Use Of National Guidelines In Management Of Severe Pre-eclampsia/ Eclampsia At Garissa Provincial General Hospital

Abstract

Background: Research shows that there is an improved outcome when standardized guidelines are used in the management of mothers with severe preeclampsia/eclampsia1, 2. Unavailability and non-use of these guidelines could contribute to deaths and poor outcomes reported in many District and Provincial Hospitals in Kenya. Lack of resources for guideline implementation and lack of continuous knowledge appraisal for healthcare workers regarding the current recommendations in the management of severe preeclampsia/eclampsia could be contributing to non-use of guidelines. According to Kenya Demographic Health Survey (KDHS) 2008/9, maternal mortality rate is higher in Garissa Provincial General Hospital (GPGH) standing at 1000-1300 per 100,000 live births, compared to the national average of 488 per 100,000 live births. The World Health Organization (WHO) has made progress in formulating evidence based policies. The Kenyan ministry of health guidelines for management of severe preeclampsia/ eclampsia uses WHO guidelines as the reference with modification to fit in with the local situations. The WHO has shown and recommended the use of magnesium sulphate (Mgo4) in the management of severe pre-eclampsia/eclampsia as it improves maternal outcome and minimizes morbidities and mortalities. Despite this policy recommendation and the eclampsia trial which showed efficacy of MgSO4 for management of severe preeclampsia/eclampsia having been published over ten years ago and despite it being a drug of choice in WHO policy, this is not widely practiced in most hospitals in Kenya. Garissa Provincial General Hospital (GPGH) is a case in point. So, clearly, shifting policy is one thing and changing behavior among health workers is another. This study helped to identify the barriers health care workers faced in application of guidelines and helped fill the gaps between policy and practice. Objective: To assess barriers to using severe preeclampsia/eclampsia guidelines at Garissa PGH. Design: A cohort study where antenatal, intrapartum and postpartum treatment given to women with severe pre-eclampsia/eclampsia were analyzed. An interviewer administered questionnaire was used to assess health workers’ knowledge, attitude and practices. A drug inventory chart was used to assess drug stocking in the hospital. Women were classified into those in whose management guidelines were adhered to and those where they were not. Their subsequent outcomes were documented. The target population was antenatal women visiting Garissa PGH and a sample size of 81 cases was used to estimate the proportion in whom guidelines were followed with a 10% precision. Recruitment was done by convenient sampling. Women were included if they developed severe pre-eclampsia/eclampsia from the 20th week of gestation or in the puerperium. Data was analyzed using SPSS 16. Outcome measures: maternal morbidity was assessed based on postnatal hospital stay, occurrence of eclampsia in a patient with severe pre-eclampsia, presence of organ damage and maternal death. Fetal outcome was assessed based on the need for admission to nursery, Apgar score at 5 minutes, birth weight and gestational age at which pregnancy was terminated. Setting: Garissa Provincial General Hospital. Materials and methods: data abstraction tool used to determine whether treatment given to women with preeclampsia/eclampsia was according to guideline recommendations. An interviewer administered questionnaire was used to assess knowledge, attitude and practices of healthcare workers. Ethical considerations: permission to carry out this research was sought from the Kenyatta National Hospital (KNH)/UoN ethics and research committee (appendix 7). Permission was obtained from the medical superintended at Garissa PGH. Health workers in this study were required to give a written informed consent (appendix 2) prior to their participation. The information gathered from research participants was treated confidentially. Results: The study showed that more nurses (61.19%) and clinical officers (23.43%) were the majority of healthcare professionals handling women with severe preeclampsia/eclampsia than trained doctors (15.38%). It also showed that doctors were generally aware of guideline recommendations than were nurses and clinical officers (p value=1.000). Though a majority of health care workers alluded to the existence of guidelines in the Hospital, medical records of patients managed with severe preeclampsia/eclampsia examined were short of the guideline recommendations. Although most of healthcare workers were in agreement that guidelines for management of severe preeclampsia/eclampsia existed, they were rarely followed, if at all and thus the high mortality and morbidity noted can be attributed to this. Conclusion: guidelines for management of severe preeclampsia/eclampsia were available in Garissa PGH but management of women with these conditions did not always adhere to guideline recommendations. Most of the staff managing these women had little or no knowledge on what to do hence the high mortality and morbidity reported. Recommendations: There is need to consider continuing medical education for nurses, clinical officers and medical officers to shore up their knowledge on management of women with severe preeclampsia/eclampsia as per the guideline recommendations. The relevant authorities charged to ensure that quality healthcare is offered should intensify supervision to ensure the recommended management is practiced. Prospective and cohort studies will be needed to validate the findings and confirm whether our findings are due to failures in recording tasks that are actually performed or whether some tasks that are recorded are actually not performed.