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Synthesis of evidence for managing hypertensive disorders of pregnancy in low middle-income countries: a scoping review

BMC Pregnancy and Childbirth volume 24, Article number: 622 (2024) Cite this article

Abstract

Background and objectives

Hypertensive disorders of pregnancy (HDPs) remain one of the leading causes of maternal mortality globally, especially in Low- and middle-income countries (LMICs). To reduce the burden of associated morbidity and mortality, standardized prompt recognition, evaluation, and treatment have been proposed. Health disparities, barriers to access to healthcare, and shortage of resources influence these conditions. We aimed to synthesize the literature evidence for the management of HDPs in LMICs.

Methods

A scoping review was conducted in five databases (PubMed, Web of Science, Epistemonikos, Clinical Key and, Scielo) using MeSh terms, keywords, and Boolean connectors. We summarized the included studies according to the following categories: study design, objectives, settings, participant characteristics, eligibility criteria, interventions, assessed outcomes, and general findings.

Results

Six hundred fifty-one articles were retrieved from the literature search in five databases. Following the selection process, 65 articles met the predefined eligibility criteria. After performing a full-text analysis, 27 articles were included. Three themes were identified from the articles reviewed: prevention of HDPs, management of HDPs (antihypertensive and non-hypertensive management) and pregnancy monitoring and follow-up. The topics were approached from the perspective of LMICs.

Conclusions

LMICs face substantial limitations and obstacles in the comprehensive management of HDPs. While management recommendations in most LMICs align with international guidelines, several factors, including limited access to crucial medications, unavailability of diagnostic tests, deficiencies in high-quality healthcare infrastructure, restrictions on continuing professional development, a shortage of trained personnel, community perceptions of preeclampsia, and outdated local clinical practice guidelines, impede the comprehensive management of patients. The development and implementation of protocols, standardized guides and intervention packages are a priority.

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Introduction

Hypertensive disorders of pregnancy (HDPs) are a significant cause of maternal and fetal mortality worldwide and the most common medical disorder during pregnancy. HDPs complicate 5% to 10% of all pregnancies [1, 2], and they are related to severe consequences that include stroke, eclampsia, renal dysfunction, and adverse fetal outcomes. The health burden associated with HDPs is estimated to account for more than 90% of HDP-related deaths in Low- and middle-income countries (LMICs) [3]. Over the past three decades, there has been a concerning stagnation in the reduction of maternal mortality rates linked to HDP, which evidences the need for prevention and management strategies that include early administration of supplements and medications in the first trimester of pregnancy after detecting any risk factor. In LMICs, a lack of effective strategies to prevent HDP is evident, particularly in areas with limited access to healthcare services for women. Urgent comprehensive interventions are needed to reduce maternal mortality rates in these regions [4].

Globally, HDPs tend to increase with the rising prevalence of cardiometabolic disease in women of reproductive age [5, 6] and increases the risk of preeclampsia in subsequent pregnancies by 25% [6]. In addition, the reported incidence of eclampsia ranges from 1.6 to 10 per 10,000 deliveries in developed countries, compared to 50 to 151 per 10,000 deliveries in developing countries. This difference is related to inadequate prenatal care, which hinders timely detection, and a general lack of established treatment protocols for acute cases in these regions [6].

Strategies to reduce the impact of HDPs include appropriate and timely diagnosis, determination of disease severity, prevention of eclampsia, blood pressure management, decision to terminate pregnancy, and location of care according to the level of complexity. These complex decisions require standardization through intervention packages for their adequate approximation [7]. Despite the available evidence, standardization and access to this knowledge to prevent maternal end-organ damage while minimizing acute changes in placental perfusion are not available in LMICs [8, 9]. Their applicability in LMICs is even more complex, when social and community determinants are considered, such as facing barriers and limitations that impact access, quality, and the effectiveness of health services [10].

We aimed to conduct a scoping review within the context of LMICs to synthesize the evidence for managing HDPs. With this evidence, it is feasible to establish opportunities for developing knowledge and integrating evidence in contexts where a high impact can be generated on reducing morbidity and mortality associated with HDPs.

