Barriers and facilitators in the identification and management of high-risk pregnancy: A scoping review of literature from India

Abstract

Objective: To identify the barriers and facilitators in the identification and management of high-risk pregnancies in India.

Methods: A systematic search of PubMed and Google Scholar was conducted from the inception of database till 27 March 2024, using predefined keywords and search terms, including “high risk pregnancy,” “identification,” “management,” “barrier,” “challenge,” “facilitator,” “enabler,” and “India,” combined using Boolean operators (AND/OR). Only studies published in English were included. Screening was conducted using Rayyan software. Data were extracted into structured tables and synthesized using a qualitative thematic approach to identify key barriers and facilitators in the identification and management of high-risk pregnancies.

Results: A total of 144 publications were identified. After screening based on eligibility criteria, 21 studies were finally included in the review. The included studies highlighted multiple barriers in the identification and management of high-risk pregnancies, including knowledge and awareness gaps among women and healthcare providers, inconsistent clinical management, and inadequate infrastructure. Financial constraints and cultural factors further added to the challenges. Women in tribal and rural areas faced additional barriers such as geographical isolation, lack of transportation, and limited access to specialized maternal healthcare. Facilitators identified in the literature included social support networks, the role of community health workers in bridging gaps between facilities and communities, and targeted education programs. Improved health literacy, standardized clinical protocols, and tailored management strategies were also reported as important facilitators.

Conclusions: This review highlights the importance of strengthening healthcare infrastructure and addressing the identified barriers comprehensively to improve maternal and fetal outcomes. Enhancing awareness, empowering community health workers, and adopting standardized management protocols can contribute significantly to better identification and management of high-risk pregnancies in India.

Keywords

Barriers / Facilitators / High-risk pregnancy / Healthcare / India

Conflict of interest statement

The authors declare no conflicts of interest.

Funding

The study received no funding.

Authors’ contributions

Sakshi Verma, Mukti Khetan, Rakhi Dhankhar, Ramesh Kumar Huda, and Ramesh Kumar Sangwan participated in the literature search, interpretation of the articles and review of the manuscript. All the authors have read and approved the final version of the manuscript.

Publisher’ s Note

The Publisher of the Journal remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

[1] Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: A systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375(9726): 1609-1623. doi: 10.1016/S0140-6736(10)60518-1.

[2] National Health Mission, Ministry of Health and Family Welfare, Government of India. Guidance note - extended PMSMA for tracking high-risk pregnancies (HRPs). New Delhi: National Health Mission, Ministry of Health and Family Welfare, Government of India; 2024. [Online] Available from: https://nhm.gov.in/New_Update-2022-23/MH/GUIDELINES-%20MH/Guidance_Note-Extended_PMSMA_for_ tracking_HRPs.pdf [Accessed 20th November 2024].

[3] Office of the Registrar General & Census Commissioner, India. Sample Registration System (SRS)-statistical report 2020. New Delhi: Ministry of Home Affairs, Government of India; 2020. [Online] Available from:https://censusindia.gov.in/nada/index.php/catalog/44376 [Accessed 20th November 2024].

[4] World Health Organization. Maternal mortality. Geneva: World Health Organization; 2024. [Online] Available from:https://www.who.int/news-room/fact-sheets/detail/maternal-mortality [Accessed 20th November 2024].

[5] Ministry of Health and Family Welfare, Government of India. High-risk conditions in pregnancy:PMSMA operational guidance. New Delhi: Ministry of Health and Family Welfare, Government of India; 2016. [Online] Available from:https://pmsma.mohfw.gov.in/wp-content/uploads/2016/10/High-Risk-Conditions-in-preg-modified-Final.pdf [Accessed 20th November 2024].

[6] Kragelund Nielsen K, Vildekilde T, Kapur A, Damm P, Seshiah V, Bygbjerg IC. “If I don’t eat enough, I won’t be healthy”: Women’s experiences with gestational diabetes mellitus treatment in rural and urban South India. ìnt J Environ Res Public Health 2020; 17(9): 3062. doi: 10.3390/ijerph17093062.

[7] Öhman SG, Saltvedt S, Grunewald C, Waldenström U. Does fetal screening affect women's worries about the health of their baby? A randomized controlled trial of ultrasound screening for Down's syndrome versus routine ultrasound screening. Acta Obstet Gynecol Scand 2004; 83(7): 634-640. doi: 10.1111/j.0001-6349.20O4.0O462.x.

[8] Dalal S, Nagar R, Hegde R, Vaishnav S, Abdullah H, Kasper J. Referral care for high-risk pregnant women in rural Rajasthan, India: A qualitative analysis of barriers and facilitators. BMC Pregnancy Childbirth 2022; 22(1): 310. doi: 10.1186/s12884-022-04601-6.

[9] Nagraj S, Hinton L, Praveen D, Kennedy S, Norton R, Hirst J. Women's and healthcare providers’ perceptions of long-term complications associated with hypertension and diabetes in pregnancy: A qualitative study. BJOG 2019; 126: 34-42. doi: 10.1111/1471-0528.15847.

[10] Majella MG, Sarveswaran G, Krishnamoorthy Y, Sivaranjini K, Arikrishnan K, Kumar SG. A longitudinal study on high-risk pregnancy and its outcome among antenatal women attending rural primary health centre in Puducherry, South India. J Educ Health Promot 2019; 8: 12. doi: 10.4103/jehp.jehp_144_18.

[11] Kuppusamy P, Prusty RK, Kale DP. High-risk pregnancy in India: Prevalence and contributing risk factors - A national survey-based analysis. J Glob Health 2023; 13: 04116. doi: 10.7189/jogh.13.04116.

[12] Prajapati AK, Kumar V, Soni K, Singh NP, Jain PK. Prevalence of high-risk pregnancy among pregnant women enrolled under Pradhan Mantri Surakshit Matritva Abhiyan in government health facilities of district Etawah, Uttar Pradesh: A cross-sectional study. J Family Med Prim Care 2022; 11(5): 1876-1882. doi: 10.4103/jfmpc.jfmpc_1636_21.

[13] Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann intern Med 2018; 169(7): 467-473. doi: 10.7326/M18-0850.

[14] Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008; 8: 45. doi: 10.1186/1471-2288-8-45.

[15] Madankar M, Kakade N, Basa L, Sabri B. Exploring maternal and child health among tribal communities in India: A life course perspective. Glob J Health Sci 2024; 16(2): 31. doi: 10.5539/gjhs.v16n2p31.

[16] Vidler M, Ramadurg U, Charantimath U, Katageri G, Karadiguddi C, Sawchuck D, et al. Utilization of maternal health care services and their determinants in Karnataka State, India. Reprod Health 2016; 13: 55. doi: 10.1186/s12978-016-0138-8.

[17] Chebrolu P, Chalem A, Ponticiello M, Broderick K, Vaidyanathan A, Lorenc R, et al. A community health worker-led program to improve access to gestational diabetes screening in urban slums of Pune, India: Results from a mixed methods study. PLOS Glob Public Health 2023; 3(10): e0001622. doi: 10.1371/journal.pgph.0001622.

[18] Nagar T, Sharma D, Choudhary M, Khoiwal S, Nagar RP, Pandita A. The role of uterine and umbilical arterial Doppler in high-risk pregnancy: A prospective observational study from India. Clin Med Insights Reprod Health 2015; 9: CMRH-S24048. doi: 10.4137/CMRH.S24048.

[19] Reddy KM, Ravula SR, Palakollu S, Betha K. Prevalence of preterm birth and perinatal outcome: A rural tertiary teaching hospital-based study. J Family Med Prim Care 2022; 11(7): 3909-3914. doi: 10.4103/jfmpc.jfmpc_1440_21.

[20] Kapoor D, Gupta Y, Desai A, Praveen D, Joshi R, Rozati R, et al. Lifestyle intervention programme for Indian women with history of gestational diabetes mellitus. Glob Health Epidemiol Genomics 2019; 4: e1. doi: 10.1017/gheg.2018.18.

[21] Jadhao AR, Gawade MD, Ughade SN. Outcome of pregnancy among high-risk pregnancies in rural area of Nagpur, Maharashtra, Central India. Int J Community Med Public Health 2017; 4: 628-633. doi: 10.18203/2394-6040.ijcmph20170443.

[22] Damor A, Mehta S. Knowledge and attitude of antenatal mother regarding high-risk pregnancy in a tertiary care hospital in Western India. Parity 2021; 12(1): 11-14.

[23] Naik S, Kumar S, Rani A, Patil S, Voorkara U, Kamath VS. Interventional challenges in non-tubal ectopic pregnancy. J Family Reprod Health 2022; 16(1): 78-85. doi: 10.18502/jfrh.v16i1.8597.

[24] Nilofer AR, Raju VS, Dakshayini BR, Zaki SA. Screening in high-risk group of gestational diabetes mellitus with its maternal and fetal outcomes. Indian J Endocrinol Metab 2012; 16(Suppl 1): S74-S78. doi: 10.4103/2230-8210.94268.

[25] Bansal P, Verma A, Bansal A, Verma D. Prenatal risk score in high-risk pregnancy cases and maternal outcome: A study from South India. Indian J Obstet Gynecol Res 2016; 3(4): 356-360. doi: 10.18231/2394-2754.2016.0013.

[26] Ghosh R, Oza H, Meel S. Third trimester Doppler ultrasound as prediction of obstetric outcome in high-risk pregnancy, Gujarat, India. Int J Reprod Contracept Obstet Gynecol 2017; 6: 3519-3523. doi: 10.18203/2320-1770.ijrcog20173475.

[27] Contractor SQ, Das A, Dasgupta J, Van Belle S. Beyond the template: The needs of tribal women and their experiences with maternity services in Odisha, India. Int J Equity Health 2018; 17(1): 134. doi: 10.1186/s12939-018-0850-9.

[28] Dwarkanath P, Muhihi A, Sudfeld CR, Wylie BJ, Wang M, Perumal N, et al. Two randomized trials of low-dose calcium supplementation in pregnancy. N Engl J Med 2024; 390(2): 143-153. doi: 10.1056/NEJMoa2307212.

[29] Das MK, Arora NK, Dalpath SK, Kumar S, Kumar AP, Khanna A, et al. Improving quality of care for pregnancy, perinatal and newborn care at district and sub-district public health facilities in three districts of Haryana, India: An implementation study. PLoS One 2021; 16(7): e0254781. doi: 10.1371/journal.pone.0254781.

[30] Seema P, Sangeetha S, Phukan P. A retrospective study on high-risk pregnancy and their outcome in a teaching hospital in South India. Medica Innovatica 2014; 3(1): 122-126.

[31] Sagili H, Pramya N, Prabhu K, Mascarenhas M, Reddi Rani P. Are teenage pregnancies at high risk? A comparison study in a developing country. Arch Gynecol Obstet 2012; 285(3): 573-577. doi: 10.1007/s00404-011-1987-6.