Met need for EmOC
The percent of all women with major direct obstetric complications who are treated in a health facility providing emergency obstetric care (EmOC) in a given reference period.
This indicator is calculated as:
(Number of women treated for direct obstetric complications at EmOC facilities, over a defined period / Estimated number of women who would have major obstetric complications (or 15% of expected births), during the same defined period) x 100
The direct or major obstetric complications include:
- Hemorrhage: antepartum, intrapartum, or postpartum;
- Prolonged/obstructed labor;
- Postpartum sepsis;
- Complications of abortion;
- Severe pre-eclampsia/eclampsia;
- Ectopic pregnancy; and
- Ruptured uterus.
Number of women with a major obstetric complication includes both women admitted with the complication and women who develop the complication in the facility.
EmOC facilities include both basic and comprehensive levels of essential obstetric care.
Met need should be calculated at all health facilities as well as at EmOC facilities to provide a more complete picture of the use of the health system and where women are being treated (WHO, 2009).
The number of women with a major obstetric complication treated in EmOC facilities during the reference period; (an estimate of) the number of women with major obstetric complications in the population during the reference period
Facility records (for number of women treated) The number of pregnant women who develop obstetric complications requiring medical care to avoid death or disability is estimated to be 15 percent (WHO, 1994a). The number of live births frequently serves as a proxy for all births or pregnancies; when data on the numbers of live births are absent, evaluators can estimate them from total expected births = population x crude birth rate.
The purpose of this indicator is to gauge the level of use of EmOC services by women experiencing a major obstetric complication in a specified time period and geographical area. Met need is a more refined measure of the use of EmOC than Proportion of all births in EmOC facilities.
Facility record-keeping systems may require adjustments for the routine collection of data on obstetric complications. A useful system will record major complications in the patient register or maternity logbook. Evaluators must ensure that they gather information from all relevant parts of the facility (e.g., gynecology ward, surgical ward, abortion ward, morgue) and not just from the maternity ward. They must also include complications from all EmOC facilities in the area under study in the numerator.
UNICEF/WHO/UNFPA has set the minimum acceptable level of “met need” as 100 percent, but in most developing country settings, this target is unrealistic. If evaluators find less than 100 percent, they conclude that some women with complications are not receiving the necessary medical care. However, if “met need” is low, researchers should seek other data to determine whether the problem lies in the availability, accessibility, quality of care provided, or other factors, such as cultural factors, that determine the utilization of services.
Theoretically “met need” can exceed 100 percent, if more than 15 percent of pregnant women in the population develop major obstetric complications. In developed countries, the proportion of women with complications managed in EmOC facilities may be greater than 15 percent of all births. Over-diagnosis of complications, which is seen in parts of Eastern Europe, can also cause this ratio to exceed 100 percent.
One difficulty with “met need” is that complications are subject to numerous recording biases and, even when standard definitions are in place, results can vary greatly with the data collection system being used and the training of the staff. Furthermore, routine maternity record systems in many countries may not register the “reason for admission” or “maternal complications”, although complications can lead to maternal deaths (WHO, 2009).
“Met need” is also particularly sensitive to the number of abortions included in the numerator. If the incidence of unsafe abortion is high, “met need” is likely to be high. The inclusion of all abortions can cause “met need” to be twice or three times as high as it would be without the abortions. Given this inflation of “met need” as a result of the inclusion of all abortion complications, a growing number of advocates for the indicator calculate it both ways, with and without all abortions. By excluding postabortion complications, estimates may be more comparable.
The appropriateness of using 15 percent of all births/ pregnancies to estimate the number of women who experience obstetric complications is also open to discussion. WHO‘s estimates of births with complications may be higher than 15 percent: hemorrhage, 10 percent of pregnancies; sepsis, 8 percent; hypertensive disorders of pregnancy, 5 percent; obstructed labor, 5 percent (WHO, 1996a). However, prospective data from West Africa suggest that 6 percent more reasonably estimates severe obstetric complications (Prual, 2000). The narrower the definition of what is considered a direct or major obstetric complication, the more reliable and comparable the estimates will be (MotherCare, 2000a). However, birth records and registries will likely lack sufficient detail on complications to allow much refinement regarding the severity of a complication.
The issue of double-counting a woman in the numerator (one who is admitted to the same facility more than once during her pregnancy or postpartum period or one who is admitted to more than one facility) is unlikely to seriously bias the results. If this situation were to occur, it would bias the indicators by presenting a more positive view of the health system than merited.
Given that the crude birth rate (CBR), the total population, and 15 percent are all estimates and that the accuracy of the CBR and population may vary according to the source, “met need” will likely be imprecise and may over- or underestimate the true value. To make the indicator useful for comparisons across facilities and districts or over time, one must use the same definitions and document the criteria used in each definition.
access, health system strengthening (HSS), obstetric fistula (OF), emergency, safe motherhood (SM)
Monitoring Emergency Obstetric Care: a handbook. WHO, UNFPA, UNICEF, AMDD, 2009.