Methods

We conducted a scoping review study based on the methodological framework proposed by Arksey and O’Malley and refined by the Joanna Briggs Institute (JBI) [11, 12]. To report this study, we followed the PRISMA extension of scoping reviews (PRISMA-ScR).

Objective and research question

The objective and research question were to describe and summarize the evidence available for managing HDPs in LMICs to answer the following research question: What interventions and recommendations related to management exist for HDPs in Low- and middle-income countries?

Search strategy

The search strategy included reviewing PubMed, Web of Science, Epistemonikos, Clinical Key, and Scielo between June and July 2022 to access relevant studies from the last ten years. The search was done in July 2022. Our search utilized MeSH terms, keywords, free-text terms, and Boolean connectors. Additional file 1 lists the complete search strategy for the PubMed database as an example of one search.

Eligibility criteria for selected studies

The following eligibility criteria inclusion were applied for selected studies: (1) Full-text articles published within the last ten years (2012—2022), and (2) studies conducted on pregnant women at any gestational age with HDPs (including Gestational Hypertension, Preeclampsia, Eclampsia, or Chronic Arterial Hypertension with superimposed preeclampsia). The identification of LMICs hinged on the World Bank's classification based on income levels for the fiscal year 2022 [13]. Articles published in middle, upper-middle, or high-income countries, articles related to animal studies, in vitro research, study protocols, abstracts, letters to the editor, and articles written in languages ​​other than Spanish, English, or Portuguese were excluded.

Selection of eligible studies

According to the criteria, 651 articles were imported into the collaborative web application for conducting systematic reviews, Rayyan (https://www.rayyan.ai/). Duplicate articles were identified and removed. Subsequently, two investigators independently reviewed the titles and abstracts, applying the inclusion criteria using a blinded option provided by Rayyan. Any disagreements regarding the inclusion criteria were resolved through in-depth discussion until a consensus was reached, involving a third investigator.

Data collection

Five researchers independently reviewed the included full-text studies, and data were obtained using standardized forms. The information collected included country, study design, sample size and interventions administered for prevention, management, and follow-up of HDPs in LMICs. A table was created to record all relevant articles subsequently included in the final review (see Table 2).

Data synthesis and analysis

As a method to synthesize and analyze the data, a narrative approach was used. Based on the information found, the aim was to create main themes that would facilitate a critical synthesis of the findings. Two synthesis tools were implemented: the first is a summary table, and the second is a presentation of the main themes in the results section.

Results

A total of 651 articles were retrieved from the literature search across five databases. Following the selection process, 65 articles met the predefined criteria for eligibility, while 586 articles were excluded. After conducting a full-text analysis, 27 articles were included (Fig. 1).

Fig. 1
figure 1

PRISMA flow diagram

Full size image

Characteristics of the included studies

Half of the studies were conducted in the African continent, followed by those in Asia. Among the included studies, 50% were quantitative and predominantly cross-sectional, followed by prospective and retrospective studies, 35,7% were qualitative with predominantly narrative reviews, and 10,7% had mixed methods. Tables 1 and 2 summarize the characteristics of the selected articles. We identified three main themes from the included studies, which are as follows:

  1. 1.

    Prevention of HDPs

  2. 2.

    Management of HDPs

  3. 3.

    Pregnancy monitoring and follow-up.

Table 1 Characteristics of the studies (N = 27)
Full size table
Table 2 Summary of studies included in the review
Full size table

Prevention of HDPs in LMICs

Aspirin

The evidence reported is focused on Africa and Asia. In South Africa, management guidelines (Qualitative narrative review) recommend preventive aspirin for women at risk for hypertensive disorders without proteinuria but lack specific details on dosage and gestational age [15]. Overall, despite international recommendations to start low-dose aspirin (150 mg/night) before week 16 and stop before week 36 for high-risk women [41, 42].

Barriers

Clarity is lacking in the identification of prenatal care risks in the reviewed literature [23, 31]. In both Indonesia, as noted in a (Qualitative systematic review), and the Democratic Republic of the Congo, as observed in a (Cross-sectional study), there are significant barriers to adopting aspirin as a preventive strategy in hypertensive disorders of pregnancy (HDPs), according to local guidelines [23, 31]. Despite its inclusion in the Essential Medicines Lists (EML) [23], these barriers lead to inconsistent access to this critical medication.

