Factors affecting use of magnesium sulphate for pre-eclampsia or eclampsia: a qualitative evidence synthesis.

BACKGROUND: Hypertensive disorders account for 14% of global maternal deaths. Magnesium sulphate (MgSO4 ) is recommended for prevention and treatment of pre-eclampsia/eclampsia. However, MgSO4 remains underused, particularly in low- and middle-income countries (LMICs).
OBJECTIVE: This qualitative evidence synthesis explores perceptions and experiences of healthcare providers, administrators and policy-makers regarding factors affecting use of MgSO4 to prevent or treat pre-eclampsia/eclampsia. SEARCH STRATEGY: We searched MEDLINE, EMBASE, Emcare, CINAHL, Global Health and Global Index Medicus, and grey literature for studies published between January 1995 and June 2021. SELECTION CRITERIA: Primary qualitative and mixed-methods studies on factors affecting use of MgSO4 in healthcare settings, from the perspectives of healthcare providers, administrators and policy-makers, were eligible for inclusion. DATA COLLECTION AND ANALYSIS: We applied a thematic synthesis approach to analysis, using COM-B behaviour change theory to map factors affecting appropriate use of MgSO4 . MAIN
RESULTS: We included 22 studies, predominantly from LMICs. Key themes included provider competence and confidence administering MgSO4 (attitudes and beliefs, complexities of administering, knowledge and experience), capability of health systems to ensure MgSO4 availability at point of use (availability, resourcing and pathways to care) and knowledge translation (dissemination of research and recommendations). Within each COM-B domain, we mapped facilitators and barriers to physical and psychological capability, physical and social opportunity, and how the interplay between these domains influences motivation.
CONCLUSIONS: These findings can inform policy and guideline development and improve implementation of MgSO4 in clinical care. Such action is needed to ensure this life-saving treatment is widely available and appropriately used. TWEETABLE ABSTRACT: Global qualitative review identifies factors affecting underutilisation of MgSO4 for pre-eclampsia and eclampsia.

Introduction

Pre‐eclampsia and eclampsia are hypertensive disorders of pregnancy experienced by 4.6% and 1.4% of women, respectively, during pregnancy and childbirth. They are characterised by high blood pressure, proteinuria and (once progressed to eclampsia) seizures, which can be fatal to both woman and baby. , Hypertensive disorders are the second leading direct cause of maternal mortality, accounting for 14% of maternal deaths. However, the precise contribution is unknown for many low‐ and middle‐income countries (LMICs) because of suboptimal detection and reporting of these conditions.

Magnesium sulphate (MgSO4) is recommended by the World Health Organization (WHO) for women with severe pre‐eclampsia/eclampsia, and has been proven to be effective in major trials , and meta‐analyses. , , , Administering MgSO4 to women who have pre‐eclampsia halves their risk of developing eclampsia, and more than halves their risk of death. MgSO4 is cost‐effective and safe, , , , , and has been on the WHO Essential Medicines List since 1996. , The current WHO recommendation for severe pre‐eclampsia/eclampsia is the administration of a full intravenous/intramuscular regimen, including an initial loading dose and maintenance doses over 24 hours. Women must be monitored for signs of magnesium toxicity between doses, therefore it is recommended that MgSO4 be administered in health facilities with adequate staffing and clinical resources for monitoring. Alternative dosage regimens of MgSO4 are also being evaluated. ,

Despite strong evidence of effectiveness and cost‐effectiveness, MgSO4 is often underused for these indications, , , , particularly in LMICs. Previous research has explored factors affecting MgSO4 guideline implementation, identifying system and market failures that restrict drug availability, absence of clinical protocols and staff reluctance. , , , However, to our knowledge, no systematic review has synthesised evidence on factors affecting use of MgSO4 for women with pre‐eclampsia/eclampsia. A qualitative evidence synthesis (QES) may help to understand why MgSO4 is not more widely adopted in practice. The aim of this QES is to explore the perceptions and experiences of healthcare providers, administrators and policy‐makers regarding factors affecting use of MgSO4 to prevent or treat pre‐eclampsia/eclampsia administered globally, and to develop a conceptual understanding of how these factors influence MgSO4 use.

