Management and referral for high-risk conditions and complications during the antenatal period: knowledge, practice and attitude survey of providers in rural public healthcare in two states of India

Samiksha Singh,Pat Doyle,G V S Murthy,Oona M R Campbell

doi:10.1186/s12978-019-0765-y

Abstract

BackgroundAppropriate antenatal care improves pregnancy outcomes. Routine antenatal care is provided at primary care facilities in rural India and women at-risk of poor outcomes are referred to advanced centres in cities. The primary care facilities include Sub-health centres, Primary health centres, and Community health centres, in ascending order of level of obstetric care provided. The latter two should provide basic and comprehensive obstetric care, respectively, but they provide only partial services. In such scenario, the management and referrals during pregnancy are less understood. This study assessed rural providers’ perspectives on management and referrals of antenatal women with high obstetric risk, or with complications.MethodsWe surveyed 147 health care providers in primary level public health care from poor and better performing districts from two states. We assessed their knowledge, attitudes and practices regarding obstetric care, referral decisions and pre-referral treatments provided for commonly occurring obstetric high-risk conditions and complications.ResultsStaff had sub-optimal knowledge of, and practices for, screening common high-risk conditions and assessing complications in pregnancy. Only 31% (47/147) mentioned screening for at least 10 of the 16 common high-risk conditions and early complications of pregnancy. Only 35% (17/49) of the staff at Primary health centres, and 51% (18/35) at Community health centres, mentioned that they managed these conditions and, the remaining staff referred most of such cases early in pregnancy. The staff mentioned inability to manage childbirth of women with high-risk conditions and complications. Thus in absence of efficient referral systems and communication, it was better for these women to receive antenatal care at the advanced centres (often far) where they should deliver. There were large gaps in knowledge of emergency treatment for obstetric complications in pregnancy and pre-referral first-aid. Staff generally were low on confidence and did not have adequate resources. Nurses had limited roles in decision making. Staff desired skill building, mentoring, moral support, and motivation from senior officers.ConclusionThe Indian health system should improve the provision of obstetric care by standardising services at each level of health care and increasing the focus on emergency treatment for complications, appropriate decision-making for referral, and improving referral communication and staff support.

Highlights

A quarter of the staff from Primary health centres, and a half from the Community health centres managed common conditions, and the remaining staff referred most of these cases early in pregnancy
The Indian health system should improve the provision of obstetric care by standardising services at each level of care and increasing the focus on emergency treatment for complications, appropriate decision-making for referral, and improving referral communication and staff support
Provision of obstetric care at the study centres The provision of antenatal care, appropriate management of complications and onward referral depended on the designation of the staff, and the infrastructural support at the centres

Summary

Introduction

WHO (2015) standards for improving the quality of antenatal care for a positive pregnancy experience focus on basic preventive and promotive antenatal care and recommend early assessment for high-risk cases and complications in pregnancy [2] These guidelines are to guide clinical decisions and are for primary level of health care, either at the facility or in the community. Whilst the level of EmOC care available defines a facility’s capabilities for managing complications in early pregnancy, it is observed in several low resource settings that centres designated as EmOC may not be able to provide all the signal functions [9,10,11,12,13] Health workers from such settings which cannot manage complications should be highly competent in prevention, risk assessment, stabilisation of complicated cases, and arranging transfer and care at functional higher referral levels [14, 15]

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Discussion

Conclusion