Setting
3. Observations and Results
3.1 Efficacy of detection of very high risk and high risk pregnancies
Historically three main causes of maternal mortality in Indonesia have always been Preeclampsia, Haemorrhage, and Infections. Our study found that the rate of post-partum haemorrhage was 7 (1.07%) compared to average of 3-10% and the rate of preeclampsia was 11 (1.6%) which was lower than average of 5-15%.(10)After the initial risk assessment by midwives followed by a review by the ObGyns the detection of high and very high risk pregnancies were 14% and 17%
respectively, using the MoM tool and antenatal ultrasonography.Fig.1.
Fig 1. The Risks Detected by Midwives and the ObGyns.
This significant increase in detection efficacy was primarily due to the use of the USG in detection several cases which was difficult to be ascertained by the physical examinations only. Apart from the use of sonography scans, the review of the pregnancy profiles in the MoM tool, by the ObGyn,
detected instances where the midwife had misclassified the risk level most likely due to the differences in skill levels of the midwives in using the Poedji-Rochatji scoring systems.
The ultrasound examination, helped detect and monitor several cases of high risk pregnancies which would have been difficult to be detected by physical examination alone, as depicted in Table1. These findings had prompted immediate actions by the midwives and ObGyn to change the plan of pregnancy care.
Table 1. Advantages offered due to antenatal ultrasound examination in various trimesters
1st One case of anencephaly detected and advised accordingly
Several cases of twins diagnosed 2 cases of fetal demise
2 cases of hydatidiform mole 2nd Several cases of placenta Praevia
Several patients followed up for Doppler due to IUGR, eclampsia or any other parameter affecting foetal well being 3rd Advised cases of expected post term
deliveries based on placenta grade on USG and on the colon grade in several cases 64% women in the first 5 months of pregnancy was identified to have anemia (Hb<10g/dl). Fig.2 shows the percentage of anaemia cases detected in the first trimester. The Haemoglobin levels of the women were tracked using the MoM tool and they were treated with Iron/Folic acid tablets or injections, depending on the severity. In the third trimester it was observed that only 1% of the women had anemia. Non–compliant patients were tracked and visited at home by the midwives to administer treatment.
Fig.2. Anaemia cases in in the first trimester and the same cases in the third trimester, illustrates
proper management of anaemic cases
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3.2 Appropriate referrals of the very high risk pregnancies to the higher centres
Appropriate referrals have been shown to reduce maternal morbidity significantly.(11) A total of 82 women were screened as very high risk pregnancies and were referred to higher centres, as shown in Table 2.
Table 2. Number of very high risk cases referred to higher centres for further management Pregnant ladies Registered 656 Number of pregnant ladies dectected
as Very High Risk and Referred
82
Number of pregnant ladies referred in the First Trimester
40 Number of pregnant ladies referred in the Second Trimester
42 Number of pregnant ladies managed at the Puskesmas after referral.
574
An interview with the doctors at the referral hospitals indicated that they were appreciative of the fact the ladies were referred in time and their management resulted in good outcomes. Care was also taken to refer any earliest sign of foetal distress or worsening of maternal health to the right referral centre with specific infrastructure and manpower.
Pregnancy outcome is definitely the litmus test of whether the team based model has positively impacted antenatal care management. The caesarean section rate was 21%, with mal-presentation and obstructed labour being the commonest indication.
94% of the babies had an APGAR score more than 8, with only 3% having a score less than 6 and needed NICU (Neonatal Intensive Care Unit) admission.
Fig. 3.
Fig. 3 Perinatal outcomes of women registered in the MoM study
The Low Birth Weight babies (less than 2500gms at birth) formed about 7% of the babies born and a large majority of them were premature.
All the premature deliveries were institutional and had already been referred to the higher centres for management. There were 4 neonatal deaths reported and the causes were due to sepsis, head injury and one death in the NICU due to birth asphyxia. The deaths due to sepsis and injury occurred at home and are unfortunate but nevertheless indicate there is a potential to extend support to pregnant women in the post natal period as well.
3.3 Remote monitoring of high risk pregnancies by ObGyns facilitated by the midwives
The review by the ObGyns of the case records facilitated by MOM, was a kind to the pregnant ladies being remotely monitored by the ObGyns.
Home visits of the midwives to the residences of women classified as high risk and those who could not travel to the puskesmas, provided additional touch points between the pregnant women and the healthcare system. Table 3 shows a comparison of several parameters of the current study with that of the previous years in the same Puskesmas.
Table 3. MoM benchmarked with the previous year 2011-2012 performance on several parameters
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The table is illustrative of the fact that the increased touch points between the pregnant women and the health services has resulted in improved monitoring and consequently better screening and referral of very high risk pregnancies. Around 47 of the pregnant women had at least two home visits by the midwives. The home visits were made to patients that were recommended increased frequency of follow up due to certain risk factors like pallor, pre- existing hypertension, abnormal glucose tolerance tests, patients non-compliant with taking Iron Folic Acid tablets etc.
In the year of 2011-2012 in the same demographic population the mortality rate was 114 and 72 per 100.000 deliveries respectively. We had no maternal death in this studied group.
3.4 Engagement of pregnant women in attending and utilizing antenatal services There was a palpable increase in patient engagement during the MoM study. The women had an opportunity to meet with their midwife and the ObGyns during the ultrasound examination. This helped the pregnant women to get their queries answered and also the team of midwives and ObGyns to tailor the antenatal care management which would suit the patient’s requirements the best.
When asked what the pregnant women considered the most important difference compared to their previous experiences. The answers were almost unanimous – they felt safer being remotely monitored by the ObGyns and secondly they had more time to discuss with the ObGyns. An improvement in engagement has been proven to result in improved outcomes by several studies in the past.(11)
Table 4. Questionnaire distributed Questionnaire to Pregnant Women How would you compare between ANC visits with MoM and your previous pregnancy’s ANC visits without MoM? (asked to multi-para women)
How would you compare between ANC visits with your Obstetrician in the private sector and the public sector MoM with ultrasonography?
How do you feel knowing your pregnancy being monitored by Obstetrician through mobile phone ? (answer on satisfaction scale)
How do you feel having your midwife home visiting then reported your data to Obstetrician
?( answer on satisfaction scale)
3.5 Improvement of skills and knowledge of midwives
The midwives considered the teaming with ObGyns resulted in efficient detection of high and
very high risk pregnancies. The midwives also had regular classes on antenatal sonography given by Dr.
Ivan and his team of ObGyns at the Bunda Medical center. The classroom sessions were very helpful in clarifying and updating their knowledge.
Table5. Pregnancy Complication detected and managed by the team in the community Puskesmas name Complications
PE* HT* PPH* D*
Air Dingin 6 1 2 21
Pauh 4 - 1 14
Seberang Padang - 1 - 12
Padang Pasir - 2 - 16
Nanggalo - - - 10
Lubuk Buaya 1 2 4 23
*PE : Pre- eclampsia HT : Hypertension
PPH : Postpartum Haemorrhage D : Diabetes