Operationalizing Obstetric ICUs in Gujarat
Health & Family Welfare Department, Government of Gujarat

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Gujarat has come a long way in improving Maternal Health. Maternal Mortality Ratio (MMR) has declined from 172 Maternal Death per 1,00,000 live births in 2001-03 to 112 Maternal Deaths per 1,00,000 live births in 2011-13, a 34% decline. (SRS Bulletins). Yet every year an estimated 1,500 mothers die during pregnancy, child birth or during post-partum period due to complications of pregnancy. Major observation for such high mortality were assessed in Maternal Death Surveillance and Response system (MDSR) and summarised as follows. • Higher mortality in tertiary care institutions: due to improved referral services in state through 108 emergency services and good road connectivity, many women developing life threatening complication during pregnancy get timely referral to tertiary care institutions. As per Maternal Death Review Analysis for year 2014-15, 24% of maternal deaths were recorded in Medical College Hospitals, which is a matter of concern. • Seriousness of cases admitted in tertiary care institutions: The annual MDR analysis suggests that causes of maternal deaths were very different and more complicated in Medical College Hospitals compared to overall causes of maternal mortality. majority of these cases are clinically very complicated and required multi-disciplinary team to save life of pregnant mother. Apart from complicated cases tertiary care institutions face unique challenge in form of managing obstetric patients requiring intensive care, as intensive care is usually provided by Medicine/Anaesthesia (Critical Care Department) departments in collaboration with obstetric management teams. • Situation of existing ICUs in Medical College Hospitals: Most of the Medical College Hospitals in Gujarat have an ICU within hospital. However, this unit is mainly run by Medicine department and caters to all departments of Medical College Hospitals. Often women with obstetric complications, who need ICU care have to wait in a queue and not able to get appropriate lifesaving critical care on time. Due to competing priorities, staff at these ICUs has difficulties to prioritize cases for admission to ICU. Once a woman with obstetric complication is shifted to general ICU the case management responsibility shifts to general ICU staff distancing care from the concerned obstetricians who knows about the detailed pre-existing and contributing obstetric history of the case.

B. Strategic Approach

 2. What was the solution?
Considering seriousness of cases admitted in Medical College Hospitals and delay in receiving intensive care in existing setup, it was proposed to establish dedicated Obstetric ICUs in all Medical College Hospitals. It was further decided to establish these units within existing Obstetric Departments to ensure provision of appropriate obstetric and intensive care to pregnant mothers. Multi-speciality team was also made responsible apart from obstetrician to ensure effective obstetric and intensive care provision to pregnant mother.

