Impact evaluation of an intervention to reduce maternal mortality in Kerala, India

Publication Details

Rohini Ghosh, Shannon Maloney
Institutional affiliations
None specified
Grant-holding institution
None specified
South Asia
Health Nutrition and Population
Health Sector Reform, Mortality, Primary Health- including reproductive health
Gender analysis
Health Sector Reform, Mortality, Primary Health- including reproductive health
Gender analysis
Equity Focus
None specified
Evaluation design
Difference-in Difference (DID)
Ongoing 3ie Funded Studies
3ie Funding Window
Policy Window Round 2


The study assesses the impact of new health standards introduced by the National Rural Health Mission (NRHM) across 71 public hospitals in 14 districts in Kerala to improve management of postpartum haemorrhage (PPH) and pregnancy induced hypertension (PIH).


PPH and PIH are the leading causes of maternal death in Kerala. Structural changes within public hospitals and local delivery rooms, such as introduction and compliance to the NRHM standards, have the potential to aid in the reduction of maternal mortality through provision of improved equipment, training of hospital staff and access to medicines. The results from the study can be a critical input for policymakers working to improve the quality of care in public hospitals in Kerala.

Research questions

The study focuses on the following:

  1. Do hospitals have the adequate infrastructure and resources in the form of medicines, machinery and information to support implementation of the quality standards?
  2. What barriers do the hospitals face in implementing the intervention?
  3. Do the quality standards improve quality of care and reduce mortality for mothers with PPH and PIH?


Intervention design

This study evaluates the impact of 10 NRHM health standards for reducing maternal mortality rates due to PPH and PIH in Kerala.

NRHM conducts training sessions for hospital staff where standards are introduced, followed by the distribution of labour room registers and poster-sized flow charts elaborating on the standards for each hospital delivery room. Hospitals are supplied with labour room registers to allow for detailed records-keeping of patients, which are submitted to NRHM monthly for inspection. The study assesses the impact of the NRHM quality standards based on: (i) presence of appropriate obstetric structures in hospitals, (ii) adherence to given maternal care guidelines, and (iii) incidences of health complications relating to PPH or PIH. A pilot intervention is implemented in a small set of government hospitals, followed by a full-scale rollout across Kerala.

Theory of change

Current delivery practices do not provide adequate facilities for mothers with PPH and PIH, leading to high rates of maternal mortality in Kerala. A list of ten quality standards have been generated to adequately diagnose, treat and reduce the risk of PPH and PIH related deaths, thus improving the standards of obstetric care and maternal health in Kerala. Key assumptions for the training to generate an impact include: 1) the training, posters and materials provided are adequate for hospital staff to properly apply the ten quality standards; 2) delivery staff are sufficiently motivated to use and apply the quality standards in their work; 3) the standards increase proper diagnosis and treatment of PPH and PIH; and 4) proper diagnosis and treatment of PPH and PIH reduce the risk of maternal death.

Evaluation design

This study uses a quasi-experimental difference-in-difference (DID) approach. The researchers collect at least 12 months of pre-intervention data and 12 months of post-intervention data for all 8 intervention hospitals. The primary data used in this study will be from patient medical records, accompanied by qualitative interviews, direct observations and labour room registers.  A cost-effectiveness analysis is conducted at the end of the study to assess the relative value of intervention.

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