Assessment of pre-eclampsia and eclampsia health commodities’ supply chains in selected hospitals of Lagos State during COVID-19 pandemic

1. Introduction

Pre-eclampsia and eclampsia (PE/E) are hypertensive disorders of pregnancy (HDP) that constitute significant causes of maternal mortality worldwide (Dulay, 2020). Pre-eclampsia is defined as the new onset or worsening of pre-existing hypertension associated with proteinuria in a pregnant woman after 20 weeks of gestation, while eclampsia is an unexplained generalized seizure in a patient with pre-eclampsia. Both conditions constitute a kind of spectrum of HDP, with untreated pre-eclampsia typically smouldering for a variable period before progressing to eclampsia in about 1 in 200 cases (Dulay, 2020). The classification of disorders under HDP comprises broadly gestational hypertension or pregnancy-induced hypertension, which is hypertension without proteinuria, pre-eclampsia, chronic hypertension or essential hypertension, which is pre-existing hypertension with or without superimposed PE/E (Program, National High Blood Pressure Education, 2000). However, most of the morbidity associated with HDP is caused by PE/E, with approximately 20 others suffering severe morbidity for every single death (Health Canada, 2004).

The HDP is estimated to cause approximately 185 maternal deaths worldwide, with an estimated 62,000 to 77,000 deaths annually (Khan et al., 2006). In addition, PE/E are significant pregnancy-related disorder that accounts for up to 10% of maternal deaths worldwide and around 14% of maternal deaths when combined with other hypertensive conditions of pregnancy (Say et al., 2014).

Abalos et al., in a systematic review of the global and regional burdens of PE/E involving 129 studies across 40 countries and a total of 39 million women estimated the global incidence of pre-eclampsia as 4.6% (95% uncertainty range 2.7–8.2) and global incidence of eclampsia as 1.4% (95% uncertainty range 1.0–2.0) per all deliveries with wide variations in patterns across regions of the world and the highest in the low- and middle-income countries especially sub-Saharan African (Abalos et al., 2013; Khan et al., 2006). These variations may reflect differences in the pattern of risk factors for developing PE/E across these regions. However, more importantly, the management modalities, their effectiveness and how readily available the essential items will play a significant role in the observed differences.

2. Logistics management of the essential commodities for pre-eclampsia and eclampsia in the health-care system

The third SDG of the United Nations is good health and well-being (Envision2030, 2015). As a prerequisite to the successful implementation of this vision, stakeholders are expected to ensure patients obtain medication that meets the six rights, affecting the product, the quality, the quantity, the time, the place and the cost (all must be right; Envision2030, 2015). PE/E are the second and third most common causes of maternal mortality, respectively, following postpartum haemorrhage (Olonade et al., 2019). While these deaths are avertible, the necessary drugs and instruments to treat these conditions are frequently unavailable in low-resource settings. This is further worsened by poor access to good health-care services.

Supply chain management is a significant component of the health-care system because it improves the availability of health commodities which is a critical facilitator for efficient health-care service delivery. An efficient health supply chain is the backbone for delivering essential supplies, including medicines and medical products. Supply chain management interruption occurs when critical products are unavailable when needed, and inventory management is not optimal (USAID | DELIVER PROJECT, 2011).

3. Methodology

4. Results and discussion

The availability of 13 (81%) of the 16 commodities tested was rated high (>80% availability index, i.e. health commodities were available in more than 40 of the 50 health facilities visited), while three (19%) were rated relatively high using the availability index (availability of items in the facilities), according to the findings of this study, detailed in Figure 1. The stockout rate varied among commodities over the period evaluated. For example, chemistry urine analysis strip had (22%) and (40%) stockout rates for the day of evaluation and six months earlier, respectively. The stock out rates of other commodities in the facilities on the day of the visit and six months earlier were as follows: hydralazine (20%) and (20%), labetalol injection (8%) and (20%), antihypertensive drug pill (24%) and (24%) and pressure gauge (8%) and (8%). These results indicated that urine analysis strip and labetalol injection as of the time of the visit had a lower percentage of stock out rate than six months earlier.

