Integrated High-Risk Pregnancy Tracking & Management Project

Integrated High Risk Pregnancy Tracking & Management (IHRPTM) 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 learning and tracking apps. The pilot has been launched in Telangana and Andhra Pradesh 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-5, only 58.1% of women had at least 4 antenatal visits.

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.

Program Design

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 partnered with UNICEF , the state government of Telangana and the state government of Andhra Pradesh to roll out an integrated, comprehensive, multi-step, systemic approach for improved identification, tracking and end-to-end management of high-risk pregnancies during the antenatal period such that there is a sustained reduction in irrational and delayed/complicated referrals and improved continuum of care for maternal health that can result in achieving the goal of Ending Preventable Maternal Mortality (EPMM).

Salient Features

In Telangana (where the program is called Amma Kosam or ‘For the Mother’), the program includes:

● Technical and programmatic guidelines for 18 prioritized high-risk conditions specific to Telangana and prevention of perineal trauma at the time of delivery
● Training every health cadre in managing high-risk pregnancies – through remote online training (conducted by ARMMAN) and face-to-face training through the master trainers of the state. We are currently training 9000 Auxiliary Nurse Midwives (ANMs), 1000 Medical Officers and 400 Specialists in Telangana.
● Creating a learning app to be embedded in the tablet of the health-care professionals. It uses multimedia e.g., live-action videos, simulations, interactive quizzes, and notifications.
● Call center and WhatsApp helpdesk support for long-term handholding when the auxiliary nurse midwives and medical officers use the protocols.
● Tracking high-risk pregnancies by integrating high-risk management data into the Reproductive and Child Health database of the government.
● Creating a dashboard for multiple levels of the state health system for real-time monitoring.
● Developing a continuous quality improvement cycle and integration of AI/ 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. We have recently started implementation in the state of Andhra Pradesh.

Measuring Impact

We will conduct a 5-year Randomized Cluster Trial starting in 2023, a community level baseline and endline survey in rural, tribal and urban geographies in Telangana and a longitudinal referral tracking survey in two blocks to measure intermediate outcomes.