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BasicEmergencyObstetricandNeonatalCareAssessment
ManufahiandAinaroDistricts
FinalReport
March2012
AnnmarieNolan,BSN,RN,MN
HealthAllianceInternationalUniversityofWashington
AcknowledgementsTheauthorwouldliketothankHealthAllianceInternationalstaff,UnitedNationsPopulationFund’sDr.AngelaBismarkandDr.AmitaPradhanThapafortheirinput,theMinistryofHealthstafffortheirparticipation,andlastlyUSAIDandHealthAllianceInternationalforprojectfunding.
TableofContentsExecutiveSummary………………………………….……………………………...…………………………………………………...1Background……………………………………………………………………………………………………………………………………..3ProblemStatement…………………………………………………………………...…………………………………………………...3Methods…………………………………………………………………………..………………………………………………………….…...4Results
Staffing……………………………………………..………………………………………………………………………………….5CaseSummaries………………………………………………………………………………………………………..……….6ServiceAvailability…………………………………………………………………………………………………...………6StaffKnowledgeLevels……………………………………………………………………………………………………7EquipmentandSupplies………………………………………………………………………………………………….9
Conclusions…………………………………………………………………………………………………………………………………..10Recommendations………………………………………………………………………………………………………………………11 ImmediateRecommendations…………..…………………………………………………………………………11 Long‐termRecommendations…………………………...…………………………………………...……………12Annex1:GovernmentHealthFacilitiesprovidingEmergencyObstetricCareServices…14Annex2:MidwifeAssessmentSupplement…………………………………………………………………………..15Annex3:ServiceAvailabilityandStaffingTable………………………………….…………………………..…..16Annex4:FacilityConditionandStaffing………………………………………………………………………………..17Annex 5: Midwife Knowledge Survey……………………………………………………………………………………….18 Annex6:EquipmentListtoPerformBEmOCbyFacility……………….…………………………………..20
Abbreviations:DemographicandHealthSurvey(DHS)NationalReproductiveHealthStrategy(NRHS)HealthAllianceInternational(HAI)AvertingMaternalDeathandDisease(AMDD)UnitedNationalPopulationFund(UNFPA)MinistryofHealth(MOH)CommunityHealthCenters(CHCs)FamilyHealthPromoters(PSFs)IntegratedCommunityHealthServices(SISCa)Emergencyobstetriccare(EmOC)Emergencyobstetricandneonatalcare(EmONC)Basicemergencyobstetriccare(BEmOC)
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ExecutiveSummaryTheTimor‐Lestegovernmenthasfoughttoreducematernalmortalityusingsafemotherhoodstrategiesonanationalscale.Despiteeffortstoreducematernaldeaths,the2009/10DemographicandHealthSurvey(DHS)foundthatthematernalmortalityratioremainshighat557per100,000livebirths.InJanuaryandFebruaryof2012,HealthAllianceInternational(HAI)assessedbasicemergencyobstetriccareinmid‐levelhealthfacilitiesinthedistrictsofAinaroandManufahi.Thepurposeoftheassessmentwastomonitorthescale‐upofbasicemergencyobstetriccareinruralareasandtoassistthedevelopmentofMobileMoms,amaternalhealthprojectaimingtoimprovehealthandcare‐seekingbehaviorsofpregnantwomenandtheirnewborns.AUnitedNationalPopulationFundsurveytoolenhancedwithadditionalinterviewquestionswasusedtoassesssevendistrictandsub‐districtlevelhealthfacilitiesandseventeenmidwives.ResultswerecomparedbetweenfacilitiesandWorldHealthOrganizationemergencyobstetriccare(EmOC)policiesandrecommendations.Thefindingsshowthat: Serviceavailabilityvariesthroughoutthetwodistricts,withthemostremote
facilitieshavingthefeweststaffmembersavailableinhibiting24hoursperdaycoverage.Supervisoryphysiciansareoftentemporarilyplacedinfacilities,causinginconsistenciesintechnicalsupportandteammanagementstyles.
Therecontinuetobeweaknesseswithinthegovernmentsurveillancesystem.Withinfacilities’monthlyrecordstherewereinconsistenciesincasenumbersandmissingdata.AmajorityofthehealthfacilitiesmanagedfewobstetriccomplicationsandmidwiveslackanadequatecaseloadtopracticeandmaintainbasicEmOCskills.
OtherthantheMaubisseReferralHospital,midwivesfromthePrinceofMonacoII
MaternityHouseweretheonlyinterviewedwhoperformedallbasicEmOCsignalfunctionsinthepastthreemonths.Skillconfidencevariedacrossfacilities,withsomemidwivesacknowledgingincreasedconfidencewithteamcaremanagementapproaches.
EquipmentisnotconsistentlyavailabletoprovidehighqualitybasicEmOC.Basic
equipmenttomonitoranddetectearlycomplicationswasmissingfromnumerousfacilities.EquipmenttoperformbasicEmOCfunctionwasmissingorstafflackedknowledgeonpropermaintenance.Atthetimeofassessment,medicineswerewelldistributed,butstaffadmittedtoexperiencingfrequentshortages.
Whileimprovementshavebeenmadesincethe2009nationalEmOCassessment,theManufahiandAinarodistrictandsub‐districtfacilitieshaveyettomeetWorldHealthOrganizationrecommendationsforprovidinghighqualitybasicemergencyobstetriccare.Beforeadditionalemphasisisfocusedonqualityimprovement,effortsneedtotargethealthsystemimprovementsbasedondistrictandindividualfacilitylevelneed.
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KeyRecommendations:Immediate1. Ensurethatfacilitieshaveequipmenttoprovidebasiccaremanagement.
RevamptheMOHequipmentandsupplyrequestprocesstodecreasewaitingperiods.Supervisorystaffshouldbeknowledgeableinandoverseeequipmentmaintenance.
2. Increaseteamapproachestocaremanagement.Inter‐professionalapproachestomanagingmaternalhealthcarehaveshowntobemoreeffectivetoimprovingqualityofcare.Prenatalanddeliverycarestaffandrecordsshouldbelocatedwithinthesamehealthfacilityincreasingcontinuityofcare.
3. ImprovegovernmentmonitoringsystemsbymentoringhealthstaffthroughroutineSafeMotherhoodandEmOCsupervisionandreviewingcasesummaryreporting.
Long‐term4. Supporttherenovationandupgradingofexistingfacilitiestoimprovepower
suppliesandwaterandsanitationsystems.5. Ensureallproviders(midwivesandphysicians)maintaintheirbasicEmOC
certification.Allmidwivesshouldcompletethecertification,prioritizingdistricthealthfacilitystaff.Routinerefreshertrainingsshouldintegratephysicianandmidwivestogethertoreinforceteamcaremanagementapproachesandmaintainskilllevels.UponbasicEmOCcertification,allprovidersshouldbeuniversallyapprovedtoindependentlyperformfunctionsasdescribedbyMOHpolicy.
6. FacilitatethetimelydistributionofUNFPAEmOCkits,ensuringthatallfacilitieshavetheequipmentnecessarytoperformbasicemergencyobstetriccare.Kitsshouldbereviewedwithreceivingstafftoensurepropermaintenanceofequipment.
