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 Table of Contents  
Year : 2012  |  Volume : 1  |  Issue : 3  |  Page : 290-298

Promoting antenatal care services for early detection of pre-eclampsia

1 Department of Medical Research (Upper ), Pyin Oo Lyin, Myanmar
2 Maternal & Child Health Section, Department of Health, Myanmar
3 University of Medicine, Mandalay, Department of Medical Science, Myanmar

Date of Web Publication25-May-2017

Correspondence Address:
Tin Tin Thein
Department of Medical Research (Upper Myanmar), Pyin Oo Lyin
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2224-3151.207025

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A prospective, quasi-experimental study was carried out in 2009 at urban health centres (UHCs) of five townships of Mandalay, Myanmar, to improve the skill of midwives (MWs) in diagnosis and referral of pre-eclampsia (PE) from UHC to the Central Women’s Hospital (CWH) and to enhance the supervision of midwives by lady health visitors (LHVs). The intervention was training on quality antenatal care focusing on PE using an updated training manual. Altogether, 75 health care providers (MWs & LHVs) participated. In this study, data were extracted from patient registers and monthly reports of UHCs and CWH. Interviewers were trained regarding the conduct of semi-structured questionnaires to elicit knowledge and to use checklists in observation of skills in screening of PE, measuring blood pressure and urine protein (dipstick test). A guide for LHVs was also used to obtain data, and data was collected six months prior to and after the intervention. Significant improvements from baseline to endline survey occurred in the knowledge (p<0.001) and skill levels (p<0.001) including skills for screening, measuring blood pressure and urine protein. At CWH, there was an increase in referred cases of PE after the intervention, from 1.25% to 2.56% (p<0.001). In conclusion, this study highlights the early detection of pre-eclampsia by widespread use of quality antenatal care, education and training of health-care providers to improve their performance and increase human resources for health care, in order to enable women in our society to have healthy pregnancies and healthy babies.

Keywords: Quality antenatal care, pre-eclampsia, blood pressure measuring, urine protein measuring, screening, training.

How to cite this article:
Thein TT, Myint T, Lwin S, Oo WM, Kyaw AK, Myint MK, Thant KZ. Promoting antenatal care services for early detection of pre-eclampsia. WHO South-East Asia J Public Health 2012;1:290-8

How to cite this URL:
Thein TT, Myint T, Lwin S, Oo WM, Kyaw AK, Myint MK, Thant KZ. Promoting antenatal care services for early detection of pre-eclampsia. WHO South-East Asia J Public Health [serial online] 2012 [cited 2022 Aug 14];1:290-8. Available from: http://www.who-seajph.org/text.asp?2012/1/3/290/207025

  Introduction Top

Pregnancy is one of the most important periods in the life of a woman, a family and a society. WHO’s definition of antenatal care includes recording medical history, assessment of individual needs, advice and guidance on pregnancy and delivery, screening tests, education on self-care and, identification of conditions detrimental to health during pregnancy, first-line management and referral if necessary.[1]

Pre-eclampsia is a pregnancy-related hypertensive disorder occurring usually after 20 weeks of gestation and a major cause of maternal and fetal death and leads to premature delivery worldwide. According to a report on progress towards achieving the United Nations Millennium Development Goals, the maternal mortality ratio (MMR) in the South-East Asia Region in 2010 was 150.[2] Hypertensive disorders contribute to about one in every six maternal deaths in South-East Asia.[3] In Myanmar, MMR was 240 per 100 000 live births in 2008[4] and antenatal care (ANC) coverage (at least four visits, 2006-2010) was 73%.[5] Moreover, eclampsia is the third leading cause of maternal death (11.3%) in Myanmar.[6] Therefore, we need to explore the dimensions of antenatal care, such as access to care, and content of care to strengthen quality of ANC. Antenatal care is one of the “four pillars” of safe motherhood, as formulated by the Maternal Health and Safe Motherhood Programme, (WHO 1994).[7] In 2009, for prenatal care, WHO emphasized that mothers should observe the periodicity of prenatal visits. It is essential for mothers to have at least four prenatal visits to ensure proper care.[8]

The benefits of antenatal care are recognized and several studies suggested that antenatal care may protect mothers from complications due to pregnancy including pre-eclampsia. Timely diagnosis and proper management prevent the complications of PE.[9]

This study was conducted with the following objectives:

  • to improve the knowledge and skill of midwives in the detection of PE;
  • to improve the referral of pregnant women with PE to the Central Women’s Hospital, Mandalay; and
  • to enhance the supervision of MWs by LHVs in the detection and referral of pre-eclampsia cases by training on quality antenatal care focusing on PE using updated training modules based on pregnancy, childbirth, postpartum and newborn care (PCPNC).[5]

  Methods Top

Study design and study area

This operations research adopted a prospective, quasi-experimental design. Myanmar is situated in South-East Asia and Mandalay is the central part of Myanmar. Mandalay is divided into seven townships, each with one UHC. This study was carried out at five UHCs.