Calcium

Concerning calcium consumption, South African guidelines (Qualitative study) advocate for the daily prescription of calcium gluconate supplements for all pregnant women, including those with chronic or gestational hypertension, as a preventive measure against the development of preeclampsia [30]. Conversely, in Indonesia (Qualitative systematic review), national guidelines propose calcium supplementation at doses ranging from 1.2 to 2.5 g/day for all pregnant women [31].

In Kenya (Prospective study), a program model aims to enhance the accessibility and provision of calcium supplements for preventing HDPs. The model involves comprehensive training for healthcare personnel and pregnant women, emphasizing the crucial role of calcium and ensuring its availability in healthcare facilities. The study employed two calcium regimens (1 g and 1.5 g), with better adherence observed for the 1-g regimen. However, adherence gradually declined as pregnancy advanced. These findings highlight the need to strengthen education for healthcare personnel and patients [21].

Barriers

The recommended dosage of calcium remains unspecified, leading to variations in practice, and occasional drug shortages further hinder the consistent administration of calcium [30]. Even in settings with a high availability of calcium (94%) and a high rate of supplement distribution (over 98%), 76% of patients did not receive the correct prescription, and adherence rates were only at 77% [21].

Management of HPDs

Antihypertensive management

  1. a

    When/where?

In LMICs there is consensus on immediate hospital treatment of severe arterial hypertension (systolic blood pressure (SBP) > 160 and diastolic blood pressure (DBP) > 110) [14, 19, 31]. In Indonesia, consider antihypertensive medication for outpatient treatment if blood pressure consistently exceeds 140/90 mmHg [42].

  1. b

    First-line treatment

In severe hypertension, there is a consensus that LMICs support immediate stabilization with recommended agents, including intravenous hydralazine, labetalol, and oral nifedipine, particularly in scenarios where venous access poses a challenge [14, 15, 19, 20, 34, 35]. An analysis of 91 EMLs from 144 LMICs (Cross-sectional study) revealed a wide range of antihypertensive therapies [32], whose selection factors include physician familiarity, availability, adverse effects, and teratogenic potential [19, 35]. In general terms (Prospective study), during the antepartum period, nifedipine and Alpha-methyldopa are often chosen to maintain arterial pressure; transitioning to amlodipine or an ACE inhibitor is recommended in the postpartum period [34].

South African guidelines (Qualitative narrative review, Feasibility study and Cross-sectional study) recommend using 10 mg of rapid-acting oral nifedipine or intravenous labetalol, followed by a maintenance regimen of 1 g of oral alpha-methyldopa [15, 28, 38]. Nitroglycerin is preferred for hypertension complicated by pulmonary edema [28]. The recommended treatment for mild preeclampsia involves the administration of alpha-methyldopa at a dosage of 500 mg three times a day [15]. In Latin America and the Philippines (Cross-sectional study and Feasibility study), administering bolus doses of oral hydralazine, labetalol, or nifedipine is the primary therapeutic approach [14, 38].

In the Philippines (Qualitative Narrative review), intravenous nicardipine is additionally recommended as a first-line management option [19]. In women presenting with well-controlled non-severe hypertension or chronic hypertension, these guidelines suggest antihypertensive use to maintain BP within specified ranges (SBP 130–155 mmHg and DBP 80–105 mmHg), with methyldopa, calcium antagonists, or beta-blockers [19]. In Nigeria (Feasibility study), community health workers often use amiloride, hydrochlorothiazide, or nifedipine as preliminary interventions before referring patients to health centers for complete treatment. Methyldopa and hydralazine are frequently adopted by nurses and physicians [38]. In Pakistan (Mixed method study), these teams also use methyldopa (250 mg) before referral [39].

Barriers: Despite the evidence from high-income countries (HIC) [19, 31], the management of chronic hypertension and non-severe hypertension suffers from a lack of clear, unified guidelines. In low- and middle-income countries (LMICs), the literature consistently highlights substantial challenges in the effective treatment of hypertensive disorders of pregnancy (HDPs). These challenges encompass a range of issues, including the absence of standardized in-hospital protocols [14, 23], limited availability of essential medications [23], insufficient recognition of different types of HDPs [30], and the underutilization of drugs for severe preeclampsia [16, 18, 38].

