Public Health System in India is pyramidal in structure. The lowest level being a Sub-centre which is usually closest in terms of accessibility for a remote community. A sub-centre is run by an Auxiliary Nurse Midwife(ANM) and a Male Health Worker(MHW) who take care of very basic health-care needs of a community. Several sub-centres report to a Primary Health Center(PHC), several of which fall under a Community Health Center(CHC). The highest facility is the District Hospitals (DH) which are often referred to as Tertiary Care Units. Medical colleges and hospitals may also be regarded as Tertiary Care Units.
Under the sub-centres, ASHAs (Accredited Social Health Activist) play crucial role in motivating families for institutional delivery i.e. making sure that the mother comes for delivery at a PHC. ASHAs and ANMs work closely to register cases for women who require antenatal care. They also educate pregnant women about various relevant government schemes and ensure that they avail them during this period. They have to ensure that all pregnant women complete at least four ANC checkups with three sonographies at recommended intervals. In the process they also keep a close tab on expected date of delivery and follow up accordingly.
In relatively developed states such as Karnataka, delivery at sub-centre level under the supervision of an ANM is strongly discouraged. The priority is always to get the mother at least at a PHC. In case of pre-registered High Risk Pregnancy (HRP) as identified during the ANC checkups, families are encouraged to go directly to higher levels of care. In-case of non-HRP cases, the woman’s labour progress is closely monitored and delivery is conducted by a Nurse.
While close monitoring of a labour progress, if any abnormalities are observed indicating a risk during delivery or obstructed labour, the mother is referred to the First Referral Unit (FRU) which may be a CHC, DH or any other Tertiary Care Unit closest to the PHC with facilities to handle the foreseen complications.
WHO’s Partograph is a tool which aims at simplifying labour monitoring process, acts as a catalyst to make real time evidence based analysis which eventually results in informed decision making at the lower levels of care. It aims to prevent delays in referrals as well as prevent unnecessary referrals thereby improving operational efficiency of labour monitoring and referral system. As per the National Rural Health Mission (NRHM), use of Partograph is mandatory at PHCs. Health workers who have undergone Skilled Birth Attendant course are trained in this process, at least on paper.
Partograph often is a part of the delivery case sheets provided by Ministry of Health and Family Welfare (MoHFW) of the State as recommended by NRHM. However, due to lack of supply, these are seldom used during the labour monitoring process or filled retrospectively as a formality. As observed on field, most of the PHCs even had the discharge sheet still intact with the delivery case sheets which ideally needs to be handed over to the woman when she is discharged from the facility. This clearly indicates that the sheets may be filled after two or more days from the actual date of delivery. Parturition register is the only relatively reliable record of deliveries conducted in the PHC. However, there are irregularities in data collection and representation from nurse to nurse despite a standard format.
In conclusion, there is no practice of recording what actually happens during a labour monitoring process. Protocols to be adhered to, like the time intervals between examining vital signs are often just a piece of information put up in the form of charts in every delivery room but seldom followed. Experience and thumb rules devised after few years of practice often influence decision making. WHO Partograph is a tool closest to standardising this procedure and if practiced sincerely can empower even a neo trained staff member to make informed decisions. It is extremely relevant in places where dearth of experienced caregivers persists.
However, due to gaps in training ( a caregiver informed us that she is a certified SBA without a single day of training), even the latest version, The Simplified Partograph by WHO is often incorrectly plotted (though retrospectively), rendering it useless for the given context. Often, the caregivers know how to complete a document for inspection but do not comprehend or buy-in the actual importance and functionality of the Partograph. For example, vitals such as foetal heart rate, pulse rate and contractions per ten minutes have to be checked every half an hour. However foetal heart rate is often observed qualitatively in absence of a foetal doppler whereas Partograph requires a quantitative plot. Contractions as per the partograph need two data points, number of contractions per ten minutes and duration of contractions. However, this data is impossible to record by an extremely busy and overburdened nurse who is often filling in for the frequently absent Medical Officer (MO). Mother’s temperature which is to be measured every two hours is often assessed without a thermometer. One of the major drawbacks of this procedure is that the Partograph is relevant only in the active stage of labour, i.e. Between 4 cm to 10 cm of cervical dilation. Woman often come fully dilated to prevent cost implications of further referrals. At such a stage, the only option remains is to deliver the baby even if the case is classified as a HRP. Such practices limit the viability and efficiency of the Partograph which as per studies does contribute to reduction in Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR).
Focussing beyond the system issues, the most straightforward approach to ensure protocol adherence is digitising the data collection process while labour monitoring with inbuilt algorithms to remind the nurse periodically about protocol adherence as well as give alerts in case of abnormalities. The data is also automatically accessible in the form of a WHO Partograph which may enable you to make informed decisions with adequate time in hand. SELCO Foundation has partnered with one such startup to pilot this Application through a tablet being given to five PHCs, namely Hudem, S.R.R. Pura, Anegundi, G.H.Koppa and Hirehal in Karnataka, which are managed by Karuna Trust. The idea is to minimize data entry time and make it extremely user friendly such that even a health worker who is assisting the nurse can enter the data while she examines the patient. Several training strategies are being devised to increase rate of adoption. Ideally this App should not be limited to just a monitoring tool but also provide a knowledge resource and bridge training gaps for the end user who are still opening up to the idea of digital education.Through this pilot, we aim to assess feasibility of this approach by understanding behavioral patterns and end user interaction with the App in the given context. Real time record maintenance is a biggest behavioral change as well as challenge in the process. Expecting end users to make decisions based on the inputs given by the App can be expected only after prolonged monitoring and evaluation. Larger goal of the project is to form a strong case study which may provide a good baseline for incorporation of this tool along with MoHFW programmes such as Mother and Child Tracking System (MCTS) and Comprehensive Primary Health Management (CPHM).