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\begin{document}

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



\author[1]{Fitriana Ekawati}%
\author[2]{Shaun Brennecke}%
\author[3]{Sharon Licqurish}%
\author[2]{Jane Gunn}%
\author[2]{Phyllis Lau}%
\affil[1]{Gadjah Mada University}%
\affil[2]{The University of Melbourne}%
\affil[3]{University of Melbourne Melbourne Medical School}%


\vspace{-1em}



  
  \date{May 08, 2024}


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\selectlanguage{english}
\begin{abstract}
Objectives: To reach consensus on evidence-based recommendations to
develop HDP management pathways for Indonesian primary care. Design: A
three-round Delphi survey Setting: N/A Population: Maternal health
practitioners and experts, including GPs, midwives, nurses and health
policy researchers from Indonesia and international background. Methods:
Participants were asked to rate their agreement on whether each of 125
statements about HDP and HDP managements extracted from international
guidelines were feasible in Indonesian primary care settings in a mix of
quantitative and qualitative questions in three-rounds Delphi survey. A
minimum of 70\% agreement among participants was needed for a statement
to be included for the HDP pathways that the pathways drafts were
presented at the third-round survey. The participants' free text
questions responses and suggestions were analysed thematically. Main
Outcome Measures: Agreement scores of the statements. Results: A total
of 52 participants participated, 48, 45, and 37 of them completed the
first, second and third-round survey respectively. The consensus was
reached for 115 of the 125 statements on HDP definition, screening,
management and long-term follow-up. The agreement scores ranged from
70.8-100.0\% and potential implementation barriers were also identified.
Drafts of HDP management pathways were also agreed upon and received
suggestions from the participants. Conclusions: Most evidence-based HDP
management recommendations achieved consensus represented in the
developed HDP management pathways can be implemented in Indonesian
settings. Further investigations are needed to explore the acceptability
and feasibility of the pathways in practice.%
\end{abstract}%



\sloppy


\textbf{Keywords: Delphi survey, management, pathways, hypertensive
disorders of pregnancy, preeclampsia, Indonesia, primary care}

Twitable abstract (110 characters):

Contextualising international recommendations to develop HDP management
pathways in Indonesian primary care settings.



\section*{Introduction:}

{\label{introduction}}

Hypertensive disorders of pregnancy (HDP) cover a range of diagnoses,
including chronic hypertension, gestational hypertension, white coat
hypertension and preeclampsia/eclampsia \textsuperscript{(1)}. In
Indonesia, HDP remains the leading cause of maternal mortality, and with
its current increasing trend, may soon replace postpartum hemorrhage as
the most common cause of direct maternal mortality \textsuperscript{(2,
3)}.

Research shows that maternal mortality from HDP is preventable if the
women receive appropriate management, however, many maternal deaths from
HDP in Indonesia are not well anticipated due to lack of practice
guidance in primary care\textsuperscript{(4)}. Current Indonesian
primary care guidelines merely recommend general practitioners (GPs) to
refer women with HDP to hospitals\textsuperscript{(5-7)}, but details of
further management such as screening, monitoring, and long-term
postpartum follow-up treatment for HDP women are
lacking\textsuperscript{(8)}. Meanwhile, the country's disparities in
health due to community beliefs, inadequate obstricians availability and
geographical locations also challenges the referral which impact on the
women often are already too severe for hospital
management\textsuperscript{(3, 9, 10)}. Due to these rationals,
therefore, the need to upgrade primary care providers in HDP management
is more than ever in Indonesia.

This research is part of a larger study to improve quality of HDP
management in Indonesian primary care \textsuperscript{(11)}. Our
previous review has identified potential evidence-based practice
improvements for HDP management \textsuperscript{(12)}; and we have also
explored the way HDP is managed in Indonesian primary care through
interviews with key stakeholders \textsuperscript{(8)}. However, to
adopt these recommendations and to develop the HDP management pathways
as improvement interventions would require additional contextualisation
process. Findings in our review indicate that not all recommendations
from the international HDP guidelines can directly be adopted into the
local context due to different practice environments, such as different
professional authority, facilities, policies or public insurance
(\emph{JKN/Jaminan Kesehatan Nasional} ) regulation \textsuperscript{(8,
12)}. There are also further considerations when contextualising HDP
recommendations for Indonesian primary care. Public primary care
services (Puskesmas/\emph{Pusat Kesehatan Masyarakat} ) in Indonesia has
to undertake maternal surveillance and maternal audit processes in the
community in addition to provide individual patient
treatment\textsuperscript{(8)}. There are also community health workers
(cadres) involved in maternal health activities but their job
description in the current Indonesian guidelines remains unclear
\textsuperscript{(13, 14)}.

