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.
Highlights
There were about 275,000 maternal deaths and 2.7 million neonatal deaths in 2015 [1,2]
A total of 12,307 admissions were included in the Facility Information System (FIS) dataset
Specific complications by month are shown in S1 Table
Summary
There were about 275,000 maternal deaths and 2.7 million neonatal deaths in 2015 [1,2]. Despite increasing institutional deliveries from 28% to 64% between 2007 and 2016, the concurrent maternal mortality ratio (MMR) in Bihar, India was 165 per 100,000 live births from 2014–2016, and the neonatal mortality rate (NMR) was 27 per 1,000 live births [3]. Postpartum hemorrhage (PPH) and hypertensive disorders of pregnancy (HDP), each impact 5–10% of deliveries [7,8], and Birth asphyxia (BA) impacts 5–10% of neonates. Low birth weight (LBW) incidence varies widely by context but is estimated as 20–30% of all births in India, and its diagnosis can lead to life-saving interventions for the newborn [9]
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