On August 1 and 2, the National Institute of Health and Care Excellence, International (UK) held a two day workshop in Kerala, India, under the auspices of the state government. The purpose of the workshop was to develop a quality standard to improve maternal care and specifically to help reduce maternal mortality due to postpartum hemorrhage in Kerala. The workshop followed from a scoping workshop held last month. The workshop was organized in partnership with the Kerala Federation of Obstetricians and Gynaecologists and with funding support from the UK Department of International Development and the Wellcome Trust.
The National Institute of Health and Care Excellence is part of the quality track of the Joint Learning Network for Universal Health Coverage. The Institute began working with policymakers from the Kerala Department of Health in 2009 by focusing 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 in India.
In Kerala, postpartum hemorrhage is the most common and major cause of maternal deaths (19.4 percent). Recognizing that some of these deaths could be prevented by improving antenatal care, the team decided that the first quality standards to be developed should focus on maternity hospital care.
The multidisciplinary working group from Kerala and the UK consulted a range of guidelines published by the Kerala Federation of Obstetricians and Gynecologists, the World Health Organization, the National Institute of Health and Care Excellence, and the Green Top Guidelines from the English Royal College of Obstetricians and Gynecologists. The group developed quality standards and quality measures to enable benchmarking and to improve the delivery of services across the state, in public and private facilities in rural and urban areas. By defining the process used to develop indicators for postpartum hemorrhage, Kerala hopes to build its own capacity to extend this process and experience to other causes of maternal mortality, as well as to other diseases and conditions. The state also hopes to share its experience with other Indian states faced with similar challenges.
As a part of this process, the government of Kerala convened the August 2012 working group meeting. The workshop participants included 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) to improve postpartum hemorrhage in maternity hospitals, focusing on three previously identified problem areas:
- Active management of the third stage of labor
- Critical care management
- Referral and transport
- Identification of a practical mechanisms to implement the standard in practice, including data collection mechanisms and statewide implementation support mechanisms.
- Development of a process and methods guide to help replicate and improve the process used to identify priorities and to develop quality standards and Measures, based on the best available evidence, adapted to the local context, and with a multistakeholder approach.
Throughout the workshop, the key participants discussed active management of the third stage of labor – one of three problem areas of postpartum hemorrhage on which the working group agreed to focus – to formulate quality standards and measures. They also discussed various inclusion and exclusion criteria, the selection of drugs used for active management of the third stage of labor, 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 lessons learned from this initial workshop were substantial. The professionals and policymakers are committed to keeping the momentum with a forthcoming multidisciplinary working group meeting later in August. The National Institute of Health and Care Excellence will continue to support the government of Kerala as the government develops quality standards in other key priority areas.
In this context, in September 2012, the National Institute will participate in a followup meeting with the Kerala working group. Representatives from the Institute look forward to collaborating with the Kerala experts to share the lessons from this work with other Indian states.
Many of the outputs from this workshop will feed into the Human Resource for Health Cell, a group that is 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.