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The feasibility of task-sharing the identification, emergency treatment, and referral for women with… Charanthimath, Umesh; Vidler, Marianne; Katageri, Geetanjali; Ramadurg, Umesh; Karadiguddi, Chandrashekhar; Kavi, Avinash; Joshi, Anjali; Mungarwadi, Geetanjali; Bannale, Sheshidhar; Rakaraddi, Sangamesh; Sawchuck, Diane; Qureshi, Rahat; Sharma, Sumedha; Payne, Beth A; von Dadelszen, Peter; Derman, Richard; Magee, Laura A; Goudar, Shivaprasad; Mallapur, Ashalata; Bellad, Mrutyunjaya; Bhutta, Zulfiqar; Naik, Sheela; Mulla, Anis; Kamle, Namdev; Dhamanekar, Vaibhav; Drebit, Sharla K; Kariya, Chirag; Lee, Tang; Li, Jing; Lui, Mansun; Khowaja, Asif R; Tu, Domena K; Revankar, Amit Jun 22, 2018

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RESEARCH Open AccessThe feasibility of task-sharing theidentification, emergency treatment, andreferral for women with pre-eclampsia bycommunity health workers in IndiaUmesh Charanthimath1, Marianne Vidler2, Geetanjali Katageri3*, Umesh Ramadurg4, Chandrashekhar Karadiguddi1,Avinash Kavi1, Anjali Joshi1, Geetanjali Mungarwadi1, Sheshidhar Bannale5, Sangamesh Rakaraddi6,Diane Sawchuck7, Rahat Qureshi8, Sumedha Sharma2, Beth A. Payne2, Peter von Dadelszen9, Richard Derman10,Laura A. Magee9, Shivaprasad Goudar1, Ashalata Mallapur3, Mrutyunjaya Bellad1, and the Community LevelInterventions for Pre-eclampsia (CLIP) India Feasibility Working Group, Zulfiqar Bhutta, Sheela Naik, Anis Mulla,Namdev Kamle, Vaibhav Dhamanekar, Sharla K. Drebit, Chirag Kariya, Tang Lee, Jing Li, Mansun Lui,Asif R. Khowaja, Domena K. Tu and Amit RevankarFrom 2nd International Conference on Maternal and Newborn Health: Translating Research Evidence to PracticeBelagavi, India. 26-27 March 2018AbstractBackground: Hypertensive disorders are the second highest direct obstetric cause of maternal death afterhaemorrhage, accounting for 14% of maternal deaths globally. Pregnancy hypertension contributes to maternaldeaths, particularly in low- and middle-income countries, due to a scarcity of doctors providing evidence-basedemergency obstetric care. Task-sharing some obstetric responsibilities may help to reduce the mortality rates. Thisstudy was conducted to assess acceptability by the community and other healthcare providers, for task-sharing bycommunity health workers (CHW) in the identification and initial care in hypertensive disorders in pregnancy.Methods: This study was conducted in two districts of Karnataka state in south India. A total of 14 focus group discussionswere convened with various community representatives: women of reproductive age (N = 6), male decision-makers (N = 2),female decision-makers (N = 3), and community leaders (N = 3). One-to-one interviews were held with medical officers(N = 2), private healthcare OBGYN specialists (N = 2), senior health administrators (N = 2), Taluka (county) health officers(N = 2), and obstetricians (N = 4). All data collection was facilitated by local researchers familiar with the setting andlanguage. Data were subsequently transcribed, translated and analysed thematically using NVivo 10 software.(Continued on next page)* Correspondence: geetanjali_mk@yahoo.co.in3Department of Obstetrics and Gynaecology, S Nijalingappa Medical College,Bagalkot, Karnataka, IndiaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Charanthimath et al. Reproductive Health 2018, 15(Suppl 1):101https://doi.org/10.1186/s12978-018-0532-5(Continued from previous page)Results: There was strong community support for home visits by CHW to measure the blood pressure of pregnant women;however, respondents were concerned about their knowledge, training and effectiveness. The treatment with oralantihypertensive agents and magnesium sulphate in emergencies was accepted by community representatives but medicalpractitioners and health administrators had reservations, and insisted on emergency transport to a higher facility. The mostimportant barriers for task-sharing were concerns regarding insufficient training, limited availability of medications, thequestionable validity of blood pressure devices, and the ability of CHW to correctly diagnose and intervene in cases ofhypertensive disorders of pregnancy.Conclusion: Task-sharing to community-based health workers has potential to facilitate early diagnosis of the hypertensivedisorders of pregnancy and assist in the provision of emergency care. We identified some facilitators and barriers forsuccessful task-sharing of emergency obstetric care aimed at reducing mortality and morbidity due to hypertensivedisorders of pregnancy.Keywords: Task-sharing, Community health workers, Pre-eclampsia, Blood pressure, Antihypertensives, Magnesium