Altogether, 75 basic health staff (MW and LHV) working in 5 UHCs participated. Since this was an operations research without a control group, all the staff from these five centres needed to be trained. After obtaining written informed consent, they were enrolled as participants in this study.

Data collection tools were patient registers and monthly reports from UHCs and CWH, data from five UHCs, semi-structured questionnaires to assess knowledge, and checklists in observation of skills in screening, measuring blood pressure and urine protein and guide for the LHVs.

The Intervention was divided into three phases.

Phase I: Preparatory phase;

Phase II: Conducting training workshops on quality antenatal care and detection of pre-eclampsia; and

Phase III: Assessment of the impact.

Phase I: Preparatory phase

The project management team was formed for overall coordination, management and monitoring of the project and an advocacy meeting was held.

Based on the translated Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice (PCPNC,WHO, 2006), A Trainees Manual and Trainers Handbook developed by the Reproductive Health Programme, Ministry of Health, the research team developed a booklet on Strengthening of Quality Antenatal Care focusing on pre-eclampsia both in English and Myanmar languages to be used in interventions.

Phase II: Conducting training workshops on quality antenatal care and detection of pre-eclampsia

The objective was to strengthen quality antenatal care focusing on PE by using the updated training manual booklet. Thirty-five participants from two townships and 40 from the remaining three townships attended the workshop separately.

The research team handed over sphygmomanometers to each township. Each participant was provided a training package containing PCPNC, trainees’ manual, home- based maternal record (HBMR), training manual booklet (both in English and Myanmar languages), and test strip boxes for measuring urine protein.

Presentations and discussions covered

(1) components of quality antenatal care;

(2) how to use home-based maternal record (HBMR); and (3) pregnancy-induced hypertension. Detailed training on accurate measurement of blood pressure of pregnant women using sphygmomanometer, and urine protein using dipstick test, was done and attention given to individual participants.

Phase III: Assessment of the impact

The aims of phase III were to evaluate the accuracy of diagnosis and correct referral of PE patients correctly to the tertiary hospital. Monitoring on service provision to 9243 AN clients was done by LHVs three months after the intervention at five UHCs. Measurement of blood pressure and urine protein validated by LHVs on every 10th sample tested by MWs.

Data were collected by extracting registers and interviewing the midwives to know the knowledge of PE six months before and after the training.

Data management

The researcher checked questionnaires and forms for completeness, consistency and errors at the end of each day and collected data were entered and analysed with the support of Epi-Info software.

Data analysis

A chi-squared test was undertaken to determine the statistically significant differences in the proportions of PE cases identified and referred comparing the pre- and post-intervention data.

Knowledge scores on screening for PE and level of skills were compared by using paired t-test to determine the extent to which training improved knowledge.

Ethical considerations

This study was approved by the Institutional Ethics Committee and informed written consent obtained from all participants.

  Results Top

A total of 75 participants including midwives and lady health visitors from these five UHCs attended this training. Assessment of the knowledge was done on midwives where we used 10 questionnaires including “How do you diagnose a case of PE?”, “Have you referred PE cases to the referral hospital in the past two months?”, “In which following pregnancies is PE more common?” etc.

There was a significant improvement of knowledge regarding some questions at the end-line comparing the baseline level: “How do you diagnose a case of PE” (p<0.001), “how often have you referred PE cases” (p<0.001), “in which pregnancy PE is common” (p<0.001), and “serious fetal outcomes of PE cases” (p<0.001).