7. EmOCsupportivesupervisionshouldbeintegratedinsafemotherhoodvisitstosustainlongevityofskillqualityaftertrainingcompletion.Measuresthatcanpreserveskillqualityincludehands‐onpractice,teamapproaches,andfollow‐uptraining,whichcanbeprovidedduringsupervisionvisits.
8. Researchmethodstopreserveskilllevelofremotelyplacedprovidersthatassistwithfewobstetriccomplications.Considerdevelopingarotationforremotemidwivestopracticeobstetricskillswithinfacilitieswithahighernumberofabnormalobstetriccasesprovidingthemthehands‐onpractice.Alternatively,theMOHcanconsideratrialoflowtechnologysimulation‐basedEmOCpractice,suchasthatavailableattheUniversityofWashington’sPRONTOproject.
9. Increaseresourcestotransportpatients,ensuringthattimelycareisaccessible.IncreasefuelsupplyforemergencytransportationandprimarycareSISCa’s.Considermonitoringthereferraltransportationsystemtoensurethatanappropriatenumberofvehiclesareavailabletoservepopulationneeds
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BackgroundTimor‐Lestehasbeeninvestedinhealthsystemstrengtheningsinceindependencein2002.EffortsbytheMinistryofHealthandnon‐governmentagencieshavetargetednumeroussectors,buthavelargelyfocusedinmaternalhealth.Yetthe2009/10DemographicandHealthSurvey(DHS)foundthatthematernalmortalityratioremainshighat557per100,000livebirths.1Behindthisstatistic,italsofoundthat70percentofbirthsarenotassistedbyaskilledattendantandonly22percentofdeliveriesoccurwithinahealthfacility.The2004Timor‐LesteNationalReproductiveHealthStrategy(NRHS)providesafour‐strategyapproachtomakepregnancysafer.2TheseSafeMotherhoodapproachesincluded1)increasingtheknowledgelevelinthegeneralpopulationonissuesrelatedtopregnancyandchildbirth;2)improvingthequalityandcoverageofprenatal,delivery,postnatal,andperinatalhealthcare;3)improvingemergencyobstetriccare(EmOC)throughrecognition,earlydetection,andmanagementorreferralofcomplicationsofpregnancyanddelivery;and4)integratingeffectivedetectionandmanagementofSTIcasesintomaternalandperinatalcare.HealthAllianceInternational(HAI)iscurrentlylaunchingafour‐yearprojectaimedatsupportingtheSafeMotherhoodcomponentoftheNRHS.TheMobileMomsprojectusesanintegratedapproachinworkingwithdistrictandsub‐districtMOHhealthfacilitiesdowntoFamilyHealthPromoters(PSFs),whoprovideaccesstotheindividualhouseholds.ThehealthstaffstrengtheningcomponentoftheMobileMomsprojectaimstoimproveskillsofhealthteamstoprovidequalitymaternalcareservicesthroughsupportivesupervisionofmidwivesinmaternalcareservicesandtraininginbasicemergencyobstetricandneonatalcare.ProblemStatementTheoverallgoaloftheHealthAllianceInternationalprojectMobileMomsistoimprovethehealthandcare‐seekingbehaviorofpregnantwomenandtheirnewborns.Asapartofthiseffort,HAIaimstosupportgovernmenthealthfacilitiestoensurethatpregnantwomenandtheirnewbornsreceivehighqualitycare.ThisaimwillbeaccomplishedthroughtechnicalsupportinSafeMotherhoodandemergencyobstetricandneonatalcare(EmONC).In2008,theUnitedNationalPopulationFund(UNFPA)conductedanationalEmOCneedsassessment.ThisassessmentfoundmultiplelimitationstoprovidingqualityEmOCinTimor‐Leste,suchaspoorinfrastructure,lackofmaternityspace,inadequateequipmentandsupplies,poortransportationandcommunicationschemes,weak
1 NationalStatisticsDirectorate(NSD)[Timor‐Leste],MinistryofFinance[Timor‐Leste],andICFMacro.2010.Timor‐LesteDemographic andHealth Survey2009‐10.Dili, Timor‐Leste:NSD [Timor‐Leste] andICFMacro.2MinistryofHealth[Tmor‐Leste].2011.NationalHealthSectorStrategicPlan.2011‐2030:TowardsaHealthEastTimoreePeopleinaHealthTimor‐Leste.
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logisticsystem,andlackofconfidenceoftrainedmidwivestoperformsomesignalfunctions.3In2010,HAIfield‐testedabasicEmOCsupervisionassessmentformwiththeMinistryofHealth(MOH)inManatutoandAinarodistrictcenters.4In2012,UNFPAandtheMOHinitiatedEmONCsupervisionvisitsinalldistrictandsub‐districtCommunityHealthCenters(CHCs)withafocusonbasicEmONCidentifiedsites.SeeAppendix1foralistofEmOCsites.ToappropriatelysupporttheAinaroandManufahimidwiveswithintheMobileMomsproject,HAIassessedcurrentbasicEmONCconditionswithinthetwodistricts.ResultsfromtheassessmentwillbeusedtoincreaseEmONCcapacitywithinthetwodistrictsandcanbeappliednationally.MethodsThisbaselineassessmenttargetedgovernmenthealthfacilitieswithintheManufahiandAinarodistricts.TomeasuretheavailabilityofBEmONCthroughoutthisgeographicregion,districtandsub‐districtCHCsandMaternityHousesweretargetedforassessment.Districtandsub‐districthealthfacilitieshavebeenidentifiedbytheMinistryofHealthandUNFPAtobedevelopedintoBEmONCfacilitiesby2015.AUniversityofWashingtongraduatenursingstudent,assistedbyHAItechnicalstaff,visitedeightsitesbetweenJanuary17thandMarch2nd2012.Thosesitesincludedhealthfacilitiesinallfoursub‐districtsinManufahi,andthreesub‐districtsinAinaro(seeTable1).Approvalfromdistrictgovernmentstaffandindividualconsentwasreceivedpriortosurveyinitiation.TheBEmONCassessmentwasconductedusingamixedmethodapproach.MultipleindicatorsweregatheredfromhealthfacilitiesusingaMOHapprovedUNFPAquestionnaire;indicatorsincludedstaffing,casesummaryreports,serviceavailability,staffknowledgelevels,equipment,supplies,anddrugs.5Thesequantitativeresultswerecompiledintoanexceldatabase.
3MinistryofHealth[Timor‐Leste].2004.NationalReproductiveHealthStrategy2004–2015.Dili,Timor‐Leste:MinistryofHealth.4MinistryofHealth[Timor‐Leste],andUnitedNationsPopulationFund(UNFPA).2008.EmergencyObstetricCare(EMOC)NeedsAssessment.Dili,Timor‐Leste:NSD[Timor‐Leste]andUNFPA.5 MinistryofHealth[Timor‐Leste],andUnitedNationsPopulationFund(UNFPA).2008.EmergencyObstetricCare(EMOC)NeedsAssessment.Dili,Timor‐Leste:NSD[Timor‐Leste]andUNFPA.
