Labour Initiation: First Steps.

The Labour Progression Tool, or Partograph, Team initiated the Bihar Innovation Lab’s fourth project by organizing one of its flagship collaborative working sessions in Patna on the 1st of April, 2015. The half-day consultation looked to gain insight and expert opinion on designing better birth preparedness, labour mobilization, and delivery management and was attended by four representatives of CARE India – ranging from obstetricians to nurses with ample field experience. 

We have been discussing the scope of the project with representatives of the Foundation to take it forward in the  direction of a broader labour management design in the context of Bihar, with the possible adaption for similar regions of northern India.  

The expectations from the workshop were to:

  • Jointly prioritize challenges that have a direct impact on labor management. 
  • Review initial innovation directions and vote for the most promising ones.
  • Define the scope of the project. 
  • Identify technical support from CARE for the project.

Prior to the consultation, a visually-rich infographic that mapped failures along mother’s labour journey from conception to delivery, was created. This infographic, designed along a linear path and divided into broad challenge areas, was conceptualized to be the centerpiece of the workshop – an open platform to and from which new challenges could be added and redundant ones omitted. 

Partograph Infographic

The participants were urged to utilize Post-It Notes to add failures that were missing on the sheet under any broad failure category from socio-behavioural to clinical, informational, and infrastructural. A number of new challenges and failures, along with solutions were identified and accordingly placed on the infographic. These ranged from an emphasis on emergency preparedness and identification of high-risk pregnant women to a tedious referral system where the beneficiary is sent from one facility to another based on the critical nature of her condition. 

A lively discussion ensued where possible solutions and existing interventions were talked about and ground realities were scrutinized. By the end of the first session, we had arrived at three broad challenge areas that the participants suggested the Lab ought to focus on. A lack of identification of high-risk pregnancies is a common occurrence in Bihar and needs to be tackled in order to mobilize women in time during labour. The second major challenge is the inadequate knowledge possessed by health care workers to deal with last-minute labour cases. Timely identification of labour and referral transport to the facility poses another large challenge. In most cases, the PHC is unable to look after complicated cases and refers the pregnant woman to the District Hospital, which may be located a few hours from the primary facility. The District Hospital, a number of times, has no doctors available after 2 pm and the case gets referred to a medical college. In a number of cases, the pregnant woman ends up at a private facility or delivers while in transit. 

On a number of occasions, to tackle last-minute labour cases, the support staff at the PHC needs to empowered to take decisions and, provided they possess the skills, execute tasks in crisis situations. Task-shifting – or moving specific tasks from trained medical providers to community health workers – is a low-cost, effective way to improve access to health services that save lives. The idea of empowering and training support staff to safely carry out deliveries at the primary facility was floated – in light of the observation that the untrained support cadre does this in times of high volume deliveries anyway. A structured approach might actually help avoid unnecessary referrals and save numerous lives.

In the second session of the workshop, the Lab presented some of its initial innovation directions to seek extension more than validation. The participants were provided concept cards and asked to work systematically to identify key barriers, primary users, viability in the context of Bihar, and answers to specific questions posed by the Lab team. Of the 11 concepts presented, two failed to get recognition as potential solutions in Bihar, while nine others were extended and worked upon. Needless to say, this exercise helped us immensely in understanding field realities without actually having worked in districts. This particular exercise will prove to be the ideal stepping stone before the Lab team actually begins field work to look for specific answers and document perception. 

It was interesting to engage in a conversation that expressed very specific design insights on the partograph itself. In the context of Bihar, experts suggested, there is little need for the partograph tool to have both the Alert and Action Lines. The Alert Line on the partograph suggests the approach of the active phase of labour, while the Action Line – which runs parallel to the Alert Line, but four hours to the right – indicates the active phase of labour and points to the timely preparation for delivery. In Bihar, however, most pregnant women arrive too late in the day for their vitals to be plotted in the zone between the Alert and Action Lines. In a nutshell, a majority of cases arrive in the active phase of labour and require action to be taken. 

Needless to say, the workshop provided us with some impeccable field realities, insights, concept extension, and technical assistance. It proved to be a good, solid start to the project and a lot of the directions will steer us to tackle the issues of labour mobilization and delivery design efficiently. 

The collaborative working session was followed by a meeting with Dr. Sridhar Srikantiah at CARE India. The Lab approached this interaction with the hope of nailing down key challenge areas and tighten the scope of the project. A number of key insights were drawn from the conversation with Dr. Srikantiah, where he suggested that among other things, the two main functions of the partograph were to detect early foetal distress and early non-progressive labour. Any innovation that happens here ought to take these two factors into consideration and get under the skin of the problem. The partograph is a highly useful tool, but is often ignored in Bihar due to user-level and technological issues. The primary users of this tool either lack the graphical understanding to plot key vitals or find it to be too cumbersome or intimidating. Therefore, any amends that may be made need to address both of these issues. Another pertinent problem that is widely observed is the inability of the ANM to value the partograph as a life-saving device. Thus, the re-design of the partograph must incorporate elements that ensure the creation of value while sensitizing the primary user to its benefits. An exercise that may prove to be beneficial in understanding the credentials of the labour progression tool is to witness its usage in an environment where it is valued – perhaps, a resource-rich health care facility with highly trained staff. While it is of utmost importance to understand the crux of the problem that leads to the partograph’s disuse, its primary function still remains the detection of foetal distress. However, in the context of Bihar, the monitoring of foetal heart rate or distress is virtually absent. Thus, even if the tool is utilized to its full potential, what does the health care worker at the facility do when they don’t possess the skill to deal with the complication and need to refer the patient to a superior facility?

The expert consultation proved to be immensely helpful in gaining clarity on many queries and tightening the scope of the project. The Lab team is still looking for answers to many questions and would be grateful to any expert out there who is looking to advise and suggest.

Please get in touch with Rohan Jain at rohan.jain@cks.in or Divya Datta at divya.datta@cks.in 

 

 

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