Assessing multidimensional care coverage for pre‐eclampsia in the era of universal health coverage: A pre–post evaluation of the Salud Mesoamérica Initiative

Abstract Objective To compare a multidimensional care package for pre‐eclampsia/eclampsia in Central American health facilities, before and after implementation of the Salud Mesoamérica Initiative. Methods An evaluation study was conducted at 67 basic‐ and comprehensive‐level health facilities serving the poorest areas in Honduras, Nicaragua, and Belize. Cases of severe pre‐eclampsia or eclampsia were randomly sampled and relevant quality of care data extracted from medical records at baseline (n=111) from January 1, 2011, to March 31, 2013, and at second‐phase follow‐up (n=249) from June 1, 2015, to September 30, 2017. The primary outcome was evidence of the delivery of multidimensional care for the management of pre‐eclampsia/eclampsia. Results The care of 360 women with severe pre‐eclampsia or eclampsia was analyzed. Odds of multidimensional care for pre‐eclampsia management (P=0.271) increased (although not significantly) in the second‐phase follow‐up compared to baseline. Multidimensional care was significantly associated with training (P<0.001), basic‐level facilities (P<0.001), and higher in Honduras (P=0.001) and Belize (P=0.024) than the reference country of Nicaragua. Conclusion Multidimensional care for pre‐eclampsia management increased across all facility types, countries, and severity of disease. The Salud Mesoamérica Initiative is a promising model for achieving such quality of care interventions in the era of universal health coverage.

With the rise in the number of deliveries occurring at health facilities in low-income countries, quality of care and multidimensional management for pre-eclampsia are gaining attention. 3,5,7,8 Interventions are expanding beyond critical, single interventions such as magnesium sulfate administration. 3,7,8 Given that timely identification of disease progression for pre-eclampsia remains a challenge for providers, 1,9 other aspects of care for pre-eclampsia that are vital for recognizing the severity of the disease, such as diagnostic examinations and earlier laboratory monitoring of end-organ dysfunction, should be targeted, along with antihypertensive therapy.
Focusing on multidimensional care, the Salud Mesoamérica Initiative (SMI) is a public-private partnership that seeks to lower maternal and child mortality for the poorest population in Mesoamerica, 1.8 million women and children, by targeting specific indicators, or intervention goals. 10,11 Mesoamerica, a region that spans southern Mexico through Central America, shares similar health challenges in poor populations. For example, in 2011, the rate of receiving one skilled prenatal care visit in Honduras was 79% in poor areas compared to 97% by national estimates. 11 SMI uses a "regional approach" to promote regional partnerships, inter-country learning, and implement health-related interventions. 12 SMI covers a wide range of public health issues, such as preventive child health care, family planning, prenatal care, and emergency obstetric and newborn care (EONC). 13 Through a stepwise approach, SMI puts into practice the WHO resolution of universal health coverage: improving quality of care, alongside access to care, for those at risk of financial hardship. 14 The first phase of SMI, a year prior to 2013-2014 data collection, targeted availability of inputs and strengthening facility infrastructure. The second phase, a year prior to 2015-2017 data collection and presented in this study, aims to improve quality of care and coverage. Specifically, for pre-eclampsia management, second-phase indicators assessed a quality improvement bundle that focused on performing relevant examinations and laboratory testing for end-organ monitoring, administering magnesium sulfate for seizure prevention and treatment, and appropriate use of antihypertensive drugs for blood pressure control.
The objective of the present study was to analyze multidimensional care practices for the management of pre-eclampsia/eclampsia, before and after the implementation of SMI, in health facilities that serve the poorest communities of Central America. In doing so, we aimed to characterize the coverage and performance of crucial maternal care interventions in low-resource settings.

| MATERIALS AND METHODS
In the present evaluation study, information from the evaluation of the SMI was analyzed, with data collection periods occurring at the baseline (January 1, 2011, to March 31, 2013) and the second-phase follow-up (June 1, 2015, to September 30, 2017). In accordance with the EONC classification, facilities for this analysis were categorized into basic-level facilities that offered fundamental care, such as providing essential medications and performing simple deliveryrelated procedures, or comprehensive-level facilities that offered higher-level services, such as administering blood transfusions and performing surgery. 13 Data were used from all 67 basic-and comprehensive-level health facilities in SMI intervention areas serving the poorest areas. No sampling on the facility level was used due to the reduced number of facilities. These facilities were located in the municipalities of Bilwi, Jinotega, Las Minas, Matagalpa, and the North Atlantic Region (RAAN) in Nicaragua; the municipalities of Choluteca, Copan, Intibuca, La Paz, Lempira, Ocotepeque, and Olancho in Honduras; and the districts of Cayo, Corozal, and Orange Walk in Belize. In accordance with census data, the poorest areas were defined as consisting of the population in the lowest quintile of income. The initial SMI design stratified the poorest areas by intervention and control areas. However, due to limited real-world resources, some countries chose to alter this design as the initiative evolved. For example, control data were not available at the baseline for Belize and at the second-phase follow-up for Nicaragua. Thus, the analysis was restricted to intervention areas.
Exemption (non-human-subject research) and approval of this study were determined by the institutional review board from the University of Washington, along with partnering data-collection agencies, and

| RESULTS
A total of 360 cases of severe pre-eclampsia or eclampsia at 67 health facilities in Nicaragua, Honduras, and Belize were included in this analysis. Medical records, patient and facility characteristics are shown in Table 1 Figure S1.     (Fig. 1) next steps in attaining the goals of better recognition of disease progression and end-organ dysfunction of pre-eclampsia that are critical to reducing poor maternal and neonatal outcomes. Raising the standard of care for pre-eclampsia management is feasible in low-resource settings and should be promoted.

AUTHOR CONTRIBUTIONS
AMK, DRZ, AHM, and BH contributed to the conception of the study.
AMK contributed to theinterpretation and analysis of data, and writing the manuscript. CKJ, MGT, and RMC contributed to data collection and analysis. DRZ, AHM, and BH contributed to collection and interpretation of data. All authors contributed to revising the manuscript, and all authors approved the final manuscript.

SUPPORTING INFORMATION
Additional supporting information may be found online in the Supporting Information section at the end of the article.