How ‘No Name, No Blame’ Maternal Death Reviews Transformed Kerala’s MMR

Kerala has pioneered confidential maternal death reviews, a critical initiative to understand causes and implement measures for reducing maternal deaths. This “no name, no blame” approach has significantly impacted Kerala’s maternal mortality ratio (MMR), bringing it down from over 80 at the turn of the century to 30 in 2023, the lowest in India. India’s overall MMR stands at 80 in 2023, a notable decline from 362 in 2000. The success of these maternal death reviews offers valuable lessons for healthcare systems aiming to improve maternal health outcomes.

KFOG’s Pioneering Role in Maternal Death Reviews

The Kerala Federation of Obstetrics and Gynaecology (KFOG) established in 2002, initiated confidential review of maternal deaths (CRMD) with state government support. This was a unique step, particularly since the government already had its own maternal death audit system. Dr. VP Paily, a founding member of KFOG, highlighted the urgency to address Kerala’s MMR, which was 82 in 2002 and appeared to be stagnating. Consequently, a workshop by the WHO’s South-East Asia Regional Office in 2003 provided the impetus to launch these reviews. Kerala was well-suited for such an initiative due to its high proportion of hospital births, nearly 95% at that time, which allowed access to essential hospital records for review.

Implementing a Confidential Review System

KFOG’s primary objective was to reduce maternal mortality, making CRMD its first major project. The WHO supported this by organizing a workshop for potential assessors, including government officials. Following this, the government issued an order directing all hospitals, both private and public, to submit anonymized case records to KFOG for review. Notably, the federation undertook this audit without any financial commitment from the government. The core principle of this audit was confidentiality, meaning assessors would not know the identity of the patient or the hospital involved. Instead, the focus remained on analyzing the circumstances surrounding the deaths to identify modifiable factors and prevent future occurrences. This approach aligns with the WHO’s recommendation to prevent preventable maternal deaths (PPMD), targeting eradication by 2030.

The “No Name, No Blame” Philosophy

An essential aspect of these maternal death reviews was the assurance provided to doctors and hospitals: their identities would remain confidential, and findings would not lead to punishment. This crucial guarantee helped overcome initial doubts and secured the cooperation of obstetricians from both private and government hospitals. In fact, the private sector, responsible for 70% of deliveries in Kerala, showed considerable willingness to participate, a trend not always seen in other states. This parallel system complemented the government’s existing audits, which involved district medical officers investigating maternal deaths. KFOG’s review served as an additional, non-punitive mechanism for learning and improvement. The “no name, no blame” principle is also a key feature of the Maternal Death Surveillance and Response (MDSR) adopted by the Government of India in 2017.

Analyzing Deaths and Fostering Continuous Improvement

Each maternal death undergoes thorough analysis to determine if it was preventable under ordinary care, advanced care, or not preventable at all. For instance, if hemorrhage caused a death, the review examines whether a lack of training or delayed support contributed to the outcome. Every three months, KFOG releases assessments, sharing reviews and learnings with the broader obstetric community. Beyond medical factors, the review considers social and educational characteristics from anonymized records, helping identify non-medical factors linked to deaths. A central review team, composed of practicing obstetricians and non-obstetric specialists like cardiologists and anaesthesiologists, conducts these assessments, all providing their services pro bono. KFOG funds other expenses through its academic activities.

Kerala’s MMR: Progress, Challenges, and Future of Maternal Death Reviews

Kerala’s MMR, while India’s lowest, saw an increase from 18 in 2020-22 to 30 in 2021-23. This rise is partly attributed to increased maternal deaths during the COVID-19 pandemic and a decline in delivery rates. When live birth numbers decrease, the MMR formula (maternal deaths/live births x 100,000) naturally causes the ratio to rise, even if the absolute number of maternal deaths remains constant. Further reducing MMR at this level is challenging, as many deaths now stem from associated chronic conditions like cardiovascular and immunological diseases. Maternal suicide also ranks among the top causes, necessitating psychosocial interventions. Nonetheless, improvements are possible through continuous training for healthcare teams, including ASHAs, nurses, and obstetricians, especially given staff mobility. Kerala also collaborates with organizations like NICE (National Institute for Health and Care Excellence), UK, to systematically reduce deaths from hemorrhage and hypertension. Swift intervention is also required for new challenges like sudden spikes in home births within specific communities. Kerala aims to reduce its MMR to 20 by 2030.

Frequently Asked Questions

Q1: What is the primary purpose of ‘no name no blame’ maternal death reviews?

The primary purpose is to identify the causes and circumstances of maternal deaths in a confidential manner, without attributing blame to individuals or institutions. This approach aims to learn from each death to prevent future preventable maternal deaths by recommending appropriate measures and improving quality of care.

Q2: How has Kerala’s maternal mortality ratio (MMR) changed over time, and what factors influence it?

Kerala’s MMR decreased significantly from over 80 in 2000 to 30 in 2023, making it the lowest in India. However, it saw an increase from 18 in 2020-22 to 30 in 2021-23. Factors influencing this include increased maternal deaths during the COVID-19 pandemic and a decline in live birth rates, which mathematically increases the MMR even if actual deaths remain stable. Chronic conditions and maternal suicide also contribute to current challenges.

Q3: How do KFOG’s confidential maternal death reviews differ from government audits?

KFOG’s reviews operate in parallel to government audits. While government audits may involve official investigations by district medical officers, KFOG’s confidential reviews assure anonymity and immunity from punishment to doctors and hospitals. This “no name, no blame” policy encourages open data submission and focuses purely on learning and systemic improvement, rather than fault-finding or legal action. KFOG’s reviews also consider social and educational factors.

References

1. Role of ‘no name no blame’ maternal death reviews in bringing down Kerala’s MMR – ETHealthworld
2. India saw 52 maternal deaths each day in 2023, second highest after Nigeria—UN report
3. India Maternal Mortality Rate | Historical Chart & Data – Macrotrends
4. How Can India Lower Its Maternal Mortality Further – Indiaspend
5. Maternal Mortality Rates in India, State Wise Data and Current Trends – StudyIQ
6. 52 deaths every day: India ranks second in maternal deaths
7. Improving quality for maternal care – a case study from Kerala, India – PMC
8. Rising Maternal Mortality Ratio (MMR) In Kerala – Only IAS
9. Confidential review of maternal deaths in a South Indian state: current status and the way forward – PMC
10. MEASURES TO REDUCE MATERNAL MORTALITY IN KERALA Problem Statement Programme Description – NHINP
11. Impacts of an Intervention to Reduce Maternal Mortality in Kerala, India – 3ie
12. Full article: Confidential review of maternal deaths in a South Indian state: current status and the way forward – Taylor & Francis Online
13. Confidential Review of Maternal Deaths in Kerala: a country case study – ResearchGate

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