01 Emergency Obstetric care

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 EmONC
•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 Experience 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
1.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
–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.