August 28, 2018

What ails good policies on prevention and management of pre-eclampsia and eclampsia: Two counties in Kenya

By Charity Ndwiga, Program Officer

In Kenya, despite the maternal mortality rate remaining high—between 2003 and 2014 (more than 400 deaths per 100,000 live births)—the proportion of mothers accessing antenatal care (ANC) and emergency obstetric and newborn care (EmONC) increased by 8 and 20 percentage points, respectively (KDHS, 2014; UNICEF, 2016). Hypertensive disorders in pregnancy, including pre-eclampsia and eclampsia (PE/E), and hemorrhage are the most common causes of maternal deaths.

In Kenya, barriers to accessing maternal health services have a significant impact on the country’s burden of PE/E. Quality ANC, EmONC and postnatal care (PNC) influence a woman and her family’s ability to access care, and as a result their birth preparedness, because these services include information on complications in pregnancy and the signs and symptoms of PE/E. And providers’ inability to detect and manage complications and refer a woman to a hospital for safe delivery limit a health systems’ capacity to provide effective and efficient services that prevent adverse maternal and newborn outcomes (Obare et al 2016).

To reduce preventable deaths from PE/E, the World Health Organization recommends use of magnesium sulphate (MgSO4) as the most effective and safest drug (WHO, 2011). The WHO released a study showing that irrespective of clinical concurrence on the efficacy of MgSO4 used during the management of PE/E, its dosing regimen and administration mechanism varied globally. African facilities demonstrated low levels of MgSO4 availability (78%), formal protocol ability (83%), and protocol distribution to staff (25%) (Abalos et al 2014).

What are the challenges in Kenya?

Kenya adopted the use of MgSO4 for management of severe PE/E in 2002, but women still face challenges in accessing pre-eclampsia services (Population Council, 2005; Warren et al, 2015; MOH 2016). In two counties – Kitui and Kakamega – Ending Eclampsia sought to find out. Our research aimed to examine the gaps between national and county policies and procedures, including observations of supply chain mechanisms, free maternity services, linkages between the quality of ANC and PNC, underutilization of EmONC, and health systems challenges.

Our findings suggest Kenya has an amenable policy environment that includes availability of policy guidelines clearly outlining prevention and management of pre-eclampsia and use of MgSO4 at all levels of health care and by all cadres of skilled birth attendants. National and county governments continue to improve mechanisms for effective and efficient delivery of health services and programs, but there is inadequate coordination between the national and county governments on provision of MNH care, including PE/E services.

Some providers lack knowledge and competency on key components of managing PE/E, such as measuring blood pressure and the dosage and administration of MgSO4. They also expressed a lack of confidence or fear of its toxicity, two barriers that limit its use by providers in dispensaries and health centers. These providers prefer to use other anticonvulsant drugs, such as valium, even when MgSO4 is available.

Overall, there was low community awareness of danger signs in pregnancy. This led to delays in seeking care, along with lack of support from spouses, birth partners, and mothers-in-law for ANC and PNC visits and the purchase of antihypertensive drugs when required.

Kenya’s has good policy and strategies aimed at reducing preventable deaths from complications like PE/E. What Kenya needs is available and accessible MgSO4 at all levels of health care because, despite being on the national essential medicines list for years, it is still not available at dispensaries and health centers, or for community midwives who, according to national policy, can administer the drug and who may be the first points of contact for women in remote settings.   Likewise, improving provider skills, competency and confidence in administration of MgSO4, especially in rural health facilities, need to be accelerated.  In addition, awareness of PE/E among pregnant women and community members, social, gender, and economic factors that deter care seeking also need to be addressed.