Table1.BEmOCAsssessmentSites
NumberofMidwives
NumberofEmOCCertifiedMidwives
CompletedFacilityAssessments
NumberofCompletedMidwifeAssessed
Manufahi CHCSame 2 x ‐ ‐PrinceofMonacoMaternityHouse 7 5 1 6TuriscaiMaternityHouse 1 0 1 1FatuberlihuMaternityHouse 3 2 1 1CHCAlas 1 0 1 1HPBetano 1 1 ‐ 1
Ainaro
CHCAinaro 3 2 1 3
CHCHatudu 1 1 1 1
CHCMaubisse 1 0 ‐ ‐
RSUMaubisse 5 4 1 3
CHCHatubelico 1 1 ‐ ‐
Total: 26 15 7 17
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MidwifecapacitywasassessedusingaUNFPAindividualstaffknowledgelevelquestionnaireenhancedwithadditionalinterviewquestions.Thistoolaimedtomeasurethefrequencyandconfidenceoftreatingobstetriccaseswhilegatheringadditionalbackgroundinformation.QualitativequestionsinquiredonbarrierstoprovidingBEmONC,qualityofhomedeliveryassistance,andearlycomplicationidentificationandcare.SeeAnnex2fortheinterviewsupplement.ThisindividualassessmentwasdistributedtoseventeenmidwivesintheAinaroandManufahidistricts,fromeverylevelofMOHfacilitiesrangingfromtheMaubisseReferralHospitaltoaManufahihealthpost.Thenumberofmidwivesinterviewedatonefacilityrangedbetweenoneandsixmidwives.Midwives’nameswerenotused,howeversurveyidentificationnumberswerelinkedtofacilityassessmentsallowingstaffandfacilitydatatobecombined.ResultsThefacilityandmidwifeassessmentresultswerecollectedandenteredintoseparateexceldatabases.Datagatheredprovideageographicrepresentationofthetwodistricts,withsurveysitesdistributedoversevenoftheeightsub‐districts.OneplannedAinarosub‐districtCHCwasnotvisitedduetotimeconstraints.Thefollowingresultsareseparatedintostaffing,casesummaryreports,serviceavailability,staffknowledgelevels,equipment,supplies,anddrugs.StaffingFacilitiesrangedinhumanresourcesupport.Fourofthesub‐districthealthfacilities(CHCsandMaternityHouses)haveonlyonemidwifeprovidingobstetricservices.Onlytwoofthefacilitiesadmittedtohavingmidwivespresenttwenty‐fourhoursaday,everyday.Onaverage,midwivesinterviewedassistwithonlysevenbirthsamonth.WhilephysicianswerenotincludedintheMOHquestionnaire,midwivescommentedontheirpresencewithinhealthfacilitiesduetotheirsupervisoryrole.TheMaubisseReferralHospitalistheonlyfacilitywithapermanentobstetricianphysicianposition.DistrictCHCshavegeneralphysicians,however,mostpositionsarefilledwithinternationalsundercontractthatleavethefacilityafterayearortwo.
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CaseSummaries
Table2.2012FacilityCaseSummaries(#)
Obstetriccases Complications Referral
Antenatalcare
consultations
Totaldeliveries
Livebirths
New
bornswithnormal
birthw
eight
Hom
ebirths
Facilitybirths
Totalobstetric
admissions
Hem
orrhagecases
Dystociaorprolonged
birthcases
Post‐partuminfection
cases
Eclampsiacases
Abortioncases
Referredobstetric
cases
Receivedobstetric
cases*
PrinceofMonacoMaternityHouse
2339 329 329 319 12 317 396 27 1 1 7 18 49 x
TuriscaiMaternityHouse
402 95 92 92 85 7 7 0 0 0 0 0 1 0
AlasMaternityHouse 438 63 63 62 33 30 30 0 0 0 0 2 10 0
FaterberlihuMaternityHouse
514 108 108 108 31 77 77 5 3 0 0 6 2 0
MaubisseReferralHospital
1567 188 184 163 13 175 194 9 6 11 23
15 4 137
AinaroCHC 844 186 186 177 64 122 122 0 1 0 1 8 2 x
HatudoCHC 686 89 89 87 37 52 52 1 0 0 0 1 1 0
*x=thesefacilitiesdidnotrecordthenumberofobstetriccasesreceived
2011casesummarydatawascollectedfromsevenfacilities(seeTable2).ThePrinceofMonacoIIMaternityHouseperformsanotablyhighernumberofbirths,evenwhencomparedtothereferralhospitalorAinarodistrictCHC.TheTuriscaiMaternityHouseistheonlyfacilitythatperformssubstantiallymorehomethanfacility‐basedbirths.Itisanewadditiontothatsub‐district,sofacility‐basedbirthsareexpectedtorisein2012.Whilethematernityhouseshaveincreasedaccesstofacility‐baseddeliveriesacrossthetwodistricts,therehasbeennoevidentshiftofhometofacility‐basedbirthsduring2011.Additionally,thefrequencyofreportedobstetriccomplicationsremainslowinmostfacilities.FewobstetricpatientswerereferredfromtheTuriscai,Alas,andHatudofacilities,reinforcingtheinfrequencyofcomplicationcasesmanagedbyhealthprofessionals.Indicationsofobstetricreferralsweredifficulttomonitorasmanyreferralswereexcludedfromfacilitycomplicationcasereports.Also,recordsdidnotuniformlydocumentcauseofreferral.Referralcasesweredifficulttotrackthroughfacilitiesandinconsistencieswithinfacilityformssuggestedsomeerroneousreporting.ServiceAvailabilityAllfacilitiesreportedhavingmidwivesavailableon‐callasneeded.Midwiveslivedinvaryingproximitiestohealthfacilitiesandinconsistenttransportationsometimescausedadelayofservices.TheMaubisseReferralHospitalandthedistrictCHCshadotherhealthstaff(nurses,midwivesandnurseassistants)availabletwenty‐fourhoursadayifskilledassistancewasrequiredduringeveningornighthours.Medicinesareavailableduringeveninghoursatallmonitoredfacilities,faultingTuriscai,whichwasnotmeasured.MaubisseReferralHospitalwastheonlyfacilitywithlaboratorytechniciansavailableatnight,howevernumerousmidwivesclaimedtoindependently
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testformalariaifneeded.Overall,veryfewlaboratorytestsareconductedatruralsites.SeeAnnex3foracompletelistofserviceavailabilityandstaffing.StaffKnowledgeLevelsSixteenoftheseventeenmidwivesinterviewedassistedwithdeliveriesin2012.Quantitativedataisbasedonthesixteenmidwivescurrentlyprovidingmaternitycare.QualitativedataincludestheseventeenthmidwifewhoprovidesantenatalintheMaubisseReferralHospital.Eight(47.1%)ofthemidwivesinterviewedworkinMaternityHouses.Five(29.4%)midwivesworkinCHCs,oneinahealthpost,andthree(17.6%)inahospital.SeventyonepercentofthemidwivesinterviewedareEmOCcertifiedbytheMinistryofHealth.
WHOcategorizesaBEmONCfacilitybydeterminingifallsignalfunctionswereperformedinthelastthreemonths.6Everymidwifewhoassistedwithdeliveriesadministereduterotonicdrugswithinthelastthreemonths.Eleven(68.8%)administeredparenteralantibiotics,nine(56.3%)removedretainedproducts,eight(50.0%)performedamanualremovalofplacenta,whileonlyfive(31.3%)administeredparenteral
anticonvulsants.Assistedvaginaldeliveryandnewbornresuscitationwasassessedduringasix‐monthdurationandnotincludedinTable4.Additionally,midwivesweregivenaquestionnaireonforty‐fiveobstetricskills,inquiringwhethertheywereconductedinthelastsixmonthsandifthepractitionerfeltconfidentinperformingthatfunction.Skillsvariedfornormalassessments,treatingabnormalcases,andBEmONCskills.Whilemanymidwivesreportedthattheyhadnotconductednumerousfunctionsinthelastsixmonths,theyclaimedtofeelconfidentinperformingthem.