sulphateBackgroundGlobally, maternal mortality has fallen by 45% over thepast two decades [1]. Since 1990, India has made signifi-cant progress in reducing the maternal mortality ratio by68.7%. The latest estimate calculated by the World Bankwas 174 per 100,000 live births. Furthermore, there hasbeen a substantial increase in accessing antenatal careand delivery in hospital [2, 3]. Nevertheless, India ac-counts for 15% of global maternal deaths annually [4].Hypertensive disorders of pregnancy (HDP) are someof the main causes of maternal death globally, and, inIndia, are estimated to cause 7.1% of maternal mortality.Symptomatic HDP, including pre-eclampsia, gestationalhypertension and chronic hypertension, often occur latein pregnancy. Repeated blood pressure (BP) monitoringis advised in pregnancy for early detection of hyperten-sion which would optimise outcomes [5]. Women withHDP require enhanced surveillance by appropriatelytrained healthcare professionals providing evidence-based care (including clinical, laboratory and ultrasoundassessments) to guide timing of delivery along with initi-ation of life-saving therapies (use of oral antihypertensiveand magnesium sulphate).Targets for many health indicators are not met as ex-pected and hence it is important to explore means ofstrengthening the health system. One of the barriers toproviding universal coverage of health services is the inad-equacies of health care professionals, especially in manylow and middle Income countries (LMICs) [6]. In 2005,the World Health Organization (WHO) estimated thatmore than 90% percent of maternal deaths are avoidablewith moderate levels of health care and task-sharing orshifting. Task-shifting, as defined by the WHO, is when“specific tasks are moved, where appropriate, from highlyqualified health workers to health workers with shortertraining and fewer qualifications in order to make moreefficient use of available resources for health”. Task-sharing is a strategy in which health care workers take onadditional duties with sufficient training and supervision[7]. Sharing of tasks from health professionals to commu-nity health workers (CHW) can improve access to careand optimize the use of limited human resources in manyresource-poor settings [8]. “Task-sharing” the serial meas-urement of blood pressure, risk stratification, and initi-ation of both life-saving therapies and referral, may beeffective in reducing HDP associated morbidity and mor-tality and serve to bridge the gap of health service deliveryto women residing in rural India. This study aims to betterunderstand the facilitators and barriers to implementationof this strategy in Karnataka, India.Study areaThis study was conducted in Belagavi and Bagalkote dis-tricts of rural Karnataka, in South India (Fig. 1). Thehealthcare infrastructures of Karnataka are inadequate forserving the rural and remote areas where there are healthworker shortages and large distances from health facilities[3]. The National Rural Health Mission (NRHM) has insti-tuted community health worker programmes throughoutthe region to increase service utilisation in the hope of im-proving health outcomes [3]. For study site characteristics,see Table 1.Community health workersCommunity health workers in India include AuxiliaryNurse Midwives (ANM) and Accredited Social HealthActivists (ASHA). ANMs provide care at the sub-centre,covering a population of 3000 to 5000 [9]. ANMs aretrained in various topics related to maternal and childhealth, such as the provision of antenatal care, skilled at-tendance at delivery, postpartum care, and the manage-ment of pregnancy complications. NRHM guidelines from2012 are used to train and authorise ANMs to administer50% magnesium sulphate for cases of severe pre-eclampsiaand eclampsia [10]. In 2005, the Government of Indialaunched the ASHA programme to bring door-to-doorCharanthimath et al. Reproductive Health 2018, 15(Suppl 1):101 Page 78 of 126health services to rural areas. ASHAs are females be-tween the ages of 25 to 45 years, with an educationequivalent to grade eight or higher, who are selectedby the local government to serve in their residentialareas. Each ASHA extends her services to a popula-tion of about 1000 individuals. ASHAs are trained toprovide health care advice in the homes (provision ofbasic maternity care, child care and nutrition counselling),create community health awareness, conducting socialmobilisation, treatment of infections, maintenance ofhealth records and increase utilization of existinghealth services. ASHAs are trained in district trainingcentres for a period of 4 weeks with the upgrading ofknowledge being done by the Lady Health Visitorsand Medical Officers of the respective