Hypertensive disorders of pregnancy (HDP) management pathways: results of a Delphi survey to contextualise international recommendations for Indonesian primary care settings

Ekawati F.M., Licqurish S., Gunn J., Brennecke S., Lau P.

Department of Family and Community Medicine, Universitas Gadjah Mada, Sleman, Yogyakarta, Indonesia; Department of General Practice, University of Melbourne, Level 2, 780 Elizabeth Street, Melbourne, VIC 3000, Australia; School of Nursing and Midwifery, Monash University, Clayton, VIC, Australia; University of Melbourne Department of Obstetrics and Gynaecology, Royal Women’s Hospital, Parkville, VIC, Australia; Pregnancy Research Centre, Department of Maternal-Fetal Medicine, Royal Women’s Hospital, Parkville, VIC, Australia


Background: Hypertensive disorders of pregnancy (HDP) are a significant contributor to the high maternal mortality rate in Indonesia. At the moment, limited guidelines are available to assist primary care providers in managing HDP cases. A previous review of 16 international HDP guidelines has identified opportunities for improving HDP management in Indonesian primary care, but it has not determined the suitability of the recommendations in practice. This study aims to achieve consensus among the experts regarding the recommendations suitability and to develop HDP pathways in Indonesian primary care. Methods: Maternal health experts, including GPs, midwives, nurses, medical specialists and health policy researchers from Indonesia and overseas were recruited for the study. They participated in a consensus development process that applied a mix of quantitative and qualitative questions in three Delphi survey rounds. At the first and second-round survey, the participants were asked to rate their agreement on whether each of 125 statements about HDP and HDP management is appropriate for use in Indonesian primary care settings. The third-round survey presented the drafts of HDP pathways and sought participants’ agreement and further suggestions. The participants’ agreement scores were calculated with a statement needing a minimum of 70% agreement to be included in the HDP pathways. The participants’ responses and suggestions to the free text questions were analysed thematically. Results: A total of 52 participants were included, with 48, 45 and 37 of them completing the first, second and third round of the survey respectively. Consensus was reached for 115 of the 125 statements on HDP definition, screening, management and long-term follow-up. Agreement scores for the statements ranged from 70.8–100.0%, and potential implementation barriers of the pathways were identified. Drafts of HDP management pathways were also agreed upon and received suggestions from the participants. Conclusions: Most evidence-based management recommendations achieved consensus and were included in the developed HDP management pathways, which can potentially be implemented in Indonesian settings. Further investigations are needed to explore the acceptability and feasibility of the developed HDP pathways in primary care practice. © 2021, The Author(s).

Delphi survey; Hypertensive disorders of pregnancy; Indonesia; Management; Pathways; Preeclampsia; Primary care


BMC Pregnancy and Childbirth

Publisher: BioMed Central Ltd

Volume 21, Issue 1, Art No 269, Page – , Page Count

Journal Link: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85103808044&doi=10.1186%2fs12884-021-03735-3&partnerID=40&md5=b1069b47e564ccf076ba020627315458