6 WorldHealthOrganization(WHO).2009.MonitoringEmergencyObstetricCare:aHandbook.WHOPress,Geneva,Switzerland.
Table3.MidwifeEmOCEducation(N=17)# %
EmOCcertified 12 70.6
IncompleteEmOCtraining 5 29.4
Table4.BEmOCSignalFunctionsPerformedinLastThreeMonths(N=16)
# %
Administeredparenteralantibiotics 11 68.8
Administereduterotonicdrugs 16 100.0Administeredparenteralanticonvulsants 5 31.3
Performedmanualremovalofplacenta
8 50.0
Removeretainedproducts 9 56.3
Table5.ObstetricSkillsPerformedinLastSixMonths&ConfidenceLevels(N=16)#%
Managedbleedinginearlypregnancy 12 70.6Confidentinmanagingbleedinginearlypregnancy
14 87.5
Managebleedinginlatepregnancyandlabor 7 43.8Confidentinmanagingbleedinginlatepregnancyandlabor
15 88.2
Managepre‐eclampsia 11 68.8
Confidentinmanagingpre‐eclampsia 14 87.5
Managefeverbeforedelivery(amnionitis) 10 62.5Confidentinmanagingafeverbeforedelivery(amnionitis)
15 93.8
Performedvacuumdelivery† 8 57.1
Con identinperformingvacuumdeliveries† 6 42.9Performednewbornresuscitation 9 56.3Confidentinperformingnewbornresuscitation 15 93.8
†Statisticbasedoffof14midwives
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Fromthequalitativeinterviews,midwiveslistedmultiplebarrierstoprovidingBEmONC.Themostcommonthemefoundwasthelackofsupport.Itwasfrequentlylinkedtothelimitednumberofhealthprofessionals(obstetriciansandmidwives)availabletoassistwithabnormalobstetriccases.Anotherissuethattheypresentedwasinconsistenciesinthesupervisionstylesofcontractphysicians.Somemidwivesreportedthatfacilitypoliciesdeterminingwhetherfunctionscouldbeindependentlymanagedbyamidwifechangedunderdifferentphysiciansdependingontheirobstetricexperiencelevel.Midwivesclaimedtohavereferrednumerousobstetriccasesthattheyweretrainedinandfeltconfidentinmanagingbecausethesupervisingphysicianwasnotconfidentofhisorherskills.ThesecondmostcommonthemeidentifiedwasinadequateequipmentorsuppliestoprovideBEmONCfunctions.Manyfacilitiesreportedhavingrequestedreplacementequipment,butaresubjecttolengthywaitperiods.Thethirdbarriercommonlylistedwaslimitedemergencytransportation.Reasonsbehindthisbarrierincludedalimitednumberofemergencyvehiclesavailable,limitedaccessduetopoorroadconditions,andinadequatefuelavailability.WhenaskedabouttheirabilitytoprovidequalityofBEmONCduringhomedeliveries,midwivesoverallreportedlimitedability.MostmidwivesreportedtransferringpatientstoafacilitypriortoprovidingBEmONC.Theyreportedthatintravenousfluidswouldbeplacedinthehomeifnecessary;however,allothercomplicationsaretreatedatahealthfacility.Additionally,whenmidwiveswererequestedtoprovideskilledassistanceduringanormal,early‐stagehomedelivery,theyconsistentlytransferredthepatienttoafacilitytogivebirth.Veryfew“homebirths”assistedbyfacilitystaffactuallydeliveredwithinthehome.Whenaskedhowthemidwivesmanageobstetriccomplicationsduringtheprenatalperiod,themostcommonresponsewasalistofdiversefactorstakenintoconsiderationtodevelopacareplan.Midwivescommonlylistedacuity,gestation,previousmedicalhistory,andgeographiclocationofthepatient’shomeasfactors.Fewmentionedresourcesusedtodevelopabirthplan,whichincludedteamapproachorEmOCmaterials.Midwivesalsolistedvariouscarestrategies,suchasprovidinginpatientcare,additionalconsultations,andrequestingpregnantmothersintheirninthmonthgestationtostaywithinashortdistancefromahealthfacility.However,nouniversalprotocolwasmentioned.AlmostallmidwivesrequestedcontinuationofEmONCtraining,eitherinitialcertificationorrefreshertraining.OnemidwifereceivedEmOCtrainingasearlyas2006,andmanyrequestedroutineupdatestoensureskillquality.EquipmentandSuppliesTheoriginalequipmentandsupplyquestionnaireincluded172items,withsectionsonfacility,equipmentandsupplies,stafftransportation,referralsystem,laboratoryequipment,infectionprevention,basicmedicalitemsandsupplies,recordsandforms,registries,drugs,anddeliveryequipment.Itemspertinenttogeneralfacilitycondition
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andperformingdirectBEmONCfunctionswerereviewedfirst.Someitemswerenotassessedduetoalackoftimeoravailabilityofstaffduringsitevisits.Thesefindingsshowthatthegeneralconditionsofthedistrictandsub‐districtfacilitieswerenotidealforprovidinghighqualityBEmOC.OnlytheMaubisseReferralHospitalhadaccesstoelectricity24hoursaday.Threefacilitieshadaccesstoelectricityduringlimitedhoursoftheday.Twofacilitiesonlyhadelectricityforspecificelectronics.Onefacility,AlasMaternityHouse,hadnoelectricity.TheonlyfacilitieswithareliablewatersupplydirectlytotheclinicweretheMaubisseReferralHospitalandtheAinaroCHC.Additionally,onlythreefacilitieshadanoxygensupply(MaubisseReferralHospital,AinaroCHC,PrinceofMonacoIIMaternityHouse).SeeAnnex4foralistoffacilityconditionsandbasicmedicalequipmentbyfacility.WorldHealthOrganizationpoliciesformanagingpregnancycomplicationswereusedtodevelopanabbreviatedlistofequipmentusedtoperformBEmONCfunctions(seeAnnex6).Thislistofnecessaryitemswasdevelopedfromthe2007WHOprovidermanual,ManagingComplicationsduringPregnancyandChildbirth:AGuideforMidwivesandDoctors.7ThismanualisusedasatrainingresourceinTimor‐Leste.ThisequipmentlistdoesnotincludebasiccaremanagementsuppliesorequipmentneededtoaddresscomplicationsthatmayarisewhileperformingBEmONC.ThislistwasusedsolelyforanalysisofBEmONCequipment.EquipmentwithinTimor‐LestevariesslightlyfromtheWHOrecommendations,sosomevariationexists.Table6depictsthepercentageofequipmentcurrentlyavailableatfacilitiesduringthe2012sitevisittocompleteBEmONCfunctions.SeeAnnex6forabreakdownofequipmentbyBEmONCfunctionandfacility.Table6showsthatnofacilitieshadacompletesetofequipmenttoprovidehighqualitycare.Ruralsub‐districtsofTuriscai,Alas,andHatudulackedthemostequipment.
