Kerala pioneered confidential review of maternal deaths (CRMD) in India to determine the causes and to recommend appropriate measures to bring down maternal deaths. Interestingly, CRMD was initiated by the Kerala Federation of Obstetrics and Gynaecology ( KFOG ) with state government support, despite the government having its own maternal death audit. Dr VP Paily, one of the founding members of KFOG, explains how CRMD was established in Kerala, the challenges involved, and its impact on bringing down Kerala’s maternal mortality ratio ( MMR ) from over 80 at the turn of the century to 30 in 2023, which is the lowest in India. India’s MMR is 88.
Why did KFOG decide to review maternal deaths?
KFOG was established in 2002. I used to work in a medical college before that and so we were already monitoring maternal deaths, mode of delivery and so on and we knew that there were many preventable deaths. In 2002, Kerala’s MMR, which is the number of maternal deaths per one lakh live births, was 82. In 2003, some of us attended a workshop organized by the South East Asia Regional Office of the WHO called Beyond the Numbers, which provided the impetus. We had collected the data for the previous year and seeing that data, the WHO team felt that we were ready to start maternal death reviews. Only states with a high proportion of hospital births can do it because we need the hospital records to do the review. By then, hospital births were already almost 95% of all births in Kerala.
How did KFOG’s maternal death review take off?
When we formed KFOG, we had decided that our first target would be to audit maternal deaths because we felt that Kerala’s MMR of 82 in 2002 was quite high and that it was stagnating. CRMD was the first project that the federation took up and bringing down maternal mortality was our first objective. The WHO agreed to do a workshop in Kerala for obstetricians who could be potential assessors. After the workshop, which was attended by government officials including the health secretary, the government issued an order asking all hospitals, both private and public, to hand over anonymised case records to KFOG for review. The federation would do the audit without any financial commitment from the government. The audit we were proposing was a confidential review of maternal deaths. This meant that the person who was treated and the hospital where the person was treated would not be revealed to the assessors. We only study the circumstances of the deaths.
The principle was to prevent preventable maternal deaths, PPMD, which is what the WHO also recommends. The target was to eradicate preventable maternal deaths by 2030. Each death is analysed to see if it was preventable in ordinary facilities, or preventable under advanced care or whether it was not preventable at all. For instance, if haemorrhage was the cause of death, we examine if timely intervention was not done due to lack of training or delay in support. Every three months we come out with the assessment and share the review and learnings with the entire obstetric community.
Why weren’t obstetricians and gynaecologists resistant to the idea of assessors reviewing the circumstances leading to the death of their patients?
The review only looked at the condition of the patient or mother, the treatment given and whether there was any modifiable factor and whether we could prevent it if it happened again. We gave an assurance to the doctors and hospitals that their identity would not be publicized and that there would be no punishment based on our findings. Anyway, parallel to this, the government’s audits of maternal deaths continued. In the government audit, whenever there is a maternal death, the district medical officer and a team will go to find out the details. Our audit was not a replacement for this government audit. It was parallel to it. There were some doubts despite our assurances and so submission of cases was a bit slow at the beginning. It was fine once we gained the trust of obstetricians. Doctors in private and government hospitals cooperated. In many states, they worry that the private sector will not cooperate. Here the private sector was more willing. Most of our members come from the private sector. 70% of deliveries in Kerala happen in the private sector.
How does your review compare with what the government is doing?
When there is enquiry from international bodies, our data is the one that the government could point to. The government was happy because it was getting the data without spending any money. Our review reports were very impressive because no other state in the country was doing it then. Even Sri Lanka was not doing confidential reviews.
The state government has issued circulars requesting all hospitals, government and private, to provide full details of every maternal death in specifically designed forms and a copy of the anonymised case record for analysis. This includes social and educational characteristics of the deceased woman and her family. Hence it is not only a case review, but also helps us identify non-medical factors associated with the death.
The anonymised records are assessed by a central review team comprising practising obstetricians drawn from different parts of the state. Non-obstetric assessors including physicians, cardiologists, anaesthesiologists and neurologists are also a part of the team. All assessors and committee members provide the service free of charge. The money for other expenses is raised by KFOG through its academic activities. There is no financial commitment from the doctors or the hospitals submitting the cases for review. They only have to photocopy the case records after anonymizing them.