doi: 10.1186/s12884-021-03735-3

Issn: 14712393

Type: All Open Access, Gold, Green


Brown, M.A., Magee, L.A., The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice (2018) Pregnancy Hypertens, 13, pp. 291-310; (2015) Indonesian Health Profile (2014) in Bahasa Indonesia, , http://www.depkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/profil-kesehatan-indonesia-2014.pdf, Ministry of Health, Jakarta; Baharuddin, M., Amelia, D., Maternal death reviews: A retrospective case series of 90 hospital-based maternal deaths in 11 hospitals in Indonesia (2019) Int J Gynecol Obstetr, 144 (S1), pp. 59-64; Say, L., Chou, D., Gemmill, A., Tunçalp, Ö., Moller, A.-B., Daniels, J., Global causes of maternal death: a WHO systematic analysis (2014) Lancet Glob Health, 2 (6), pp. e323-e333. , (,):., https://doi.org/10.1016/S2214-109X(14)70227-X; (2013) Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan, , http://www.searo.who.int/indonesia/documents/976-602-235-265-5-buku-saku-pelayanan-kesehatan-ibu.pdf?ua=1; D’Ambruoso, L., Martha, E., Maternal mortality and severe morbidity in rural Indonesia Part 1: The community perspective (2013) Soc Med, 7 (2), p. 47; Dibaichsan, F., Healthcare providers’ perception of the referral system in maternal care facilities in Aceh, Indonesia: A cross-sectional study (2019) BMJ Open, 9 (12), pp. 1-8. , https://bmjopen.bmj.com/content/bmjopen/9/12/e031484.full.pdf; Ekawati, F.M., Licqurish, S., Developing management pathways for hypertensive disorders of pregnancy (HDP) in Indonesian primary care: a study protocol (2019) Reproductive Health, 16 (1). , (,):,., https://doi.org/10.1186/s12978-019-0674-0; (1998) A guide to the development, implementation and evaluation of clinical practice guidelines, , https://www.nhmrc.gov.au/guidelines-publications/cp30; (2000) How to put the evidence into practice: implementation and dissemination strategies Handbook series on preparing clinical practice guidelines, , https://www.nhmrc.gov.au/guidelines-publications/cp71; Campbell, H., Hotchkiss, R., Integrated care pathways (1998) BMJ, 316 (7125), p. 133. , COI: 1:STN:280:DyaK1c7itlyktg%3D%3D; De Bleser, L., Depreitere, R., Defining pathways (2006) J Nurs Manag, 14 (7), pp. 553-563; Ekawati, F.M., Emilia, O., Opportunities for improving hypertensive disorders of pregnancy (HDP) management in primary care settings: A review of international published guidelines in the context of pregnancy care in Indonesia (2020) Pregnancy Hypertens, 19, pp. 195-204; Ekawati, F.M., Emilia, O., The elephant in the room: an exploratory study of hypertensive disorders of pregnancy (HDP) management in Indonesian primary care settings (2020) BMC Fam Pract, 21 (1), p. 242; (2016) Maternal death surveillance guideline (Pedoman surveilans kematian ibu). Series Editor, editor^editors, , https://indonesia.unfpa.org/sites/default/files/pub-pdf/MHH_MDSR_NationalGuidelines_20161222_final.pdf, Ministry of Health Republic Indonesia, Jakarta: Date. Number of 70 p.https://indonesia.unfpa.org/sites/default/files/pub-pdf/MHH_MDSR_NationalGuidelines_20161222_final.pdf. 12 February 2019; (2014) WHO Handbook for Guideline Development, , http://apps.who.int/medicinedocs/documents/s22083en/s22083en.pdf; Minas, H., Jorm, A.F., Where there is no evidence: use of expert consensus methods to fill the evidence gap in low-income countries and cultural minorities (2010) Int J Ment Health Syst, 4 (1), p. 33; Keeney, S., McKenna, H., (2010) The Delphi Technique in Nursing and Health Research. [electronic resource], p. 1. , Wiley, Hoboken; Norman, G., Likert scales, levels of measurement and the “Laws” of statistics (2010) Adv Health Sci Educ, 15 (5), pp. 625-632; Dawes, J., Do data characteristics change according to the number of scale points used? (2008) Int J Mark Res, 50 (1), pp. 61-77; Birko, S., Dove, E.S., Evaluation of Nine Consensus Indices in Delphi Foresight Research and Their Dependency on Delphi Survey Characteristics: A Simulation Study and Debate on Delphi Design and Interpretation (2015) Plos One, 10 (8); (2019) Nvivo (software) version 12.2.0 (3262), , https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/support-services/nvivo-downloads; Patton, M.Q., (2002) Qualitative research & evaluation methods / Michael Quinn Patton, , Sage Publications, Thousand Oaks: c2002. 