Improving Quality of Health Care to Reduce Maternal Mortality in Kerala, India

This assessment examines the impact of a quality standards training program based on guidelines to improve on the management of postpartum haemorrhage (PPH) and pregnancy-induced hypertension (PIH) in public hospitals in Kerala.

With an annual rate of reduction of 5%, India’s maternal mortality rate has seen a substantial decline during 2004-2006 to 2014-2016. However, the reduction is still short of the National Health Policy target. The Department of Health at the Directorate of Health in Kerala, in partnership with the National Rural Health Mission (NRHM), Government of Kerala and ACCESS Health International, has introduced a set of quality guidelines designed to improve provider practices in terms of obstetric care delivery within public hospitals in Kerala, India. These quality standards consisted of ten evidence-based guidelines to reduce Post-Partum Hemorrhage (PPH) and Pregnancy Induced Hypertension (PIH) which were identified to be the major causes of maternal death in Kerala. This study assesses the quality standards training program (QSP) on improving maternal outcomes in order to better inform policy makers working to improve public health care facilities and services in Kerala.

Beginning with a pilot in eight hospitals in 2013, NHM rolled out the QSP across 22 hospitals that provided antenatal and delivery services. These hospitals were spread across 13 of the 14 districts in Kerala with the exception of Kozhikode. The primary components of the MMR intervention are the ten quality standards and data collection with labor registers. However, the training program underwent significant changes in terms of how it was delivered when it was expanded to the 22 hospitals in the rollout phase. The rollout training program was a single day training session with negligible hospital administrative involvement. These training sessions were accompanied by distribution of labour room registers and posters of flow charts elaborating on the standards for each delivery room. Researchers used a quasi-experimental difference-in-differences Approach. They collected 12 months of pre-intervention data and 12 months of post-intervention data for all intervention hospitals. Patient medical records, qualitative interviews, direct observations and labour room registers were used as sources for primary data. A cost-effectiveness analysis was also conducted to examine the relative value of the intervention.

Key Findings

Hospitals that were a part of the treatment group  in the pilot phase of the saw a significant improvement in measurement of blood loss as a quantity and were also more likely to increase the number of case sheets with blood loss measured as a quantity as compared to symbols and phrases. Fourth stage blood pressure and pulse recordings were likely to be more in treatment hospitals. Post-delivery measurement of pallor was more likely to be not recorded in treatment hospitals. No significant effects were noted in terms of rates of administration of oxytocin at birth.

In terms of the impact of the MMR QSP in the rollout phase, no impact was detected on PPH rates, PIH, eclampsia or pre-eclampsia for treatment hospitals. The intervention did not have a significant impact on any preventive care measures like recording of blood loss as a quantity, administering oxytocin at birth, optimum care in case of excessive blood loss, fourth stage monitoring, prescription or receiving of antihypertensive drugs during antenatal and postpartum period was detected for the treatment hospitals.

While the pilot programme resulted in improvements in several preventive care measures across hospitals participating in the intervention, the full rollout displayed no discernible effects. The intervention also had no significant effects on the major health outcomes measured in the study during the full rollout of the programme. The findings point towards positive effects on the care practices of the provider when these were supported with infrastructural improvements, supply of medicines, equipment’s and monitoring. These insights suggest that a single day of training is not sufficient to improve maternal outcomes. They require strengthening of structural changes to support the QSPs, and a holistic approach that focuses on infrastructure and administration, to bring a culture more focused on patient centredness and accountability.

Thematic area


Project Leads

Rohini Ghosh, Shannon Maloney




National Health Mission, Kerala