PERSISTING CHALLENGES IN THE PROVISION OF QUALITY OBSTETRIC

PERSISTING CHALLENGES IN THE PROVISION OF QUALITY OBSTETRIC CARE TO WOMEN WITH PRE -ECLAMPSIA AND ECLAMPSIA IN NIGERIA: ASSESSMENT OF HEALTH PROVIDERS' PREPAREDNESS AND FACILITY READINESS Gloria Adoyi Salisu Mohammed Ishaku; Oginni Ayodeji Babatunde; Karen Kirk. 20 th World Congress meeting of the International Society for the Study of Hypertension in Pregnancy (ISSHP) 24 October 2016 Sao Paulo, Brazil.

BACKGROUND • In Nigeria, an estimated 40 percent of pregnant women experienced pregnancy-related health problems during or after pregnancy and childbirth (Mutihir, 2011). • Common maternal health problems/complications a woman may experience during pregnancy include Pre-eclampsia and Eclampsia (PE/E). • Screening, early antenatal detection, and timely management are the most effective ways for preventing morbidity and mortality from these pregnancy-related disorders • However, low level of access to, and utilization of quality obstetric care is a major contributing factor to why most maternal deaths occur in Nigeria.

OBJECTIVES • To assess the preparedness of frontline health care providers and facilities readiness for early detection and management of PE/E in seven states in Nigeria • To analyze the gaps in providers’ competence to prevent, detect and manage PE/E • To determine facility capacity to manage PE/E

FACILITY INSIGHTS EARLY DETECTION OF PE

STUDY AREA

METHODOLOGY • Data collection : June to August, 2015 • Study sites: Secondary, primary health care facilities and a few tertiary • Study Design: Quantitative research using a self- administered, semi-structured questionnaires. 1. Provider Assessment 2. Facility Inventory

Summary of quantitative data States Cross River Ebonyi Ondo Kogi Sokoto Bauchi Katsina Total Health provider Facility inventory Interview 59 46 59 44 61 55 55 379 11 20 11 8 11 14 21 96

HEALTH PROVIDERS' PREPAREDNESS FINDINGS

Type of facility (inventory) n=96 5 10 Tertiary 28 57 Secondary PHC Clinic

Distribution of health provider respondents by: (n=376) Level of health facility Type of provider 3% 5% 8% 21% 30% 38% 53% 33% Tertiary 9% General Hosp PHC Clinic Dr N/MW CHEW CHO Others

PROVIDER KNOWLEDGE: A pregnant woman was seen in the ANC at 12 weeks gestation with BP of 160/100 mm. Hg with 100 no proteinuria. What is the diagnosis? Providers able to properly diagnose hypertension 80 % 60 61 55. 7 43. 2 40 52. 2 50. 8 48. 5 Ebonyi Cross River All 40 34. 5 20 0 Kogi Katsina Sokoto Bauchi Ondo

PROVIDER KNOWLEDGE: What are the signs/symptoms of PE, SPE & E? 100 96 91 90 82 80 80 71 75 64 81 78 71 67 64 64 60 % 46 PE SPE E 46 40 20 14 13 8 12 6 9 5 9 0 Kogi Katsina Sokoto Bauchi Ondo Ebonyi Cross River Composite scores All

PROVIDER PRACTICE: Assessing the risk of PE, screening for PE and advising client of danger signs of PE/E 100 % 80 100 82 78 73 ANC Provider-Client Observation: Composite scores 73 60 53 50 40 32 30 30 24 20 11 8 0 0 Kogi 0 0 0 Katsina Sokoto Bauchi Assess risk of PE Detect PE 9 15 14 0 Ondo 0 Ebonyi 11 0 Cross River All Advise on Symptoms of Eclampsia

PROVIDER KNOWLEDGE: Less than 21% were aware of prophylactic drugs for prevention of PE 100 80 0 10 25 32 15 70 20 0 9 58 63 50 0 13 0 23 33 Other drugs Calcium 17 0 44 20 Don't know 73 62 % 40 23 50 56 60 9 9 9 Kogi Katsina Sokoto Bauchi Ondo Ebonyi Cross River 5 14 All Aspirin

PROVIDER KNOWLEDGE • Only 12% providers knew correct loading dose of Mg. SO 4 (Pritchard regime) • 10% knew the correct maintenance dose • 7% knew which drug used to manage Mg. SO 4 toxicity • <11% providers could list 3 ways to monitor Mg. SO 4 toxicity

FACILITY READINESS

FACILITY INVENTORY: How do facilities obtain Mg. SO 4? 100 0 80 60 50 40 20 0 10 33 30 0 Kogi 47 50 29 14 0 % 60 38 80 43 18 Ondo 39 50 29 Katsina Sokoto Bauchi 20 0 36 33 Ebonyi 17 Cross River Receive as regular supply from central level Purchase from the market/local purchase Client purchases it from the market when needed All

Availability of guidelines for management of PE/E , ANC equipment and Mg. SO 4 All 17 Cross River 18 States Ebonyi 10 18 Bauchi 0 10 9 27 57 18 13 13 0 55 38 Katsina Kogi 36 46 25 25 Ondo Sokoto 34 31 43 43 29 25 20 40 60 You see, the problem here is that, all these policies are available at the national level; but we the implementers don’t have or see the copies. 80 % Mg. SO 4 ANC equipment All Protocols/Guidelines available 100

INVENTORY: Is Mg. SO 4 used for treating Preeclampsia or eclampsia in this facility? (n-96) 100 80 25 % 60 25 29 29 27 18 19 36 24 70 18 20 9 40 20 55 38 50 42 55 57 46 15 36 42 Cross River All 15 0 Kogi Katsina Sokoto Bauchi Mg. SO 4 is always used Mg. SO 4 is never used Ondo Ebonyi Mg. SO 4 is used but not always

CONCLUSION • Reduction in PE/E-related mortality and morbidity hinges on health care providers’ ability to recognize PE/E and have essential tools and commodities available to manage cases • Attention must be paid to the in-service training of frontline antenatal care providers (in Nigeria, these include nurses, midwives and community health extension workers) to be able to early detect, prevent and manage PE/E effectively. • Health care facilities should be equipped with essential tools and live-saving commodities for managing women with PE/E.

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