 3. How did the initiative solve the problem and improve people’s lives?
Obstetric ICUs are operationalized with following objectives in medical college hospitals. • To establish Obstetric Intensive Care Units (Obs ICU) in Medical College Hospitals to ensure adequate obstetric and intensive care to pregnant mothers with life threatening complications, enhancing their survival opportunities. • To develop standardize treatment protocols for improved outcomes in all Obs ICUs • To develop Information Technology enabled monitoring system for real time monitoring of Obstetric ICU performance. Dedicated Obstetric ICUs in Medical College Hospitals have made huge impact on quality of care provided to pregnant mothers during serious complications. Out of 20 Obstetric ICUs planned for operationalization, 7 Obstetric ICUs at (Surat, Vadodara, Jamnagar, Junagadh, Ahmedabad, Bhavnagar and Sola) are already operationalized. These unit provides opportunity to an obstetrician for continuous involvement in management of complicated cases. Timely support from intensivist, physician and other specialty further improves quality of intensive care. With availability of Obstetric ICUs, most of the complicated mothers are treated within close vicinity of labour room by obstetrician thus by improving outcome. With establishment of dedicated unit following positive responses have observed:  More than 3200 mothers have been admitted so far in these units and 3062 mothers (96%) have been successfully discharged.  Maternal mortality in near miss cases have reduced from 2.3% to 1.1% after establishment of Obstetric ICUs.  Overall bed occupancy rate of Obstetric ICUs has been nearly 70% in all obstetric ICUs. Availability of timely intensive care for pregnant women has drastically reduced time to access critical care and thus by improved outcome.  Major interventions provided at Obstetric ICU includes and are not limited to provision of ventilation, blood transfusion, administration and monitoring of anti Convulsants, anti-hypertensive and intensive monitoring Obstetric Hysterectomy and others.  All services in Obstetric ICUs are provided completely free of cost. Intensive care cost is usually very high and one of the major reason for illness-poverty-illness vicious cycle. Obstetric ICUs have successfully broken this vicious cycle and improved financial protection to pregnant mothers.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
There are no formal guidelines available globally for developing obstetric ICUs. This innovation started from discussion with medical college faculties regarding improving quality of care in medical college hospitals. Primary proposal for this innovation was developed in collaboration with medical college hospitals and technical inputs were taken from UNICEF. Furthermore, there were no standards available for Human resource and equipment requirement. Entire exercise was done in house with medical college faculty. Gujarat is the first state across India to start this innovation on such a scale. National Guidelines for developing Obstetric ICU has recently launched by Government of India in March 2016, one and half year after Gujarat first proposed Obstetric ICU in October 2014. Obstetric ICUs are high impact intervention which envisages dedicated intensive care for pregnant mothers. In days to come, with increasing work load in public health institutions, many specialties will require dedicated ICUs in their own branches. Obstetric ICUs are predecessor to all such developments.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Implementing agency: Health & Family Welfare Department, Government of Gujarat is the implementation agency for the present innovation. Funding support for present innovation is through stage government budget and National Health Mission, Government of India. Population affected: every year nearly 13 lakh women become pregnant in Gujarat. Out of these pregnant mothers, any one developing serious life threatening complication is eligible for admission in to these ICUs without any conditionalities. So far, more than 3200 mothers have benefited from these units in span of 2.5 years.
 6. How was the strategy implemented and what resources were mobilized?
Proposal for establishing Obstetric ICU was prepared in co-ordination with Department of Obstetrics & Gynaecology from Medical College Hospitals. Initially it was proposed to start 6 bedded units in every hospital considering the average annual delivery load of these hospitals. Each Obstetric ICU has to have the following minimum Standards. Human resources: • 1 Intensivist/ Anaesthetist (Team leader) • 4 Medical Officers, for round the clock availability of one Medical Officer in ICU • 12 Staff Nurses, for ensuring 3 staff nurse availability round the clock. (1 Staff Nurse round the clock for every 2 beds in ICU, one of these senior staff nurse should be entrusted with responsibility of In-charge sister for Obstetric ICU) • 1 Monitoring & Evaluation assistant for data management • Other key specialists to provide support on call basis – Internist; Paediatrician; Surgeon; Nephrologist Equipments: State level expert group on Obstetric ICU constituted with representation from every Medical College Hospital, where Obstetric ICU is proposed. This expert group discussed requirements and finalized list of major and minor equipments through consultative process. Major equipments are procured through Gujarat Medical Service Corporation Ltd (GMSCL), while minor equipments are purchased at local level by respective hospitals. 15 major equipments were decided as necessary for every Obstetric ICU. The list of these 15 equipments along with required quantity is as follows. These requirements are considering 6 bedded units; it may increase as per increase in number of beds in Obstetric ICU as well as case load. 1. Infusion Pump – 6 2. Syringe Infusion pump –(6-12) 3. Multipara Monitor – 6 4. Pulse Oxymeter – 4 5. Fowler beds – 6 6. Portable USG Machine – 1 (with all required probes) 7. Central Monitoring System compatible with Multipara monitor – 1 8. Portable X-ray Machine (100 mA) – 1 9. Defibrillator – 2 10. Radiant Warmer – 1* 11. Foetal Monitors – 6 12. Anaesthesia Work Station – 1 13. Adult Ventilator – 3 14. Portable 12 lead ECG machine – 1 15. Thermoelastometer - 1 *Keeping baby healthy is equally important and hence a dedicated radiant warmer is made available within the ICU to provide appropriate care to new-born and staff nurses will be appropriately trained for that. All efforts will be made to keep mother and baby together. Only sick Newborns will be admitted to SNCUs within the same facilities. Infrastructure upgradation: All obstetric ICUs are proposed within existing Ob-Gy departments, within close proximity of existing labour rooms. All the facilities are asked to undertake need assessment for infrastructure development (Repair, Renovation or Expansion) in close co-ordination of PIU (Program Implementation Unit) of the district. Standardized recording & reporting format: to ensure timely reporting in standardized formats, state level expert group was formulated to design formats. These formats are implemented in all Obstetric ICUs. IT enabled monitoring system will also be developed to further strengthen recording and reporting formats. Resources Mobilized: First three Obstetric ICUs were established in 2014-15 at three Medical College Hospitals through NHM funds. Later on this initiative was up scaled using state and NHM budget to accelerate the pace of operationalizing Obstetric ICUs. As of March 2017, total 20 Obstetric ICUs are proposed to be operationalized. Total 13 Obstetric ICUs are funded through state health budget while remaining 7 are funded from National Health Mission budget. So far 297 million INR (4.6 million USD) have been leveraged for Obstetric ICUs.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Following stakeholders were involved in designing and implementation of Obstetric ICUs.  Health and Family Welfare Department, Government of Gujarat  UNICEF, Gujarat  National Health Mission, Government of India  Medical college faculties from Government Medical College hospitals, Gujarat  Representatives from FOGSI

