Strengthening early identification of pregnant women ‘at nutritional risk’ attending primary health care facilities in a rural area of Haryana, India- A Quality Improvement initiative

<title>Abstract</title> <p> <bold>Background</bold> Maternal malnutrition leads to poor maternal and foetal outcomes. Early recognition of malnutrition and its risk factors, by the health care providers, is crucial for timely management and prevention of complications. Systematic identification of gaps in detecting maternal malnutrition, followed by targeted interventions - such as training and job aids, and skill strengthening of healthcare providers, can lead to improved maternal and child health outcomes. In this study we wanted to assess the effect of selected interventions on delivery of maternal nutrition services in primary health settings, by using a quality improvement approach. <bold>Methods</bold> A quality improvement initiative was implemented across five primary health care facilities in rural Haryana incorporating four Plan-Do-Study-Act (PDSA) cycles over a period of six months (August 2024 – January 2025). Baseline assessment and root cause analysis were done to identify gaps. Based on the gaps identified, interventions were planned, and 37 primary health care providers were trained in various components of facility-based maternal nutrition services. Job aids for counselling were also provided. Follow up was done to see for improvements. Change was expressed in proportions, using Fischer exact test. <bold>Results</bold> We assessed the proportionate coverage of various maternal nutrition services, during the first PDSA cycle (baseline), followed by endline assessments during third PDSA cycle (two weeks post-training) and fourth PDSA cycle (three months post-training). During the third PDSA cycle, different anthropometric assessments improved by 40–84% above the baseline. Similarly for various clinical examinations the improvements ranged up to 74%, and for counselling by 68–86%. Hemoglobin measurements were sustained at 100% coverage. By the fourth PDSA cycle, most indicators declined compared to the previous cycle (up to 44% for anthropometry), but remained 10% <italic>i.e</italic> . 72% higher than the baseline levels. Interviews with the health care providers identified key areas of challenges for providing maternal nutrition services, such as limited awareness, perceived need for training, lack of resources and cultural practices. <bold>Conclusions</bold> Implementation of a targeted intervention (capacity-strengthening and provision of job aids) significantly improved the nutritional service delivery in ante natal care facilities in a rural area of Haryana. </p>