7 WorldHealthOrganization(WHO).2007.ManagingComplicationsinPregnancyandChildbirth:Aguideformidwivesanddoctors.WHOPress,Geneva,Switzerland.
Table6.BasicEmOCEquipmentandSupplies(percentageavailable)
MaubisseHospital
MonacoMaternityHouse
TuriscaiMaternityHouse
AlasMaternityHouse
Fater‐berlihuMaternityHouse
AinaroMaternityHouse
HatuduMaternityHouse
1 Admisterparenteralantibiotics 100.0% 100.0% 81.8% 81.8% 90.9% 100.0% 90.9%
2Administeruterotonicdrugs(i.e.parenteraloxytocin) 91.7% 91.7% 66.7% 75.0% 83.3% 91.7% 91.7%
3Administerparenteralanticonvulsantsforpre‐eclampsiaandeclampsia 81.8% 81.8% 63.6% 54.4% 63.6% 81.8% 72.7%
4 Manuallyremovetheplacenta 100.0% 87.5% 62.5% 87.5% 93.8% 100.0% 87.5%
5 Removeretainedproducts(vacuumextraction,dilationandcurettage)
90.0%,93.8%
90.0%,87.5%
60.0%,62.5%
65.0%,81.3%
75.0%,68.8%
90.0%,93.8%
55.0%,62.5%
6Performassistedvaginaldelivery(i.e.vacuumextraction) 83.3% 83.3% 33.3% 50.0% 50.0% 100.0% 33.3%
7Performbasicneonatalresuscitation(i.e.withbagandmask) 100.0% 100.0% 75.0% 87.5% 100.0% 100.0% 0.0%
BasedonWorldHealthOrganization'sprovidermanual"ManagingComplicationsinPregnancyandChildbirth:AGuideforMidwivesandDoctors"
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ConclusionIn2002,theNationalPlanningCommitteeelegantlysummarizedthestateofmaternalhealth,statingthat“womenbearanunacceptableburdenofmortalityandmorbidity,withmaternalmortalityratesat350‐800per100,000livebirths”.8Eightyearslater,womencontinuetobesubjecttothisheavyburden.Since2002,emergencyobstetricserviceshaveimproved.However,AinaroandManufahifacilitiesprovideincompletebasicservices,especiallyatruralsub‐districtsites.IdentifyingandtargetingindividualfacilityweaknessisthemosteffectivestrategytoincreasingdistrictBEmONCcapacity.9,10,Thisassessmentfoundmanyofthelimitationslistedinthe2008UNFPAEmOCNeedsAssessmentstillexistandrequireadditionalfocusandresources.TheframeworkontherightisColumbiaUniversity’s“AvertingMaternalDeathandDisability”(AMDD)tooltomeasureEmOCimplementation.11Thisbuildingblockframeworkbreaksdownhoweachactivityrelatestotheothersandinwhatsequencetheymustbeinitiated.Thebottomtworowsarethefoundationtoprovidingsustainable,highqualityemergencyobstetriccareandmake‐upthepreparationstage.AMDDandUNFPAagreethatdevelopingstronghealthsystemsprecludesEmONCqualityimprovementinterventions.12Focusingontheframework’sbottomlevel:whilethehealthfacilitieshavemadeimprovementsinrenovations,facilitysetup,suppliesandequipmentsincethe2008EmOCassessment,manyweaknessesarestillevident.Additionaleffortisstillneededtoimprovefacilityconditions,equipmentmaintenance,suppliesandequipment,andimprovetheaccuracyofdatacollection.EquipmentandsupplieswerewellstockedandfunctioningintheMaubisseReferralHospital.However,otherfacilitiesaresubjecttolongwaitingperiodsforequipmentandsupplyreplacementandrestock.Basicmedicalequipmentneededforcareofroutineandemergencyconditionsweremissingfromnumerousfacilities,especiallythemostremotesites.Bettermaintenanceandsupplyofequipmentisneededtodetectandconfirmearlyobstetriccomplications.
8 NationalPlanningCommittee.2002.NationalDevelopmentPlan.Dili,EastTimor.9Freedman,L.P.,Graham,W.J.,Brazier,E.,Smith,J.M.,Ensor,T.,Fauveau,V.,Themmen,E.,Currie,S.,Agarwal,K.2007.Practicallessonsfromglobalsafemotherhoodinitiatives:timeforanewfocusonimplementation.Lancet,370:1383–91.10AvertingMaternalDeathandDisability.2006.AvertingMaternalDeathandDisabilityProgramReport1999‐2005.ColumbiaUniversity,NewYork,USA.11Campbell,O.M.R.andGraham,W.J.2006.Strategiesforreducingmaternalmortality:gettingonwithwhatworks.Lancet,368:1284–99.12Freedmanetal.2007.
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Thesefirst‐layeractivitieswithinthetoolsupportthesubsequentpreparationstagelayer.RoutinerefreshertrainingsonEmONCandsafemotherhoodneedtobeintegratedintohealthprofessional’scareers.IncreasingstaffingwouldprovidemidwivessupporttoprovideBEmONCinruralsitesduring24hoursperday.Teambuildingtrainingsandexerciseswouldincreaseinter‐professionalapproachesandqualityofcare.UsingtheAMDD’sframeworkshowsaneedfortheMOHtofocusonimprovinghealthsystemissuesbeforeBEmONCqualitycanbefullyaddressed.Whileworkingonthesefoundationalissues,theMOHcanplanhowtoaugmentthefirstlayeroftheservicedeliverystage,consistingofcontinualreadinessandconstantemergencyobstetriccare.Obstetriccomplicationsatsub‐districtfacilitiesareinfrequentandthesecasesareoftenreferredtothedistrictorreferralhospitallevelbasedonacuity.Withcurrentlevelsofhealthcareutilization,remotelyplacedmidwiveslackasufficientnumberofopportunitiestopracticetheirBEmONCskills.RecommendationsManyinterventionsaddressingmaternalmortalitywereintegratedintothenationalplanfromtheSafeMotherhoodinitiative.Communityoutreachefforts,suchasSISCa(IntegratedCommunityHealthServices)andPSFsincreasedtheuseofhealthfacilityandtrainedstaffservices.Whilequalityofcarehasbeensupportedthroughspecialtytrainingsandsupervisionvisits,furtherhealthsystemimprovementsareneededtoprovideauniversalstandardofcareacrossfacilitylevels.Globally,therehasbeenanincreasedfocusontheimplementationofinterventionswithevidence‐basedscale‐upstrategies.13Duetoinconsistenciesinfacilityconditions,supplies,serviceavailability,andstaffing,basicsystemlevelfactorsatthedistrictandsub‐districtlevelhealthfacilitieshavetoimproveasaconditionofexpandingEmOCservices.Additionally,byaddressingsystemlevelissues,benefitswilloccuracrossabroadspectrumofhealthconditionsincludingpreventivecare.Thefollowingisalistofimmediatesystemlevelchangessuggestedandlong‐termrecommendationsfocusingonEmOC.Recommendationsweredevelopedfromassessmentresults,aliteraturereview,andinterviewswithfieldexperts.ImmediateRecommendations
1. Ensurethatthefacilitieshavethebasicequipmentnecessarytoprovidecaremanagement.RevamptheMOHequipmentandsuppliesrequestprocesstodecreasewaitingperiods.Frequentequipmentallotmentshouldbeanticipatedanddistributedinatimelymanner.Equipmentmustbeavailableforcomplicationstobedetectedearlyandappropriatemanaged.
