Download: Management of Hypertension in Pregnancy as a Quality Indicator of Antenatal Care in Rural Tanzania

Management of Hypertension in Pregnancy as a Quality Indicator of Antenatal Care in Rural Tanzania David P Urassa,1,3, Lennarth Nystrom 2, Anders Carlstedt 1, Gernard I … To assess the ability of antenatal care to manage hypertension in pregnancy, a cross-sectional study involving 379 pregnant women was conducted in 16 randomly selected antenatal clinics in Rufiji district of Tanzania. We observed necessary structural availability, provider client interaction, interviewed women attending antenatal clinics, and measured their blood pressure. Measurements made by observers and health workers were compared. One third of the women were not checked for hypertension and health workers detected only four out of twelve women with elevated blood pressure. There was disagreement in diagnosis of blood pressure as measured by health workers and observers. Only one woman with elevated blood pressure was managed appropriately. The low quality of screening and management of hypertension in pregnancy…

71 and advice they received. She then assessed their satisfaction with the services. The study used explicit measurements of three components of quality of care including structural process and outcome indicators relevant for detection and management of hypertension in pregnancy at ANC. An observation checklist was used to assess the availability of necessary structural facilities for detection of hypertension in pregnancy. Using an observation check list, the observer took notes on the qualification of staff, whether a blood pressure measurement was performed, whether a feedback to the mother was given on risk factors detected and type of advice given or action taken. Women were examined twice for blood pressure, first by a health worker and then by an observer without having knowledge of results of the previous blood pressure measurement. Using a newly purchased aneroid sphygmomanometer the observer measured blood pressure on the right arm with the mother seated and her arm resting on a table at the same level as the heart, after a minimum of five minutes rest. The systolic and diastolic pressures were determined at Korotkoff phases I and V respectively. For ethical reasons mothers found by the observer to have elevated blood pressure (? 140/ 90mmHg) were sent back to the health worker with their blood pressure results for further investigations, treatment or referral after exit interviews. No attempt was made to follow the kind of action the women took after that. To assess women’s experience with the service, the second research assistant at exit interviewed mothers on the type of investigations or examinations done. She also asked if they had received any feedback on detected problems, any individual counselling or medication, and whether they were satisfied with the service received. Blood pressure readings from antenatal cards as reported by the health workers were also recorded. Standards The trained staff in the antenatal clinic had been exposed to midwifery during their basic training. In this study, an MCH aide with two years training in midwifery skills was considered to be the lowest cadre of trained staff. A pregnant woman was expected to attend a facility with a qualified staff and equipment for detection and management of hypertension in pregnancy as a structural requirement. Following the guideline in the antenatal card, women were expected to be examined for blood pressure, investigated for urinalysis and given the results of any investigation or examination even if the results were normal. It is recommended that all pregnant women with elevated blood pressure ? 140/90mmHg should be referred to the hospital level for expert care. Statistical Analysis The data were cleaned, coded, entered, checked for consistency and analysed using Epi Info . The agreement between health workers and observers was assessed by Kappa coefficient with value (k) indicating < 0.20 for poor, 0.21-0.40 for fair, 0.41- 0.60 for moderate, 0.61-0.80 for substantial and ? 0.81 for almost perfect agreement between assessors.12 The operational cut-off level for blood pressure > 140/90mmHg was used for hypertension in pregnancy, suggesting the need for further investigation, treatment or referral according to the guidelines in the antenatal card. To test whether differences in prevalence between the health institutions were due to random variation or not a student t-test was used. Results We investigated 30% (16/54) of the health institutions that provide antenatal care at the dispensary, health centre and hospital levels in the district. Nine out of ten dispensaries had adequate number of qualified staff as well as a sphygmomanometer and a stethoscope (Table 1). Only one dispensary was capable of investigating albumin in urine and none had anti-hypertensive drugs. One of the four RHCs did not have either a stethoscope or a sphygmomanometer. Only the hospitals had all necessary infrastructure available for managing hypertension in pregnancy. Women who attended care services in institutions without qualified staff (n = 15) or equipment to measure….

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