This research then aims to establish experts' consensus on the
identified 125 international and local HDP management recommendations to
develop HDP management pathways for Indonesian primary health care
setting.

\section*{Methods}

{\label{methods}}

\textbf{Study design: consensus development using Delphi technique}

Consensus is usually defined as 'general
agreement'\textsuperscript{(15)}. Consensus development is a process
commonly used in guideline or pathway development to determine general
agreement from experts regarding recommendations used in the
guideline\textsuperscript{(15)}, or to explore the experts' opinions
regarding feasibilities of international recommendations to be used for
a specific practice setting where evidence to support their
implementation is limited \textsuperscript{(16)}.

One of the most common consensus development method in pathway
development is Delphi technique-in which the experts provide their
judgment directly or indirectly through surveys or
interviews\textsuperscript{(17)}. In the study, three rounds of
anonymous online Delphi survey were used to develop consensus on the
applicability of 125 statements based on HDP management recommendations
and draft HDP pathways that can be used by GPs, midwives and nurses in
Indonesian primary care settings \textsuperscript{(12)}.

\textbf{Survey statements}

HDP statements in the survey were extracted from the results of our
review of HDP guidelines \textsuperscript{(12)} and exploratory
interviews in primary care \textsuperscript{(8)}. The 125 HDP statements
were then grouped into HDP definitions, risks, screening and diagnosis,
prevention, management, monitoring, long-term follow-up, facilities, and
HDP surveillance in primary care.

\textbf{Participants}

Indonesian and international experts in maternal health identified
through the authors' professional networks and snowballing recruitment
process were invited to participate in this study. The participants
inclusion criteria were\textsuperscript{(11)}:

\begin{enumerate}
\tightlist
\item
  GPs, midwives, nurses, specialists, local health officers, or
  policymakers in maternal health.
\item
  Have a minimum of two years working experience;
\item
  Have an academic degree background in health sciences;
\item
  Familiar with the context of primary care in Indonesia or other low
  and middle-income countries (LMICs); and
\item
  Keen to participate in all three survey rounds.
\end{enumerate}

\textbf{Recruitment}

All prospective participants were recruited by email and/or WhatsApp
messenger\textsuperscript{(18)} containing link for the study
recruitment pages. The recruitment pages were provided bilingually in
Bahasa Indonesia and English, and the participants were able to choose
their preferred language. Prospective participants who did not meet the
inclusive criteria were excluded and only those who satisfied the
criteria were able to carry on to the survey's online plain language
statement (PLS) and electronically sign the consent page. The
participants' identity was confidential to other participants and was
only be identifiable by researchers in this study.

\textbf{Data collection}

The data collection applied three rounds of online survey using the
University of Melbourne REDcap (Research Electronic Data Capture)
\textbackslash{}soutplatform \textsuperscript{(19)}, and each survey
round consisted of:

\begin{itemize}
\tightlist
\item
  a questionnaire asking participants to provide their judgement on
  statements on a five-point Likert scales (1= strong disagreement, 2 =
  disagreement, 3 = indicated neutral position, 4 = agreement, and
  5 = strong agreement) \textsuperscript{(20, 21)}. Participants were
  asked to rate their judgment on (i) whether the recommendation was
  useful to improve HDP management in primary care and (ii) whether the
  recommendation was likely to be applicable in practice in Indonesia or
  needed to be contextualised;
\item
  free-text questions to ask the participants further suggestions
  related to the tested statements.
\end{itemize}

Participants were given three weeks to complete each round. They
received short messages and email reminders on one week and three days
before the survey closed. Once a round was completed, participants were
sent a link to the next survey round.

\emph{First-round suvey}

After completing the PLS and consent pages, the participants were sent
with the first-round survey link asking them to rate 62 statements: HDP
definitions (n=7), risks (n=16), screening and diagnosis (n=16),
prevention (n=10), and long-term follow up (n=13) in primary care. Other
than the basic free-text questions above, there were also initial three
questions presented specified for the first-round\textsuperscript{(11)}:

\begin{enumerate}
\tightlist
\item
  What are the roles of Indonesian primary care in HDP management?
\item
  What potential practices that can be conducted by primary care
  providers in HDP management?
\item
  What are barriers and facilitators of HDP management in Indonesian
  primary care?
\end{enumerate}

\emph{Second-round survey}

This round tested 63 statements regarding HDP management (n=14),
monitoring (n=31), required facilities (n=8), and surveillance (n=10) in
primary care. The survey pages also contained results of the first-round
survey and participants were able to review and revise their responses
on statements that had not reached consensus in the first-round survey.