Methods

We followed the Cochrane Effective Practice and Organisation of Care (EPOC) QES guidance and report our findings according to the ‘Enhancing transparency in reporting the synthesis of qualitative research’ (ENTREQ) statement (Appendix [Link], [Link]); the review protocol is registered with PROSPERO (CRD42020167185). There was no patient or public involvement, and a core outcome set was not applicable in this review.

Inclusion criteria

Eligible studies considered factors affecting use of MgSO4 (any dosage regimen) for pre‐eclampsia/eclampsia prevention or treatment during the antenatal, intrapartum and postpartum periods. Eligible studies included participants who were health system stakeholders (policy‐makers, administrators, health workers and lay health workers). Eligible studies were conducted in healthcare facilities of any level (e.g. hospitals, clinics and primary health care) in any country. Home or community settings were excluded as MgSO4 is not recommended for use outside healthcare facilities. Eligible studies were primary studies using qualitative methods for data collection and analysis. Conference abstracts, posters and clinical case studies were excluded. Mixed‐method studies were eligible if they used qualitative data collection and analysis methods.

Search methods

We searched MEDLINE, EMBASE, Emcare, CINAHL, Global Health and Global Index Medicus for studies from 1 January 1995 (when the Eclampsia Collaborative study definitively established MgSO4 as an effective treatment for eclampsia ) to 28 June 2021. Search strategies were developed using MgSO4, anticonvulsant, pre‐eclampsia/eclampsia and hypertension terms (Table [Link], [Link]). We did not use a methodological filter. We searched OpenGrey, AHRQ, NICE, Jhpiego, Population Council, WHO international and Google Scholar for grey literature, and reviewed reference lists of included studies. , , , ,

Study selection and data extraction

Two reviewers (from KEE, RIZ, MAB, JPV) independently reviewed each title and abstract for eligibility. We retrieved full texts for potentially relevant studies and two reviewers independently assessed eligibility (from KEE, RIZ, MAB). Disagreements at either stage were resolved by discussion, involving a third reviewer if necessary. We used Google Translate to translate titles and abstracts published in languages other than English; where translation indicated possible inclusion, we planned to list as ‘studies awaiting classification’ (no articles met these criteria). Where more than one paper reported the same study (using the same sample and methods), the papers were collated to ensure the study was the unit of interest. A data extraction form was developed and used to extract data on context and design, and qualitative data (author themes, interpretation and participant quotes).

Methodological limitations of included studies

Critical appraisal of included studies was conducted by two reviewers independently (KEE, RIZ) using an adaptation of the Critical Skills Appraisal Programme (CASP) tool. Consensus was reached through discussion. We assessed study aims, methodology, design, recruitment, data collection, data analysis, reflexivity, ethical considerations, findings and research contribution. We did not exclude studies based on this assessment, but used the assessments in GRADE‐CERQual (Confidence in the Evidence from Reviews of Qualitative Research) assessments.

Data management, analysis and synthesis

We used an inductive ‘thematic synthesis’ approach to synthesise themes emerging from the data (KEE, RIZ, MAB). We began by free line‐by‐line coding results of five highly relevant studies covering different health system levels and stakeholder types. Codes were organised into a hierarchy, grouping related codes under descriptive themes. Results from included studies were coded line‐by‐line in nvivo using the codebook, which developed iteratively throughout analysis. Text assigned to each code was checked for consistency and further division into sub‐codes. We developed higher‐order analytical themes to identify health system factors affecting use of MgSO4. We then used COM‐B behaviour change theory to explore and categorise health system stakeholders’ Capability, Opportunity, Motivation to appropriately use MgSO4.

Confidence in the review findings

Two review authors (KEE, RIZ) used the GRADE‐CERQual approach to assess confidence in each review finding, based on methodological limitations, coherence, adequacy and relevance. We assessed each component by levels of concern (no or very minor/minor/moderate/serious), then made a judgement about the overall confidence in the review finding (high/moderate/low/very low). All findings started as high and were downgraded where concerns about GRADE‐CERQual components were identified. We present summaries of findings and GRADE‐CERQual assessments in a summary of qualitative findings table (Table [Link], [Link]) and evidence profile (Table [Link], [Link]).

