Quality of Care for Screening and Management of Pre-Eclampsia/Eclampsia: Review of Data from Six Countries

Koki Agarwal MCHIP/Jhpiego October 11, 2012

Acknowledgments
Ministries of Health and staff and clients of the study facilities in Kenya, Ethiopia, Madagascar, Mozambique, Rwanda, and Tanzania Data collection teams in each country Core study team members: Linda Bartlett, Jim Ricca, David Cantor, Heather Rosen, Eva Bazant, Rebecca Levine, Patricia Gomez, Joseph de Graft Johnson, Sheena Currie, Bob Bozsa National Coordinating Agency for Population and Development and MEASURE DHS (Kenya), Tandem consulting (Madagascar), USAID Washington colleagues
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Quality of Care1 Study Overview

Focuses on prevention and management of the most serious maternal and newborn complications, including postpartum hemorrhage (PPH), preeclampsia/eclampsia (PE/E), and newborn asphyxia The survey also includes other routine antenatal care (ANC) and labor and delivery (L&D) care Direct observation was used to assess quality of care during ANC and L&D Mobile smart phones were employed for data collection in all but one country
1.The Maternal and Newborn Complications Quality of Care (QoC) health facility survey 3

Six QoC Assessment Countries

MCHIP QoC assessments implemented in six countries in subSaharan Africa from 2010-2011 Data cleaning and analysis is still in progress in Zimbabwe
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PE/E-Related Study Questions

How well are opportunities during ANC and maternity services actually being used to screen for pre-eclampsia? How well prepared are providers and facilities to screen for pre-eclampsia and manage severe PE/E? Are cases of severe PE/E being managed according to standards?

Standards Used as Benchmarks

WHO IMPAC guidelines for ANC and Labor and Delivery, especially Managing Complications in Pregnancy and Childbirth.
For screening for pre-eclampsia:
History taking elements: headache, blurred vision, swollen

hands/face Take BP with proper technique Test urine for protein

For management of severe PE / eclampsia:

Use of MgSO4 Use of an anti-hypertensive (hydralazine, labetalol, nifedipine)
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Summary of Samples
Assessed 643 facilities in 6 countries; observed over 2,500 deliveries and close to 3,000 ANC consults; interviewed over 1,000 health workers.
Sample Kenya Ethiopia Tanzania Zanzibar Rwanda Mada- Mozamgascar bique 19 100% 0% 318 192 107 126 79 52 23% 77% 880 489 306 391 206 9 56% 44% 274 217 106 57 51 72 58% 42% 604 293 187 311 146 36 75% 25% 670 347 268 323 140 46 46% 54% 4781 525 378 303 186 Total

Facilities -Hospital -Health Center/dispensary Observations of care -Deliveries *Initial assessment -ANC consults Health workers interviewed

409 52% 48% 2035 626 452 1409 249

643 53% 47% 9562 2689 1804 2920 1057

PE/E - RELATED FINDINGS

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Screening for Pre-Eclampsia During ANC

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 39% Asks about at least 1 danger sign 68% Take client's BP with appropriate technique 31% 46% Both PE/E screening Perform or refer for urine elements (ask about at test least 1 danger sign and Take BP) Note: Blue bars represent average of scores for each country High-low line shows the by-country range

Note: Danger signs include headache/blurred vision or swollen hands/face 9

Counselling During ANC on Signs of PE

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 31% Counsels to return if headache or blurred vision 24% Counsels to return if swollen hands or face Note: Blue bars represent average of scores for each country and high-low line shows the bycountry range.

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How do Results for PE/E Screening Compare to Other Elements of ANC?

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Note: Blue bars represent average of scores for each country and high-low line shows the bycountry range.

63% Preventive treatments at 1st visit (1)

75%

93%

39%

31% PE/E screening

HIV/syphilis testing Checks health and Asks about vaginal at 1st visit (2) growth of baby (3) bleeding (4)

(1) Mean score of: tetanus toxoid, iron and/or folic acid (both at first visit) (2) Mean score of: HIV testing, syphilis testing (both at first visit) (3) Mean score of: weighs client, palpates for uterine height, listens for fetal heartbeat (any visit) (4) Any visit 11

Screening for Pre-Eclampsia During L&D

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 27% 77% 22% Both PE/E screening elements 7% Tests urine for presence of protein Asks about signs of PE/E Initial blood pressure (1) check Note: Blue bars represent average of scores for each country and high-low line shows the bycountry range.

1) Headache/blurred vision or swollen hands/face (any danger sign Kenya and Ethiopia) 12

How do results for PE/E screening during L&D compare to other elements of care?
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 67% Infection prevention (1) 31% Full partograph use (2) 27% AMTSL (3) 54% 64% 22% Note: Blue bars represent average of scores for each country and high-low line shows the by-country range.

