Prereferral management of preeclampsia with severity features in a low-income country—characteristics and challenges in a Sub-Saharan setting: a mixed method study

Abstract

Background: Preeclampsia continues to be a major cause of maternal and perinatal mortality and morbidity, globally. Although pre-referral treatment constitutes a bigger part of the management package for preeclampsia with severity features in low-income settings, little is known regarding the characteristics and challenges of preeclampsia pre-referral and referral management in the Sub-Saharan setting. ObjectiveTo determine the characteristics and challenges of pre-referral and referral management of preeclampsia with severity features Study design: We conducted a mixed method study on the pre-referral management of pregnant women who complicated by preeclampsia with severity features in Ethiopia. We prospectively collected data on clinical characteristics, management outcomes, and pre-referral characteristics of pregnant women who complicated by preeclampsia with severity features. Data were collected using a structured questionnaire. For the qualitative part of our study, we conducted 20-30 minutes, semi-structured, qualitative face-face in depth-interview with 14 health professionals. Quantitative data were analyzed using SPSS version 23 and simple descriptive statistics was employed. We used thematic analysis on Open Code 4.03 software to analyze the qualitative data. - ResultsA total of 261 pregnant women who had preeclampsia with severity features were included in the study and 14 care providers were interviewed on existing challenges with pre-referral management for patients with preeclampsia with severity features. The mean systolic and diastolic blood pressures were 154.3mmHg and 100.3mmHg, respectively. The total perinatal mortality was 6.5% (17/261). Three mothers (1.1%) complicated by intra-cranial hemorrhage and other three (1.1%) other women developed pulmonary edema. Out of 261 patients, only 41 patients (15.7%) received magnesium sulphate. Similarly, antihypertensive was given only to 35 patients constituting 13.4%. Eight mothers convulsed (3.1%) during referral. Two mothers (0.8%) developed pulmonary edema when they arrived at recipient health institutions after referral. Likewise, another two (0.8%) women developed disseminated intravascular coagulation (DIC) by the time of arrival from referring health institution. Up on qualitative data analysis, three overarching themes were recognized: (i) challenges related Patient and family resistance, (ii) Challenges related to healthcare providers’ knowledge, skill and confidence, and (iii) health system related challenges. Low utilization of magnesium sulphate and ant-hypertensive drugs, patient misperceptions regarding reasons for referral, providers lack of knowledge on the pre-referral management, inadequate communication between referring and recipient health institution, and non-existence of uniform pre-eclampsia pre-referral and referral management protocols among the referring institutions were the identified gaps. ConclusionWe found a significant gap in pre-referral management for patients with preeclampsia with severity features. Preeclampsia management policy reforms should include introduction of adequate patients counselling platforms, increasing community awareness creation, providing in-service training on pre-referral management of preeclampsia for health personnel, ensuring constant availability of anti-convulsant and antihypertensive drugs and uniform implementation of preeclampsia pre-referral management protocols across health institutions.