Reflexivity

We maintained a reflexive stance throughout the review process and regularly discussed and critically reflected on our positionality. , At the outset of this review, the review team considered that MgSO4 is an effective intervention that should be used for prevention and treatment of pre‐eclampsia/eclampsia, and that health system barriers probably limit the implementation in practice. The review team has expertise in public health (KEE, RIZ, JPV, MAB), women's health (KEE, RIZ, JPV, MAB), health economics (KEE), social science (MAB), medicine (JPV) and epidemiology (KEE, RIZ, JPV, MAB). We remained mindful of our presuppositions to minimise the risk of these skewing our analysis or interpretation. , Specifically, we used refutational analysis techniques, such as exploring and explaining any contradictory findings between studies.

Results

We included 25 papers from 22 studies (Figure 1, Table 1), published between 2005 and 2021. One global study was conducted in 24 countries, the remaining 21 studies were conducted in 12 countries: Bangladesh, Brazil, Ethiopia, India, Kenya, Malawi, Mexico, Mozambique, Pakistan, Nigeria, South Africa and Zimbabwe. All but the global study were from LMICs. Studies included perspectives of facility administrators, , , , , , , , , , , , , , , health researchers, , , , policy‐makers, , , , , , , , , , doctors, , , , , , , , , , midwives/nurses, , , , , , , , , , and community health workers. , ,

Figure 1

PRISMA diagram.

Table 1

Characteristics of included studies

Author and year	Country	Type and number of participants	Data collection	Data analysis
Aaserud 2005	Multiple	Doctors, midwives, researchers, health managers	Observations, 5 group discussions	Thematic and policy framework analysis
Alabintei 2021a,b	Nigeria	Health‐facility managers	29 key informant interviews	Thematic analysis
Barua 2011	India	Nurses, clinicians, obstetricians and gynaecologists	7 FGDs	Grounded theory
Bigdeli 2013	Pakistan	Healthcare providers, policy‐makers, academics	Document review, 48 IDIs, unknown number of FGDs, observation	Deductive content analysis
Charanthimath 2018	India	Community leaders, doctors, administrators	14 FGDs and 12 IDIs	Thematic analysis
Chaturvedi 2013	India	Doctors, administrators, district health officials, and programme managers	39 IDIs, observation, record analysis	Thematic analysis
Chikalipo 2020	Malawi	Nurses, midwives, technicians	1 FGD and 10 IDIs	Thematic analysis
Danmusa 2014 & 2016	Nigeria	Global experts, local key informants and stakeholders	23 IDIs	Not specified
Hossain 2019	Bangladesh	Policy‐makers and programme managers	37 IDIs	Content and thematic analysis
Ishaku 2019	Nigeria	Policy‐makers and programme stakeholders	64 IDIs	Content and thematic analysis
Lotufo 2016	Brazil	Healthcare managers	Document analysis, observation, interviews	Deductive content analysis
Lotufo 2017	Brazil	Obstetricians	30 IDIs	Content analysis
Ndwiga 2018	Kenya	Policy‐makers, midwives, doctors, community health workers, and traditional birth attendants	98 IDIs	Thematic analysis
Oguntunde 2015	Nigeria	Healthcare facility manager	30 IDIs, survey, observational checklists	Thematic analysis
Ramadurg 2016	India	Nurses, Auxiliary Nurse Midwives, accredited social health activist (ASHAs)	8 FGDs, surveys	Thematic analysis
Raney 2019	India	Nurse mentors	12 IDIs	Thematic content analysis
Sheikh 2016	Pakistan	Lady health workers, lady health supervisors, traditional birth attendants, doctors	7 FGDs and 26 IDIs	Thematic analysis
Sripad 2018	Ethiopia	Policy‐makers, health officers, representatives from MoH and professional associations	62 IDIs	Thematic analysis
Van Dijk 2013	Mexico	Maternal health researchers, doctors	13 IDIs	Content analysis
Warren 2015a	Nigeria	Policy‐makers and programme stakeholders	72 IDIs	Content analysis
Warren 2015b	Bangladesh	Policy‐makers and programme manager stakeholders	50 IDIs	Content and thematic analysis
Woelk 2009 and Sevene 2005	Mozambique, South Africa, Zimbabwe	Policy‐makers	Document review, 49 IDIs	Thematic analysis

Danmusa 2014 and Danmusa 2014 are from a single study; Woelk 2009 and Sevene 2005 are from a single study; Alabintei 2021 and Alabintei 2021 are from a single study.

