Improving the quality of integrated antenatal care and care for preeclampsia/eclampsia in Jinja, Uganda
From June 2015 through March 2017 the USAID ASSIST Project supported the Ministry of Health of Uganda to implement an improvement activity in 10 high delivery volume health facilities in Jinja District to improve the quality of primary ANC services through implementation of an integrated package of antenatal care best practices. These included prevention, early detection, initial management and referral of the most common obstetric conditions with an emphasis on improving screening, diagnosis, treatment and referral of preeclampsia/eclampsia as one of the major causes of preventable maternal death; as well as on early screening, detection, initial management and referral of locally frequent maternal infections such as malaria and syphilis and nutritional deficiencies such as anemia.
The 10 high-volume facilities were randomly selected from the catchment area of the Jinja Regional Referral Hospital. Nine additional randomly selected facilities were included to serve as a control group. Baseline and end line assessments were conducted in both the intervention and control groups to measure the impact of the interventions.
ASSIST used a collaborative improvement approach to implement the ANC activity which relied on individual quality improvement (QI) teams simultaneously testing changes focused on the same clinical area (preeclampsia/eclampsia, malaria and syphilis, or anemia), using common indicators to track improvement, and then sharing the results of the most effective changes in “learning sessions”. The ANC improvement activity was organized in three waves, each lasting approximately three months and focusing on a particular clinical area (preeclampsia/eclampsia, malaria and syphilis, and anemia). During both the second and the third waves, 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.
QI teams achieved statistically significant results in all three major improvement areas. Under preeclampsia/eclampsia (PE/E) care, all 10 intervention facilities saw improvement in the measurement of blood pressure (BP) for women attending ANC (from 48% during baseline to 98% during end line) and in the percentage of women with BP ≥ 140/90 who were assessed for protein in urine (96 percentage point increase), the two main drivers for improving screening of PE/E prioritized by QI teams. A statistically significant increase in the diagnosis of preeclampsia during ANC was also observed. Similar improvements were also seen in provision of malaria prophylaxis (percentage of mothers receiving Isoniazid Preventive Therapy between 28-36 weeks increased by 61 percentage points), malaria diagnosis and treatment (increased from 1% to 4%), syphilis screening (33% at baseline vs. 65% during end line), syphilis treatment (0% at baseline vs. 88% at end line), and anemia prevention (% of women receiving iron-folate increased from 39% to 95%), screening (57 percentage point increase in women whose hemoglobin was assessed during ANC) and diagnosis (7 percentage point increase in diagnosis using laboratory investigations).
Treatment of PE/E with magnesium sulfate was one of the most challenging areas for improvement teams. While health workers showed sufficient confidence in diagnosing and treating malaria, anemia, and syphilis, the project observed a considerable lack of confidence surrounding both diagnosis of PE/E and treatment with MgSO4. Given the relative rarity of the condition, many health workers had no practical experience in identifying PE/E and administering treatment and often referred patients to a higher level of care without administering a loading dose of magnesium sulfate even when the drug was available. To combat this, ASSIST provided refresher training to facility-based staff within the MCH departments of the intervention facilities, emphasizing through both theoretical and practical, skills-based sessions, the necessary steps to screen for, diagnose, and treat preeclampsia/eclampsia. To reinforce knowledge learned through training sessions, ASSIST identified skilled staff from within the facilities – such as the head of maternal health for a sub-district of Jinja – who could serve as mentors for the rest of the facility on how to handle high-risk cases. To increase exposure to these cases and improve management, coaches emphasized the necessity of calling for assistance from a colleague when treating a preeclamptic/eclamptic patient. Lastly, ASSIST developed and introduced a job aid that demonstrated how to prepare loading and maintenance doses with commonly available supplies.