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Community Health Worker Knowledge and Management of Pre-Eclampsia

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Community Health Worker Knowledge and Management of Pre-Eclampsia The Author(s) Reproductive Health 2016, 13(Suppl 2):113 DOI 10.1186/s12978-016-0219-8 RESEARCH Open Access Community health worker knowledge and management of pre-eclampsia in rural Karnataka State, India Umesh Ramadurg1, Marianne Vidler2*, Umesh Charanthimath3, Geetanjali Katageri4, Mrutyunjaya Bellad3, Ashalata Mallapur4, Shivaprasad Goudar3, Shashidhar Bannale5, Chandrashekhar Karadiguddi3, Diane Sawchuck6, Rahat Qureshi7, Peter von Dadelszen8, Richard Derman9 and the Community Level Interventions for Pre-eclampsia (CLIP) India Feasibility Working Group Abstract Background: In India, the hypertensive disorders of pregnancy and postpartum haemorrhage are responsible for nearly 40 % of all maternal deaths. Most of these deaths occur in primary health settings which frequently lack essential equipment and medication, are understaffed, and have limited or no access to specialist care. Community health care workers are regarded as essential providers of basic maternity care; and the quality of care they provide is dependent on the level of knowledge and skills they possess. However, there is limited research regarding their ability to manage pregnancy complications. This study aims to describe the current state of knowledge regarding pre-eclampsia and eclampsia among community health care workers (auxiliary nurse midwives, accredited social health activists, staff nurses) in northern Karnataka, India. Furthermore, this study describes the treatment approaches used by various cadres of community health workers for these conditions. The findings of this study can help plan focussed training sessions to build upon their strengths and to address the identified gaps. Methods: Data were collected as part of a larger study aimed at assessing the feasibility of community-based treatment for pre-eclampsia. Eight focus group discussions were conducted in 2012–2013 in northern Karnataka State: four with staff nurses and auxiliary nurse midwives and four with accredited social health activists. In addition, twelve auxiliary nurse midwives and staff nurses completed questionnaires to explore their competence and self-efficacy in managing pre-eclampsia. Qualitative data were audio-recorded, transcribed verbatim and translated for thematic analysis using NVivo 10. Results: Community health workers described their understanding of the origins of hypertension and seizures in pregnancy. Psychological explanations of hypertension were most commonly reported: stress, tension, and fear. The most common explanation for eclampsia was not receiving a tetanus vaccination. Despite some common misperceptions regarding aetiology, these community health workers demonstrated a good grasp of the potential consequences of hypertension in pregnancy. According to auxiliary nurse midwives and staff nurses, if hypertension was detected they encouraged rest, decreased salt intake, iron supplementation and tetanus vaccination. In addition, some staff nurses administered antihypertensives, MgSO4, or other anticonvulsants. All auxiliary nurse midwives had some awareness of MgSO4, but none had administered it themselves. (Continued on next page) * Correspondence: [email protected] 2Department of Obstetrics and Gynaecology, and the Child and Family Research Unit, University of British Columbia, Vancouver V5Z 4H4, Canada Full list of author information is available at the end of the article © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. The Author(s) Reproductive Health 2016, 13(Suppl 2):113 Page 142 of 162 (Continued from previous page) Conclusions: This study showed that knowledge regarding the aetiology of pre-eclampsia was limited. Nevertheless, their basic knowledge and skills could be strengthened to more effectively manage the hypertensive disorders of pregnancy in their communities. Trial registration: NCT01911494 Keywords: Blood pressure, Community health workers, Community health services, Developing countries, Eclampsia, Hypertension, India, Magnesium sulfate, Maternal health, Maternal mortality, Nurse midwives, Pre-eclampsia, Pregnancy, Proteinuria, Public health, Referral and consultation, Rural health Plain English summary maternal deaths [1]. The current maternal mortality ra- In India, pregnancy complications related to hyperten- tio (MMR) of India is 167 per 100,000 livebirths and sion or are responsible for nearly 40 % of all maternal 144 in Karnataka State (SRS 