Standards manual being implemented in select hospitals to bring down maternal mortality

Post-partum haemorrhage (PPH) or excessive bleeding of mothers after delivery is one of the nightmarish scenarios that gynaecologists have to deal with every other day in the labour room.

If the bleeding is not detected at the proper time and immediate medical management initiated, a mother could bleed to death within five to 10 minutes. In many cases, the mother is rushed in a very critical condition to a tertiary care centre, where gynaecologists have to resort to very risky surgical procedures and extreme management measures, often lasting hours, to revive a woman who has gone into shock or organ failure.

Till April this year, this used to be the story at SAT Hospital here, where all referred cases of PPH in the district used to accumulate. This story has been totally rewritten now, thanks to some simple interventions that are part of a quality standards manual developed by the Health Department to reduce maternal mortality.

The manual ‘Quality standards on PPH and hypertensive disorders of pregnancy’ currently being piloted in select hospitals in the district has made such a difference that SAT Hospital, which used to report at least one PPH death a month, has not reported a single death from PPH since April.

“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 have been initiated before the mothers were sent here. An excellent initiative, these standards need to be adopted in all maternal care hospitals,” C. Nirmala, Professor and head of Ob-Gyn Department at SAT Hospital, said.

Similar sentiments are expressed by a senior gynaecologist at the Women and Children Hospital, Thycaud, a secondary care centre which handles approximately 500 to 600 deliveries a month.

“The implementation of the quality standards has totally changed the way we used to handle obstetric emergencies, and we hardly need refer any PPH case now. We closely monitor our mothers up till the fourth stage of labour (labour recovery stage, up to two hours post-delivery). More importantly, all doctors and our labour room staff are alert to recognising and diagnosing PPH, and initiating appropriate measures to manage it,” she said.

The 10-point quality standard manual, the first ever to be developed in the State, is derived from evidence-based internationally accepted clinical guidelines, and is a result of a multi-stakeholder partnership between the State Health Department, the National Rural Health Mission, the Kerala Federation of Obstetrics and Gynaecology (KFOG), and the National Institute for Health and Care Excellence (NICE) International, U.K.

The quality standards cover the management of PPH and hypertensive disorders of pregnancy, two of the documented major causes of maternal mortality in the State. They clearly chart out clinical measures that need to be adopted in labour rooms, starting with active management of the third stage of labour, to reduce PPH deaths.

“These interventions are taught to us as medical students, but somehow were ignored in practice either because of physical circumstances or that these were not clearly written, and we were all scared of taking responsibility for any risks involved. The support from the Health Department has clearly made us all more aware and confident,” the doctor said.

The outcome of the implementation of the quality standards, wherever it has been piloted, has been dramatic and palpable, obstetricians said at a review meeting last week.

The Chirayinkeezhu taluk hospital, which handles about 250 deliveries a month, said the number of referrals to SAT Hospital between April to September last year was 40, and this was brought down to 10 in the same period this year.

“Since the pilot was launched, the KFOG has trained over 400 doctors, nurses and nursing attendants in the quality standards and emergency obstetric care and life support training. The private sector, where almost 70 per cent of the deliveries take place, must also be made part of this initiative to reduce maternal mortality,” V.P. Paily, a former professor of Obstetrics and a key resource person of the KFOG, said.

“Kerala has broken new ground in taking maternal care improvement to another level, and the State of Odisha has expressed its eagerness to learn from you. Drawing on our experience from Kerala, we have now initiated the development of a quality standards manual for stroke management with the Ministry of Health in Vietnam,” Francoise Cluzeau, Associate Director, NICE International, who has been interacting with the State health administration since last year to help Kerala draw up the quality standards, told The Hindu.

“We have not been able to measure the outcome of this initiative in clear terms as no baseline data was collected from hospitals prior to the initiation of the pilot. We have now decided to rope in two hospitals – Victoria hospital, Palakkad, and Kottaparambu hospital, Kozhikode – in the project. An external agency has been engaged to do the baseline assessment of these hospitals before and after the pilot,” M. Beena, Mission Director, NRHM, said.

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