primary healthcentres. ASHAs have been deemed to bridge the gapbetween the community, ANMs, primary health cen-tres, and referral facilities [11].Fig. 1 Map of the study siteTable 1 Site characteristicsIndia South India KarnatakaSite characteristicsPopulation 1028,610,328a 61095297d# States 35 5 (30 Districts)Dominant religion Hinduc Hinduc HinducWomen’s literacy 55%c 68%c 58%cEmployment 36% currently employedc 41% currently employedc 40% currently employedcRural /Urban 32% urbana 39% urbandFertility rate 2.8c 1.9c 2.1cMaternal mortality ratio 178 per 100,000 live birthsb 105 per 100,000 live birthsa 144 per 100,000 live birthsaMaternal health care utilizationANY ANC 76.4%c 94%c 89%c≥ 4 ANC 48%c 89%c (3+) 76%c(3+)Facility delivery (%) 39%c 79%c 65%cSkilled attendant at delivery 47%c 84%c 70%caWorld Health Organization Country Profile: India 2012bOffice of the Registrar of India, 2013cDemographic Health Survey 2013dRural Health Statistics in India 2012Charanthimath et al. Reproductive Health 2018, 15(Suppl 1):101 Page 79 of 126MethodsThis qualitative study was conducted as part of a largercountry assessment in the preparation of a cluster ran-domized control trial, the Community Level Interven-tions for Pre-eclampsia (CLIP) Trial (NCT01911494).This study consisted of focus group discussions(FGD) and in-depth interviews (IDI). FGDs werepreferred to encourage group dialogue from all par-ticipants. Researchers selected various participantgroups including community leaders, male and fe-male decision-makers and women of reproductiveage. The community leaders are representatives fromthe local government or other members who areheld in high esteem by the community. They play animportant role in decision-making, affecting their re-spective locality. The male and female decision-makers were the family members who took responsi-bility for healthcare related decisions for the family.In-depth interviews were conducted with medical officers,senior health administrators and obstetricians from bothprivate and government institutions. These groups werechosen to represent the spectrum of the communities’ andhealth care providers’ views (Table 2). Fourteen FGDs andtwelve IDIs were conducted between January andMarch 2013. Data saturation was noted after theseinterviews and FGDs.Local clinicians and researchers with the knowledgeof cultural nuances and dynamics, with no knownassociation with the respondents, were chosen andtrained for qualitative study methods to facilitate in-terviews and focus group discussions. Focus groupand interview guides were developed for the studyand were semi-structured to promote a natural dis-cussion progression. The FGDs were conducted in thelocal language, Kannada, to best promote interactionwith participants and obtain the richest data. AllFGDs were facilitated by one researcher and assistedby a second researcher who recorded field notes in-cluding non-verbal communication. IDIs were con-ducted in English. All FGDs and IDIs were audiorecorded. The first FGD incorporating 55 women ofreproductive age was conducted as a pilot to sensitisethe local research team regarding effective ways ofdata collection in qualitative research.The remaining stakeholder groups were convenedseparately and comprised a varied number of partici-pants (between seven and eighteen). Participants wereidentified through local health system networks ofASHA and ANMs. Male and female decision-makersin the family were approached for participation whenthey accompanied women of reproductive age to localhealth centres.All audio recordings were later transcribed verbatim andtranslated into English for analysis, with the incorporationof field notes. Data were analysed using NVivo 10software. Transcripts were coded by one rater (MV),Table 2 Characteristics of focus group participants# Stakeholder Group District Education status Total ParticipantsA B C D1 Community Leaders Bagalkote 0 6 1 0 72 Community Leaders Bagalkote 1 8 1 0 103 Community Leaders Belagavi – – – 10 104 Male Decision-Makers Bagalkote 3 3 2 0 85 Male Decision-Makers Belagavi 0 9 2 0 116 Female Decision-Makers Bagalkote 8 2 0 0 107 Female Decision-Makers Belagavi 12 4 2 0 188 Female Decision-Makers Belagavi 11 2 0 0 139 Women of Reproductive Age Belagavi – – – 55 5510 Women of Reproductive Age Bagalkote 0 15 1 0 1611 Women of Reproductive Age Bagalkote 3 8 3 0 1412 Women of Reproductive Age Belagavi 0 15 2 0 1713 Women of Reproductive Age Belagavi 3 8 3 0 1414 Women of Reproductive Age Belagavi 0 10 6 0 1641 (18.7%) 90 (41.1%) 23 (10.5%) 65 (29.68%)TOTAL 219A – IlliterateB- Primary/Secondary SchoolingC – Pre university / UniversityD – Don’t KnowCharanthimath et al. Reproductive Health 2018, 15(Suppl 