A cross sectional study to assess the utilization of Mother andChild Protection Card in High-Risk Pregnancy screening

Introduction

The Mother and Child Protection (MCP/Thayi) card as a service tool was introduced on 1st April 2010 through a collaborative effort of the Ministry of Women and Child Development and the Ministry of Health & Family Welfare, Government of India.The MCP card is a tool for informing and educating the mother and family on different aspects of maternal and child care. It helps in timely identification, referral and management of complications during pregnancy and child birth.¹ Maternal mortality is considered a key health indicator and the direct causes of maternal deaths are well known and largely preventable and treatable. All women need access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth. Access to health services is often dependent on a families’ or mother’s economic status and where they reside.² Identification of high-risk pregnancy through quality antenatal care such as appropriate laboratory investigations and referral services helps in achieving favorable maternal, obstetric and neonatal outcome.³ In addition, women identified to be at high risk need to be followed up at regular intervals through routine care by the health workers. The MCP card captures some of these key services delivered to the mother & child during antenatal, intra-natal & postnatal care and ensuring that the minimum package of services is delivered to the beneficiary. This study was taken up to assess whether the services such as screening for high risk conditions and recording of the same in Thayi card, is being carried out byhealth care workers. In this way, we can assess the proper utilization of the MCP card. Hence the present study was planned to assess the utilization of Thayi card in early diagnosis and treatment/referral of High Risk Pregnancies (HRP) and to assess the completeness of Thayi card entries.

Materials and methods

A hospital based cross-sectional study was conducted at a tertiary care hospital in Bengaluru during May to July 2019. In pilot study it was found that 70% of HRP cases and 90% non-HRP cases had undergone screening for all high risk conditions. With desired power of 80% and level of significance of 0.05, the sample size calculated was 130 (65+65) using Epi Info software.

130 MCP cards of postnatal mothers admitted at PNC and High Risk Pregnancy wards were randomly selected. A structured checklist was used to assess whether screening was done for the common high-risk conditions and the completeness of entries.

High-risk pregnancy (HRP) was classified based on the guidelines provided by Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) for identification of high-risk pregnancy by healthcare workers.³

Data analysis

Data collected was entered in SPSS Version 20.0 Descriptive statistics mean and standard deviation for continuous variables and frequencies, proportions for categorical variables were used to arrive at the following study results.

Results

The study participants were in the age range of 18 to 36 years, with mean of 24.95 (±4.18 SD) years. About 50 (38%) of the women were educated up to middle school. 74 (57%) of the women were housewife by occupation. 

Majority of the non-High Risk Pregnancy (HRP) mothers, 38 (58.4%) were primigravida, while 36 (55.4%) of the high risk pregnancy mothers were gravida 2.

Screening among non-High Risk Pregnancy cases

27 (41.5%) of the women were referred to this centre for delivery. 90.7% have had at least 4 regular ANC visits.

Table 3 shows percentage distribution of non-HRP cases who underwent screening during pregnancy. 62 out of 65 women were screened for anemia by testing Hemoglobin percent at every visit. 25 out of 65 non-HRP cases were found to have mild anemia in the first visit – with mean Hemoglobin of 10.45gm%. According to Thayi card entries, all mothers had been prescribed IFA tablets.At the time of delivery, 23 out of these 25 cases still had mild anemia (with mean Hb of 10.57gm%)

59 (90.7%) were screened for Pregnancy-Induced Hypertension (PIH) by recording blood pressure (BP) at every visit. Only 42 (64.61%) were screened for Gestational Diabetes Mellitus (GDM) through Oral Glucose Tolerance test (OGTT). All women screened for Rh incompatibility, multiple pregnancy and previous LSCS.

Screening among High-risk pregnancy cases

In this study, GDM was found to be the most common high risk condition among pregnant women, followed by PIH.