At the baseline survey, the mean knowledge level among midwives from UHCs was 5.71 and at the end-line, it was 8.47 (p<0.001) [Table 1] and comparison of knowledge level was analysed by using paired t test.
Table 1: Mean level of knowledge and mean net improvement of midwives in each centre

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Table 2: Skill of the midwives

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Figure 1: Knowledge scores of midwives by centre, before and after intervention

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There were three parts concerned with assessment of skill: (1) observation of skill in screening; (2) measuring blood pressure; and (3) correct methods of measuring urine protein. The skill of midwives was assessed by LHVs and research assistants using checklists. We observed the skill of midwives in screening, by asking the pregnant women the following questions: number of taking pregnancy, age of pregnant women, family history of PE, underlying medical conditions, assessment of symptoms of PE, assessment of blood pressure and urine protein at the booking. We used the checklist for midwives while they were measuring blood pressure and urine protein of pregnant women. There was statistical significance between baseline and end-line survey in regard to these three components (p<0.001). At the baseline survey, the mean score on skill among midwives from UHCs was 12.45 and at the end-line, it was 18.21 (p<0.001).

Case detection

In this study, data collection tools mentioned above were used. Moreover, we applied the supervision checklist for LHVs. As we compared baseline and end-line levels in case detection, there were many PE cases detected at baseline level in all centres apart from Centre E than at end-line. However, the number of total pregnant women attending ANC was more at the end-line in these centres [Table 3].
Table 3: Detection of PE in UHCs

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At Centre E, there were urban health centres and some NGO clinics as well and pregnant women from this area also went there. Thus, not only an absence of PE cases was detected but also a reduction in the total number of pregnant women attending ANCs compared with the four other centres [Table 3].

Regarding the referral of PE cases to tertiary hospital, we extracted data on referred PE cases from the hospital register. Referred cases were not only from these five UHCs, but from other private clinics and NGOs also [Table 4].
Table 4: Referral of PE case to Central Women's Hospital (Mandalay)

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  Discussion Top

Despite increased antenatal care coverage in Myanmar (63.9% in 2006, 64.6% in 2007), the maternal mortality ratio was 240 per 100 000 live births in 2008.[4] This is still above the Millennium Development Goal target. Maternal mortality has been likened to the tip of the iceberg, and maternal morbidity to its base. Moreover, maternal disease is reflected in the offspring which underlines the importance of this issue.[10]

A majority of PE-related deaths in low- and middle-income countries (LMIC) occur in the community, thus intervention must be focused at this level.[11] In Myanmar, maternal death due to eclampsia is 11.3 % and it is the third leading cause of death.[6]

Therefore, prevention strategies should be applied to every pregnant woman since we cannot predict who will develop PE. Three primary delays lead to an increased incidence of maternal mortality from PE: delay in decision to seek, delay in reaching the health facility and delay in health service provision.

In our study, there was a significant improvement of knowledge and skill concerned with screening, measuring blood pressure and urine protein by dipstick test at the end-line comparing the baseline level. It showed an improvement in their practice. As a consequence, they could detect PE cases correctly. One study from United Republic of Tanzania revealed that provider performance is considered to be directly proportional to skills obtained after training and motivation, which includes appreciation by the supervisors and the opportunity for increased training.[12] However, it is considered to be inversely proportional to barriers such as low salaries and poor working conditions.[13],[14] Affordability of detection tools to measure blood pressure and proteinuria is challenging due to financial cost and lack of training as well.[11]

Regarding case detection, there was a reduction in new PE cases in these centres at the end-line. However, there was an improvement in the skill of midwives at the end-line compared with the baseline (p<0.001). This means there was a reduction in the number of new PE cases in these areas quantitatively, but they were able to detect the correct cases of PE qualitatively. Boller C et al. (2003) support that using well-trained and skilled providers leads to better counselling and provision of maternal care.[15]

Our study revealed an improvement in referral of PE cases to the tertiary hospital from all five UHCs and from other clinics as well. By providing training to our participants, they were well equipped with knowledge about quality antenatal care and PE. Therefore, they were able to create awareness through health education among pregnant women on PE. Thus, pregnant women themselves from these townships might come to CWH for antenatal care.

Enhancement of supervision of MWs by the LHVs in the detection and referral of PE cases was conducted in our study. We used checklists to observe the screening of midwives’ PE cases, skill of midwives in measuring blood pressure and urine protein at antenatal clinics. These activities of midwives were supervised by LHVs of concerned townships. If there were some mistakes by midwives, LHVs corrected the mistakes and enhanced supervision to bring them on the right track. One study mentioned that strengthening supportive supervision from the management team in order to improve counselling during antenatal care was crucial.[12]

  Conclusion Top

This study highlights the detection of pre-eclampsia by widespread use of quality antenatal care, education and training of health care providers to improve their performance and increase human resources for improved health care. We hope that well trained and skillful midwives could provide essential maternal care ensuring universal coverage of maternal services.