Non-hypertensive management

  1. a

    Magnesium sulfate

Most of the reviewed articles highlight the pivotal role of magnesium sulfate (MgSO4) in preventing and treating eclampsia, especially in resource-constrained settings due to its cost-effectiveness and empirical efficacy across diverse populations [17, 18, 24, 26, 28, 31, 32, 35, 39]. While MgSO4 is included in 84.6% of EMLs in LMICs (Cross-sectional study) [32], A comprehensive study across 15 countries (Cross-sectional study) in Africa, Latin America, and Asia, involving 147 health facilities, found that while magnesium sulfate (MgSO4) was consistently accessible in most surveyed facilities, its prevalence was notably lower in Africa compared to other regions [18].

A systematic review across LMICs identified 39 different MgSO4 dosing regimens, commonly involving a 4 g intravenous loading dose. However, variations in dosages and administration routes were prevalent, with unique practices such as a 10 g loading dose (4 g IV + 6 g IM) documented in Bangladesh, highlighting diversity in MgSO4 administration practices across LMICs settings [26]. In Latin America (Randomized clinical trial), a study reported a MgSO4 regimen involving a 4 g intravenous loading dose followed by 1 g per hour for 24–48 h, maintained until 24 h after delivery [20]. Research emphasizes the need to effectively incorporate MgSO4 into emergency obstetric protocols in developing nations to mitigate maternal mortality and optimize health systems [27, 37].

Barriers

Disparities exist in the availability and utilization of MgSO4 [14, 18, 27]. Studies in Ethiopia [40] and the Democratic Republic of Congo [23] reveal low use of MgSO4 prophylaxis, poor adherence to guidelines, and a significant gap between clinical recommendations and their implementation in hospital settings. Alarmingly, only 10% of health professionals monitor the potential toxicity associated with MgSO4 [23]. In Pakistan, rapid referrals lacking emergency care are attributed to a lack of familiarity with MgSO4, leading to a preference for diazepam [24]. The prevalent use of diazepam over MgSO4 is evident in several low-resource countries [17, 24, 36, 38, 39] despite MgSO4's recommended status [17, 24, 39].

Despite being safe and cost-efficient, the utilization of MgSO4 in LMICs is restricted due to uncertainties and lack of confidence among healthcare personnel [25, 28, 36]. Additionally, the documented concurrent usage of these two drugs raises potential safety concerns [24, 36].

  1. b

    Gestational age at delivery

The definitive treatment for preeclampsia is the delivery of the fetus and placenta [36]. The evidence from HIC advocates for mild preeclampsia planned preterm delivery at 37 weeks unless specific factors necessitate earlier intervention in instances where gestational hypertension or preeclampsia with severe features diagnosed at 34 weeks or later warrants prompt delivery after maternal stabilization, with an emphasis on not delaying decisions due to steroid administration. In cases of severe preeclampsia identified before 34 weeks, a reasonable approach involves considering expectant management if both maternal and fetal conditions are stable. However, individual patient circumstances must be carefully evaluated to determine the most appropriate action [42].

A feasibility study in India and Zambia to understand the disease burden and management of preeclampsia, including perceptions of patients and their families, was developed over three months before the conduct of CRADLE 4. The randomized, multicenter, open-label, parallel-group controlled trial was developed, comparing planned delivery versus expectant management in women with preeclampsia from 34 + 0 to 36 + 6 weeks of gestation (CRADLE 4). The objective was to evaluate whether planned delivery between 34 + 0 and 36 + 6 weeks of gestation can reduce maternal mortality and morbidity without increasing perinatal complications in India and Zambia. With 565 women, there was a significant reduction in severe maternal hypertension (adjusted RR 0.83, 95% CI 0.70 to 0.99) and stillbirth (0.25, 0.07 to 0.87) associated with planned delivery. Data showed that 19.5% of women with preeclampsia who gave birth beyond 34 weeks experienced an adverse outcome, and the lived experience of women and healthcare providers highlighted the severe consequences of preeclampsia. Preference for spontaneous birth and limited neonatal resources were identified as potential barriers [33].

