This document discusses the importance of emergency obstetric care (EmOC) in saving women's lives during pregnancy and childbirth complications. It outlines eight key EmOC functions and describes basic and comprehensive EmOC facilities. Six process indicators are presented to monitor access, utilization and quality of EmOC services, including the number of facilities per population, proportion of births at facilities, and case fatality rates. Regular monitoring of these indicators can help identify issues and guide improvements to maternal healthcare.

1. Emergency Obstetric care

2. To Avert Death and Disability… … We Need to Ensure that Women have Access To… Emergency Obstetric Care (EmOC)

3. How Can We Improve Access to EmOC? By making sure health facilities provide the services needed to save women’s lives. Eight key functions “signal” a facility’s ability to provide EmOC

4. EmOC Key Functions Cover These Services: Antibiotics (intravenous or by injection) Oxytocic Drugs (intravenous or by injection) Anticonvulsants (intravenous or by injection) Manual Removal of Placenta Removal of Retained Products Assisted Vaginal Delivery Surgery (Cesarean Section) Blood Transfusion

5. Basic and Comprehensive EmOC Facilities Antibiotics (intravenous or by injection) Oxytocic Drugs (intravenous or by injection) Anticonvulsants (intravenous or by injection) Manual Removal of Placenta Removal of Retained Products Assisted Vaginal Delivery BASIC EmOC Facilities Provide the First Six Services

6. Basic and Comprehensive EmOC Facilities Antibiotics (intravenous or by injection) Oxytocic Drugs (intravenous or by injection) Anticonvulsants (intravenous or by injection) Manual Removal of Placenta Removal of Retained Products Assisted Vaginal Delivery COMPREHENSIVE EmOC Facilities Provide All Eight Services Surgery (Cesarean Section) Blood Transfusion

7. Continuum of Care From Mother to Newborn From EmOC to EmO N C From Community to Facility MCH Centres under NRHM: level 1 (24x7 delivery) Level 2 (BEmONC) Level 3 (CEmONC)

8. THE GOOD NEWS Not all these functions need hospitals and doctors Well-trained nurses and midwives can perform most functions at Basic EmOC Facilities An Important Point for Resource Poor Areas

9. How Can We Tell We Are Making a Difference? If we know we have provided enough EmOC… … and if we know that these services are being used by women suffering obstetric complications… WE CAN BE CONFIDENT THAT WE ARE SAVING WOMEN’S LIVES

10. How Do We Know Which Women Will E xperience Complications? WE DON’T

11. … But we do know that of any population of pregnant women at least 15% will experience an obstetric complication … This is as true of pregnant women in the US and Europe as of women in Africa, Asia and Latin America Nobody Knows Why This Happens. It is a Fact of Life.

12. Can We Really Tell if Services Are Functioning? In 1991, United Nations Children’s Fund (UNICEF) and Columbia University developed 6 Process Indicators to do just that. These were issued by UNICEF/WHO/United Nation’s Population Fund (UNFPA) in 1997: Guidelines for Monitoring Availability and Use of Obstetric Services … And Are Being Used?

13. In general, process indicators show you the changes in the conditions that lead to an outcome (such as death or disability) Process Indicators

14. Access to… THE 6 PROCESS INDICATORS tell us about changes in: Utilization of… and Quality of… EmOC Services

15. EmOC Process Indicators For every 500,000 population, there should be at least: 1 Comprehensive EmOC Facility & 4 Basic EmOC Facilities Geographical Distribution of EmOC Facilities: EmOC Facilities should be well-distributed to serve 500,000 people Proportion of All Births in EmOC Facilities: At Least 15% of All Births in the Community Should Take Place in EmOC Facilities Met Need for EmOC Services: At Least 100% of Women Estimated to Have Obstetric Complications Should Be Treated in EmOC Facilities Cesarean Sections as a Percentage of All Births Minimum: 5% Maximum: 15% Case Fatality Rate: Proportion of Women with Obstetric Complications Admitted to a Facility Who Die: Maximum Acceptable Level: 1%

16. INDICATOR #1 For every 500,000 population, there should be at least: 1 Comprehensive EmOC Facility 4 Basic EmOC Facilities

17. INDICATOR #2 Geographical Distribution of EmOC Facilities EmOC Facilities should be well-distributed to serve 500,000 people Minimum: 1 Comprehensive and 4 Basic EmOC Facilities

18. INDICATOR #3 Proportion of All Births in EmOC Facilities At Least 15% of All Births in the Community Should Take Place in EmOC Facilities

19. INDICATOR #4 Met Need for EmOC Services At Least 100% of Women Estimated to Have Obstetric Complications Should Be Treated in EmOC Facilities

20. INDICATOR #5 Cesarean Sections as a Percentage of All Births Minimum: 5% Maximum: 15%

21. INDICATOR #6 Case Fatality Rate Proportion of Women with Obstetric Complications Admitted to a Facility Who Die: Maximum Acceptable Level: 1%

22. CALCULATING ALL 6 INDICATORS Gives you an indication of where the problems lie and where action is needed. Also, these indicators are sensitive to change: within months, you can know if your project is making a difference.

23. ACCESS TO EmOC Problems: Does Indicator # 1 show you need more EmOC facilities? Does Indicator # 2 show you need better distributed EmOC facilities? Action: Most countries already have enough facilities; they may just need to upgrade services to ensure 1 Comprehensive and 4 Basic EmOC facilities per 500,000 population.

24. UTILIZATION OF EmOC Does Indicator # 3 show that births in your EmOC facilities are fewer than 15% of all births in the population? Does Indicator # 4 show that “Met Need” is less than 100% (i.e., that not all women who experience obstetric complications are using EmOC facilities)? Does Indicator # 5 show that less than 5% of all births in the population are by Cesarean section? Problems

25. UTILIZATION OF EmOC Do you have enough qualified staff? Do you need to train staff on management of emergency obstetric complications? Does hospital management need improvement? What is the supply situation like? What is the equipment situation like? If all the above is in place, conduct focus groups in the community to find out why women are not coming for care Action: Collect More Information First

26. QUALITY OF EmOC Does Indicator # 6 show that more than 1% of women treated for obstetric complications are dying at your EmOC facilities? Problem:

27. QUALITY OF EmOC Find out if your EmOC facilities are really functioning Check staff numbers, skills, management capacity, supplies and equipment Lobby your health ministry for more support — and get the community to lobby with you Action: Get More Information

28. Any Country Can Avert Maternal Death and Disability if it Makes Good EmOC Available and Accessible on Time

29. References Loudon I. 1991. On maternal and infant mortality 1900 – 1960. Soc Hist Med 4(1): 29 – 73. Maine D. 1991. Safe Motherhood Programs: Options and Issues . Columbia University: New York. UNFPA and AMDD. 2002. Reducing Maternal Deaths: Selecting Priorities, Tracking Progress, Distance Learning Courses on Population Issues . Turin: UN System Staff College. UNICEF/WHO/UNFPA. 1997. Guidelines for Monitoring the Availability and Use of Obstetric Services . UNICEF: New York.