3rd ed; Duncan, E., O’Cathain, A., Guidance for reporting intervention development studies in health research (GUIDED): an evidence-based consensus study (2020) BMJ Open, 10 (4); Charlotte, E., Warren, H., Ismail, S.M., A primary health care model for managing pre-eclampsia and eclampsia in low-and middle-income countries (2020) Reprod Health, 17 (1), pp. 1-7; Perez-Cuevasfraser, R.W., Critical pathways for the management of preeclampsia and severe preeclampsia in institutionalised health care settings (2003) BMC Pregnancy Childbirth, 3. , no pagination; Roberge, S., Bujold, E., Aspirin for the prevention of preterm and term preeclampsia: systematic review and metaanalysis (2018) Am J Obstetr Gynecol, 218 (3), pp. 287-293. e281. , COI: 1:CAS:528:DC%2BC2sXhvFOhsLfI; Roberge, S., Nicolaides, K., The role of aspirin dose on the prevention of preeclampsia and fetal growth restriction: systematic review and meta-analysis (2017) Am J Obstetr Gynecol, 216 (2), pp. 110-120. e116. , COI: 1:CAS:528:DC%2BC2sXhvVeju74%3D; Roberge, S., Bujold, E., Meta-analysis on the effect of aspirin use for prevention of preeclampsia on placental abruption and antepartum hemorrhage (2018) Am J Obstet Gynecol, 218 (5), pp. 483-489; Matthew, K., Hoffman, Goudar, Shivaprasad S, et al. low-dose aspirin for the prevention of preterm delivery in nulliparous women with a singleton pregnancy (ASPIRIN): a randomised, double-blind, placebo-controlled trial (2020) Lancet, 395 (10220), pp. 285-293; LeFevre, M.L., Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia: U.S. Preventive Services Task Force Recommendation Statement (2014) Ann Intern Med, 161 (11), pp. 819-826. , (,):., https://doi.org/10.7326/m14-1884; Kementerian Kesehatan, R.I., ; Kementerian Kesehatan, R.I., (2017); (2013) Hypertension in Pregnancy, , https://www.acog.org/~/media/Task%20Force%20and%20Work%20Group%20Reports/public/HypertensioninPregnancy.pdf; (2017) Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors: World Health Organization, , https://apps.who.int/iris/bitstream/handle/10665/255760/9789241565493-eng.pdf, Accessed 20 May 2018; Ekawati, F.M., Claramita, M., Patients’ experience of using primary care services in the context of Indonesian universal health coverage reforms (2017) Asia Pac Fam Med, 16. , https://doi.org/10.1186/s12930-017-0034-6; Claramita, M., Ekawati, F.M., Preparatory graduate professional training in general practice by using the’experiential learning’framework (2018) Asia Pac Fam Med, 17 (1), p. 4; Ekawati, F.M., Claramita, M., The Indonesian general practitioners’ perspectives on formal postgraduate training in primary care (2018) Asia Pac Fam Med, 17 (1), p. 10; R Avella, J., Delphi panels: Research design, procedures, advantages, and challenges (2016) Int J Dr Stud, 11 (1), pp. 305-321; Murphy, M.K., Consensus development methods and their use in clinical guideline development (1998) Health Technol Assess, 2, pp. 1-88; Claramita, M., Riskiyana, R., Interprofessional communication in a socio-hierarchical culture: development of the TRI-O guide (2019) J Multidiscip Healthc, 12, pp. 191-204; McMillan, S., King, M., How to use the nominal group and Delphi techniques (2016) Int J Clin Pharm, 38 (3), pp. 655-662; Vernon, W., The Delphi technique: A review (2009) Int J Ther Rehabil, 16 (2), pp. 69-76; Bennett, L.R., Wiweko, B., Indonesian infertility patients’ health seeking behaviour and patterns of access to biomedical infertility care: an interviewer administered survey conducted in three clinics (2012) Reprod Health, 9 (1), p. 24; Taylor, E., Purvis. Assisted reproduction in Indonesia: policy reform in an Islamic culture and developing nation (2015) Reprod BioMed Online, 31 (5), pp. 697-705; Akbar, M.I.A., Bachnas, M.A., The massive problem of preeclampsia in indonesia: In need of a redesigned national health care system (2018) Pregnancy Hypertens, 13, p. S16; Bilano, V.L., Ota, E., Risk Factors of Pre-Eclampsia/Eclampsia and Its Adverse Outcomes in Low- and Middle-Income Countries: A WHO Secondary Analysis (2014) Plos One, 9 (3); Abdelaziem, A., Ali, R., Duria, A., Severe anaemia is associated with a higher risk for preeclampsia and poor perinatal outcomes in Kassala hospital, eastern Sudan (2011) BMC Res Notes, 4, p. 311; Steketee, R.W., Nahlen, B.L., The burden of malaria in pregnancy in malaria-endemic areas (2001) Am J Trop Med Hyg, 64, pp. 28-35. , COI: 1:STN:280:DC%2BD3MzmsVOjsA%3D%3D

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