Among the 65 HRP cases, 46 had regular ANC at other centers. Among these 46 cases, 33 HRP were diagnosed early and treated. 13 HRP were diagnosed at the time of delivery and referred and 2 were newly diagnosed at this centre at the time of delivery as shown in Table 4.

The Thayi card entries in sections of family identification were complete in all cards; present pregnancy details were adequately completed in 97% of the cards.Only 71.5% of the cards had recorded complete details about antenatal care. 58 (44.6%) of the Thayi card had details filled in regarding immediate postnatal period, like birth weight, breastfeeding, etc. which can be filled by health workers during subsequent postnatal visits at home. 

Discussion

According to the National Health and Family Survey4 (2015-16), 80.3% of pregnant mothers had received Mother and Child Protection Card. Only 51.2% of mothers had at least 4 antenatal care visits.⁴

In contrast, the current study shows that 90.7% of non-HRP and 89.2% of HRP cases had at least 4 antenatal care visits. The major causes of maternal mortality according to the 2001-2003 SRS are hemorrhage, sepsis, hypertension, obstructed labor, abortion, and other medical conditions.

Anemia accounted for 19 % of total maternal deaths.5 It is not only one of the leading causes of death but also an aggravating factor in hemorrhage, sepsis and toxemia. In the present study, 95.3% of the non-HRP cases were tested for Hb % at every visit. Although IFA tablets were prescribed to all mothers, 23 out 25 mothers had mild anemia at the time of delivery. Among the high-risk pregnancies, 3 out of 10 severe anemia cases were diagnosed with at the time of delivery.This may be due to non-compliance to medication or due to lack of follow-up measures by health care workers during antenatal period.

Hypertensive disorders of pregnancy, particularly eclampsia, result in about 13% of all maternal deaths.⁵ In this study, 90.7% of non-HRP cases were screened for PIH by recording of blood pressure at every visit.⁷ out of 18 (38.9%) PIH were diagnosed at the time of delivery. In a study conducted in Puducherry to assess the prevalence of HRPs, it was found that the major cause of high risk condition was maternal age and PIH.⁶

Complications such as eclampsia (convulsions) in PIH can be prevented through careful monitoring of BP during pregnancy and treatment with antihypertensives on confirmation of diagnosis.

Gestational diabetes can occur at any stage of pregnancy but is more common in the second half. Among non-HRPs 64.61% of cases were screened for GDM through OGTT. Among HRPs, 5 out of 29 GDM cases were diagnosed at this centre at the time of delivery. Hyperglycemia during pregnancy can harm mother and the fetus, increasing risk of high BP, preeclampsia, miscarriage or stillbirth, birth defects and big baby.⁷ To prevent these complications, early diagnosis of GDM is important.

High-risk conditions such as Rh-incompatibility, multiple pregnancy and medical disorders (hypo/ hyperthyroidism) were tested for among all the mothers in this study.

71.5% of the cards had recorded complete details about Antenatal care. 58 (44.6%) of the Thayi card had details filled in regarding immediate postnatal period. A study done in West Bengal showed similar findings.⁸

Conclusion and recommendations

High risk conditions mainly, Gestational Diabetes Mellitus, Pregnancy Induced Hypertension and severe anemia are not being adequately screened at the peripheral health centers, due to which many of these cases are being detected only at the time of delivery at the tertiary care centre. The Mother and Child Protection card in spite of being issued to all mothers, is not being utilized to its complete and intended purpose of early detection of high risk pregnancy. Although the health care workers have successfully completed the initial identification and family details, entries pertaining to antenatal visits and the postnatal period remain incomplete. Due importance should be given by the health care worker in ensuring that high risk conditions in the mother are tested timely for to make further management or referral easier. It is crucial to record important neonatal outcome such as time of birth, birth weight, breastfeeding, etc. This can be entered into the Mother and Child Tracking System facilitate monitoring of delivery of health care services. Efforts should be made by ASHAs/ANMs to educate the mothers regarding importance of regular antenatal visits and utilize the Thayi card to test and record the findings from high risk pregnancy screening.