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), pre-eclampsia/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 sub-Saharan 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?

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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-gascar

Mozam-bique

Total

Facilities 409 19 52 9 72 36 46 643

-Hospital 52% 100% 23% 56% 58% 75% 46% 53%

-Health Center/dispensary 48% 0% 77% 44% 42% 25% 54% 47%

Observations of care 2035 318 880 274 604 670 4781 9562

-Deliveries 626 192 489 217 293 347 525 2689

*Initial assessment 452 107 306 106 187 268 378 1804

-ANC consults 1409 126 391 57 311 323 303 2920

Health workers interviewed 249 79 206 51 146 140 186 1057

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PE/E - RELATED FINDINGS

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39% 68% 31% 46% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Asks about at least 1danger sign

Take client's BP withappropriate technique

Both PE/E screeningelements (ask about atleast 1 danger sign and

Take BP)

Perform or refer for urinetest

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

Note: • Blue bars represent average of scores for

each country

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Screening for Pre-Eclampsia During ANC

• High-low line shows the by-country range

Counselling During ANC on Signs of PE

31% 24% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Counsels to return if headache or blurredvision

Counsels to return if swollen hands or face

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

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

(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

63% 75% 93% 39% 31% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Preventivetreatments at 1st

visit (1)

HIV/syphilis testingat 1st visit (2)

Checks health andgrowth of baby (3)

Asks about vaginalbleeding (4)

PE/E screening

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

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Screening for Pre-Eclampsia During L&D

27% 77% 22% 7% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Asks about signs of PE/E(1)

Initial blood pressurecheck

Both PE/E screeningelements

Tests urine for presenceof protein

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

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

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How do results for PE/E screening during L&D compare to other elements of care?

(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

67% 31% 27% 54% 64% 22% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Infectionprevention (1)

Full partographuse (2)

AMTSL (3) Women-centeredcare (4)

Immediatenewborn care (5)

PE/E screeningin L&D

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

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Policies and Guidelines

Presence of guidelines or protocols in ANC and L&D service delivery areas

Country average Lowest value Highest value Guidelines in ANC service area

- ANC 55% 22% 76%

- Pre-eclampsia/eclampsia 21% 8% 38%

Guidelines in L&D service area

- Normal birth 37% 16% 67%

- Emergency obstetric care 45% 16% 89%

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Health Worker Knowledge Scores for Key Areas of Maternal and Newborn Care

44%

51%

55%

39%

40%

40%

44%

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

Newborn resuscitation (7)

Immediate newborn care (6)

Newborn sepsis (5)

Maternal sepsis (4)

Obstructed labor (3)

Postpartum hemorrhage (2)

Pre-eclampsia/eclampsia (1)

(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)

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

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Health Worker Knowledge of PE/E Signs and Management

45% 44% 88% 56% 40% 32% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Essentialsupplies &equipment

Examinationactions

Diagnosis Action to take Actions ifpresented with

convulsions

Actions to take1hr later

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

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Constraints Analysis for Screening for PE/E

(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

89% 93% 62% 61% 44% 31% 22% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Policy (1) Personnel (2) Supervision (3) Supplies (4) Knowledge (5) PE/Escreening at

ANC

PE/Escreening at

L&D

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

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Summary of PE/E Cases Observed 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.

Parameter Total Cases of PE/E observed 50

Description of problem Eclampsia 18 Severe pre-eclampsia 17 Mild pre-eclampsia 15 Anti-convulsant used Magnesium sulfate 19 Diazepam 9 No anti-convulsant 28 Other medication used Antihypertensive 14 Calcium gluconate 0 Outcomes Maternal deaths 0 Newborn deaths 2

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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 pre-eclampsia 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

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There is at least as much need for emphasis on training and supervision as on commodity supply

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Look for the final country study reports on the MCHIP website.