World Preeclampsia Day: Using a collaborative learning approach to improve early detection and management of preeclampsia in Jinja District, Uganda
(A quality improvement team in Jinja District, Uganda reviews changes tested to increase early detection of preeclampsia. Photo credit: Connie Namajji, URC)
Today, May 22, marks the first-ever World Preeclampsia Day—a global effort to increase awareness of preeclampsia as a life-threatening complication of pregnancy.
The USAID ASSIST Project has been using improvement methods to support facilities to reduce preventable deaths from preeclampsia and eclampsia (PE/E). In the Jinja District of Uganda, ASSIST has been working in a “slice” of the health care system since July 2015 to improve the quality of primary antenatal care (ANC) services. We do this through implementation of antenatal care best practices, including prevention, early detection, and treatment of preeclampsia and eclampsia at all levels of health service delivery. This activity is being implemented in 10 health facilities within the catchment area of the Jinja Regional Referral Hospital; an area that includes five health centers III, three health centers IV, and one general district hospital, in addition to the regional referral hospital. Nine additional facilities were included in a baseline and end line assessment to serve as a control group.
The ANC improvement activity was organized in three waves, each lasting approximately three months. The first wave (November 2015–February 2016) focused on improving early detection and management of preeclampsia among pregnant women. The second wave (March–May 2016) concentrated on improving screening, diagnosis, and management of malaria and syphilis. In the third and final wave (June–September 2016), teams worked to improve screening and management of anemia. During both the second and the third waves, quality improvement (QI) teams continued to improve care processes initiated during earlier phases so that, by the end of the third wave, teams had developed a comprehensive set of changes to improve antenatal care.
Driver diagram to improve detection of preeclampsia/eclampsia, Jinja District
ASSIST used a collaborative improvement approach to overcome obstacles and improve the quality of antenatal care in Jinja. To begin the improvement work, QI teams identified:
- an improvement aim, that all pregnant women be screened and appropriately diagnosed for preeclampsia/eclampsia during antenatal care;
- the main drivers for improvement towards that aim; and
- evidence-based interventions and change concepts that can influence those drivers.
Individual teams then tested changes in care delivery to address each concept and analyzed results using time-series charts. All ten teams worked on the same aim at the same time, collected data on common indicators, and met periodically in learning sessions to share the changes that they had tested and their results. Learning sessions allowed individual teams to hear about successful changes tested in other facilities—sparking ideas and “aha” moments—and allowed for friendly competition among teams to get the best results. Results for the entire collaborative were then validated, consolidated, and synthesized for use by other teams. The collaborative improvement approach has facilitated rapid gains in antenatal care delivery by harnessing the power of multiple teams simultaneously testing changes, using common indicators, and sharing the results of the most effective changes to improve care.
(Mini-labs were established in the maternal and child health departments and ANC clinics to allow midwives to conduct urine dipstick testing on the spot, rather than sending pregnant women to the laboratory for testing.)
Two primary drivers for improving early detection of preeclampsia (blood pressure correctly measured and interpreted for each pregnant woman attending an ANC visit and mothers with a BP > 140/90 assessed for protein in urine) improved significantly over time in all participating facilities.
The figure below highlights the main obstacles that QI teams faced while implementing evidence-based interventions; outlines the successful change ideas tested by the QI teams—including reassigning students and redundant staff to take blood pressure measurements during the triage process, and creating “mini-labs” within the maternal and child health departments to allow midwives to conduct urine protein testing—and presents the ensuing results.
Addressing primary drivers of early detection of preeclampsia/eclampsia, Jinja District (Mar 2015-Feb 2017): obstacles, tested changes, and illustrative results
A “harvest meeting,” held in October 2016, brought together key members from all ten QI teams to identify and discuss change ideas that helped improve early detection and management of preeclampsia, along with other elements of comprehensive antenatal care, and synthesize lessons learned. During the discussions, four main steps critical to improving care emerged:
- Create a managerial environment primed for quality care by strengthening leadership, creating accountability, and recognizing and rewarding staff who prioritize improvement.
- Ensure basic inputs by strengthening health workers’ knowledge and skills and increase availability of basic supplies (for example, blood pressure machines and urine dipsticks).
- Optimize key care processes by redesigning them and supporting QI teams to test changes and overcome obstacles.
- Build a mechanism for continuously measuring and improving care through quarterly learning sessions and monthly coaching to facility-based QI teams.
As we reflect on the devastating effects of preeclampsia on World Preeclampsia Day, ASSIST’s work in Jinja presents a useful model for how we can improve early detection and management of preeclampsia, with minimal additional inputs, through a collaborative learning approach.