Quality of care in early detection and management of pre-eclampsia/eclampsia in health facilities in Afghanistan

Nasratullah Ansari,Jelle Stekelenburg,Sheena Currie,Partamin Manalai,Jos Van Roosmalen,Farzana Maruf,Young-Mi Kim,Hannah Tappis

doi:10.1186/s12884-018-2143-0

Abstract

BackgroundAfghanistan faces a high burden of maternal and neonatal morbidity and mortality. Hypertensive disorders of pregnancy, including pre-eclampsia and eclampsia (PE/E), are among the most common causes of maternal and neonatal complications. Hypertensive disorders of pregnancy can lead to fatal complications for both the mother and fetus. The 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment assessed quality of early detection and management of PE/E in health facilities and skilled birth attendants’ (SBAs) perceptions of their working environment.MethodsAll accessible public health facilities with an average of at least five births per day (n = 77), a nationally representative sample of public health facilities with less than five births per day (n = 149), and 20 purposively selected private health facilities were assessed. Methods included a facility inventory and record review, interviews with SBAs, and direct clinical observation of antenatal care (ANC), intrapartum care and immediate postnatal care (PNC), as well as severe PE/E case management.ResultsMost facilities had supplies and medicines for early detection and management of PE/E.At public health facilities, 357 of 414 (86.2%) clients observed during ANC consultations had their blood pressure checked and 159 (38.4%) were asked if they had experienced symptoms of PE/E. Only 553 of 734 (72.6%) SBAs interviewed were able to correctly identify severe pre-eclampsia described in a case scenario. Of 29 PE/E cases observed, 17 women (59%) received the correct loading dose of magnesium sulfate (MgSO4) and 12 women (41%) received the correct maintenance dose of MgSO4.At private health facilities, 39 of 45 ANC clients had their blood pressure checked and 9 of 45 (20%) were asked about symptoms of PE/E. Fifty-four of 64(84.4%) SBAs in private facilities correctly identified severe pre-eclampsia described in a case scenario.ConclusionNotable gaps in SBAs’ knowledge and clinical practices in detection and management of PE/E in various health facilities increase the risk of maternal and perinatal mortality. Continuing education of health care providers and increased investment in focused quality improvement initiatives will be critical to improve the quality of health care services in Afghanistan.

Highlights

Afghanistan faces a high burden of maternal and neonatal morbidity and mortality
This study examines the quality of early detection and management of pre-eclampsia and eclampsia (PE/E) in public and private health facilities in 2016, documents Skilled birth attendant (SBA)’ perceptions of their working environment, and assesses whether quality of care varies by different levels of public health facilities
Observation checklist content was based on World Health Organization (WHO) guidelines and adapted from tools used in conducting quality of care assessments in other countries [12]; the content of other tools was adapted from Demographic and Health Survey Service Provision Assessment [13], and emergency obstetric and newborn care (EmONC) assessments supported by the Averting Maternal Death and Disability (AMDD) program [14]

Summary

Introduction

Afghanistan faces a high burden of maternal and neonatal morbidity and mortality. Hypertensive disorders of pregnancy, including pre-eclampsia and eclampsia (PE/E), are among the most common causes of maternal and neonatal complications. Hypertensive disorders of pregnancy, including preeclampsia/eclampsia (PE/E), are the second most common cause of maternal mortality, accounting for 14.1% of maternal deaths, and are associated with fetal and neonatal mortality worldwide [1]. PE/E complicates 3–5% of pregnancies and occurs in the second half of pregnancy, during labor, and in the postpartum period [2]. It is one of the most common causes of preterm birth [3]. The 2010 Afghanistan Mortality Survey showed that hypertensive disorders of pregnancy account for 20% of maternal deaths, and are the second most common cause of death after obstetric hemorrhage [5]. The 2015 Afghanistan Demographic Health Survey did not examine causes of maternal mortality, a 2011 study showed that hypertensive disorders of pregnancy are the leading cause of maternal mortality in two districts reflective of the most urban (Kabul City) and most remote (Ragh district, Badakshan) areas in Afghanistan [6]

Methods

Results

Discussion

Conclusion