Globally, eclampsia remains one of the leading causes of maternal and neonatal mortality and morbidity, accounting for 50,000 maternal deaths annually[1]. Over the last three decades, due to deliberate actions, these deaths have significantly reduced. However, in Sub-Saharan Africa, maternal deaths due to eclampsia remain high and account for 9% of all maternal deaths[2]. In Nigeria, pre-eclampsia and eclampsia rank as the second major drivers of maternal mortality after hemorrhagic complications, with a prevalence of 163 per 10,000 deliveries[3].
Eclampsia is a severe form of pregnancy hypertension and is commonly defined as the new onset of grand mal seizure activity and/or unexplained coma during or postpartum in a woman with symptoms of pre-eclampsia. Pre-eclampsia which is usually the precursor to eclampsia is described as when a pregnant woman has high blood pressure and protein in her urine during pregnancy or after delivery[1]. Eclampsia cases commonly occur during or after the 20th week of gestation or in the postpartum period. It is usually life-threatening for both the woman and the unborn neonate, and its exact cause remains unclear.
In 2017, Health Strategy and Delivery Foundation (HSDF) collaborated with the Lagos State Health Service Commission (HSC) to implement a quality improvement initiative to reduce facility-based maternal and neonatal mortality. To achieve this, improving care processes for managing the leading causes of maternal and neonatal deaths were the focus. To improve facility care processes for the management of pregnant women with pre-eclampsia/eclampsia, the use of the pre-eclampsia/eclampsia (SPE/E) checklist was prioritized in 18 general hospitals in Lagos State. The choice of change idea was based on a retrospective study conducted on the management of SPE/E patients, which showed poor adherence to evidence-based protocols. Hence the prioritization of the checklist serves as a guide to facilitate compliance. From November 2018 to January 2019, the use of the SPE/E checklist was implemented using a four-pronged approach:
Development of the SPE/E checklist: In collaboration with five Obstetrics and Gynecology experts selected from these general hospitals, the SPE/E checklist was developed using The Society of Gynaecology and Obstetrics of Nigeria (SOGON) guidelines. The checklist emphasized the correct and continuous use of anti-hypertensives, fluid management, and close monitoring of fluid intake and output.
Piloting of the checklist: The developed checklist was piloted in five pre-selected general hospitals. Following this, a convergence of all stakeholders was held to review and validate the developed checklist based on feedback.
Deployment of the SPE/E checklist to all general hospitals: The capacity of frontline health care workers was built to understand and ensure proper utilization of the checklist. The checklist was deployed to facilities in February 2019.
Conducting clinical audits: To ensure adherence in the use of the SPE/E checklist, monthly clinical audits were conducted. The clinical audits focused on assessing the management of an eclamptic woman according to protocol using the SPE/E checklist as a guide. These audits were conducted in 18 general hospitals from February 2019 to January 2020; they were conducted by the facility quality improvement mentors and validated by the HSDF team.
During the review period, a total of 547 SPE/E cases were audited. 42% (232) of these cases had the checklist attached to the patients’ folder, and 72% (166) of these cases had an appropriately filled checklist (Figure 1). In addition, the proportion of eclampsia cases managed in line with the protocol using the SPE/E checklist increased over the months, between March 2019 to January 2020 after deploying the checklist to facilities (Figure 2).
Figure 1: Total number of patient folders reviewed, and checklist appropriately filled Figure 2: Proportion of SPE/E cases managed in line withprotocol
The findings of this intervention showed the considerable impact of using a checklist towards adhering to evidence-based protocol and an overall improvement in health care outcomes. Also, the interviewed frontline workers identified an improvement in care management documentation and an increased awareness of the importance of documentation. Thus, the crucial role of using checklists to improve adherence to care protocol should be explored further. Despite the remarkable result, interviewed frontline workers identified some implementation challenges which include: a shortage of the checklist and high patient load despite the limited staffing.
References
[1] Ratan Das and Saumya Biswas. “Eclampsia: The Major Cause of Maternal Mortality in Eastern India”. Das R, Biswas S. Eclapmsia: The Major Cause of Maternal Mortality in Eastern India. Ethiop J Health Sci. 2015 Apr;25(2):111-6. doi: 10.4314/ejhs.v25i2.2. PMID: 26124617; PMCID: PMC4478261.
[3] EC Ezugwu, PU Agu, MO Nwoke, FO Ezugwu “Reducing maternal deaths in a low resource setting in Nigeria”.
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