Discussion
This study is the first study to seek experts’ consensus and opinions on
a set of HDP management recommendations for Indonesian primary care
setting. Despite of some identified challenges that may limit their
implementation in primary care, the surveys demonstrated that almost all
of the HDP recommendations are suitable and the HDP management pathways
have reached consensus for their implementation in Indonesia.
There were some statements that had not re-tested in the third-round
survey due to local contextual considerations. In-vitro fertilisation
(IVF) was not re-tested due to its irrelevance with the Indonesian
population context as IVF is usually accessed by subfertile-married
couples (26, 27). Contraception and antihypertensive
medication were further accommodated using two tables in the
supplementary materials (that are not included in this publication)
aiming to provide more comprehensive educational information for the
targeted audience in primary care.
The developed HDP pathways provide step-by-step clinical guidance on HDO
management embedded in the routine ANC and shift the clinicians’ focus
to early signs, symptoms and risk factors for preeclampsia. The
developed pathways also have abilities to equip GPs and midwives in
Indonesia with comprehensive HDP guidance in primary care as have been
expected by key stakeholders in our exploratory consultation(8). The pathways are also able to complement a
preeclampsia management model recently developed for LMICs that covers
principles of the management but lack of detailed clinical
recommendations for primary care(28) and other HDP
guidelines which was published more than a decade ago and focused only
on preeclampsia management and secondary care (5, 29).
Potential challenges that may limit the recommendations uptakes in
practice have also been identified in the survey, such as tensions of
interprofessional authority between the clinicians, and clinical inertia
of the HDP management in primary care. It was implied in the survey
results of the participants’ hesitance to agree on some HDP managements,
such as low-dose aspirin prescription even though, the medicine has
benefits of reducing risks of preterm
preeclampsia(30-32), relatively safe for pregnant
women (33, 34), and is also widely available in
Puskesmas (35). The primary care participants also
seems resign on the fact that only nifedipine that is available for HDP
treatment in the Puskesmas and hesitance to agree on other
antihypertensive agents prescriptions, such as methyldopa and labetalol
that are only available in the hospitals or accessible throughs
prescription in private pharmacies (36).
Some participants also recommended different preeclampsia management
based on its severity cathegory according to their current standard that
are different to the recommendations in international guidelines(1, 12). Based on an Indonesian guideline, pregnant
women with blood pressure ≥ 140/90 mmHg and positive (+1) proteinuria or
increased creatinine level are categorised as having mild to moderate
preeclampsia, while women with severe preeclampsia are those who have
blood pressure ≥ 160/90mmHg, positive (+2) proteinuria and preeclampsia
symptoms such asas headache or visual disturbance (7).
However, recent international guidelines on preeclampsia reccomend to
avoid those categorisations above in practice, as they are often
confusing and that women with preeclampsia can deteriorate very rapidly
into more severe conditions (1, 37, 38). It is
therefore not surprising that some participants in the survey suggested
formal policy changes to secure additional preeclampsia managenment in
primary care while some obstetrician participants also voiced their
opinions that the pathways should be developed by more competent
experts.
The primary care clinicians’ hesitance and inertia above are likely
influenced by gaps of the clinincians’ medical training and hierarchical
culture in Indonesian health care. GPs in Indonesia are only required to
complete a medical doctor bachelor degree in a university to be able to
practice in primary care, whereas specialists are required to undertake
another three to four years of specialty training at a hospital. This
gave the misconception that GPs are less competent and confident than
specialists resulting in GPs’ low status in the eyes of patients and
specialists (39-41). However, if the GPs and midwives
in primary care are not well supported and encouraged to perform HDP
managements, then who will be able to appropriately manage HDP women at
the first place considering challenges of referral and disparities in
Indonesian health care.