Why did Kerala’s MMR go up from 18 in 2020-22 to 30 in the 2021-23 period?
The data for MMR comes from the Sample Registration System (SRS). Sample surveys are needed when you do not have reliable data. In Kerala, we know practically all the maternal deaths happening and we do not need a survey to know how many maternal deaths happen. About 120 deaths per year. The latest data would include increased maternal deaths due to Covid , which stopped once the vaccination took off. So, the Covid deaths could be one reason for the spike in MMR. The other reason is that our delivery rates are rapidly declining while maternal mortality has remained more or less the same. However, because of the MMR formula (number of maternal deaths/number of live births x 100,000) when the number of live births comes down, the MMR goes up though the number of maternal deaths have remained the same.
Sri Lanka’s MMR is 18, and Iran’s and China’s is 16. In the developed world, MMR is in single digits. Why are maternal deaths not going down in Kerala?
Kerala has among the lowest MMR in India. It is not easy to reduce it at this level. We have to continue analysing every death and see where we could have made a difference. Many deaths are happening due to associated conditions like cardiovascular diseases and immunological diseases. Conditions like these are not easy to control as these are chronic. Maternal suicide is among the top causes and that needs psychosocial interventions. Still, there are areas where improvement is possible. We got a team from NICE (National Institute for Health and Care Excellence), UK to analyse our experience and to help with a systematic approach to reduce deaths due to haemorrhage and hypertension. Hypertension is still an important cause and we can try and prevent that by appropriate training. There has to be continuous training because teams are changing all the time-- doctors, nurses, paramedics—with many going abroad. Six months after the training, they might not be in the same position. There must be constant arrangements for training ASHAs, health workers, obstetricians and labour room nurses. With the government’s support, training was provided by our association with programmes for training the trainers. It is a dynamic process that is still going on and it helps to identify trends. New challenges can come up like the sudden spike in home births in some areas restricted to specific communities. We need to intervene quickly.
Why did KFOG decide to review maternal deaths?
KFOG was established in 2002. I used to work in a medical college before that and so we were already monitoring maternal deaths, mode of delivery and so on and we knew that there were many preventable deaths. In 2002, Kerala’s MMR, which is the number of maternal deaths per one lakh live births, was 82. In 2003, some of us attended a workshop organized by the South East Asia Regional Office of the WHO called Beyond the Numbers, which provided the impetus. We had collected the data for the previous year and seeing that data, the WHO team felt that we were ready to start maternal death reviews. Only states with a high proportion of hospital births can do it because we need the hospital records to do the review. By then, hospital births were already almost 95% of all births in Kerala.
How did KFOG’s maternal death review take off?
When we formed KFOG, we had decided that our first target would be to audit maternal deaths because we felt that Kerala’s MMR of 82 in 2002 was quite high and that it was stagnating. CRMD was the first project that the federation took up and bringing down maternal mortality was our first objective. The WHO agreed to do a workshop in Kerala for obstetricians who could be potential assessors. After the workshop, which was attended by government officials including the health secretary, the government issued an order asking all hospitals, both private and public, to hand over anonymised case records to KFOG for review. The federation would do the audit without any financial commitment from the government. The audit we were proposing was a confidential review of maternal deaths. This meant that the person who was treated and the hospital where the person was treated would not be revealed to the assessors. We only study the circumstances of the deaths.
The principle was to prevent preventable maternal deaths, PPMD, which is what the WHO also recommends. The target was to eradicate preventable maternal deaths by 2030. Each death is analysed to see if it was preventable in ordinary facilities, or preventable under advanced care or whether it was not preventable at all. For instance, if haemorrhage was the cause of death, we examine if timely intervention was not done due to lack of training or delay in support. Every three months we come out with the assessment and share the review and learnings with the entire obstetric community.
Why weren’t obstetricians and gynaecologists resistant to the idea of assessors reviewing the circumstances leading to the death of their patients?
