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Developing quality standards for post-partum haemorrhage to reduce maternal mortality in Kerala

Photo credit: NICE International
Following a scoping workshop in July 2012, and under the auspices of the Government of Kerala, NICE International (UK), part of the Quality Track of the Joint Learning Network for Universal Health Coverage, held a two-day workshop in Kerala, India in partnership with the Kerala Federation of Obstetricians and Gynaecologists and with funding support from the UK’s Department of International Development (DFID), and the Wellcome Trust. The meeting was held on August 1-2, 2012 to develop a quality standard for improving maternal care and help reduce maternal mortality due to post-partum haemorrhage (PPH) in the state of Kerala.

NICE began working with policymakers from Kerala’s Department of Health in 2009 with a focus on clinical guidelines and standards. Based on these meetings, Kerala policymakers identified maternal mortality as a high priority issue for improvement – even though Kerala has the lowest maternal mortality rates (MMR) in India.

In Kerala, PPH is the most common and major cause of maternal deaths (19.4%). Recognizing that some of the deaths could be prevented by improving antenatal care, the team decided that the first quality standards should be developed that focus on maternity/hospital care.

Using guidelines published by the Kerala Federation of Obstetricians & Gynecologists (KFOG), the World Health Organization (WHO), NICE, and the Green Top Guidelines from the English Royal College of Obstetricians and Gynecologists, the multidisciplinary Kerala/UK working group developed a Quality Standards with accompanying Quality Measures for benchmarking and improving the delivery of services across the State, in public and private and urban, and rural centred. By defining the process of developing indicators for PPH, Kerala hopes to build its own capacity to extend this process and experience to other causes of maternal mortality, as well as other diseases and conditions, and also to apply their experience to other Indian states faced with similar challenges.

As a part of this process, the Government of Kerala convened the August 2012 working group meeting comprising hospital and State administrators, professionals (clinicians and nurses), policymakers and providers with experience in maternal care. The key outcomes from this workshop included:

  • Development of a quality standard (including relevant measures) for improving PPH in maternity hospitals focusing specifically on the three previously identified problem areas: (1) Active Management of Third Stage of Labour (AMTSL), (2) Critical care management, (3) Referral and transport
  • Identification of a practical mechanism for implementing the standard in practice including data collection mechanisms and state-wide implementation support mechanisms.
  • Development of a process and methods guide for replicating and improving on the process for identifying priorities and developing Quality Standards and Measures, based on the best available evidence, adapted to the local context, and on a multi-stakeholder approach.
Photo credit: NICE International
Throughout the workshop, the key stakeholders discussed Active Management of Third Stage Labour (AMSTL) – one of three areas of PPH that the working group has agreed to focus on – in relation to formulating a quality statement and quality measures. They also discussed various inclusion and exclusion criteria, the selection of drugs used for active management of the 3rd stage of labour, timing and mode of administration, availability of resources and supplies, the setting of health provision, training and human resource requirements and current mechanisms for data collection.

The learning’s from this initial workshop were substantial and the professionals and policy makers are committed to keeping the momentum with a forthcoming multidisciplinary working group meeting later in August, NICE will continue supporting the government of Kerala in developing quality standards in key priority areas, as instructed by the Government of Kerala.

In this context, in September 2012, NICE will participate in a follow-up meeting with the Kerala working group and is looking forward to taking the lessons from this work, in collaboration with the Kerala experts (professionals and policy makers), to other Indian states.

Many of the outputs from this workshop will feed into the Human Resource for Health (HRH) Cell, a group looking into the utilization and training of resources for health in the state. In addition, the work and the experience from Kerala will become a learning platform that can be shared with other states, especially in the field of primary care and Universal Healthcare Coverage.

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