Association Between the Level of Health Care Facility and Adverse Pregnancy Outcomes in Women With Preeclampsia With Severe Features Managed at Kenyatta National Hospital Between 2020 and 2021

Abstract

Background: Hypertensive disorders of pregnancy including Preeclampsia/eclampsia are the second leading cause of maternal mortality globally. In Kenyatta National Hospital, it was found to be the leading cause of maternal death in the year 2021. Among women managed for Preeclampsia/eclampsia at KNH 20% were referrals from other levels of care. The quality of care provided at different levels of care may influence the outcome. This study was set to assess the association of the level of health care facility with adverse pregnancy outcomes among patients with Preeclampsia with severe features who were managed at KHN between January 2020 and December 2021. Objective: To determine the association between the level of health care facility and adverse obstetric outcomes among women with Preeclampsia with severe features managed at KNH between 2020 and 2021. Methodology: This was a facility-based descriptive retrospective cohort study. Data of patients with a diagnosis of Preeclampsia with severe features who were managed at the KNH for the period between January 2020 to December 2021 was collected from the records department. The exposed group comprised of 140 files of patients with a diagnosis of Preeclampsia with severe features who attended ANC and were referred from lower tier (levels 2 to 3), while the unexposed group comprised of 140 files of patients with Preeclampsia with severe features who attended ANC in higher tiers (levels 4, 5 and 6.) Socio-demographic, obstetric, clinical and outcome data was extracted and analyzed with SPSS version 23.0. The comparison between adverse maternal and perinatal outcomes and levels of health care facility was done using Chi-Square test. Univariate and multivariate analysis with the use of log-binomial regression was done to establish any association between the level of health care facility and the development of poor outcomes. A level of significance was evaluated at p-value of ≤ 0.05. Results: Women who attended ANC in tier 2, had 2-fold (67.6%) adverse maternal outcomes as compared to women who attended ANC in tier 3 and 4 (32.4%). This was statistically significant with a P value <0.001. Women in tier 2 had 65% adverse perinatal outcomes compared to 35% in women in tier 3 and 4, with P value <0.001. Women in tier 2 had aRR (adjusted Relative Risk) 1.6(1.2-2.1) for AKI with a P value 0.001 compared to women in tier 3 and 4. Women in tier 2 had aRR 1.7(1.1-2.5) for stillbirths with a P value 0.015 compared to xiii women in tier 3 and 4. There were no differences in sociodemographic and clinical characteristics in both groups but women who attended ANC in tier 2 were <30 years old. Conclusion: Results from this study indicate that women who attended ANC in tier 2 (Level 2 and 3) had more adverse maternal and perinatal outcomes compared to women who attended ANC in tier 3(Level 4 and 5) and tier 4 (Level 6). The data generated will help in policy formulation in streamlining the national referral system to better manage patients with pre-eclampsia with severe features, thus reducing adverse pregnancy outcomes.