 8. What were the most successful outputs and why was the initiative effective?
• Reducing Maternal deaths in tertiary care institutions: single most successful output of Obstetric ICU is reduction in maternal deaths in tertiary care institutions. Maternal mortality in near miss cases have reduced from 2.3% before Obstetric ICUs to 1.1% after Obstetric ICUs. • Cost effectiveness of the initiative: cost of treatment in private ICUs is approximately 25000 INR (~400 USD) per day, while the same treatment is provided completely free to the patient in public health institution. At the same time average cost to run Obstetric ICU in public health institution was as low as 2240 INR (~35 USD) per patient per day. • Improving impression of public health institutions: State of the art facilities such as Obstetric ICUs have helped in building trust in public health institutions which have further positively deviated in form of increased public institutional deliveries and management of life threatening complications. There were no special promotion strategies for these ICUs, but testimonies of beneficiaries has further build image of public health institutions. • Health System Strengthening: Obstetric ICUs have facilitated development of dedicated facility for life threatening complications. These facility has also increased availability of sophisticated equipments and management as well as availability of well-trained health care professionals in tertiary care institutions. Within short span of two and half year this initiative has proven its effectiveness and government has up scaled it to all tertiary care institutions across the state. • Confidence building of health care professionals in public health institutions: availability of Obstetric ICU has tremendously helped in increasing confidence and competency of health care professionals in managing complications during pregnancy. At the same time peripheral institutions also feel confident of conducting deliveries at their institutions considering availability of tertiary care in nearby vicinity.

 9. What were the main obstacles encountered and how were they overcome?
Following were the major challenges encountered during operationalization of Obstetric ICUs. • Developing standards for operationalizing Obstetric ICUs was a challenging task since it is being developed for the first time in public health institutions. With the technical support of expert group and UNICEF, these challenges are being addressed now. However, there will be huge scope for improving quality of care and operating procedures. • Designing Obstetric ICUs in the existing medical college hospitals was a challenge considering limited availability of space and scope for renovation. However, in the newly planned hospitals there is scope to improve floor planning and designing. • Equipping all obstetric ICUs with all necessary equipment considering patient load and needs of the specialists is a constant challenge. After finalizing operational guidelines this has been addressed to some extent. • Recruitment and retention of specialists and medical officers considering low salary structure and undefined career progression opportunities. • Improving inter departmental co-ordination between department of Obstetrics, Anaesthesia and medicine within the medical college is challenge. Through periodic state level reviews with the Medical Superintendents and Head of Departments, this issue has been addressed to some extent. Continuous efforts will be required to foster co-ordination and work efficiency. • Tracking patients after discharge at least for 42 days to ensure intact survival.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Obstetric ICU at New Civil Hospital, Surat was selected to understand benefit from Obstetric ICU in improving maternal health. The methodology adopted was to select maternal near miss cases admitted in the same hospital from period of April 2014 - March 2014 and compare mortality in these cases compared to mortality in patients admitted in Obstetric ICU in same hospital during period of April 2015 – March 2016. Maternal Mortality has reduced significantly in almost all cases of near miss in Surat. • Post-Partum Haemorrhage: mortality has reduced from 10.5% (8 deaths/76 cases) to 2.3% (2 deaths/86 cases) • Ante-Partum Haemorrhage: mortality has reduced from 1.5% (2 deaths/133 cases) to 0% (0 deaths/172 cases) • Severe Anaemia: mortality has reduced from 0.8% (7 deaths/917 cases) to 0.3% (4 deaths/1167 cases) • Disseminated Intravascular coagulation (DIC): mortality has reduced from 100% (4 deaths/4 cases) to 60% (6 deaths/10 cases) • Jaundice in pregnancy: mortality has reduced from 14.8% (12 deaths/81 cases) to 5.4% (6 deaths/112 cases) • Sickle Cell Crisis in pregnancy: mortality has reduced from 13.3% (10 deaths/75 cases) to 1.8% (2 deaths/112 cases) • Overall Mortality reduction: Overall mortality reduced from 2.3% (51 deaths/2264 cases) to 1.1% (28 deaths/2479 cases). It can be observed that all indicators have shown decline in mortality while number of admission have increased substantially. It is further to be noted that cost of treatment in ICU setup in private sector costs around 400 USD per day while the same level of care is provided completely free to all beneficiary without discrimination cast, race, geography etc. similarly, expansion of this initiative across the state have ensured easy accessibility of dedicated ICUs for obstetric patients and thus by increasing utilization of services in these institutions.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Not Applicable

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Present initiative is exclusively developed for pregnant mothers. Furthermore, two obstetric ICUs are established at Himmatnagar and Valsad, which are high priority districts having large vulnerable population.

Contact Information

Institution Name:   Health & Family Welfare Department, Government of Gujarat
Institution Type:   Government Department  
Contact Person:   Dr. Prakash Vaghela
Title:   Additional Director (Family Welfare)  
Telephone/ Fax:   00917923253211
Institution's / Project's Website:  
E-mail:   addir.health.fw@gmail.com  
Address:   Commissionerate of Health, Block 5, Jivraj Mehta Bhavan
Postal Code:   382011
City:   Gandhinagar
State/Province:   Gujarat

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