The review only looked at the condition of the patient or mother, the treatment given and whether there was any modifiable factor and whether we could prevent it if it happened again. We gave an assurance to the doctors and hospitals that their identity would not be publicized and that there would be no punishment based on our findings. Anyway, parallel to this, the government’s audits of maternal deaths continued. In the government audit, whenever there is a maternal death, the district medical officer and a team will go to find out the details. Our audit was not a replacement for this government audit. It was parallel to it. There were some doubts despite our assurances and so submission of cases was a bit slow at the beginning. It was fine once we gained the trust of obstetricians. Doctors in private and government hospitals cooperated. In many states, they worry that the private sector will not cooperate. Here the private sector was more willing. Most of our members come from the private sector. 70% of deliveries in Kerala happen in the private sector.
How does your review compare with what the government is doing?
When there is enquiry from international bodies, our data is the one that the government could point to. The government was happy because it was getting the data without spending any money. Our review reports were very impressive because no other state in the country was doing it then. Even Sri Lanka was not doing confidential reviews.
The state government has issued circulars requesting all hospitals, government and private, to provide full details of every maternal death in specifically designed forms and a copy of the anonymised case record for analysis. This includes social and educational characteristics of the deceased woman and her family. Hence it is not only a case review, but also helps us identify non-medical factors associated with the death.
The anonymised records are assessed by a central review team comprising practising obstetricians drawn from different parts of the state. Non-obstetric assessors including physicians, cardiologists, anaesthesiologists and neurologists are also a part of the team. All assessors and committee members provide the service free of charge. The money for other expenses is raised by KFOG through its academic activities. There is no financial commitment from the doctors or the hospitals submitting the cases for review. They only have to photocopy the case records after anonymizing them.
Why did Kerala’s MMR go up from 18 in 2020-22 to 30 in the 2021-23 period?
The data for MMR comes from the Sample Registration System (SRS). Sample surveys are needed when you do not have reliable data. In Kerala, we know practically all the maternal deaths happening and we do not need a survey to know how many maternal deaths happen. About 120 deaths per year. The latest data would include increased maternal deaths due to Covid , which stopped once the vaccination took off. So, the Covid deaths could be one reason for the spike in MMR. The other reason is that our delivery rates are rapidly declining while maternal mortality has remained more or less the same. However, because of the MMR formula (number of maternal deaths/number of live births x 100,000) when the number of live births comes down, the MMR goes up though the number of maternal deaths have remained the same.
Sri Lanka’s MMR is 18, and Iran’s and China’s is 16. In the developed world, MMR is in single digits. Why are maternal deaths not going down in Kerala?
Kerala has among the lowest MMR in India. It is not easy to reduce it at this level. We have to continue analysing every death and see where we could have made a difference. Many deaths are happening due to associated conditions like cardiovascular diseases and immunological diseases. Conditions like these are not easy to control as these are chronic. Maternal suicide is among the top causes and that needs psychosocial interventions. Still, there are areas where improvement is possible. We got a team from NICE (National Institute for Health and Care Excellence), UK to analyse our experience and to help with a systematic approach to reduce deaths due to haemorrhage and hypertension. Hypertension is still an important cause and we can try and prevent that by appropriate training. There has to be continuous training because teams are changing all the time-- doctors, nurses, paramedics—with many going abroad. Six months after the training, they might not be in the same position. There must be constant arrangements for training ASHAs, health workers, obstetricians and labour room nurses. With the government’s support, training was provided by our association with programmes for training the trainers. It is a dynamic process that is still going on and it helps to identify trends. New challenges can come up like the sudden spike in home births in some areas restricted to specific communities. We need to intervene quickly.
You may also like
Paul C Brunson furiously scolds 'disrespectful' MAFS UK bride in explosive scenes
Joao Pedro sent off as Chelsea dealt THIRD red card in four games
Arsenal boss Mikel Arteta explains Ethan Nwaneri omission as Noni Madueke injury update issued
Ed Miliband accuses Nigel Farage of 'waging war' on- workers with anti-green plan
Hamas 'put in a corner' with new ultimatum from Donald Trump
