Background

Global Context for Maternal Health

Maternal morbidity and mortality are key indicators of health that hold longitudinal economic and social consequences [1]. Almost 95% of maternal deaths occur in developing countries, but the majority are preventable with timely and effective care [2]. The United Nations has a Sustainable Development Goal to reduce global maternal mortality to less than 70 per 100,000 live births by 2030 [3]. Nigeria has the largest burden at 917 deaths per 100,000 live births, accounting for 23% of global maternal deaths. Among women in Nigeria of reproductive age, 24.3% of all deaths are due to pregnancy complications and the lifetime risk of maternal mortality is 1 in 19 [4]. 

State of Postpartum Care in Nigeria

The highest incidence of maternal deaths occurs in the six weeks after birth when the mother’s care is often transferred from an obstetrician to a primary care provider [5,6]. There is currently no standardized, evidence-based protocol regarding the essential elements of postnatal care, although the World Health Organization (WHO) recommends postpartum women should have contact with healthcare providers within 24 hours, at day three, between days 10-14, and 6 weeks post-delivery to mitigate potential risks and complications [7,8,9]. Despite this, only 38% of women and 42% of newborns in Nigeria received a postnatal check in the first two days after birth, and 58% of women had no postnatal checkup [10,11]. Common factors limiting the ability of women in developing countries to access postnatal care include low maternal education, perception of quality of services, user fees, and attitudes of healthcare providers [12,13]. There is also a large disparity in early postnatal care by location of delivery, where less than 20% of mothers delivering outside facilities received skilled postnatal care within two days of birth, compared to 80% in facilities [14]. It is estimated that if 90% of women and babies received postnatal care, 10-27% of newborn deaths could be averted in Africa, saving over 300,000 lives a year [8].

Hypertensive Disorders of Pregnancy

The leading causes of maternal deaths in Nigeria are hypertensive disorders of pregnancy (HDP), which are associated with increased risks of long-term cardiovascular disease, such as stroke, heart failure, and myocardial infarction, as well as adverse fetal outcomes, such as preterm birth, low birth weight, neonatal death, and poor cardiometabolic profiles [15,16,17,18]. The prevalence of hypertension (HTN), defined as a blood pressure (BP) greater than or equal to 140/90 mmHg, is 30.6% in Nigeria, with treatment and control rates at 12% and 3%, respectively [19]. About 1 in 10 maternal deaths in Sub-Saharan Africa are caused by HDP,  most of which can be avoided with comprehensive postpartum follow-up and BP monitoring, as recommended by the American College of Obstetricians and Gynecologists and the WHO [20, 21, 22, 5, 23]. Even for women without a history of HTN, BP often increases after delivery, with a peak between three and eight days postpartum [24].

Need to Adapt Systems to Resource-Limited Setting

In the United States, home BP monitoring has been successful in identifying and treating cardiovascular complications [25]. There have been small randomized trials investigating text-based remote monitoring BP systems, but these require substantial time commitments from researchers, healthcare providers, and the patient [26]. Thus far, these systems have only been implemented in English, however, the languages of Hausa, Yoruba, and Igbo are native to 30 million, 19 million, and 24 million, respectively [27]. Additionally, over 25% of Nigerians have inadequate health literacy, posing challenges to the comprehension of monitoring information [28]. 

Feasibility of Remote Blood Pressure Monitoring in Global Sphere

Remote monitoring systems are increasing in prevalence in sub-Saharan for the management of non-life-threatening diseases [29]. With the expansion of technology access in LMICs, internet access in urban African populations has risen drastically, with 64% of individuals actively accessing the internet and 61% owning at least one mobile phone [30]. In this landscape, it would be beneficial to create remote blood pressure monitoring (RBPM) systems with automatic messaging to the healthcare team to circumvent text-based infrastructure and audio translation of the result into the mother’s native language. Dr. Zainab Mahmoud and the Dr. O’Brien Laboratory at Washington University in St. Louis aim to solve global problems in maternal-fetal health and reproductive disease, and thus is an ideal client to collaborate with on this issue. Researchers in this lab have previously assessed small-scale, text-based RBPM in Nigeria and this project aims to create more sustainable systems that can be widely implemented for diverse populations. 

References

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