors read the approved the final manuscript.Ethics approval and consent to participateThis study was approved by ethics review committees at the University ofBritish Columbia, Vancouver Canada (H12-00132) and KLE University,Belgaum (Ref No: MDC/IECHSR/2013-14/A-28) India. Furthermore, approvalwas also obtained from the Ministry of Health and Family Welfare, India.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Department of Obstetrics and Gynaecology, S Nijalingappa Medical College,Bagalkot, Karnataka, India. 2KLE Academy of Higher Education and Research’sJ N Medical College, Belagavi, Karnataka, India. 3Department of Obstetricsand Gynaecology, University of British Columbia, Vancouver, BC, Canada.4Department of Community Medicine, S Nijalingappa Medical College,Bagalkot, Karnataka, India. 5Department of Pharmacology, S NijalingappaMedical College, Bagalkot, Karnataka, India. 6Department of Anatomy, SNijalingappa Medical College, Bagalkot, Karnataka, India. 7School of LifeCourse Sciences, Faculty of Life Sciences and Medicine, King’s CollegeLondon, London, UK. 8Global Affairs, Thomas Jefferson University,Philadelphia, USA. 9Division of Women and Child Health, Aga KhanUniversity, Karachi, Sindh, Pakistan. 10Department of Research, VancouverIsland Health Authority, British Columbia, Canada.Published: 22 June 2018References1. 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