The expectant management of remote severe preeclampsia at term was evaluated in the MEXPRE Latin Study. The study's objective was to determine whether expectant management of severe preeclampsia before 34 weeks of gestation produces better neonatal outcomes in resource-limited countries. It was carried out in 8 tertiary hospitals in Latin America. With a total of 267 patients, the perinatal mortality rate (relative risk [RR], 0.91; 95% confidence interval [CI], 0.34–1.93) did not improve with expectant management, nor did the combination of neonatal morbidity (RR, 01.01; 95% CI, 0.81–1.26). There were no significant differences in maternal morbidity (RR, 1.24; 95% CI, 0.79–1.94). However, small-for-gestational-age babies (RR, 2.27; 95% CI, 1.21–4.14) and abruption were more common with expectant management (RR, 5.07; 95% CI, 1.13–22.7; P = 0.01). There were no maternal deaths. Published evidence has shown that the possibility of renewing expectant management will depend on having well-equipped hospitals capable of addressing emergencies and guaranteeing continuous neonatal care in LMICs (Randomized clinical trial) [20].

Pregnancy monitoring and follow-up

Early and accurate diagnosis

Accurate and timely diagnosis is based on recognition of the risk factors for the development of HDPs, the presence of signs and symptoms, and biomarkers in prediction and management models [43]. Monitoring and educating pregnant women about danger signs that reflect hypertensive encephalopathy, including headaches and visual disturbances, is essential [15, 31, 36]. Studies in sub-Saharan Africa and Bangladesh (Cross-sectional study) highlight insufficient attention paid by health personnel to danger signs [14, 36]. In another study encompassing 643 health centers in LMICs, less than a quarter (24%) of women admitted to labor and delivery services were queried about potential signs of preeclampsia [36].

Barriers: There is a significant barrier in the development of diagnostic models for hypertensive disorders of pregnancy (HDPs) that integrate advanced biomarkers and tests. These models are predominantly available in tertiary hospitals and are not easily accessible in low- and middle-income countries (LMICs), presenting a considerable challenge to their widespread implementation [31].

Paraclinical monitoring

Women at risk of preeclampsia should undergo regular urinalysis for the identification of proteinuria [15, 27], laboratory examinations (kidney function (creatinine), liver function (AST, ALT), complete blood counts, LDH), and fetal well-being tests [15, 31]. In a study of 100 Ghanaian primary healthcare clinics (Cross sectional study), only 17% had on-site tests, forcing pregnant women to travel far to access facilities with the required diagnostic capabilities [22].

Barriers

The limited availability of essential tests outside tertiary hospitals in LMICs poses challenges in distinguishing between gestational hypertension and preeclampsia [22, 23, 36].

Place of hospitalization and precise BP control

Obstetric emergencies such as hypertensive crises and eclampsia, and the management of HDPs in general, require an adequate referral system and the centralization of patients in hospitals with the best diagnostic and management capabilities and intensive care units if necessary [20]. These recommendations are practically null in LMICs [44].

Several articles emphasize a need for more knowledge and skills of healthcare professionals providing maternal health services in primary healthcare facilities within these regions. A significant number of these healthcare workers deliver inadequate maternal care due to insufficient training in maternal health [14, 18, 23, 28]. Furthermore, this challenge is exacerbated by a shortage of adequately trained healthcare personnel and the absence of management protocols for preeclampsia within institutions [14, 18, 23].

Midwives in LMICs (Cross sectional study) operating within primary healthcare settings play a crucial role. They must possess specific knowledge to assess, diagnose, and effectively manage HDPs, given that they administer most pregnancy-related care. However, studies evaluating midwives' perceived knowledge and skills in managing HDPs reveal a concerning trend, with many midwives demonstrating an inability to identify and differentiate between HDPs [28, 29]. Despite some midwives exhibiting accurate knowledge (Qualitative study), skills, and competence in managing pregnant women with pre-eclampsia, a notable proportion still lacked proficiency [28, 30].

