1. Quality Standards in Obstetric Care-The right approach to reduce maternal mortality- Kerala experience. Transmitted to South Africa on 6 th April 2016 vppaily@gmail.com

2. MMR Best index of health care of a society.

3. MMR reflects Not just obstetric care, but Socio economic status of women Women’s educational standard The respect women get Government’s willingness to spend on women’s health.

4. To ensure low MMR and safe maternity care several players are required. Woman herself Her family Medical team – Doctors & Nurses Administrators Politicians

5. To ensure low MMR The most critical step - the care during delivery We are convinced of this because of our experience in Kerala

6. Kerala India Total population33.4 Million1.237 Billion Infant Mortality rate (2012) 1242 Maternal Mortality Ratio(2010-12)* 66178 Female Literacy91.9865.4 *Sample Registration Survey

7. Kerala_the maternity landscape Institutional deliveries: 98.4% (28% public, 72% private) No insurance cover (most pay out of pocket )

8. Maternal Mortality in Kerala We conduct Confidential Review of Maternal Deaths - 2004 Realised that many avoidable maternal deaths still occur.

9. Audit of maternal deaths KFOG started Confidential Review of Maternal Deaths (CRMD) in 2004 Based on UK Confidential Enquiry into Maternal Deaths CRMD Identified the causes of maternal deaths

10. Causes of maternal deaths 200420052006200720082009201020112012 % Hemorrhage20.224.128.420.327.81018.427.121 Hypertension15.118.610.115.216.51913.316.311.5 Heart disease3.713.14.56.754.78.16.54.2 Sepsis3.77.66.411.813.98.34.17.65.2 AFE13.88.89.18.46.38.34.15.58.4 Thromboembolism8.83.30.9153.72.325.54.2 Pl.prev.accreta13 7224 SUICIDE334168

11. Kerala_the maternity landscape Kerala’s MMR has not decreased much in the past 20 years This is a concern for everyone Reducing MMR is a key priority in Kerala

12. In 2012, Govt of Kerala consulted NICE International To identify the issues and suggest steps to reduce MMR. NICE relied heavily on the findings of CRMD published as “Why Mothers Die-Kerala”.

13. Q S- Collaborative work Kerala Government Health Services National Health Mission ( Central government) Kerala Federation of Obstetrics and Gynecology (KFOG) NICE International Rajeev Sadanandan (Principal Secretary) Beena Mahadevan (NRHM Director) Dr Paily (KFOG) Dr Kalipso Chalkidou & Dr Francoise Cluzeau (NICE Intrenational)

14. How the QS was developed Convened multidisciplinary* group Selected areas of priority for the QS Based on NICE’s Quality Standard methods KFOG with NICE International support drafted statements These were discussed by multidisciplinary group Went through several iterations Developed an implementation plan The process took 9 months 14 * Public & private sector, expert clinicians/academics, providers, NRHM, insurers

15. Local & adapted international evidence Data available from the CRMD Using WHO, NICE, KFOG and RCOG guideline recommendations as evidence base 10 statements with measurable indicators 1.Active Management of Third Stage of Labour 2.PPH Prevention – 4th Stage Management 3.Management of Post-Partum Haemorrhage with Blood and Blood Products 4.Obstetric Intensive Care 5.Placenta Praevia Accreta 6.Pre eclampsia 7.Anti-hypertensive Treatment 8.Severe Hypertension in pregnancy and in Immediate Postpartum Period 9.HELLP 10.Eclampsia

16. Launching the MMR Quality Standard The Quality Standard was launched by the Honorable Chief Minister and Health Minister of Kerala in the presence of UK Health Minister Anna Soubry, Principal Secretary Health, NRHM Director, KFOG & NICE International In Jan 2013

17. Implementing the QS QS was implemented in 8 pilot (public & private) hospitals on 1 st April 2013 Data collected, monthly review meetings held Attended by all pilot hospitals Chaired by The Principal Health Secretary Run by the NRHM Director and KFOG 17

18. Preparing for implementation_1 Flowcharts developed and displayed New labour register designed and implemented Disposable delivery kits and other new equipment purchased and distributed Staff were redeployed

19. Preparing for implementation_2 All staff working in the Labor room and maternity ward trained (>400) NRHM Director & KFOG visited all hospitals to review the programme Needs assessment conducted in hospitals

20. Impact from pilot March 2014 Process: Good compliance with some QS indicators 100% compliance with active management of third stage of labour and two hour observation of women in the labour room after delivery ( 4th stage) Outcome (suggest improvement in PPH) Reduced average blood loss Reduced number of blood transfusions

21. Quote “ All of us gynaecology unit chiefs are able to sleep peacefully at night these days. PPH referral emergencies have come down drastically in the past five months. Even when such referrals come, our job is easier because all required first aid measures would be initiated before the mothers were sent here. An excellent initiative, these standards need to be adopted in all maternal care hospitals: “ From Gynaecologist at Tertiary Referral CentreThe Hindu, 16 Oct 2013

22. Initial perceptions suggest positive impact 22 “ PPH referral emergencies have come down drastically in the past five months. An excellent initiative, these standards need to be adopted in all maternal care hospitals” Head of Ob-Gyn Department at a pilot hospital The Hindu, 16 October 2013

23. Longer term impact: Local commitment to extending quality care Learning from maternal care QS extended to neonatal mortality Sharing experience internationally and with other Indian states (Odisha & Bihar) NICE International Developed QS process guide to be used in other Low & Middle Income Countries

24. What next The QS has been extended to include sepsis and Amniotic fluid embolism Plan to roll out the QS to all district hospitals in Kerala Other main causes of MMR will need addressing: Thromboembolism, Heart disease & Suicide

25. Good leadership Commitment of work force Perseverance Good data collection and analysis Effective and regular feedback & follow up Financial and manpower input For Quality standards to succeed

26. The downside Of late, it has lost momentum, because of lack of commitment from the administration and decreased financial input.

27. Our mistake Launched the programme before collecting baseline data. So it is difficult to prove with data, the impact of the project.

28. Suggestion Before launching the programme, collect data regarding _ How often is AMTSL followed. How much is blood loss in every delivery. How many needed blood transfusion. How many severe preeclampsia and eclampsia occur etc

29. Conclusions Quality standards in obstetric care are simple, easy to follow and do-able steps in everyday obstetric practice. The emphasis has to be on local needs and practices. It needs sustained commitment on the part of the administration and the profession. It gives immediate dividends in terms of better outcome

30. Thank You