As the world enters the seventh month of the global pandemic of coronavirus, more than 10,110,000 individuals have been struck by the disease, which has claimed the lives of over 500,000. Without any viable cures for this illness, many are fearing for their lives - none more so than soon-to-be mothers. Globally, 116 million babies are expected to be born during the current pandemic; in Bangladesh, that figure is 2.4 million. Pregnant women are facing a grim reality of containment measures, overwhelmed healthcare facilities, shortages of supply and equipment, and a lack of skilled birth attendants.
While pregnant women do not appear to be more susceptible to COVID-19 than the general population, they have been strongly advised to avoid contact as much as possible through social distancing measures. In Bangladesh, pregnant women are unlikely to maintain regular, scheduled prenatal and postnatal care even during normal times.
Thus, the onset of a global infectious disease has thrown these women an immense curveball. According to the Directorate General of Health Services, since the beginning of the COVID-19 crisis, there has been a significant reduction in the uptake of maternal and new born health services from the health facilities. Only 33 district hospitals in Bangladesh are performing all key functions of emergency obstetric care out of 63.
The World Health Organization considers mobile-health (m-Health) to be a potential game changer, transforming the face of health service delivery worldwide. Recently, efforts have been undertaken globally to utilise smart phone applications in health service delivery. Against this backdrop, a team of researchers from icddr,b endeavoured to develop an innovative m-Health scheme to ensure quick access to safe blood for transfusion during a medical emergency.
Blood Information Management Application (BIMA)
The principal investigator of the research, Dr Aminur Rahman shared their vision “Our study on digitalise information about the location and availability of blood made the blood acquisition process more convenient and accessible, particularly in emergency situations for the patients”. This was achieved through the development of a digitalised system called the Blood Information Management Application (BIMA). It was implemented at Dhaka Medical College Hospital (DMCH), a tertiary level public hospital, which is considered one of the busiest health facilities in Bangladesh, primarily serving patients from underprivileged backgrounds.
BIMA is essentially an online blood information management application, which grants access to various blood information databases both within and outside the hospital. It operates by capturing specific details (e.g. name, proximate location, licensed blood centres, current stock of each type of blood available in each facility, and donor list) and facilitate reservation of specific quantities and types of blood through the booking information system.
After a request is lodged for a particular type and quantity of blood, a booking identification number is generated along with the name and address of the blood centre. These details are then provided to the patient’s relatives so that they can purchase the blood from the stipulated blood bank.
The implementation of BIMA in the obstetrical ward of DMCH helped reduce the median duration for blood availability from 152 minutes to 122 minutes. The highest decline in waiting time was observed in women with pregnancy-induced hypertension (a remarkable reduction of over two hours, from 245 minutes to 122 minutes) and postpartum haemorrhage (an hour-long reduction, from 175 minutes to 112.5 minutes).
BIMA has been instrumental in reducing the waiting time for blood transfusion in obstetric emergencies. However, this study was only implemented in an urban setting where blood banks are conveniently located to health facilities; this is not the case in rural areas. A modified BIMA approach could be developed as a solution to ensure safe and timely access to blood to all patients attending public hospitals in Bangladesh. This application has potential to create a national blood donor database for timely and safe transfusion of the required patients.
Dr Rahman recognises the success of BIMA in an emergency situation; especially during this global pandemic, stating “We have observed BIMA’s achievements in reducing waiting time for blood transfusions. If this approach was tweaked and adopted, we could likely match patients with the closest available healthcare facility. This could potentially save precious minutes; especially during a medical emergency”.
Another m-Healthfeature, which could provide life-saving services at this critical moment is the adoption of e-partographs. A large proportion of maternal deaths occur as a result of prolonged labour, which is also very risky for newborns. Early detection of abnormal labour progression is key and the partograph is an effective tool to monitor labour and identify women in need of an emergency obstetric interventions.
In Bangladesh, the use of the partograph is recommended for all deliveries, both vaginal and C-section. However, the utilisation of the partograph is very low. Furthermore, a high-user rate does not always translate to correct usage of the tool. Thus, digital partographs have been globally proposed as an efficient and more accurate tool. A recent study by scientists at icddr,b tested the feasibility and effectiveness of e-partograph usage (compared to paper partograph) during the birthing process in two secondary level hospitals in Jessore and Kushtia districts.
The electronic version of the partograph used in the study could be accessed through smart phone, tablet PC or computer device. Crucially, it had a built-in mechanism in the software to raise a red signal for any maternal or foetal abnormality during the labour process. Among all deliveries observed during the study, more than 90% took place before reaching the red signal, an indication of the intervention’s success in reducing the prevalence of complicated deliveries. An increase in e-partograph utilisation has also led to a reduction in prolonged labour and subsequent birth complications. Moreover, the rate of prolonged labour was less with e-partograph than with the paper partograph (42% vs 30%).
Overall, the study demonstrated that the user rate of the e-partograph is significantly higher than the paper partograph during both phases of the study (38% vs. 21.3% during the firstphase; and 38% vs 2.8% during the second phase). One of the reasons for its success was because the barriers of partograph use were identified and remedied through various trainings for the nurses and midwives; healthcare providers were educated on the clinical usefulness of the tool, leading to an uptake in its use. In cases of remote access, doctors can facilitate midwives for safe delivery even if they are not present in the hospital.
Scaling up of e-partograph usage has the potential to improve the quality of maternal and neonatal healthcare services. Bangladesh is in an advantageous position to adopt digital technology as some of the methods required have already been practiced through introduction of DHIS-2 software. The research team, led by Dr Aminur Rahman, is currently taking their recommendations from the study to policymakers for wide-scale implementation.
Bangladesh has recently been moving towards electronic data collection and electronic record-keeping systems. These two studies lend credence to the need for digitalising healthcare information systems and implementing electronic systems in lieu of paper records. This will reduce lags in time, which can potentially save the lives of mothers and babies born at a time when the healthcare system at all levels is overwhelmed with patients suffering from COVID-19.