Rationale

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

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