01 emergency obstetric care
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Emergency Obstetric care
To Avert Death and Disability…
To Avert Death and Disability…
…We Need to Ensurethat Women have Access To…
…We Need to Ensurethat Women have Access To…
Emergency Obstetric CareEmergency Obstetric Care
(EmOC)(EmOC)
How Can We Improve Access
to EmOC?
How Can We Improve Access
to EmOC?
By making sure health facilities provide the
services needed to save women’s lives.
By making sure health facilities provide the
services needed to save women’s lives.
Eight key functions “signal” a facility’sability to provide EmOC
Eight key functions “signal” a facility’sability to provide EmOC
EmOC Key FunctionsCover These Services:
EmOC Key FunctionsCover 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
Basic and Comprehensive EmOC FacilitiesBasic 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
• 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
BASICBASICEmOC Facilities Provide the First Six Services
Basic and Comprehensive EmOC FacilitiesBasic 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
COMPREHENSIVECOMPREHENSIVEEmOC Facilities Provide All Eight Services
• Surgery (Cesarean Section)• Blood Transfusion
Continuum of Care
• From Mother to Newborn• From EmOC to EmONC• From Community to Facility• MCH Centres under NRHM:– level 1 (24x7 delivery)– Level 2 (BEmONC)– Level 3 (CEmONC)
THE GOOD NEWSTHE GOOD NEWSNot 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
An Important Point for Resource Poor Areas
How Can We Tell We Are Making a Difference?
How Can We Tell We Are Making a Difference?
If we know we have provided enough EmOC…If we know we have provided enough EmOC…
…and if we know that these services are being used by women suffering obstetric complications…
…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
WE CAN BE CONFIDENT THAT WE ARE SAVING WOMEN’S LIVES
How Do We Know Which Women
Will Experience Complications?
How Do We Know Which Women
Will Experience Complications?
WE DON’TWE DON’T
…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.
Nobody Knows Why This Happens.It is a Fact of Life.
Can We Really Tellif Services Are Functioning?
Can We Really Tellif Services Are Functioning?
In 1991, United Nations Children’s Fund (UNICEF) and Columbia University developed 6
Process Indicators to do just that.
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
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?…And Are Being Used?
In general, process indicators show you the changes in the conditions that lead to an outcome
(such as death or disability)
In general, process indicators show you the changes in the conditions that lead to an outcome
(such as death or disability)
Process IndicatorsProcess Indicators
Access to…Access to…
THE 6 PROCESS INDICATORSTHE 6 PROCESS INDICATORS
tell us about changes in:tell us about changes in:
Utilization of…Utilization of… and Quality of…and Quality of…
EmOC ServicesEmOC Services
EmOC Process Indicators1. For every 500,000 population, there should be at least: 1
Comprehensive EmOC Facility & 4 Basic EmOC Facilities
2. Geographical Distribution of EmOC Facilities: EmOC Facilities should be well-distributed to serve 500,000 people
3. Proportion of All Births in EmOC Facilities: At Least 15% of All Births in the Community Should Take Place in EmOC Facilities
4. Met Need for EmOC Services: At Least 100% of Women Estimated to Have Obstetric Complications Should Be Treated in EmOC Facilities
5. Cesarean Sections as a Percentage of All Births
1. Minimum: 5% Maximum: 15%
6. Case Fatality Rate: Proportion of Women with Obstetric Complications Admitted to a Facility Who Die: Maximum Acceptable Level: 1%
INDICATOR #1INDICATOR #1
For every 500,000 population,there should be at least:
For every 500,000 population,there should be at least:
1 Comprehensive EmOC Facility4 Basic EmOC Facilities
1 Comprehensive EmOC Facility4 Basic EmOC Facilities
INDICATOR #2INDICATOR #2Geographical Distribution
of EmOC FacilitiesGeographical Distribution
of EmOC Facilities
EmOC Facilities should be well-distributed to serve 500,000 people
EmOC Facilities should be well-distributed to serve 500,000 people
Minimum: 1 Comprehensive and 4 Basic EmOC FacilitiesMinimum: 1 Comprehensive and 4 Basic EmOC Facilities
INDICATOR #3INDICATOR #3Proportion of All Births
in EmOC FacilitiesProportion of All Births
in EmOC Facilities
At Least 15% of All Births in the Community
Should Take Place in EmOC Facilities
At Least 15% of All Births in the Community
Should Take Place in EmOC Facilities
INDICATOR #4INDICATOR #4
Met Need for EmOC ServicesMet Need for EmOC Services
At Least 100% of Women Estimated to Have Obstetric Complications Should Be
Treated in EmOC Facilities
At Least 100% of Women Estimated to Have Obstetric Complications Should Be
Treated in EmOC Facilities
INDICATOR #5INDICATOR #5
Cesarean Sections as a Percentage of All Births
Cesarean Sections as a Percentage of All Births
Minimum: 5%Maximum: 15%Minimum: 5%Maximum: 15%
INDICATOR #6INDICATOR #6Case Fatality RateCase Fatality Rate
Proportion of Women with Obstetric Complications
Admitted to a Facility Who Die:
Proportion of Women with Obstetric Complications
Admitted to a Facility Who Die:
Maximum Acceptable Level:
1%
CALCULATING ALL 6 INDICATORSCALCULATING 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.
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.
ACCESS TO EmOCACCESS TO EmOCProblems:
Does Indicator # 1 show you need more EmOC facilities?
Does Indicator # 2 show you need better distributed EmOC facilities?
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.
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.
UTILIZATION OF EmOCUTILIZATION 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?
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?
ProblemsProblems
UTILIZATION OF EmOCUTILIZATION 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?
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
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
Action: Collect More Information First
QUALITY OF EmOCQUALITY OF EmOC
Does Indicator # 6 show that more than 1% of women treated for obstetric complications are dying at your EmOC facilities?
Does Indicator # 6 show that more than 1% of women treated for obstetric complications are dying at your EmOC facilities?
Problem:Problem:
QUALITY OF EmOCQUALITY 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
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
Action:Get More Information
Any Country Can Avert
Maternal Death and Disability
if it Makes Good EmOC
Any Country Can Avert
Maternal Death and Disability
if it Makes Good EmOC
Available and Accessibleon Time
Available and Accessibleon Time
ReferencesReferences
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.