Some facilities have stock out of some items on the day of the visit and in the previous six months, which is different in all facilities with stock out. For example, eleven facilities have stock out on the day of the visit, and up to 20 have stock out in the last six months for urinalysis strips. This availability of items is not unique to the facilities, and since more facilities did not have the urinalysis strip in the previous six months (40%) and the urinalysis strip was available in more facilities on our day of visitation, since they had lower stock out of 22%.

These findings contradict an earlier report that stated the reduction in the supply of health commodities during COVID- 19 pandemic (Okafor et al., 2021). The timing of our data collection, which was early into the pandemic (January to mid-February 2020) when the impacts on the changes in the sixteen essential commodities for PE/E might have yet to occur, may explain the differences in our findings.

However, as shown in Figure 2, five (31%) items were out of stock during the visitation period and six months before the visits. Our study’s stockout result appeared moderate but remained a significant observation because of the health commodities involved considering their significance in diagnosing and managing PE/E. Among the items out of stock were urinalysis strips, labetalol injection, labetalol tablet and hydralazine injection. Urinalysis strips are used at routine antenatal visits to detect proteinuria, which in its presence, coupled with elevated blood pressure after 20 weeks of gestation, is diagnostic of PE. Likewise, labetalol and hydralazine are antihypertensive agents used in controlling hypertension associated with PE/E. These stockout records raised concerns that the facilities in the state where they were recorded would not have been well positioned for early diagnosis, prevention and management of PE/E at such periods, a scenario with potential attendant poor obstetrics outcomes. These concerns are consistent with the findings of Nkamba et al., who showed poor availability of supplies to diagnose, prevent and treat pre-eclampsia in 30 primary health centres (PHCs) and 28 referral facilities (hospitals) randomly selected in Kinshasa, Democratic Republic of Congo with poor knowledge about the prevention and management of PE/E among the health-care providers studied despite their excellent knowledge about diagnosis (Nkamba et al., 2020). Similarly, gaps in knowledge and clinical practices in the detection and management of PE/E among safe birth attendants (SBA) in Afghanistan, despite adequate supplies of required medicines and commodities, have been identified to increase the risk of maternal and perinatal mortality (Ansari et al., 2019). It would, therefore, be essential to research the impacts of the knowledge base of the health workers in Lagos State and other parts of Nigeria in the nearest future, learning from findings from these other developing countries.

Furthermore, the implications of health commodities stockouts have been well illustrated by a study among women in Akwa Ibom state, South-Southern part of Nigeria, where stockout and availability of health commodities in public health institutions were demonstrated to be associated with hazards and relapses of the people’s illnesses due to noncompliance with treatment prescriptions, fake drugs, exposure to expired and drugs that are adulterated (Ikoh et al., 2009).

The availability of Magnesium Sulphate in this study was 100% in all health facilities visited. In contrast, another study from Nigeria reported a lower availability of 47.4%. It noted that better knowledge and awareness of the health professionals in using magnesium sulphate might contribute to its availability (Duduyemi et al., 2019). However, a study done in Addis Ababa revealed insufficient knowledge and awareness about the level of importance of magnesium sulphate and reported 63% availability (Damtew et al., 2019).

All the 50 health facilities studied observed nine (75%) out of the twelve storage pointers, and 36 (72%) had an ideal score of all the factors for storage condition. It is observed from this study that “13 health commodities (81%)” for PE/E of pregnancy within the essential drug’s list (based on the WHO availability index – >80%) are available; there were still some public hospitals with a few of the commodities below 80%.

Of all the 50 health facilities involved in the study, only 36 (72%) had a perfect score of 100%, as they fulfilled all the storage condition criteria and maintained acceptable storage conditions. In addition, as shown in Table 1, all 50 (100%) facilities have good storage conditions by meeting at least nine of the twelve criteria defined for storage conditions.