\emph{Pathways development}

Statements that reached consensus at the first and second-round survey
were used to develop the pathways initialy designed by the first author.
The pathways drafts however, were discussed, received suggestions and
agreed by all of the project investigators before their presentations to
the participants in the third-round survey.

\emph{Third-round survey}

The third-round survey asked for the participants' agreement and
suggestions on the HDP management pathway drafts. Results of the
second-round survey were also presented and the participants were able
to review and revise their responses on statements that had not reached
consensus. Statements that achieved consensus at this round, including
the participants' suggestions were used to finalise the HDP management
pathways.

\textbf{Data analysis}

The participants' agreement scores in each survey were analysed
descriptively using Microsoft Excel software \textsuperscript{(22)}. The
participants' responses were calculated for each statement to generate
total agreement scores, standard deviation and interquartile ranges. The
minimum requirement set for each round was: at least 60\% participation
and the statements had to have at least 70\% agreement to be included in
the HDP pathway\textsuperscript{(17)}.

The free-text responses and suggestions from the participants were
imported into the NVIVO software\textsuperscript{(23)} and analysed
thematically\textsuperscript{(24)}. The free-text responses in Bahasa
Indonesia were translated into English and are uploaded to the NVIVO for
coding. Codes were grouped based on their similarities and patterns were
then used to establish overarching themes and subthemes. Codes and
themes were also discussed and mutually agreed by all project
investigators. Presentation of this study follows standard of reporting
intervention development studies (GUIDED) \textsuperscript{(25)}.

\textbf{Language validation}

All of the survey statements and questions were initially created in
English. They were then translated into Bahasa Indonesia by the first
author and presented to participants based on their language preference.
Participants' responses written in Bahasa Indonesia were also translated
into English to enable analysis and discussion between the project
investigators. All questionnaires and a quarter of the free-text
responses were also back-translated into English and were reviewed by
another two native Indonesian speakers to ensure the translation
validation.

\textbf{Survey validation}

The recruitment and survey pages were tested to ensure internal
validation. Each of the survey pages had a minimum of ten trials by the
validation participants before distribution to the survey participants.

\section*{Results}

{\label{results}}

The surveys were conducted from November 2018 to May 2019. A total of 52
participants agreed to participants, of these, 48, 45, and 37
participants completed the first, second, and third round of surveys.
The participants baseline demographic data are presented in Table 1.

\textbf{{[}insert Table 1 here{]}}

\subsection*{First-round survey}

{\label{first-round-survey}}

Around 85.5\% of the statements reached consensus at the first-round
survey and the agreement score ranged from 40.9\% to 100.0\%. Statements
that achieved 100.0 \% agreement include `\emph{routine blood pressure
measurement for HDP screening} ' and `\emph{pregnant women have to be
informed and counseled about HDP risk factors} '. Nine statements did
not reach 70.0\% agreement and these include statements of `\emph{most
antihypertensive medication can be used to control the women's blood
pressure during breastfeeding periods} ' (43.2\%) and `\emph{most all
contraception methods dan be prescribed for women with a history of HDP}
' (40.9\%). These statements were then brought forward into the
second-round survey (Please refer to Table 2 and the supplementary
table).

\textbf{{[}Insert Table 2 here{]}}

Free text-responses in the first-round highlighted the roles of primary
care physicians in HDP management and the most prominent theme emerging
in the analysis was authority (with 219 quotes). Most participants
believed that primary care have responsibilities to conduct antenatal
care (ANC), identify women with increased risks of HDP and refer
patients who are at risk to obstetricians. They also had to not only
provide HDP clinical management in primary care but also care
coordination with hospitals.

The participants also conceded that routine ANC had already well applied
in Indonesian primary care practice and blood pressure monitoring and
dipstick urine tests been routinely conducted to screen for
preeclampsia. However, some participants claimed that primary care had
limited resources available in practice. For instance, only nifedipine
was available as a treatment for pregnancy hypertension and the doctors'
limited time for pregnancy consultation.

Interestingly, many of the clinician participants also indicated their
own doubt with the quality of HDP management they currently provide in
practice, particularly the referral timing and patient monitoring
procedures. They also expected guidance and skills upgrades on such HDP
management in primary care (Table 3).

