LABOUR MANAGEMENT TOOL

Transcription

1 LAB NOTE 1 Defining the Challenge of Delayed Case Referrals LABOUR MANAGEMENT TOOL The Bihar Innovation Lab conceives, builds and implements high impact solutions for the public health sector to save more lives and improve the health of women and children. It is supported by the Bill and Melinda Gates Foundation and the Government of Bihar. The Lab envisions an easy to use aid or tool that can enable timely and accurate detection of labor complications and indicate the nature of intervention required.

2 Defining the Challenge of Delayed Case Referrals in Bihar Referral systems are designed to rely significantly on close coordination between all levels of the health system in order to deliver suitable care to beneficiaries that is easily accessible. When referring labour cases, a delayed referral could severely affect the condition of both the mother and child, and in some case contribute to their deaths. On past and recent field expeditions, the Bihar Innovation Lab (BIL) learnt of a number of referral cases through observations and conversations with Auxiliary Nurse Midwives (ANM) at Primary Health Centres and District or Sub-Divisional Hospitals across the state. Through a number of interactions with ANMs at public health facilities in Bihar, the Lab gained first-hand knowledge of the referral process and some of the challenges that the staff faces. In a particular case, an ANM was required to think on her feet when a complication arose late at night and the doctor was absent to approve the referral. After failing to convince the family to move the patient to the District Hospital, the ANM was forced to break protocol and treat her at the PHC. While the patient made it through the complication, the family lodged a complaint against the frontline worker. The ANM had asked the family members to acquire expensive drugs which, as per regulation, were not available at the PHC. Ultimately, the PHC reimbursed the amount and the case was laid to rest. It was found that delays in referrals could be caused due to a variety of reasons including a lack of protocols supporting frontline decision-making, knowledge gaps among community mobilizers and Auxiliary Nurse Midwives (ANMs), the family s reluctance to move to a superior facility that may be located far from their home, and the absence of diagnostic facilities at the frontline, and approval protocols. Due to multiple players and interactions that comprise the referral system, the Lab has found it useful to employ a multi perspectival approach to breaking down the challenge of delayed referrals in Bihar, represented in four synthetic themes: Representative Partograph Convining families to move to a diferent facility can be an arduous task. Labour Room

3 1. Knowledge Gaps among Community Mobilizers Given the ASHA s crucial position as the first point of contact between the health system and beneficiaries, she is presented with the opportunity to make preliminary assessments that could be pivotal in ensuring timely case referral. However, it is essential to understand the capacity constraints of community mobilizers and how they understand their responsibilities. ASHA workers view their role to be largely centered around mobilization, and invariably take women to primary health centers regardless of whether the facility is capable of handling their specific case. In order to make these assessments, a variety of indicators, both visible and invisible, could be recognized on encountering a beneficiary at the onset of labour. Visible symptoms such as swollen feet, profuse bleeding, and meconium stains provide a clear indication of abnormal delivery. Aside from these, there are a series of invisible symptoms such as acute headaches, nausea, abdominal pains, and slow fetal movement that can be verbally described in response to simple questioning by the ASHA. Understanding patient history, including whether the patient has previously had a c-section, low hemoglobin or blood pressure, and frequent, closely-spaced pregnancies, among others, could also intimate that a beneficiary could face complications during delivery. However, ASHAs are not trained to recognise such symptoms and the relative danger associated to each. Moreover, most ASHAs don t grasp the difference between care provision capacity and health infrastructure at PHCs and district level hospitals. Even in the event that such indicators are recognised, ASHAS invariably mobilize women to PHCs due to the absence of any protocol to support such decision making at the time of mobilization. 2. Inadequate Tools for Clinical Decision-Making Within the labour room, a number of parameters require tools to be diagnosed accurately. In the absence of these diagnostic tools the ANMs rely on alternative methods to gauge these parameters, which often express inaccurate results. For instance, an ANM may conduct a manual check on the pregnant woman to determine anaemia. These methods are time consuming and often yield inaccurate results, thereby incapacitating the ANM to raise an alarm in time and commence the process of referral. Clinical decision making around referral takes more time if the vitals of the pregnant woman are not plotted on the partograph that projects an accurate graphical representation of labour progression. Vitals are noted down in registers, and not on the partograph.

4 3. Delays in Approval The initial medical examination of the pregnant woman and the detection of complications is first done by the ANM in the labour room. In cases of complication, the PHC is mandated to refer the patient to a superior facility. However, the ANM is not authorised to approve referrals. Once a complication has been detected, protocol requires the ANM to notify the doctor who would be informed about the patient s condition and take the necessary steps. The biggest hurdle in the process of seeking approval for referrals is the absence of a doctor at the facility. In such cases, the ANM is expected to resolve the complication at the PHC, a task that may require skills that she does not possess. 4. Beneficiary Apprehensions of Seeking Care at Superior Institutions Families have an inherent reluctance to move to institutions higher up the public health service delivery system despite being aware of the superior facilities available there. The perception of District or Sub-Divisional Hospitals is built on a lack of personal interaction with nurses, poor care provision, inattentive staff due to a higher volume of patients, and the expense involved in transporting the patient from one location to another. Thus, ANMs often face reluctance from families when they suggest a referral to the Sadar or Sub-Divisional Hospital. Getting approvals for referral is a tedious and time consuming process.

5 Designing for a Timely Referral Process To design within a system that has bottlenecks at varying levels, involving different stakeholders with disparate capacity constraints, the Lab aims to design for multiple perspectives for a strengthened referral system. In order to achieve this, the lab is designing component solutions in line with each of these user perspectives, channels through which these solutions can compliment one another, consequently creating a robust loop of interactions to ensure timely referral. In close alignment with framed challenges the Lab has focussed their innovations toward: Developing Protocols for Visible and Verbal Assessments at the Frontline Visual Frameworks for Clinical Decision Making within the Labour Room Creating Processes for Expedited Approval Counselling Families to Seek Suitable Care Over the past few months, the Lab has generated concept innovations for each of these opportunities exploring paper based checklists, to digital concepts that design protocol to support timely decision making. These solutions have received preliminary user validation through FGDs conducted with ANMs at the facilitylevel in a district. The Lab is working towards conceptualizing new solutions and field testing existing ones over the next few months. When a family member wishes to take the patient home instead of a different facility. Vitals may be noted on a sheet of paper instead of the partograph.