2. Ensurestaffisknowledgeableinequipmentmaintenance,i.e.sterilizationofmanualsuctionmachine.Supervisingstaffshouldberesponsibleforensuringequipmentmaintenanceandstandardsofcare.Adequatecareofequipmentincreasesitslongevityandqualityofcare.
13 Freedmanetal.2007.
12
3. Encourageteamapproachestopatientcaremanagementduringsupervisionvisitsandtrainings.Inter‐professionalapproachestomanagingmaternalhealthcarehaveshowntobemoreeffectivetoimprovingqualityofcare.14
4. ImprovegovernmentmonitoringsystemsbymentoringhealthstaffthroughroutineSafeMotherhoodandBEmONCsupervisionindistrictandsub‐districthealthfacilitiesandreviewingcasesummaryreporting.15WHO,UNFPA,UNICEFandAMDDpromotetheintegrationoftheEmONCindicatorsintohealthmanagementinformationsystemsasanefficientwayofmonitoringtheavailabilityanduseofsuchcareovertime.16Additionally,itestablishesthecapacityofafacilitytotrackitsownprogressandtofocusattentiononproblemareas.17
5. Provideafour‐wheeldriveemergencyvehicletotheAinarodistricthealthfacility.Despitethisfacilityservingalargegeographicregionwithroughterrain,itlackedavehiclethatcouldnavigateroadsduringheavyrains.
Long‐termRecommendations1. Supportforrenovationandupgradingofexistingfacilitiestoimprovewater
andsanitationsystemsandpowersupply.2. EnsureallmidwivesarecertifiedinBEmONC,prioritizingdistricthealth
facilitystaff.UponBEmONCcertification,allmidwivesshouldbeuniversallyapprovedtoindependentlyperformfunctionsasdescribedbyMOHpolicy.Inconsistenciesinmidwife’sindependencelevelsresultsinconfusion.
3. MOHshouldcontinuetrainingphysicianstounderstandmidwifecapacityandwhichprocedurestheycanandareauthorizedtoindependentlyperformaccordingtoMOHpolicy.AnyphysiciansnotalreadycompetentinEmONCproceduresshouldbetrainedforthoseskills.
4. FacilitatethetimelydistributionofUNFPAEmONCkits,ensuringthatallfacilitieshavetheequipmentnecessarytoperformbasicemergencyobstetriccare.Kitsshouldbereviewedwithreceivingstafftoensurepropermaintenanceofequipment.
5. Developandimplementapolicyonroutinerefreshertrainingstomaintainskilllevelofobstetriccare(EmONCandSafeMotherhood).Thishands‐onpracticeandfollow‐uptrainingsincreasequalityofskilllevelovertime.18
6. EmONCsupportivesupervisionshouldbeintegratedinSafeMotherhoodvisitstosustainlongevityofskillqualityaftertrainingcompletion.Measures that can preserve skill quality include hands-on practice, team approaches, and follow-up training, which can be provided during supervision visits.19
7. Developarotationforremotemidwivestopracticeobstetricskillswithinfacilitieswithahighernumberofabnormalobstetriccasesprovidingthemthehands‐onpractice.Alternatively,theMOHshouldconsideratrialoflow‐
14Freedmanetal.2007.15Campbell,O.M.R.andGraham,W.J.2006.16WorldHealthOrganization.200917AvertingMaternalDeathandDisability.2006.18vanLonkhuijzen,L.,Dijkman,A.,vanRoosmalen,J.,Zeeman,G.,Scherpbier,A.2010.Asystematicreviewoftheeffectivenessoftraininginemergencyobstetriccareinlow‐resourceenvironments.InternationalJournalofObstetrics&Gynaecology117:777–787.19vanLonkhuijzenetal.2010.
13
technologysimulation‐basedEmOCpractice,suchasthatavailableattheUniversityofWashingtoninthePRONTOproject.
8. IntegrateprenatalcareintoMaternityHousestofacilitaterecordsharingandcontinuityofcare.Midwivespracticingprenatalcareshouldbebasedoutofthematernityhouses.
9. Increaseresourcestotransportpatients,ensuringthattimelycareisaccessible.IncreasefuelsupplyforemergencytransportationandprimarycareSISCa’s.Monitorthereferraltransportationsystemtoensurethatanappropriatenumberofvehiclesareavailabletoservepopulationneeds.
14
Annex1:GovernmentHealthFacilitiesprovidingEmergencyObstetricCareServicesinEastTimorBasicEmOCServiceFacilities;Functioningin20081. LosPalosDistrictCHC2. ViquequeDistrictCHC3. ManatutoDistrictMaternityHouse4. SamePrinceofMonacoIIMaternityHouseBacisEmOCServiceFacilities;Plannedfor20151. Alldistrictandsub‐districtmaternalhealthfacilitiesComprehensiveEmOCServiceFacilities;Functioningin2012:1. BaucauReferralHospital2. MaubisseReferralHospital3. NationalDiliHospital
15
Annex2:MidwifeAssessmentSupplement Please answer the following questions about EmOC in your health facility?
What do you perceive as barriers to providing quality basic emergency obstetric care?
How well can you provide basic emergency obstetric care while managing home births?
Are special care plans used for pregnant women with known complications?
