The XXI International Society of Hypertension in Pregnancy meeting,São Paulo,Brazil – A global health perspective

The sustainable development goals

Stating only one explicit goal for health among its 17 sustainable development goals (SDGs), the United Nations has confirmed that improvements in health cannot be achieved in isolation. Rather, there is an inextricable link between improvements in health and wellbeing and each of the other 16 aspirational SDGs, such as those targeting poverty, hunger, and gender equality. ² This need for integrated action was addressed in the opening ceremony by Peter von Dadelszen, who highlighted that global burden of maternal health reflected inequity in human rights and showcased how steps towards promoting gender equity, reproductive health rights, nutrition and education of girls can avert maternal deaths and illness among vulnerable populations.

This message of inequity was re-iterated in the opening ceremony by Shuchita Mundle, who presented the ‘ecology of eclampsia’ for women in Maharashtra, India. Dr. Mundle emphasized that the poor awareness of eclampsia in this population was a common barrier to accessing timely care. Dr. Mundle was the recipient of the inaugural 2014 EMPOWER (Empowering Progress in Obstetric and Women's hEalth Research) grant, a program designed to begin to address inequity in research by providing funding and mentorship between experienced individuals and groups in under-resourced settings. EMPOWER is a collaboration of the International Society for the Study of Hypertension in Pregnancy, the Preeclampsia Foundation, PRE-EMPT/Global Pregnancy Collaboration, and New Zealand Action on Pre-eclampsia. It was telling that Dr. Mundle found, just as in high-income settings, that women lack sufficient information about the hypertensive disorders of pregnancy to minimize risk and optimize outcomes. Further evidence of how misconceptions and myths serve as barriers to effective early case detection and treatment were illustrated by the results of studies of attitudes and knowledge of pre-eclampsia and eclampsia by women and men in Nigeria ³ and Bangladesh. ⁴

Quality and providers of care

In a panel presentation, Charlotte Warren (of Ending Eclampsia, Population Council, USA) brought a patient-centered perspective to the audience. Dr. Warren highlighted a lack of respectful maternity care, especially in resource-constrained settings. Other studies highlighted that women who have experienced hypertension in pregnancy are more likely to report that their birthing experience was ‘traumatic’, and that ‘trust’ and ‘continuity of care’ served as important mediator variables in improving their perceived quality of care. ¹⁴ To address these gaps and provide quality maternal healthcare will require investment in the health workforce. Of 379 maternal health providers from 96 healthcare facilities across Nigeria, only 56.9% of doctors and 70% of nurses and midwives could identify signs and symptoms of pre-eclampsia. ¹⁵ In 29 primary healthcare centres in Ogun State, Nigeria, ¹⁶ 170 community-based health providers were able to safely and effectively provide treatment for pre-eclampsia and eclampsia; there were no cases of hematoma or infection following 137 intramuscular magnesium sulphate injections for pre-eclampsia. In settings where the majority of preventable maternal deaths are a function of delays in triage, treatment, and transport to facility, these findings bring imperatives for optimising health worker roles and for generating recommendations for task sharing.

Integrated solutions

The new United Nations ‘Global Strategy’, calls for integrated solutions to achieve the highest state of health for mothers, newborns, and adolescents. ¹⁷ These solutions mandate research that integrates maternal, newborn, child, and adolescent health. However, research focussed on the hypertensive disorders in pregnancy does not necessarily include key outcomes required. In a systematic review of 79 randomised trials of therapeutic approaches for pre-eclampsia, James N Duffy highlighted important gaps. Only 23 (29.1%) trials reported neonatal outcomes, and fewer than half contained any relevant information regarding harm, for mother, newborn, or child. ¹⁸ This work is fueling a Delphi consensus process on the topic – iHOPE (International Collaboration to Harmonise Outcomes for Pre-Eclampsia, https://www.phc.ox.ac.uk/research/hypertension/pregnancy/ihope-collaboration-outcomes-preeclampsia-pregnancy). ¹⁹

At the Congress, however, there was active discussion of perinatal mortality and morbidity, as well as childhood development. They highlight the need for studies on causality and underlying mechanisms to mitigate the intergenerational effect of pregnancy hypertension. Presentations were made that related antenatal hypertension with elevated risks of autism spectrum disorder, ²⁰ largely reassuring data about developmental programming of growth and the hypothalamic–pituitary–adrenal axis following hypertensive pregnancy,^21,22 and behavioral and physical development of infants in the P4 study. ²³

The significance of the investigating in the life course approach to maternal health was addressed.

In his state-of-the-art lecture, entitled ‘Life course approach to obesity prevention; the importance of pre-conception and maternal periods’ Mark Hanson emphasized the life course approach – a method that examines people's lives within structural, social, and cultural contexts as these aspects are all powerfully interconnected. Maternal obesity is associated not only with the perinatal complications and long-term maternal complications that are usually discussed at medical meetings but also with elevated risks of offspring obesity, coronary heart disease, stroke, type 2 diabetes mellitus, and asthma. Hanson emphasized that a ‘whole-of-society intervention approach’ will be required to address the cascade of events that are related to maternal obesity.

Focussed harmonization with the Global South

The Joint ISSHP and ISOM Global Health Committee held a global health symposium with the aim of engaging the delegates, identifying needs, and discussing the Committee’s role in promoting best clinical, research, and advocacy practices in under-resourced settings. Three key directions emerged from this session: (1) providing support and training for emergency obstetric care; (2) increasing access to the existing evidence base; and (3) strengthening capacity for robust basic science research, particularly to understand the pathophysiology of pre-eclampsia in diverse populations. The need for the latter was further illustrated by a study of placental disorders and fetal aneuploidies in 398 Ghanaian women, demonstrating differences in biomarker levels (placental growth factor and pregnancy-associated plasma protein-A), observed to be substantially higher in the sub-Saharan African populations, compared with Caucasian or Afro-Caribbean populations; the latter are currently used for screening purposes. ²⁴

Another step towards addressing inequity in research was taken when the 2016 EMPOWER grant awardee was announced to be Dr. Sarah Manyame, a physician-researcher with the Department of Obstetrics and Gynaecology at the University of Zimbabwe Parirenvatwa Group of Hospitals. She was awarded $60,000 USD for her two-year project, ‘Urine Biomarkers for Preeclampsia in High Risk Women’; the results will be presented at the 2018 ISSHP conference in Amsterdam.

Future recommendations

More than ever before, the 21st World Congress of the ISSHP showcased global maternal health, one of the key ‘seven steps’ laid out by the agenda of the President, Professor Mark Brown. Ongoing threats to global maternal health such as posed by Zika virus, or internal displacements due to conflicts in fragile and conflict states, have shown that global momentum towards maternal health is vulnerable to shocks, and that progress can only made by strengthening health systems and building resilience, within clinical and research communities. There is a particular need for an engaged community, interested in knowledge brokering and translation, a role that ISSHP and ISOM should lead in their in order to address the global epidemiological transition towards later and indirect causes of maternal death. When asked, please give of your expertise and share your views, freely.