Barriers

The strict monitoring of blood pressure, the indications for invasive monitoring, the safety conditions for the use of medication, the training of teams, and the frequency of care have not been explicitly described, nor have they been adapted to the contexts of LMICs [15, 22, 23]. Some studies indicate that in certain LMICs, healthcare providers exhibit inadequacies when conducting comprehensive medical histories. They also struggle with distinguishing between HDPs [14, 18, 23, 28], employing suboptimal blood pressure measurement techniques, and infrequently using recommended medications such as magnesium sulfate (MgSO4) [18, 24, 39].

Discussion

This scoping review consolidates available international research on management and recommendations for HDPs within LMICs. The evidence identifies gaps in knowledge and implementation of evidence-based recommendations adapted to the LMIC context.

Despite advances in HIC, HDP-related preventable maternal mortality rates remain high in LMICs, especially in sub-Saharan Africa and South Asia [45]. It is feasible that the gaps found in this scoping review concern maternal and perinatal health indicators in treating eclampsia and may alleviate the challenges of standardized care. Structural deficiencies in health systems, such as inadequate equipment and training, prevent healthcare providers from delivering cost-effective interventions. Challenges persist even with essential commodities available [46] due to insufficiently trained providers and the absence of evidence-based care guidelines [47, 48]. A comprehensive approach that includes strategic investments, improved training programs, alert systems, and clear guidelines is crucial to ensure consistently high-quality maternal care in these regions [49,50,51]. Many LMIC adopt international recommendations in the absence of national policies. However, resource limitations pose a significant barrier to effective treatment. Despite the inclusion of essential medications such as antihypertensives and magnesium sulfate in these countries' EMLs [23, 32], these critical medications are often inaccessible for use or dispensing [14, 18, 21, 23, 27]. Even when accessible, underutilization may occur due to potential gaps in healthcare workers' essential knowledge about dosing, safety, and administration protocols [23, 24, 36, 40].

In 2001, the Institute for Healthcare Improvement (IHI) in the United States defined intervention packages (or bundles) as "small sets of evidence-based interventions for a defined patient population and care settings that, when implemented together, result in outcomes." significantly better than when implemented individually." From the point of view of managing obstetric emergencies, they correspond to multimodal strategies, which comprehensively address management involving multiple intervention points and actors. Applied to the HDPS approach, a quality prospective study showed that maternal morbidity would improve using a standardized approach to treat critically elevated blood pressure. In 23 hospitals in the USA, better compliance with treatment recommendations was reported (from 50.5% to more than 90%), and the use of intravenous blood pressure medication and magnesium sulfate increased. Maternal morbidity severe decreased by 16.7%, from 2.4 ± 0.10% to 2.0 ± 0.15% (P < 0.01). For LMICs, it is essential to organize the evidence in the context and around the HDPS bundles, defining state and national treatment guidelines with monitoring [52].

The reduction in the rate of eclampsia may be attributed to the additive or synergistic effect of the combined treatment of magnesium sulfate and an antihypertensive drug. Therefore, the generation of clear protocols for the prevention of eclampsia in people with severe preeclampsia and the acute treatment of eclamptic seizures at all levels of medical care is a priority to obtain better maternal and neonatal outcomes with appropriate and accurate use. of magnesium sulfate. Eclamptic seizures will occur in 2% of women with preeclampsia with severe features who do not receive magnesium sulfate and in < 0.6% of those who receive magnesium sulfate. For this reason, any national policy to reduce maternal mortality must address these concerns and promote awareness among health professionals of the use of MgSO4 in maternal health care in resource-limited settings [6]. The knowledge gap in an aspect as basic, economical, and cost-effective as the use of magnesium, associated with insufficient skills, has cascading effects, resulting in a high rate of maternal morbidity and mortality [28].

The second essential aspect of protocolization is the use of antihypertensive medications in preeclampsia and the risk of maternal stroke when it is not done appropriately. A retrospective cohort study with 301 hospitals and 239,454 patients with preeclampsia, which evaluated the use of antihypertensive medications (nifedipine, hydralazine, and oral and intravenous labetalol), showed a decrease in the risk of stroke from 13.5 per 10,000 births to 6. 0 with proper use of these medications (38% to 49%) in women with preeclampsia. It is necessary to extend these policies according to the availability and financial sustainability of the treatments always applied to the context but supported by the available evidence [53].