Comments
16
Annex3:ServiceAvailabilityandStaffingTable
ServiceAvailability&Staffing
MonacoMaternityHouse
TuriscaiMaternityHouse
AlasMaternityHouse
Fater‐berlihuMaternityHouse
MaubisseReferralHospital
AinaroMaternityHouse
HatuduMaternityHouse
ImmediateServiceAvailabilityDuring24HoursaDay
Laboranddeliveryservicebymidwife √ ‐ ‐ ‐ √ ‐ ‐Laboranddeliveryservicesbyotherhealthstaff √ ‐ ‐ ‐ √ √ ‐EmOCmedications √ x √ √ √ √ √Laboratoryservices ‐ ‐ ‐ √ √ ‐ ‐
StaffingMidwives
Total 6 1 1 3 5 3 1Present24hoursperday 1 0 0 0 2 0 0EmOCcertified 4 0 2 2 5 2 1
PharmacistTotal 1 1 1 1 3 2 xPresent24hoursperday 0 0 0 0 1 0 x
LabtechnicianTotal 1 1 1 1 4 1 1Present24hoursperday 0 0 0 1 1 0 0
MidwifeAssistantorNursingAssistantTotal 0 1 0 0 6 x xPresent24hoursperday 0 0 0 0 x x x
PhysicianTotal 5 x x x 4 2 xPresent24hoursperday 0 x x x x 0 x
AmbulanceDriverTotal 2 1 1 1 x 2 1Present24hoursperday 1 0 0 0 x 2 0
CleanerTotal 3 1 1 1 17 5 1Present24hoursperday 0 0 0 0 2 0 0x=notreportedbyfacilities
17
Annex 4: Facility Condition and Basic Equipment Supply
Facility condition Clean water
supply directly inside
clinic
Electricity and/or power source Radiant warmer/work
surface for newborn
resuscitation
Operating oxygen
source with flow meter
Clock with second hand
visible from the delivery table
Working refrigerator
24 hrs daily
Only a few hours daily
Only for specific appliances
Prince of Monaco II Maternity House - - √ - √ √ √ √
Turiscai Maternity House - - - √ - - - √ Alas Maternity House - - - - - - - √ Faterberlihu Maternity House - - - √ √ - - √ Maubisse Referral Hospital √ √ - - √ √ √ √ Ainaro CHC √ - √ - √ √ √ √ Hatudo CHC - - √ - - - - -
Basic Equipment
Blood pressure
apparatus
Stethoscope
Therm -o- meter
Ambubag with mask Scales
Plastic or rubber aprons
Povidone iodine 10% antiseptic (Betadine)
Sterile gloves (fitted) Adult Fetal Adult
Neo-nates Adults Infant
Prince of Monaco II Maternity House √ √ √ - √ √ √ √ √ √ √
Turiscai Maternity House - √ √ √ - √ √ √ √ √ √ Alas Maternity House - √ √ - √ - - √ √ √ √ Faterberlihu Maternity House √ √ √ √ - √ √ √ √ √ √ Maubisse Referral Hospital √ √ √ √ √ √ √ √ √ √ √ Ainaro CHC √ √ √ √ √ √ √ √ √ √ √ Hatudo CHC √ √ √ √ - - √ - √ √ √
18
Annex 5: Midwife Knowledge Survey
Obstetricskills(lastsixmonths)* #
TotalInter‐viewed
Managedbleedinginearlypregnancy 12 16Confidentinmanagingbleedinginearlypregnancy 14 16Managebleedinginlatepregnancyandlabor 7 16Confidentinmanagingbleedinginlatepregnancyandlabor 15 16Managepre‐eclampsia 11 16Confidentinmanagingpre‐eclampsia 14 16Madeareferralforeclampsia 6 16Confidentinreferringeclampsiacases 13 16Managedafeverbeforedelivery 10 16Confidentinmanagingafeverbeforedelivery 15 16Managedafeverafterdelivery 9 16Confidentinmanagingafeverafterdelivery 14 16Assessedthefetalposition 12 12Confidentinassessingfetalposition 12 12Assessedprogressoflabor 12 12Confidentinassessinglaborprogress 12 12Useapartographcorrectly&completelyuptophase4 14 16Confidentinusingapartograph 16 16Managedanormallabor 12 12Confidentinmanaginganormallabor 12 12Managedabnormalearlylabor 13 15Confidentinmanagingabnormalearlylabor 14 15Managedabnormalactivelabor(firststage) 11 16Confidentinmanagingabnormalactivelabor(firststage) 15 16Managedabnormalactivelabor(secondstage) 11 16Confidentinmanagingabnormalactivelabor(secondstage) 7 16Managedabnormalactivelabor(thirdstage) 7 16Confidentinmanagingabnormalactivelabor(thirdstage) 14 16Inducedlabor 11 16Confidentininducinglabor 13 16Managedanormalbirth 12 12Confidentinmanaginganormalbirth 12 12Performedvacuumdelivery 8 16Confidentinperformingavacuumdelivery 6 16Performedforcepsdelivery 1 16Confidentinperformingforcepsdelivery 1 16Removedofplacenta 8 12Confidentinremovalofplacenta 12 12Performedmanualvacuumaspirationinlast6months 11 14Confidentinperformingmanualvacuumaspiration 13 16Recognizedbreechposition 12 16Confidentinidentifyingbreechposition 12 16Managedprolapsedumbilicalcord 6 16Confidentinmanagingaprolapsedumbilicalcord 5 16Managedmalariaduringlabor&delivery 8 12Confidentinmanagingmalariaduringlabor&delivery 12 12Performedanamniotomy 12 15
19
Confidentinperforminganamniotomy 13 15Suturedanepisiotomywithabsorbablestitches 12 14Confidentinsuturinganepisiotomy 14 14Repairedfirstdegreeepisotomytear 12 14Confidentinrepairingfirstdegreeepisiotomytears 14 14Repairedseconddegreeepisiotomytear 10 14Confidentinrepairingseconddegreeepisiotomytears 10 14Repairedthirddegreeepisiotomytear 3 14Confidentinrepairingthirddegreeepisiotomy 3 14Repairedacervicaltear 5 14Confidentinrepairingacervicaltear 7 14Performedmaneuversforshoulderdystocia 9 16Confidentinperformingmaneuversforshoulderdystocia 16 16Managedatwindelivery 9 16Confidentinmanagingtwinsdeliver 16 16Performedmanualremovalofplacenta 10 14Confidentinmanualremovalofplacenta 11 12Performedcurettageorexploration 9 16Confidentinperformingacurettageorexploration 13 16Performbimanualcompression 14 16Confidentinperformingabimanualcompression 14 16Performedabdominalaorticcompressioninlast6months 3 16Confidentinperformingabdominalaorticcompression 12 15Dopostpartumcarevisitsatday1,3,7(BSP)&day3,7andweek6(lisio)
5 5
Confidentinpostpartumcare 5 5PerformedanIUDinsertionafterdeliveryorabortion 4 4ConfidentininsertingIUD 4 4Providedcontraceptionpills(COC/POP) 4 4Confidentinprovidingcontraceptionpills 4 4Injecteddepo‐provera 4 4Confidentininjectingdepo‐provera 4 4Insertednorplantimplant 2 3Confidentininsertingnorplant 3 3Performednewbornresuscitation 9 16Confidentinperformingnewbornresuscitation 15 16Conductedrapidinitialassessmentforemergencies 13 16Confidentinconductingrapidinitialassessmentforemergencies 13 16Managedshockfrombleeding 10 16Confidentinmanagingshockfrombleeding 15 16Managedshockfromsepsis 13 16Confidentinmanagingshockfromsepsis 13 16Implementedinfectionpreventionmeasures 13 13Confidentinimplementinginfectionpreventionmeasures 13 13
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Annex6:EquipmentListtoPerformBasicEmergencyObstetricCareServicesbyFacility(DevelopedfromtheWHOprovidermanual.)
