rawlins_quality of care in pee review of data from six countries

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Quality of Care for Screening and

Management ofPre-eclampsia/Eclampsia:

Review of Data from 6 Countries

Barbara Rawlins

MCHIP

May 5, 2012


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Acknowledgments

Ministries of Health and staff and clients of the studyfacilities in Kenya, Ethiopia, Madagascar, Mozambique,Rwanda, and Tanzania

Data collection teams in each country

Core study team members: Jim Ricca, David Cantor,Heather Rosen, Linda Bartlett, Eva Bazant, RebeccaLevine, Patricia Gomez, Joseph de Graft Johnson, SheenaCurrie, Bob Bozsa

National Coordinating Agency for Population andDevelopment and MEASURE DHS (Kenya), Tandemconsulting (Madagascar),

USAID Washington colleagues

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Quality of Care Study Overview

The Maternal and Newborn Complications Quality of Care(QoC) health facility survey focuses on prevention andmanagement of the most serious maternal and newborncomplications, 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 inall but one country

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Seven QoC Assessment Countries

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MCHIP QoCassessmentsimplemented in seven

countries in sub-Saharan Africa from2010-2011

Data cleaning andanalysis is still inprogress in Zimbabwe


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PE/E-Related Study Questions

How well are opportunities during ANC andmaternity services actually being used to screen for

pre-eclampsia? How well prepared are providers and facilities to

screen for pre-eclampsia and manage severePE/E?

Are cases of severe PE/E being managedaccording to standards?

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Standards Used as Benchmarks

WHO IMPAC guidelines for ANC and Labor andDelivery, especially Managing Complications inPregnancy and Childbirth.

For screening for pre-eclampsia: History taking elements: headache, blurred vision, swollen

hands/face

Take BP with proper technique

Test urine for proteinFor 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 2,500deliveries and close to 3,000 ANC consults; interviewed over1,000 health workers.

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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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Screening for Pre-eclampsia during ANC

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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 averageof scores for each countryand high-low line shows theby-country range.


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Counselling during ANC on Signs of PE

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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:



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How do results for PE/E screeningcompare to other elements of ANC?

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(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 fetalheartbeat (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:



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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:


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 duringL&D compare to other elements of care?

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(1)Mean score of 9 IP tasks during L&D; (2) Mean score of 4 partograph components; (3) Any uterotonicgiven within 3 minutes of delivery with controlled cord traction and uterine massage; (4) Mean scoreof 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:



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Policies and Guidelines

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

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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 KeyAreas of Maternal and Newborn Care

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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 Mozambique); (2) Mean score of 2knowledge 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 dataMadagascar); (6) Mean score of 2 knowledge area: examinations, interventions (no data Madagascar); (7) Mean score of 2 knowledge areas:equipment, resuscitation steps (from written test or simulation); no data Mozambique

Note:



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Health Worker Knowledge of PE/ESigns and Management

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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:



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Constraints Analysis for Screeningfor PE/E

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(1) MgSO4 registered, on EDL, first line PEE 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 offacilities with: functioning blood pressure apparatus (in ANC room, except Kenya in delivery room), ability to conduct urinetesting, 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 averageof scores for each countryand high-low line shows theby-country range.


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Summary of PE/E cases observed

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A G2 P1 woman was admitted to L&D at 9:25AM by a femalenurse with graduate level training/diploma. She had had anuneventful previous pregnancy. No ANC. Her initial BP wasrecorded and was elevated, but not above DBP = 110. Urinewas not checked for protein. Progress was plotted on a WHOpartograph and BP recorded every 4 hours. She had a normalSVD , giving birth to a live infant at 2:00PM.

During the 3rd

stage of labor she had a generalized seizureand became unconscious.- Nurse evaluated vital signs and checked airway by listeningto chest, but did not prop on left side or check for neckrigidity. Intubation was not necessary.- She gave oxygen at 4-6 liters per min and protected frominjury, but did not place on left side, nor aspirate mouth andthroat after convulsion

- No anti-convulsant medications given, although facility hadmagnesium 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 wentto recovery ward.

Parameter Total

Cases of PE/E observed 50

Description of problem

Eclampsia 18

Severe pre-eclampsia 17

Mild pre-eclampsia 15Anti-convulsant used

Magnesium sulfate 19

Diazepam 9

No anti-convulsant 28

Other medication used

Antihypertensive 14Calcium 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 minimalConstraints to PE/E screening and management include:

Policies not always in place: In some countries prevention andtreatment of eclampsia is still based on diazepam or combination ofdiazepam 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 wasavailable 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 onhistory taking and counseling, and not justphysical examination and testing

There is at least as much need for emphasison training and supervision as on commoditysupply

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