2010–12) [2]. The hyper- deaths. Most of these deaths occur in primary health fa- tensive disorders of pregnancy (HDP) are a leading cilities which frequently lack essential equipment and causes of maternal death [3, 4], accounting for 10–15 % medication, are understaffed, and have limited access to of all direct maternal deaths globally [3–6]. Most of specialist care. Community health workers are essential these deaths occur in low- and middle-income coun- providers of basic maternity care in these settings. The tries (LMIC) [6]. In India, postpartum haemorrhage quality of care they provide is dependent on the level of and the HDPs contribute to nearly 40 % of all maternal knowledge and skills they possess; however, there is lim- deaths [7]. The HDP are challenging because of the silent ited evidence regarding their knowledge and confidence nature of the disease. Apart from being an important in managing pregnancy complications. This study aims cause of maternal mortality, the HDPs are associated with to describe the current state of knowledge regarding serious maternal and neonatal morbidities. pre-eclampsia (a complication of pregnancy character- Most maternal deaths and morbidities occur in pri- ized by high blood pressure, protein in the urine, and/or mary health settings which lack essential resources, are symptoms) and eclampsia (seizures in pregnancy) among understaffed, and have limited or no access to specialist community health workers (auxiliary nurse midwives, care [5]. In the Indian public health system, primary accredited social health activists, and staff nurses) in health centres (PHC) serve as the first point of care. northern Karnataka State, India. Each PHC is staffed by one doctor and three to five staff Eight focus group discussions were conducted in nurses, and each sub-centre is staffed by one auxiliary 2012–2013: four with staff nurses and auxiliary nurse nurse midwife (ANM) [8, 9]. ANMs provide health ser- midwives and four with accredited social health activists. vices including screening, management, and referral for In addition, twelve auxiliary nurse midwives and staff pregnancy and newborn complications. Since 2005, the nurses completed questionnaires to explore their skills National Rural Health Mission (NRHM) has introduced and confidence in providing obstetric care. innovative strategies to accelerate progress towards im- Community health workers provided psychological ex- proving health outcomes. These strategies include planations for the origin of hypertension in pregnancy, mobilization efforts by frontline workers, namely the such as stress, tension, and fear. Despite some common accredited social health activists (ASHA), and numerous misperceptions, community health workers demon- of initiatives to increase institutional deliveries [10]. In strated a good grasp of the potential outcomes related to spite of these efforts, Karnataka State has not achieved pregnancy complications. According to auxiliary nurse the expected level of reduction in maternal mortality. midwives and staff nurses, if hypertension was detected, The community health care workers serve as the point they encouraged rest, decreased salt intake, iron supple- of entry into the health system and therefore can play an mentation and tetanus vaccination. important role in improving pregnancy outcomes. The This study showed that community health workers proximity of these health workers to their communities had limited knowledge of pre-eclampsia, and their basic is advantageous as it increases familiarity and trust. En- knowledge and skills could be strengthened to more ef- suring adequate knowledge of pregnancy complications fectively manage the hypertensive disorders of pregnancy by these health workers is essential. There is limited re- in their communities. search available regarding the knowledge and skills among community health care workers (ANM, ASHA, Background staff nurse) to manage pregnancy complications in India. India contributes significantly to the global burden of The aim of this study was to assess the knowledge of com- maternal mortality, as it is responsible for 17 % of all munity health workers regarding pre-eclampsia and The Author(s) Reproductive Health 2016, 13(Suppl 2):113 Page 143 of 162 eclampsia and how they act upon presentation of these health workers based at PHCs, they provide preventive conditions in their communities. and curative services, and are trained as skilled birth at- tendants [9] (Table 1). Data for this study were collected Methods as part of a larger study aimed at assessing the feasibility
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