FIGO 2012, Rome

Pre-Eclampsia and Eclampsia (PE/ E)

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 & Tandem
Session Outline

 Context for PE/ E assessment in Madagascar

 Objectives of the assessment
 Methods
 Results
 Conclusions
Context: In Madagascar
Globally, hypertensive disorders of pregnancy – one of the lea ding ca uses of
ma terna l dea th – contribute to 9.1% of ma terna l dea ths (Kha n 2006). Existing,
evidenced-based solutions ha ve uneven covera ge.
Maternal and Reproductive Health Maternal Mortality
 Popula tion: 20 million  MMR: 498 per 100,000 live births
 Tota l fertility ra te: 4.8 (per DHS IV (DHS)
2008)  Ra nked 141 out of 181 countries
 Contra ceptive preva lence: 40% (Hoga n 2010 La ncet)
(modern methods: 29%)  Ma jor ca uses of ma terna l dea th
 Antena ta l ca re: 86% for 1+ visit (EmO NC survey 2010):
 Hemorrha ge: 39%
 Home delivery is high: 64% (ha s
rema ined high)  Prolonged la bor: 22%
 Infection: 20%
 PE/ E: 15%
 No specific PE/ E policy statement, but
RH norms do include PPH
Study Objectives
 Purpose: Study is the first to assess quality of
actual PE/ E practices in Madagascar’s health
facilities
 Specific objectives of this session:
 To share analysis on facility and provider
readiness related to PE/ E prevention and
management in facilities that address maternal
complications
 To describe the observations of quality of PE/ E
prevention and management interventions in
facility-based care
Materials and Methods
 A cross-sectional national assessment
 Sample: All facilities with > 2 births per day; n= 36 facilities
 Data sources:
 Facility Inventory re PPH: Done in n= 36 facilities
 Interview with provider on knowledge and experience: n= 139 (note:
69% were nurse/ midwives)
 Observations of Labor & Delivery clients: n= 347 (84% ended in
spontaneous vaginal delivery; included 15 suspected PPH cases)
 Collected by external trained medical staff
 Used smart phones
 Descriptive statistical analysis conducted
 Data reviewed from each suspected PE/ E case
 (n= 10)
Results (1): Inventory
Characteristic N= 36 Facilities
 *ma gnesium sulfa te, dia zepa m or phenytoin
Ava ila bility of injecta ble a nticonvulsa nt in L&D 72%
wa rd*
Ava ila bility of MgSO 4 47%
Ava ila bility of ca lcium glucona te/ lidoca ine 53%
Ava ila bility of a ntihypertensives 50%
Mea n score for a va ila bility of 63%
drugs/ equipment rela ted to PE/ E (e.g.,
a nticonvulsa nts, a ntihypertensives, syringes)
Functioning BP a ppa ra tus 82%
Results (2): Provider Knowledge

 Nearly all (96%) providers interviewed

correctly identified a PE/ E dia gnosis on ca se
scena rio.
 However, only a third (33%) of providers knew
to sta bilize with MgSO 4 a nd
a ntihypertensives.
 Mea n score for ma na gement of convulsions
questions: 50%
Results (3): PE/ E Screening/ Detection

 Nearly all ANC clients ha d blood pressure

(BP) ta ken a nd were a sked a bout da nger
signs of PE/ E.
 However, only half of ca ses ha d BP ta ken with
correct technique, a nd just 29% received a
urine test.
 Multigra vida e women were rarely a sked
a bout convulsions or hypertension in prior
pregna ncies.
Results (4): PE/ E Screening/ Detection
100

90
 Performed
82 82
80

less often in L&D 70

tha n in ANC 60

50
39 ANC
40
32 L&D
29
30
19
20 16

10 7

0
Asks a bout Asks a bout Ta kes blood Performs or
headache or swollen hands pressure refers for
blurred vision or fa ce urine test
Results (5): PE/ E Care

 Ma gnesium sulfa te is first-line drug for ca re.

 MgSO 4 wa s a va ila ble in 4 of 7 fa cilities where suspected
severe PE/ E ca ses were observed.
 However, in suspected severe PE/ E ca ses observed
(n= 10):
 MgSO 4 wa s not a dministered in a ny ca se. Dia zepa m wa s
a dministered in the 5 ca ses.
 No a nti-convulsa nt a dministered in rema ining 5 ca ses.
 O ne ca se experienced convulsions, but no a nti-
convulsa nt wa s a dministered, even though MgSO 4 wa s
a va ila ble.
Conclusions
 Correct PE/ E practices must be urgently adopted and maintained:
 Regarding PE/ E screening/ detection in ANC and L&D
 Regarding management using MgSO4 and antihypertensives in L&D
 Providers need support to ensure complete provision of PE/ E interventions:
 MgSO4 not administered even when available, consistent with findings of
poor provider knowledge regarding PE/ E management.
 Recommendations:
 Create an operational plan related to PE/ E based on guidance currently
in disparate policy documents.
 Ensure adequate supply of MgSO4, related drugs and visible job aids at
each facility; monitor health facility supply.
 Provide sustained training and regular supervision of providers.
 Add all effective antihypertensives to Essential Drug List.
Thank you
SUPPLEMENTAL SLIDES
 Table 1: Distribution of observation sample and provider
interviews by provider cadre and facility type

L&D O bservation
Characteristic Provider Interview (n= 139)
(n= 347)
Cadre
Midwife 68.9% 64.0%
O bstetrician 6.6% 1.4%
O ther physician 12.1% 23.7%
Nurse 3.7% 5.8%
O ther 8.1% 4.3%
Type of Facility
University hospital (5 facilities) 35.2% 12.9%
Regional hospital (11 facilities) 24.5% 33.1%
District hospital 2 (7 facilities) 14.7% 23.0%
District hospital 1 (4 facilities) 6.6% 10.1%
Basic health center 2 (9 facilities) 19.3% 21.6%