\textbf{(Insert Table 3 here)}

\subsection*{Second-round survey}

{\label{second-round-survey}}

Most of the statements (92.0\%) reached consensus in this round. Similar
to the first-round survey results, the statements' agreement scores were
high particularly on statements related to community surveillance and
home visits for women with HDP (mean agreement scores: 98.0\%). Five
statements did not reach consensus in this round and the statements were
re-tested in the third-round survey (Please refer to Table 2 and the
supplementary table).

Seven participants also revised their responses to statements in the
first-round survey and increased the agreement scores to above 70.0\%
for three statements: `\emph{systemic lupus erythematosus as a risks
factor for preeclampsia} ' (72.9\%), `\emph{serum creatinine as a
baseline examination for women with preeclampsia risk factors} '
(70.8\%) and `\emph{low dose aspirin prescription by GPs} ' (70.8\%).

Some participants in the free-text questions in this round raised
further opinions regarding authority of HDP in primary care, such as
suggesting different management of mild and severe preeclampsia based on
their usual practice and a need for a government policy to facilitate
the pathways' implementation in practice (Table 3). Again, a participant
also wrote another limitation in practice, i.e that only certain
medicine available in primary care.

\textbf{Pathways development:}

The HDP management pathways drafts had been developed from statements
that reached consensus from the first and the second round survey. HDP
management pathways drafts were presented in three flowcharts: (i) HDP
diagnosis, (ii) HDP management, and (iii) HDP maternal surveillance
flowchart in primary care. The HDP management pathway itself was divided
into five sections: (i) screening for preeclampsia risk factors at the
first pregnancy visit, (ii) HDP screening activities during routine ANC,
(iii) HDP management and monitoring, (iv) delivery plans for women with
HDP, and (v) postpartum follow up for women with HDP in primary care.

The project investigators also considered and discussed statements that
had not achieved consensus at the first and second round survey. The
pathways accomodated statements related to contraception and
antihypertensive medication used for women with HDP history were later
accommodated using information tables (that are not included in this
publication). Another statements were also considered not to be
re-tested in the third-round survey, i.e IVF as isk factor for
preeclampsia.

\subsection*{Third-round}

{\label{third-round}}

Most participants agreed on the HDP management pathway drafts. The
pathways' agreement scores ranged from 78.4\% for HDP monitoring to 89.2
\% for preeclampsia risk factors screening (Table 2). Eleven
participants revised their response on statement that had not received
consensus at the previous rounds. Their revised responses, however, only
changed agreement score for platelet count as baseline data for pregnant
women with risks of preeclampsia (from 68.2\% to 70.8\%). The complete
final agreement score for each statement and the diagnosis flowchart are
attached as supplementary materials.

There were participants opinions and suggestions obtained from the
third-round free text questions. Spme participants suggested improvement
on the triage for pregnant women. A participant expessed his
disagreement on HDP pathway development through the survey. He mentioned
that the pathways drafts were way too complicated and they should not be
developed through surveys. There were, again, a suggestion to
differentiate management of mild and severe preeclampsia and further
pressure to refer women with HDP to hospitals. Further suggestion was
also obtained for the HDP surveillance pathway to respect on the
patients' confidentiality during patient management. It was previously
mentioned at the surveillance pathways drafts that any HDP cases should
be referred to public primary care clinics for surveillance data and be
follow up by cadre home visits or receiving supports from community
leaders. The suggestion on patient confidentiality was used to improve
the statements listed in the surveillance pathway (Table 3).

\textbf{Final revised pathways}

The pathways drafts were revised after receiving the participants
suggestions. The triage of women were improved by providing statements
if aspirin was initiated before 16\textsuperscript{th} week and after
20\textsuperscript{th} week of pregnancy. However, the surveillance for
HDP women were also added with statements to respect the patients
confidentiality. The participant suggestion to differentiate management
of mild-moderate and severe preeclampsia was not accommodated in this
stage. The final HDP management pathways and surveillance pathways in
primary care are presented in \textbf{Figure 1, and Suplementary Figure
1 and 2} .

\textbf{{[}insert Figure 1 here{]}}

\section*{Discussion}

{\label{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 \textsuperscript{(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\textsuperscript{(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\textsuperscript{(28)} and other HDP
guidelines which was published more than a decade ago and focused only
on preeclampsia management and secondary care \textsuperscript{(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\textsuperscript{(30-32)}, relatively safe for pregnant
women \textsuperscript{(33, 34)}, and is also widely available in
Puskesmas \textsuperscript{(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 \textsuperscript{(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\textsuperscript{(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
\textsuperscript{(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
\textsuperscript{(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 \textsuperscript{(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.

