Introduction: In this article, we describe a pilot telehealth project for identifying women at risk of developing serious complications early and for instituting timely, appropriate, and up-to-date management even in situations with limited resources and skilled obstetric services. Maternal mortality remains unacceptably high, with less than two-thirds of the signatories to the 2015 Millennium Development Goals achieving the outlined 75% reduction in maternal mortality ratio (MMR) from 1990 to 2015. Looking forward to 2030, the Sustainable Development Goals (SDGs) lay out a target of reducing the MMR in every country to below 70 per 100,000 live births. This will require progress in low-and-middle-income countries at a rate much greater than that seen over the past 15 years. Given that 94% of the global maternal deaths occur in low- and-middle-income countries, a solution to meet the unique challenges of these countries will be necessary to achieve the SDG. The Women’s Obstetrical Neonatal Death and Reduction (WONDER) telehealth system described here offers a potential telehealth solution to reduce mortality and morbidity rates in resource-limited environments by early identification of risk indicators and initiation of care. Materials and methods: The WONDER system consists of a cloud-based electronic health record with a Clinical Decision Support tool and a color-coded alert system. The Clinical Decision Support tool is based upon Maternal Early Warning Signs and provides real-time assistance to caregivers via relevant national treatment guidelines. This system uses inexpensive computing hardware, displays, and cell-phone technology. This system was tested in a 2-year pilot study in India. A total of 15,184 patients were monitored during labor and the postpartum period. Results: Within limitations of the study, the incidence of in-hospital eclampsia was reduced by 91.7%, and in 95% of cases, timely treatment was started within an hour of identifying the abnormality in vital signs. Maternal mortality was reduced by 50.1% over local benchmark figures. Conclusions: The WONDER system identified at-risk patients, directed skilled care to those patients at risk for complications, and helped to institute effective, timely treatment, demonstrating a potential solution for women in resource-limited locations.

Background: India accounts for nearly one in six maternal deaths and over the last two decades, maternal mortality in India has decreased rapidly and faster than the global rate. However, the rate of decline has been slowing and further progress calls for new interventions and improvements in existing programs and the care-delivery process. Objective(s): We developed and tested a telehealth solution that included an early warning system and a clinical decision support tool for timely detection of clinical deterioration and appropriate management of women in labor at a large general hospital in India. The pilot study with 15,184 patients was associated with a significant decrease in maternal mortality and in-hospital eclampsia. The results were published earlier this year. Here we examine and analyze the maternal deaths that occurred during that study period and discuss reasons why preventable deaths occurred despite the telehealth early warning system and recommend possible approaches to further reduce the maternal mortality rate. Study Design: We carefully reviewed medical records of all maternal deaths during the two-year pilot from admission until death or transfer of these patients to a tertiary care center. We deconstructed the events leading to the adverse outcome and evaluated each based on the three delay modules for maternal deaths, namely seeking care, reaching the facility, and receiving care after reaching the facility. Results: Twelve maternal deaths occurred during the period of the study, six deaths occurred at the study sites and six deaths occurred after transport to a tertiary institution. Nine deaths were determined to be preventable. In five cases although multiple alerts were created indicating a clinical deterioration of the patients’ condition, lack of adequate knowledge and insufficient training on the part of the staff contributed to delays in initiating treatment and/or delays in timely transport. In all cases where the deaths occurred after the patient was transported, the warning system had identified the acute risk appropriately prior to the initiation of the transport. Considering all cases, the telehealth early warning system generated red alerts in every case, indicating an acute emergency (66.7%) and/or yellow alerts requiring continued observation (33.3%). Conclusion(s): Telehealth solutions incorporating early warning capability for identifying clinical deterioration among patients can play a crucial role in resource-constrained settings.  Telehealth early warning systems have the potential to accelerate the care-delivery process and expose gaps in an organization’s operating procedures as well as in the knowledge base of providers. Successful implementation of such telehealth systems requires strong referral networks and appropriate protocols to take advantage of the system’s early warning capabilities. In addition, it may be necessary that the early warning system be implemented in all referring and receiving institution within the system to ensure no fallout in patient care.