FGD, focus group discussion; GD, group discussion; IDI, in‐depth interview; MoH, Ministry of Health.

Studies primarily used in‐depth interviews and/or focus group discussions. Detailed critical appraisals are provided (Table [Link], [Link]); the primary reasons for downgrading were limitations in recruitment/sampling strategies, reflexivity, informed consent and ethics approval, data analysis, and insufficient evidence to support findings. Explanations for GRADE‐CERQual assessments are in Table [Link], [Link]: of 28 review findings, we graded ten as high confidence, 17 as moderate confidence and one as very low confidence. The primary reason for downgrading was for relevance – this was a global review with almost all evidence from LMICs.

Qualitative synthesis findings

We developed nine overarching themes under three domains: provider competence and confidence, health system capability and knowledge translation (Figure 2). Table [Link], [Link] presents the summary of qualitative findings and CERQual assessments.

Figure 2

Domains and themes.

Provider competence and confidence

Attitudes and beliefs about MgSO

MgSO , , , , , , , , , Providers in two studies were more aware of MgSO4’s effectiveness for eclampsia than severe pre‐eclampsia, , potentially because effectiveness was first demonstrated for eclampsia.

Some providers preferred alternative drugs (particularly diazepam and phenytoin) because of past training, less cumbersome protocols for use, perceived safety or familiarity. Providers’ decisions to use alternatives may be based on positive attitudes towards the alternative, or negative perceptions of MgSO , , , , , , Many providers were trained and comfortable in using diazepam; for some, familiarity outweighed ‘newer’ and less familiar MgSO4 regimens. , , Compared with diazepam, MgSO4 was considered more difficult to administer and less safe. , Phenytoin was considered an alternative treatment in India and Mexico, where some believed it to be superior. ,

Fear of complications or adverse events from MgSO , , , , , , , , , , Providers’ fear, caution and concern were most commonly due to their perceived risk that complications may cause harm or death. , , , , , , , , , , Some providers held persisting beliefs about the “toxicity” of MgSO4. , , , For some, fears were based on lived experiences. , Fears can lead providers to feel inadequate or stressed using MgSO4, , , resulting in hesitation or avoidance. ,

Complexities of administering MgSO

, , , , , , , , Some providers were unsure about recognising disease severity (mild versus severe pre‐eclampsia) and indications for MgSO4 use. , , Providers also experienced confusion about methods for administration, , , , and believe that administration is difficult. , , However, some felt those not using it are ‘lazy’.

, , , , , , Training may be inadequate or incorrect, and requirements are harder to remember when pre‐eclampsia/eclampsia is encountered relatively infrequently. Variability in local dosage regimens causes confusion, , and MgSO4 packaging sizes differ from recommended dose amounts. , Difficulties with dosing lead to providers delaying or avoiding MgSO4 use. ,

, , , , , , Monitoring is considered resource and labour‐intensive, contributing to a perception that MgSO4 can only be used in higher‐level facilities. , , , ,

, , , , , , , , There were diverse views about what cadres of provider should administer MgSO4. , , , , , , Some considered that it can only be administered by doctors, , , , , whereas others felt that trained nurses and midwives can administer it. , , , Concerns included that lower cadres may not have sufficient skills or motivation to monitor women post‐administration, and allowing them to administer could result in abuse or harm.

Provider knowledge and experience of MgSO

Knowledge about the benefits and risks of MgSO , , , , , , , , , Limited knowledge can lead to inappropriate practice, such as sending a woman home after administering the loading dose.

