Pre-eclampsia and Eclampsia Prevention and Management: Quality of Care in Madagascar Jean Pierre Rakotovao (MCHIP Chief of Party), Eva Bazant (Sr. Monitoring, Evaluation and Research Advisor), Vandana Tripathi (Consultant, Jhpiego), Justin Ranjalahy Rasolofomanana (Professor of Higher Learning and Public Health Research)
Introduction This assessment provides the first data regarding quality of actual PE/E-related practices in Madagascar This analysis focuses on facility readiness, provider knowledge, and interventions related to pre-eclampsia and eclampsia(pe/e).
Context Population: 20 M DHS IV TFR: 4.8 CPR : 40% /Modern method: 29% ANC: 86% at least one MMR: 498 deaths per 100000 live births Home delivery: 64 % EMONC survey 2010 Major causes of maternal death Hemorrhage : 38.89% Prolonged labor: 22. 22 %PE/E Infection: 20.37% PE/E: 14.81%
Objective To provide information on quality of prevention and management interventions in facility-based care that address maternal complications.
Materials and Methods A cross-sectional national assessment in facilities with higher caseload of birth (>2 per day) Descriptive statistical analysis was conducted Inventories : 36 facilities Interview : 139 providers, largely midwives Observations : 323 ANC consultations and 347 labor & delivery (L&D) mostly in hospitals. Review of Data from observation of each of 10 suspected PE/E cases.
Results (1) Inventory The mean score for availability of drugs, supplies, and equipment related to PE/E was 63%, Injectable anticonvulsants were available in 72% of L&D wards, Magnesium sulphate (MgSO4) and antihypertensives were available in only half of facilities. Characteristic N=36 Facilities Availability of injectable anticonvulsant in L&D ward 72% Availability of MgSO4 47% Availability of calcium gluconate/lidocaine 53% Availability of antihypertensives 50% Mean score for availability of drugs/equipment related to PE/E (e.g., anticonvulsants, antihypertensives, syringes) 63% Functioning BP apparatus 82% Use of parenteral anticonvulsants in past 3 months 53%
Results (2) Provider knowledge Nearly all providers interviewed correctly identified a PE/E diagnosis on case scenario, Overall mean score on examination, diagnosis, and management was 51%, and Only a third of providers knew to stabilize with MgSO4 and antihypertensives.
Results (3) Observation Nearly all ANC clients had blood pressure (BP) taken and were asked about danger signs of PE/E, only half of cases had BP taken with correct technique, and just 29% received a urine test. Multigravidae women were rarely asked about convulsions or hypertension in prior pregnancies. PE/E screening was performed less often in L&D than in ANC.
Results (4) PE/E cases observed MgSO4 was available in 4 of 7 facilities where suspected PE/E cases were observed. MgSO4 was not administered in any of these cases, and diazepam was administered in 5 cases. One case experienced convulsions: MgSO4 was reportedly available but not administered. Observation Number Convulsing or conscious 1 Magnesium sulfate administered 0 Diazepam administered 5 Antihypertensive administered 2 Maternal deaths 0 Newborn deaths 1
Conclusions Correct practices in ANC regarding PE/E screening/detection and management in L&D using MgSO4 and antihypertensives urgently need to be adopted. Providers need support to ensure complete provision of PE/E interventions. Recommendations include making an operational plan related to PE/E from policy documents, ensuring adequate supply of MgSO4, related drugs, and visible job aids at each facility, and sustained training and regular supervision of providers. All effective antihypertensives need to be on the Essential Drug List
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