Integrated High-Risk Pregnancy Management Project
Integrated High Risk Pregnancy Management (IHRPM) project focuses on training Auxiliary Nurse Midwives (ANMs), Medical Officers (MOs) and Specialist doctors on high-risk pregnancy management and tracking through tech-enabled training, two-way communication support (WhatsApp helpdesk/ thin app/call center) with multimedia content and a learning and tracking app. The pilot has been launched in Telangana with planned pan-India scale-up.
Many high-risk factors responsible for maternal and neonatal mortality have their roots in the antenatal period. Secondly, 25% of maternal mortality occurs in the antenatal period resulting from high risk factors directly linked to pregnancy. The only effective approach to reducing the mortality and morbidity resulting from these conditions is identifying high-risk factors early and ensuring timely referral and efficient management through pregnancy before their descent into a critical stage. But, according to NFHS-4, only half (51.2%) of women had at least 4 antenatal visits and just 21% had received the full range of antenatal services.
Currently, the provision of continuum of care for high-risk pregnancy, which includes early identification of risk factors, appropriate referral, treatment and follow up after discharge/treatment until safe delivery, is inadequate. There is often confusion regarding the individual roles to be played by the ANM, the MO and the specialist in the management of high-risk pregnancy, resulting in many pregnant women falling through gaps in the system following diagnosis of a high-risk factor.
Hence, there is a pressing need for evidence-based guidelines that clearly delineate the role of each health care provider at every level of the referral chain in the management of high-risk pregnancy. There is also a need to conduct comprehensive training in these protocols and incorporate the protocols into an intuitive digital algorithmic decision support tool to support the health workers and officers in identification, tracking and end-to-end care management of high-risk pregnancies.
ARMMAN was a part of the antenatal guidelines revision committee of the MoHFW in 2019 which comprised experts from WHO, UNICEF, JHPIEGO and other multilateral agencies. As a part of that, ARMMAN put together a team of doctors led by Dr. Aparna Hegde that created protocols for high risk conditions in pregnancies. The guidelines are algorithmic in nature, simple and easy to follow in the field, yet comprehensive and detailed. There are different colour-coded sections for the ANM (red), MO (green) and the specialist (blue) for clear understanding of the division of duties in the management of these conditions.
ARMMAN has started the rollout of an integrated, comprehensive, multi-step, systemic approach for improved identification, tracking and end-to-end management of high risk pregnancies so that there is sustained reduction in both delayed referral and number of high-risk referrals to tertiary facilities resulting in lessening of the burden on them, leading to their improved functioning and overall reduction in maternal and neonatal mortality and morbidity in Telangana.
Steps include finalization of technical and programmatic guidelines for 18 prioritized high-risk conditions specific to Telangana, training of the ANMs, MOs and specialists in the high-risk protocols through remote online training and multimedia based approaches, integration of the protocols into an intuitive decision support tool (integrated with the ANMOL app) that will handhold the various levels of the health cadre through the care process, integration of the backend data with the KCR portal for better tracking, creation of a dashboard for multiple levels of the state health system for real-time monitoring, development of a continuous quality improvement cycle and integration of AI and predictive analytics.
The state of Telangana will serve as a model state following which the intervention can be scaled across the country in a phased manner.
Online Training of:
- 9000 ANMs (Auxiliary Nurse Midwives)
- 1000 MOs (Medical Officers)
- 300 Specialist Doctors
Creating a Learning and Tracking App: This is an intuitive algorithm-based decision support tool which will handhold the various levels of the health cadres through the care process by taking them through the signs and symptoms to be noted, diagnostic investigations to be performed and provide intuitive and real-time situational alerts regarding the high risk factor present along with treatment to be given at each level of the health and need for referral. The app which will be uploaded onto the tablets of the ANMs, MOs and Specialist doctors will contain multi-media content including live action videos, interactive quizzes, periodic notifications etc and will be available in multiple formats for use both on tablets and as WhatsApp videos.
Capacity Building Assessment: Conduct pre-post assessment to assess the improvement in knowledge and skills based on the online remote training for 4 high-risk antenatal conditions (anemia, hypertension, gestational diabetes and antepartum hemorrhage among specialists, Medical Officers (MOs) and ANMs in Telangana.
Situational Analysis: Conduct a situational and gap analysis on the current identification, management, tracking of high-risk pregnancies in Telangana in two pilot intervention district.