, , , , , , , , , , , , , , Training increases perceptions that providers can administer MgSO4 correctly. , , , , Training is more likely to be effective if it is practical , , , and recent. , ,

Practical, first‐hand experience administering MgSO , , , , , , , , , Observing the positive effects of MgSO4 influenced providers' attitudes, becoming ‘convinced’ and advocating for its use. ,

Health system capability

Availability of MgSO

, , , , , , , , , , , , , , , Stock‐outs occur across different facility levels, including primary care settings, secondary and tertiary hospitals, and rural facilities. , , , , Even in settings where MgSO4 is available there can be a disconnect between perceptions of system‐level and facility‐level availability, with those in administrative or policy roles unaware that stock‐outs are occurring, or those at facility‐level unaware that it is available to procure. , , , , Access is less likely to be a problem in high‐income countries.

Supply chain issues: manufacturing, marketing, logistics and procurement

, , , , , MgSO4 may not be registered for use in all settings. , , Reasons include that policy‐makers may be unconvinced it is necessary, with some believing diazepam is equally effective.

13, 14, 18, 29, 44, 51, 52

, , , , , , , , , Several studies note the importance of distribution and logistics for MgSO4 access, , , , and the presence of bottlenecks and problems in distribution. , , Providers described expiration of MgSO4 because of relatively infrequent use, particularly at lower‐level facilities. ,

, , , , , , , , Problems with procurement included: mismatched demand from hospital departments and national medicines lists, clinicians failing to request MgSO4, , exclusion of MgSO4 from central procurement, , and complex, unreliable requisition processes. , , Failures can occur at central or local government levels, , or facility‐level. , Primary and community health facilities are more likely to experience problems obtaining MgSO4. , If pre‐eclampsia/eclampsia is not encountered often or is considered uncommon at a facility, administrators may choose not to procure MgSO4. Failures in national procurement systems contribute to stock‐outs. , , , , , , , Procurement could be more effective with improved supply monitoring, transparency regarding quantities required, and facility‐level coordination to match supply and demand.

, , , , , , Private purchase may be required because of facility stock‐outs, , , , or as standard practice to manage demand. , , , Retail outlets generally charge higher prices. , ,

Adequate resourcing: equipment, supplies, facilities and staffing

28, 29, 48, 49, 53, 56, 57, 59, 61, 62

, , , , , , , , , , Staff shortages occurred across multiple levels, involving nurses, , , midwives, , , doctors , , , , , , and paramedics, at primary and community health centres , , , , , or hospitals. , , , , ,

Perspectives varied on appropriate facility level(s) for administration of MgSO , , , , , , , , , , Some suggested that MgSO4 could be used at primary health facilities or emergency mobile health services with training and resourcing; , , others felt use in primary health settings was inappropriate. , , , Use of MgSO4 may not always occur at lower‐level hospitals. , ,

Pathway to care for pre‐eclampsia/eclampsia: antenatal care, referral systems and loading dose administration

46, 51, 53, 58, 60

46, 48, 52, 53, 58, 61, 62

, , , , , , , , , , Loading dose administration is considered less complicated than the full regimen, described by some as ‘easy’ and ‘safe’. , Administration of a loading dose was considered necessary because of barriers for women from rural areas accessing higher‐level care , , , and skilled staff shortages. , However, a loading dose may not be given even where permitted because of perceived safety issues, , inadequate resourcing , , , , or providers being unaware of its importance. ,

Knowledge translation

Availability and use of appropriate policies and clinical practice guidelines

, , , , , Guidelines should specify indications for MgSO4 use, , and how to administer it, including dosage and administration methods. , , , ,

, , , , It is unclear whether including local clinicians or administrators to create ownership and increase uptake is effective. , Governments' receptiveness to input from clinicians is considered an important facilitator in policy development.

, , , , , , , , , , , , Policies should be translated into clinical practice guidelines and made available at facility‐level , , , , , in wards. , ,

, , , , , , , , , , A lack of interest or awareness about guidelines and updates is noted particularly among older physicians. , , Facility administrators and providers are not obligated to follow policies or guidelines. , , , Variable protocols at facility‐level can leave staff confused and result in practice that is not consistent with national or international recommendations. , , ,

Research dissemination and advocacy by ‘champions’ can facilitate uptake

Evidence from research, such as clinical trials of effectiveness, can influence clinical practice and improve MgSO , , , , Local participation in international trials may increase the uptake of MgSO4 by developing local champions and increasing the local credibility of findings or providing local complementary evidence. , Dissemination of research findings may be via journal publication and participation by researchers in policy formulation.

