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Streamlined maternal referral network: A step towards saving the lives of pregnant women

Jan 11 2024 / Posted in Maternal health

– Subham Mohapatra, Documentation Coordinator, SNEHA
‘Motherhood is bliss,’ is a sentiment often endorsed by celebrities, influencers and even our close family members . However, for many pregnant women in India, the process of giving birth is also challenging and frightening.
As per the article published by the Ministry of Women & Child Development department, Govt. of India on
“Significant decline in Maternal Mortality in India”; Reducing the maternal mortality rate is a crucial goal set by the United Nations in 2015, aiming for a rate of less than 70 per lakh live births by 2030, globally. The National Health Policy 2017 set a target for the maternal mortality rate in India, aiming to achieve a rate below 100 per lakh live births by 2020.
The government system successfully achieved this milestone by bringing down the rate to 97 per lakh live births in 2020, meeting the targets within the specified timeframe. States like Kerala, Maharashtra, Telangana, and Andhra Pradesh have made ceaseless efforts to reduce the maternal mortality rate. Maharashtra, in particular, has set an exemplary status with a rate of 33 per lakh live births.
Despite a commendable 14.6% reduction in maternal mortality across Mumbai, the M-East ward, characterised by the lowest human development index, has once again reported the highest maternal mortality rates in the city for the year 2021.

Due to the unavailability of formal referral linkages, and lack of communication resulting in insufficient knowledge of available service provisions at diverse levels of health facilities (Image-1). Absence of ingrained awareness about the health, hygiene and sanitation especially focusing on antenatal, neonatal and postnatal care poses challenges. Because women in need of maternal care especially in case of high-risk pregnancies, either spend more in travelling to reach adequate health facilities or exhibit hesitancy in accessing services. Hence it becomes imperative to address three delays viz deciding to seek appropriate medical help for an obstetric emergency, reaching an appropriate health facility and receiving adequate care & services after reaching an appropriate health facility.
Essentially to address the challenges and implement effective interventions; healthcare providers & public health administration, civic organisations, public-private partnerships, Corporate Social Responsibilities (CSR), philanthropists and communities have to work together. By strengthening healthcare infrastructure, improving access to quality health care, and raising awareness about maternal health, Mumbai can make significant strides in reducing its maternal mortality rate and ensuring better health outcomes for mothers and neonates.
SNEHA (Society for Nutrition, Education & Health Action) being a strategic contributor to maternal and child health has adopted different approaches, visioning to strengthen and streamline the existing maternity referral processes with innovative and sustainable interventions, ensuring swift and efficient referral of pregnant women experiencing labour complications. It enables the public healthcare providers to offer appropriate care during pregnancy and childbirth, addressing complications promptly and ultimately contributing to safer childbirth experiences and improved maternal health outcomes. Over the years, the organisation has scaled its collaboration with seven municipal corporations across the the Mumbai Metropolitan Region Development Authority (MMRDA) and recently expanded into three more municipal councils considering the unique socio-economic and demographics challenges of the city.

Need for sustainable and evidence-based espousal:

Mumbai, along with the MMRDA regions, has a population of nearly 23 million, as per the census of 2011. However, there are significant gaps in public healthcare infrastructure, availability of human resources, service provisions, and knowledge about healthcare services to accommodate . These gaps can have adverse impacts on the overall health outcomes of the population.
Civil Society organisations like SNEHA play a crucial role in bolstering up the Public Health System, especially in enhancing healthcare services for maternal and child health. SNEHA has been actively engaging with the public Health systems, providing data evidence collected through its ground implementers. This evidence-based approach helps identify areas of improvement and informs strategic interventions to address the gaps in service delivery and accessibility of quality healthcare.
SNEHA's interventions focus on streamlining of services at the Primary Health Centres aiming to provide comprehensive and quality care to pregnant women, mothers, and new-borns. SNEHA also emphasizes spreading awareness among lower socio-economic marginalized communities about healthcare services, preventive measures, and health-seeking behaviours, thereby working towards achieving Sustainable Development Goal (SDG) 3, "Health for All.’

Maternal Referral Mechanism:

While four tertiary care institutes are operational under Brihanmumbai Municipal Corporation (BMC) there is only one state-led major hospital that accommodates high-risk maternal cases. Further, the distribution of cases is also channelised to the peripheral hospitals and maternity homes in accordance to the intensity of risk and emergencies.
SNEHA has provided support to the public healthcare administration in the municipal corporations to revise clinical protocols and establish linkages. This revision aimed to smoothen and streamline the maternal referral case management, making it more efficient and hassle-free. Furthermore, SNEHA has been influencing the management of referrals to Neonatal Intensive Care Units (NICUs) and Special New-born Care Units (SNCUs). By improving the coordination and efficiency of referrals, SNEHA aims to ensure that expectant mothers and new-borns receive timely and appropriate care, hence reducing the risk of complications and improving their chances of survival.

Data driven & tech enabled communication:

SNEHA also has been catering to the need for capacity building of healthcare providers to keep them updated about different skill sets and knowledge so that the referral communication is strengthened. To facilitate effective referrals, SNEHA encourages referring health facilities to refer high-risk and emergency maternal cases with complete documentation, case history, and pre-referral communication using technology like as; digital referral formats & whatsapp. With all relevant information is communicated upfront, higher-level health facilities can prepare in advance and reduce the time required to make an accurate diagnosis and provide appropriate care.
While health facilities have started adopting these practices, SNEHA continues to provide support to streamline and sustain the process. In one way this is done is by assisting health facilities in analysing birth outcomes. This analysis helps identify gaps in the healthcare system and provides insights for interventions and improvements. By reflecting on the birth outcomes, the healthcare system can proactively identify areas for intervention, refine protocols, and enhance the quality of care provided to pregnant women and new-borns.

Shifting focus towards outcome driven strategies:

A well-designed primary healthcare system plays a pivotal role in alleviating the strain on secondary and tertiary care institutions, enhancing national productivity, and reducing the overall cost of healthcare services. To ensure the efficacy of such initiatives, it is imperative to establish early mechanisms for monitoring and evaluation. This includes not only tracking outputs and activities but also measuring outcomes biased to national maternal & new-born health indicators. By collecting and analysing real-time referral & its outcome data, decision-makers can make informed choices and implement course corrections if necessary. This data-driven approach helps prioritize high-quality interventions and ensures that resources are utilized effectively.
SNEHA has been fostering accountability and transparency in the public healthcare system through its own robust monitoring and evaluation framework. It enables stakeholders (healthcare providers, administrators) to assess the effectiveness of interventions, identify gaps, and influence for necessary changes. Ultimately, tracking of progress and outcomes ensures that efforts to improve healthcare access and infrastructure are targeted and sustainable, leading to better health outcomes for the population. In this process, the public healthcare systems is appointing & designating nodal persons at each level of health facilities in order to ensure smooth obstetric care referral management and coordination, alongside a capable data persons who will be responsible for overseeing the validity and accuracy of maternal referral data so that the healthcare system will be enable to take futuristic decisions impacting better maternal health outcomes.
Also Read:- Pregnancy prevention is still a woman’s problem

SNEHA with it’s North Star:

SNEHA has been working with the public health system to streamline the obstetric care referral linkages with smooth communication amongst both from the referring and receiving health facilities. Incepted in 2007, SNEHA’s model of obstetric care referral management has gradually been adopted by the public healthcare system across its intervention locations in Maharashtra, which have been implicated as one of the successful models with the maximised scope of replicability. In the coming years SNEHA is planning to bring intensified innovations into the model so that it can be universally accepted by the public healthcare system across any dense population, geographically.