According to the survey results, 4% of the facilities visited failed to protect their products and cartons from water and humidity and could not free the storage area from insects and rodents. As observed in these facilities, the effects of high humidity and exposure of pharmaceutical products to water are complementary, causing the products to absorb water from the environment. These results in degradation and sometimes toxicities in some products, compromising the affected products’ safety, effectiveness and potency. The World Health Organization has recommended an optimal storage condition for pharmaceutical products of room temperature between 15°C and 25°C (59°–77°F) and relative humidity levels around 50%. An increase in relative humidity from 60 and above is potentially dangerous as it enhances the growth of bacteria, mould, fungi and mites. On the other hand, low humidity also results in static build-up, which could dry out medications and affect the intended actions of the solvents used in their production (Kelly, 2018; Szakonyi and Zelkó, 2012).

Similarly, the observed access of storage areas to rodents and insects potentially carries many risks to the integrity of the products and the overall safety of the end users. There is increasing evidence in recent times showing that antimicrobial resistance occurs in insects, wildlife, rodents and birds. Several insects, including edible ones and those commonly found in households like cockroaches, houseflies, ants, mosquitos, mice and rats, have been reported to harbour antimicrobial-resistant pathogens (Odetoyin et al., 2020; Desvars-larrive et al., 2019; Obeng-Nkrumah et al., 2019).

The products affected by inadequate water and humidity exposures and infestation by insects and pests when the products are used are likely to be non-efficacious. Therefore, centres that may observe some due diligence and put the usage of such compromised products on hold could lead to the non-availability of such products when needed.

While commending the centres that met the set criteria for adequate product storage, adequate measures must be put in place to achieve optimal storage conditions according to international best practices, especially in those facilities that recorded inadequate storage indices. These should include training, capacity building and deployment of necessary instruments and such conditions should be monitored and documented as recommended for quality assurance.

Furthermore, 24% of hospitals needed more storage room for medical supplies. The shortage of storage capacities may be because the current structures and facilities in use at these institutions were similar and have been in use for decades with no expansion.

Presumably from the literature search, this is the first study in Lagos State, Nigeria, to assess the logistics management systems of PE/E health commodities using validated tools (LIAT) by USAID.

The limitation of this study is the number of health facilities studied relative to the total number of health facilities in Lagos State. However, this does not invalidate the outcome and strength of this study, and our findings constitute an indicator of the status of health commodity supplies for PE/E in Lagos State. The fact that maternal and perinatal morbidity remains unacceptably high within the country despite the demonstrated high availability of the studied commodities and medicines calls for a more critical appraisal of the likely causes of mortalities. These perhaps will include questions on access to health-care facilities, lack or inadequate attendance of antenatal care services, delayed presentations and non-affordability of the commodities as the majority of the population still pay for health care “out of pocket”, a situation worsened by poverty and the socio-economic hardships highly prevalent in the country (Ewelukwa et al., 2013). These findings should inform appropriate interventions.

5. Conclusion

This study centred on the availability, stockout rate and storage conditions of PE/E health commodities in selected public health facilities – secondary and primary levels. The availability of pre-eclampsia health commodities within the facilities varied from a relatively high to high availability index. In addition, we found inadequate storage capability for the selected health commodities.

Overall, the availability of the product, the stock out rate, and the storage conditions from this study indicate a necessity to emphasize and encourage the health-care managers on the need for adequate storage conditions and availability of PE/E health commodities to reduce and possibly eliminate maternal mortality in our community.

The inaccessibility and improper storage of PE/E health commodities in public health facilities might worsen MMRs. Subsequently, it may negatively impact the SDG 2030 goal of good health and well-being.

COVID-19 impact on the outcome of the study may not be established since there needed to be more longitudinal basal data on the supply chain of PE/E items in the studied health facilities before the pandemic. Nevertheless, our results outlined the state of the PE/E essentials items in the studied health facilities. Therefore, health facilities should prepare their PE/E health commodity list and adequately monitor the supply chain and logistics management system. Also, regular supportive supervision would be essential. Furthermore, the ministry of health should take action in Lagos to strengthen the state’s health logistics management structure while formulating policies to improve access and utilization of available maternal and perinatal services.