, , , , Champions' influence may increase ‘political will’ and put the issue ‘on the policy agenda’. , , ,

Figure 3 depicts abbreviated findings using the COM‐B model to understand how addressing factors affecting implementation may influence behaviour change toward appropriate use of MgSO4. Within each COM‐B domain, we mapped facilitators and barriers to physical and psychological capability, and physical and social opportunity, and how the interplay between these domains influences motivation (reflective and automatic). When these facilitators are reinforced, and barriers are addressed, we expect behaviour (appropriate use of MgSO4 for pre‐eclampsia/eclampsia) to improve. In turn, positive experience using MgSO4 reinforces providers' capability, opportunity and motivation to continue its use.

Figure 3

COM‐B model of appropriate use of MgSO4.

Discussion

Main findings

This QES revealed a broad range of factors affecting MgSO4 use operating across multiple health system levels. First, whether providers will use MgSO4 appropriately depends on their competence and confidence, which may be undermined by MgSO4's unfamiliarity and perceived riskiness, and strengthened through training and experience. Second, appropriate MgSO4 use depends on the capability of health systems to ensure that it is consistently available at facilities that are adequately resourced and accessible to women. Finally, appropriate MgSO4 use depends on effective knowledge translation through research dissemination, clear guidelines and protocols, and local champions.

The COM‐B model shows how factors may be addressed to improve the implementation of MgSO4. Appropriate MgSO4 use depends on the collective behaviour of policy‐makers promoting MgSO4 and ensuring its availability, administrators translating policy into practice by creating an enabling environment for MgSO4 use, and providers making appropriate clinical decisions to administer MgSO4 for individual women. The model can be used to inform development of interventions for particular settings by providing a framework to consider the full range of options and select the best option to target specific barriers.

Interpretation

The factors identified in this QES are consistent with those found in other studies, such as Ridge et al. who used a case study to develop a ‘fishbone diagram’ of requirements for rational use of MgSO4 at a health facility in Zambia. Our QES furthers this understanding, by combining evidence from a global synthesis of qualitative evidence with the COM‐B model to explore how such factors affect behaviour. Many of our findings align with evidence from quantitative studies, including providers' preference for diazepam , , and desire for simplified dosing regimens, , , concerns about availability of MgSO4, , , , , and the impact of inadequate resourcing. , , , Task‐shifting has been proposed as a solution to address staffing shortages and barriers to accessing higher‐level facilities; WHO guidelines currently allow for nurses and midwives to administer MgSO4 under certain circumstances (e.g. as a loading dose, or where higher‐cadre staff are unavailable).

Implications for practice

We developed the following questions based on our findings to assist health system administrators, policy‐makers and other stakeholders. When developing interventions and policies to identify and address barriers to appropriate use of MgSO4 for pre‐eclampsia/eclampsia in a given context, these individuals could consider the following:

Increasing provider competence and confidence

Are providers aware of the benefits of MgSO4 compared with alternatives?

Do providers have pre‐existing fears regarding adverse events that need to be addressed?

Do providers receive regular and refresher in‐service training that is sufficiently practical (including clinical simulations)?

Can MgSO4 administration processes be simplified, including through simpler, lower‐dose regimens and improving calibration of how MgSO4 is packaged and administered (e.g. through ready‐to‐use doses)?

Are resources and training adapted for the local context?

Improving health system capability

Is MgSO4 consistently available at all health facilities in which it is recommended for use? If not, how can bottlenecks in supply chains or procurement systems be removed?

Is MgSO4 supplied free‐of‐charge or at an affordable price for women and families?

Is MgSO4 supplied in a form that is appropriate for the recommended dosage regimen?

Is the health facility sufficiently well‐equipped to facilitate MgSO4 administration?

In lower‐resource settings with staffing shortages, can MgSO4 be safely administered by lower‐cadre healthcare workers?

Ensuring effective knowledge translation

Are national policies consistent with international guidelines, translated into local guidelines and tools (including algorithms or job aids), and disseminated effectively?

Are local stakeholders equipped to ‘champion’ use of MgSO4?

