Increases in diagnosis and management of obstetric and neonatal complications in district hospitals during a high intensity nurse-mentoring program in Bihar, India

Abstract

Maternal and neonatal mortality in Bihar, India was far higher than the aspirational levels set out by the Sustainable Development Goals. Provider training programs have been implemented in many low-resource settings to improve obstetric and neonatal outcomes. This longitudinal investigation assessed diagnoses and management of postpartum hemorrhage (PPH), hypertensive disorders of pregnancy, birth asphyxia (BA), and low birth weight (LBW), as part of the CARE’s AMANAT program in 22 District Hospitals in Bihar, between 2015 and 2017. Physicians and nurse mentors conducted clinical instruction, simulations and teamwork and communication activities, infrastructure and management support, and data collection for 6 consecutive months. Analysis of diagnosis included 11,259 non-referred and management included 11,800 total (non-referred and referred) admissions that were observed. Data were analyzed using the chi-square test for trend. PPH was diagnosed in 3.7% with no significant trend but diagnosis of hypertensive disorders increased from 1.0% to 1.7%, (ptrend = 0.04), over the 6 months. BA was diagnosed in 5.8% with no significant trend but LBW diagnoses increased from 11% to 16% (ptrend<0.01). Among PPH patients, 96% received fluids, 85% received uterotonics and 11% received Tranexamic Acid (TXA). There was a significant positive trend in the number of patients receiving TXA for PPH (6% to 13.8%, ptrend = 0.03). Of all neonates with BA, there were statistically significant increases in the proportion who were initially warmed, dried, and stimulated (78% to 94%, ptrend = 0.02), received airway suction (80% to 93%, ptrend = 0.03), and supplemental oxygen without positive pressure ventilation (73% to 86%, ptrend = 0.05). Diagnoses of hypertensive disorders and LBW as well as initial management of BA increased during the AMANAT program. However, underdiagnoses of PPH and hypertensive disorders relative to population levels remain critical barriers to improving maternal morbidity and mortality.

Tranexamic Acid for Postpartum Hemorrhage Treatment in Low-Resource Settings: A Rapid Scoping Review

“…Out of the 20 studies examining TXA effectiveness, 14 (70%) were randomized controlled trials (RCTs) [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 ] and the rest non-randomized trials [ 32 , 33 , 34 , 35 , 36 , 37 ].…”

“…Most of the clinical trials enrolled women with a singleton pregnancy who delivered vaginally or by cesarean section. Their sample sizes were relatively small to moderate (n = 40 to 300) [ 29 , 32 ] except in the studies by Abdel-Aleem (n = 740) [ 18 ] and Joudeh (n > 12,000) [ 36 ].…”

“…Most clinical and non-clinical studies took place in tertiary care and often university hospitals in the country capital or a major urban setting. Exceptions include studies by Joudeh (district hospitals) [ 36 ], McClure (homes and clinics in addition to hospitals) [ 41 ], and Resch (homes, community health centers, primary health clinics, and district hospitals) [ 39 ].…”

“…McClure’s mathematical model also examined TXA effectiveness but in decreasing PPH-related maternal mortality. Financial feasibility [ 20 , 38 , 39 ] and operational feasibility in terms of commodity security [ 20 ], health staff capacitation [ 36 ], and service delivery [ 39 ] were addressed by a handful of studies. The acceptability of TXA by women was only examined by Diop [ 21 ].…”

Super Divya, an Interactive Digital Storytelling Instructional Comic Series to Sustain Facilitation Skills of Labor and Delivery Nurse Mentors in Bihar, India—A Pilot Study

“…During the AMANAT program, a pair of NMS spent one week per month training labor and delivery care nurses in each facility for eight consecutive months. Specific details of the program have been published elsewhere [ 13 , 14 , 15 ]. After the successful completion of the AMANAT program, in 2018, a modified version of the program known as “AMANAT Jyoti” was launched in 330 Basic Emergency Obstetric and Newborn Care and 35 Emergency Obstetric and Newborn Care facilities with an emphasis on sustainability and transition to management by the state Government of Bihar [ 16 ].…”