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.