Strengths and limitations

A limitation of this QES is that data regarding system‐level issues (e.g. procurement and supply) were often specific to particular local contexts – only high‐level, generalised conclusions could be drawn. System‐level constraints and bottlenecks are likely to vary between countries and regions, and should be assessed for each implementation context. All relevant qualitative evidence since effectiveness of MgSO4 for pre‐eclampsia/eclampsia was demonstrated (2002 and 1995, respectively) was included, and factors affecting use may have changed over time. However, over 90% of included studies were published after 2010, so available evidence probably reflects current practices. Finally, six grey literature reports were linked to work by the Population Council’s Ending Eclampsia projects in four countries, , , , , , and the issues explored in these projects (specifically, policy awareness and task‐shifting of loading dose) may be somewhat overrepresented. This was mitigated during analysis by exploring these issues within themes identified across all included studies, and considering evidence from pre‐ and post‐intervention reports concurrently. Although a comparison of views of different cadres of health workers would provide interesting insight into factors affecting MgSO4 use from different perspectives, we were unable to explore this in our analysis, as most included studies did not report this level of detail.

Despite these limitations, this QES presents the first global review of factors affecting implementation of MgSO4 to treat pre‐eclampsia/eclampsia from the perspective of health system stakeholders. Taking a health systems approach encompasses supply‐side barriers at all levels, enabling a full picture of things that can ‘go wrong’ in the chain of events required to get MgSO4 to all women who need it.

Conclusion

This QES identified a range of factors affecting use of MgSO4 for pre‐eclampsia/eclampsia relating to provider competence and confidence, health system capability and knowledge translation. Policy‐makers and researchers should consider these findings when designing and implementing policies and interventions to increase appropriate use. Contrary to some providers' beliefs about the riskiness of MgSO4, in practice adverse events from MgSO4 are uncommon and translation of this knowledge could improve uptake. , Practical training for providers, translating knowledge into clear clinical practice guidelines adapted for local contexts, and addressing systematic problems in supply chains and procurement mechanisms may improve MgSO4 uptake. Studies are also exploring the efficacy of simpler, lower‐dose regimens , , that may be easier and safer to administer. As this review did not find evidence regarding specific dosage regimens, further primary research is needed to understand provider perspectives on specific regimens and whether some are easier to use than others.

Further research is also needed to explore the experiences, attitudes and beliefs of women and their partners or families regarding use of MgSO4 for pre‐eclampsia/eclampsia – including, for example, experience of pain or adverse effects. Context‐specific research on facility‐level stock audits or surveys of providers' knowledge and preferences could complement insights from this QES to inform local implementation strategies. Ultimately, action by policy‐makers, administrators and providers across multiple health system levels will be crucial to improve uptake of this life‐saving treatment.

Disclosure of interests

None disclosed.

Contribution to authorship

KEE designed this study with input from JPV and MAB. KEE, RIZ, MAB and JPV conducted study screening, data extraction, critical appraisal and GRADE‐CERQual assessments. KEE led the analysis and manuscript writing, with input from RIZ, JPV and MAB. All authors reviewed and approved the final manuscript.

Details of ethics approval

Not applicable, this is a systematic review of published qualitative studies.

Funding

The authors received no funding for this work, which was completed as part of KEE's MPH at University of Melbourne School of Population and Global Health.

Acknowledgements

We would like to acknowledge the support from our institutions in facilitating the completion of this work. RIZ is sponsored by an Australian Awards Scholarship (ST000SSF2) for her master's education, funded by the Australian Department of Foreign Affairs and Trade (DFAT). MAB's time is supported by an Australian Research Council Discovery Early Career Researcher Award (DE200100264) and a Dame Kate Campbell Fellowship (University of Melbourne Faculty of Medicine, Dentistry, and Health Sciences). JPV is supported by a National Health and Medical Research Council Investigator Grant (1194248).

Table S1. Summary of qualitative findings.

Table S2. Evidence profile.

Table S3. CASP assessments of included studies.

Appendix S1. Search strategies.

Appendix S2. ENTREQ statement.

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Supplementary Material

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Supplementary Material

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Supplementary Material

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Supplementary Material

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