\textbf{Strengths and limitations of the study}

Delphi technique in this survey is not bound by geographical locations
of the participants and offers flexible opportunities for them to share
their opinions and minimising bias of dominant
experts\textsuperscript{(17, 42)}. The process is anonymous and hence
has the advantage of minimising challenges of the hierarchical culture
that we would anticipate among Indonesian health care
professionals\textsuperscript{(43-45)}.

Although sample size in this study was small, the recruitment of
participants with various backgrounds and experiences have captured
broad views and opinions from the experts \textsuperscript{(46)}. The
survey has also optimised the participants interaction by providing them
opportunities to view and revise their responses at the previous rounds.
Result validity of the study is justified by the high survey
participation rates in each round and the high percentages of agreed
statements completed with good agreement scores \textsuperscript{(17,
47)}.

\textbf{Suggestion for further research}

Further research is desired to investigate the pathways acceptability in
practice and to confirm suitability of aspirin prescription for anemic
women. Towards the end of the study, new evidence emerged to indicate
that anaemia in pregnancy might also be a risk factor for preeclampsia
in LMICs \textsuperscript{(48, 49)}. This is directly relevant to
situations in Indonesia where anemia prevalence is high due to
malnutrition, genetics or infections such as malaria and hookworm, that
cause inflammation in the placenta \textsuperscript{(48-51)}. The use of
aspirin in anaemic women, however, is not currently supported in any of
the existing international HDP guidelines \textsuperscript{(12)} or
tested in the survey, that therefore the management requires further
careful clinical investigation.

\section*{Conclusion}

{\label{conclusion}}

Most of HDP management recommendations extracted from international HDP
guidelines \textsuperscript{(12)} achieved concensus in this study and
the developed HDP management pathways are potentially implementable in
Indonesian primary care. Further research is needed to explore the
pathways' acceptability and feasibility in Indonesian practice and to
investigate the appropriateness of anemia as another preeclampsia risk
factors in LMICs, including the use of low-dose aspirin in anemic
pregnant women with other underlying preeclampsia risk factors.

\subsection*{Declaration}

{\label{declaration}}

Ethics approval and consent to participate

Ethics approval for this study has been obtained from The Human Ethics
Sub Committee, The University of Melbourne (Research ID number
1853074.1).

Consent for publication

The participants had provided consent for their responses to be
published in a peer-reviewed journal or conferences.

Availability of data and material

A supplementary data of the final agreement scores at the survey
statements is included in this publication. However, raw qualitative
data and survey response materials are not shared to protect the
participants' confidentiality.

Competing interests

All authors declare no competing interests.

Funding

The first author receives a scholarship from Indonesian Endowment Fund
for Education from The Indonesian Ministry of Finance.

Authors' contributions

All authors contributed to the study design and manuscript writings. FE
recruited the participants, conducted the study and prepared the first
manuscript draft. JG, SL, PL and SB were involved in the study design
and provided significant contributions for the manuscript writing.

Acknowledgment Survey data in this study were collected and managed
using REDCap electronic data capture tools hosted by the University of
Melbourne.

\section*{References:}

{\label{references}}

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\textbf{Hosted file}

\verb`Figure 1. HDP management pathway.docx`  available at \url{https://authorea.com/users/349866/articles/474848-hypertensive-disorders-of-pregnancy-hdp-management-pathways-results-of-a-delphi-survey-to-contextualise-international-recommendations-for-indonesian-primary-care-settings}

\textbf{Hosted file}

\verb`Table 1. Summary of participants demographic background.docx`  available at \url{https://authorea.com/users/349866/articles/474848-hypertensive-disorders-of-pregnancy-hdp-management-pathways-results-of-a-delphi-survey-to-contextualise-international-recommendations-for-indonesian-primary-care-settings}

\textbf{Hosted file}

\verb`Table 2. Summary of total agreement score.docx`  available at \url{https://authorea.com/users/349866/articles/474848-hypertensive-disorders-of-pregnancy-hdp-management-pathways-results-of-a-delphi-survey-to-contextualise-international-recommendations-for-indonesian-primary-care-settings}

\textbf{Hosted file}

\verb`Table 3. Quotes from the participants' free-text questions responses in the survey.docx`  available at \url{https://authorea.com/users/349866/articles/474848-hypertensive-disorders-of-pregnancy-hdp-management-pathways-results-of-a-delphi-survey-to-contextualise-international-recommendations-for-indonesian-primary-care-settings}

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