1):101 Page 80 of 126after which all coded transcripts and themes werecross-checked by the local research team to resolveor clarify any misinterpretation. Using deductive rea-soning, results were then grouped into predeterminedkey themes. During analysis, inductive reasoning wasused to incorporate new and unexpected ideas. Thisproduced a comprehensive analysis structure to reflectthe richness and variety of responses.ResultsParticipants in the community leaders FGD had di-verse backgrounds: some were illiterate with no for-mal schooling while others had completed universityeducation or college. They ranged in age between 24and 51 years. Male decision-makers were aged be-tween 18 to 57 years; 85% were illiterate, most identi-fied themselves as labourers and farmers and wereoften the husband or father/father-in-law of the preg-nant woman. Female decision-makers were 28 to65 years of age, most had no formal schooling andcould not read or write (71%), and the majority iden-tified themselves as housewives and mothers-in-law.Women of reproductive age had an average age of23 years, nearly all of them were housewives (91%),most were pregnant at the time of data collection(79%), and over half (66%) had at least one childunder the age of five.Two IDIs were conducted with medical officers, eachresponsible for one primary health centre which servesas the entry point to the health system. Senior districthealth system administrators (N = 4) were invited to par-ticipate, as they coordinate reproductive health servicesthroughout the district and have a unique perspective.They are actively involved in the implementation of re-productive and child health services by local, state andcentral government. Three were obstetricians and gynae-cologists; and one, a general surgeon.Two obstetricians from secondary and four from tertiaryfacilities serving in the private and government sectors, withvarying experience and training were interviewed. Theyprovided specialist care to women coming from the studyarea. For more participant details, see Table 2 and Table 3.Home blood pressure monitoring visits by ASHA workersMost community leaders agreed that ASHAs couldsafely measure BP in the home; however, some had con-cerns regarding their knowledge, education, effective-ness, training, experience and supervision. Overall, therewas an acceptance of ASHAs being tasked with themeasurement of BP at home once they were appropri-ately trained.“In the future, ASHAs might do if they are welleducated and trained about BP measurement”(Community Leader)“A life is dependent on appropriate BP measurement.How will you come to know that ASHAs haveunderstood? It is not possible. Is there any exam?”(Community Leader)Nearly all decision-makers agreed that a shift of thisactivity to ASHAs would be acceptable in their commu-nities. In contrast, one group of male decision-makersstrongly opposed this suggestion and argued that theywould be unable to judge if an ASHA had not beenproperly trained and the possibility of a misdiagnosiswas high.“Because even a MBBS qualified person who hasstudied for 4-5 years cannot do it, then how can anSSLC graduate do...if training would suffice theneverybody would have taken training”(Male Decision-Maker)Table 3 Characteristics of In-depth Interview participants# Stakeholder Training Level of Care Pregnancies/ Week1 Medical Officer MBBS Primary 50–602 Medical Officer MBBS Primary 10–153 Private Practitioner MBBS, MD in OBG Tertiary 40–504 Private Practitioner MBBS, MD in OBG Tertiary 280–3005 Senior Health Administrator MS General Surgery NA NA6 Senior Health Administrator MBBS & Diploma in OBG NA NA7 Taluka Health Officer MBBS, Diploma in OBG Secondary 200–2508 Taluka Health Officer MBBS & Diploma OBG Secondary 50–609 Obstetrician MBBS, MD in OBG Tertiary 25010 Obstetrician MBBS, DGO, MD in OBG Tertiary 200–30011 Obstetrician MBBS, Diploma in OBG Tertiary 4512 Obstetrician MBBS, MD in OBG Tertiary –Charanthimath et al. Reproductive Health 2018, 15(Suppl 1):101 Page 81 of 126Two Medical officers and three obstetricians expressedconfidence in ASHAs measuring BP if they were pro-vided with a reliable easy-to-use digital device. Someobstetricians who were already using a digital appar-atus spoke about the problems associated with thesedevices, such as erroneous readings, battery life andexpressed concern whether ASHAs would be able toovercome these challenges. These practitioners didnot comment on the technique required to measureaccurate BP. They appeared to feel strongly that thisjob requires experience and qualification; and less-educated or under-trained workers like ASHAs couldnot do it effectively.Most Women of reproductive age were happy toaccept ASHAs for recording