Pre-Eclampsia / Eclampsia: How well are we screening for and managing PE/E?

1. Pre-Eclampsia / Eclampsia: How well are we screening for and managing PE/E? Jim Ricca MCHIP/Jhpiego Interventions for Impact in Essential Obstetric and Newborn CareAfrica Regional Meeting, 21–25 February 2011

2. Acknowledgments • Ministries of Health and staff of the study facilities in Ethiopia, Madagascar, Rwanda, and United Republic of Tanzania • Data collection teams in each country • Other study team members based in the USA: Heather Rosen, Barbara Rawlins, David Cantor, Bob Bozsa, Linda Bartlett, Eva Bazant, Rebecca Levine, Patricia Gomez, Joseph de Graft Johnson • Jhpiego in-country staff; Tandem consulting (Madagascar)

3. Questions for consideration Opportunities for intervention • Facility-based births: 7 - 50% in countries assessed • ANC Coverage: 27 - 80% in countries assessed Our questions • How well are these opportunities actually being used to screen for pre-eclampsia? • How well prepared are providers and facilities to screen for pre-eclampsia and manage PE/E? • How well are cases of severe pre-eclampsia / eclampsia being managed?

4. QoC-MNC study • QoC-MNC study focuses on routine care and prevention and management of the most serious maternal and newborn complications, including PE/E • Core of assessment is direct observation to assess quality of care, both in ANC and on Labor and Delivery

5. QoC-MNC Assessments • MCHIP QoC-MNC assessments implemented in 5 countries in 2009-2010 • Zimbabwe is planned for 2011

6. Standards used as benchmarks Current WHO guidelines for ANC, Labor and Delivery, especially those in 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 (hydalazine, labetalol, nifedipine)

7. Summary of Samples Assessed 177 facilities in 4 countries; observed over 1,300 deliveries and over 1,100 ANC consults; interviewed almost 600 health workers.

8. Screening for Pre-eclampsia in ANC

9. ANC clients counselled on symptoms of PE

10. How do these results compare to other areas of ANC care (FANC)? (1) Health promotion = counseling on pregnancy danger signs, PPFP (2) Preventive treatments = administration of Tetanus Toxoid, Iron Folic Acid (3) Birth Prep. Counseling = Ask client where she will deliver; counsel to set aside money, use skilled birth attendant, and have items for emergency home delivery if needed

11. Screening for Pre-eclampsia in Labor & Delivery

12. How do L&D results for PE/E screening compare to management for other issues? (1) initial assessment (asking about danger signs, past history, general examination) and care during 2nd and 3rd stage ; (2) see slide 15; (3) explains procedures, is supportive and shows respect to client and support person; (4) handwashing, protective clothing, proper disposal and decontamination; (5) partograph initiated at correct time, plotted every half hour, BP recorded every 4 hrs, filled-in after delivery (all deliveries); (6) dry and wrap, clean blade, 2+ min delay to clamp cord, initiate breastfeeding w/in 1hr, skin-to-skin * Values are mean score

13. Policies and Guidelines Antenatal Care Service Delivery Area • 50% of facilities had ANC guidelines present (country range 22-76%) • 19% of facilities had guidelines on management of pre-eclampsia /eclampsia (country range 8-29%) Labor and Delivery Service Area • 40% of facilities had guidelines on normal birth (country range 21-65%) • 41% of facilities had guidelines on emergency obstetric care (country range 16-69%)

14. Health Worker Knowledge Scores for Key Areas of Maternal and Newborn Care (1) n=423, no data for Madagascar; (2) written test for Ethiopia, simulation for Tanzania, Rwanda, Madagascar * Values are mean score

15. Health worker knowledge of PE/E signs and management * Values are mean score

16. PE/E Clinical Practice – Gap Analysis (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) births in facilities stocked with MgSO4, missing data 117 births, Kenya excluded; (5) personnel knowledgeable in PE/E care

17. 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, foetal heart rate. Started IV fluids. - No other seizures were observed and mother and baby went to recovery ward.

18. Something more to consider… More to teamwork than knowledge, skill and attitude Siassakos D, Draycott T, Crofts J, Hunt L, Winter C, Fox R., BJOG 2010;117:1262–1269. Conclusions: The knowledge, manual skills and attitudes of the individuals comprising each team, measured by established methods, did not correlate in this study with the team’s clinical efficiency in the management of simulated eclampsia. The inference is that unidentified characteristic(s) play a crucial part in the efficiency of teams managing emergencies. Any emphasis of training programmes to promote individual knowledge, skills and attitudes alone may have to be re-examined. This highlights a need to understand what makes a team efficient in dealing with clinical emergencies.

19. Conclusions There are currently missed opportunities for screening • Screening during ANC and L&D by taking BP is high and mainly with proper technique BUT • History taking for PE/E danger signs in both the ANC clinic and L&D ward is minimal “Policy – Practice Gap” for screening and management • Policies not all in place: In some countries prevention and treatment of eclampsia is still based on diazepam • Commodities also lacking in some places: MgSO4 for treatment was available in less than half of facilities - 39% (country range 16-49%) • BUT as with PPH, knowledge/skills and supervision are also problems

20. 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

21. THANK YOU! Look for the finalized study protocol, assessment tools, smart phone applications, and web tables on the MCHIP website. www.mchip.net Follow us on: