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Monitoring emergency obstetric care
a handbook
Monitoringemergency obstetric care
a handbook
WHO Library Cataloguing-in-Publication Data :
Monitoring emergency obstetric care: a handbook.
1.Obstetrics - standards. 2.Emergency services, Hospital - statistics and numerical data. 3.Data collection - methods. 4.Quality indicators, Health care. 5.Maternal health services - supply and distribution. 6.Maternal mortality - prevention and control. 7.Handbooks. I.World Health Organization. II.United Nations Population Fund. III.UNICEF. IV.Mailman School of Public Health. Averting Maternal Death and Disability.
ISBN 978 92 4 154773 4 (NLM classification: WA 310)
© World Health Organization 2009
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Printed in
ContentsAbbreviations iv
Acknowledgements v
Preface vi
Executivesummary vii
1. INTRODUCTION 1
1.1Overviewofindicators 4
1.2SignalfunctionsofEmOC 6
1.3UseoftheEmOCindicators 9
2. INDICATORSFOREmOC 10
2.1Indicator1:AvailabilityofEmOCservices 10
2.2Indicator2:GeographicaldistributionofEmOCfacilities 13
2.3Indicator3:ProportionofallbirthsinEmOCfacilities 16
2.4Indicator4:MetneedforEmOC 19
2.5Indicator5:Caesareansectionsasaproportionofallbirths 25
2.6Indicator6:Directobstetriccasefatalityrate 31
2.7Indicator7:Intrapartumandveryearlyneonataldeathrate 34
2.8Indicator8:ProportionofdeathsduetoindirectcausesinEmOCfacilities 36
2.9Summaryandinterpretationofindicators1–8 38
3. COLLECTINGDATAFORTHEINDICATORS 43
3.1Typesofdatarequired 43
3.2Preparation 43
3.3Form1:AllpotentialEmOCfacilitiesinselectedareas 46
3.4Form2:ReviewofEmOCatfacilities 48
3.5Form3:SummaryofdataonEmOCfacilitiesinanarea 50
3.6Form4:Calculationofindicatorsforeacharea 51
3.7Form5:Calculationofindicatorsforthecountry 51
3.8Monitoringatthearealevel 51
REFERENCES 54
APPENDIXA: FormsandworksheetsfordatacollectionandcalculationofEmOCindicators 61
Form1.ListofpossibleEmOCfacilities 63
Form2.ReviewofpossibleEmOCfacilities 69
Form3.SummaryofdataonEmOCfacilitiesinthearea 85
Form4.Calculationofindicatorsforgeographicalarea 107
Form5.Calculationofindicatorsforacountry 123
APPENDIXB: Informationonregistersanddatacollection 145
APPENDIXC: Randomnumbertable 151
Monitoringemergencyobstetriccare:ahandbook iv
AbbreviationsAMDD AvertingMaternalDeathandDisabilityProgram
EmOC EmergencyObstetricCare
HIV Humanimmunodeficiencyvirus
UNFPA UnitedNationsPopulationFund
UNICEF UnitedNationsChildren’sFund
WHO WorldHealthOrganization
5Monitoringemergencyobstetriccare:ahandbook v
AcknowledgementsMonitoring emergency obstetric care: a handbook
waspreparedbyDeborahMaine(BostonUniversity,
Boston, Massachusetts, United States of America,
and the Averting Maternal Death and Disability
Program (AMDD),MailmanSchoolofPublicHealth,
ColumbiaUniversity,NewYorkCity,NewYork,United
States), Patsy Bailey (Family Health International,
Research Triangle Park, North Carolina, United
States, and AMDD), Samantha Lobis (AMDD) and
JudithFortney(AMDD).
ThehandbookisbasedonthepublicationGuidelines
for monitoring the availability and use of obstet-
ric services (1997) prepared by Deborah Maine,
TessaWardlaw(UNICEF)andateamfromColumbia
University(VictoriaWard,JamesMcCarthy,Amanda
Birnbaum,MuratAlkalinandJenniferBrown),andon
recommendations made during a technical consul-
tationheld in2006atWHOinGeneva, inwhichthe
following persons participated: Patsy Bailey (Family
Health International and AMDD), Shelah Bloom
(University of North Carolina, Chapel Hill, North
Carolina,UnitedStates),DavidBraunholtz (Initiative
for Maternal Mortality Programme Assessment
(IMMPACT) Project, University of Aberdeen,
Aberdeen, Scotland), Vincent de Brouwere (Prince
Leopold Institute of Tropical Medicine, Antwerp,
Belgium),MarcDerveeuw(UNFPA),HemantDwivedi
(UNFPA), Øystein Evjen Olsen (Institute for Health
ResearchandDevelopmentandPrimaryHealthCare,
Iringa,UnitedRepublicofTanzania),VincentFauveau
(UNFPA), Judith Fortney (AMDD), Lynn Freedman
(AMDD), Joan Healy (Ipas, Chapel Hill, North
Carolina, United States) Justus Hofmeyr (University
of the Witwatersrand, Johannesburg, South Africa),
Samantha Lobis (AMDD), Deborah Maine (Boston
University, Boston, Massachusetts, United States,
and AMDD), Saramma Mathai (UNFPA), Affette
McCaw-Binns(UniversityoftheWestIndies),Isabelle
Moreira(UNFPA),LuweiPearson(UNICEF),Rosalind
Raine(UniversityCollegeLondon,London,England),
Geetha Rana (UNICEF), Judith Standley (UNICEF),
Nancy Terreri (UNICEF), Kanako Yamashita-Allen
(World Bank, Washington DC, United States), Jelka
Zupan (WHO), Katherine Ba-Thike (WHO), Alexis
Ntabona(WHO),MatthewsMatthai(WHO).
LaleSay(WHO)helpedinrevisionofthehandbookby
facilitating the technicalconsultation, reviewingdraft
versions, and coordinating the publishing process.
VincentFauveau (UNFPA), JudithStandley (UNICEF)
and Lynn Freedman (AMDD) reviewed many drafts
within their organizations. Jennifer Potts (AMDD)
and Vincent de Brouwere reviewed several versions
andmadesubstantivecontributionstothetext.Yves
Bergevin (UNFPA), Luc de Bernis (UNFPA), Juliana
Bol (RAISE Initiative, Columbia University, New York
City, New York, United States), Sara Casey (RAISE
Initiative),FranceDonnay(UNFPA),MetinGulmezoglu
(WHO),JoanHealy(Ipas),RitaKabra(WHO),Barbara
Kwast(AMDD),CarineRonsmans(LondonSchoolof
HygieneandTropicalMedicine,London,England)and
CynthiaStanton(JohnsHopkinsBloombergSchoolof
PublicHealth,Baltimore,Maryland,UnitedStates)also
reviewed the handbook. Lucy Anderson, Alexandra
DelValle, Gina Gambone, Laura Harris, and Christen
Mullenhelped incompilationof the references.Paul
VanLookreviewedthetext.
ConflictofinterestThe participants of the technical consultation were
primarily independent experts from academia. No
conflicts of interest were declared. Other partici-
pantsincludedstafffromWHO,UNFPA,UNICEF,and
Columbia University who have been engaged in in-
countryapplicationoftheindicatorsreviewedatthe
consultation.
Monitoringemergencyobstetriccare:ahandbook vi
PrefaceEfforts to improve the lives of women and children
aroundtheworldhaveintensifiedsinceworldleaders
adoptedtheUnitedNationsMillenniumDeclarationin
September2000andcommittedthemselvestoreach-
ingMillenniumDevelopmentGoals4and5,onchild
mortalityandmaternalhealth.Theoriginaltargetsfor
theseGoalswereatwo-thirdsreductioninthemortal-
ityofchildrenunder5andathree-quartersreduction
inthematernalmortalityratiobetween1990and2015.
Thereisworldwideconsensusthat,inordertoreach
thesetargets,good-qualityessentialservicesmustbe
integratedintostronghealthsystems.Theadditionin
2007ofanewtarget inGoal5—universalaccess to
reproductivehealthby2015—reinforcesthisconsen-
sus:allpeopleshouldhaveaccesstoessentialmater-
nal,newborn,childand reproductivehealthservices
providedinacontinuumofcare.
In order to reduce maternal mortality, Emergency
ObstetricCare(EmOC)mustbeavailableandacces-
sible toallwomen.Whileallaspectsof reproductive
healthcareincludingfamilyplanninganddeliverywith
the help of a skilled health professional also plays
an important role in reducingmaternal andneonatal
mortality, this handbook focuses on the critical role
of EmOC in saving the lives of women with obstet-
riccomplicationsduringpregnancyandchildbirthand
savingthe livesofnewborns intrapartum.Thehand-
bookdescribesindicatorsthatcanbeusedtoassess,
monitorandevaluatetheavailability,useandquality
ofEmOC.
Whilst this handbook focuses on emergency care,
abroadersetof indicatorsshouldbeused tomoni-
tor fundamental aspects of reproductive health pro-
grammes designed to reduce maternal mortality,
ensure universal access to reproductive health care
andreducechildmortality.
7 This page has been left blank
ExecutivesummaryReducing maternal mortality has arrived at the top
of health anddevelopment agendas.Toachieve the
MillenniumDevelopmentGoalofa75%reduction in
thematernalmortalityratiobetween1990and2015,
countries throughout the world are investing more
energy and resources into providing equitable, ade-
quate maternal health services. One way of reduc-
ingmaternalmortalityisbyimprovingtheavailability,
accessibility,qualityanduseofservicesforthetreat-
ment of complications that arise during pregnancy
andchildbirth.Theseservicesarecollectivelyknown
asEmergencyObstetricCare(EmOC).
Sound programmes for reducing maternal mortality,
likeallpublichealthprogrammes,shouldhaveclear
indicators in order to identify needs, monitor imple-
mentation and measure progress. In order to fulfil
these functions, thedatausedtoconstruct the indi-
catorsshouldbeeitheralreadyavailableorrelatively
easyandeconomicaltoobtain.Theindicatorsshould
beabletoshowprogressoverarelativelyshorttime,
insmallaswellaslargeareas.Most importantly,the
indicators should provide clear guidance for pro-
grammes—showing which components are working
well,whichneedmore inputorneed tobechanged
andwhatadditionalresearchisneeded.
For a variety of technical and financial reasons, the
maternalmortalityratiodoesnotmeettheserequire-
ments.Consequently,in1991,UNICEFaskedColumbia
University(NewYorkCity,NewYork,UnitedStatesof
America)todesignanewsetofindicatorsforEmOC.
Thefirstversionwastestedin1992.In1997,theindi-
cators were published as Guidelines for monitoring
theavailabilityanduseofobstetricservices,issuedby
UNICEF,WHOandUNFPA(1).Theseindicatorshave
beenusedbyministriesofhealth,internationalagen-
cies and programme managers in over 50 countries
aroundtheworld.
InJune2006,aninternationalpanelofexpertspartici-
patedinatechnicalconsultationinGenevatodiscuss
modificationstotheexistingindicatorsforEmOCand
revisions to the Guidelines, taking into account the
accumulatedexperienceandincreasedknowledgein
theareaofmaternalhealthcare.Thepresenthand-
book contains the agreed changes, including two
newindicatorsandanadditionalsignalfunction,with
updated evidence and new resources. In addition,
the Guidelines were renamed as the Handbook, to
emphasizethepracticalpurposeofthispublication.
The purpose of this handbook is to describe the
indicatorsandtogiveguidanceonconductingstud-
iestopeopleworkinginthefield.Itincludesalistof
life-savingservices,or ‘signal functions’, thatdefine
a health facility with regard to its capacity to treat
obstetricandnewbornemergencies.Theemphasisis
onactual rather thantheoretical functioning.Onthe
basisoftheperformanceoflife-savingservicesinthe
past3months,facilitiesarecategorizedas‘basic’or
‘comprehensive’.Thesectiononsignalfunctionsalso
includesanswerstofrequentlyaskedquestions.
TheEmOCindicatorsdescribedinthishandbookcan
beusedtomeasureprogressinaprogrammaticcon-
tinuum:fromtheavailabilityofandaccesstoEmOC
totheuseandqualityofthoseservices.Theindica-
torsaddressthefollowingquestions:
• ArethereenoughfacilitiesprovidingEmOC?
• Arethefacilitieswelldistributed?
• Areenoughwomenusingthefacilities?
• Aretherightwomen(i.e.womenwithobstetric
complications)usingthefacilities?
• Areenoughcriticalservicesbeingprovided?
• Isthequalityoftheservicesadequate?
Monitoringemergencyobstetriccare:ahandbook vii
Monitoringemergencyobstetriccare:ahandbook
Thehandbookprovidesadescriptionofeachindica-
torandhowitisconstructedandhowitcanbeused;
the minimum and/or maximum acceptable level (if
appropriate); the background of the indicator; data
collection and analysis; interpretation and presenta-
tionoftheindicator;andsuggestionsforsupplemen-
tarystudies.Thereisafurthersectiononinterpretation
ofthefullsetofindicators.Sampleformsfordatacol-
lectionandanalysisareprovided.
Useof theseEmOC indicators toassessneedscan
help programme planners to identify priorities and
interventions. Regular monitoring of the indicators
alerts managers to areas in which advances have
beenmadeandthosethatneedstrengthening.Close
attention to the functioningofkeyservicesandpro-
grammescansubstantiallyandrapidlyreducemater-
nalmortalityindevelopingcountries.
viii
Monitoringemergencyobstetriccare:ahandbook 1
1.IntroductionOverthepasttwodecades,theinternationalcommu-
nityhasrepeatedlydeclareditscommitmenttoreduce
the high levels of maternal mortality in developing
countries, starting with the 1987 Safe Motherhood
Conference in Nairobi, Kenya, followed by the 1990
World Summit for Children at United Nations head-
quarters, the 1994 International Conference on
Population and Development in Cairo, Egypt, the
1995FourthWorldConferenceonWomeninBeijing,
China,‘Nairobi10YearsOn’inSriLankain1997,and
theMillenniumDevelopmentGoalsestablishedbythe
UnitedNationsin2000.In2007,anumberofevents
marked the20thanniversaryof the launchingof the
Safe Motherhood Initiative, including the Women
DeliverConferenceinLondon,England,atwhichcalls
were made for renewed commitment, programmes
and monitoring. Most importantly, over the past 20
years,consensushasbeenreachedontheinterven-
tions that are priorities in reducing maternal mortal-
ity (2). Stakeholders agree that good-quality EmOC
shouldbeuniversallyavailableandaccessible,thatall
womenshoulddelivertheirinfantsinthepresenceof
aprofessional,skilledbirthattendant,andthatthese
keyservicesshouldbeintegratedintohealthsystems.
It becameclear earlyon, however, that itwouldnot
be simple to measure progress in this area. The
conventional approach was to monitor the number
of maternal deaths with ‘impact’ indicators such
as the maternal mortality ratio. In theory, repeated
measurements of this ratio over time can be used
to monitor trends. This approach has a number of
serious drawbacks, both technical and substantive.
Maternal mortality is extremely difficult and costly
to measure when vital registration systems are
weak, and even when systems are strong (3). Even
innovativemethodspresentdifficulties.Forexample,
the direct ‘sisterhood’ method provides information
forareferenceperiodof7yearsbeforeasurvey;thus,
the informationgathereddoesnotreflectthecurrent
situationorprogressmaderecently.Recentadvances
in sampling procedures for the sisterhood method
have, however, greatly increased its efficiency and
havedecreasedcosts.Thesechangesallowforlarger
samplesandconsequentlyashorterreferenceperiod
andnarrowerconfidenceintervalsthanthetraditional
approach. Even this method, however, is known to
give underestimates of the maternal mortality ratio
(4,5).
Another approach is use of ‘process,’ ‘output’ or
‘outcome’ indicators, to measure the actions that
prevent deaths or illness. Widely used process
indicatorsincluderatesofchildhoodimmunizationand
contraceptiveprevalence.Thishandbookpresentsa
seriesofindicatorsdesignedtomonitorinterventions
that reduce maternal mortality by improving the
availability, accessibility, use and quality of services
for the treatmentofcomplicationsduringpregnancy
andchildbirth.Theindicatorsarebasedoninformation
from health facilities with data on population and
birth rates. There are several advantages to this
approach. First, the indicators can be measured
repeatedlyatshortintervals.Secondly,theindicators
provide information that isdirectlyuseful forguiding
policies and programmes and making programme
adjustments.Itisimportanttorememberthatalthough
‘process,’‘output’and‘outcome’indicatorsaremore
useful,practicaland feasible than impact indicators,
formanyreasons, thesemeasurescannotsubstitute
formaternalmortalityratiosasadirectmeasureofthe
overalllevelofmaternalmortalityinapopulation.
TheGuidelinesformonitoringtheavailabilityanduseof
obstetricserviceswereinitiallydevelopedbyColumbia
University’sSchoolofPublicHealth,supportedbyand
incollaborationwithUNICEFandWHO.Adraftversion
wasissuedin1992,andtheguidelineswereformally
publishedbyUNICEF,WHOandUNFPA in1997 (1).
Since then, they have been used in many countries
(Table 1). The present document is a revision of the
1997versionoftheguidelines,incorporatingchanges
based on monitoring and assessment conducted
worldwide.
The recommendations related to measuring the
indicatorswerereviewedandupdatedonthebasisof
existingevidence,aswellasexperienceinusingthe
indicatorswithincountryprogrammes.
These recommendations will be updated regularly
usingstandardWHOprocedures. It isexpectedthat
thenextupdatewillbein2014.
1
Monitoringemergencyobstetriccare:ahandbook 2
Regionandcountry Useofindicators References
Africa
Angola Nationalneedsassessment(reportinprogress)
Benin Nationalneedsassessment (6,7)
Burundi NeedsassessmentplannedwithUNICEF
Cameroon Subnationalneedsassessment (8-10)
Chad Nationalneedsassessment (7,11)
Comoros (12)
Côted’Ivoire Nationalneedsassessment (10,13)
Eritrea Needsassessmentwithpartialcoverage (14)
Ethiopia Programmemonitoringandevaluation;needsassessmentwithpartialcoverage1
(15)
Gabon Nationalneedsassessment (16,17)
Gambia Nationalneedsassessment (17,18)
Ghana Subnationalneedsassessment (19)
Guinea Subnationalneedsassessment (20)
GuineaBissau Nationalneedsassessment (17,21)
Kenya Subnationalneedsassessments2 (22-24)
Lesotho Nationalneedsassessment (25)
Madagascar Subnationalneedsassessments (26)
Malawi Nationalneedsassessment;programmemonitoringandevaluation
(27-30)
Mali Nationalneedsassessment;programmemonitoringandevaluation
(31,32)
Mauritania Nationalneedsassessment (10,33)
Mozambique Nationalneedsassessment;programmemonitoringandevaluation(datanotyetanalysed)
(34-37)
Namibia Needsassessment (38)
Niger Needsassessment (10,39)
Rwanda Subnationalneedsassessment;programmemonitoringandevaluation
(15,23,39-42)
Senegal Nationalneedsassessment (10,37,43)
SierraLeone Nationalneedsassessment (44)
Uganda Nationalneedsassessment (23,45,46)
UnitedRepublicofTanzania Nationalneedsassessment;programmemonitoringandevaluation
(15,39,47-51)
Zambia Nationalneedsassessment (52)
Zimbabwe Nationalneedsassessment (53,54)
Americas
Bolivia Nationalneedsassessment3 (55,56)
Ecuador NationalneedsassessmentwithUNFPA,2006
ElSalvador Nationalneedsassessment (56-58)
Guatemala Needsassessment (59)
Honduras Nationalneedsassessment (56,60)
Nicaragua Nationalandsubnationalneedsassessments;programmemonitoringandevaluation
(61,62)
Peru Needsassessmentswithpartialcoverage;programmemonitoringandevaluation4
(63-65)
UnitedStates Nationalneedsassessment (66)
Table 1. Selected countries in which emergency obstetric care indicators were used in assessing needs or for monitoring and evaluation (2000–2007)
Monitoringemergencyobstetriccare:ahandbook 3
Regionandcountry Useofindicators References
EasternMediterranean
Afghanistan Needsassessmentswithpartialcoverage (67)
Djibouti Nationalneedsassessment (68)
Iraq Needsassessmentplanned
Morocco Nationalneedsassessment;programmemonitoringandevaluation
(62,69)
Pakistan Needsassessmentswithpartialcoverage;programmemonitoringandevaluation
(70-73)
Somalia Subnationalneedsassessment (74)
Sudan Nationalneedsassessment (23,75)
SyrianArabRepublic Nationalneedsassessment5
Yemen Needsassessmentswithpartialcoverage
Europe
Kyrgyzstan Nationalneedsassessment6
Tajikistan Nationalneedsassessment;programmemonitoringandevaluation7
(76)
South-EastAsia
Bangladesh Nationalandsubnationalneedsassessments;programmemonitoringandevaluation
(77-79)
Bhutan Needsassessment;programmemonitoringandevaluation (9,80)
India Needsassessmentswithpartialcoverage;programmemonitoringandevaluation
(9,81-85)
Nepal Subnationalneedsassessment;programmemonitoringandevaluation
(37,86-88)
SriLanka Subnationalneedsassessment;programmemonitoringandevaluation
(62,89)
Thailand Needsassessmentwithpartialcoverage (90)
WesternPacific
Cambodia Planned
Mongolia Planned
VietNam Needsassessmentwithpartialcoverage;programmemonitoringandevaluation
(91,92)
1CARE.Unpublisheddata.2000.2DoctorsoftheWorld.WestPokotfacilityneedsassessment—maternalandnewborncare.Unpublisheddata.Nairobi,2007.3EngenderHealthAcquireProject.Unpublisheddata.2007.4CARE.Unpublisheddata.2004:Huancavelicaregion,Peru.5MinistryofHealthandUNICEF,Unpublisheddata.2004:Syria.6MinistryofHealthofKyrgyzstanandUNICEF,StatusofEmergencyObstetricCare(EOC)intheKyrgyzRepublic.Unpublished.2005.7MinistryofHealthofTajikistanandUNICEF,Unpublisheddata.Dushanbe,2005.
Monitoringemergencyobstetriccare:ahandbook 4
Inthisnewedition,theindicatorshavebeenrevisedto
reflect10years’wealthofexperience.Otherchanges
reflect the broadening of programmes; e.g. a signal
function on treatment of complications in newborns
and new indicators on perinatal mortality and on
maternaldeaths reportedasdue to indirect causes,
such as HIV and malaria, have been added. These
changes were discussed and agreed by an interna-
tionalpanelofexpertsatthetechnicalconsultationin
June2006(93).Duringthereview,itwasalsodecided
tochangethetitle.Weusetheterm‘handbook’rather
than ‘guidelines,’ because ‘handbook’ reflects more
accurately the practical nature of this document.
Anotherchangemadeinthiseditionisreplacementof
‘essentialobstetriccare’by‘EmOC’.1Overtheyears,
theterminologyhasbeenadjustedsothattheindica-
torsrelatespecificallytotreatmentoftheemergency
obstetric complications that cause most maternal
deaths.
Thishandbookincludesanexplanationofthecurrent
indicatorsforEmOCandtheirimplications,suggests
supplementarystudiesthatcanimproveunderstanding
ofthesituationinagivenarea,andprovidesanswers
to common questions that arise when using the
indicators.Thisisfollowedbyworksheetsandtables
toillustratestudyquestionsandcalculations.
Theindicatorsdescribedcanbeusedatanystageof
thedesignandimplementationofEmOCprogrammes
and can be incorporated into routine health
managementinformationsystems.Inmanycountries,
theseindicatorshaveprovidedtheframeworkformore
detailed assessments of national needs for EmOC,
establishingtheavailability,useandqualityofservices
and the specific information needed for detailed
programmeplanning,suchasequipmentinventories.2
Modules for conducting needs assessments can be
foundat:www.amddprogram.org.
1.1Overviewofindicators
Inthesectionsbelow,wepresentaseriesofindicators
formonitoringprogressinthepreventionofmaternal
andperinataldeaths.Theirorderisbasedonthelogic
that,forwomentoreceiveprompt,adequatetreatment
forcomplicationsofpregnancyandchildbirth,facilities
forprovidingEmOCmust:
• existandfunction,
• begeographicallyandequitablydistributed,
• beusedbypregnantwomen,
• beusedbywomenwithcomplications,
• providesufficientlife-savingservices,and
• providegood-qualitycare.
Thus,theindicatorsanswerthefollowingquestions:
• ArethereenoughfacilitiesprovidingEmOC?
• Arethefacilitieswelldistributed?
• Areenoughwomenusingthefacilities?
• Aretherightwomenusingthefacilities?
• Areenoughcriticalservicesbeingprovided?
• Isthequalityofservicesadequate?
Thefirstindicatorthereforefocusesontheavailability
ofEmOCservices.Adequatecoveragemeansthatall
pregnantwomenhaveaccesstofunctioningfacilities.
Once availability is established, questions of use
can be addressed. Even if services are functioning,
if women with complications do not use them (for
whateverreason),theirlivesareindanger.Finally,the
indicators cover theperformanceof health services.
Afterall,manywomendieinhospital:someofthemdie
because theywerenotadmitteduntil theircondition
wascritical;manyothers,however,diebecausethey
didnotreceivetimelytreatmentatahealthfacilityor
becausethetreatmenttheyreceivedwasinadequate.
Table2showsthesixEmOCindicatorsissuedin1997,
withsomeminormodificationssuggestedbythe2006
technicalconsultationonthebasisoftheparticipants’
expertiseandexperienceinvariouscountries:
1
‘Emergency obstetric care’ or ‘EmOC’ is being used in thisdocument rather than ‘emergency obstetric and newborn care’or ‘EmONC’ because this set of indicators focus primarily onobstetric complications and procedures. While there is one newsignalfunctiononneonatalresuscitationandonenewindicatoronintrapartumcare fromtheperspectiveof thenewborn, thesetofindicatorsdonot represent the full rangeofemergencynewbornprocedures.2Theseassessmentsalsoincludemoreinformationonemergencynewborncare,andareoftencalledEmONCneedsassessments.
Monitoringemergencyobstetriccare:ahandbook 5
• Therecommendationforthemixtureofbasic
andcomprehensiveEmOCfacilitiesper500000
populationhasbeenchangedfrom‘atleastone
comprehensiveandfourbasicEmOCfacilitiesper
500000population’to‘atleastfiveEmOCfacili-
tiesincludingatleastonecomprehensivefacility
per500000population’.
Table 2. The original six emergency obstetric care indicators, with modifications
Indicator Acceptablelevel
1. Availabilityofemergencyobstetriccare:basicandcomprehensivecarefacilities
Thereareatleastfiveemergencyobstetriccarefacilities(includingatleastonecomprehensivefacility)forevery500000population
2. Geographicaldistributionofemergencyobstetriccarefacilities
Allsubnationalareashaveatleastfiveemergencyobstetriccarefacilities(includingatleastonecomprehensivefacility)forevery500000population
3. Proportionofallbirthsinemergencyobstetriccarefacilitiesa
(Minimumacceptableleveltobesetlocally)
4. Metneedforemergencyobstetriccare:proportionofwomenwithmajordirectobstetriccomplicationswhoaretreatedinsuchfacilitiesa
100%ofwomenestimatedtohavemajordirectobstetriccomplicationsbaretreatedinemergencyobstetriccarefacilities
5. Caesareansectionsasaproportionofallbirthsa Theestimatedproportionofbirthsbycaesareansectioninthepopulationisnotlessthan5%ormorethan15%c
6. Directobstetriccasefatalityratea Thecasefatalityrateamongwomenwithdirectobstetriccomplicationsinemergencyobstetriccarefacilitiesislessthan1%
• Theminimumacceptablelevelforindicator3was
removed,andcountriesareadvisedtousetheir
owntargets.
• Thenameofindicator6hasbeenupdatedfrom:
‘casefatalityrate’to‘directobstetriccasefatality
rate’.
Adaptedfromreference(1).aWhiletheseindicatorsfocusonservicesprovidedinfacilitiesthatmeetcertainconditions(andthereforequalifyas‘emergencyobstetriccarefacilities’),westronglyrecommendthattheseindicatorsbecalculatedagainwithdatafromallmaternityfacilitiesintheareaeveniftheydonotqualifyasemergencyobstetriccarefacilities.bTheproportionofmajordirectobstetriccomplicationsthroughoutpregnancy,deliveryandimmediatelypostpartumisestimatedtobe15%ofexpectedbirths.cSeesection2.5foradiscussionofthisrange.
These indicators refer to the availability and use of
facilitiesandtheperformanceofhealth-caresystems
insavingthelivesofwomenwithobstetriccomplica-
tions.Theacceptablelevelsofmostoftheindicators
are specified as minimum and/or maximum and are
necessarilyapproximate.Theyarebasedonthebest
data,estimates,andassumptionscurrentlyavailable.
The acceptable levels can be adapted according to
countries’circumstances;however, if theyaremodi-
fied,itisimportanttoreportthefindingsinrelationto
thestandardlevelssuggestedhere,sothattheresults
canbecomparedwiththosefromotherstudies.
Theseindicatorscanbeusedtosetprioritiesforpro-
grammes as well as to monitor them. Programme
plannersandmanagers responsible for reducing the
numberofmaternaldeathscanstartatthetopofthe
listandworkdown.Whentheyreachanindicatorfor
whichthecountrydoesnotmeettheacceptablelevel,
appropriateinterventionsareneeded.Forexample,if
a country meets the acceptable levels for the num-
ber and distribution of EmOC facilities but not for
theiruse,interventionsareneededtounderstandand
improveuse.
Monitoringemergencyobstetriccare:ahandbook 6
Table3setsouttwonewindicatorsthatwereadopted
at the2006technicalconsultationontheguidelines.
Thesereflecttheevolutionofthematernalhealthfield:
indicator7reflectstherenewedfocusonthequalityof
obstetriccareandtheassociationbetweenmaternal
andneonatalhealth,and indicator8 reflects indirect
causesofmaternaldeathsinsomecountries,suchas
malaria.
Table 3. New indicators for emergency obstetric care
Indicator Acceptablelevel
7. Intrapartumandveryearlyneonataldeathrate Standardstobedetermined
8. Proportionofmaternaldeathsduetoindirectcausesinemergencyobstetriccarefacilities
Nostandardcanbeset
Theseindicatorsshouldalsobecalculatedwithdataforallfacilitiesinthearea,ifpossible.
1.2SignalfunctionsofEmOC
Forthepurposesofassessingandmonitoringthelevel
ofcarethatafacilityisactuallyproviding,itishelpful
touseashortlistofclearlydefined‘signalfunctions’.
Thesearekeymedical interventionsthatareusedto
treatthedirectobstetriccomplicationsthatcausethe
vastmajorityofmaternaldeathsaroundtheglobe.The
listofsignalfunctionsdoesnotincludeeveryservice
thatoughttobeprovidedtowomenwithcomplicated
pregnancies or to pregnant women and their new-
bornsingeneral;thatinformationisprovidedinother
publications (94-96).Thesignal functionsare indica-
torsofthelevelofcarebeingprovided.Furthermore,
somecriticalservicesaresubsumedwithinthesesig-
nalfunctions.Forexample,ifcaesareansectionsare
performedinafacility,thisimpliesthatanaesthesiais
being provided. While the signal functions are used
toclassify facilitiesonthebasisthat thesefunctions
havebeenperformedinthepast3months,itishelpful
touseamoreinclusivelistoffunctionsandsupplies
whenassessingneedforEmOCinordertoplanpro-
grammes.
Thelistofsignalfunctionsinthiseditionofthehand-
bookhasbeenupdatedwiththeadditionofthenew
function:‘performneonatalresuscitation’atbasicand
comprehensivelevels.Inaddition,thenameofthesec-
ondsignal functionhasbeenchanged from ‘admin-
ister parenteral oxytocics’ to ‘administer uterotonic
drugs’.ThelistofsignalfunctionsinTable4includes
afewexamplesofdrugsorequipmentthatcouldbe
usedwhenperformingthesignalfunctions;however,
the drugs and procedures mentioned are illustrative
and not exhaustive. For a complete list of recom-
mendedproceduresanddrugs,pleaserefertoWHO’s
Managingcomplicationsinpregnancyandchildbirth:
aguideformidwivesanddoctors(95)andManaging
newborn problems: a guide for doctors, nurses and
midwives(96).
Monitoringemergencyobstetriccare:ahandbook 7
Table 4. Signal functions used to identify basic and comprehensive emergency obstetric care services
Basicservices Comprehensiveservices
(1) Administerparenteral1antibiotics Performsignalfunctions1–7,plus:
(2)Administeruterotonicdrugs2(i.e.parenteraloxytocin)
(8)Performsurgery(e.g.caesareansection)
(3)Administerparenteralanticonvulsantsforpre-eclampsiaandeclampsia(i.e.magnesiumsulfate).
(9)Performbloodtransfusion
(4) Manuallyremovetheplacenta
(5)Removeretainedproducts(e.g.manualvacuumextraction,dilationandcurettage)
6) Performassistedvaginaldelivery(e.g.vacuumextraction,forcepsdelivery)
(7) Performbasicneonatalresuscitation(e.g.withbagandmask)
Abasicemergencyobstetriccarefacilityisoneinwhichallfunctions1–7areperformed.Acomprehensiveemergencyobstetriccarefacilityisoneinwhichallfunctions1–9areperformed.
Pleaserefertothefollowingwebsitesforrecommendedproceduresforeachsignalfunctionlistedabove:- Managingcomplicationsinpregnancyandchildbirth:aguideformidwivesanddoctors: http://www.who.int/making_pregnancy_safer/documents/9241545879/en/index.html- Cochranereviews:http://www.cochrane.org/reviews
Adaptedfromreference(1).1Injectionorintravenousinfusion.2Uterotonicdrugsareadministeredbothtopreventandtotreatpostpartumhaemorrhage.ArecentWHOtechnicalconsultation(Nov2008)todevelopguidelinesforinterventionsforpreventingpostpartumhaemorrhage,reviewedallavailableevidence,andidentifiedparenteraloxytocinastherecommendedchoiceofdrugforpreventionofpostpartumharemorrhage.Parenteralergometrine(2ndline)andmisoprostol(3rdline)areoptionsthatshouldonlybeusedwhereoxytocinisnotavailable.
Table 5. Signal functions and related complications
Majorobstetriccomplication Signalfunction
Haemorrhage Antepartum:PerformbloodtransfusionPerformsurgery(e.g.caesareansectionforplacentapraevia)Postpartum:AdministeruterotonicdrugsPerformbloodtransfusionPerformmanualremovalofplacentaPerformremovalofretainedproductsPerformsurgery(hysterectomy)foruterinerupture
Prolongedorobstructedlabour PerformassistedvaginaldeliveryPerformsurgery(caesareansection)AdministeruterotonicdrugsPerformneonatalresuscitation
Postpartumsepsis AdministerparenteralantibioticsRemoveretainedproductsPerformsurgeryforpelvicabscess
Table5 showswhichsignal functionsareused to treat themajordirectobstetric complications that cause
mostmaternaldeaths.Box1listsanumberofquestionsfrequentlyaskedaboutthesignalfunctions,withtheir
answers.
Monitoringemergencyobstetriccare:ahandbook 8
Majorobstetriccomplication Signalfunction
Complicationsofabortion Forhaemorrhage:PerformbloodtransfusionRemoveretainedproductsForsepsis:AdministerparenteralantibioticsRemoveretainedproductsForintra-abdominalinjury:AdministerparenteralantibioticsPerformbloodtransfusionPerformsurgery
Pre-eclampsiaoreclampsia AdministerparenteralanticonvulsantsPerformneonatalresuscitationPerformsurgery(caesareansection)
Ectopicpregnancy PerformsurgeryPerformbloodtransfusion
Ruptureduterus PerformsurgeryPerformbloodtransfusionAdministerparenteralantibiotics
Newborndistress(intrapartum) PerformnewbornresuscitationPerformsurgery(caesareansection)
Adaptedfromreference(97).
Box 1. Frequently asked questions about signal functions
• Whyuseparenteraladministration,ratherthanoral?Inanemergency,theremustbeaquickphysiologicalresponsetoantibiotics,oxytocicsandanticonvulsantswhenneeded.Inaddition,thekeylifesavingdrugsformaincomplicationscanonlybeadministeredparenteral.Therefore,thedefinitionspecifiesparenteralratherthanoraladministration.
• Whyweretheseitemsselectedassignalfunctionsandnotothers?Other itemshavebeendiscussedassignalfunctions,suchasuseofthepartograph,activemanagementofthethirdstageoflabour,availabilityofservices24h/day,7days/week,intravenousfluids,anaesthesiaandplasmaexpanders.Useofthepar-tographandactivemanagementofthethirdstageoflabourarebothpartofgoodobstetricpracticeandshouldbeusedforallwomeninlabourtopreventprolonged,obstructedlabouranditssequelae,suchasobstetricfistula.Availabilityofservices24h/day,7days/weekisafunctionofmanagementandplanningratherthana life-savingskill. Intravenousfluidsare implicit inthesignal functionsthatrequireparenteraldrugs.Anaesthesiaandplasmaexpandersarealsoimplicitintheavailabilityofobstetricsurgery,e.g.cae-sareansection.Althoughtheeightoriginalobstetricsignal functionsdonot formanexhaustive list, theywerechosenbecauseoftheroletheyplayinthetreatmentofthefivemajorcausesofmaternaldeath.
• WherecanIobtainamorecompletelistoffunctionsandequipmentformaternalandnewbornhealth?Thewebsites of WHO (http://www.who.int/reproductive-health/publications/pcpnc/) (98), the Johns HopkinsProgramfor InternationalEducationinGynecologyandObstetrics(http://www.jhpiego.org/scripts/pubs/category_detail.asp?category_id=24) (99) and AMDD (http://www.amddprogram.org/resources/DesignEvalMM-EN.pdf) (100)provide linkstomanualswithmorecomplete inventoriesofdrugs,suppliesandequipmentforhealthcentresandhospitals.
Monitoringemergencyobstetriccare:ahandbook 9
• Whydon’tthesignalfunctionsincludespecificdrugsorequipment?Wehopethatinternationalstandardsofcarewillbeusedtodetermineinpracticewhichdrugsandtypesofequipmentareusedtoperformthesignalfunctions.Thesestandardsaredynamicandcanchangeoverlongperiodswithtechnologicalprog-ress.WeencourageuseoftheWHOguidelinesofcare,theReproductiveHealthLibrary(http://www.who.int/rhl),theCochraneCollaborationsystematicreviewsandotherinternationalresources.ThelistofsignalfunctionsinTable4doesincludeafewexamplesofdrugsorequipmentthatcouldbeused,butthelistofoptionsisnotexhaustive.
• Whyusethe3–monthreferenceperiodasopposedtoalongertime?The3–monthreferenceperiodwaschosenbecauseitprovidesasnapshotofthecurrentfunctioningofafacility.Itwasalsoselectedbecauserecallislessaccurateoverlongerperiodsandbecauseskills(suchasvaginaldeliverywithavacuumextrac-tor,caesareansectionormanualremovaloftheplacenta)aremorelikelytobemaintainediftheyareusedfrequently.Monitoringthedeliveryofservicesandstockoutsareconsiderationsforhealthserviceplanners.
• Whatshouldwedowhena facility that isbeingmonitoredprovidesbasicorcomprehensiveemergencyobstetriccareirregularlybecauseofoneortwomissingsignalfunctions?Thisisnotaprobleminafacility-basedsurveyoraneedsassessment,asthetechnicalguidelineistoassesstheperformanceofthesignalfunctionsinthemostrecent3–monthperiod.Itbecomesanissuewhenmonitoringemergencyobstetriccarestatusovertime.Itisnotuncommonforafacilitytochangeitsstatuswhenithasasmallcaseloadorfrequentstaffturnover.Forpragmaticandprogrammaticreasonsinregionalornationalmonitoring,werec-ommendannualreclassification.Districtmanagerscanmonitortheirownperformancemorefrequentlyandshouldbeencouragedtodosoinordertoassesstheirfunctioningandtoprovidedatafordecision-makingtoimproveservices.
• Whatdowedoifasignalfunctionisperformedduringthe3–monthreferenceperiodbutnotinanobstetriccontext?Mostofthesignalfunctionsarelikelytobeperformedonlyinanobstetriccontext,butparenteralantibioticsoranticonvulsantsandbloodtransfusionscanbeadministeredinothercontexts.Inanassess-mentofaninstitution’scapacityandperformancefordeliveringemergencyobstetriccare,thesignalfunc-tionsshouldhavebeenperformedinanobstetriccontext.
1.3UseoftheEmOCindicators
Asshown inTable1, the indicators forEmOChave
been used in more than 50 countries to plan pro-
grammes and to monitor and evaluate progress in
reducing maternal mortality. Some countries have
conducted more detailed needs assessments that
also include other indicators and information use-
ful for planning safe motherhood programmes. (For
sample data collection forms, refer to: http://www.
amddprogram.org/).Inothercountries,morefocused
needsassessmentshavebeenconducted,datacol-
lectionbeinglimitedtotheindicatorsonformssimilar
to those in Appendix A. The more focused compo-
nentsofneedsassessmentsdescribedinthishand-
bookcanbe integrated intoneedsassessments for
otherhealthissues,suchaspreventionofmother-to-
childtransmissionofHIVinfection,orforahealthsys-
temoverall.RegardlessofwhethertheEmOCneeds
assessment ismoredetailedormore focused, itwill
yielddata thatcanbeused tomonitorandevaluate
progress in reducing maternal mortality and provide
valuable information for health ministries and health
managerstoshapestrategiesandactivitiestoimprove
maternalhealthoutcomes.
Inmoreandmorecountries,theEmOCindicatorshave
beenintegratedintoroutinehealthmanagementinfor-
mationsystemstotrackprogressatdistrict,regional
andnationallevels.Whileperiodicneedsassessments
anddatacollectionsystemssetupoutsidehealthman-
agement informationsystemsmayplayanimportant
role, integration of the EmOC indicators into health
management informationsystems isamoreefficient
wayofmonitoringtheavailabilityanduseofsuchcare
overtime.Countriesthatareintentonreducingmater-
nalmortalityshouldstrivetoincludetheseindicators
intotheirhealthmanagementinformationsystems.
10
2.IndicatorsforEmOCBelow, the explanation of each EmOC indicator
includes a description, the recommended minimum
or maximum acceptable level (if appropriate), back-
groundinformation,adviceondatacollection,analy-
sis, interpretationandpresentation,andsuggestions
for supplementary studies related to the indicator.
Worksheets are provided in Appendix A to facilitate
thecalculations.
2.1Indicator1:AvailabilityofEmOCservices
Description
TheavailabilityofEmOCservicesismeasuredbythe
numberof facilities thatperformthecompletesetof
signal functions inrelationto thesizeof thepopula-
tion.Whenstaffhascarriedoutthesevensignalfunc-
tions of basic EmOC in the 3-month period before
theassessment,thefacilityisconsideredtobeafully
functioning basic facility. The facility is classified as
functioningatthecomprehensivelevelwhenitoffers
thesevensignal functionsplussurgery (e.g.caesar-
ean)andbloodtransfusion(Table4).
Todeterminetheminimumacceptablenumberofbasic
andcomprehensiveEmOC facilities for a countryor
region (dependingon thescopeof theassessment),
beginbydividingthetotalpopulationby500000.This
istheminimumacceptablenumberofcomprehensive
facilities.Then,multiplythatnumberby5tocalculate
the overall minimum number of facilities, both basic
andcomprehensive.Thesenumbersshouldbecom-
pared with the actual number of facilities found in
ordertoclassifytheservicesasfullyfunctioningbasic
orcomprehensiveEmOCfacilities.
Theresultsofthisexercisecanalsobeexpressedas
apercentageof theminimumacceptablenumberof
basic or comprehensive care facilities. To calculate
thepercentageof therecommendedminimumnum-
beroffacilitiesthatisactuallyavailabletothepopu-
lation, divide the number of existing facilities by the
recommendednumberandmultiplyby100.Asimilar
exercisewilldeterminewhatpercentageoftherecom-
mendedminimumnumberofcomprehensivefacilities
isavailable.
Minimumacceptablelevel
Forevery500000population, theminimumaccept-
ablelevelisfiveEmOCfacilities,atleastoneofwhich
providescomprehensivecare.
Backgroundanddiscussion
To save women with obstetric complications, the
healthsystemmusthavefacilitiesthatareequipped,
staffed and actually provide EmOC. The composite
natureof this indicator tellsusnotonlywhether the
signalfunctionswereperformedrecently;italsoindi-
rectlytellsusabouttheavailabilityofequipmentand
drugsandtheavailabilityandskillofthestaff.
ThenumberofEmOCfacilitiesrequiredtotreatcom-
plications depends on where facilities are located,
wherepeopleliveandthesizeandcapabilitiesofthe
facilities.Onecouldcountonlyfacilitieswhereallnine
EmOCproceduresareperformed,butthatwouldgive
thewrongmessage,implyingthatonlyhospitalswith
sophisticated equipment and specialist physicians
canreducematernalmortality.Apromising interven-
tionistheupgradingofhealthcentresandothersmall
facilitiestoenablethemtoprovidebasicEmOC(36,
65). The ‘health centre intrapartum care strategy’,
proposed in the Lancet series on maternal health,
suggeststhatallbirthstakeplaceinafacility;thisis
likelytobeoneofthemorecost-efficientstrategiesfor
reducingmaternalmortality,providedthatthequality
ofcareisadequate(101).
A health centre that provides basic EmOC can pre-
vent many maternal and perinatal deaths. For some
conditions (e.g. some cases of postpartum haemor-
rhage), basic care will be sufficient. For other com-
plications (e.g.obstructed labour), higher-level treat-
ment is required.Even then, firstaidcansave lives,
becauseawoman’sconditioncanbestabilizedbefore
sheisreferred.Forexample,awomanwithobstructed
labourcannotbetreated inahealthcentrethatpro-
videsonlybasiccare:sheneedsacaesareansection.
Monitoringemergencyobstetriccare:ahandbook 11
Thechancesofthemotherandhernewbornofsurviv-
ingacaesareansectionare,however,greatlyimproved
ifshedoesnotarriveatthehospitaldehydratedand
infected.Topreventthis,intravenousfluidsandantibi-
oticscanbeadministeredatthehealthcentre,espe-
ciallywhenthetriptothehospital is long.TheWHO
guidelines for primary health care, Pregnancy, child-
birth,postpartum,newborncare:aguidetoessential
practice(98)recommendsthatwomenwithcomplica-
tionsbegiventhefirstdoseofantibiotics,oxytocin,or
magnesiumsulfate(asrequired)beforereferral.
In the previous edition of this document, the rec-
ommended minimum ratio of EmOC facilities to
500000populationwasonecomprehensiveandfour
basic facilities.Since1997,experience inmore than
40 countries has shown that health systems often
haveatleastonecomprehensivefacilityper500000
population and sometimes more. Fully functioning
basicfacilities,however,aremuchlesscommon.On
thebasisof thisexperience, thegroupdecided that
the ratio of one comprehensive to four basic facili-
tiesmightbelessimportantthanhavingatleastone
comprehensive facility and emphasizing the number
offacilitiesper500000population.
Arecentanalysisof24nationalornear-nationalneeds
assessments showed that all but two countries met
theminimumacceptablelevelofonecomprehensive
EmOCfacilityper500000population.Thecountries
includedsomewithhighmaternalmortalityratios,but
theyhadveryfewfullyfunctioningbasicfacilities(102).
IntheUnitedStates(theonlycountrywitharelatively
lowmaternalmortalityratio inwhichtheEmOCindi-
catorshavebeenmeasured),nobasicfacilitieswere
identified,buttherearemanycomprehensivefacilities,
witharatioofonecomprehensivefacilityfor100000
population(66).
ImplicitinthedefinitionofanEmOCfacilityisthatthe
signal functions be available to women at any hour
oftheday,everydayoftheweek.Ifawomanneeds
a caesarean section at midnight on a Saturday, she
should have the same quality of care as a woman
requiringthesameserviceat10:00onaWednesday
morning. The primary obstacle to the provision of
EmOC24h/day,7days/weekinmanycountriesisa
lack of essential cadres of health workers (i.e. mid-
wives, practitioners who can operate anaesthetists
and laboratory technicians). When facilities are not
abletoprovidethesignalfunctions24h/day,7days/
week, local and other management must search for
creativesolutions.Somemayinvolvesimplerotation
ofpersonnel,butothersmay requireapolicy review
ofwhatcadreofproviderisauthorizedandtrainedto
provideEmOC,oradditionalbudgetaryallocations.In
somesituations,accommodationforhealthpractitio-
nershasbeenbuiltonhospitalgroundstoallowcon-
tinuousservice.
Datacollectionandanalysis
Thisindicatordependsontheclassificationofafacili-
ty’sEmOCstatusafterdirectinspection.Often,afacil-
ityisassumedtobefunctioning,butavisitshowsthat
therealityisquitedifferent.Theimportantdistinction
betweenthewayafacilityissupposedtofunctionand
whatitactuallydoesisillustratedbyacasestudyin
Uganda.In2003,theneedforEmOCwasassessed,
inordertoprovidetheGovernmentwithbackground
for drawing up an operational strategy to reduce
maternaldeaths.Withinthehealthinfrastructureplan
in Uganda, district hospitals and health centres IV
shouldbeabletoprovidecomprehensiveEmOC.The
assessmentshowed,however,thatonly21ofthe32
hospitalsassessed(65%)werecomprehensive,while
theother11 functionedat thebasic level.Of the36
healthcentresIVvisited,onlytwo(6%)functionedat
thecomprehensivelevelandanothertwoatthebasic
level. Health centres III theoretically provide basic
EmOC,butonly5(4%)ofthe129assessedfunctioned
attheirintendedlevel.Theresults—particularlywhich
signalfunctionsweremissing—wereusedtoprepare
theannualplan for thesector-wideapproach,which
calledforanationalefforttoimproveEmOC(46).
Incalculatingthisindicator,thenumberoffunctioning
facilitiesiscomparedwiththesizeofthepopulation.
Themostrecentcensusshouldbeusedtodetermine
thepopulationsizeinagivenarea.Ifthelastcensus
ismorethan5yearsold,nationalinstitutesofstatis-
ticsarelikelytohaveprojectionsthatthegovernment
(including the ministry of health) uses for planning.
Recent heavy in- or out-migration might have to be
takenintoconsideration.
Monitoringemergencyobstetriccare:ahandbook 12
The minimum acceptable level for Indicator 1 has
beendefinedinrelationtothepopulationratherthan
birthsbecausemosthealthplanningisbasedonpop-
ulationsize.If,however,itisjudgedmoreappropriate
toassesstheadequacyofEmOCservicesinrelation
tobirths, the comparableminimumacceptable level
wouldbefivefacilitiesforevery20000annualbirths
(includingatleastonecomprehensivefacility).
Ifacountryhasamixofpublicandprivatefacilities,a
decisionmustbemadeaboutwhethertocollectdata
fromallofthemortofocusononesector (generally
thepublicsector).Onlybyincludingtheprivatesector,
however,willtherebeacompletepictureofhowwell
thehealthsystemfunctionsand theoverall levelsof
availability,useandqualityofcare.Becausetheindi-
catorsarebasedonpopulationestimates(totalpopu-
lation,forexample),itmakessensethatallhealthfacil-
ities (ora representativesample)beselected for the
assessment.Themoreacountryreliesonprivatefacil-
itiesforEmOC,themoreimportantitistoincludethe
privatesector.Asanillustrationofthispoint,aneeds
assessmentconductedinBeninin2003showedthat
onefourthoffacilitiesprovidingcomprehensiveEmOC
and almost all the facilities functioning at the basic
levelwereprivatelyoperated(7).
Interpretationandpresentation
If,intheaggregate,acountryorregiondoesnothave
fiveEmOCfacilities(includingatleastonecomprehen-
sivefacility)per500000population,theoverallmini-
mumacceptable levelofEmOCservices isnotmet.
Inthiscase,ahighpriorityistoincreasethenumber
offunctioningfacilitiesuntilatleasttheminimumlevel
is met. This may be done in different ways, e.g. by
upgradingexistingfacilitiesorbuildingnewfacilities,
orsomecombinationofthetwo.
IftheoverallminimumacceptablelevelofEmOCser-
vicesismet, it isreasonabletoconcludethat, inthe
aggregate,anacceptableminimumnumberoffacilities
currentlyexists.Thenextstepwouldbetolookatthe
geographicaldistributionofthefacilities(Indicator2).
We strongly recommend that, in addition to looking
attheratiooffacilitiestopopulation,dataonperfor-
manceof thesignal functionsbepresented in terms
oftheproportionoffacilitiesprovidingeachofthesig-
nalfunctions,asillustratedinFigure1.Suchdataare
extremelyusefulforplanningandsettingprioritiesfor
interventions.Figure1showsthatinBeninin2003,not
allhospitalsthatprovidedobstetricsurgeryalsohad
thecapacitytotransfuseblood.Furthermore,only9%
ofhealthcentresbutalmost90%ofhospitalsremoved
retainedproducts.Today,manual vacuumaspiration
is often used to treat complications of abortion by
mid-levelprofessionalsathealthcentresanddistrict
hospitals (103).Thisprocedurereducestheneedfor
referral,whichoftenentailsconsiderableexpensefor
thefamily,life-threateningdelaysandevendeaths.
Insomecountriescertainsignalfunctionsarevirtually
missingbecausetheyarenotincludedinpre-service
trainingofhealthpersonnelornationaltreatmentpro-
tocols. If a signal function is systematically absent
in a country, it is possible to use the designation
‘Comprehensiveminus1’or‘Basicminus1’asatem-
porarymeasure,whilepoliciesarereviewedandpro-
grammaticinterventionsplannedtoremedythelack.
Supplementarystudies
Reasonsfornotperformingsignalfunctions
Thereareanumberofpossiblereasonsthatahealth
centre or small hospital does not qualify as a basic
EmOC facility. Very often, it is the result of some
management problem. When determining a facility’s
EmOCstatus,consider the following foreachsignal
function:
• Isstaffatthefacilitytrainedandconfidentintheir
skillstoperformtheservice?
• Arethecadresofstaffworkingatthefacilityor
thefacilityitselfauthorizedtoperformthesignal
function?
• Aretherequisitesuppliesandequipmentinplace
andfunctioning?
• Weretherecasesforwhichtheuseofaparticular
signalfunctionwasindicated?
Monitoringemergencyobstetriccare:ahandbook 13
0%88%
81%0%
58%
9%
2%
88%
0%
92%
86%98%
78%
100%
59%
10%
86%
20% 30%
96%
40% 50% 60% 70% 80% 90% 100%
Hospitals (N=48) Health Centres (N=234)
Cesarean delivery
Blood transfusion
Assisted vaginal delivery
Removal of retained products
Manual removal of placenta
Parenteral anticonvulsants
Parenteral oxytocics
Parenteral antibiotics
Figure 1. Proportion of health facilities in which each signal function was performed during the past 3 months,
Benin, 2003
The last explanation refers to the fact that a facility
may have a low caseload, with the result that there
mighthavebeennoneedforoneofthesignalfunc-
tionsduringthe3-monthperiod.Thequestionofcase
load, in turn, could be investigated by determining
whetherthecatchmentpopulation istoosmallgiven
theincidenceofthecomplicationinquestion,ifaccess
is a serious problem for reasons related to informa-
tion,cost,distance,transportorculturalpractices,or
ifbypassingthisfacilityforanother,better-functioning
facilityiscommonpractice.
Whendataonsignalfunctionsarepresentedasshown
inFigure1,itmaybepossibletoseeapatternatthe
countryordistrictlevel,e.g.whetheraparticularsignal
functionisnotbeingperformed.Itwouldbeusefulto
enquire further, for example by discussing the issue
withfacilitystafftolearnwhattheyperceivetheprob-
lemstobe.Thatwillnotelucidatewhywomenuseor
donotuseaparticularfacility;thatkindofinformation
can be derived only from women in the community.
Focus groups are often used to collect this kind of
information.Communitysurveysmightalsobe infor-
mative, but they are more difficult and expensive to
conductthanfocusgroups.
2.2Indicator2:GeographicaldistributionofEmOCfacilities
Description
The second indicator is calculated in the same way
as the first, but it takes into consideration the geo-
graphicaldistributionandaccessibilityof facilities. It
can help programme planners to gather information
aboutequityinaccesstoservicesatsubnationallevel.
To determine the minimum acceptable number of
basic and comprehensive facilities, begin by divid-
ingthesubnational(e.g.provinces,statesordistricts)
population by 500 000. This will give you the mini-
mum acceptable number of comprehensive EmOC
facilities for thesubnationalarea.Then,multiply that
numberby5 tocalculate theoverallminimumnum-
beroffacilities,bothbasicandcomprehensive,forthe
subnationalarea.Tocalculate thepercentageof the
recommended minimum number of facilities that is
actuallyavailabletothesubnationalpopulation,divide
thenumberoffunctioningEmOCfacilitiesbytherec-
ommended number and multiply by 100. A similar
exercisewilldeterminewhatpercentageoftherecom-
mended minimum number of comprehensive EmOC
facilitiesisavailable.
FromMinistèredelaSantéPubliqueduBénin,2003,citedinreferences(6,104).
Monitoringemergencyobstetriccare:ahandbook 14
To determine the percentage of subnational areas
thathavetherecommendednumberofEmOCfacili-
ties(includingtheminimumnumberofcomprehensive
facilities)fortheirpopulationsize,thenumberofsub-
nationalareaswiththerecommendedminimumnum-
berisdividedbythenumberofsubnationalareasand
multipliedby100.
Minimumacceptablelevel
To ensure equity and access, 100% of subnational
areasshouldhavetheminimumacceptablenumbers
ofEmOCfacilitiesoratleastfivefacilities(includingat
leastonecomprehensivefacility)per500000popula-
tion.
Backgroundanddiscussion
Facilities that offer EmOC must be distributed so
thatwomencanreachthem.Iffacilitiesareclustered
aroundacapitalcityoronlyinlargecommercialcen-
tres, women in more remote regions will experience
delayingettingtreatment,whichmightthreatentheir
survival and the survival of their newborns. Table 6
showstheestimatedaveragetimefromonsetof the
majorobstetriccomplicationstodeath.Itcanbeseen
that theaverage time todeath is 12hoursormore,
although postpartum haemorrhage can kill faster.
Therefore,livescouldbesavedatruralhealthfacilities
withinjectableuterotonicsandrehydrationwithintra-
venousfluids.
Complication Hours Days
Haemorrhage•Postpartum•Antepartum
212
Ruptureduterus 1
Eclampsia 2
Obstructedlabour 3
Infection 6
Table 6. Estimated average interval between onset of major obstetric complications and death, in the absence of medical interventions
From Maine, D. Prevention of Maternal Deaths in DevelopingCountries: Program Options and Practical Considerations, inInternational Safe Motherhood Conference. 1987. Unpublisheddata:Nairobi.
In view of the urgency of maternal complications,
EmOC services must be distributed throughout a
country. The distribution can be checked efficiently
by calculating the number of facilities available in
subnationalareas.Ananalysisatregional,state,pro-
vincial, district or other level often reveals discrep-
ancies in health services equity. The ratio of EmOC
facilitiestothetotalpopulationisoftenhigherthanfor
smallergeographicalareas.InNicaraguain2001,for
instance, thecoverageof thecombinedpopulations
of nine administrative regions with comprehensive
EmOCfacilitiesmorethanmettherequiredminimum
(225%).Whentheregionswereexaminedindividually,
however,onlyfourhadtheminimumacceptablelevel
ofcomprehensivecare(102).Aneedsassessmentin
Mauritaniain2000showedthatthenumberanddis-
tributionoffacilitiesprovidingEmOCwerebothinsuf-
ficient. Only eight of the 67 facilities surveyed pro-
videdsuchcare(sevenprovidedcomprehensivecare
and one provided basic care). More than half of all
thecomprehensiveEmOCfacilitieswereinthecapital
city,Nouakchott,and9of13regionshadnoEmOC
facilities(105).
Insomesituations,especiallywherethepopulationis
widelydispersedandtravelisdifficult,itmaybeadvis-
ableforgovernmentstoexceedtheminimumaccept-
ablelevel.InBhutan,forexample,anassessmentof
needsforEmOCrevealedproblemsinthegeographi-
cal distribution of facilities, and the Government
promptlyupgradedfacilitiestoimprovetheavailability
ofcare(Figure2).
Monitoringemergencyobstetriccare:ahandbook 15
Figure 2. Emergency obstetric care facilities in Bhutan
FromUNICEF,DepartmentofHealthServices,andMinistryofHealthandEducation.Semi-annualreportstoAMDD,Jan–June2002&July–Dec2002.Unpublisheddata.2002:Bhutan,citedinreference(104).
Samdrup Jongkha
Resirboo
TrashigangMongar
Trashi Yangtse
Pemagatshel
WangduePhodrang
Zhemgang
Trongsa
BumthangLhuentse
SarpangTsirang
Punakha
Gasa
Thimphu
DaganaChukha
Phuentsholing
Samtse
Haa
Paro
Comprehensive EmOC centres – 4
Basic EmOC centres – 4
Monitoringemergencyobstetriccare:ahandbook 16
Datacollectionandanalysis
Manyofthesameissuesindatacollectionthatexist
for Indicator1arealsorelevant for Indicator2.One
issueis,however,morelikelytoariseinsubnational
thaninnationalcoverage:Howmanyandwhattype
ofEmOCfacilitiesarerecommendedforpopulations
smaller than 500 000? No one answer fits all situ-
ations, but ‘prorating’ would be advised, e.g. if the
populationiscloseto250000,threefacilitieswould
beacceptable(roundingupisthemoreconservative
response).Whetheroneofthethreeshouldbecom-
prehensive depends on the location and proximity
(distanceintermsoftime)ofcomprehensivefacilities
inneighbouringareas.
Emergency obstetric care facilities in subnational
areascanalsobestratifiedbymanagement,todeter-
mine thedistributionofpublic andprivate facilities.
Thisanalysiscanbeparticularlyrevealinginanarea
withprivatebutnogovernmentfacilities,wheregov-
ernmentfacilitiesofferfreeservicesandprivatefacili-
tieschargeuserfees,orwheregovernmentfacilities
chargeandmissionhospitalsarefree.
Interpretationandpresentation
If subnational geographical areas do not meet the
minimumacceptableratio,underservedareasshould
betargetedandresourcesdevotedtoimprovingthe
availabilityofservices.
The numbers of comprehensive and basic EmOC
facilitiespersubnationalpopulationcanbepresented
ineithertablesormapsonwhichsubnationalareas
areshadedaccordingtothelevelofcoverage(100%
ormoreandatincrementsoflessthan100%).
Supplementarystudy
Indicatorsofaccess toEmOCincludedistanceand
time.Asdigitalmappingandgeographical informa-
tion systems become more widely available, use of
thisindicatorislikelytoincrease.Areasonablestan-
dardfortheavailabilityofservicescanbeestablished,
such as having basic and comprehensive facilities
availablewithin2–3hoursoftravelformostwomen.In
thepast,determiningthedistancebetweenfacilities
and where people live was cumbersome; however,
geographical information systems make calculations
ofdistanceandtraveltimemucheasier,andmeasure-
mentmethodswillbecomemoreconsistent(106).
MapsthatshowtheEmOCstatusoffacilities,thedis-
tanceofcommunitiesfrombasicandcomprehensive
facilities(bothintraveltimeandinrelationtoroadnet-
works), populationdispersionanddensity andother
features that show inequities in terms of access to
carecanbeeffectiveadvocacyandplanningtools.
2.3Indicator3:ProportionofallbirthsinEmOCfacilities
Description
Indicator3istheproportionofallbirthsinanareathat
take place in EmOC health facilities (basic or com-
prehensive).Thenumerator isthenumberofwomen
registeredashavinggivenbirth infacilitiesclassified
asEmOCfacilities.Thedenominatorisanestimateof
all the livebirthsexpected in thearea, regardlessof
wherethebirthtakesplace.
Westronglyrecommendaparallelindicator:thepro-
portionofbirths inall health facilities in thearea,or
‘institutionalbirths’or‘institutionaldeliveries’.Werec-
ommend this in order to give a more complete pic-
tureof thepatternsofuseof thehealthsystem(see
Figure 3). The numerator is always service statistics
fordeliveriesinthefacilities,whilethedenominator—
theexpectednumberoflivebirths—isusuallycalcu-
latedfromthebestavailabledataandbymultiplying
thetotalpopulationoftheareabythecrudebirthrate
of thesamearea.Othermethods forcalculating the
expectednumberoflivebirthscanalsobeused.
Minimumacceptablelevel
Nominimumacceptablelevelisproposed.Inthepre-
viouseditionofthishandbook,theminimumaccept-
able levelwassetat15%ofexpectedbirths. In the
intervening years, many governments have commit-
tedthemselvestoincreasingtheproportionofwomen
whogivebirthinhealthfacilities,andsomeareaiming
for100%.Therefore,theminimumtargetforthisindi-
catorshouldbesetbynationalorlocalgovernments.
Monitoringemergencyobstetriccare:ahandbook 17
Background
Indicator 3 was originally proposed to determine
whetherwomenareusingtheEmOCfacilitiesidenti-
fiedbyindicators1(AvailabilityofEmOCservices)and
2(GeographicaldistributionofEmOCfacilities),andit
servesasacrudeindicatoroftheuseofobstetricser-
vicesbypregnantwomen.Insituationswhererecord
systemsareinadequatetocollectdataforIndicator4
(Met need for EmOC), the number of women giving
birthinhealthfacilitiesisalmostalwaysavailable.Use
ofthesedatacangiveadministratorsaroughideaof
the extent to which pregnant women are using the
healthsystem,especiallywhencombinedwith infor-
mationonwhichfacilitiesprovideEmOC.
Theoptimallong-termobjectiveisthatallbirthstake
place in (or very near to) health facilities in which
obstetric complications can be treated when they
arise. Many countries have made having 100% of
deliveriesininstitutionstheirmainstrategyforreduc-
ing maternal mortality. As they move closer to that
objective, other problems arise. In many countries,
health systems are unable to cope with the added
patientloadwithoutmajorexpansioninfacilitiesand
staff,andmanagershavelimitedinformationonhow
healthfacilitiesarefunctioning.Givingbirthinahealth
facilitydoesnotnecessarilyequatewithhigh-quality
careorfewermaternaldeaths.Smallerhealthfacilities
may not have adequately trained staff, or staff may
nothavetheequipmentor theauthority to treat life-
threateningcomplications.Manyfacilitiesdonotfunc-
tionwellbecauseofpoormanagement,whichshould
beremediedbeforethenumberofbirthsinthefacil-
ityisincreasedgreatly(107,108).Forthesereasons,
the EmOC status of health facilities is included in
Indicator3(ProportionofallbirthsinEmOCfacilities),
andwerecommendthat this indicatorbecalculated
andinterpretedwiththeotherindicators.
Datacollectionandanalysis
Although the name of the indicator is ‘Proportion of
birthsinEmOCfacilities,’inpracticethenumeratoris
thenumberofwomengivingbirthandnotthenumber
ofinfantsborn.Werecognizethatthenumberofbirths
willbeslightlyhigherthanthenumberofwomengiv-
ingbirth,becauseofmultiplebirths;however,theextra
effortneededtocountbirthsratherthanwomengiving
birthmightnotbenecessary,norisitlikelytochange
theconclusionsdrawnfromtheresults.Thenumbers
of women giving birth in facilities are obtained from
healthfacilityrecordsystemsandareoftencollected
for monthly reports to the government. The EmOC
statusofthehealthfacilityinwhichthedeliverytakes
placeisavailablefromtheresultsofroutinemonitoring
orneedsassessmentsunderIndicator1.
Thetotalexpectednumberofbirthsinanareaisbased
oninformationaboutthepopulationandthecrudebirth
rate.Nationalstatisticsofficestendtobasepopulation
projectionsontheresultsoftheirmostrecentcensus.
Theymayalsohaveregionalcrudebirthrates.Ifnot,
the crude birth rate is often available from national
population-basedsurveys,suchasDemographicand
HealthSurveys.Whenpossible,estimatesforthespe-
cific geographical area should be used rather than
applying the national crude birth rate to all regions.
Regions are often selected for interventions or pro-
grammes because of special needs and therefore
tendtohavepoorer indicatorsthanatnational level.
Usually,thebirthrateinpoorerareasishigherthanthe
nationalaverage,sothatuseofthenationalaverage
wouldresultinanunderestimateoftheexpectednum-
berofbirths,andtheproportiondeliveredinfacilities
wouldthereforebeoverestimated.
Parallelanalysisoftheproportionofallbirthsinallthe
facilitiessurveyedallowscomparisonoftheproportion
ofbirthsinEmOCfacilitieswiththeproportionofbirths
inallfacilities.Thisindicatestheextenttowhichother
facilities provide delivery services. Figure 3 shows
that,forexampleinChadallthebirthsinfacilitieswere
inEmOCfacilities,while inBolivia,Mozambiqueand
Senegal,theproportionsofbirthsinnon-EmOCfacili-
tiesadded9–22%.Incontrast,inBenin,onlyasmall
proportionof institutionalbirthsoccurred in facilities
wheremostobstetriccomplicationscouldbetreated.
Thisindicatorcanalsobeanalysedbyleveloffacility
(hospitalandnon-hospital),byownershipormanage-
ment(publicandprivate)andbysubnationalarea,in
order todeterminewherewomenaredelivering.Are
women more likely to deliver in private or govern-
mentfacilities?Aretheremoreinstitutionaldeliveries
Monitoringemergencyobstetriccare:ahandbook 18
Figure 3. Proportions of all births in EmOC facilities and all surveyed facilities
Fromreferences(7,37,56).
Interpretationandpresentation
Overall, this indicator shows the volume of mater-
nity services provided by facilities. If there appears
tobeunder-use,thereasonsshouldbeexplored.To
increaseuse,emphasisshouldbeplacedonenabling
womenwithcomplicationstouseEmOCfacilities.The
firstgoalofprogrammestoreducematernalmortality
shouldbetoensurethat100%ofwomenwithobstet-
ric complications have access to functioning emer-
gencyfacilities.
Supplementarystudies
Atthelocallevel,additionalstudiestounderstandthe
useofservicesbetterarealmostalwaysuseful.Which
groups of women are using the services? Which
women are not, and why? Clearly, the answers to
thesequestionshaveimportantimplicationsforpublic
healthandhumanrights.
Whichwomenarenotcomingtothefacilities?
Even if the use of health facilities (including EmOC
facilities) is fairly high, it is worthwhile investigating
which women are not using them. Certain factors
strongly affect use of services in a particular area,
suchasdistance to the facility,prevalenceofethnic
orreligiousminoritygroups, levelofeducation(often
an indication of social status), the reputation of the
facilityandpoverty.Informationonsomeofthesefac-
tors, suchas residence,mayalreadybeavailable in
health facility records, and records can be reviewed
todeterminewhetherwomencomefromallpartsof
thecatchmentareaoronlyfromthetowninwhichthe
facilityislocated.Forfactorsforwhichinformationis
notroutinelyrecorded,astudycanbeconducted.For
example,studentsorstaffmemberscanbepostedin
amaternitywardforafewweeksoramonthtorecord
relevant information.Itwouldbeimportant,however,
9% 10%
24%
12% 13%
19%
9%
22%
59%
0%
20%
40%
60%
80%
Chad (2002) Senegal (2001) Bolivia (2003) Mozambique (2000) Benin (2002)
Inst
itutio
nal b
irth
EmOC Facilities Non-EmOC facilities
in certain subnational areas? Disaggregating data in
thiswaycanprovidemorespecificinformationabout
whichinterventionsaremostneeded,andwhere.
Monitoringemergencyobstetriccare:ahandbook 19
totrainandsupervisethesedatacollectorstoensure
thattheyfollowconfidentialityrules,treatpatientsand
theirfamiliesrespectfullyandaskforinformationinan
unbiasedmanner.
Ideally,theprofileofthewomenwhousetheservices
canbecomparedwiththatofwomeninthepopulation
(nationalpopulation-basedsurveys)inordertodeter-
minethecharacteristicsofthewomenwhoareunder-
representedasusersofthefacility(109).
Whydosomewomennotusethefacility?
Oncethegroupsofwomenwhoareunderrepresented
in the facility have been identified, it is important to
findoutwhy.Oneshouldnotassumethattheyknow
thereason,eveniftheyhavegrownupintheregion.If
theassumptioniswrong,any‘correctiveaction’taken
willprobablynotwork(110).Womenshouldbeques-
tioned, either through interviews or in focus groups;
orstudiestocomparesubpopulationscouldbecon-
ducted,afteradjustmentforneedorstatisticalcontrol
forconfoundingfactors.
Variousactivitiescanbeusedtoimproveuse,depend-
ingonthefactorsthatdiscourageit.
• Iffocusgroupdiscussionsshowthatpeoplelack
basicinformationaboutobstetriccomplications,
acommunityeducationprogrammewouldbein
order.Thepreciseformoftheprogrammewould
bedeterminedbylocalcircumstances,butit
shouldbeaimednotonlyatpregnantwomenbut
alsoatthepeoplewhoinfluencetheirdecisionto
seekcare,suchasotherwomenofreproductive
age,partners,mothers-in-lawandtraditionalbirth
attendants.
• IftransportfromavillagetotheEmOCfacilityis
aproblem,thecommunitycouldbemobilizedto
coordinatetheuseofexistingvehicles.
• Ifpoorroadsareabarriertocare,thelocal
governmentshouldbeapproachedtoimprove
them.Ifshortagesofsuppliesorpooroverall
qualityofcaremakepeoplefeelthatgoingtothe
hospitalisnotworththetrouble,solutionstothe
problemsshouldbesought.
• Ifwomenarereluctanttousetheservices
becauseofpracticestheyhavepreviously
experiencedorhaveheardabout,thosepractices
canbediscussedwithstaffatthefacilityto
determinehowthefacilitynormscanbeadapted
tolocalcustomsordesires.
• Ifthecostofservicesisanobstacle,medical
emergencyfundsorinsuranceschemeshave
provensuccessfulinsomeplaces(111).
Whoattendsbirthsinfacilities?
Deliveries in institutionsarenotnecessarilyattended
by skilled birth attendants (112). Therefore, a study
couldbecarriedouttoseewhichcadresofworkers
are involved in deliveries and their level of compe-
tence. Providers could be interviewed to determine
their understanding; observational studies would
allowon-siteverificationofpractices;andretrospec-
tivechartreviewswouldallowanassessmentofthose
aspectsofcarethatshouldbedocumentedoncharts
orpatientrecords.
2.4Indicator4:MetneedforEmOC
Description
‘Met need’ is an estimate of the proportion of all
womenwithmajordirectobstetriccomplicationswho
aretreatedinahealthfacilityprovidingEmOC(basic
or comprehensive). The numerator is the number of
women treated for direct obstetric complications at
emergencycarefacilitiesoveradefinedperiod,divided
bytheexpectednumberofwomenwhowouldhave
major obstetric complications, or 15% of expected
births,duringthesameperiodinaspecifiedarea.The
directobstetriccomplicationsincludedinthisindica-
tor are: haemorrhage (antepartum and postpartum),
prolongedandobstructedlabour,postpartumsepsis,
complicationsofabortion,severepre-eclampsiaand
eclampsia, ectopic pregnancy and ruptured uterus.
(Fortheoperationaldefinitionsofthesedirectobstet-
riccomplications,refertoBox2.)
AswedidforIndicator3,westronglyrecommendthat
metneedbecalculatedatallhealthfacilitiesaswellas
atEmOCfacilities,toprovideamorecompletepicture
oftheuseofthehealthsystemandwherewomenare
beingtreated.
Monitoringemergencyobstetriccare:ahandbook 20
Box 2. Operational definitions of major direct obstetric complications
HaemorrhageAntepartum• severebleedingbeforeandduringlabour:placentapraevia,placentalabruption
Postpartum(anyofthefollowing)• bleedingthatrequirestreatment(e.g.provisionofintravenousfluids,uterotonicdrugsorblood)• retainedplacenta• severebleedingfromlacerations(vaginalorcervical)• vaginalbleedinginexcessof500mlafterchildbirth• morethanonepadsoakedinbloodin5minutes
Prolongedorobstructedlabour(dystocia,abnormallabour)(anyofthefollowing)• prolongedestablishedfirststageoflabour(>12h)• prolongedsecondstageoflabour(>1h)• cephalo-pelvicdisproportion,includingscarreduterus• malpresentation:transverse,broworfacepresentation
Postpartumsepsis• Atemperatureof38°Corhighermorethan24hafterdelivery(withatleasttworeadings,aslabouralone
cancausesomefever)andanyoneofthefollowingsignsandsymptoms:lowerabdominalpain,purulent,offensivevaginaldischarge(lochia),tenderuterus,uterusnotwellcontracted,historyofheavyvaginalbleeding.(Ruleoutmalaria)
Complicationsofabortion(spontaneousorinduced)• haemorrhage due to abortion which requires resuscitation with intravenous fluids, blood transfusion
oruterotonics• sepsisduetoabortion(includingperforationandpelvicabscess)
Severepre-eclampsiaandeclampsia• Severepre-eclampsia:Diastolicbloodpressure≥110mmHgorproteinuria≥3after20weeks’gestation.
Varioussignsandsymptoms:headache,hyperflexia,blurredvision,oliguria,epigastricpain,pulmonaryoedema
• Eclampsia• Convulsions;diastolicbloodpressure≥90mmHgafter20weeks’gestationorproteinuria≥2.
Signsandsymptomsofseverepre-eclampsiamaybepresent
Ectopicpregnancy• Internalbleedingfromapregnancyoutsidetheuterus;lowerabdominalpainandshockpossiblefrom
internalbleeding;delayedmensesorpositivepregnancytest
Ruptureduterus• Uterine rupture with a history of prolonged or obstructed labour when uterine contractions suddenly
stopped.Painfulabdomen(painmaydecreaseafterruptureofuterus).Patientmaybeinshockfrominternalorvaginalbleeding
Fromreferences(95,97,98).
Monitoringemergencyobstetriccare:ahandbook 21
Minimumacceptablelevel
Asthegoalisthatallwomenwhohaveobstetriccom-
plicationswillreceiveEmOC,theminimumacceptable
level is100%.Governmentsmaywishtoset interim
targets once they have a baseline and they have
embarkedoninterventionstoimprovetheavailability
anduseofsuchcare.
Background
Met need is a more refined measure of the use of
EmOC than Indicator 3 (Proportion of all births in
EmOC health facilities), as it addresses whether the
women who really need life-saving obstetric care
receiveit.
In order to estimate met need for EmOC, one must
firstestimate the totalneed,and thencompare it to
thenumberofwomenwithseriousobstetriccompli-
cationswhoreceiveemergencycareinsuchfacilities.
Thetotalneed forEmOCisestimatedtobe15%of
allbirths,although therehasbeenconsiderabledis-
cussionabouttheexpectednumberofcomplications.
Studieshaveproducedarangeofresults:
• Areviewofstudiesinvariousgeographicalregions
basedonvariousdefinitionsandmethodshave
shownlevelsofmetneedaslowas1%(113).
• Oneprospectivepopulation-basedstudyinsix
WestAfricancountriesshowedthat6%ofpreg-
nantwomenhadseveredirectobstetriccomplica-
tions(114).Theauthorsreportedthattheirfindings
werelikelytobeunderestimatesbecausethedefi-
nitionsofthecomplicationsthattheyusedwere
linkedtomedicalinterventionsthatmightnothave
beenavailableatalltheparticipatingfacilities.In
addition,theyincludedonlydirectobstetriccom-
plicationsoccurringinlatestagesofpregnancy
andomittedcomplicationsofabortionandectopic
pregnancies.
• Asystematicreviewoftheprevalenceofsevere
acutematernalmorbidity(‘nearmiss’events)
basedondisease-specificcriteriashowedaprev-
alenceof0.8–8.2%(113).Reviewedstudiesvaried
intermsoftherangeandseverityofobstetric
complicationsincludedandthetimingofcompli-
cations(intrapartumandpostpartumperiods).
• AprospectivestudyofdeliveriesinIndiashoweda
17.7%incidenceofdirectobstetriccomplications
duringlabour.Thisstudydidnotincludecom-
plicationsoccurringduringpregnancy(suchas
complicationsofabortion),sotheactualpercent-
ageofwomenwithdirectcomplicationswasprob-
ablyhigher.Theauthorsconcludedthat15.3%of
womenneededEmOC,and24%moreneeded
non-emergencymedicalattention(115).
• AsecondstudyinIndiashowedthat14.4%of
deliverieswereassociatedwithseriouscomplica-
tions,butthisstudytoowasrestrictedtocompli-
cationsaroundthetimeofchildbirth(116).
• Astudyofnationaldatafor1991–1992inthe
UnitedStates,acountrywithlowmaternalmortal-
ity,showedatotalof18hospitalizationsforobstet-
ricandpregnancylossper100births(117).These
findingswereconfirmedbymorerecentdata(66).
• Althoughtheresultsvary,thetechnicalconsulta-
tiondecidedtomaintain15%asanaverageesti-
mateofthefrequencyofseriousdirectcomplica-
tionsforthepurposesofestimatingtheneedfor
EmOC.
Datacollectionandanalysis
To calculate met need, information is needed on
women in these facilities who are treated for the
major obstetric complications listed in Box 2. The
definitionswerederived fromWHO (Managingcom-
plicationsinpregnancyandchildbirthandPregnancy,
childbirth, postpartum and newborn care) (95,98)
andtheInternationalFederationofGynaecologyand
ObstetricsSavetheMothersProject.Standardization
ofdefinitionscanbeimprovedbytrainingandsuper-
vision.Thesedefinitionsarecriticalfortraininghealth
workers, enumerators or interviewers who collect
suchdataeitherroutinelyoraspartofanEmOCneeds
assessment.
Monitoringemergencyobstetriccare:ahandbook 22
Routinematernity recordsystems inmanycountries
maynotregisterthe‘reasonforadmission’or‘mater-
nal complications’, although complications can lead
to maternal deaths. Appendix B gives a list of the
informationneededtocalculatetheindicatorsandthe
typesofregistersthatshouldbeconsulted.Italsolists
itemsthatgoodregistersmight include,suchas the
timeofadmissionandthetimeofdefinitiveinterven-
tion,whichareusefulforstudyingtheintervalbetween
admission and emergency caesarean section as an
indicatorofhospitalefficiency(118).
Itislikelythatincompleteorpoorrecordswillbefound
whendataforcalculatingmetneedandsomeofthe
otherindicatorsarecollected,especiallythefirsttime.
Asperiodiccollectionofsuchdatabecomespartof
routineprogrammemonitoring,recordkeepingshould
improve.Thequestioniswhattodowhendatacollec-
tionproblemsareencountered?
Poor recordsusuallybias findings, leading tounder-
estimatesofcomplicationsinfacilities,andthismust
be taken into account in interpreting the data. In
manysituations,thelevelofEmOCbeingprovidedis
so low that, allowing for substantial under-counting,
theresultsdonotchangeverymuch.Figure4shows
actualmeasurementsofmetneedoverseveralyears.
Iftherecordsshowthatonly6%oftheneedforEmOC
is being met in an area and the true proportion is
assumedtobetwiceashigh,themetneedisstillonly
12%.Thissortofchangewillnotalterprogramming.
As recordkeeping improves,however,metneedwill
increaseandthechallengewillbetounderstandthe
attribution:Istheincreaseinmetneedatrueincrease
orisitafunctionofbetterdatacollection?Improved
datacollectionisasuccessinitself,andlongerpro-
grammemonitoringshouldhelpdetermineifthemet
needisreallyincreasing.
Figure 4. Increases in met need for EmOC during AMDD-supported projects (2000–2004)
FromBailey,P.EvaluatingAMDDPhase1:PolicyandServiceImprovements.InDeliveringSaferMotherhoodSymposium-SharingtheEvidence.2007.London,UK:Unpublisheddata.
Countries in Latin America
Countries in North Africa
Countries in sub-Saharan Africa
Countriesin Asia
Monitoringemergencyobstetriccare:ahandbook 23
The most variable element in estimating met need
for EmOC is likely to be complications of abortion.
While it is difficult to gather information on the inci-
denceofunsafeabortions(becausetheyaregenerally
clandestine),theWHOreportUnsafeabortion:global
and regional estimates of incidence of unsafe abor-
tionandassociatedmortalityin2003showedthatthe
frequencyofunsafeabortionsvariesbygeographical
area,fromthreeper100livebirthsinEuropeto29per
100livebirthsinAfrica(119).
Moreover,recordingofabortioncomplicationsishighly
variable, including inaccuracies inwhether theabor-
tion was merely incomplete (which could eventually
lead toacomplicatedabortion)or trulycomplicated
(withhaemorrhageorsepsis)atthetimeoftreatment
oradmission.Insomesettings,noattemptismadeto
distinguishbetween the two.Thus,complicationsof
abortionmightactuallybeover-reported.Thedefini-
tiongiveninBox2coversonlythoseabortioncompli-
cationsthatincludehaemorrhageorsepsis.
Itwouldnotbeappropriate,however,toexcludeabor-
tionsfromthecalculationofmetneed,ascomplica-
tionsofabortionareamajorcauseofmaternaldeath
insomecountriesandregions.Forexample,inLatin
AmericaandtheCaribbean,12%ofmaternaldeaths
areattributabletocomplicationsfromabortion(120).
Given the reporting difficulties, analysts presenting
dataonmetneedshouldstateexplicitlywhat types
ofabortiontheyhaveincludedandconsiderconduct-
ingstudiestoexaminethesubjectingreaterdetail.If
itissuspectedthatabortionswithoutseriouscompli-
cations(i.e.withouthaemorrhageorsepsis)arebeing
recordedas‘obstetriccomplications’,itmightbeuse-
fultocalculateandreportmetneedwithandwithout
abortions,forcomparison(88).
Afrequentlyaskedquestionisthepossibilityofover-
reportingdueto‘double-counting’ofwomenwhoare
admittedtomorethanonefacility,asinthecaseofa
referral,orwhoareadmittedtothesamefacilitymore
than once during a pregnancy. We recommend that
referralsbecountedatthefacilityatwhichthewomen
receive definitive treatment. A study in Thailand
showedthatmetneedwasinflatedby16%because
ofdoublecountinganddroppedto96%onceithad
beenadjustedfor(90).Ifthereisconcernaboutdou-
blecountingand itseffectonmetneed,we recom-
mendthatastudybedesignedtomeasuretheeffect.
Theresultsofthisspecialstudycanthenbetakeninto
accountwheninterpretingthegeneralfindings.
Manyhealthfacilities,ofcourse,performsomebutnot
allofthebasicEmOCsignalfunctions.Asthesefacili-
tiesmaywellavertsomematernaldeaths,werecom-
mendthatmetneedinbothEmOCfacilitiesandinall
thefacilitiessurveyedbecalculated.Evenwhenmany
facilitiesdonotperformafewsignalfunctions,itisstill
important to find out how many obstetric complica-
tionstheymanage.
Interpretationandpresentation
Iftheminimumacceptablelevelforthisindicatorisnot
met,i.e.islessthan100%,somewomenwithcompli-
cationsarenotreceivingthemedicalcaretheyneed.
This is likely tobe thenormwherematernalmortal-
ity is high. If there are adequate numbers of EmOC
facilities,womengivebirth inthosefacilitiesandthe
metneedislessthan100%,thenationalprioritymust
be to improve use of the facilities by women with
complications. Depending on the situation, strate-
giesformeetingthisobjectivecouldincludeimprov-
ingthequalityofcareatfacilities,eliminatingbarriers
toseekingcare(e.g.transportorcost)andeducating
the community to recognize complications and the
importanceofseekingcare.Metneedmayalsobelow
becauseobstetriccomplicationsarepoorlyrecorded
inregisters.Inthiscase,itisadvisabletostudyrecord
keepingatthefacility(seediscussionaboveand‘sup-
plementarystudies’below).
If the met need is close to 100%, one might ask
whatdefinitionofabortion isused,because it isnot
uncommonformetneedtoexceed100%ifallabor-
tions(incomplete,missed,spontaneous,induced)are
includedinthenumerator.Ifthatisnotthecase,itis
reasonable toconclude thatmostwomenwhoneed
EmOCservicesarereceivingthem.Asdiscussedear-
lier, since the true incidence of complications in the
populationmightbegreater than15%, it ispossible
thateven ifmetneed is100%therearestillwomen
whoarenot receivingthe life-savingEmOCservices
theyneed.Forthisreasonalone,thelevelofmetneed
mightbegreaterthan100%.Thisshouldnotbeinter-
Monitoringemergencyobstetriccare:ahandbook 24
pretedasbeingduetofaultydata,e.g.over-diagnosis
ofcomplications; it ispossible that thegeographical
distribution of EmOC facilities is uneven, and met
need exceeds 100% because women from outside
thecatchmentareacometothefacility.Liketheques-
tionofdoublecounting,astudyofwhousesthefacil-
itycouldhelpexplainametneedhigherthan100%.
Wheninterpretingtheindicators,itishelpfultolookat
indicators3and4atthesametime.
Supplementarystudies
Whilemetneed forEmOC isagaugeof the levelof
suchcareinanarea,itdoesnotshowwhatisrequired,
andalowmetneedcannotindicatewheretheprob-
lemlies.Itmightbeduetounder-recordingofcompli-
cationsortooneofmanyfactorsthataffecttheuseof
services,andfurtherinvestigationisrequired.
Itisimportanttoensurethatwomenfromallthecom-
munitiesintheareaaretreatedatthefacility.(Seethe
section on additional studies under Indicator 3 for
morewaysofexploringthistopic.)Studiestoaddress
twoquestionswouldprovideadeeperunderstanding
ofwho is included inmetneedandhow theyaffect
thisindicator:
• Howmanywomenhavecomplicationsafterthey
wereadmittedtohospital,andwhichcomplica-
tionswerethey?
• Howmanywomenareadmittedwithsigns
andsymptomsofcomplications,andwhich
complicationswerethey?
When women with complications are stabilized at a
lower-level facilitybefore referral to ahigher level of
care, we suggest that they be counted only at the
facilitywheretheyreceivedefinitivetreatment.There
is no easy mechanism for finding out whether a
referred woman reaches her destination. A study of
the women referred, their treatment before referral,
theircompliancewithreferralandtheirdefinitivetreat-
mentwouldelucidatetheeffectofdoublecountingon
metneedandwouldalsoshowhowwellthereferral
systemfunctions.Inthefield,staffatlowerlevelshas
argued in favourofcounting thesewomen twice,as
they claim that they too have treated them, usually
bystabilization.Toraisemorale,programmemanag-
ers might consider counting them twice, and with a
studyof referrals theycanalsodocument theeffect
ofdoublecountingonmetneedandmakeanyneces-
saryadjustments.
Several typesofstudycouldbeused toexplore the
qualityofrecordkeepingatafacility:
• Examinehowrecordsarekept.Doessomeone
entercomplicationsintotheregister24h/day,or
doestheseniornursedocumentthemonlyonce
adayfromverbalreportsbyotherstaff?This
practicecouldleadtoseriousunderreporting.
Discussionswithstaffaboutrecentcasescanpro-
videinsightintohowrecordsarekept.
• Comparethecomplicationsrecordedinthemater-
nityregisterwithpatientcharts,operatingtheatre
registersoremergencyadmissionslogbooks.
Whatproportionofseriouscomplicationsisnot
reportedintheregisterthatisusuallyusedforcal-
culatingmetneed?Whichcomplicationsappear
tobemostunderreported?Howdoyourfindings
changewhenyoucorrectforthisunderreport-
ing?Howoftendoesadiagnosisofcomplication
changebetweentheadmissionsregisterandthe
operatingtheatreregister?
• Examinehowabortioncomplicationsarerecorded
bydiscussingtherecordsandcasenotes
withstaff.Areminorcomplications,orevenall
incompleteabortions,countedas‘complications’?
Remember,forcalculatingmetneed,onlyserious
complications,suchascomplicationsofabortion
withsepsisandhaemorrhage,arecounted.
• Formoredetailedmonitoringofabortion
complications,werecommendasetof‘process
indicatorsforsafeabortion’,whichinclude
11signalfunctionsthatdefinebasicand
comprehensivecare.LiketheEmOCindicators,
thesafeabortionindicatorsmeasurethe
availability,distribution,useandqualityofsafe
abortionservices(121-123).
• Knowingmoreabouthowwellandhowcompletely
logbooksarekeptupcanidentifyproblems.
Investigatewhetherstafftrainingorsupervisionof
recordkeepingreducesunderreportingovertime,
andthendisseminateyourresults.
Monitoringemergencyobstetriccare:ahandbook 25
2.5Indicator5:Caesareansectionsasaproportionofallbirths
Description
Theproportionofalldeliveriesbycaesareansection
inageographicalareaisameasureofaccesstoand
use of a common obstetric intervention for averting
maternalandneonataldeathsandforpreventingcom-
plicationssuchasobstetric fistula.Thenumerator is
thenumberofcaesareansectionsperformedinEmOC
facilities for any indication during a specific period,
and thedenominator is theexpectednumberof live
births(inthewholecatchmentarea,notjustininstitu-
tions)duringthesameperiod.
Occasionally, hospitals in which caesarean sections
areperformedlackoneofthebasicsignalfunctionsof
EmOCanddonotqualifyassuchafacility.Therefore,
asforindicators3and4,werecommendthatthisindi-
cator be calculated for both EmOC facilities and all
facilities.
Minimumandmaximumacceptablelevels
Bothverylowandveryhighratesofcaesareansection
canbedangerous,buttheoptimumrateisunknown.
Pending further research, users of this handbook
mightwanttocontinuetousearangeof5–15%orset
theirownstandards.
Background
The proportion of births by caesarean section was
chosenastheindicatorofprovisionoflife-savingser-
vicesforbothmothersandnewborns,althoughother
surgicalinterventions(suchashysterectomyforarup-
tureduterusorlaparotomyforanectopicpregnancy)
can also save maternal lives. Of all the procedures
used to treat major obstetric complications, caesar-
eansectionisoneofthecommonest,andreportingis
relativelyreliable(124).
Earliereditionsofthishandbooksetaminimum(5%)
and a maximum (15%) acceptable level for caesar-
eansection.AlthoughWHOhasrecommendedsince
1985 that the rate not exceed 10–15% (125), there
isnoempiricalevidence foranoptimumpercentage
or rangeofpercentages,despite agrowingbodyof
research that shows a negative effect of high rates
(126-128).Itshouldbenotedthattheproposedupper
limitof15%isnotatargettobeachievedbutrathera
thresholdnottobeexceeded.Nevertheless,therates
inmostdevelopedcountriesandinmanyurbanareas
of lesser-developedcountriesareabove that thresh-
old.Ultimately,whatmattersmost is thatallwomen
whoneedcaesareansectionsactuallyreceivethem.
Thetechnicalconsultationfortheseguidelinesnoted
thedifficultyofestablishingalowerorupperlimitfor
theproportionofcaesareansectionsandsuggested
that a lower limit of 5% is reasonable for caesar-
eansperformedforbothmaternalandfetal reasons.
If elective or planned caesarean sections and those
performedforfetalindicationswereexcluded,alower
rangewouldbeindicated;however,therecordsystem
maynotalwaysregistertheindicationfortheoperation
andsuchprecisionisusuallynotavailable.Adetailed
analysisofthereasonsforcaesareansectioninahos-
pitalwouldbeworthwhile.
Wherematernalmortalityishigh,therateofcaesarean
sectionstendstobe low,especially in ruralareas.A
recentreviewofglobal,regionalandnationalratesof
caesareansectionshowedthatthelowestrate(3.5%)
wasinAfrica;inthe49least-developedcountries,the
ratesrangedfrom0.4%inChadto6%inCapeVerde
(oranaverageof2%)(129).Figure5showshowlow
ratesofcaesareansectioninseveralcountriesofAsia
andinsub-SaharanAfricachangedafterseveralyears
ofinterventionstoimproveEmOC.
Despite the clear inverse relation between very high
maternal mortality and low rates of caesarean sec-
tion,thisprocedure(likeanymajorsurgery)carriesa
risk for surgical or anaesthetic accident, postopera-
tiveinfection,andevendeathforthepatient(129).A
uterine scar increases the risk for uterine rupture in
futurepregnancies.Whereconditions inafacilityare
particularly precarious, the case fatality rate among
womenwhoundergocaesareansectionscanbeunac-
ceptably high, as found by the Network for Unmet
ObstetricNeedinBenin,BurkinaFaso,Haiti,Maliand
Nigerin1998and1999.1Therisksshouldbeweighed
against the potential benefits of the surgery. In the
1deBrouwereV.Personalcommunicationaboutcasefertilityratesforcaesareans,2006.
Monitoringemergencyobstetriccare:ahandbook 26
Figure 5. Caesarean sections as a proportion of births in AMDD-supported projects (2000–2005)
FromBailey,P.EvaluatingAMDDPhase1:PolicyandServiceImprovementsinDeliveringSaferMotherhoodSymposium-SharingtheEvidence.2007.London,UK:Unpublisheddata.
caseoftransversefetallie,whenexternalversionfails
or isnotadvisable, thebenefitsof surgerydefinitely
outweightherisks.Withoutacaesareansection,most
women with obstructed labour will either die or be
severelymaimed(130).Acaesareansectionisthekey
interventionforpreventingobstetricfistulacausedby
prolongedorobstructedlabour,makingthisindicator
animportantmeansformeasuringprogressinthepre-
ventionofthiscondition.
Manyobserversconsiderthatweareexperiencinga
worldwideepidemicofoveruseofcaesareansection
(131)and that the rateswillcontinue to rise, inview
ofpractitioners’andadministrators’ fearof litigation,
localhospitalcultureandpractitionerstyleaswellas
increasingpressure fromwomen inhighly industrial-
izedcountriestoundergocaesareansectionsfornon-
medicalreasons(132,133).Atthesametime,evidence
forthenegativeconsequencesofcaesareansectionis
increasing:recentstudiesincountrieswithhighrates
suggestthatcaesareansectioncarriesincreasedrisks
for maternal and neonatal morbidity and mortality
(126-128).
Datacollectionandanalysis
Whiledataontherateofcaesareansectionscanbe
collectedinpopulationsurveys,suchasdemographic
and health surveys, data for this indicator are col-
lectedfromhospitalrecords(134),asratesbasedon
service statistics are considered more precise than
population-based rates,which tend tobemarginally
higher than those based on health facility records
(124).Facilitydataarecollectedroutinelyfromoperat-
ingtheatrelogbooks,whichareoftenthemostcom-
pleterecordsavailable.
Thenumeratorforthisindicatorcoverscaesareansec-
tionsperformedforallindications,includingthosefor
maternalandneonatalreasons,aswellascaesarean
sectionsperformedinemergenciesandthosethatare
plannedorscheduled.
Throughoutthediscussionoftheindicators,wehave
stressed the importance of including data from all
types of facilities. In countries or regions where the
privatesectorplaysamajorroleindeliveringobstet-
s
Monitoringemergencyobstetriccare:ahandbook 27
ricservices,therateofcaesareansectionwillbepar-
ticularly sensitive to inclusion of such hospitals. For
instance,inLatinAmericaandAsia,theproportionof
caesareansectionsishigherinprivatethaninpublic
facilities.InElSalvador,roughlyone-halfofallcaesar-
eansectionsareperformedoutsidethepublicsector,
throughtheprivatesectorandsocialsecurityhospi-
tals(135).Thisraisesthepossibilitythatsomeofthese
operationsareperformed(ornot)forfinancial,rather
thanmedical,reasons.
Acommonmisunderstandingofthisindicatoristhatit
referstotheproportionofdeliveriesinahospitalthat
are performed by caesarean section, i.e. the ‘insti-
tutional caesarean section rate’ or the proportion of
deliveries in the facility that are done by caesarean
section.Theinstitutionalcaesareanrateisdifficultto
interpret, because it depends on the patients in the
hospital(Isthehospitalaregionalreferralhospitalthat
receivesmanycomplicatedcases?Or is it adistrict
hospital,wheremostcomplicatedcasesarereferred
further?)aswellastheskills,preferencesandhabitsof
theproviders.Thepopulation-basedindicatorrecom-
mendedheregivesanoverviewofthelevelofprovi-
sionofthiscriticalserviceinageographicalregion.
Toreducethepossibilitythatthis indicatorwillmask
inequitiesinaccesstoanduseofcaesareansection,
we strongly encourage authorities to look closely at
their data. For instance, in Morocco, Peru and Viet
Nam, the national rates of caesarean section are
5–15%,but thenationaldatamaskthehighrates in
majorcitiesandtheverylowratesinruralareas.The
rangeofpatternsisshowninTable7.
Table 7. Population rates of caesarean section from Demographic and Health Surveys among women who gave birth within three years of the survey.
Region Country YearRateofcaesareansection
Total Urban Rural
LatinAmerica DominicanRepublicPeru
20022000
33.112.9
36.221.0
27.23.2
South-EastAsia BangladeshNepalVietNam
200420012002
4.51.09.9
13.75.022.9
2.20.77.2
Africa EthiopiaKenyaMoroccoZambia
20002003
2003–20042001–2002
0.64.35.62.2
5.29.59.34.4
0.13.01.91.2
Fromreference(134).
Anotherexampleof inequitableaccesstocaesarean
sectionispresentedinFigure6.Ronsmansetal.used
demographic and health survey data to show the
rangeofratesbywealthquintilein13countrieswith
nationalratesof2.0–4.9%(136).Thisanalysisshows
thatthepoorestwomenhavelessaccesstothislife-
savingprocedure.
Monitoringemergencyobstetriccare:ahandbook 28
Figure 6. Rates of caesarean section by wealth quintile in 13 countries with national rates between 2.0%
and 4.9%
Reproduced,withpermission,fromreference(136).
Interpretationandpresentation
Whenlessthan1–2%ofbirthsarebycaesareansec-
tion, there is littledoubt thatpregnantwomenhave
pooraccesstosurgicalfacilities.Ratesinthisrange
arecommoninruralsub-SaharanAfricaandinsome
countriesofSouthAsia(Figure6andTable7).Where
caesareansectionratesareverylow,mostareprob-
ably done for maternal emergencies; as the rates
increase,agreatersharemaybefor fetalemergen-
cies.Asthenumberofcaesareansectionsincreases,
the uncertainty between these classifications also
increases(137).
Supplementarystudies
Whohascaesareansectionandwhere?
Studiesoncaesareansectionsshouldincludethepro-
portionsofbirthsinurbanandruralareas,aswellasin
smalleradministrativeorgeographicalunits.Variables
that are used to measure equity, such as economic
Rwanda 00 Bangladesh 04
Côte d’lvoire 98 Uganda 00 Pakistan 90
Mozambique 02 Kenya 03
Indonesia 02 Tanzania 99
15
16
17
18
19
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0Poorest quintile Poor quintile Middle quintile Richer quintile Richest quintile
Per
cent
of d
eliv
erie
s b
y ca
esar
ean
Malawi 00 Ghana 03 Benin 01
Comoros 96
Key: Country and year data
Monitoringemergencyobstetriccare:ahandbook 29
quintiles, ethnicity and education, can be used to
reveal where access to services is limited. Another
method for understanding data on caesarean sec-
tionsisinvestigatingthetypeofhospital(e.g.publicor
private)wherecaesareansectionsareperformed,as
thiscanindicatehowthevariouscomponentsofthe
healthsysteminteract.
Indicationsforcaesareansection
The final responsibility for ensuring that caesarean
sectionisperformedonlywhennecessaryiswithcli-
nicians. The chief medical officer or the head of an
obstetricsandgynaecologydepartmentinahospital
shouldreviewtheindicationsforthecaesareansthat
are performed. One approach is to look at the pro-
portion performed for absolute maternal indications,
which would almost certainly lead to the woman’s
deathifuntreated,includingsevereantepartumhaem-
orrhageduetoplacentapraeviaorplacentalabruption,
majorcephalo-pelvicdisproportion,transverselieand
browpresentation(138).Anotherapproachistoiden-
tifycaesareansectionsthatareperformedformater-
nalandforfetalindications,andathirdapproachisto
usetheRobsonclassificationsystem,whichrelieson
thecharacteristicsofwomenwhohavehadcaesarean
sections(139).Theclassificationsortswomeninto10
mutuallyexclusivegroupsonthebasisofparity,previ-
ousobstetrichistory,thecourseoflabouranddelivery
andgestationalage (140). It canbeused to identify
womenwhohavehadcaesareansectionsforreasons
otherthanasaresponsetoanimminentemergency.
Whoperformscaesareansections?
When the level of Indicator 5 is under the recom-
mendedminimum,poorlyfunctioninghealthfacilities
maybeacontributing factor.Thisoften results from
factorssuchaspostingsandtransfersofkeystaffor
arealshortageofhealthprofessionalstrainedtoper-
formthis life-savingservice.Studiescanbedoneto
investigatewhether this indicator isaffectedby lack
ofhumanresources.Forexample,ananalysisofwho
is trained and authorized to provide caesarean sec-
tionsmaybe informative. Incountrieswhereasmall
groupofhealthprofessionals,primarilybasedatfacili-
ties in largeurbancentres,are theonlypractitioners
abletoprovidecaesareansection,astrategymustbe
devisedtoaddressshortagesofhealthprofessionals
inruralareas.Onestrategythathasbeensuccessfully
usedinMalawi,MozambiqueandtheUnitedRepublic
ofTanzaniaistotrainmid-levelproviders(e.g.clinical
officers, assistant medical officers) to perform cae-
sarean sections (141–144). Similarly, in India, a new
programme under the auspices of the Government
and the obstetrics society is training doctors with a
Bachelor’sdegreeinmedicineandsurgeryincompre-
hensiveEmOC,includingcaesareansection(145).
Qualityofcare
Training,supervisionand leadershipbyseniorphysi-
ciansareimportantinmaintainingstandards.National
societies of obstetrics and gynaecology should
encourage the use of evidence-based protocols. In
facilitiesatalllevels,routineclinicalauditscanbeused
tomonitor change, improvepracticeandmaintaina
good quality of care; several tools exist to facilitate
this process (146–148). The infection rate in women
whohaveundergoneobstetricsurgeryisanotherindi-
catorofthequalityofcare.
Unmetobstetricneed
The indicator ‘Unmet obstetric need’ is unrelated to
Indicator4(MetneedforEmOC).Itdescribestheneed
forobstetricsurgeryforabsolutematernalindications,
whileIndicator4encompassesallthedirectobstetric
complicationstreatedwiththeEmOCsignalfunctions,
whicharebothsurgicalandnonsurgical (e.g.paren-
teralanticonvulsants,uterotonicdrugs).Theindicator
forunmetobstetricneedreferstotheneedforobstet-
ric surgery, including hysterectomy or laparotomy,
in addition to caesarean section. Caesarean section
constitutes most obstetric surgical procedures. This
indicator focusesstrictlyonmaternal life-threatening
conditions for which major obstetric surgery is per-
formed.Itisintendedtohelphealthpersonnelanswer
thequestions:
• Arepregnantwomenreceivingthemajorsurgical
obstetricinterventionstheyneed?
• Howmanywomen’sneedsareunmet?
• Wherearethosewomenwhoseneedsareunmet?
Box3providesdetailedinformationonthisindicator.
Monitoringemergencyobstetriccare:ahandbook 30
Box 3. Indicator of unmet obstetric need
Unmetobstetricneedisanestimateofthenumberofwomenneedingamajorobstetricinterventionforlife-threateningcomplicationswhodidnothaveaccesstoappropriatecare.Thisindicatorisparticularlyappropriateforidentifyinggeographicalorsocialinequityinaccesstohospitalcare.
Theconcept
Theconceptofunmetobstetricneedisthedifferencebetweenthenumberofwomenwhoneedobstetricsurgeryandthenumberofwomenwhoareinfactcoveredbyhealthservices.
Theindicatorisrestrictedtoabsolute(life-threatening)obstetricindicationsthatrequireobstetricsurgery(caesareansection,hysterectomy,laparotomy)orinternalversionandcraniotomy.Astandardlistofsuchindicationswasdrawnuponthebasisofthedegreeofseverityoftheindication,therelativestabilityofitsincidenceandrelativelyreproduciblediagnosis.Itcomprises:
• antepartumhaemorrhageduetoplacentapraeviaorabruptioplacenta;
• abnormalpresentation(transverselieorshoulderpresentation,facewithpersistentmento-
posteriorpositionorbrowpresentation);
• majorfeto-pelvicdisproportion(e.g.mechanicalcephalo-pelvicdisproportion,smallpelvis
includingpre-ruptureandruptureofuterus);and
• uncontrollablepostpartumhaemorrhage.
Inmostsituations,theincidenceofobstetricneedisnotknownprecisely.Abenchmarkcanbeusedtoestimatethenumberofwomenwithabsolutematernalindications,whichis1.4%(95%confidenceinterval,1.27–1.52),themedianforfivesub-SaharanAfricancountries,Haiti,MoroccoandPakistan(http://www.uonn.org/uonn/pdf/engintc00.pdf).Multipliedbythenumberofexpectedbirthsinanarea,thisgivestheestimatednumberofwomenwithabsolutematernalindicationsinthearea.Thesecondelementoftheequation—thenumberofmajorobstetricinterventionsactuallyperformedforabsolutematernalindications—isthesumofallsuchinterventionsperformedinthepopulationofwomeninthearea,wherevertheinterventiontookplace(privateorpublicsector,inoroutsidethedefinedarea).Thedifferencebetweenthenumberofwomenwithabsolutematernalindicationsandthenumberofmajorobstetricinterventionsactuallyperformedforthoseindicationsistheunmetneed.
Example:IntheruralpartofdistrictX,20000birthsareexpectedin2007.Thenumberofmajorobstetricinterventionsforabsolutematernalindicationsisestimatedtobe1.4%(benchmark)x20000=280interventions.Whenallpublicandprivatecomprehensiveemergencyobstetriccarefacilitieshadbeenvisited,thetotalnumberofmajorobstetricinterventionsperformedforabsolutematernalindicationswas84.Theunmetneedwasthus280–84=196,oranunmetneedof70%.Thismeansthat196womendidnothaveaccesstonecessarylife-savingsurgery.
Foradditionalinformationandformsusedtoconstructthisindicator,seethewebsiteoftheunmetobstetricneedsnetwork,www.uonn.org.
Observednumber
ofmajorobstetric
interventions
performedfor
absolutematernal
indications
Estimated
numberof
absolutematernal
indications
Estimatednumber
ofwomenwho
neededbutdidnot
receivelife-saving
care
=–
Monitoringemergencyobstetriccare:ahandbook 31
2.6Indicator6:Directobstetriccasefatalityrate
Description
Thedirectobstetriccasefatalityrateistheproportion
of women admitted to an EmOC facility with major
direct obstetric complications, or who develop such
complications after admission, and die before dis-
charge.Weincludeallsevenmajorobstetriccompli-
cationslistedinBox2.
Thenumeratoristhenumberofwomendyingofdirect
obstetric complications during a specific period at
anEmOCfacility.Thedenominator is thenumberof
womenwhoweretreatedforalldirectobstetriccom-
plicationsatthesamefacilityduringthesameperiod.
In general, the denominator for the direct obstetric
casefatalityrateisthenumeratorformetneed.
Like indicators 3–5, the direct obstetric case fatal-
ityrateshouldbecalculatedforall facilities,not just
EmOC facilities. It is usually calculated at individual
facilitiesandacross facilities,especially thoseof the
sametype,suchasdistricthospitals.
Maximumacceptablelevel
Themaximumacceptablelevelislessthan1%.
Background
Afterdeterminingtheavailabilityanduseofservices,
thenextconcernisqualityofcare,whichisthesubject
ofagrowing,complexliterature.ThesetofEmOCindi-
catorsincludesthedirectobstetriccasefatalityrateas
a relativelycrude indicatorofquality.Thisshouldbe
supplementedwithmoredetailedassessments.
Intheearliereditionsofthispublication,thisindicator
wassimplycalledthe‘casefatalityrate’.Ithasbeen
renamed ‘Direct obstetric case fatality rate’ for the
sakeofclarityandbecauseanewindicatorhasbeen
addedforindirectobstetriccomplications.
Researchershavegainedsubstantialexperiencewith
this indicator in thepast10years.Periodicmonitor-
ing(every6–12months)hasbeenthenormwhenthe
EmOCindicatorsareusedroutinely(15,36,65).The
available data, an example of which is presented in
Table8,indicatesthatsubstantialreductionsarepos-
sible within 3–5 years, if not sooner, with improved
quality of obstetric care. The direct obstetric case
fatality rate in thesestudies ranged fromalmost2%
to 10%, whereas an analysis of application of the
EmOC indicators to data from the United States in
2000 showed a direct obstetric case fatality rate of
0.06%(66).
Table 8. Direct obstetric case fatality rates before and after interventions to improve emergency obstetric care
Setting Beforeinterventions Afterinterventions Reduction
Ayacucho,Peru(2000–2004,fivefacilities)
1.7% 0.1% 94%
Gisarme,Rwanda(2001–2004,threefacilities)
2.0% 0.9% 55%
Mwanza,UnitedRepublicofTanzania(2000–2004,fourfacilities)
3.0% 1.9% 37%
Sofala,Mozambique(2000–2005,12facilities)
3.5% 1.7% 51%
Oromiya,Ethiopia(2000–2004,threefacilities)
10.4% 5.2% 50%
Fromreferences(15,36,65).
Monitoringemergencyobstetriccare:ahandbook 32
Giventherange,1%wouldappeartobeareasonable
maximumacceptable level, fallingbetweentherates
for less and more developed countries. The post-
interventionratesinTable8showthatitispossibleto
reduceahigh rate tobelow1%;however,countries
thatreachthisbenchmarkshouldstrivetoreducethe
rateevenfurther.Sometimes,circumstancesbeyond
thecontrolofhospitalmanagersmaymakeitdifficult
to achieve a rate below 1%. If few facilities provide
basicandcomprehensiveEmOC,womenwithcom-
plicationsarelikelytoarriveatthehospitalafteralong
journey, jeopardizing their survival. There are never-
theless low-costwaysto improvethequalityofcare
and to reduce the direct obstetric case fatality rate
progressively.
Datacollectionandanalysis
The direct obstetric case fatality rate can be calcu-
lated forany facility that treatscomplications,expe-
riences maternal deaths and has adequate records
on both these events. The same issues in collect-
ing data on major direct obstetric complications for
met need apply, although new issues arise for the
collection of information on the number of maternal
deaths. Maternal deaths are notoriously underesti-
mated because of misclassification or underreport-
ing,sometimesoutoffearofrebukeorreprisal(149).
Bothdeathsandcomplicationsshouldbethoroughly
soughtinallwardswhereadultwomenareadmitted,
notonlytheobstetricward.
Weencouragecalculationofseparatecause-specific
fatality rates for eachof themajor causesofmater-
naldeath.Treatmentofsomecomplications,suchas
obstructed labour, may improve more rapidly than
others,suchaseclampsia.Cause-specificcasefatal-
ityratesindicatewhereprogresshasbeenmadeand
whereithasnot(36).Thenumberofmaternaldeaths
in a given facility or aggregate of facilities is, how-
ever,oftentoosmall(e.g.fewerthan20)tocalculate
astablerateforeachcomplication.Therefore,inmost
facilities,onlyanaggregatedirectobstetriccasefatal-
ityratewillbecalculated.
There are good reasons for using this indicator for
individualfacilities,forallfacilitiestoreflectthestate
of the health system, or for a subset of facilities in
that system (see Table 11 in section 2.9). Averaging
theratesforallfacilitiesisonecrudemonitoringmea-
sure,but itdoesnotshowwhichfacilitiescontribute
mostheavily to thedirectobstetriccase fatality rate
and therefore where interventions are most needed.
Toidentifythosefacilitiesorregionsthatneedgreater
attention, data from various types of facilities (or in
differentareas)canbeanalysedseparatelyandthen
combined.
Interpretationandpresentation
Direct obstetric case fatality rates do not take into
accountdeathsoutsidethehealthsystem.Thisdoes
notaffectthevalueoftheindicator,becauseitisused
onlytomeasuretheperformanceoftheEmOCfacility.
Iftheindicatorsoftheavailabilityoffacilities,thepro-
portionofbirthsinfacilitiesandmetneed(indicators
1–5)showthatEmOCservicesarewelldistributedand
well usedand thedirectobstetriccase fatality rates
are low, it issafe tosay that thematernalcaresys-
tem in thecountry isworking fairlywell. If,however,
thedirectobstetriccasefatalityrateisacceptablebut
EmOCcoverageormetneedisinsufficient,theimpli-
cation is that women who deliver in EmOC facilities
arelikelytosurvivebutmaternaldeathsoutsidehealth
facilitiesmightstillbecommon.
Comparisons of direct obstetric case fatality rates
amongindividualfacilitiescanbedifficulttointerpret
whenthefacilitiesarenotcomparable.Forexample,it
maynotbevalidtocomparetherateinadistricthos-
pitalwiththat inateachinghospital,aswomenwith
themostseriouscomplicationsmaybereferredtothe
teachinghospitalatthelastmoment,wheretheydie.
Thisdifferencewould lowerthedirectobstetriccase
fatality rateat thedistricthospitalandraise itat the
teachinghospital.
Thedirectobstetriccasefatalityrate inafacilitycan
exceedthemaximumacceptablelevelforseveralrea-
sons.Inmanycases,thequalityofcareisinadequate;
however,theremaybeotherexplanations.Forexam-
ple,longdelaysinreachingEmOCfacilitiescanresult
inapoorstatusonarrival;orafacilitywithahighdirect
obstetriccasefatalityratemightbetheend-pointof
Monitoringemergencyobstetriccare:ahandbook 33
thelocalreferralchain,sothatwomenwiththemost
seriouscomplicationsaresentthere.Itisalsoimpor-
tant to consider the number of women counted in
calculatingthedirectobstetriccasefatalityrate.Ifthe
rate is based on a small number of women, even a
singledeathcancreateadeceptively large increase.
Giventheproblemsofinterpretingsmallnumbers,the
directobstetriccasefatalityrateismostusefulatdis-
trict levelorathigh-volumefacilitieswherethereare
manymaternaldeaths.Therefore,theseratestendto
becalculatedonlyatcomprehensiveEmOCfacilities.
Theoccurrenceofsomematernaldeathsinafacility
canindicatethatwomengotherefortreatmentofcom-
plications;conversely,theabsenceofmaternaldeaths
mightindicatethatwomenwithseriouscomplications
arenotbroughtthereorareroutinelyreferredon,even
when they should be treated on site. The absence
of reported deaths could also suggest that deaths
are not being reported. In addition, the numbers of
deaths and direct obstetric case fatality rates may
increase when efforts are made to improve hospital
servicesandmorewomencome for treatment, from
further away. Thus, the direct obstetric case fatality
ratemustbe interpreted in thecontextof theprevi-
ous indicators,andstudiesshouldbeconductedfor
deeperunderstanding.Bynomeansshouldthedirect
obstetriccasefatalityratebeacauseforadministra-
tivesanctions.Thatwouldjustincreasethelikelihood
thatwomenwithseriouscomplicationsarereferredto
anotherfacilityratherthantreated,orthatdeathsthat
occuronsitearenotreported.
Bar charts or scatter plots can effectively highlight
variationsindirectobstetriccasefatalityratesatdif-
ferent levels or in different types of health facility or
geographicalregion.Eachtypeoffacilityorregioncan
bedepictedasaseparategraph,ordifferentcolours
and shading can highlight differences in the same
graph.
Supplementarystudies
Highdirectobstetriccasefatalityratesindicateprob-
lems but do not, by themselves, identify corrective
actions.Theyare,however,agoodbeginningforfur-
therstudies.
Casestudiesofwomen’sconditiononadmission
Information on the condition of women with major
complications at the time of admission (e.g. pulse,
blood pressure, and temperature) can be collected,
forwomenwhosurviveandthosewhodonot.Better
understanding of patients’ condition on admission
would help differentiate the effect of condition on
arrivalfromthequalityofcareafterarrival.
Delaysindiagnosisortreatment
Therearemanypossiblereasonsfordelayeddiagno-
sisortreatmentonceawomanhasreachedafacility.
Forexample,patients’familiesmayhavetobuydrugs
andmedicalsuppliesfromlocalpharmaciesbecause
the hospitals do not have enough. The causes of
delays can vary from back-ups in the emergency
room,toagatekeeperwhodemandsatip,toelectric-
ityfailures(150).
Studiesof‘thethirddelay’(oncewomenhavereached
healthfacilities)andthe‘clientflowanalysis’exercise
intheToolbookfor improvingthequalityofservices
(150) are useful models for this type of supplemen-
tarystudy;theysystematizetheobservationandmea-
surementofdelaysandallowresearchers to identify
atwhatstage theyaremost frequent.Theexercises
are based on evidence-based standards and expert
opiniontodeterminewhatconstitutesadelay.Another
approachistocollectdataontheintervalbetweenthe
time a woman with a complication is admitted and
whenshereceivesdefinitive treatment.Good-quality
monitoring revealswhichdelaysare the longestand
mostdangerous,andthedirectobstetriccasefatality
ratecanbeloweredbyreducingthosedelays.
In the university hospital of Zaria, Nigeria, the inter-
valbetweenadmissionandtreatmentwasreducedby
57%(from3.7to1.6hours)between1990and1995.
During this time, the case fatality rate (combining
directand indirectcauses)decreasedby21%, from
14%to11%(151).
Reviewingmaternaldeaths
When a direct obstetric case fatality rate is high or
fails to decrease, a study should be conducted.
Maternal deaths can be reviewed in health facilities
and at district, regional or national level (sometimes
Monitoringemergencyobstetriccare:ahandbook 34
referred to as ‘confidential enquiry’) to identify gaps
inmanagementorclinicalservicedelivery.TheWHO
publicationBeyondthenumbers—reviewingmaternal
deaths and complications to make pregnancy safer
(148)describestwotypesofreview:
• Afacility-basedreviewisadetailedstudyofthe
systemiccausesofandcircumstancessurround-
ingmaternaldeathsatthefacility.Thegoalisto
determinewhichofthefactorsthatcontributedto
maternaldeathswereavoidableandwhatcould
bechangedtoimprovethequalityofEmOCatthe
facility.
• Aconfidentialenquiryintomaternaldeathsisan
anonymous,systematicstudyofallorarandom
sampleofmaternaldeathsoccurringinaspecified
area(urban,district,regionornational).The
researcherslookatissuessuchassubstandard
care,women’saccesstocareandtheavailability
ofmedicinesanddrugs.Byaggregatingthe
causesandfactorsthatcontributetomaternal
deathsinawiderarea,evidencecanbegenerated
tohelpdecision-makersdesignandimplement
systematicsolutionsforimprovingEmOC.
Reviewingcasesofwomenwhosurvivelife-
threateningcomplications(‘nearmisses’)
An alternative, more positive and sometimes less
threateningapproachtoimprovingqualityistostudy
systematically the care given to women with life-
threateningobstetriccomplicationswhoaresavedby
thehealth facility (‘nearmisses’).Onebenefitof this
methodisthatnearmissesoccurmorefrequentlythan
maternaldeathsandthereforeprovidemoreopportu-
nitiesforstudyingthequalityofcare.Anotherbenefit
isthatsuchareviewprovidesanoccasiontolookat
what health professionals did correctly to save the
womanratherthanfocusontheproblems.Thishelps
tocreateamoresupportiveenvironment inwhichto
discussaspectsofcarethatcouldbeimproved.The
WHO publication Beyond the numbers (148) gives
moredetailedinformation,includingoperationaldefi-
nitionsofnearmissesandastandardsetof criteria
with which a near-miss case is identified is being
developedbyWHO(1,52).
2.7Indicator7:Intrapartumandveryearlyneonataldeathrate
Description
Indicator 7 is the proportion of births that result in
a very early neonatal death or an intrapartum death
(freshstillbirth) inanEmOCfacility.Thisnew indica-
torhasbeenproposedtoshedlightonthequalityof
intrapartumcareforfoetusesandnewbornsdelivered
atfacilities(153).Thenumeratoristhesumofintrapar-
tumandveryearlyneonataldeathswithinthefirst24
hoursoflifeoccurringinthefacilityduringaspecific
period,and thedenominator isallwomenwhogave
birthinthefacilityduringthesameperiod.
Becausetheobjectiveofthisindicatoristomeasure
thequalityofintrapartumandnewborncare,itisrec-
ommendedthatnewbornsunder2.5kgbeexcluded
from the numerator and the denominator whenever
thedatapermit,aslowbirthweightinfantshaveahigh
fatalityrateinmostcircumstances.
As for the previous indicators, the intrapartum and
veryearlyneonataldeathrateshouldbecalculatedfor
allfacilities,notjustEmOCfacilities.
Maximumacceptablelevel
No standard has been set; a maximum acceptable
levelmaybedeterminedaftertheindicatorhasbeen
testedinvariouscircumstances.
Background
Globally,nearly2millioninfantsdieeachyeararound
thetimeofdelivery:900000neonataldeaths,or23%
of all neonatal deaths, and 1.02 million intrapartum
stillbirths,or26%ofallstillbirths(154).Good-quality
intrapartum care is therefore crucial for both the
motherandherinfant.Whenappropriate,timelycare
isprovided,mostmaternalandneonataldeathscan
beprevented.
Amajorcauseof fetaldeath intrapartumor immedi-
ately postpartum is birth asphyxia, which can result
from poorly managed obstetric complications, such
as obstructed or prolonged labour, ruptured uterus,
Monitoringemergencyobstetriccare:ahandbook 35
eclampsia or antepartum haemorrhage, and the
absenceofneonatalresuscitation(155).Birthasphyxia
canalsobearesultofpretermbirthorcongenitalmal-
formation, conditions that are not directly related to
thequalityofcaregivenintrapartum.Aswearecon-
cernedhereprimarilywiththehealthsystem’sability
to provide good-quality intrapartum and immediate
postpartumcare,thisindicatorfocusesonthosestill-
birthsandveryearlyneonataldeathsthatcouldhave
beenavertedbytheavailabilityanduseofgood-qual-
ityobstetriccareandneonatalresuscitation.
Datacollectionandquality
The operational definitions for this indicator include
the following components, as defined by Lawn and
colleagues(154):
• Stillbirthsoccurringintrapartumorfreshstillbirths:
infantsborndeadaftermorethan28weeksof
gestationwithoutsignsofskindisintegration
ormaceration;thedeathisassumedtohave
occurredlessthan12hoursbeforedelivery;
excludesthosebornwithsevere,lethalcongenital
abnormalities.
• Earlyneonataldeathsrelatedtointrapartum
events:neonatesbornattermwhocouldnotbe
resuscitated(orforwhomresuscitationwasnot
available)orwhohadaspecificbirthtrauma.
Thedeathmusthaveoccurredwithin24hoursof
delivery.
These two subgroups should not be equated with
perinatal deaths. The universally accepted definition
ofperinataldeathisdeathintheuterusafterthe28th
weekofpregnancyplusdeathsofallliveborninfants
upto7daysoflife.Thisnewindicatorexcludesmac-
eratedstillbirthsandnewbornswhodieafterthefirst
24h,becausemothersandtheirinfantsareoftendis-
chargedat24h,ifnotearlier.
Atthetechnicalconsultationin2006,itwassuggested
thatthisindicatorincludeonlystillbirthsandneonates
weighing≥2.5kg,whichistheinternationalstandard;
however,countriesmayprefer touse2.0kgastheir
threshold.Manysmallfacilitiesinpoorcountriesmight
nothavedataonbirthweight,especiallyofstillbirths.
Accuraterecordingofstillbirths(freshandmacerated)
andveryearlyneonataldeathsmaybeanaspectof
currentinformationsystemsthatalsowillrequiremore
attention.
Onewayofdeterminingwhetheranintrapartumdeath
occurredduringlabouristoascertainwhetherthefetal
heartbeat is recordedontheadmission log. Inprac-
tice,infacilitieswithhighturnoverandwheremothers
staylessthan24hoursafterdelivery,itmaybewise
torestrictneonataldeathstothoseoccurringintheir
first6–12hours(ratherthan24hours),becausedeaths
occurringafterdischargewillgoundetected.
Thedenominatorforthisindicatoris‘allwomengiving
birthintheEmOCfacility’,whichisthesamenumera-
torasforIndicator3(ProportionofallbirthsinEmOC
facilities). This denominator was chosen to facilitate
datacollectionand is recommended for thesakeof
international comparability. As information systems
improve,thedenominatormaybecomebirths,andthe
indicatorwillbecomeatruerate.
Supplementarystudies
Testingtheindicator
This indicatorshouldbe tested,and the resultswith
and without the birth weight restriction should be
comparedtodeterminewhether2.0kgor2.5kgisthe
better threshold. If the birth weight restriction is too
onerousintermsofdatacollection,studiesareneeded
todeterminewhethernobirthweightrestrictionwould
affectthedeathrate.Additionally,amaximumaccept-
ablelevelfortheindicatorshouldbeexploredandset,
ifappropriate.
Refiningthedata
Other studies that would improve understanding of
intrapartumandearlyneonatalcareincludeinvestiga-
tionsofwhether the fetalheartbeat is recorded rou-
tinelyatadmissionandwhetherstillbornsareroutinely
weighedanddocumented.Itcouldalsobeimportant
tostudytheexacttimeofearlyneonataldeath,which
israrelyrecordedwithprecision.
Infacilitieswithhighearlyneonatalandstillbirthrates,
it might be useful to conduct perinatal death audits
togainabetterunderstandingofhowtoimprovethe
qualityofcare(156).
Monitoringemergencyobstetriccare:ahandbook 36
2.8Indicator8:ProportionofdeathsduetoindirectcausesinEmOCfacilities
Description
The numerator of this new indicator is all maternal
deathsduetoindirectcausesinEmOCfacilitiesduring
aspecificperiod,anditsdenominatorisallmaternal
deathsinthesamefacilitiesduringthesameperiod.
Directcausesofdeatharethose‘resultingfromobstet-
ric complications of the pregnant state (pregnancy,
labour, and puerperium), from interventions, omis-
sions, incorrect treatment,or fromachainofevents
fromanyoftheabove’.Indirectcausesofdeathresult
from‘previousexistingdiseaseordiseasethatdevel-
oped during pregnancy and which was not due to
directobstetriccauses,butwhichwasaggravatedby
thephysiologiceffectsofpregnancy’(157).
Other categories of maternal death (death after 42
dayspostpartum,fortuitous,coincidentalorincidental
deaths)aregenerallynotincludedinthecalculationof
maternaldeathratesorratios,andtheyareexcluded
forthepurposesofthisindicator.
Acceptablelevel
This indicatordoesnot lend itselfeasily toa recom-
mendedorideallevel.Instead,ithighlightsthelarger
socialandmedicalcontextofacountryorregionand
hasimplicationsforinterventionstrategies,especially
inadditiontoEmOC,whereindirectcauseskillmany
womenofreproductiveage.
Background
A substantial proportion of maternal deaths in most
countriesaredue to indirectcauses.This isparticu-
larly true where HIV and other endemic infections,
suchasmalariaandhepatitis,areprevalent.Toooften,
whereinfectiousandcommunicablediseaseratesare
high, the number of maternal deaths due to direct
causes is also high. The causes of maternal deaths
areoftenmisclassifiedinsuchcases;forexample,the
death of an HIV-positive woman might be classified
asdue toAIDSeven if itwasdue toadirectcause
suchashaemorrhageorsepsis.Mostmaternaldeaths
fallintothecategorieslistedinTable9;weknoweven
lessabout ‘accidentalor incidental’causesofdeath
forwomeninpoorcountries.
The most recent systematic study of the causes of
maternal death was published in 2006 by research-
ers atWHO,who reviewed the literature since1990
(120).Table10summarizes theproportionsofdirect
andindirectcausesofdeathbyworldregion.
Table 9. Main conditions leading to maternal death
Directcauses Indirectcauses
Haemorrhage Infections(e.g.malaria,hepatitis)
Hypertensivediseases Cardiovasculardisease
Abortion Psychiatricillnesses,includingsuicideandviolence
Sepsisorinfections Tuberculosis
Obstructedlabour Epilepsy
Ectopicpregnancy Diabetes
Embolism
Anaesthesia-related
Monitoringemergencyobstetriccare:ahandbook 37
Table 10. Estimates of direct and indirect causes of maternal death by region
RegionMaternaldeaths(%)
Duetoindirectcauses
Duetodirectcauses Unclassified
Developedcountries 14.4 80.8 4.8
Africa 26.6 68.0 5.4
Asia 25.3 68.6 6.1
LatinAmericaandtheCaribbean 3.9 84.4 11.7
Fromreferences(120).
Datacollectionandquality
Thereportingofmaternaldeathsandtheircausesvar-
ieswidelyandisassociatedwithacountry’sstatisti-
caldevelopment;nevertheless,alltendtofollowsome
versionof the InternationalClassificationofDiseases
(157).Incountrieswithwell-developedstatisticalsys-
tems,thesourceofthisinformationisthevitalregis-
trationsystem,but,asstatedabove,misclassification
results inseriousunder-recording inofficialstatistics
in virtually all countries.Wherevital registrationsys-
temsareweak,omissionandmisclassificationleadto
under-recordingandproblemsofattributionofcause.
Deathcertificatesmayneverbefilledout,ortheymay
failtoindicatewhetherpregnancywasarecentoccur-
rence;therefore,thefactthatthedeathwasamater-
naldeathgoesundetected.Multiplecausesofdeath
may be listed, but an underlying cause may not be
registered.
ThisislikelytobethecasewithregardtoHIVinfec-
tion. In many countries with a high prevalence of
HIVinfection,thenumberofmaternaldeathsamong
HIV-positivewomenwillbeunderreported,untilthere
is universal HIV testing, serological status is reliably
recordedandreported,anddiscriminationandstigma
donot inhibit testingor reporting.On theonehand,
HIV infection might be an underreported cause of
maternaldeath.Ontheother,whenthewoman’sHIV
statusisknown,thecauseofdeathmaybereported
as AIDS even though the actual cause was a direct
obstetriccondition.
Althoughofficialstatistics inresource-poorcountries
arelikelytoincludeunderreportingofindirectcauses
of death, industrialized countries also underreport.
InareviewofWHOdatabasesonmaternalhealth in
1991–1993,ofthe60countriesreportingvitalregistra-
tionfiguresforcausesofmaternaldeaths,33reported
noindirectdeaths(158).
Collectingdataforthisnewindicatorwillbedifficult;
however, the technical consultation considered that
itwouldbeuseful forgovernmentsand international
agencies. Inafewyears,weshallreviewexperience
withthesenewindicatorstoseewhethertheyareuse-
fulandwhethertheyshouldbemodified.
Supplementarystudies
Agreatdealofresearchremainstobedoneinthearea
of indirectmaternaldeaths, includingonthemecha-
nisms by which indirect conditions cause maternal
death and programmes that could reduce them. As
with the recording of obstetric complications, train-
ing staff to complywithnational standardsofdeath
certificatecompletioncanresultinmoreaccurateand
completerecording.Reviewsofalldeathsofwomen
ofreproductiveageinfacilities,especiallythosewho
donotdieonthematernityward,couldleadtomore
completerecording.Asdiscussedunder Indicator6,
itmightbeusefultoreviewmaternaldeathsandnear
missestolearnhowtoimprovethequalityofcare.
Monitoringemergencyobstetriccare:ahandbook 38
2.9Summaryandinterpretationofindicators1–8
Table11providesasummaryof the indicators,how
they are calculated, and acceptable levels, when
appropriate.Oneofthebenefitsofusingtheseindica-
torsisthat,whenusedasaset,theygiveafullpicture
ofahealthsystem’s response toobstetricemergen-
cies.Below,wediscussissuesthataffecttheinterpre-
tationofmostoftheindicators,includingdistinguish-
ing between ‘minimum or maximum’ and ‘optimum’
levels, assessing the generalizability of results and
working with incomplete or poor data. The section
alsoprovidesexamplesofinterpretingsetsofindica-
torsandendswithanexerciseininterpretingtheindi-
catorstogether.
Minimumormaximumandoptimumlevels
An important distinction that applies to most of the
indicators is the difference between minimum or
maximumandoptimumlevels.Bynecessity,themini-
mumormaximumacceptablelevelsproposedinthis
manualareapproximations.Therefore, if theaccept-
able level is met for a particular indicator, this does
not imply that theoptimum level hasbeen reached.
Forinstance,akeyassumptioninsettingacceptable
levelsisthatapproximately15%ofpregnantwomen
experience serious obstetric complications. If this
is an underestimate—as recent studies indicate it
maybe—themaximum level for Indicator5 (15%of
expectedbirthsaredeliveredbycaesareansectionin
EmOCfacilities)maybelow(159,160).Anumberof
studieshaveshown,however,thatitisdifficultoreven
impossibletomeasuremorbidityaccuratelyfromsur-
veys(161).Therefore,weassume(onthebasisofthe
evidenceusedthroughoutthismanual)thatacountry
thatachievesacceptablelevelsforeachindicatorhas
astrongprogrammeforreducingmaternaldeaths.
Even if the minimum acceptable level for an indica-
torismetatthenationallevel,however,theremaybe
problemsinspecificareas.Whenthelevelfallsbelow
theminimumacceptable,onecanconcludethat the
needforEmOCisnotbeingmetinmostareasofthe
country.Thegeneralprincipleisthatfavourablefind-
ings, while reassuring, do not justify complacency;
unfavourable findings clearly indicate that action is
needed.
Generalizabilityofresults
When subnational areas or facilities are selected for
study, the generalizability of the findings may be a
concern.Visitingallthefacilitiesinanarea,whenpos-
sible,canhavestrongprogrammaticimplications,as
health managers will be able to design site-specific
changes. Insection3.2,onpreparationfordatacol-
lection,theselectionoffacilitiesforstudycomprises
twosteps:selectionofareasand,withintheseareas,
selectionof facilities. If thesestepsare followed(i.e.
theworksheetisused),biasisminimized.
If it appears that, due to chance, random selec-
tion has produced a bias (for example, most of the
facilities selected are concentrated in one area of a
certainregion),thisshouldbenoted,asevenbiased
dataareuseful if thedirectionof thebias isknown.
Forinstance,supposethattheEmOCfacilitiesinthe
studywerenotrandomlyselectedandweretherefore
muchmorelikelytobelocatedonamajorroadthan
a randomlyselectedgroupwouldhavebeen. In this
case, it is possible to say with reasonable certainly
thathospitalsfarfrommajorroadsarelesslikelythan
hospitalsonmajor roads toperformcaesareansec-
tions.Therefore,theestimatederivedfromthebiased
sample probably presents an unrealistically favour-
ablepictureof Indicator5,andthesituationisprob-
ablyworsethanthedataindicate.Iftheinformationis
stillnotusefulforgeneralization,e.g. if it isnotclear
whichwaythebiasworks,thedatamaynevertheless
beuseful formanagingorevaluatinghealthservices
inthearea.Tousetheexampleabove,thedatamay
showthatsomehospitalsarenotprovidinglife-saving
servicessuchascaesareansection,eventhoughgov-
ernmentstandardsstatethattheyshould.This infor-
mation, by itself, can be used to guide activities to
reducematernaldeaths.
Incompleteorpoordata
Routinematernity recordsystems inmanycountries
do not facilitate the collection of data on obstetric
complications, maternal deaths, stillbirths and very
earlyneonataldeaths.Often,staffhasfallenoutofthe
habitoffillinginsomeofthecolumnsofthematernity
registerortheadmissionsanddischargeregisters.This
isamanagementproblemthatrequiresattentionover
timetoensurecomplete,accuraterecordkeeping.
Monitoringemergencyobstetriccare:ahandbook 39
Indicator Description Numerator Denominator Acceptablelevel
1&2* AvailabilityofEmOC(nationalorsubnational)
RatioofEmOCfacilitiestopopulationandgeographicaldistributionoffacilities
No.offacilitiesinareaprovidingbasicorcomprehensiveEmOC
Populationofareadividedby500000
≥5EmOCfacilitiesper500000population
No.offacilitiesinareaprovidingcomprehensiveEmOC
Populationofareadividedby500000
≥1comprehensivefacilityper500000population
3 ProportionofallbirthsinEmOCfacilities
ProportionofallbirthsinpopulationinEmOCfacilities
No.ofwomengivingbirthinEmOCfacilitiesinspecifiedperiod
Expectedno.ofbirthsinareainsameperiod
Recommendedleveltobesetlocally
4 MetneedforEmOC
ProportionofwomenwithmajordirectobstetriccomplicationstreatedatEmOCfacilities
No.ofwomenwithmajordirectobstetriccomplicationstreatedinEmOCfacilitiesinspecifiedperiod
Expectedno.ofwomenwithseveredirectobstetriccomplicationsinareainsameperiod**
100%
5 Caesareansectionasaproportionofallbirths
ProportionofallbirthsinpopulationbycaesareansectioninEmOCfacilities
No.ofcaesareansectionsinEmOCfacilitiesinspecifiedperiod
Expectedno.ofbirthsinareainsameperiod
5–15%
6 Directobstetriccasefatalityrate
ProportionofwomenwithmajordirectobstetriccomplicationswhodieinEmOCfacilities
No.ofmaternaldeathsduetodirectobstetriccausesinEmOCfacilitiesinspecifiedperiod
No.ofwomentreatedfordirectobstetriccomplicationsinEmOCfacilitiesinsameperiod
<1%
7 Intrapartumandveryearlyneonataldeathrate
Proportionofbirthsthatresultinanintrapartumoraveryearlyneonataldeathwithinthefirst24hinEmOCfacilities
No.ofintrapartumdeaths(freshstillbirths;≥2.5kg)andveryearlyneonataldeaths(<24h;≥2.5kg)inEmOCfacilitiesinspecifiedperiod
No.ofwomengivingbirthinEmOCfacilitiesinsameperiod
Tobedecided
8 Proportionofmaternaldeathsduetoindirectcauses
PercentageofallmaternaldeathsinEmOCfacilitiesduetoindirectcauses
No.ofmaternaldeathsduetoindirectcausesinEmOCfacilitiesinspecifiedperiod
Allmaternaldeaths(fromdirectandindirectcauses)inEmOCfacilitiesinsameperiod
Noneset
Table 11. Emergency obstetric care indicators
*Indicators1and2involvethesamecalculations,withdataonthecorrespondingregionalpopulationandfacilityinsteadofaggregatednationaldata.
**Equalto15%ofexpectedbirthsinthesameareaandperiod.
Monitoringemergencyobstetriccare:ahandbook 40
As stated earlier, in many countries maternity regis-
tersdonothaveacolumnfor‘reasonforadmission’
or ‘maternalcomplications’.Whenproviderswant to
recordmaternalcomplications,therefore,theyhaveto
makeanoteinanothercolumn,suchas‘remarks’,or
inthemargin.Whilethismayappeartobeanadminis-
trativedetail,itisastrongindicationofcommitmentto
improvingmaternalhealth.Thereisoftenroominreg-
isterstoaddsuchacolumn,perhapsbyreplacinga
columnusedforuncommonevents,suchasmultiple
births.Persuadingministriesofhealth(andfunders)to
addthiscolumnisanimportantstepinmakingthese
indicatorspartofhealthmanagementinformationsys-
tems.(AppendixBliststheitemsthatshouldappear
in facility registers.) As periodic collection of these
databecomespartofroutineprogrammemonitoring,
recordkeepingshouldimprove.
Dataonmaternaldeaths,stillbirthsandveryearlyneo-
nataldeathsareoftendifficult tocollect forsomeof
thesamereasonsstatedabove.Inaddition,because
of the sensitive nature of these events, health staff
maynotrecordthemforfearofreprisal.Interventions
geared to improve the working environment should,
over time, help health staff feel more comfortable
aboutaccuratelyrecordingdeaths.
Asrecordkeepingofcomplications,maternaldeaths,
stillbirths and very early neonatal deaths improves,
the reportednumberofcomplicationsanddeaths in
the facilitywill increase. It iscritical to reassurestaff
that these temporary increases will be appropriately
interpreted; that theywill notbeassumed tobe the
resultofpoorordeterioratingpatientcare.Oneway
ofidentifying‘recordingbias’istouseotherindicators
inthesetasbenchmarks,especiallythoseindicators
basedonservicesthatarereportedoftenandarefairly
reliable,suchas thenumbersofwomengivingbirth
andcaesareansectionsinthefacility.Usingtheindi-
catorsasasetcanhelpclarifywhethertheapparent
increase in complications or deaths is due to better
reportingorifitisarealincrease.Forexample,ifthe
reportednumberofwomenwithmajorcomplications
treatedinthefacilityincreasesby150%over3years,
but the number of women giving birth in the facility
increasesby75%andthenumberofcaesareansec-
tionsperformedincreasesby50%,itcanbeassumed
thatsomeofthereportedincreaseincomplicationsis
duetobetterreporting(probably intherangeofone
halftotwothirds).Asthecommunity’sconfidencein
thequalityofcareimprovesandwomenwithcompli-
cations are more likely to be brought for treatment,
manyofthewomenwillrequireacaesareansection;
therefore, thenumbersofcomplicationsandofcae-
sareansections should rise together, unless there is
a problem that limits the availability of surgery. This
exampleillustratesthekindofexplorationofthedata
thatcanbeusefulatlocallevel.
RelationofEmOCindicatorstomaternalmortality
Asnotedearlierinthishandbook,metneedforEmOC
and caesarean section as a proportion of all births
are closely correlated with maternal mortality ratios,
and it is logical that as met need goes up and the
direct obstetric case fatality rate declines, the num-
berofdeathsinthepopulationduetodirectobstetric
complicationswilldeclineaswell.Maternalmortality
ratios,however,aredifficulttomeasure,especiallyin
arelativelysmallarea(suchasaprojectarea)orover
a short period. Nevertheless, methods for capturing
theeffectofmaternalhealthprogrammesarecontinu-
ingtoimprove.Forexample,amethodforestimating
deathsaverted,basedon theEmOC indicators,has
beenproposed,althoughitmustbetested(162).Aset
of tools is available at: http://www.immpact-interna-
tional.org/index.php?id=67&top=60.
Anexerciseininterpretingtheindicatorsasaset
Table 12 shows three very different scenarios for
EmOCindicators.Thisexerciseshowsthatsuchdata
aredirectlyapplicableforprogramming.Examinethe
setsofindicatorsinthethreescenariosasifyouwere
anofficialoftheministryofhealthincountryX,look-
ing at data from various districts of the country. On
thebasisofthehypotheticaldataandtheacceptable
levels,identifyprioritiesforimprovingthesituationfor
womenwithobstetriccomplications.
Monitoringemergencyobstetriccare:ahandbook 41
Indicator Level
Scenario1
Population 950000
NumberoffunctioningEmOCfacilities:
•basic 2•comprehensive 1
GeographicaldistributionofEmOCfacilities Mostlyindistrictcapital
ProportionofallbirthsinbasicandcomprehensiveEmOCfacilities 10%
MetneedforEmOC 8%
Caesareansectionsasapercentageofallbirths 0.7%
Directobstetriccasefatalityrate 5%
Scenario2
Population 950000
NumberofEmOCfacilities:
•basic 7•comprehensive 2
GeographicaldistributionofEmOCfacilities Someurban,somerural
ProportionofallbirthsinbasicandcomprehensiveEmOCfacilities 10%
MetneedforEmOC 8%
Caesareansectionsasapercentageofallbirths 2%
Directobstetriccasefatalityrate 2%
Scenario3
Population 950000
NumberofEmOCfacilities
•basic 10•comprehensive 3
GeographicaldistributionofEmOCfacilities Someurban,somerural
ProportionofallbirthsinbasicandcomprehensiveEmOCfacilities 25%
MetneedforEmOC 65%
Caesareansectionsasapercentageofallbirths 12%
Directobstetriccasefatalityrate 15%
InScenario1,therearefartoofewfunctioningEmOC
facilities. For a population of nearly 1 million, there
should be 10 such facilities, at least two of which
are comprehensive, rather than the existing three.
Furthermore, the functioning facilities are mostly in
urbanareas.Theother indicatorsarenotverygood
either(e.g.thedirectobstetriccasefatalityrateistoo
highat5%),butclearlythefirstpriorityistoseewhich
healthfacilitiescanbeupgradedtoprovideappropri-
atecare,especiallyinruralareas.
InScenario2,thenumberoffunctioningEmOCfacili-
tiesismuchhigher:therearenine;twoofthesepro-
videcomprehensivecare,andsomeareinruralareas.
Table 12. Three scenarios for emergency obstetric care (EmOC) indicators and levels
Monitoringemergencyobstetriccare:ahandbook 42
Theproportionofdeliveries that takeplace in these
facilities is, however, low (10%), as is the met need
(8%).Thedirectobstetriccasefatalityrateisnotvery
high(at2%),butthisisnotareasonforcomplacency,
becausesofewwomenarecaredforat thesefacili-
ties.Thehighestpriorityherewouldbetofindoutwhy
use is so low, by using a variety of methods: com-
munityfocusgroups,discussionswithstaff,observa-
tionoftheservicesandareviewoftherecord-keeping
system.
InScenario3,thereismorethantheminimumnum-
ber of EmOC facilities (13); three of these are com-
prehensive(ratherthantheminimumoftwo),andthey
seemtobewelldistributedintermsofurbanandrural
areas. The proportion of births in the facilities (25%
ofallbirths)andmetneed(65%)arefairlyhigh.The
proportionofdeliveriesbycaesareansection(12%)is
towardsthehighendoftheacceptablerange(5–15%),
andthedirectobstetriccasefatalityrateisveryhighat
15%(withamaximumacceptablelevelof1%).Inthis
situation,thequalityofcareintheEmOCfacilities is
thefirstconcern.Clinicalauditsanddirectobservation
ofserviceswouldbeappropriate.Asmetneedandthe
directobstetriccasefatalityratearebothhighinthis
scenario,itisimportanttoanalysewhy.Forinstance,
women may present at the health facility very late,
whichisnotrelatedtothequalityofthehealthfacility.
Maternal death audits and verbal autopsies present
opportunities forhealthmanagers tounderstand the
relevantissues.
Monitoringemergencyobstetriccare:ahandbook 43
3.1Typesofdatarequired
Constructing the EmOC indicators proposed in this
documentrequiresdataonthepopulation,birthrate,
andhealthfacility.Table13showshowtheindicators
arecomposedofsuchdata.
Information on population and birth rates is avail-
ableinmostcountriesatcentrallevel(e.g.thecentral
statisticaloffice).Gatheringinformationonthesignal
functions,modeofchildbirth,obstetriccomplications
andmaternaldeaths,however,meansvisitinghealth
facilitiesandreviewingfacilityregisters.Theemphasis
ison theEmOCservices that a facility actuallypro-
videsratherthanonwhatitissupposedtobeableto
provide.
Thissectionlaysoutthestepsforcollectingthedata
necessaryfortheindicatorsofEmOC.Table14givesa
summaryofthesteps,andeachisdiscussedindetail
below.Sampledatacollectionformsaretobefoundin
AppendixAandarediscussedhere.Inaddition,sug-
gestionsaregivenaboutadditionaldatathatcanbeof
useinareamonitoring.
3.2Preparation
Mostofthedatanecessaryforcalculatingtheseindi-
catorswillbecollectedinfacilities.Inarelativelysmall
country,visitingeveryhospitalshouldnotbetoodif-
ficult,butinalargecountryitmightnotbepossible.
VisitingeveryhealthcentrethatmightprovideEmOC,
althoughidealfromaprogrammeviewpointwouldbe
difficult even in some small countries. Therefore, in
mostcountries,asubsetofpotentialEmOCfacilities
willhavetobeselectedforreview.
Wehope that ina fewyears thekindof information
requiredfortheseindicatorswillbereportedroutinely
toministriesofhealth,inwhichcasedataforallfacili-
tieswouldbecompiledandavailable.Ifthisinforma-
tionisavailableinaregularhealthmanagementinfor-
mationsystem,itiseasiertoassesstheavailabilityof
servicesandmakechangesandimprovementsinthe
healthsystem.
Thestepsdescribed inthissectionandthenextwill
helpinidentifyingagroupoffacilitiesthatgivesarea-
sonablyaccuratepictureofthesituation,whileatthe
same timenot requiringanunreasonable amountof
work.Incountrieswherefinancialandhumanresources
are constrained, the approach described below will
suffice to yield informative data about the maternity
care system. Ensuring that the facilities selected for
review give a fairly accurate picture of the situation
depends largely on avoiding two major pitfalls: sys-
tematicbiasandtheeffectsofchancevariation.
Systematicbiascanoccurwhenconsciousoruncon-
sciousfactorsaffecttheselectionoffacilitiesforstudy.
Forexample,thepeopleselectingthefacilitiesmight
want topresent thesituation in themost favourable
light possible, or they might select facilities that are
easilyaccessible(e.g.onapavedroadornearalarge
town).Ineithercase,thedatacollectedmightgivean
overly favourable impression. The effects of chance
are, of course, unpredictable, but they do tend to
diminishasthenumberoffacilitiesstudiedincreases.
Selection isdone intwostages:selectingareasofa
country for study and then selecting facilities within
thoseareas.Sections3.2.1and3.2.2presentaguide
forselectingareasforstudyatnationallevel.Facilities
within those areas are selected at the area level, as
describedinsections3.3.1and3.3.2.
3.2.1Determinethenumberofareastobestudied
Considera levelsmallerthan‘national’.Thetermfor
thisadministrativelevelwillvarybycountry,e.g.state,
province,butisreferredtohereasan‘area’.Inafew
countrieswheretheadministrativeunitsof‘provinces’
or ‘states’ are exceptionally large, it may be prefer-
able to define smaller areas, e.g. district or county,
for selection into the study. Alternatively, it may be
logisticallybetter toselect theoriginaladministrative
unitseveniftheyarelarge,butthenselectsubareas
forstudyatasecondstage.Asa roughguide, ifan
areahasmorethan100hospitals(publicandprivate),
subareas may be selected; the number of subareas
3.Collectingdatafortheindicators
Monitoringemergencyobstetriccare:ahandbook 44
Typ
eo
fd
ata
Ind
icat
or
1A
vaila
bili
tyo
fE
mO
C(b
asic
and
co
mp
rehe
nsiv
e)
Ind
icat
or
2G
eog
rap
hica
ld
istr
ibut
ion
of
Em
OC
faci
litie
s
Ind
icat
or
3P
rop
ort
ion
ofa
llb
irth
sin
Em
OC
fa
cilit
ies
Ind
icat
or
4M
etn
eed
for
Em
OC
Ind
icat
or
5C
aesa
rean
se
ctio
nsa
sp
rop
ort
ion
of
allb
irth
s
Ind
icat
or
6D
irect
ob
stet
ric
case
fata
lity
rate
Ind
icat
or
7In
trap
artu
m
and
ver
yea
rly
neo
nata
ld
eath
rat
e
Ind
icat
or
8P
rop
ort
ion
ofm
ater
nal
dea
ths
due
to
ind
irect
ca
uses
Exi
stin
ges
timat
es:
Pop
ulat
ion
size
xx
xx
x
Cru
de
bir
thr
ate
ofa
rea
xx
x
Hea
lthf
acili
tyd
ata:
Em
OC
sig
nalf
unct
ions
xx
xx
xx
xx
No.
ofw
om
eng
ivin
gb
irth
xx
No.
ofw
om
enw
ith
ob
stet
ricc
om
plic
atio
nsx
x
No.
ofc
aesa
rean
s
ectio
nsx
No.
ofm
ater
nald
eath
sd
uet
od
irect
ob
stet
ric
cau
ses
xx
No.
ofm
ater
nald
eath
sd
uet
oin
dire
ctc
ause
sx
Int
rap
artu
md
eath
s(
fres
hst
illb
irth
s;
≥2
.5k
g)a
ndv
ery
early
neo
nata
ldea
ths
(≤
24h
;≥2
.5k
g)i
nfa
cilit
y
x
Tab
le 1
3. T
ypes
of d
ata
used
to
co
nstr
uct
emer
gen
cy o
bst
etri
c ca
re in
dic
ato
rs
Monitoringemergencyobstetriccare:ahandbook 45
Table 14. Guide to data collection and forms
Activity Action Refertooruse
Sampleselection 1. Selectareasforstudy,ifnotnational.2. Determineasingle12–monthperiodtostudy
andenteronform2(Facilitycasesummaryform).
3. ListallpossiblefacilitiesintheareathatmightprovideEmOC.
4. Ifsamplingisnecessary,selectfacilitiestobevisited.
Sections3.2.1,3.2.2.Section3.2.3.
Sections3.3–3.3.2,form1andworksheets1aand1b
Datacollection 5. Conductsitevisitstofacilities. Section3andform2
Datapreparation 6. Ifasampleoffacilitieswasvisited,separatethemintohealthcentres(orotherlower-levelfacilities)andhospitalsbyareaandthenadjustthedataforareaestimates.
7. Ifallfacilitiesinanareaweresurveyed,separatethemintothreegroupsbyarea:• actualcomprehensiveEmOCfacilities• actualbasicEmOCfacilities• non-EmOCfacilities
8. Summarizefindingsforallindicatorsdisaggregatedbyclassifiedleveloffacility(i.e.basicandcomprehensiveandallsurveyedfacilities).
Section3.5,form3andworksheets3a,3band3corworksheets3d,3eand3f
Calculationandinterpretationofindicators
9. Calculateindicatorsfor(each)area(forEmOCfacilitiesandforallfacilities).
10.Interpret.11.Consolidateforms1–4(withworksheets)forall
studyareasifnational.12.Calculateindicatorsforentirecountry.13.Interpret.
Section3.6andform4Section3.1andtextoneachindicator(section2)Section3.7,form5andworksheet5aSection3.1andtextoneachindicator(section2)
Anareaistheadministrativelevelorgeographicareainthecountryincludedinthefacilitysurvey;e.g.,district,
state,province.
studiedshouldrepresentatleast30%ofthetotal.For
the purposes of the forms, each subarea should be
consideredan‘area’.Professionalhelpfromastatisti-
cianshouldbesoughtinobtainingnationalestimates
incountrieswheresubareasareselected.
Thefollowingguidelinesshouldbeusedtodetermine
whethertostudyallareasofacountry:
• Ifacountryhas100orfewerhospitals(publicand
private),thenstudyallareas.
• Ifacountryhasmorethan100hospitals(pub-
licandprivate),thenasubsetofareasmaybe
selectedforstudy.Selectasmanysubnational
areasaspossible,butthenumberselectedshould
beatleast30%ofthetotalnumberofsubnational
areasinthecountry.
Inselectingasubsetofareas, theaimshouldbe to
study as many areas as possible, without compro-
misingthequalityofthedatacollected.Forexample,
if there are 21 administrative areas in a country, 10
might be selected for study. Fewer can be studied
if resources are scarce, but the proportion selected
shouldnotbelessthan30%oraminimumofseven
administrativeareas.
Monitoringemergencyobstetriccare:ahandbook 46
3.2.2Randomselectionofareas
Toavoidbias,describedabove,theselectionofareas
withineachtypemustberandom.Theprocedurefor
randomselectionisasfollows:
Step1:Makealistofallareasinthecountry.Thelist
shouldbeinalphabeticalorder,tominimizethepos-
sibilityofbias.
Step2:Assigneachareaaconsecutivenumber,start-
ingwith1forthefirstareaonthelist.
Step3:Calculatethe‘samplinginterval’,whichwilltell
you toselecteveryntharea,once the firstareahas
beenselectedatrandom.Usethefollowingformula:
Samplinginterval=
totalnumberofareasinthecountry
dividedby
numberofareasselected
CountryWhasatotalof21areas,ofwhich10areto
beselectedforstudy,givingasamplingintervalof2
(21/10=2.1).Samplingintervalsshouldberoundedto
thenearestwholenumber.If,forexample,ithadbeen
decidedthat15ofthe21areaswouldbestudied,the
samplingintervalwouldbe1.4,whichwouldtherefore
rounddownto1,anindicationthateitherfewerareas
should be selected for study or all areas should be
includedinthesample.
Step 4: Identify the first area to be included in the
samplebygeneratinga randomnumber that is less
thanorequaltothesamplingintervalbutgreaterthan
zero.Thiscanbedonewitha randomnumber table
(Appendix C). To use the table, look away from the
pageandtouchitwiththepointofapencil.Thedigit
closest to where the pencil touches the page is the
randomnumber.Ifthedigitislessthanorequaltothe
samplingintervalandgreaterthanzero,useit;ifnot,
read from left to right until a digit that satisfies this
conditionisreached.Thisnumberwillbethefirstarea
selected.
For country W, the sampling interval is 2. Using the
randomnumbertable,ourpencilpointfallsonthedigit
7,atrow22,column5.Thisislargerthanoursampling
interval,sowereadfromlefttoright,passingthedigits
0,7and0,untilwecometo2.Thus,area2onthelist
willbethefirstareaselected.
Step5: Identifyallotherareas tobe included in the
samplebyaddingthesamplingintervaltothenumber
ofthefirstareaandcontinuetoselectareasuntilthe
desirednumberhasbeenreached.Asthefirstselected
areais2onthelistofareas,thenextonewouldbe2
plus2,or4,andthenext6,andsoon,until10areas
havebeenselected.
3.2.3Determineanationallyuniform12–monthperiodtobestudied
Thedatacollectedfromfacilitieswillberetrospective,
butthe12-monthperiodselectedshouldbearecent
one,toensurethatthedatawillstillbeavailable.For
comparabilityofdata,itisimportantthatalldatacol-
lected throughout the country be for the same 12–
monthperiod.Adecisionaboutwhichperiodtouse
shouldbemadeatnationallevel,anditshouldthenbe
enteredonthetopofthefacilitycasesummaryformof
form2beforeitisduplicatedforuse.Thiswillensure
that data collected at all facilities refer to the same
period.The12–monthperiodcanbeeither acalen-
daryear(e.g.1January2010–31December2010)or
anyother12-monthperiod(e.g.1June2012–31May
2013).
Onceareashavebeenselectedforstudy, forms1–4
and all the worksheets should be duplicated and a
complete set given to the person coordinating the
researchineacharea.
3.3Form1:AllpotentialEmOCfacilitiesinselectedareas
Thefirststepingatheringtherequireddataistomake
anexhaustive,up-to-datelistofallthefacilitiesineach
selected areas that may be providing delivery and
EmOCservices(basicorcomprehensive),asdefined
bythesignalfunctions(Table4).Afacilitythatmaybe
providingEmOCservicesisonethatis:
• ontheministryofhealth’slistofhospitalsand
lower-levelfacilitiesthatshouldbeprovidingdeliv-
eryservices;
Monitoringemergencyobstetriccare:ahandbook 47
• onalistofprivatehospitalsandlowerlevelfacili-
tiesthatmightbeprovidingatleastsomedelivery
services;or
• knownbytheareamedicalofficeraspossiblypro-
vidingdeliveryservices.
Thelistshouldbeascompleteaspossiblesothatno
EmOCfacilityisoverlooked;however,careshouldbe
takentoavoiddoublecounting.Worksheets1aand1b
canbeusedforthispurposeandshouldbeusedto
listallofthevariousfacilities—hospitals,maternities,
healthcentres,clinicsandhealthposts—thatmaybe
providingbasicorcomprehensiveEmOCinthearea.
Aseachworksheethasspacetolistonly10facilities,it
islikelythatthelistsofeachtypeoffacilitywillbesev-
eralpageslong.Itisrecommendedthattheselistsbe
inalphabeticalordertoreduceanybiasintheselec-
tionprocess(see3.3.2below).Form1summarizesthe
numberoffacilitieslistedonworksheets1aand1b.
3.3.1Determinethenumberoffacilitiestobereviewed
In a relatively small area, it may be possible to visit
every hospital, while in larger areas it will not. Even
in small areas, it will often be difficult to visit every
lower-levelfacilitythatprovidesdeliveryservicesand
mightbeprovidingbasicEmOC.Thus,inmostareas,
a subset of facilities may be selected for review. To
avoidbias,thissecondstageofselectionshouldalso
berandom.Thecriteriabelowcanbeusedtodecide
whethertostudyallfacilitiesortoselectasubsetfor
review.
Itisimportanttoincludeprivatesectorfacilitiesinthis
exercise. Therefore, countries may want to conduct
thefollowingexerciseseparatelyforpublicandprivate
facilities.
Hospitals(e.g.regional,district,rural,maternity):
• Ifthereare25orfewer,studyallofthem.
• Iftherearemorethan25,asubsetcanbe
selected.Selectasmanyaspossible,butthe
numbershouldrepresentatleast30%andthere
shouldnotbefewerthan20facilities.
Lower-levelfacilities(e.g.healthcentres,healthposts,
clinics):
• Ifthereare100orfewer,studyallofthem.
• Iftherearemorethan100,asubsetcanbe
selected.Selectasmanyaspossible,butthe
numbershouldrepresentatleast30%.
Example:InareaX,thereare48hospitalsofdifferent
levelsandtypes.Although48isgreaterthan25,itis
decidedthatitisfeasibletovisitallofthem.Thereare
also390healthcentresandhealthposts,butitwould
be too difficult and costly to visit all of them and a
subsetofthesefacilitiesmustbeselectedforreview.
Ifasubsetofeithertypeoffacilityistobeselected,the
numbertobevisitedmustbedecided.Asdescribed
above,thisnumbershouldbeaslargeaspossiblein
ordertominimizetheeffectsofchancevariation,and
shouldbeatleast30%ofallfacilitiesofeachtype.In
determiningthenumberoffacilitiestovisit,itisimpor-
tanttostrikeagoodbalancebetweenthenumberof
facilitiesand thequalityof thedata thatwill becol-
lectedfromthem.Inotherwords,thenumberoffacili-
tiesselectedshouldbeaslargeaspossiblewhilestill
allowingforcarefuldatacollectionateachfacility.
Example:InareaX,all48hospitalswillbevisited,and
40%ofthehealthcentresandpostswillbeselected
for review. Thus, 156 (0.4 x 390) health centres and
posts will be selected. The percentages of selected
hospitalsandlower-levelfacilitiesineachareashould
be recorded, so that thiscanbe taken intoaccount
whencombining the information fromall areas.This
stepisnotneededifthesamepercentageisselected
inallareas.
3.3.2Randomselectionoffacilities
Once thenumberof facilities tobevisitedhasbeen
decided,thenextstepistoselecttheactualfacilities.
Tominimizethechanceofbias,thisshouldbedone
randomly, inaproceduresimilar to that followed for
selecting areas. If all facilities are to be visited, this
stepwillnotbenecessary.Ifasubsetofbothhospi-
talsandlower-levelfacilitiesistobeselected,random
selection should be carried out separately for each
level.Theprocedureisoutlinedbelow.Randomselec-
Monitoringemergencyobstetriccare:ahandbook 48
tionwillbedonewithall the lists inworksheet1aor
1bthathavebeenfilledoutforthegeographicalarea
inquestion.
Step 1: Assign each facility a consecutive number.
In order to minimize the possibility of bias, facilities
should be listed in alphabetical order before being
numbered.
Step2:Calculatethesamplinginterval,whichwilltell
youtoselecteverynthfacilityoncethefirstfacilityhas
beenselectedatrandom.Usethefollowingformula:
Samplinginterval=
numberoffacilitiesinthearea
dividedby
numberoffacilitiestobeselected
Example: InareaX,a totalof390healthcentres,of
which156are tobeselected for review,producesa
samplingintervalof3(390/156=2.5).Samplinginter-
valsareroundedtothenearestwholenumber.
Step3: Identify the first facility tobe included in the
samplebygeneratinga randomnumber that is less
thanorequaltothesamplingintervalbutgreaterthan
zero.Thiscanbedoneusingarandomnumbertable
(Appendix C). To use the table, look away from the
pageandtouchitwiththepointofapencil.Thedigit
closest to where the pencil touches the page is the
random number. If the digit is less than or equal to
thesampling intervalandgreater thanzero,use it; if
not, read from left to right until a digit that satisfies
thisconditionisreached.Thisnumberwillbethefirst
facilityselected.
Example:Forlower-levelfacilitiesinareaX,thesam-
plingintervalis3.Usingtherandomnumbertable,our
pencilpointfallsonthedigit4, inrow12,column2.
This is larger thanoursampling interval,sowe read
from left to right,passing thedigits0,9and6,until
wecometo1.Thus,facility1onthelistoflower-level
facilitieswillbethefirstareaselected.
Step 4: Identify all other facilities to be studied by
addingthesamplingintervaltothenumberofthefirst
facility. Continue to select facilities until the desired
numberhasbeenreached.Ifyoucometotheendof
the list in theselectionprocess, return to thebegin-
ning,butdonotcountthosefacilitiesthathavealready
beenselected.
Example: Since the first selected facility is 1 on the
list, the next one would be 1 plus 3, or 4, and the
next7,andsoon.Facility388willbethe129thfacility
selected,andfacility3willbethe130th(sincefacility1
hasalreadybeenselectedandshouldnotbecounted
inthesecondpassthroughthelist).Everythirdfacil-
itywillcontinuetobeselectedinthiswayuntilall156
havebeenselected.
Oncethefacilitiestobereviewedhavebeenselected,
sitevisitstocollectdataateachfacilitycanbegin.
3.4Form2:ReviewofEmOCatfacilities
Acopyof form2 shouldbeusedat each facility to
recordthetypeandamountofservicesprovided.The
informationcompiledonthisformwillenableresearch
staff to determine whether a given facility is actu-
allyprovidingEmOCservicesand, if it is,whether it
is functioning at the basic or comprehensive level.
Exceptfordataonpopulationsizeandthecrudebirth
rate,alltheinformationneededtoconstructtheindi-
catorsiscontainedinform2.
EmOCsignalfunctions
TodeterminewhethertheEmOCsignalfunctionswere
performedinthepast3months,reviewfacilityregis-
ters,observeandifnecessaryinterviewhealthwork-
ersinthematernitywardandotherdepartments.
• Recordwhetherthesignalfunctionhasbeenper-
formedinthepast3monthsand,ifnot,whyithas
notbeenperformed.
• Considerallthefollowingwhendetermining
whetheraparticularsignalfunctionwasavailable:
– Isstaffatfacilitytrainedtoprovidetheservice?
– Aretherequisitesuppliesandequipmentpres-
ent?Istheequipmentfunctioning?
– Weretherecasesforwhichtheuseofa
particularsignalfunctionwasindicated?
– Arethecadresofstaffworkingatthefacility
authorizedtoperformtheservice?
Monitoringemergencyobstetriccare:ahandbook 49
• Ifasignalfunctionwasnotperformedinthepast
3months,indicatewhynot,usingthefollowing
definitions:
– Trainingissues:
- Authorizedcadreisavailable,butnottrained;
- Providerslackconfidenceintheirskills.
– Suppliesandequipmentissues:
- Suppliesorequipmentarenotavailable,not
functionalorbroken;
- Neededdrugsareunavailable.
– Managementissues:
- Providersdemandcompensationtoperform
thisfunction;
- Providersareencouragedtoperform
alternativeprocedures;
- Providersareuncomfortableorunwillingto
performtheprocedureforreasonsunrelated
totraining.
– Policyissues:
- Therequiredlevelofstaffisnotpostedtothis
facilityinadequatenumbers(oratall);
- Nationalorhospitalpoliciesdonotallowthe
functiontobeperformed.
– Noindication:
- Nowomanneedingthisprocedurecameto
thefacilityduringtheperiod.(Beforemarking
‘Noindication’,considertheprevious
options;forexample,ifasitedoesnothave
someonetrainedtoprovideaprocedureor
equipmentanddrugs,womenwillnotcome
fortheprocedure.).
Numberofwomengivingbirth• Thisisthenumberofwomenwithnormalvaginal
births+thenumberofwomenwithassisted
vaginaldeliveries+thenumberofcaesarean
sectionsinthefacility.
• Ifbreechdeliveriesarerecordedseparately,add
theseaswell,butremembertocheckthatthey
arenotalreadyincludedinnormaldeliveriesor
caesareansections.
• Remembertocountthenumberofwomenandnot
thenumberofbirths(i.e.infants).
Numberofcaesareansections• Remembertocountallemergencycaesarean
sectionsandallplannedorscheduledcaesarean
sections.
• Countcaesareansectionsperformedforneonatal
aswellasmaternalreasons.
Numberofwomenwithdirectobstetriccomplications• Inordertobeconsideredacaseandtobe
includedinthedata,awomanmustbepregnant
atthetimeofadmission,recentlydeliveredor
aborted.
• Includeonlyeventsofsufficientseveritythat
shouldbetreatedwithalife-savingprocedureor
arestabilizedandthenreferredtoanotherfacility.
• Thepatienthasacleardiagnosisofanyoneofthe
obstetriccomplications(seeBox2).
• Treatmentwasstartedbeforereferraltoanother
facility(includingstabilization).
• Whendiagnosisofcomplicationsisnotavailable,
usethefollowingcriteriaforinclusion:
– Recordsindicateclearsignsorsymptomssuch
asbleeding,highbloodpressure,feverwith
dischargeandconvulsions.
– Recordsindicatedefiniteinterventionssuchas
caesareansection,vacuumorforcepsdelivery,
bloodtransfusion,manualremovalofplacenta,
injectionofanticonvulsantorinjectionof
oxytocin.
• Excludewomenwhowereadmittedwithoutany
diagnosis(orcluesleadingtoadiagnosisas
mentionedabove)andwhoreceivednotreatment
beforebeingreferredtoanotherfacility.
• Ifonepatienthastwodiagnoses,selectthemore
seriousone.Forexample,ifapregnantwoman
wasadmittedforhaemorrhageandruptured
uterus,themaindiagnosisisruptureduterus.Ifthe
interviewerisunsureaboutthediagnosis,heor
sheshouldconsultthestaffworkinginthehealth
Monitoringemergencyobstetriccare:ahandbook 50
facility.Remembertocountthenumberofwomen
withobstetriccomplicationsandnotthenumber
ofobstetriccomplications.
• Abortioncomplicationsincludeonlythosewith
infectionorhaemorrhage(seecasedefinitionsin
Box2).
• Complicationsofabortioncanresultfromeither
inducedorspontaneousabortion.
• Whensearchingforcomplicationsofabortion,the
teamshouldlookinfemalewardregisters,emer-
gencyregistersandmaternity,labour,delivery,or
wardregisters.
Numberofmaternaldeathsduetodirectobstetriccauses• TheWHOdefinitionof‘maternaldeath’shouldbe
used:“Thedeathofawomanwhilepregnantor
within42daysofterminationofpregnancy,irre-
spectiveofthedurationorsiteofthepregnancy,
fromanycauserelatedtooraggravatedbythe
pregnancyoritsmanagement,butnotfromacci-
dentalcauses.”
• Countonlymaternaldeathsthatoccurredinthe
facilitybeingstudied.
• ThedefinitionsofobstetriccauseslistedinBox2
shouldbereferredtowhenfillinginthissection.
• Maternaldeathscanbedifficulttofindinsome
facilityregisters.Therefore,itisveryimportantto
lookatasmanysourcesaspossible(e.g.mater-
nitywardregisters,morguerecordbooks,emer-
gencyroomrecords).
• Maternaldeathscanbeasensitiveissuetodis-
cusswithhealthworkers.Sometimesitmightbe
helpfultoexplainthatthereviewisnotanaudit.
Inordertomakestafffeelmoreatease,onecan
pointoutsomethingpositiveabouttheirfacility(for
example,howmanywomentheyhavebeenable
totreat).
Numberofindirectmaternaldeaths• Beforefillingintheform,listthemajorindirect
causesofmaternaldeathsthatarerelevanttothe
countryunderreview,e.g.HIVinfection,severe
anaemiaandmalaria.
Numberoffreshstillbirthsandveryearlyneonataldeaths≥2.5kg• Refertothedefinitionsoffreshstillbirthsandvery
earlyneonataldeathsabove.
• Omitveryearlyneonataldeathswhenmothers
gavebirthoutsidehealthfacilities(i.e.inthecom-
munityorathome).
• Whenthebirthweightisunavailable,recordthe
deathandstatethatthebirthweightwasunknown.
Collectingcasesummarydata
Dependingon thesizeofeach facilityand thequal-
ityofitsrecords,itmaybetoodifficulttocollectthe
necessary information for the entire year directly on
form2.Therefore,twoplansarepresented.
Plan 1 should be followed whenever possible. This
entailscompletingthegridonform2(i.e.recordingthe
numberofwomengivingbirth,eachtypeofcomplica-
tion,caesareansection,maternaldeaths,intrapartum
deathsandveryearlyneonataldeaths)at thefacility
duringeachofthe12monthsbeingstudied.
Plan2canbefollowedifthefacility’spatientvolume
is so large that collecting this information for all 12
monthswouldbetootime-consuming(e.g.ifthereare
morethan10000deliveriesperyear). Inthisplan,a
sampleof4monthsdistributedthroughouttheyearis
usedandthenmultipliedbythreetoestimatethetotal
numberfortheyear.Incountrieswheretherearevast
seasonaldifferencesindeliveries,itmaybeimportant
tochoose4monthsdistributedthroughouttheyearto
accountforthisvariation.
3.5Form3:SummaryofdataonEmOCfacilitiesinanarea
Iftheanalysisistobeconductedmanuallyandnotby
computer,afterall thesectionsof form2havebeen
completed,theformsshouldbecollectedandsorted
bygeographicalarea.Thenextstepistosummarize
thefindingsforeacharea.Form3isusedforthispur-
poseandhastwosections,AandB,onlyoneofwhich
shouldbecompleted.
Monitoringemergencyobstetriccare:ahandbook 51
Section Awhichrequestsastraightforwardsummary
of the data collected from facilities, should be used
only if all facilities in the area were visited (that is,
therewasno selectionof facilities). Facilities should
besortedintothreegroupsonthebasisoftheentries
in the box entitled ‘Determination of EmOC status’
onform2.Thethreegroupsarefacilitiesthatprovide
comprehensive EmOC, facilities that provide basic
EmOC and facilities that do not fully provide either
basicorcomprehensiveservices.Worksheets3a,3b
and3carethenusedtopreparethesummary.
Section Bshouldbeusedifasampleoffacilitieswas
chosen.Itincludesanintermediatestepforadjusting
thedatacollectedintoestimatesforallfacilitiesinthe
area.Worksheets3d,3eand3fareneededtoprepare
thissummary.
Thus,onecopyofform3willbefilledoutforeacharea
included in thestudy,completingeithersectionAor
sectionB(deletethepartyoudonotuse).
3.6Form4:Calculationofindicatorsforeacharea
Oncethefindingsfromsitevisitshavebeensumma-
rized,form4canbeusedtocalculatetheindicators
foreacharea.This form laysout thesteps forusing
theinformationsummarizedinform3andincludesa
summarychecklisttodeterminewhethereachindica-
tormeetsanacceptablelevel.
While,ultimately, thedataon facilitieswillbeaggre-
gatedinordertocalculatetheindicatorsforthewhole
country,thearea-levelindicatorsprovideusefulinfor-
mation for setting programme priorities at the area
level,andanentiresetofcompletedforms1–4should
bemaintainedintheareaforthispurpose.Secondly,
theseindicatorsallowcomparisonsamongstudyareas
at the national level. Using the information obtained
foreachselectedarea,researcherscanexaminedif-
ferencesintheavailabilityofEmOCservices,useand
performanceindifferentareasofthecountry.Thiscan
haveimportantimplicationsforpolicyandsettingpro-
grammepriorities.
3.7Form5:Calculationofindicatorsforthecountry
In order to calculate the EmOC indicators for the
countryasawhole, researchersmustcollectcopies
ofallforms3and4(includingworksheets)fromeach
studyarea.Theinformationneededforthisfinalstep
issummarizedonform5andworksheet5a.Thelat-
tersummarizes informationonthenumberofEmOC
facilities, women giving birth, women with obstetric
complications, caesarean sections, maternal deaths
(direct and indirect) and intrapartum and very early
neonataldeathsinalltheareasselected.
The indicators for thecountryasawholearedeter-
minedonform5.Similarlytoform4forthecalculation
ofindicatorsatthearealevel,asummarychecklistof
acceptablelevelsforeachindicatorisprovided.
Oncetheindicatorshavebeencalculated,thelaststep
isinterpretation.Generalnotesontheinterpretationof
EmOCindicatorsareincludedunderthedescriptionof
eachindicatorinthefirstsectionofthishandbook.
3.8Monitoringatthearealevel
Area officials and planners may be interested in
greaterdetailthanisrequiredfornationalmonitoring.
Therefore, further questions might be added during
site visits to facilities. This can be done by attach-
inganextrasheettoform2(ReviewofEmOCfacili-
ties). Some questions that might be of interest are
discussedbelow.Itisimportant,however,thatallthe
data required for thecalculationof the indicatorsbe
collecteduniformlyforthewholecountry.Whileques-
tions may be added to form 2, none of the existing
questions should be modified or deleted. Additional
modules useful for conducting a more extensive
needsassessmentareavailableat:http://www.amd-
dprogram.org
3.8.1Leveloffunctioningoffacilities
Forthepurposesofmonitoring,it iscrucialthatonly
facilities that provide full basic or comprehensive
EmOC(i.e.facilitiesthatperformedallthedesignated
signal functions inTable4 in thepast 3months)be
includedinthefirstanalysis.Areaplannersmightalso
Monitoringemergencyobstetriccare:ahandbook 52
be interested in knowing what signal functions the
otherfacilitiesintheareahaveperformed,andwhich
of them could potentially function as basic or com-
prehensive EmOC facilities. Tables can be prepared
to determine how many facilities did not perform
oneormoresignalfunctions,andwhichsignalfunc-
tionsfacilitiestheydidordidnotprovideinthepast3
months.Understandingwhysignalfunctionswerenot
performedisimportant.Theseinvestigationswouldbe
particularlyuseful if theanalysisofEmOC indicators
revealsashortageoffacilities.Inthatcase,information
aboutwhichfacilitiesareclosetoprovidingsuchcare
canbeusedinplanningwhichfacilitiestoupgrade.If
aparticularsignal function,suchasassistedvaginal
delivery,isoftennotperformed,apolicyreviewmight
becalledforinordertoascertainwhoistrainedtodo
what,atwhatlevelofthehealthsystem.
3.8.2Timeavailabilityofservices
Anotherfactorthatareaofficialsmightwishtoexam-
ine is whether obstetric services are available 24 h/
day, 7 days/week at facilities that are already fully
functioning.Forexample,aquestiononthehoursper
dayanddaysperweekthatsignalfunctionsareactu-
allyavailablemightbeaddedtothefacilityreviewform
(form2).Asobstetriccomplicationsareunpredictable,
itisimportantthatwomenhaveaccesstolife-saving
EmOCaroundtheclock.Analysesoflocalpatternsin
theavailabilityofsignalfunctionsmightshowthatthe
EmOCcoverageisactuallylowerthanthenumberof
facilities would imply. In such cases, expanding the
hourswhenservicesareavailable isstronglyrecom-
mended.
3.8.3Geographicaldistributionofserviceswithinareas
ThegeographicaldistributionofEmOCfacilitiesalso
affects the accessibility of services. Although the
numberoffacilities inanareamightmeetorexceed
the minimum acceptable level, smaller geographical
regionsmayhavetoofewornofacilities.Atthearea
level,therefore,itmaybedesirabletolocatefacilities
onamapinordertoidentifylocalareaswherewomen
donothaveaccesstoEmOC,eitherbecausefacilities
donotexistorbecausetheexistingfacilitiesarenot
accessible,e.g.becauseofpoorornonexistentroads
andbridges.
3.8.4Differencesbetweenpublic-andprivate-sectorfacilities
Health planners may be interested in examining dif-
ferencesbetweenfacilitiesthataregovernment-oper-
ated and those that are managed by religious insti-
tutions, nongovernmental organizations or for-profit
organizations. Such differences can have important
implicationsforprogramming.Forexample,onemight
want to know the proportions of women with com-
plications who are receiving EmOC in public and in
private facilities, or which types of facilities perform
moreEmOCsignal functions.Onemightalsoexam-
inedifferencesincasefatalityratesinhospitalbytype
offacility.Insomesituations,accesstoservicesand
issues of equity can be related to facility ownership
andcostofservices.
3.8.5Qualityofcareatfacilities
As discussed earlier, case fatality rates are a crude
indicatorof the levelofperformanceatEmOCfacili-
ties.Area researchersoradministratorsmight there-
forewishtocollectadditionalinformationtogainmore
insight into the quality of care provided at selected
localfacilities.Oneapproachistocollectdataonthe
intervalbetweenthetimeawomanisadmittedtoan
EmOCfacilityandthetimesheactuallyreceivestreat-
ment,asdiscussedunder‘Supplementarystudies’in
thesectionondirectobstetriccasefatalityrates.
Detailed case reviews or audits of both maternal
deaths and ‘near misses’ can also provide valuable
information about the quality of care. Case reviews
andauditshavetheadvantageofidentifyingproblem
areas within facilities and suggesting possible rem-
edies.Someresourcesthatcanbeusedforstudiesof
thequalityofcareare:
• EngenderHealthandAMDD.Qualityimprovement
forEmOC:leadershipmanualandtoolbook
(http://www.engenderhealth.org/pubs/maternal/
qi-emoc.php)(163).Thispublicationcanhelp
health-careproviderstoidentifyandsolvetheir
ownproblems.Itoutlinesacontinuous,four-step
Monitoringemergencyobstetriccare:ahandbook 53
qualityimprovementprocessbasedonparticipa-
toryprinciples,withstaffinvolvementandowner-
shipandfocusingonclients’rightsandneeds.It
alsocontainsinstrumentsforcollectinginforma-
tionandinstructionsfortheiruse.
• AMDD.ImprovingEmOCthroughcriterion-
basedaudit,2002(http://www.amddprogram.
org/resources/CriterionBased%20AuditEN.pdf).
Thismanualdescribes‘criterion-basedaudit’as
acomparisonofactualpracticewithevidence-
basedstandardsofcare.Itisusedtoimproveclin-
icalandmanagerialpractice,tomakemoreratio-
naluseofscarceresourcesandtoimprovestaff
morale.Theauditcycleincludesdatacollection,
analysis,andaplanofactiontocorrectdeficien-
cies,implementationofthatplanandrepetition
ofthecycletomeasurechange.Criterion-based
auditcanalsobeusedtoexaminemanagementor
theorganizationofservicesandhumanrightsina
clinicalsetting.
• WHO.Beyondthenumbers.Reviewingmaternal
deathsandcomplicationstomakepregnancy
safer,2004(http://www.who.int/reproductive-
health/publications/btn).Thisbookisdirectedat
healthprofessionals,health-careplannersand
managersworkingonmaternalandnewborn
healthwhowishtoimprovethequalityofcare
provided.Theyshouldbeinapositionandwilling
totakeremedialactiononthebasisofthefindings
ofthesereviews.Theinformationcanbeusedto
improvematernalhealthoutcomesbyencouraging
healthprofessionalstoevaluatecurrentpractices
criticallyandtochangethemifnecessary.As
actionistheultimategoalofthesereviews,itis
importantthatpeoplewhocanimplementtherec-
ommendedchangesparticipateactively.
3.8.6Qualityoffacilityrecords
Area-level officials should examine the method by
which the number of women with complications is
derivedinthefacilityreviewforms(form2).Theform
offers twoplans forarrivingat thisnumber (seedis-
cussion in section 3.4). Some facilities are probably
treating more women with obstetric complications
thantheirrecordsindicate,andthefinalquestionson
theformaskthereviewertogiveaninformedopinion
aboutthecompletenessofthefacility’srecords.Area-
level officials might be interested in examining the
repliestothisquestionforfacilitiesintheirarea.Ifthe
recordsforanumberoffacilitiesappeartobeincom-
plete,aworkshoponfacilityrecordkeepingcouldbe
conducted.
Monitoringemergencyobstetriccare:ahandbook 54
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70. UNICEF Karachi. Needs assessment for 9 districts in Sindh Province. UNICEF Karachi and Pakistan Medical Association, 2000.
71. Ali M et al. Emergency obstetric care in Pakistan: Potential for reduced maternal mortality through improved basic emergency obstetric care facilities, services, and access. International Journal of Gynecology and Obstetrics, 2005, 91(1):105-112.
72. Ali M et al. Emergency obstetric care availability, accessibility and utilization in eight districts in Pakistan’s Northwest Frontier Province. Journal of the Ayub Medical College of Abbottabad, 2006, 18(4):10-15.
73. Ali M, Kuroiwa C. Accurate record keeping in referral hospi-tals in Pakistan’s Northwest Frontier Province and Punjab: A crucial step needed to improve maternal health. Journal of the Pakistan Medical Association, 2007, 57(9):443-446.
74. Reproductive Health Program and UNICEF. Draft report of the needs assessment for emergency obstetrics care Somaliland (NWZ). Mogadishu, 2007.
75. Federal Ministry of Health and Reproductive Health Direc-torate. Report on: National emergency obstetric care needs assessment: October - December 2005. Khartoum, 2005.
76. Kashmiry A. Final report: Baseline assessment for the FEMME project. Dushanbe, CARE Tajikistan, 2000.
Monitoringemergencyobstetriccare:ahandbook 57
77. Associates for Community and Population Research. Review of availability and use of emergency obstetric care services in Bangladesh. Dhaka, UNICEF, 2001.
78. Reproductive Health Program et al. Emergency obstetric care services: Inventory report. Dhaka, 2006.
79. Islam MT et al. Improvement of coverage and utilization of emergency obstetric care services in southwestern Bangladesh. International Journal of Gynecology and Obstetrics, 2005, 91(3):298-305.
80. Wangmo D et al. Report on first phase needs assessment in emergency obstetric care facilities and service delivery in the district hospitals of Bhutan. Thimphu, Ministry of Health and Education, Department of Health Services, 2000.
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86. Family Health Division of Ministry of Health and UNICEF. Needs assessment on the availability of emergency obstetric care services in eastern, western and mid-western regions of Nepal. Final report. New era. Katmandu, 2000.
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91. Save the Children. Needs assessment reports for the provinces of Quang Tri and Thanh Hoa. Hanoi, 2000.
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94. Complications of abortion: Technical and managerial guidelines for prevention and treatment. World Health Organization, Geneva, 1994.
95. Managing complications in pregnancy and childbirth: A guide for midwives and doctors. (WHO/RHR/00.7). World Health Organization, Geneva, 2003.
96. Managing newborn problems: A guide for doctors, nurses, and midwives. Geneva, World Health Organization, 2003.
97. Paxton A, Maine D, Hijab N. Using the UN process indicators of emergency obstetric care: Questions and answers. AMDD Workbook. New York, AMDD Program, Heilbrunn Department of Population and Family Health, 2003.
98. Pregnancy, childbirth, postpartum and newborn care: A guide to essential practice. World Health Organization, Geneva, 2003.
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108. Koblinsky M et al. Going to scale with professional skilled care. Lancet, 2006, 368(9544):1377-1386.
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110. Wilson JB et al. The maternity waiting home concept: The Nsawam, Ghana experience. International Journal of Gynecology and Obstetrics, 1997, 59 (Suppl. 2):S 165-172.
111. Renaudin P et al. Ensuring financial access to emergency obstetric care: Three years of experience with obstetric risk insurance in Nouakchott, Mauritania. International Journal of Gynecology and Obstetrics, 2007, 99(2):183-190.
112. Harvey SA et al. Skilled birth attendant competence: An initial assessment in four countries, and implications for the safe motherhood movement. International Journal of Gynecology and Obstetrics, 2004, 87(2):203-210.
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115. Bang RA et al. Maternal morbidity during labour and the puerperium in rural homes and the need for medical at-tention: A prospective observational study in Gadchiroli, India. British Journal of Obstetrics and Gynecology, 2004, 111(3):231-238.
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122. Otsea K. Workbook for monitoring safe abortion care (SAC) service provision. Chapel Hill, North Carolina, Ipas, 2007.
123. Otsea K, Tesfaye S. Monitoring safe abortion care service provision in Tigray, Ethiopia: Report of a baseline assess-ment in public-sector facilities. Chapel Hill, North Carolina, Ipas, 2007.
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128. Villar J et al. Caesarean delivery rates and pregnancy outcomes: The 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet, 2006, 367(9525):1819-1829.
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Appendix A: Forms and worksheets for data collection and calculation of
EmOC indicators
Form 1 Possible EmOC facilities
Worksheet 1a List of health centres, health clinics and health posts
Worksheet 1b List of hospitals
Form 2 Review of potential EmOC facilities
Form 3 Summary of data on EmOC facilities in the area
Worksheet 3a Summary of reviews of basic EmOC facilities
Worksheet 3b Summary of reviews of comprehensive EmOC facilities
Worksheet 3c Summary of reviews of non-EmOC facilities
Worksheet 3d Summary of health centres and other lower-level facilities
Worksheet 3e Summary of hospitals
Worksheet 3f Area-wide estimates of EmOC
Form 4 Calculation of indicators for geographic area
Form 5 Calculation of indicators for a country
Worksheet 5a Amount of EmOC services
These forms are useful for collecting information. The format can be adapted if necessary. It is important that all the data be
collected in order to have a complete picture of the services available and services needed.
61Monitoringemergencyobstetriccare:ahandbook
62 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 63
Form 1. Possible EmOC facilities
1. Name of area
2. Population of area
3. Crude birth rate of area
4. Form completed by (list name and title)
5. Form completed on (date)
Worksheets 1a–1b need to be completed before filling in the total below.
6. Total number of health centres, health clinics and health posts
7. Total number of hospitals
64 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 65
Wor
kshe
et 1
a. L
ist o
f hea
lth c
entr
es, h
ealth
clin
ics
and
heal
th p
osts
Area
(pro
vinc
e, re
gion
, dis
trict
, etc
.) __
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
This
wor
kshe
et s
houl
d be
use
d to
list
all
faci
litie
s th
at p
rovi
de s
ome
mat
erni
ty c
are
but a
re n
ot h
ospi
tals
, inc
ludi
ng h
ealth
cen
tres,
hea
lth c
linic
s an
d he
alth
pos
ts.
The
easi
est w
ay to
org
aniz
e th
is in
form
atio
n is
to c
reat
e a
tabl
e in
Exc
el o
r ano
ther
sof
twar
e pa
ckag
e.
Faci
lity
nam
eLo
catio
nTy
pe o
f fac
ility
(hea
lth c
entre
, clin
ic)
Owne
rshi
p (g
over
nmen
t, pr
ivat
e, m
issi
on)
Tota
l num
ber o
f fac
ilitie
s th
at a
re n
ot h
ospi
tals
but
offe
r som
e m
ater
nity
car
e
66 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 67
Wor
kshe
et 1
b. L
ist o
f hos
pita
ls
Area
(pro
vinc
e, re
gion
, dis
trict
): __
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
This
wor
kshe
et s
houl
d be
use
d to
list
all
hosp
itals
that
pro
vide
mat
erni
ty c
are.
The
eas
iest
way
to o
rgan
ize
this
info
rmat
ion
is to
cre
ate
a ta
ble
in E
xcel
or a
noth
er s
oftw
are
pack
age.
Faci
lity
nam
eLo
catio
nTy
pe o
f fac
ility
(dis
trict
hos
pita
l, re
gion
al h
ospi
tal)
Owne
rshi
p (g
over
nmen
t, pr
ivat
e, m
issi
on)
Tota
l num
ber o
f hos
pita
ls o
fferin
g m
ater
nity
car
e
68 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 69
Form 2. Review of possible EmOC facilities
Identification
Facility name District name (or other subnational area)
Region name (or other subnational area)
Date of data collection Interviewer
Day Month Year Name
Adapt the following lists of options to the local situation.
Type of facility: (circle one)
1. National hospital 2. Regional hospital 3. District hospital 4. Maternity
5. Health centre 6. Clinic 7. Other: specify__________________________
Type of operating agency: (circle one)
1. Government 2. Private 3. Nongovernmental organization 4. Religious mission
5. Other: specify__________________
EmOC signal functions
Answer the following questions about EmOC signal functions by reviewing facility registers, through observation and if necessary
interviewing health workers in the maternity ward and other departments. Record whether the function has been performed in the past
3 months, and if not, why it has not been performed.
Consider all of the following when determining whether a particular signal function was performed:
Are staff at the facility trained to provide the service?
Are the requisite supplies and equipment present? Is the equipment functioning?
Were there no cases for which the use of a particular signal function was indicated?
Are the cadres of staff working at the facility authorized to perform the service?
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Monitoringemergencyobstetriccare:ahandbook 71
Performance of signal functions
Item Performed in past
3 months?
If not performed in past 3 months, why?
(a) Administer parenteral antibiotics 0. No
1. Yes
1. Training issues
2. Supplies, equipment, drugs issue
3. Management issue
4. Policy issues
5. No indication
(b) Administer uterotonic drugs
(i.e. parenteral oxytocin)
0. No
1. Yes
1. Training issues
2. Supplies, equipment, drugs issue
3. Management issue
4. Policy issues
5. No indication
(c) Administer parenteral
anticonvulsants for pre-eclampsia and
eclampsia (i.e. magnesium sulfate)
0. No
1. Yes
1. Training issues
2. Supplies, equipment, drugs issue
3. Management issue
4. Policy issues
5. No indication
(d) Perform manual removal of placenta 0. No
1. Yes
1. Training issues
2. Supplies, equipment, drugs issue
3. Management issue
4. Policy issues
5. No indication
(e) Perform removal of retained
products (e.g. manual vacuum
aspiration, dilation and curettage)
0. No
1. Yes
1. Training issues
2. Supplies, equipment, drugs issue
3. Management issue
4. Policy issues
5. No indication
(f) Perform assisted vaginal delivery
(e.g. vacuum extraction, forceps
delivery)
0. No
1. Yes
1. Training issues
2. Supplies, equipment, drugs issue
3. Management issue
4. Policy issues
5. No indication
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Monitoringemergencyobstetriccare:ahandbook 73
Item Performed in past
3 months?
If not performed in past 3 months, why?
(g) Perform newborn resuscitation
(e.g. with bag and mask)
0. No
1. Yes
1. Training issues
2. Supplies, equipment, drugs issue
3. Management issue
4. Policy issues
5. No indication
(h) Perform blood transfusion 0. No
1. Yes
1. Training issues
2. Supplies, equipment, drugs issue
3. Management issue
4. Policy issues
5. No indication
(i) Perform surgery
(e.g. caesarean section)
0. No
1. Yes
1. Training issues
2. Supplies, equipment, drugs issue
3. Management issue
4. Policy issues
5. No indication
Training issues: Authorized cadre is available but not trained, or there is lack of confidence in providers’ skills.
Supplies, equipment issue: Supplies or equipment are not available, not functional or broken, or needed drugs are unavailable.
Management issues: Providers desire compensation to perform this function, providers are encouraged to perform alternative
procedures, or providers uncomfortable or unwilling to perform procedure for reasons unrelated to training.
Policy issues: Required level of staff is not posted to this facility in adequate numbers (or at all), or national or hospital policies do
not allow function to be performed.
No indication: No client needing this procedure came to the facility during this period.
Determination of EmOC status
Use the questions above on the performance of signal functions. Check only one category below.
If all questions a–i = Yes, tick _____ comprehensive EmOC
If all questions a–g = Yes, tick _____ basic EmOC
If any questions a–g = No, tick _____ non-EmOC
74 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 75
Form
2 (c
ontin
ued)
Faci
lity
case
sum
mar
y
Faci
lity
nam
e
Com
plet
e th
e fo
llow
ing
char
t by
rev
iew
ing
faci
lity
regi
ster
s an
d co
untin
g th
e nu
mbe
r of
wom
en g
ivin
g bi
rth, t
he n
umbe
r of
cae
sare
an s
ectio
ns, t
he n
umbe
r of
wom
en w
ith o
bste
tric
com
plic
atio
ns, t
he n
umbe
r of m
ater
nal d
eath
s an
d th
e nu
mbe
r of i
ntra
partu
m a
nd v
ery
early
neo
nata
l dea
ths.
Data
col
lect
ion
plan
1: F
or fa
cilit
ies
in w
hich
few
er th
an 1
0 00
0 w
omen
giv
e bi
rth p
er y
ear,
data
for a
ll 12
mon
ths
are
the
mos
t use
ful.
Data
col
lect
ion
plan
2: I
f m
ore
than
10
000
wom
en g
ive
birth
per
yea
r, se
lect
4 m
onth
s th
at p
rovi
de a
goo
d di
strib
utio
n of
dat
a th
roug
hout
the
yea
r (e
.g. m
onth
s 1,
4, 7
and
10)
.
For m
ore
info
rmat
ion
on p
lan
2, re
fer t
o se
ctio
n 3.
4 of
the
hand
book
.
EmOC
indi
cato
r dat
a
Mon
th (w
rite
the
nam
e of
a
mon
th a
bove
eac
h nu
mbe
r)
Year
12
34
56
78
910
1112
Tota
l1
No. o
f wom
en g
ivin
g bi
rth (n
orm
al
vagi
nal,
assi
sted
vag
inal
, bre
ech
and
caes
area
n)
No. o
f cae
sare
an s
ectio
ns
Dire
ct o
bste
tric
com
plic
atio
ns tr
eate
d
Haem
orrh
age
(ant
e- a
nd
post
partu
m)
Obst
ruct
ed o
r pro
long
ed la
bour
Rupt
ured
ute
rus
Post
partu
m s
epsi
s
76 This page has been left blank Monitoringemergencyobstetriccare:ahandbook 77
76 This page has been left blank Monitoringemergencyobstetriccare:ahandbook 77
Mon
th (w
rite
the
nam
e of
a
mon
th a
bove
eac
h nu
mbe
r)
Year
12
34
56
78
910
1112
Tota
l1
Seve
re p
re-e
clam
psia
or
ecla
mps
ia
Com
plic
atio
ns o
f abo
rtion
(with
hae
mor
rhag
e or
sep
sis)
Ecto
pic
preg
nanc
y
Tota
l no.
of d
irect
obs
tetr
ic
com
plic
atio
ns tr
eate
d (a
dd e
ach
colu
mn)
Othe
r dire
ct o
bste
tric
com
plic
a-
tions
that
wer
e tre
ated
but
are
not
liste
d ab
ove
or n
ot s
peci
fied;
list
som
e of
the
caus
es, i
f spe
cifie
d,
in th
e sp
ace
belo
w:
78 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 79
Year
12
34
56
78
910
1112
Tota
l1
Mat
erna
l dea
ths
from
di
rect
obs
tetr
ic c
ause
s
Haem
orrh
age
(ant
e- a
nd p
ostp
artu
m)
Obst
ruct
ed o
r pro
long
ed
labo
ur
Rupt
ured
ute
rus
Post
partu
m s
epsi
s
Seve
re p
re-e
clam
psia
or
ecla
mps
ia
Com
plic
atio
ns o
f abo
rtion
(with
hae
mor
rhag
e or
sep
sis)
Ecto
pic
preg
nanc
y
Tota
l no.
of m
ater
nal
deat
hs fr
om d
irect
ob
stet
ric c
ause
s (a
dd e
ach
colu
mn)
Othe
r mat
erna
l dea
ths
due
to d
irect
obs
tetri
c ca
uses
, ot
her t
han
thos
e lis
ted
abov
e or
not
spe
cifie
d; li
st s
ome
of
the
caus
es, i
f spe
cifie
d, in
th
e sp
ace
belo
w:
80 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 81
Year
12
34
56
78
910
1112
Tota
l1
Indi
rect
mat
erna
l dea
ths:
Lis
t cau
ses
of in
dire
ct o
bste
tric
com
plic
atio
ns a
nd m
ater
nal d
eath
s th
at a
re re
leva
nt fo
r the
loca
l con
text
(e.g
. HIV
, sev
ere
anae
mia
, mal
aria
)
Indi
rect
mat
erna
l dea
th
(put
rele
vant
cau
se h
ere)
Indi
rect
mat
erna
l dea
th
(put
rele
vant
cau
se h
ere)
All o
ther
indi
rect
mat
erna
l
deat
hs
Still
birt
hs a
nd n
eona
tal d
eath
s
Intra
partu
m d
eath
s (fr
esh
still
birth
s) ≥
2.5
kg
Very
ear
ly n
eona
tal d
eath
s
(< 2
4 h)
≥ 2
.5 k
g
1 If p
lan
2 w
as s
elec
ted
(i.e.
onl
y 4
mon
ths
of d
ata
wer
e co
llect
ed),
mul
tiply
the
tota
l of 4
mon
ths
by 3
to e
stim
ate
the
data
for 1
2 m
onth
s.
82 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 83
Quality of information
Item Responses
In your informed opinion (e.g. from talking to staff, looking at the
record system), what proportion of complications treated in the
facility are recorded on this form?
(tick one)
None
Some (less than half)
Most (more than half)
All
In your informed opinion (from talking to staff, looking at the record
system, etc.), what proportion of the maternal deaths that occurred
in the facility are recorded on this form?
(tick one)
None
Some
Most
All
Type of register used Yes No
Maternity ward register
Delivery register or book
General admissions register
Operating theatre register
Female ward register
Discharge register
Other:
Other:
What sources of data were used to complete this form? (e.g. maternity ward register, delivery book, general admissions
register, operating theatre register, female ward register, discharge register).
84 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 85
Form 3. Summary of data on EmOC facilities in the area
This form summarizes all the data on facilities within the geographical area that have been entered in all sections of form 2.
One copy of form 3 should be completed for each area.
Name of area
Population size of area
Crude birth rate (no. of births per 1000 population) of area
Expected births in area
[(crude birth rate of area ÷ 1000) x Population size of area]
Complete either section A or section B on the following page. The other section can then be deleted.
If all facilities in the area were visited, complete section A only (and delete section B).
If a subset of facilities in the area were selected, complete section B only (and delete section A).
86 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 87
Section A:
Use worksheets 3a–c on the following pages to complete the table below.
In a 12-month period Column 1
Basic EmOC facilities
Column 2
Comprehensive EmOC facilities
Column 3
Total no. from EmOC
facilities
(column 1+
column 2)
Column 4
Non-EmOC facilities
Column 5
Total from all facilities
surveyed
(column 3 +
column 4)
No. of facilities
No. of women giving birth
No. of women with direct
obstetric complications treated
No. of caesarean sections
No. of maternal deaths from
direct obstetric causes
No. of maternal deaths from
indirect causes
No. of intrapartum deaths
(fresh stillbirths; ≥ 2.5 kg)
+ No. of very early neonatal
deaths (≤ 24 h; ≥ 2.5 kg)
88 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 89
Section B:
Use worksheets 3d–f to complete the table below.
In 12-month period: Column 1
Basic EmOC facilities
Column 2
Comprehensive EmOC facilities
Column 3
Total no. from EmOC facilities
(column 1+
column 2)
Column 4
Non-EmOC facilities
Column 5
Total from all facilities
surveyed
(column 3 +
column 4)
No. of facilities
No. of women giving birth
No. of women with direct
obstetric complications
treated
No. of caesarean sections
No. of maternal deaths
from direct obstetric
causes
No. of maternal deaths
from indirect causes
No. of intrapartum deaths
(fresh stillbirths; ≥ 2.5 kg)
+ No. of very early neonatal
deaths (≤ 24 h; ≥ 2.5 kg)
90 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 91
Wor
kshe
et 3
a. S
umm
ary
of re
view
s of
bas
ic E
mOC
faci
litie
s
Area
: ___
____
____
____
____
____
____
____
____
____
____
___
This
wor
kshe
et s
umm
ariz
es th
e da
ta c
olle
cted
on
form
2 fr
om a
ll ba
sic
EmOC
faci
litie
s. U
se fo
rm 2
to id
entif
y al
l bas
ic E
mOC
faci
litie
s.
Atta
ch a
dditi
onal
she
ets
if ne
cess
ary.
Exce
l or a
noth
er s
oftw
are
pack
age
can
be u
sed
for t
his
sum
mar
y.
Colu
mn
1Co
lum
n 2
Colu
mn
3Co
lum
n 4
Colu
mn
5Co
lum
n 6
Colu
mn
7
Faci
lity
No. o
f wom
en g
ivin
g
birth
No. o
f wom
en w
ith
dire
ct o
bste
tric
com
plic
atio
ns tr
eate
d
No. o
f cae
sare
an
sect
ions
No. o
f mat
erna
l dea
ths
from
dire
ct o
bste
tric
caus
es
No. o
f mat
erna
l dea
ths
from
indi
rect
cau
ses
No. o
f int
rapa
rtum
deat
hs (f
resh
stil
l-
birth
s; ≥
2.5
kg)
+ N
o.
of v
ery
early
neo
nata
l
deat
hs
(≤ 2
4 h;
≥ 2
.5 k
g)
Colu
mn
tota
ls*
*If m
ore
than
one
she
et w
as u
sed,
add
she
et to
tals
to o
btai
n th
e ov
eral
l tot
al.
Tota
l num
ber o
f bas
ic E
mOC
faci
litie
s lis
ted
in c
olum
n 1
=
92 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 93
Wor
kshe
et 3
b. S
umm
ary
of re
view
s of
com
preh
ensi
ve E
mOC
faci
litie
s
Area
: ___
____
____
____
____
____
____
____
____
____
____
___
This
wor
kshe
et s
umm
ariz
es th
e da
ta c
olle
cted
on
form
2 fr
om a
ll co
mpr
ehen
sive
Em
OC fa
cilit
ies.
Use
form
2 to
iden
tify
all c
ompr
ehen
sive
Em
OC fa
cilit
ies.
Atta
ch a
dditi
onal
she
ets
if ne
cess
ary.
Exce
l or a
noth
er s
oftw
are
pack
age
can
be u
sed
for t
his
sum
mar
y.
Colu
mn
1Co
lum
n 2
Colu
mn
3Co
lum
n 4
Colu
mn
5Co
lum
n 6
Colu
mn
7
Faci
lity
No. o
f wom
en g
ivin
g
birth
No. o
f wom
en w
ith
dire
ct o
bste
tric
com
plic
atio
ns tr
eate
d
No. o
f cae
sare
an
sect
ions
No. o
f mat
erna
l dea
ths
from
dire
ct o
bste
tric
caus
es
No. o
f mat
erna
l dea
ths
from
indi
rect
cau
ses
No. o
f int
rapa
rtum
deat
hs (f
resh
stil
l-
birth
s; >
2.5
kg)
+ N
o.
of v
ery
early
neo
nata
l
deat
hs (≤
24
hour
s;
> 2
.5 k
g)
Colu
mn
tota
ls*
*If m
ore
than
one
she
et w
as u
sed,
add
she
et to
tals
to o
btai
n th
e ov
eral
l tot
al.
Tota
l num
ber o
f com
preh
ensi
ve E
mOC
faci
litie
s lis
ted
in c
olum
n 1
=
94 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 95
Wor
kshe
et 3
c. S
umm
ary
of re
view
s of
non
-Em
OC fa
cilit
ies
Area
: ___
____
____
____
____
____
____
____
____
____
____
___
This
wor
kshe
et s
umm
ariz
es th
e da
ta c
olle
cted
on
form
2 fr
om a
ll no
n-Em
OC fa
cilit
ies.
Use
form
2 to
iden
tify
all n
on-E
mOC
faci
litie
s.
Atta
ch a
dditi
onal
she
ets
if ne
cess
ary.
Exce
l or a
noth
er s
oftw
are
pack
age
can
be u
sed
for t
his
sum
mar
y.
Colu
mn
1Co
lum
n 2
Colu
mn
3Co
lum
n 4
Colu
mn
5Co
lum
n 6
Colu
mn
7
Faci
lity
No. o
f wom
en g
ivin
g
birth
No. o
f wom
en w
ith
dire
ct o
bste
tric
com
plic
atio
ns tr
eate
d
No. o
f cae
sare
an
sect
ions
No. o
f mat
erna
l dea
ths
from
dire
ct o
bste
tric
caus
es
No. o
f mat
erna
l dea
ths
from
indi
rect
cau
ses
No. o
f int
rapa
rtum
deat
hs (f
resh
stil
l-
birth
s; ≥
2.5
kg)
+ N
o.
of v
ery
early
neo
nata
l
deat
hs
(≤ 2
4 h;
≥ 2
.5 k
g)
Colu
mn
tota
ls*
* If
mor
e th
an o
ne s
heet
was
use
d, a
dd s
heet
tota
ls to
obt
ain
the
over
all t
otal
.
Tota
l num
ber o
f non
-Em
OC fa
cilit
ies
liste
d in
col
umn
1 =
96 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 97
Wor
kshe
et 3
d. S
umm
ary
of h
ealth
cen
tres
and
oth
er lo
wer
-lev
el fa
cilit
ies
Area
: ___
____
____
____
____
____
____
____
____
____
____
___
This
wor
kshe
et s
umm
ariz
es d
ata
colle
cted
on
form
2 fr
om a
ll he
alth
cen
tres
and
othe
r low
er-le
vel f
acili
ties
in a
geo
grap
hica
l are
a. U
se fo
rm 2
to id
entif
y th
e Em
OC s
tatu
s of
the
heal
th
cent
res
and
othe
r low
er-le
vel f
acili
ties
visi
ted.
Atta
ch a
dditi
onal
she
ets
if ne
cess
ary.
Exce
l or a
noth
er s
oftw
are
pack
age
can
be u
sed
for t
his
sum
mar
y.
Colu
mn
1Co
lum
n 2
Colu
mn
3Co
lum
n 4
Colu
mn
5Co
lum
n 6
Colu
mn
7Co
lum
n 8
Faci
lity
EmOC
sta
tus
(bas
ic,
com
preh
ensi
ve o
r
none
)
No. o
f wom
en
givi
ng b
irth
No. o
f wom
en w
ith
dire
ct o
bste
tric
com
plic
atio
ns
treat
ed
No. o
f cae
sare
an
sect
ions
No. o
f mat
erna
l
deat
hs fr
om d
irect
obst
etric
cau
ses
No. o
f mat
erna
l
deat
hs fr
om
indi
rect
cau
ses
No. o
f int
rapa
rtum
deat
hs (f
resh
stil
l-
birth
s; (≥
2.5
kg)
+ N
o. o
f ver
y ea
rly
neon
atal
dea
ths
(≤ 2
4 h;
≥ 2
.5 k
g)
Colu
mn
tota
ls*
* If
mor
e th
an o
ne s
heet
was
use
d, a
dd s
heet
tota
ls to
obt
ain
the
over
all t
otal
Tota
l num
ber o
f bas
ic E
mOC
faci
litie
s lis
ted
in c
olum
n 2
=
Tota
l num
ber o
f com
preh
ensi
ve E
mOC
faci
litie
s lis
ted
in c
olum
n 2
=
Tota
l num
ber o
f non
-Em
OC fa
cilit
ies
liste
d in
col
umn
2 =
98 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 99
Wor
kshe
et 3
e. S
umm
ary
of h
ospi
tals
Area
: ___
____
____
____
____
____
____
____
____
____
____
___
This
wor
kshe
et s
umm
ariz
es d
ata
colle
cted
on
form
2 fr
om a
ll ho
spita
ls in
a g
eogr
aphi
cal a
rea.
Use
form
2 to
iden
tify
the
EmOC
sta
tus
of th
e ho
spita
ls v
isite
d.
Atta
ch a
dditi
onal
she
ets
if ne
cess
ary.
Exce
l or a
noth
er s
oftw
are
pack
age
can
be u
sed
for t
his
sum
mar
y.
Colu
mn
1Co
lum
n 2
Colu
mn
3Co
lum
n 4
Colu
mn
5Co
lum
n 6
Colu
mn
7Co
lum
n 8
Faci
lity
EmOC
sta
tus
(bas
ic, c
ompr
ehen
-
sive
or n
one)
No. o
f wom
en
givi
ng b
irth
NNo.
of w
omen
with
dire
ct o
bste
tric
com
plic
atio
ns
treat
ed
No. o
f cae
sare
an
sect
ions
No. o
f mat
erna
l
deat
hs fr
om d
irect
obst
etric
cau
ses
No. o
f mat
erna
l
deat
hs fr
om
indi
rect
cau
ses
No. o
f int
rapa
rtum
deat
hs (f
resh
stil
l-
birth
s; ≥
2.5
kg)
+
No. o
f ver
y ea
rly
neon
atal
dea
ths
(≤ 2
4 h;
≥ 2
.5 k
g)
Colu
mn
tota
ls*
*If m
ore
than
one
she
et w
as u
sed,
add
she
et to
tals
to o
btai
n th
e ov
eral
l tot
al.
Tota
l num
ber o
f bas
ic E
mOC
faci
litie
s lis
ted
in c
olum
n 2
=
Tota
l num
ber o
f com
preh
ensi
ve E
mOC
faci
litie
s lis
ted
in c
olum
n 2
=
Tota
l num
ber o
f non
-Em
OC fa
cilit
ies
liste
d in
col
umn
2 =
100 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 101
Worksheet 3f. Area-wide estimates of EmOC
Area: ______________________________________________
This worksheet allows conversion of the data from the subset of facilities that were selected for site visits into estimates
for the entire area.
If a subset of health centres (and other lower-level facilities) were selected for study:
No. of health centres (or other) visited in area
Total no. of health centres (or other) in area
Proportion of health centres (or other) for which data were collected (No. of health centres
visited in area ÷ Total no. of health centres in area)
Use worksheet 3d for the health centres (and other lower-level facilities) studied.
Totals from facilities visited
÷ Proportion of health centres
visited
(see chart above)
= Estimate for area
Estimated no. of basic EmOC facilities ÷ =
Estimated no. of comprehensive EmOC facilities ÷ =
Estimated no. of non-EmOC facilities ÷ =
Estimated no. of women giving birth in facilities
classified as basic and comprehensive facilities
÷ =
Estimated no. of women giving birth in facilities
classified as non-EmOC facilities
÷ =
Estimated no. of women with direct obstetric com-
plications treated in facilities classified as basic
and comprehensive facilities
÷ =
Estimated no. of women with direct obstetric
complications treated in facilities classified as non-
EmOC facilities
÷ =
Estimated no. of caesarean sections in facilities
classified as basic and comprehensive facilities
÷ =
Estimated no. of caesarean sections in facilities
classified as non-EmOC facilities
÷ =
Estimated no. of maternal deaths from direct
obstetric causes in facilities classified as basic and
comprehensive
÷ =
102 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 103
Totals from facilities visited
÷ Proportion of health centres
visited
(see chart above)
= Estimate for area
Estimated no. of maternal deaths from direct
obstetric causes in facilities classified as non-
EmOC
÷ =
Estimated no. of maternal deaths from indirect
causes in facilities classified as basic and
comprehensive
÷ =
Estimated no. of maternal deaths from indirect
causes in facilities classified as non-EmOC
÷ =
Estimated no. of intrapartum deaths (fresh
stillbirths; ≥ 2.5 kg) and very early neonatal deaths
(≤ 24 h; ≥ 2.5 kg) in facilities classified as basic
and comprehensive
÷ =
Estimated no. of intrapartum deaths (fresh
stillbirths; ≥ 2.5 kg) and very early neonatal deaths
(≤ 24 h; ≥ 2.5 kg) in facilities classified as
non-EmOC
÷ =
If a sub-set of hospitals was selected for study:
No. of hospitals visited in area
Total no. of hospitals in area
Proportion of hospitals for which data were collected above (No. of hospitals visited in area ÷
Total no. of hospitals in area)
104 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 105
Use worksheet 3e for the hospitals studied.
Totals from facilities visited
÷ Proportion of hos-pitals visited (see
chart above)
= Estimate for area
Estimated no. of basic EmOC facilities ÷ =
Estimated no. of comprehensive EmOC facilities ÷ =
Estimated no. of non-EmOC facilities ÷ =
Estimated no. of women giving birth in facilities
classified as basic and comprehensive
÷ =
Estimated no. of women giving birth in facilities
classified as non-EmOC
÷ =
Estimated no. of women with direct obstetric
complications treated in facilities classified as
basic and comprehensive
÷ =
Estimated no. of women with direct obstetric
complications treated in facilities classified as non-
EmOC
÷ =
Estimated no. of caesarean sections in facilities
classified as basic and comprehensive
÷ =
Estimated no. of caesarean sections in facilities
classified as non-EmOC
÷ =
Estimated no. of maternal deaths from direct
obstetric causes in facilities classified as basic and
comprehensive
÷ =
Estimated no. of maternal deaths from direct
obstetric causes in facilities classified as non-
EmOC
÷ =
Estimated no. of maternal deaths from indirect
causes in facilities classified as basic and
comprehensive
÷ =
Estimated no. of maternal deaths from indirect
causes in facilities classified as non-EmOC
÷ =
Estimated no. of intrapartum deaths (fresh
stillbirths; ≥ 2.5 kg) and of very early neonatal
deaths (≤ 24 h; ≥ 2.5 kg) in facilities classified as
basic and comprehensive
÷ =
Estimated no. of intrapartum deaths (fresh
stillbirths; ≥ 2.5 kg) and of very early neonatal
deaths (≤ 24 h; ≥ 2.5 kg) in facilities classified as
non-EmOC
÷ =
106 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 107
Form
4.
Calc
ulat
ion
of in
dica
tors
for g
eogr
aphi
c ar
ea
Use
form
3, s
ectio
n A
or B
, to
calc
ulat
e th
e in
dica
tors
bel
ow.
Area
: ___
____
____
____
____
_
Indi
cato
r 1: A
vaila
bilit
y of
Em
OC
Is a
ccep
tabl
e le
vel m
et?
Tota
l no.
of b
asic
+
com
preh
ensi
ve E
mOC
faci
litie
s in
are
a
Popu
latio
n of
are
a
Indi
cato
r 1a
No. o
f Em
OC fa
cilit
ies
per 5
00 0
00
popu
latio
n
Min
imum
acc
epta
ble
leve
l
≥ 5
per 5
00 0
00 p
opul
atio
n
(÷
)X
500
000
=o
Met
o N
ot m
et
Tota
l no.
of c
ompr
ehen
sive
EmOC
faci
litie
s in
are
aPo
pula
tion
of a
rea
Indi
cato
r 1b
No. o
f com
preh
ensi
ve E
mOC
faci
litie
s
per 5
00 0
00 p
opul
atio
n
Min
imum
acc
epta
ble
leve
l
≥ 1
per 5
00 0
00 p
opul
atio
n
(÷
)X
500
000
=o
Met
o N
ot m
et
108 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 109
Indicator 2: Geographical distribution of EmOC facilities
This indicator is generally intended for use at the national level. In large areas (e.g. with millions of inhabitants), it is reasonable
to calculate the distribution of EmOC facilities for subareas. This can be done by repeating the steps above (in Indicator 1), and
then calculating the percentage of subareas meeting the minimum acceptable levels. The minimum acceptable level for this
indicator is 100%.
Another option is to lay the facilities in the area on a map that shows roads and topographic areas, to identify problems of access
and showing referral systems. This can be done with a geographical information system or another mapping method.
110 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 111
Indi
cato
r 3:
Prop
ortio
n of
all
birt
hs in
Em
OC fa
cilit
ies
and
all s
urve
yed
faci
litie
s
Tota
l no.
of w
omen
giv
ing
birth
in
EmOC
faci
litie
s in
are
aEx
pect
ed b
irths
in a
rea
Indi
cato
r 3a
Prop
ortio
n of
birt
hs in
Em
OC fa
cilit
ies
Min
imum
acc
epta
ble
leve
l: ta
rget
s to
be
set
loca
lly
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
Tota
l no.
of w
omen
giv
ing
birth
in
all s
urve
yed
faci
litie
s in
are
aEx
pect
ed b
irths
in a
rea
Indi
cato
r 3b
Prop
ortio
n of
birt
hs in
all
surv
eyed
faci
litie
s
Min
imum
acc
epta
ble
leve
l: ta
rget
s to
be
set
loca
lly
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
112 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 113
Indi
cato
r 4:
Met
nee
d fo
r Em
OC
No. o
f wom
en w
ith d
irect
obse
tric
com
plic
atio
ns
treat
ed in
Em
OC fa
cilit
ies
in a
rea
No. o
f exp
ecte
d bi
rths
in a
rea
Indi
cato
r 4a
Prop
ortio
n of
wom
en e
stim
ated
to h
ave
obst
etric
com
plic
atio
ns w
ho a
re tr
eate
d in
EmOC
faci
litie
s
Acce
ptab
le le
vel =
100
%
oM
et
oNo
t met
÷(
X0.
15*
)=
____
__ x
100
= _
____
_ %
No. o
f wom
en w
ith d
irect
obse
tric
com
plic
atio
ns in
all s
urve
yed
faci
litie
s
in a
rea
No. o
f exp
ecte
d bi
rths
in a
rea
Indi
cato
r 4b
Prop
ortio
n of
wom
en e
stim
ated
to h
ave
obst
etric
com
plic
atio
ns w
ho a
re tr
eate
d in
all s
urve
yed
faci
litie
s
Acce
ptab
le le
vel =
100
%
oM
et
oNo
t met
÷(
X0.
15*
)=
____
__ x
100
= _
____
_ %
* Ex
pect
ed b
irths
are
mul
tiplie
d by
0.1
5 to
est
imat
e th
e to
tal o
bste
tric
com
plic
atio
ns in
the
popu
latio
n.
114 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 115
Indi
cato
r 5:
Caes
area
n se
ctio
ns a
s a
prop
ortio
n of
all
birt
hs
Tota
l no.
of c
aesa
rean
sec
tions
in
EmOC
faci
litie
s in
are
a
Expe
cted
birt
hs in
are
aIn
dica
tor 5
a
Caes
area
n se
ctio
ns in
Em
OC fa
cilit
ies
as a
prop
ortio
n of
all
birth
s
Acce
ptab
le le
vel:
5–15
%
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
Tota
l no.
of c
aesa
rean
sec
tions
in
all s
urve
yed
faci
litie
s in
are
aEx
pect
ed b
irths
in a
rea
Indi
cato
r 5b
Caes
area
n se
ctio
ns in
all
surv
eyed
faci
litie
s as
a
prop
ortio
n of
all
birth
s
Acce
ptab
le le
vel:
5–15
%
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
116 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 117
Indi
cato
r 6:
Dire
ct o
bste
tric
cas
e fa
talit
y ra
te
Tota
l no.
of m
ater
nal d
eath
s fro
m
dire
ct o
bste
tric
caus
es in
Em
OC
faci
litie
s in
are
a
Tota
l no.
of w
omen
with
obst
etric
com
plic
atio
ns in
EmOC
faci
litie
s in
are
a
Indi
cato
r 6a
Dire
ct o
bste
tric
case
fata
lity
rate
in E
mOC
faci
litie
s
Acce
ptab
le le
vel:
≤ 1%
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
Tota
l no.
of m
ater
nal d
eath
s fro
m
dire
ct o
bste
tric
caus
es in
all
sur-
veye
d fa
cilit
ies
in a
rea
Tota
l no.
of w
omen
with
obst
etric
com
plic
atio
ns in
all
surv
eyed
faci
litie
s in
are
a
Indi
cato
r 6b
Dire
ct o
bste
tric
case
fata
lity
rate
in a
ll su
rvey
ed
faci
litie
s
Acce
ptab
le le
vel:
≤ 1%
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
In a
dditi
on to
the
aggr
egat
ed c
alcu
latio
ns, t
he d
irect
obs
tetri
c ca
se fa
talit
y ra
te s
houl
d be
cal
cula
ted
for e
ach
hosp
ital.
The
resu
lts c
an b
e pr
esen
ted
as a
bar
cha
rt: th
e ho
rizon
tal a
xis
shou
ld b
e la
belle
d w
ith th
e fa
cilit
y na
mes
, and
the
verti
cal a
xis
shou
ld b
e la
belle
d “D
irect
obs
tetri
c ca
se fa
talit
y ra
te (%
)”. A
noth
er w
ay o
f pre
sent
ing
faci
lity-
base
d re
sults
is to
giv
e th
e
rang
e of
dire
ct o
bste
tric
case
fata
lity
rate
s fro
m d
iffer
ent h
ospi
tals
as
wel
l as
the
aggr
egat
e di
rect
cas
e fa
talit
y ra
te.
118 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 119
Indi
cato
r 7:
Intr
apar
tum
and
ver
y ea
rly n
eona
tal d
eath
rate
Tota
l no.
of i
ntra
partu
m d
eath
s
(≥ 2
.5 k
g) +
ver
y ea
rly n
eona
-
tal d
eath
s (≤
24
h; ≥
2.5
kg)
in
EmOC
faci
litie
s in
are
a
Tota
l no.
of w
omen
giv
ing
birth
in E
mOC
faci
litie
s in
are
a
Indi
cato
r 7a
Intra
partu
m a
nd v
ery
early
neo
nata
l dea
th ra
te in
EmOC
faci
litie
s
Acce
ptab
le le
vel:
oNo
sta
ndar
d ha
s be
en s
et
oNo
t app
licab
le÷
=__
____
___
x 10
0 =
___
____
_ %
Tota
l no.
of i
ntra
partu
m d
eath
s
(≥ 2
.5 k
g) +
ver
y ea
rly n
eona
tal
deat
hs (≤
24
h; ≥
2.5
kg)
in a
ll
surv
eyed
faci
litie
s in
are
a
Tota
l no.
of w
omen
giv
ing
birth
in a
ll su
rvey
ed fa
cilit
ies
in a
rea
Indi
cato
r 7b
Intra
partu
m a
nd v
ery
early
neo
nata
l dea
th ra
te in
all
surv
eyed
faci
litie
s
Acce
ptab
le le
vel:
oNo
sta
ndar
d ha
s be
en s
et
oNo
t app
licab
le÷
=__
____
___
x 10
0 =
___
____
_ %
120 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 121
Indi
cato
r 8:
Prop
ortio
n of
mat
erna
l dea
ths
due
to in
dire
ct c
ause
s
Tota
l no.
of m
ater
nal d
eath
s fro
m
indi
rect
cau
ses
in E
mOC
faci
litie
s
in a
rea
Tota
l no.
of m
ater
nal d
eath
s
from
all
caus
es in
Em
OC
faci
litie
s in
are
a
Indi
cato
r 8a
Prop
ortio
n of
mat
erna
l dea
ths
due
to in
dire
ct c
ause
s
in E
mOC
faci
litie
sAc
cept
able
leve
l:
oNo
sta
ndar
d ha
s be
en s
et
oNo
t app
licab
le÷
=__
____
___
x 10
0 =
___
____
_ %
Tota
l no.
of m
ater
nal d
eath
s fro
m
indi
rect
cau
ses
in a
ll su
rvey
ed
faci
litie
s in
are
a
Tota
l no.
of m
ater
nal d
eath
s
from
all
caus
es in
all
surv
eyed
faci
litie
s in
are
a
Indi
cato
r 8b
Prop
ortio
n of
mat
erna
l dea
ths
due
to in
dire
ct c
ause
s
in a
ll su
rvey
ed fa
cilit
ies
Acce
ptab
le le
vel:
oNo
sta
ndar
d ha
s be
en s
et
oNo
t app
licab
le÷
=__
____
___
x 10
0 =
___
____
_ %
122 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 123
Form
5.
Calc
ulat
ion
of in
dica
tors
for a
cou
ntry
Com
plet
e w
orks
heet
5a
befo
re c
alcu
latin
g th
e in
dica
tors
bel
ow.
Indi
cato
r 1:
Avai
labi
lity
of E
mOC
ser
vice
s
Is a
ccep
tabl
e le
vel m
et?
Tota
l no.
of b
asic
+
com
preh
ensi
ve E
mOC
faci
litie
s
Tota
l pop
ulat
ion
(wor
kshe
et 5
a; c
olum
n 3
tota
l)
Indi
cato
r 1a
No. o
f Em
OC fa
cilit
ies
per 5
00 0
00
popu
latio
n
Min
imum
acc
epta
ble
leve
l
≥ 5
per 5
00 0
00 p
opul
atio
n
(÷
)X
500
000
=o
Met
o N
ot m
et
Tota
l no.
of c
ompr
ehen
sive
EmOC
faci
litie
sTo
tal p
opul
atio
n
Indi
cato
r 1b
No. o
f com
preh
ensi
ve E
mOC
faci
litie
s
per 5
00 0
00 p
opul
atio
n
Min
imum
acc
epta
ble
leve
l
≥ 1
per 5
00 0
00 p
opul
atio
n
(÷
)X
500
000
=o
Met
o N
ot m
et
124 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 125
Indi
cato
r 2:
Geog
raph
ical
dis
trib
utio
n of
Em
OC fa
cilit
ies
No. o
f are
as in
cou
ntry
mee
ting
min
imum
leve
ls (i
.e. a
t lea
st 5
faci
litie
s pe
r 500
000
pop
ulat
ion
incl
udin
g at
leas
t 1 c
ompr
ehen
sive
faci
lity)
No. o
f are
as in
cou
ntry
Indi
cato
r 2
Prop
ortio
n of
are
as w
ith th
e m
inim
um a
ccep
tabl
e
num
ber o
f Em
OC fa
cilit
ies
Acce
ptab
le le
vel:
100%
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
126 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 127
Indi
cato
r 3: P
ropo
rtio
n of
all
birt
hs in
Em
OC fa
cilit
ies
and
all s
urve
yed
faci
litie
s
Tota
l no.
of w
omen
giv
ing
birth
in a
ll
EmOC
faci
litie
sTo
tal e
xpec
ted
birth
sIn
dica
tor 3
a
Prop
ortio
n of
all
birth
s in
Em
OC fa
cilit
ies
Min
imum
acc
epta
ble
leve
l:
targ
ets
to b
e se
t loc
ally
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
Tota
l no.
of w
omen
giv
ing
birth
in a
ll
surv
eyed
faci
litie
sTo
tal n
o. o
f exp
ecte
d bi
rths
Indi
cato
r 3b
Prop
ortio
n of
all
birth
s in
all
surv
eyed
faci
litie
s
Min
imum
acc
epta
ble
leve
l:
targ
ets
to b
e se
t loc
ally
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
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Monitoringemergencyobstetriccare:ahandbook 129
Indi
cato
r 4:
Met
nee
d fo
r Em
OC
Tota
l no.
of w
omen
with
dire
ct o
bste
tric
com
plic
atio
ns
treat
ed in
all
EmOC
faci
litie
s
Tota
l no.
of e
xpec
ted
birth
s
Indi
cato
r 4a
Prop
ortio
n of
wom
en e
stim
ated
to h
ave
obst
etric
com
plic
atio
ns w
ho a
re tr
eate
d in
EmOC
faci
litie
s
Acce
ptab
le le
vel =
100
%
oM
et
oNo
t met
÷(
x0.
15*
)=
____
__ x
100
= _
____
_ %
Tota
l no.
of w
omen
with
dire
ct o
bste
tric
com
plic
a-
tions
trea
ted
in a
ll su
rvey
ed
faci
litie
s
Tota
l no.
of e
xpec
ted
birth
s
Indi
cato
r 4b
Prop
ortio
n of
wom
en e
stim
ated
to h
ave
obst
etric
com
plic
atio
ns w
ho a
re tr
eate
d in
all
surv
eyed
faci
litie
s
Acce
ptab
le le
vel =
100
%
oM
et
oNo
t met
÷(
x0.
15*
)=
____
__ x
100
= _
____
_ %
* Ex
pect
ed b
irths
are
mul
tiplie
d by
0.1
5 to
est
imat
e th
e to
tal o
bste
tric
com
plic
atio
ns in
the
popu
latio
n.
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Monitoringemergencyobstetriccare:ahandbook 131
Indi
cato
r 5:
Caes
area
n se
ctio
ns a
s a
prop
ortio
n of
all
birt
hs
Tota
l no.
of c
aesa
rean
sec
tions
in a
ll
EmOC
faci
litie
sTo
tal n
o. o
f exp
ecte
d bi
rths
Indi
cato
r 5a
Caes
area
n se
ctio
ns in
Em
OC fa
cilit
ies
as a
pro
porti
on
of a
ll bi
rths
Acce
ptab
le le
vel:
5–15
%
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
Tota
l no.
of c
aesa
rean
sec
tions
in a
ll
surv
eyed
faci
litie
sTo
tal n
o. o
f exp
ecte
d bi
rths
Indi
cato
r 5b
Caes
area
n se
ctio
ns in
all
surv
eyed
faci
litie
s as
a p
ro-
porti
on o
f all
birth
s
Acce
ptab
le le
vel:
5–15
%
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
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Monitoringemergencyobstetriccare:ahandbook 133
Indi
cato
r 6:
Dire
ct o
bste
tric
cas
e fa
talit
y ra
te
Tota
l no.
of m
ater
nal d
eath
s fro
m
dire
ct o
bste
tric
caus
es in
all
EmOC
faci
litie
s
Tota
l no.
of w
omen
with
dire
ct
obst
etric
com
plic
atio
ns in
all
EmOC
faci
litie
s
Indi
cato
r 6a
Dire
ct o
bste
tric
case
fata
lity
rate
in E
mOC
faci
litie
s
Acce
ptab
le le
vel:
≤ 1%
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
Tota
l no.
of m
ater
nal d
eath
s fro
m
dire
ct o
bste
tric
caus
es in
all
surv
eyed
faci
litie
s
Tota
l no.
of w
omen
with
dire
ct
obst
etric
com
plic
atio
ns in
all
surv
eyed
faci
litie
s
Indi
cato
r 6b
Dire
ct o
bste
tric
case
fata
lity
rate
in a
ll su
rvey
ed
faci
litie
s
Acce
ptab
le le
vel:
≤ 1%
÷=
____
____
_ x
100
= _
____
___
%o
Met
o N
ot m
et
In a
dditi
on, t
he d
irect
obs
tetri
c ca
se fa
talit
y ra
te s
houl
d be
cal
cula
ted
for a
ll ho
spita
ls in
eac
h su
bare
a. T
he re
sults
can
be
pres
ente
d as
a b
ar c
hart:
the
horiz
onta
l axi
s sh
ould
be
labe
lled
with
the
suba
rea
nam
es, a
nd th
e ve
rtica
l axi
s sh
ould
be
labe
lled
“Dire
ct o
bste
tric
case
fata
lity
rate
(%)”
. Ano
ther
way
of p
rese
ntin
g th
e re
sults
is to
giv
e th
e ra
nge
of c
ase
fata
lity
rate
s
from
dire
ct o
bste
tric
caus
es fo
r sub
area
s.
134 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 135
Indi
cato
r 7:
Intr
apar
tum
and
ver
y ea
rly n
eona
tal d
eath
rate
Tota
l no.
of i
ntra
partu
m d
eath
s
(≥ 2
.5 k
g) +
ver
y ea
rly n
eona
tal
deat
hs (≤
24
h; ≥
2.5
kg)
in a
ll
EmOC
faci
litie
s
Tota
l no.
of w
omen
giv
ing
birth
in a
ll Em
OC fa
cilit
ies
Indi
cato
r 7a
Intra
partu
m a
nd v
ery
early
neo
nata
l dea
th ra
te in
EmOC
faci
litie
s
Acce
ptab
le le
vel:
oNo
sta
ndar
d ha
s be
en s
et
oNo
t app
licab
le÷
=__
____
___
x 10
0 =
___
____
_ %
Tota
l no.
of i
ntra
partu
m d
eath
s
(≥ 2
.5 k
g) +
ver
y ea
rly n
eona
tal
deat
hs (≤
24
h; ≥
2.5
kg)
in a
ll
surv
eyed
faci
litie
s
Tota
l no.
of w
omen
giv
ing
birth
in a
ll su
rvey
ed fa
cilit
ies
Indi
cato
r 7b
Intra
partu
m a
nd v
ery
early
neo
nata
l dea
th ra
te in
all
surv
eyed
faci
litie
s
Acce
ptab
le le
vel:
oNo
sta
ndar
d ha
s be
en s
et
oNo
t app
licab
le÷
=__
____
___
x 10
0 =
___
____
_ %
136 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 137
Indi
cato
r 8:
Prop
ortio
n of
mat
erna
l dea
ths
due
to in
dire
ct c
ause
s
Tota
l no.
of m
ater
nal d
eath
s fro
m
indi
rect
cau
ses
in a
ll Em
OC fa
cilit
ies
Tota
l no.
of m
ater
nal d
eath
s
from
all
caus
es in
all
EmOC
faci
litie
s
Indi
cato
r 8a
Prop
ortio
n of
mat
erna
l dea
ths
due
to in
dire
ct c
ause
s in
EmOC
faci
litie
sAc
cept
able
leve
l:
oNo
sta
ndar
d ha
s be
en s
et
oNo
t app
licab
le÷
=__
____
___
x 10
0 =
___
____
_ %
Tota
l no.
of m
ater
nal d
eath
s fro
m
indi
rect
cau
ses
in a
ll su
rvey
ed
faci
litie
s
Tota
l no.
of m
ater
nal d
eath
s
from
all
caus
es in
all
surv
eyed
faci
litie
s
Indi
cato
r 8b
Prop
ortio
n of
mat
erna
l dea
ths
due
to in
dire
ct c
ause
s in
all f
acili
ties
Acce
ptab
le le
vel:
oNo
sta
ndar
d ha
s be
en s
et
oNo
t app
licab
le÷
=__
____
___
x 10
0 =
___
____
_ %
138 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 139
Worksheet 5a. Amount of EmOC services
Use forms 3 and 4 to fill in the information below.
Name of area No. of basic
EmOC facilities
in area
No. of comp-
rehensive EmOC
facilities in area
Population of
area
Has the minimum level of
EmOC been met?
If yes, please tick in column.
Column totals*
* If more than one sheet is used, add sheet totals to obtain the overall column total.
140 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 141
Wor
kshe
et 5
a (c
ontin
ued)
Nam
e of
are
aTo
tal n
o. o
f
expe
cted
birt
hs
Tota
l no.
of
wom
en g
ivin
g
birth
in a
ll
EmOC
faci
litie
s
Tota
l no.
of
wom
en g
ivin
g
birth
in a
ll
surv
eyed
faci
litie
s
Tota
l no.
of w
omen
with
com
plic
atio
ns in
all E
mOC
faci
litie
s
Tota
l no.
of w
omen
with
com
plic
atio
ns in
all s
urve
yed
faci
litie
s
Tota
l no.
of
caes
area
n
sect
ions
in a
ll
EmOC
faci
litie
s
Tota
l no.
of
caes
area
n
sect
ions
in
all s
urve
yed
faci
litie
s
Colu
mn
tota
ls*
*If m
ore
than
one
she
et is
use
d, a
dd s
heet
tota
ls to
obt
ain
the
over
all c
olum
n to
tal.
142 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 143
Nam
e of
are
aTo
tal n
o. o
f
mat
erna
l dea
ths
from
dire
ct
obst
etric
cau
ses
in
all E
mOC
faci
litie
s
Tota
l no.
of
mat
erna
l dea
ths
from
dire
ct
obst
etric
cau
ses
in a
ll su
rvey
ed
faci
litie
s
Tota
l no.
of
mat
erna
l dea
ths
from
indi
rect
caus
es in
all
EmOC
faci
litie
s
Tota
l no.
of
mat
erna
l dea
ths
from
indi
rect
caus
es in
all
surv
eyed
faci
litie
s
Tota
l no.
of
intra
partu
m d
eath
s
(≥ 2
.5 k
g) a
nd v
ery
early
neo
nata
l dea
ths
(≤ 2
4 h;
≥ 2
.5 k
g) in
all E
mOC
faci
litie
s
Tota
l no.
of
intra
partu
m d
eath
s
(≥ 2
.5 k
g) a
nd v
ery
early
neo
nata
l dea
ths
(≤ 2
4 h;
≥ 2
.5 k
g) in
all s
urve
yed
faci
litie
s
Colu
mn
tota
ls*
*If m
ore
than
one
she
et is
use
d, a
dd s
heet
tota
ls to
obt
ain
the
over
all c
olum
n to
tal.
144 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 145
Appendix B: Information on registers and data collection
Signal functions:
To determine whether a facility offers each of the signal functions, data collectors should:
• observe the availability of requisite drugs, supplies, and equipment;
• interview health workers in the maternity ward and other departments; and
• review facility registers (see below).
It is important to consider all the following when determining whether a particular signal function was provided:
• Is staff at the facility trained to perform the service?
• Do the requisite supplies and equipment exist? Are they functioning?
• Were there any cases for which a particular signal function was indicated?
• Are the cadres of staff working at the facility authorized to perform the service?
Other variables:
To collect the data necessary to calculate the EmOC indicators, data from registers in many different rooms or departments at the facility must be reviewed and abstracted. The table below provides an overview of where to look for different variables.
146 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 147
Regi
ster
s an
d ot
her s
ourc
es to
be
used
to c
olle
ct d
ata
for t
he E
mOC
indi
cato
rs
Info
rmat
ion
Regi
ster
s in
mat
erni
ty w
ard
(incl
udin
g th
ose
foun
d in
: lab
our,
deliv
ery,
pre-
and
post
partu
m a
nd
neon
atal
room
s)
Regi
ster
s in
ope
ratin
g
thea
tre (i
nclu
ding
thos
e fo
r maj
or a
nd
min
or s
urge
ry)
Regi
ster
s in
the
fem
ale
or
gyna
ecol
ogic
al
war
ds (i
nclu
ding
post
-abo
rtion
car
e
regi
ster
s)
Regi
ster
s in
the
outp
atie
nt d
epar
tmen
t
Regi
ster
s fo
r
inpa
tient
s an
d
adm
issi
ons
Over
all a
dmin
istra
tion
(incl
udin
g re
cord
s
and
regi
ster
s in
the
mor
gue,
reco
rds
offic
e, h
ead
heal
th
wor
kers
’ offi
ce)
No. o
f wom
en g
ivin
g bi
rthX
No. o
f wom
en w
ith o
bste
tric
com
plic
atio
nsX
XX
XX
X
No. o
f cae
sare
an s
ectio
nsX
X
No. o
f mat
erna
l dea
ths
due
to d
irect
obs
tetri
c ca
uses
XX
XX
X
No. o
f mat
erna
l dea
ths
due
to in
dire
ct o
bste
tric
caus
esX
XX
XX
No. o
f fre
sh s
tillb
irths
and
intra
partu
m d
eath
s ≥
2.5
kgX
XX
No. o
f ver
y ea
rly n
eona
tal
deat
hs (1
st 2
4 h)
≥ 2
.5 k
gX
X
148 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 149
As can be seen from the table above, the registers in maternity departments should, in theory, contain a lot of the data necessary
to calculate the EmOC indicators; however, it is likely that they will not have all of the data needed. Monitoring should help facility
managers to perceive the need for maintaining good quality, complete records and will help them to improve record-keeping
systems.
Some of the most important columns that should be included in maternity registers are:
• admission time and date;
• mode of delivery (normal vaginal, assisted vaginal, caesarean section);
• obstetric complications (e.g. antepartum haemorrhage, postpartum haemorrhage, obstructed labour, prolonged labour,
pre-eclampsia, eclampsia, ruptured uterus, postpartum sepsis, complications of abortion, ectopic pregnancies) (Cases
of complications of abortion and ectopic pregnancies will usually be found in other departments in the facility, such as
the female or gynaecology ward, operating theatres or outpatient registers.);
• treatment or intervention provided to woman, including time of intervention (e.g. magnesium sulfate administered,
oxytocin provided, manual removal of the placenta);
• treatment or intervention provided to newborn, including time of intervention (e.g. resuscitated);
• outcome of mother (e.g. discharged, with time and date, referred to X facility, death); and
• outcome of infant (e.g. discharged, referred to X facility, fresh stillbirth, macerated stillbirth, very early neonatal death).
Note: Cases of complications of abortion and ectopic pregnancies are often found in other departments of the hospital than the
maternity, such as the female or gynaecology ward, operating theatres or outpatient or emergency departments.
150 This page has been left blank
Monitoringemergencyobstetriccare:ahandbook 151
Appe
ndix
C.
Rand
om n
umbe
r tab
le
12
34
56
78
910
1112
1314
110
480
1501
101
536
0201
181
647
9164
669
179
1419
462
590
3620
720
969
9957
091
291
9070
0
222
368
4657
325
595
8539
330
995
8919
827
982
5340
293
965
3409
552
666
1917
439
615
9950
5
324
130
4836
022
527
9726
576
393
6480
915
179
2483
049
340
3208
130
680
1965
563
348
5862
9
442
167
9309
306
243
6168
007
856
1637
639
440
5353
771
341
5700
484
974
917
9775
816
379
537
570
3397
581
837
1665
606
121
9178
260
468
8130
549
684
6067
214
110
0692
701
263
5461
3
677
921
0690
711
008
4275
127
756
5349
818
602
7065
990
655
1505
321
916
8182
544
394
4288
0
799
562
7290
556
420
6999
498
872
3101
671
194
1873
844
013
4884
063
213
2106
910
634
1295
2
896
301
9197
705
463
0797
218
876
2092
294
595
5686
969
014
6004
518
425
8490
342
508
3230
7
989
579
1434
263
661
1028
117
453
1810
357
740
8437
825
331
1256
658
678
4494
755
8556
941
1085
475
3685
753
342
5398
853
060
5953
338
867
6230
008
158
1798
316
439
1145
818
593
6495
2
1128
918
6957
888
231
3327
670
997
7993
656
865
0585
990
106
3159
501
547
8559
091
610
7818
8
1263
553
4096
148
235
0342
749
626
6944
518
663
7269
552
180
2084
712
234
9051
133
703
9032
2
1309
429
9396
952
636
9273
788
974
3348
836
320
1761
730
015
0827
284
115
2715
630
613
7495
2
1410
365
6112
987
529
8568
948
237
5226
767
689
9339
401
511
2635
885
104
2028
529
975
8986
8
1507
119
9733
671
048
0817
877
233
1391
647
564
8105
697
735
8597
729
372
7446
128
551
9070
7
1651
085
1276
551
821
5125
977
452
1630
860
756
9214
449
442
5390
070
960
6399
075
601
4071
9
1702
368
2138
252
404
6026
889
368
1988
555
322
4481
901
188
6525
564
835
4491
905
944
5515
7
1801
011
5409
233
362
9490
431
273
0414
618
594
2985
271
585
8503
051
132
0191
592
747
6495
1
1952
162
5391
646
369
5858
623
216
1451
383
149
9873
623
495
6435
094
738
1775
235
156
3574
9
2007
056
9762
833
787
0999
842
698
6691
7698
813
602
5185
146
104
8891
619
509
2562
558
104
2148
663
9124
585
828
1434
609
172
3016
890
229
0473
459
193
2217
830
421
6166
699
904
3281
2
2254
164
5849
222
421
7410
347
070
2530
676
468
2638
458
151
0664
621
524
1522
796
909
4459
2
2332
639
3236
305
597
2420
013
363
3800
594
342
2872
835
806
0691
217
012
6416
118
296
2285
1
2429
334
2700
187
637
8730
858
731
0025
645
834
1539
846
557
4113
510
367
0768
436
188
1851
0
2502
488
3306
228
834
0735
119
731
9242
060
952
6128
050
001
6765
832
586
8667
950
720
9495
3
Abrid
ged
from
Bey
er W
H, e
d. H
andb
ook
of ta
bles
for p
roba
bilit
y an
d st
atis
tics,
2nd
ed.
Boc
a Ra
ton,
Flo
rida,
The
Che
mic
al R
ubbe
r Co.
, 196
8. U
sed
with
the
perm
issi
on o
f CRC
Pre
ss, I
nc.
152 This page has been left blank 152
This handbook is an update of an earlier publication on monitoring the availability and use of obstetric services, issued by UNICEF, WHO and UNFPA in 1997. The indicators defined within the publication have been used by ministries of health, international agencies and programme managers in over 50 countries around the world. This revision incorporates changes based on monitoring and assessment conducted worldwide and the emerging evidence on the topic over the years, and has been agreed by an international panel of experts. It includes two new indicators and an additional signal function, with updated evidence and new resources.
This handbook aims to describe the indicators and to give guidance on conducting studies to people working in the field. It includes a list of life-saving services, or ‘signal functions’, that define a health facility with regard to its capacity to treat obstetric emergencies. The emphasis is on actual rather than theoretical functioning. The emergency obstetric care indicators described in this handbook can be used to measure progress in a programmatic continuum: from the availability of and access to emergency obstetric care to the use and quality of those services.
ISBN 978 92 4 154773 4