blood pressure at home.Health administrators did not support BP measurementby ASHAs. Private practitioners were not familiar withthe capabilities of the ASHA workers and had no opin-ion or suggestions to make.Initiation of treatment with oral antihypertensive byANMsAll community leaders and male decision maker sup-ported treatment by ANMs except two, who stronglyopposed treatment. The remaining participants sup-ported this task-sharing by ANMs, but stressed theneed for swift transport to the higher facility for furthermanagement. These respondents believed that ANMs hadbeen adequately trained to provide oral emergency treat-ment but there should be someone who takes the respon-sibility for training and supervision.“In my opinion, not all ANMs are experiencedespecially newly appointed ones. Some ANMs areexperienced, such ANMs should be designated to givethe medicines when the doctor is not there”.(Community Leader)“No……No…. Who will do that? They cannot givetreatment in an emergency”(Male Decision-Maker)The women of reproductive age were ready to acceptmedications from ANMs in emergency situations.Some obstetricians accepted the new role for theANM; however, some voiced concerns regarding theirability to manage side-effects resulting from the useof the medication. All obstetricians emphasised theimportance of proper training and urgent referral.“I don’t support this. Methyldopa causes sedation sobefore giving that drug we convince them, we counselthem. So the same thing is done by ANM they willhave to be well educated of everything” (OBGYNtertiary care hospital)Administration of magnesium sulphate loading dose byANMsCommunity leaders accepted that with proper training,ANMs could be permitted to administer magnesiumsulphate treatment in urgent cases. They expressed thatsuch an emergency intervention might increase the like-lihood of a woman’s survival before she reaches a refer-ral centre. Female decision-makers and women ofreproductive age expressed strong acceptance for receiv-ing treatment from ANMs and expressed faith in care byANMs. Obstetricians supported the administration of aloading dose of magnesium sulphate as it is safe inter-vention, needs no extensive monitoring and believedthat it would reduce the complications associated withpreeclampsia and eclampsia. All groups were in favourof giving magnesium sulphate but stressed appropriatetraining. A few mentioned that ANMs should contact amedical officer before giving the treatment and arrangefor transport. Health administrators emphasised the im-portance of ensuring uninterrupted availability of drugsand proper training prior to task-sharing.Availability of transport and acceptability of referralFGD and interview participants emphasized that treat-ment should not be continued at the community level andwoman needed to be referred from the community tohigher referral centre. With the availability of robust freeambulance services by the state government in this local-ity (free ambulance service on dialling 108), transport wasnot seen as much of a challenge. Women of reproductiveage claimed that they would refuse emergency treatmentand referral if a family member was unavailable to decideon her behalf or accompany her.DiscussionThe study aimed to identify facilitators and barriers fortask-sharing in the identification and emergency treatmentof pregnant women with HDP (Fig. 2). Enhanced ante-natal and postnatal surveillance at home by the ASHAworkers with measurement of BP and when indicated, ad-ministration of oral antihypertensives and intramuscularmagnesium sulphate by the ANM prior to referral formthe key components of the CLIP (NCT01911494) Trial.There was strong community support for home visitsby CHW to measure the blood pressure of pregnantwomen; however, respondents were concerned abouttheir knowledge, training and effectiveness. The treat-ment with oral antihypertensive agents and magnesiumsulphate in emergencies was accepted by communityrepresentatives but medical practitioners and health ad-ministrators had reservations, and insisted on emergencyCharanthimath et al. Reproductive Health 2018, 15(Suppl 1):101 Page 82 of 126transport to a higher facility. The most important bar-riers for task-sharing were concerns regarding insuffi-cient training, limited availability of medications, thequestionable validity of blood pressure devices, and theability of CHW to correctly diagnose and intervene incases of hypertensive disorders of pregnancy.Task-sharing is a process which has been proposed toovercome manpower shortages faced by the health caresystem. This shifts the tasks to “lay workers” or CHWwho are not formally trained in the task assigned tothem but can be expected to carry out