By Ann K. Blanc and Katharine J. McCarthy
Accurate estimates of the coverage of life saving maternal interventions, such as those that prevent, detect, and treat eclampsia, is one of the major challenges facing the maternal health field. Measuring coverage of pre-eclampsia and eclampsia (PE/E) is critical as hypertension is the second leading direct cause of maternal death , and is effectively managed with timely access to lifesaving and low costs drugs such as magnesium sulfate. Coverage – which is defined as the proportion of those who need an intervention who receive it – can be measured at the population level or at the facility level. Population-based coverage refers to the proportion of the population (e.g., pregnant women) who receive a needed intervention while facility-based coverage refers only to those who receive services at health facilities.
For tracking progress in the scaling up of best practices for eclampsia prevention and detection, we would ideally like to know the proportion of pregnant women at risk of developing PE/E who are prescribed aspirin and the proportion with raised blood pressure who received antihypertensive drugs. If we only measure these indicators among women who attend antenatal care at a health facility, we are likely to overestimate coverage because those who do not attend antenatal care are left out of the calculation. For this reason, and in the absence of high quality health information systems, population-based surveys are often used to measure maternal health indicators, such as the proportion of women who deliver with a skilled attendant, as well as the proportion who receive critical interventions such as cesarean section.
Council researchers and others have undertaken a series of studies over the last several years that attempt to determine the extent to which women can accurately recall interventions received during pregnancy, childbirth, and the postpartum period. For example, Council research compared women’s recall of interventions received during childbirth in Kenya and Mexico to observations by a third party observer. In general, and consistent with prior research, our findings showed women tend to overestimate the extent to which they experience complications. To assess the validity of reporting on PE/E, women were asked whether they experienced symptoms of high blood pressure, seizures, blurred vision, severe headaches, or swelling in the hands and face during or immediately following birth. In Mexico women overreported experiencing these symptoms by more than nine times. Importantly, however, these women were able to accurately report whether they had provided a urine sample upon hospital admission. Urine is screened to assess for the presence of certain proteins indicative of PE/E risk and identifying high-risk women can increase the likelihood of their access to appropriate treatment.
While we were not able to assess the validity of these indicators in Kenya due to their low observed prevalence (<2%), our results show promise for including indicators such as urine screening in routine household survey programs, such as the Demographic and Health Survey (DHS). Currently, these surveys only measure the coverage of urine screening during the antenatal phase. However, a greater share of maternal deaths due to complications occur in the postnatal period relative to any other phase . It is evident that monitoring of the coverage of PE/E screening in the intrapartum and immediate postnatal period is warranted.
As attention in maternal health shifts to a new emphasis on ending preventable maternal mortality (EPMM) and addressing inequities, the tracking of progress will remain important. A key aspect of these future efforts will require the valid measurement of not only contact with maternal and newborn health services but also coverage of key interventions that reflect the quality of services received. Until recently, however, little attention has been paid to improving the measurement of intervention coverage and quality at the population level. This information is needed to set programmatic priorities and to allocate resources effectively. Given the effect that this information can have on improvements in the lives of women and newborns, priority should be given to work that ensures that indicators of progress are selected, measured, and interpreted accurately.
- Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health. 2014;2: e323–33. doi:10.1016/S2214-109X(14)70227-X
- Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. Elsevier; 2014;384: 980–1004. doi:10.1016/S0140-6736(14)60696-6