Quality of Antenatal Care Services and Pregnancy Outcomes Among Patients With Pre-eclampsia With Severe Features Managed at Kenyatta National Hospital

Abstract

QUALITY OF ANTENATAL CARE SERVICES AND PREGNANCY OUTCOMES AMONG PATIENTS WITH PRE-ECLAMPSIA WITH SEVERE FEATURES MANAGED AT KENYATTA NATIONAL HOSPITAL Introduction. Hypertensive disorders in pregnancy are the second most common cause of maternal mortality after obstetric hemorrhage and occur in 6-8% of all pregnancies Pre-eclampsia with severe features (PES) still remains a major medical and public health concern. High quality of antenatal care (ANC) is associated with improved maternal, fetal and neonatal outcomes. Globally although 86% of pregnant women access ANC with skilled health personnel at least once, only 3 in 5 (62%) receive ≥ 4 ANC visits (UNICEF, 2016). In Kenya, 60% of pregnant women had ≥ 4 ANC visits (KDHS 2014) Objective: The primary objectives were to determine the association between the quality of ANC services, pregnancy outcomes, the types of health facilities and the patients’ perception of ANC services among patients with PES managed at Kenyatta National Hospital. Methodology This was a descriptive cross-sectional study in which postpartum patients who were diagnosed with PES at a gestation period of 28 weeks or higher and who had delivered within the first 72 hrs were consecutively sampled. The study was conducted at the Post Natal Wards (GFA, GFB, 1A) of Kenyatta National Hospital. Quality of care was defined as presence of all parameters of the 2016 ANC World Health Organization (WHO) recommendations and Ministry of Health guidelines which were; appropriate ANC visits by gestation, prescription of prenatal vitamins, a complete antenatal profile (HIV/VDRL/HB/Urinalysis/Blood Group/Blood sugar/), discussion of a delivery plan, weight measurement, counseling on fetal movements, assessment of uterine fundal height and fetal heart rate, nutritional counseling and information on progress of antecedent pregnancy. Hypertension related parameters that were assessed during ANC included: blood pressure, administration of antihypertensive drugs, counseling on danger signs, and administration of MgSO4. These parameters were assessed using the patients file, ANC booklet, and interviewer questionnaires. Pregnancy outcomes were adverse or good maternal, fetal and neonatal outcomes. Data was entered into and analyzed using of SPSS® version 21. Categorical data was analyzed and presented as frequencies and proportions; continuous data was summarized and presented as means and standard deviations and compared using the chi-square test. Continuous variables were calculated using mean and SD or median and inter-quartile range and compared using Independent t- test. Chi square test was used to assess factors associated with adverse outcomes. Results: Between April and July 2019, 240 postpartum women with PES were screened and 161 (67%) who were eligible enrolled. About one third (n=56, 35%) of study participants received good quality of ANC. The most performed general ANC parameter was prescription of prenatal vitamins (70.2%) while the least performed was discussion of a delivery plan during ANC (55.3%). The most performed hypertension related ANC parameter was weight measurement during ANC (68.3%) while the least was administration of MgSO4(38.5%) There were more adverse maternal and neonatal xvi outcomes in women who had poor (61%) compared to those who had good (31%) quality of ANC, however this was not statistically significant (p=0.085). Majority (61%) of patients who had poor quality of care, received ANC from government health facilities. Patients who received poor quality of ANC ranked their care at 75% compared to those who received good quality ANC who ranked their care at 85% Conclusion: Overall poor quality of ANC services was offered to patients with PES. Poor quality of ANC services was associated with adverse outcomes (maternal/fetal/neonatal). Patients with PES were more likely to receive poor quality of ANC services in a government facility as compared to a non-government facility. There was no difference between perceived and received quality of care. Recommendation: Antenatal clinics especially those at government facilities should improve the quality of care overall and for patients with preeclampsia. Patients with PES who attend ANC should be given prenatal vitamins, have a complete antenatal profile, be counseled on fetal movements, undergo fetal surveillance (detection of fetal heart), be informed on the progress of their ongoing pregnancy, have nutritional counseling and have discussed and agreed on a delivery plan. Under hypertension related parameters all patients with PES should have their blood pressures monitored, be given the necessary antihypertensives, be counseled on danger signs in pregnancy and be given MgSO4. ANC clients should be educated and encouraged to demand better quality of ANC services offered to them by healthcare workers.