the responsibil-ities after some training and with supervision [8]. Thiscauses an improvement in early diagnosis and treatmentof emergency conditions and is cost-effective [12, 13].Task-sharing could improve access to health workers inresource-constrained settings and possibly have animpact on reducing mortality and morbidity [8].More commonly, tasks expected from the “lay workers”are related to preventive and health promotional activities.The importance of “Community Embeddedness” of thelay worker has been stressed [14]. Women of reproductiveage and decision makers in this study favoured home visitsby the ASHA for BP monitoring. This has also been notedby other studies that found that this could be because itwould reduce visits to the hospital for measurement of BPwhich were missed at times due to lack of knowledge,poor transportation facilities, competing responsibilitiesand commitments, loss of daily wages due to the visit andfinancial constraints [15]. People tend to preferably seekhealth care if the facility is close by rather than at a greatdistance [16]. Pregnant women and female decision-makers also supported this as the ASHA belongs to theirlocality and lives in close proximity; and could be helpfulduring emergencies, as other studies have reported [12].The ASHA workers are not trained in measuring BPor other clinical examinations but are capable of identi-fying the danger signs of HDP [11]. The use of CHW forthe measurement of BP in chronic hypertension hasbeen reported in several studies, with favourable out-comes in the participants [17, 18]. A study done in northIndia demonstrated that ASHA workers could be trainedto measure BP and concluded that they could be usedfor monitoring hypertension antenatally [19].Some obstetricians raised concern regarding the useof an oscillometric digital apparatus, as well as valid-ation and errors in recording. It is however importantthat the BP devices be validated for the purpose theyare intended. The Microlife 3AS 1–2 semi-automatichandheld BP device, used by the ASHAs in the CLIPTrial has been validated for use in pregnant womenincluding those with pre-eclampsia. This handheld de-vice can be used effectively by unskilled personnelafter minimal training [20, 21]. The concerns abouterrors in the BP readings can be substantially reducedby proper ongoing training sessions, validation andcalibration of the device [22, 23].Fig. 2 Pictorial representations of facilitators and barriers for task-sharingCharanthimath et al. Reproductive Health 2018, 15(Suppl 1):101 Page 83 of 126WHO recognises that lay workers are more likely to bemotivated if their tasks include curative aspects along withthe preventive [8]. The ANMs were expected to adminis-ter methyldopa orally if the woman was found to have se-vere hypertension, in addition to magnesium sulphateinjection intramuscularly in certain clinical scenarios,prior to referral. The ANMs are familiar with many drugs,Intravenous fluids, and injectable medications and vac-cines [10]. Women of reproductive age and decisionmakers voiced trust in the ANM for treating women withHDP using oral antihypertensives and referring them tohigher centres for further management. Since the antihy-pertensive in question here is in tablet form, skill develop-ment is not needed for administration.Task-sharing in the provision of healthcare is not anew concept and has been implemented widely for themanagement of various conditions such as malaria, HIV,and tuberculosis (TB) [24–28]. Lewin et al. found thatthe use of lay health workers improved the uptake ofimmunization and breastfeeding practices; and also de-creased morbidity and mortality from common child-hood illnesses and additionally led to improved TBtreatment outcomes [29].Some obstetricians expressed concern about the ANMgiving methyldopa due to concerns of adverse effects;however, it is widely recommended for use in HDP [30].Methyldopa is found to be safe in HDP when used toprevent maternal and foetal complications. Though itmay sometimes cause sedation or drowsiness, there isno evidence of acute complications in HDP with a load-ing dose of methyldopa [31–33].The other task expected of the ANMs was the admin-istration of magnesium sulphate injection intramuscu-larly before referral. The Magpie trial revealed thatadministration of magnesium sulphate leads to a 58% re-duction in the risk of convulsions and its safety is wellestablished [34, 35]. Magnesium sulphate is on theWHO Essential Medicines List for the use in severe pre-eclampsia and eclampsia [36]. Obstetricians interviewedin this study were also supportive of the administrationof magnesium sulphate before referral and perceived itbe safe. According to the guidelines