Addressing hypertensive disorders of pregnancy in rural Uganda: a sustainable approach to workforce capacity development and global health education.

Hypertensive disorders of pregnancy are one of the major contributors to maternal death in low and middle income countries.ⁱ Ugandan women have had higher than expected morbidity and mortality rates due to hypertensive disorders with a case specific morality ratio of 1940 per 100,000 live births for severe preeclampsia.ⁱⁱ After assessing near miss cases defined by WHO criteria in over 2600 Ugandan women, severe preeclampsia was the highest cause of morbidity in a prospective cohort study.ⁱⁱⁱ This high burden has been attributed to “delayed recognition of hypertensive disorders” and “few numbers of lower level healthcare providers to recognize and manage complications.” ⁱⁱ

 OneWorld Health is a nonprofit organization that aims to provide sustainable and accessible healthcare to the people of rural Uganda. Masindi Kitara Medical Centre (MKMC), the main hospital operated by OneWorld Health, is a self-sufficient facility with an entirely Ugandan staff and affiliated clinics in Bulima, Kijunjubwa, and Bweyale.^iv We partnered with OneWorld Health to design and implement a curriculum aimed at addressing knowledge gaps in diagnosis and management of hypertensive disorders of pregnancy for midwives in Masindi, Uganda.

Our curriculum incorporated simulation and discussion while using Ugandan clinical guidelines and WHO practice guidelines as our main resource.^v,vi To supplement their learning and address knowledge gaps, we also formulated delivery guidelines for each subset of hypertensive disorder that was tailored to the healthcare capacity of their facility and accounted for recommendations given by WHO for low resource settings. These guidelines were reviewed by hospital leadership for appropriateness and later printed and hung throughout the maternity ward for reference by clinical staff. Amid preparing this curriculum, it was discussed that education and review of neonatal resuscitation was also an area of need given that many women with severe cases of preeclampsia were delivering preterm. As a result, neonatal resuscitation review was incorporated into the curriculum using Ugandan and WHO guidelines and educational materials from Helping Babies Breathe.^vii

Implementing this curriculum started with establishing strong relationships with the midwives, learning the ways in which they practiced obstetrics, and understanding how they wanted to grow as providers. With months of collaborative work, we were able to create an interactive curriculum that could be shared and facilitated with others. Each topic was introduced with an assessment of midwives understanding of hypertensive disorders and neonatal resuscitation. They worked in groups to present their own understanding and protocol for management. This was followed by review of Ugandan guidelines using case-based learning and ended with an assessment of knowledge and or simulation such as neonatal resuscitation using a NeoNatalie resuscitation mannequin.^vii Supplemental educational materials were provided, including PowerPoint slides and case-based learning with review questions regarding hypertensive disorders. Midwives were also given badge reminders highlighting clinical pearls for them to be able to carry easily on their person.

Throughout my career, I only dreamed of creating partnerships and implementing initiatives such as this. Growing up in multiple countries throughout my life, it made sense to me to pursue medicine as an interplay between the union of different communities and the shared value of health. What I didn’t realize was how challenging that would be. When we think of global health initiatives, particularly those in education and workforce capacity development, we are quick to impose our own biases and perceptions of how medicine should be practiced without considering that those practices were developed in entirely different communities with an entirely different set of resources. Our team prioritized using Ugandan and WHO guidelines, with incorporation of feedback that was feasible for their health system, leading ultimately to a sustainable curriculum centered on eliminating a major health disparity. More importantly, our work was led by the Ugandan medical community and made for Ugandan pregnant people.

Investing in education and professional development of midlevel providers and midwives in low- and middle-income countries is essential to ensuring equity for pregnant people, as many of them independently manage high risk obstetrical complications, such as hypertensive disorders of pregnancy, within rural communities’^{, ix, x} We believe our curriculum serves as an example for a successful and sustainable method of building capacity and achieving the universal goal of reducing maternal and neonatal morbidity and mortality in marginalized communities.

— Anna Marie Pacheco Young, MD, MPH

Dr. Young is a fourth-year resident at Northwestern McGaw Obstetrics and Gynecology. She will be matching into maternal fetal medicine fellowship this fall with the hope of continuing her work in serving marginalized pregnant patients and leading innovative programs and research focused on health equity and perinatal infections on a local and global scale.

1. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367(9516):1066–74.
2. Nakimuli et al. The burden of maternal morbidity and mortality attributable to hypertensive disorders in pregnancy: a prospective cohort study from Uganda. BMC Pregnancy and Childbirth (2016) 16:205
3. Nakimuli et al. Maternal near misses from two referral hospitals in Uganda: a prospective cohort study on incidence, determinants, and prognostic factors. BMC Pregnancy and Childbirth (2016) 16:24.
4. OneWorld Health. Accessed August 2024. https://oneworldhealth.com
5. Republic of Uganda Ministry of Health. Uganda Clinical Guidelines 2016: National Guidelines for Management of Common Conditions. Accessed August 2024. https://www.prb.org/wp-content/uploads/2018/05/Uganda-Clinical-Guidelines-2016-National-Guidelines-for-Management-of-Common-Conditions.pdf
6. World Health Organization. WHO Recommendations for prevention and treatment of preeclampsia and eclampsia, 2011. Accessed August 2024. https://iris.who.int/bitstream/handle/10665/44703/9789241548335_eng.pdf?sequence=1
7. American Academy of Pediatrics. Helping Babies Breathe 2^nd Edition. Accessed August 2024. https://www.aap.org/en/aap-global/helping-babies-survive/our-programs/helping-babies-breathe/helping-babies-breathe-2nd-edition/
8. Kruk ME, Larson E, Twum-Danso NAY. Time for a quality revolution in global health. Lancet Glob Health. 2016;4(9):e594-e596
9. World Health Organization. Standards for improving quality of maternal and newborn core in health
10. facilities [WHO website]. 2016. https://www.who.int/maternal_child_adolescent/documents/improving- mater nal- newbo rn- care- quali ty/en/. Accessed May 11, 2021.
11. Akachi Y, Tarp F, Kelley E, Addison T, Kruk ME. Measuring quality-of-care in the context of sustainable development goal 3: a call for papers. Bull World Health Organ. 2016;94:160-160A