BEmOC Signal Functions and their Equipment According to WHO standards
MonacoMaternityHouse
TuriscaiMaternityHouse
AlasMaternityHouse
Fater‐berlihuMaternityHouse
MaubisseReferralHospital
AinaroMaternityHouse
HatuduMaternityHouse
Administerparenteralantibiotics
Ampicillin1gram/vial √ ‐ √ √ √ √ √
Gentamicin80mg/ampule √ √ ‐ √ √ √ √
Metronidazole500mg/vial √ √ √ √ √ √ √IVtubing √ √ √ √ √ √ √
IVcannulag16and/org20/22/24/28 √ √ √ √ √ √ √Ringer'sLactate √ √ √ √ √ √ √Normalsaline0.9% √ ‐ √ √ √ √ √Sterilegloves √ √ √ √ √ √ √Sterilecottonorgauze √ √ √ √ √ √ √Ringforceps √ ‐ ‐ ‐ √ √ ‐Povidoneiodine10%Antiseptic(Betadine) √ √ √ √ √ √ √
Administeruterotonicdrugs(i.e.parenteraloxytocin)Oxytocin10Units/ampule ‐ √ √ ‐ √ √ √Methylergometrine0.2mg/ampule √ ‐ ‐ √ √ √ √Salbutamol4mg/tablet √ √ √ √ √ √ √Salbutamol1mg/ampule √ ‐ ‐ √ ‐ ‐ √IVtubing √ √ √ √ √ √ √IVcannulag16and/org20/22/24/28 √ √ √ √ √ √ √Ringer'sLactate √ √ √ √ √ √ √Normalsaline0.9% √ ‐ √ √ √ √ √Sterilegloves √ √ √ √ √ √ √Sterilecottonorgauze √ √ √ √ √ √ √Ringforceps √ ‐ ‐ ‐ √ √ ‐
Povidoneiodine10%Antiseptic(Betadine) √ √ √ √ √ √ √
21
Annex6:Continued‐EquipmentListtoPerformBEmOCbyFacilityBEmOC Signal Functions and their Equipment According to WHO standards
MonacoMaternityHouse
TuriscaiMaternityHouse
AlasMaternityHouse
Fater‐berlihuMaternityHouse
MaubisseReferralHospital
AinaroMaternityHouse
HatuduMaternityHouse
Administer parenteral anticonvulsants for pre-eclampsia and eclampsia Magnesium sulfate 50% solution √ √ - - √ √ √ Magnesium sulfate 20% solution - √ - - - - -
Diazepam 10mg/2ml √ - √ √ √ √ √
Calcium gluconate 10% - - - - √ - -
IV tubing √ √ √ √ √ √ √ IV cannula g16 and/or g20/22/24/28 √ √ √ √ √ √ √
Sterile gloves √ √ √ √ √ √ √
Sterile cotton or gauze √ √ √ √ √ √ √ Ring forcepts √ - - - √ √ - Povidone iodine 10% Antiseptic (Betadine) √ √ √ √ √ √ √ Blood pressure apparatus √ - - √ √ √ √
Manually remove the placenta
Diazepam 10mg/2ml √ - √ √ √ √ √ Ampicillin 1 gram/vial and Metronidazole 500mg/vial √ - √ √ √ √ √ Umbilical clamp (artery clamps) √ √ √ - √ √ √ Sterile gloves √ √ √ √ √ √ √
Plastic or rubber aprons √ √ √ √ √ √ √ Oxytocin 10 units - √ √ √ √ √ √ Normal saline 0.9% √ - √ √ √ √ √
Ringer's Lactate √ √ √ √ √ √ √
IV tubing √ √ √ √ √ √ √ IV cannula g16 and/or g20/22/24/28 √ √ √ √ √ √ √
Sterile gloves √ √ √ √ √ √ √ Sterile cotton or gauze √ √ √ √ √ √ √ Povidone iodine 10% Antiseptic (Betadine) √ √ √ √ √ √ √ Ergometrine 0.2 mg IM or prostaglandins Medicine not included on Question- naire
Ovum forceps - - - √ √ √ - Wide curette (Curette small, medium, postpartum) √ - √ √ √ √ -
Blood pressure apparatus √ - - √ √ √ √
22
Annex6:Continued‐EquipmentListtoPerformBEmOCbyFacilityBEmOC Signal Functions and their Equipment According to WHO standards
MonacoMaternityHouse
TuriscaiMaternityHouse
AlasMaternityHouse
Fater‐berlihuMaternityHouse
MaubisseReferralHospital
AinaroMaternityHouse
HatuduMaternityHouse
Removeretainedproducts(i.e.vacuumextraction,dilationandcurettage)Vacuumextraction
MVAsyringe √ √ ‐ √ √ √ ‐MVAadaptorsforsize6,7,8,9,10 √ ‐ ‐ √ √ √ ‐Paracetamol500mg/tablet √ √ √ √ √ √ √Oxytocin10Units/ampule ‐ √ √ √ √ √ √IVtubing √ √ √ √ √ √ √IVcannulag16and/org20/22/24/28 √ √ √ √ √ √ √Ringer'sLactate √ √ √ √ √ √ √Normalsaline0.9% √ ‐ √ √ √ √ √Sterilegloves √ √ √ √ √ √ √
Sterilecottonorgauze √ √ √ √ √ √ √Ringforceps √ ‐ ‐ ‐ √ √ ‐Povidoneiodine10%Antiseptic(Betadine) √ √ √ √ √ √ √Vaginalspeculumorvaginalretractor √ √ √ ‐ √ √ √Ringorspongeforceps √ ‐ ‐ ‐ √ √ ‐Cannulaesize6,7,8,9,10,12 √ √ ‐ √ √ √ ‐Curette:small,medium,postpartum √ ‐ √ √ √ √ ‐Vulsellumorsingle‐toothedtenaculum √ ‐ √ √ √ √ ‐Smallbowl √ √ √ √ √ √ √Dilators ‐ ‐ ‐ ‐ ‐ ‐ ‐
DilationandCurettageOxytocin10unitsIM ‐ √ √ √ √ √ √IVtubing √ √ √ √ √ √ √IVcannulag16and/org20/22/24/28 √ √ √ √ √ √ √Sterilegloves √ √ √ √ √ √ √Sterilecottonorgauze √ √ √ √ √ √ √Ringforceps √ ‐ ‐ ‐ √ √ ‐Povidoneiodine10%Antiseptic(Betadine) √ √ √ √ √ √ √VaginalspeculumORvaginalretractor √ √ ‐ ‐ √ √ √Povidoneiodine10%Antiseptic(Betadine) √ √ √ √ √ √ √Ringorspongeforceps √ ‐ ‐ ‐ √ √ ‐Vulsellumorsingle‐toothedtenaculum √ ‐ √ √ √ √ ‐Widecurette √ ‐ √ √ √ √ ‐Dilators ‐ ‐ ‐ ‐ ‐ ‐ ‐Ringforcepsoralargecurette √ ‐ ‐ √ √ √ ‐Paracetamol500mg √ √ √ √ √ √ √
23
Annex6:Continued‐EquipmentListtoPerformBEmOCbyFacility BEmOC Signal Functions and their Equipment According to WHO standards
Monaco Maternity
House
Turiscai Maternity
House
Alas Maternity
House
Fater-berlihu
Maternity House
Maubisse Referral Hospital
Ainaro Maternity
House
Hatudu Maternity
House Perform assisted vaginal delivery (vacuum extraction only since forceps are rarely performed)
Tubings/rubber hose for suction √ - - - √ √ -
VE plastic suction cup √ - √ √ √ √ -
Vacuum pump with pressure gauge √ - - - √ √ -
Manual pump - - √ √ √ √ -
Sterile gloves √ √ √ √ √ √ √
Mayo/episiotomy scissor √ √ - - - √ √ Perform basic neonatal resuscitation (i.e. with bag and mask)
Suction machine (manual or electric) √ √ √ √ √ √ -
Ambubag for neonates √ √ √ √ √ √ -
Oxygen mask and tubing for neonates √ √ √ √ √ √ -
Mask for neonates No.0 √ √ √ √ √ √ -
Mask for neonates No.1 √ √ √ √ √ √ -
Blankets/linen √ √ √ √ √ √ -
Clock with second hand in delivery room √ - √ √ √ √ -
Radiant warmer/Work surface for NBR near delivery area √ - - √ √ √ -
24