for skilled birth at-tendants in India, ANMs are authorised to use 10 gmagnesium sulphate as a deep intramuscular injection(5 g on each buttock) prior to referral in severe pre-eclampsia and eclampsia. Although provision of magne-sium sulphate is in the current ANM guidelines, it israrely followed in practice. This could be overcome byadministrative support and effective training [10].An adjunctive study conducted in tandem with thepresent study found that ANMs perceived magnesiumsulphate to be an antihypertensive and nifedipine to be ananticonvulsant. It is necessary to address these misconcep-tions. Nevertheless, ANMs expressed confidence in theadministration of intramuscular injections and this self-assessed competence could be strengthened to enablethem to use magnesium sulphate appropriately [37].In evaluating the role of CHW for strengthening childhealth programmes in Mali, the authors found thatprovision of continuous training, transport means, ad-equate supervision and motivation through financial in-centives and remuneration are important [38]. In asimilar study done in Pakistan to evaluate task sharingwith Lady Health Workers for the identification andmanagement of pre-eclampsia, the authors concludedthat appropriate training, equipment availability andsupervision is a must for successful implementation [39].In this study too, the need for training and adequatesupervision were brought up during the discussions, tobe important pre-requisites for the proposed task-sharing. Many studies have reported significant capacityfor skill development if the trainees have refresher train-ing in skills to which they were not previously exposed,this being one of the most important factors favouringtask-sharing [15].Recommendations and guidelines have been framedfor task- sharing but it has been emphasized that thelower cadre of providers who may be entrusted withnew responsibilities will have to fit into the existinghealth system framework. This is unique to each region,and hence national and local bodies should frame andadopt policies which are relevant to their communities.There must be strong support for these workers basedon governance, financing, the supply of medicines andequipment and support from the rest of the formalhealth system for referral services [8, 40]. Mombo et al.state that task-sharing, if implemented properly, has thepotential to play a major role in better access to andmore equitable provision of basic health care. However,failure to follow appropriate methods and poor planningand implementation could be counterproductive, withcompromised health care delivery [41]. This study foundduring discussions and interviews that most of the par-ticipants favoured task-sharing and emphasised the needfor adequate training, supervision and logistical supportfor the CHW.ConclusionThis qualitative study found strong support for task-sharing activities such as home based blood pressuremonitoring by community health workers; initiation ofemergency treatment and transfer of pregnant womenidentified as having hypertensive disorders of pregnancyto higher centers by health care providers for furthermanagement. The concerns raised were inadequateknowledge, training, experience, supervision and abilityof lower cadre health workers to appropriately deliverthese services in the community. These concerns couldCharanthimath et al. Reproductive Health 2018, 15(Suppl 1):101 Page 84 of 126be addressed by community engagement, repeated train-ing to bridge the knowledge gap and active monitoringof the newly assigned tasks by trained personnel. The fu-ture implication of this study is to help in implementinga larger trial to evaluate whether these task-sharing canhelp in reducing mortality and morbidity among preg-nant women suffering from HDP and can strengthenexisting healthcare infrastructure with constraint humanresources.Strengths of the studyThis study was conducted in collaboration with Indianand multinational researchers who are experienced indeveloping qualitative protocols and analysis. Their ex-perience has generated robust study design. The localsite researchers are familiar with the local Kannada lan-guage, which helped participants express their opinionsfreely and contributed to a better understanding by thefacilitators.Limitations of the studyPrimary health centre staff identified the participantsfrom the local community and this may have resulted inselection bias. The participants who did not access pri-mary care through the formal health care delivery sys-tem were unlikely to be contacted for participation. Theparticipants who were never exposed to such FGDscould have been hesitant in expressing their thoughtsfreely or may have withheld their