1. 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

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

3. 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

4. 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

5. 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

6. 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.

7. Rwanda DHS
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).

8. 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

9. 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

10. 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.

11. 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

12. 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

13. Measures to improve BP measurements

14. 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.

15. 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