Changes in Knowledge and Management Skills of ANMs To Screen, Manage and Refer Pregnant Women with Five High-Risk Conditions: Results from A Pre-Post-Training and A Six-Month Follow-Up Assessment in Telangana, India

Background: Auxiliary Nurse Midwives (ANMs) are key providers of maternal, newborn and child health services, and are the first point of contact for high-risk pregnancies (HRPs). In partnership with Government of Telangana, under Integrated HighRisk Pregnancy Tracking and Management (IHRPTM) program, all the ANMs of the state were trained to screen and manage five HRPs: anaemia; gestational diabetes-GD; pregnancy induced hypertension-PIH; ante-partum haemorrhage-APH; and quality-Antenatal care (ANC). Assessed pre- and post-class-room and six months after class-room training capabilities of ANMs. Methods: Immediate-gains through class-room-training and six-months after class-room training knowledge/skills from 7,553 and 529 ANMs respectively, were assessed using a checklist of 15 questions per HRP-condition. Also obtained, qualitative insights about class-room training. Results: Due to class-room training, there was 8-17% improvement in immediate-gain in knowledge/skills to diagnose, manage/ refer women with HRPs. Improvement in mean correct responses (out of 15 questions per-HRP) between pre-and-post-training assessments was maximum for GD: mean 7.6 at pre-training, improved to 10.2 by post-training; APH: 9.7 to 11.7; qualityANC: 10.2 to 11.7; PIH: 9.3 to 10.7; and anaemia:11.0 to 12.3. Gain in knowledge/skills as Cohen’s-d effect-size was large (0.7-0.8) for GD, APH, quality-ANC, PIH, and medium (0.6) for anaemia, as pre-training knowledge/skills was already better for anaemia. Mean gain per HRP was more than three questions in four districts and < 0.5 questions in two districts. Mean gain did not differ much according to age, work experience and training-time. As compared to pre-training level, retention of knowledge/skills, six-to-nine months after class-room training dropped substantially (Cohen’s-d effect-size≤ 0.2) for all HRPs, except for anaemia (d=0.4). Training gave them confidence to stabilize emergency cases at sub-centre level before referring to higher facility! Conclusion: Through IHRPTM’s protocol-based training: screening, management/referral of HRPs by ANMs is feasible. Standardized-training supplemented with handholding leads to provision of obstetric care.