comments. Eventhough the researchers were well-trained to facilitateequal inputs from all the participants, group dynamicsand cultural barriers may have enhanced or hindered thedialogues by some participants. Non–probabilistic sam-pling methods limit the ability to generalize results.AbbreviationANM: Auxiliary nurse-midwives; ASHA: Accredited social health activists;CHW: Community health workers; DGO: Diploma in gynaecology andobstetrics; FGD: Focus group discussion; HDP: Hypertensive disorders ofpregnancy; IDI: In-depth interview; MBBS: Batchelor of medicine/bachelor ofsurgery; MD: Medicine doctor; OBGYN: Obstetrician and gynaecologist;SBA: Skilled birth attendant; WHO: World Health Organisation; WRA: Womenof reproductive ageAcknowledgementsThis work is part of the University of British Columbia PRE-EMPT (Pre-eclamp-sia/Eclampsia, Monitoring, Prevention and Treatment) initiative supported bythe Bill & Melinda Gates Foundation. We gratefully acknowledge contributionsof the Community Level Interventions for Pre-eclampsia (CLIP) India FeasibilityWorking Group: Zulfiqar Bhutta, Sheela Naik, Anis Mulla, Namdev Kamle, VaibhavDhamanekar, Sharla K Drebit, Chirag Kariya, Tang Lee, Jing Li, Mansun Lui, Asif RKhowaja, Domena K. Tu and Amit Revankar. We also acknowledge the supportof KLE University, JN Medical College, SN Medical College, University of BritishColumbia, Government of Karnataka, the district health administration ofBelgaum and Bagalkote Districts. We also thank health centre staff and communityleaders for their participation and their efforts in motivating community participation.We additionally acknowledge the research office staff for assisting in data translationand transcription. Finally, a special thanks to all the focus group and interviewparticipants.FundingThis study was undertaken as a part of the PRE-EMPT (Pre-eclampsia EclampsiaMonitoring Prevention and Treatment) grant awarded to the University of BritishColumbia, a grantee of the Bill & Melinda Gates Foundation. The funding bodyhad no role in the design or conduct of the study or in the reporting of theresults. Publication charges for this supplement were funded by the University ofBritish Columbia PRE-EMPT (Pre-eclampsia/Eclampsia, Monitoring, Prevention andTreatment) initiative supported by the Bill & Melinda Gates Foundation.Availability of data and materialsThe datasets used and/or analysed during the current study are availablefrom the corresponding author on reasonable request.About this supplementThis article has been published as part of Reproductive Health Volume 15Supplement 1, 2018: Improving pregnancy outcomes - Proceedings of the2nd International Conference on Maternal and Newborn Health: TranslatingResearch Evidence to Practice. The full contents of the supplement will beavailable online at https://reproductive-health-journal.biomedcentral.com/articles/supplements/volume-15-supplement-1.Authors’ contributionsUC, GK and UR were involved in the preparation of the study materials, datacollection and prepared the manuscript. AJ, SB, SR, CK, GM, AK were involvedin data collection. RD, SG, SS, MV, AM, MB, DS, BP, LAM were responsible forprotocol preparation and overseeing the study. PVD and RQ were thePrincipal Investigators. All authors read and approved the final manuscript.Ethics approval and consent to participateThis study was approved by ethics review committees at the University ofBritish Columbia, Vancouver Canada (H12–00132)and KLE University,Belgaum (Ref No: MDC/IECHSR/2013–14/A-28) India. Furthermore, approvalwas also obtained from the Ministry of Health and Family Welfare, India.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1KLE Academy of Higher Education and Research’s, J N Medical College,Belagavi, Karnataka, India. 2Department of Obstetrics and Gynaecology, andthe Child and Family Research Unit, University of British, Columbia,Vancouver, BC, Canada. 3Department of Obstetrics and Gynaecology, SNijalingappa Medical College, Bagalkot, Karnataka, India. 4Department ofCommunity Medicine, S Nijalingappa Medical College, Bagalkot, Karnataka,India. 5Department of Pharmacology, S Nijalingappa Medical College,Bagalkot, Karnataka, India. 6Department of Anatomy, S Nijalingappa MedicalCollege, Bagalkot, Karnataka, India. 7Department of Research, VancouverIsland Health Authority, Victoria, BC, Canada. 8Division of Women and ChildHealth, Aga Khan University, Karachi, Sindh, Pakistan. 9School of Life CourseSciences, Faculty of Life Sciences and Medicine, King’s College London,London, England. 10Department Kings of Obstetrics, Thomas JeffersonUniversity, Philadelphia, PA, USA.Published: 22 June 2018References1. 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