Antenatal care (ANC): Quality vs quantity – it’s the content that counts for improving pre-eclampsia /eclampsia (PEE) outcomes Sheena Currie, Senior Maternal Health Adviser, Maternal Child Survival Program

Presentation Outline ANC – minimum requirements for quality PEE care Challenges and how we overcome these?

Introduction Disease burden for women and newborns due to PEE is high in pregnancy, labour and postpartum Reliable data on PEE prevalence is unavailable in most settings ANC serves as an important entry point for early identification and prevention of PEE progression to severe PEE and eclampsia

Current practice re frequency ANC Antenatal care is a complex intervention Considerable differences across countries in what constitutes standard care In most low-resource settings the standard minimum 4 antenatal visits is inline with current WHO guidelines but coverage of ANC4+ variable Number and frequency ANC visits currently being revised by WHO Many women do not receive ANC

Historically little focus on quality of ANC ‘Focusing on the proportion of pregnant women making at least 4 antenatal visits to measure program performance has drawn the attention away from the content of care to mere contact.’ The quality–coverage gap in antenatal care. Hodgins 2014

ANC serves as an important platform for prevention, identification, and management of PEE Primary Prevention e.g. Calcium Supplementation Secondary Prevention: Activities aimed at early disease detection and management to reduce PEE progression to severe PEE and eclampsia Focused on identifying women with elevated BP and other PEE features (e.g. proteinuria) and checking for danger signs Focused antenatal care is the most important part of secondary and tertiary prevention. The decrease in maternal mortality and serious morbidity results mainly from the screening (checking BP and testing urine for protein) and tertiary prevention (such as timed delivery) associated with organized antenatal care. In order for antenatal care to be effective, however, health care providers must be adequately trained to identify, prevent, and manage pre-eclampsia and should have all of the essential equipment (in particular accurate sphygmomanometers and means to detect protein in the urine), commodities, and consumables (in particular for testing urine). In addition, adequate systems must be in place to stabilize the woman and transfer her to the appropriate level of care. Women, families, and communities need to understand danger signs and the importance of seeking early and regular antenatal care. During antenatal care, health care providers can assist women and their families to develop a birth preparedness and complication readiness plan that will ensure that women access care in a timely manner.

Rwanda DHS 2014-2015 Among women who received ANC for their most recent birth: 84% had their BP measured 79% were informed of pregnancy complications 58% had a urine sample taken. Just released Education on key dangers signs in pregnancy ranged from 4% (convulsions) to 16% (severe abdominal pain), and education on birth preparedness and complication readiness ranged from 5% (discussed items to have on hand for an emergency) to 15% (asked the client where she plans to deliver).  

ANC Coverage & Quality- Sindh, Pakistan 87% of women received at least one ANC checkup 81% had BP measured 73% had urine tested 72% had blood tested 65% took iron tablets ANC coverage is high. Even among women in the poorest quintile, 70% receive at least one ANC visit. Most women (70%) obtained ANC services from the private sector 79% in highest wealth quintile use private sector 58% in lowest wealth quintile use private sector 4,000 married women aged 15-49 Live births in 2 years before survey Multistage, stratified sampling Average age: 27 years Average family size: 3 children 49% urban / 51% rural 43% have primary education 61% received 2+ tetanus shots 56% had weight measured Only 28% of ANC users received all 6 elements of care

One example: Key ANC services, Tanzania Data from MCHIP Quality of Care Study All Facilities 2010 (n=391) 2012 (n=366) Key Services % BP taken 79 84 Any urine test 40 50 Counselling danger signs (headache /blurred vision) 42 78 Checking BP is generally high – however quality of BP checking unknown. Over 90% HF had functional BP equipment Availability of key supplies and medications for prevention and management of PE/E were assessed through inventories conducted in the ANC and maternity ward. All regional hospitals had a functioning BP machine in both assessments. In the lower-level health facilities, the availability of a functioning BP machine rose from 69% to 100% between baseline and endline.   Direct observation care

Tanzania: Performance of screening components PEE during ANC, 2010 and 2012 Figure 1 shows improvements between 2010 and 2012 across all screening components for PE/E during ANC, with notable increases for appropriately taking blood pressure, asking about headache and blurred vision, and asking about swollen hands or face. Almost no improvement was noted for urine testing. Despite the increases, at endline just over one-fourth of women (27%) received BP screening and were asked about symptoms of PE/E; nominal improvement was seen in this indicator as a result of project activities.

Quality ANC for PEE care needs functional and accountable health system Reliable early detection of PEE along the continuum of care from household to health facility Ensure women with pre-eclampsia or eclampsia promptly receive appropriate interventions, according to WHO guidelines (WHO 2015) – also applies in ANC Coordinating PEE care across system levels (community, primary, referral) and phases of care (pregnancy, intra and postpartum) Measuring & tracking ANC quality of care measures e.g. proportion of ANC visits at which blood pressure (BP) was measured Explore alternative models for ANC services as platforms for improved and integrated service delivery to reach every woman Providers at a minimum should be competent to diagnose & provide initial Rx including administration MgSO4 & antihypertensive in SPE/E

Solutions to Challenges Updated national guidelines /protocols Availability Adherence Ensure national guidelines on prevention & management PEE operationalized Criterion-based audit Lack of skills in BP measurement On-the-job training/mentoring Track BP measurement as quality of care standard Use of automated or semiautomated devices Availability of reliable BP machines Low-cost, durable automated or semiautomated BP machines Capacity to detect severe PEE and provide initial management at ANC then refer Quality improvement approaches including facility readiness e.g. regular clinical drills Functional- referral and counter-referral systems Availability of anti convulsants (MgSO4) and antihypertensive drugs Life saving commodities also available at ANC sites Shortage of confident , competent staff esp. lower level facilities Task-shifting and shifting Simplified tools and job aids Overall commitment to improve system governance and accountability

Measures to improve BP measurements

The new healthcare paradigm HEALTH SECTOR More comprehensive patient centered ANC Technological developments (diagnostic, communications) An informed client who has more control on her condition (e.g. when to return for BP check; self testing urine) Enabling and mobilizing individuals and communities The new paradigm is one of partnership – community mobilisation & increased awareness of danger signs.

Ending preventable maternal deaths …. Health sectors that are moving towards empowered clients who are potentially the most effective agents for improving their own health. Like other complications early detection and management of PEE needs accountable and functional health systems Improved metrics / use of data to track and sharpen implementation