Impact of a Multicomponent Intervention to Build Capacity of Public Health Workers to Make Algorithmic Diagnosis and Management of High-Risk Pregnancies in Uttar Pradesh, India: Protocol for a Matched-Control, Before-After, Quasi-Experimental Study With a Mixed Methods Design.

Background: In India, 20%-30% of pregnancies are high-risk, contributing to 75% of perinatal mortality and morbidity. An effective approach to reduce this mortality and morbidity is early identification, effective management, and timely referral of high-risk pregnancies (HRPs). The Integrated High-Risk Pregnancy Tracking and Management program aims to enhance the capacity of auxiliary nurse midwives (ANMs), medical officers (MOs), and specialist gynecologists by (1) providing algorithmic, color-coded, detailed yet simple HRP protocols, customized for each role; (2) offering live training; (3) delivering digital training and handholding; and (4) tracking management details for HRPs. Equipping health workers (HWs) with these interventions supports early identification, effective management, and timely referral of HRPs, ultimately improving primary care and enhancing satisfaction of mothers with HRPs. These interventions are implemented in the intervention arm for over 18 months. During this time, HWs of intervention and control arms will continue to receive routine training through state and national programs, and pregnant women of both arms have access to standard maternity services. Objective: At the system level, the program evaluates the impact on the knowledge and skills of HWs in diagnosing and managing HRPs. At the community level, it assesses translation of this knowledge into practice in terms of early diagnosis and protocol-based management of women with HRPs. Methods: The program will be implemented in 2 intervention (Sambhal and Shravasti) and 2 matched control districts (Budaun and Gonda) of Uttar Pradesh, on 6 HRPs. The study uses a "quasi-experimental, before-and-after design" with intervention and control arms. However, the impact of the program will be assessed only on 3 HRPs: moderate or severe anemia, pregnancy-induced hypertension, and antepartum hemorrhage. System-level impacts will be assessed through qualitative data from district officials, specialist gynecologists, MOs, and ANMs at baseline and end line. The community-level impacts will be assessed by comparing quantitative data from recently delivered women at baseline and end line. Community-level impact assessed using the difference-in-difference (DiD) technique. The study received ethical approval. Results: By November 2024, all the ANMs, MOs, specialist gynecologists, staff nurses, and community health officers in 2 intervention districts were trained on 6 HRP protocols, after the protocols were vetted by the Government of Uttar Pradesh. A digital learning tool and WhatsApp-based support system were introduced to facilitate continued learning and handholding of ANMs in managing HRPs and to address queries. Baseline data were collected from 2 arms during June-October 2024. Conclusions: This trial will provide valuable insights into the feasibility and effectiveness of the program at system and community levels in an emerging state like Uttar Pradesh. These insights can feed into capacitating HWs across all the districts and support expansion of the program to include additional HRPs, with significant potential for improving maternal and neonatal outcomes.