For sustainability, as a research output utilization, the maternal and child health section, Department of Health revised the training manual booklet and applied the revised handbook in the community.

  Recommendation Top

  1. To enable early detection of PE, non-invasive screening methods using blood pressure apparatus and urine dipstick test at all antenatal clinics in both urban and rural areas should be practised.
  2. Health care providers need to attend a refresher course on screening methods of PE.
  3. The correct usage of measuring BP and urine protein by supervisors should be regularly assessed.

  Strengths and challenges Top


  • Encourage midwives to conduct the instructions according to the training manual booklet.
  • They become quite confident in dealing with patients as they are familiar with the training manual booklet.


  • Midwives are overloaded with both MCH tasks and other public health activities. Thus, they do not have enough time to concentrate on quality antenatal care.
  • Midwives training on how to measure blood pressure of pregnant mothers correctly and urine protein with the dipstick test precisely.
  • It is necessary to explain to the trainees that, they must strictly adhere to instructions to achieve accuracy.

  Acknowledgements Top

The authors would like to acknowledge the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) for funding this project. Thanks are also extended to local health and administrative authorities, all healthcare providers in the five Urban Health Centres in Mandalay and all pregnant mothers who participated in this study.

  References Top

World Health Organization. Health services coverage statistics: antenatal care coverage (percentage). Geneva. http://www.who.int/healthinfo/statistics/ indantenatal/en/index.html - accessed 22 August 2012.  Back to cited text no. 1
World Health Organization. Trends in maternal mortality: 1990-2010: WHO, UNICEF, UNFPA and The World Bank estimates. Geneva: WHO, 2012.  Back to cited text no. 2
Acuin CS, Khor GL, Liabsuetrakul T, Achadi EL, Htay TT, Firestone R, Bhutta ZA. Maternal, neonatal, and child health in sourtheast Asia: towards greater regional collaboration. Lancet. 2011 Feb 5; 377(9764): 516-525.  Back to cited text no. 3
Myanmar - maternal mortality ratio. http:// www.indexmundi.com/facts/myanmar/maternal- mortality-ratio - accessed 22 August 2012.  Back to cited text no. 4
United Nations Children’s Fund. Statistics. Republic of the Union of Myanmar. http://www.unicef.org/ infobycountry/myanmar_statistics.html - accessed 22 August 2012.  Back to cited text no. 5
Five-Year Strategic Plan for Reproductive Health (2009-2013), Department of Health, Ministry of Health. Causes of maternal mortality, sources: The nationwide cause-specific Maternal Mortality Survey (NCSMMS). Department of Health (DoH) and UNICEF, (2004-2005).  Back to cited text no. 6
World Health Organization. Mother-baby package: implementing safe motherhood in countries: practical guide. Geneva: WHO, 1996.  Back to cited text no. 7
World Health Organization. WHO recommended interventions for improving maternal and newborn health. Geneva: WHO, 2009.  Back to cited text no. 8
Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet. 2005; 365: 785–799.  Back to cited text no. 9
Bergström S . Maternal health: a priority in reproductive health. In: Lankinen KS, Bergström S, Mäkelä PH & Peltomaa M, eds. Health and disease in developing countries. London: The Macmillan Press Limited, 1994. pp. 305-15.  Back to cited text no. 10
Firoz T, Sanghvi H, Merialdi M, von Dadelszen P. Pre-eclampsia in low and middle income countries. Best Pract Res Clin Obstet Gynaecol. 2011 Aug; 25(4): 537-48  Back to cited text no. 11
Pembe AB, Carlstedt A, Urassa DP, Lindmark G, Nyström L, Darj E. Quality of antenatal care in rural Tanzania: counselling on pregnancy danger signs. BMC Pregnancy and Childbirth. 2010 Jul 1; 10: 35.  Back to cited text no. 12
Dieleman M, Cuong PV, Anh LV, Martineau T. Identifying factors for job motivation of rural health workers in North Viet Nam. Hum Resour Health. 2003; 1: 10.  Back to cited text no. 13
Fathalla MF. Good anatomy does not mean good physiology: a commentary. Int J Gynaecol Obstet. 2003; 82: 104-6.  Back to cited text no. 14
Boller C, Wyss K, Mtasiwa D, Tanner M. Quality and comparison of antenatal care in public and private providers in the United Republic of Tanzania. Bull World Health Organ. 2003; 81:116-22.  Back to cited text no. 15


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

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