Hospitals that offer primary and specialized maternity services provide obstetric care for most pregnant women in the world, concentrating high-risk patients in hospitals with specialty and subspecialty services [54, 55]. Pregnant women with a high comorbidity index have a significantly higher adjusted relative risk of extreme maternal morbidity when the birth occurs in low-complexity hospitals (adjusted OR, 9.55; 95% CI, 6.83 to 13.35) compared with high-complexity hospitals (adjusted OR, 6.50; 95% CI, 5.94 to 7.09) [56].

The volume of patients for obstetric hospital care, the number of providers, and the hospital level determines maternal outcomes. Regionalized maternal care aims to maintain and increase access to care by developing, strengthening, and better defining relationships between hospitals within a region or care network. Therefore, generating evidence for LMICs must include the leveled care criteria and the effective treatment network adapted to each country's national policy [57,58,59].

With clear guidelines for medication use and essential supplies at the point of care, competency-based training and supportive supervision will ultimately enable frontline providers to meet the detection and treatment of HDPs. Therefore, the generation of knowledge must include the manner, periodicity, and monitoring of the training of health worker teams in HDPs. Evidence supports the effectiveness of sector team training. A comprehensive review of 23 published studies on obstetric emergency training has established that multi-professional training conducted at the obstetric unit level is the most effective model. This effectiveness arises from an emphasis on training teams to skillfully use tools aligned with local practices, such as charts and checklists, and fostering learning within local communities of practice. This approach prioritizes the practical application of knowledge and skills within the context of existing local practices rather than mere knowledge transfer [60].

With clear guidelines for medication use and essential supplies at the point of care, competency-based training and supportive supervision will ultimately enable frontline providers to meet the detection and treatment of HDPs. Therefore, the generation of knowledge must include the manner, periodicity, and monitoring of the training of health worker teams in HDPs. Evidence supports the effectiveness of sector team training. A comprehensive review of 23 published studies on obstetric emergency training has established that multi-professional training conducted at the obstetric unit level is the most effective model. This effectiveness arises from an emphasis on training teams to skillfully use tools aligned with local practices, such as charts and checklists, and fostering learning within local communities of practice. This approach prioritizes the practical application of knowledge and skills within the context of existing local practices rather than mere knowledge transfer [60].

Midwives are crucial in primary health care; however, the literature reviewed reveals a significant knowledge gap among midwives in accurately classifying and treating HDPs [28,29,30]. This finding is reinforced in multiple studies. A review of 29 articles in PBI and PIM related to midwives' knowledge of preeclampsia showed that midwives have knowledge deficits regarding risk factors, clinical manifestations, blood pressure assessment, monitoring, and medication administration in women with preeclampsia [61]. This underscores the critical need for continuing professional education encompassing theoretical understanding and clinical skills to enhance their competency in effectively managing HDP cases. The World Health Organization (WHO) has supported training traditional birth attendants to address maternal and neonatal mortality. Current evidence, although limited, suggests promising results. A systematic review of six studies involving 1,345 traditional midwives, 32,000 women, and 57,000 deliveries showed a significant 45% reduction in neonatal mortality rates in the intervention groups compared to controls (22.8% vs 40 0.2%, adjusted RR 0.54, 95% CI). 0.32 to 0.92). However, no significant impact on maternal mortality was observed [62].

Finally, although not the focus of this review, leveraging technology and implementing tools supported by artificial intelligence (AI) could assist healthcare personnel in identifying, diagnosing, and treating HDPs, particularly in rural care centers with limited access to specialized services. Implementing AI systems for managing preeclampsia could help overcome barriers by offering recommendations based on algorithms and predefined rules.

Results in context

Strengths and limitations

This review is the first to identify evidence and recommendations for managing hypertensive disorders of HDPs in LMIC. Despite the rigorous systematic search strategy, there may be unidentified studies and gray literature that were not included or considered. This could apply to national clinical practice guidelines from LMIC, which limits the ability to compare these guidelines with international recommendations. Although this aspect is beyond the scope of this study, it represents an area of significant interest for future research. The extrapolation of the results from this study should be approached with caution, as the unique conditions and barriers of the countries from which the recommendations originate must be considered.