Women-centered Immediate PE/E screening care (4) newborn care (5) in L&D

(1) Mean score of 9 IP tasks during L&D; (2) Mean score of 4 partograph components; (3) Any uterotonic given within 3 minutes of delivery with controlled cord traction and uterine massage; (4) Mean score of 10 elements of women-friendly care; (5) Mean score of 5 newborn care tasks

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Policies and Guidelines

Presence of guidelines or protocols in ANC and L&D service delivery areas
Country average Guidelines in ANC service area - ANC - Pre-eclampsia/eclampsia Guidelines in L&D service area - Normal birth - Emergency obstetric care 37% 45% 16% 16% 67% 89% 55% 21% 22% 8% 76% 38% Lowest value Highest value

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Health Worker Knowledge Scores for Key Areas of Maternal and Newborn Care
Pre-eclampsia/eclampsia (1) Postpartum hemorrhage (2) Obstructed labor (3) Maternal sepsis (4) Newborn sepsis (5) Immediate newborn care (6) Newborn resuscitation (7) 44% 40% 40% 39% 55% 51% 44% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Note: Blue bars represent average of scores for each country and high-low line shows the bycountry range.

(1) Mean score of 4 knowledge areas: examination, diagnosis, treatment, equipment (fewer treatment questions for Mozambique); (2) Mean score of 2 knowledge areas: signs, tests, and interventions; (3) Mean score of 2 knowledge areas: signs, tests, and interventions (no data for Mozambique); (4) Mean score of 2 knowledge areas: signs, tests, and interventions (signs only for Mozambique); (5) Mean score of 1 knowledge area: signs (no data for Madagascar); (6) Mean score of 2 knowledge area: examinations, interventions (no data for Madagascar); (7) Mean score of 2 knowledge areas: equipment, resuscitation steps (from written test or simulation) (no data for Mozambique)

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Health Worker Knowledge of PE/E Signs and Management

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 45% Essential supplies & equipment 44% Examination actions 88% Diagnosis 56% Action to take 40% Actions if presented with convulsions 32% Actions to take 1hr later Note: Blue bars represent average of scores for each country and high-low line shows the bycountry range.

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Constraints Analysis for Screening for PE/E

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 89% Policy (1) 93% 62% 61% 44% 31% PE/E screening at ANC 22% PE/E screening at L&D Personnel (2) Supervision (3) Supplies (4) Knowledge (5) Note: Blue bars represent average of scores for each country and high-low line shows the bycountry range.

(1) MgSO4 registered, on EDL, first line PE/E in SDGs and SDLs, SBAs authorized to give first dose, screening in SDGs;

(2) Births attended by skilled attendants; (3) Personnel received supervision within last 3 months; (4) Mean score of facilities with: functioning blood pressure apparatus (in ANC room, except Kenya in delivery room), ability to conduct urine testing, magnesium sulfate in delivery room; (5) Aggregate score of PE/E knowledge

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Summary of PE/E Cases Observed

Parameter Cases of PE/E observed Description of problem Eclampsia Severe pre-eclampsia Mild pre-eclampsia Anti-convulsant used Magnesium sulfate Diazepam No anti-convulsant Other medication used Antihypertensive Calcium gluconate Outcomes Maternal deaths Newborn deaths Total 50
A G2 P1 woman was admitted to L&D at 9:25AM by a female nurse with graduate level training/diploma. She had had an uneventful previous pregnancy. No ANC. Her initial BP was recorded and was elevated, but not above DBP = 110. Urine was not checked for protein. Progress was plotted on a WHO partograph and BP recorded every 4 hours. She had a normal SVD , giving birth to a live infant at 2:00PM. During the 3rd stage of labor she had a generalized seizure and became unconscious. - Nurse evaluated vital signs and checked airway by listening to chest, but did not prop on left side or check for neck rigidity. Intubation was not necessary. - She gave oxygen at 4-6 liters per min and protected from injury, but did not place on left side, nor aspirate mouth and throat after convulsion. - No anti-convulsant medications given, although facility had magnesium sulfate. No anti-hypertensive was available. Follow-up care: - Nurse recorded respiratory rate, heart rate, fetal heart rate. Started IV fluids. - No other seizures were observed and mother and baby went to recovery ward. 18

18 17 15 19 9 28 14 0 0 2

Conclusions
There are currently missed opportunities for PE screening
Screening during ANC and L&D by taking BP is high and mainly with

proper technique during ANC, BUT History taking for PE/E danger signs in both the ANC clinic and L&D ward is minimal

Constraints to PE/E screening and management include:

Policies not always in place: In some countries prevention and

treatment of eclampsia is still based on diazepam or combination of diazepam and MgSO4, which could be harmful; screening for preeclampsia is missing from ANC guidelines in some countries Commodities lacking in some places: MgSO4 for treatment was available in only about half of facilities - 55% (country range 16-98%) Provider knowledge and supervision also need improvement
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Recommendations
There needs to be a renewed emphasis on history taking and counseling, and not just physical examination and testing There is at least as much need for emphasis on training and supervision as on commodity supply

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THANK YOU!
Look for the final country study reports on the MCHIP website.

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