Future implications

Reducing maternal mortality is part of one of the sustainable development goals and is what all countries aim for in public health, even when talking about global health. However, achieving this objective in LMICs is of greater importance because they are the ones that present the highest maternal deaths. With the enormous impact of HDPs on public health indicators in LMICs, it has been necessary to generate knowledge, standardize and disseminate the available and applicable evidence globally and implement the concept of bundles at the level of each country. For this, building management guides adjusted to each of the populations or countries involved is an immediate need. These guides must be built considering the availability of medicines, the perceptions of the communities, the health service providers available for the population, and high-quality health centers, among other aspects.

Relevance to clinical practice

Our study has unveiled significant challenges hindering the advancement of medical care for pregnant women in these regions. This research highlights the necessity of developing new tools for both the general population and healthcare professionals to recognize alarming situations. This is not only pertinent for improving patient outcomes but also for helping healthcare providers comprehend the multifaceted nature of maternal health, encompassing social, cultural, and psychological contexts.

Nevertheless, the formulation of guidelines alone is insufficient if LMICs lack access to essential pharmacological and technological resources. Therefore, it is imperative to ensure the distribution of key medicines and to persist in educating both healthcare personnel and patients. This multifaceted approach is essential to overcoming barriers and enhancing maternal care in resource-constrained settings.

Conclusions

This study concisely summarizes the available evidence regarding management recommendations for HDPs in LMICs. The significance of this contribution is underscored by the substantial challenges these countries face, encompassing limited access to vital medications, deficiencies in high-quality healthcare infrastructure, ongoing constraints in professional development, and the absence of up-to-date national clinical practice guidelines.

It is imperative to acknowledge that relying solely on guidelines from American or European contexts may not adequately address the unique needs and resource constraints specific to each LMICs. Therefore, a critical advancement involves the development of individualized medical management guides tailored to the distinct characteristics of each population. Furthermore, ensuring access to essential medical, pharmaceutical, and technical resources is paramount for reducing maternal mortality and improving healthcare outcomes in these regions.

This scoping review provides a knowledge base that can aid in the development of more effective healthcare strategies for managing HDPs in LMICs. Its findings can guide interventions in key areas such as improving the availability and utilization of essential medications, enhancing healthcare professionals' knowledge base and educating communities about HDPs. Addressing the identified shortcomings could mitigate the maternal and fetal risks associated with HDPs, thus elevating the overall quality of healthcare in these regions.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Data availability

All data supporting the findings of this study are available within the paper and its Supplementary Information.

Abbreviations

LMICs:

Low-and-middle income countries

HDPS:

Hypertensive disorders of pregnancy

EML:

Essential Medicines Lists

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Authors and Affiliations

  1. Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia

    María Fernanda Escobar

  2. Facultad de Ciencias de La Salud, Universidad Icesi, Calle 18 No. 122 -135, Cali, Colombia

    María Fernanda Escobar, Nicole Benitez-Díaz, Isabella Blanco-Londoño & Juan Sebastián Galindo

  3. Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia

    Catalina Cerón-Garcés, Evelyn E. Peña-Zárate, Lizbeth A. Guevara-Calderón, Laura Libreros-Peña & Juan Sebastián Galindo

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Contributions

LLP and EEP performed the literature search and reviewed the titles and abstracts, applying the inclusion criteria using a blind option provided by Rayyan. NBD, IBL, CCC, LAG, and EEP conducted independent reviews of the full-text studies included in the analysis, summarizing the pertinent information into standardized forms. EEP and LAG prepared Fig. 1. EEP, LLP, CCC, NBD, and LAG prepared Table 2. NBD, LAG, and MFE wrote the original draft of the manuscript. JSB provided methodological advice and reviewed the manuscript periodically until approval. All authors reviewed the manuscript, and MFE performed the final revision.

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Correspondence to María Fernanda Escobar.

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Escobar, M.F., Benitez-Díaz, N., Blanco-Londoño, I. et al. Synthesis of evidence for managing hypertensive disorders of pregnancy in low middle-income countries: a scoping review. BMC Pregnancy Childbirth 24, 622 (2024). https://doi.org/10.1186/s12884-024-06796-2

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BMC Pregnancy and Childbirth

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