Number of facilities per 500,00 providing basic and comprehensive emergency obstetric care
The number of facilities providing basic and comprehensive obstetric services (known as signal functions) at least once in the previous three months per 500,000 population.
Basic obstetric services are defined as:
- Administration of parenteral antibiotics;
- Administration of uterotonic drugs (i.e. parenteral oxytocin);
- Administration of parenteral anticonvulsants for pre-eclamsia and eclampsia (i.e. magnesium sulphate);
- Manual removal of the placenta;
- Removal of retained products (e.g.,manual vacuum aspiration);
- Perform assisted vaginal delivery (e.g., vacuum extraction, forceps); and
In addition to these six, a comprehensive emergency obstetric care facility will also:
- Perform surgery (e.g., cesarean section); and
- Perform blood transfusion.
Facilities are divided into those that provide “basic” emergency obstetric care (EmOC) and “comprehensive” EmOC. If a facility has performed each of the first six functions in the past three months, it qualifies as providing basic EOC. If it has provided all eight of the functions, it qualifies as a “comprehensive” EmOC facility.
Other items have been discussed as signal functions, but these nine were chosen by technical consultation because of the role they play in the treatment of the five major causes of maternal death.
Count of the facilities meeting the requirements for “basic” and “comprehensive” EmOC. If there are at least five basic and emergency obstetric care facilities (including one comprehensive facility) for every 500,000 population, then this indicator meets the acceptable level as defined by WHO/UNICEF/UNFPA/AMDD (2009).
Facility surveys that examine medical records or service statistics. Ideally, records should provide the emergency obstetric signal functions. Personal interviews with knowledgeable staff who attend obstetric patients are a second, albeit, potentially more biased source of information than written records are.
This indicator demonstrates the existence of life-saving obstetric care services. It distinguishes between “basic” and “comprehensive” care services to emphasize that maternal lives can be saved not only in hospitals providing all the services listed above, but also at health centers or smaller hospitals that do not.
The list is intentionally brief to facilitate assessment and monitoring; it does not constitute the complete list of services that either a basic or comprehensive EmOC facility should provide but rather focuses on the key medical interventions that are used to treat the vast majority of global maternal deaths. For a complete list of recommended procedures and drugs, refer to WHO’s Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors and Managing Newborn Problems: A guide for doctors, nurses, and midwives.
This indicator is relatively easy to produce, but it should reflect how facilities are actually functioning and not how they are supposed to function. For example, providers may lack confidence in their skills and refer patients to a higher level, although they are otherwise equipped to treat these patients.
Generally, facility-based assessments cover all the facilities in a specific area. Private facilities may be more reluctant to collaborate than may public facilities. Also, samples of facilities generalizable to a national level such as the Service Provision Assessment (SPA) are possible, but may not always include all the signal functions listed above (MEASURE DHS+, 2000).
This indicator should respond to changes within a fairly short period of time (e.g., 6-12 months).
Generally, this indicator applies to a large region or country. The recommendation (as a minimum acceptable level for every 500,000 population) is one or more facilities providing comprehensive EmOC and four or more facilities providing basic EmOC. For this reason, the indicator is often shown as two indicators:
- Availability of basic essential obstetric care.
- Availability of comprehensive essentail obstetric care.
If areas fall short of the overall minimum level, they may upgrade existing facilities and/or build new ones. If the minimum level is met, evaluators should study the geographical distribution by looking at smaller divisions of the population. National summary measures may hide important sub-national disparities. Disaggregation by geographic (urban/rural) and by administrative (public/ private) divisions is recommended (Bertrand and Tsui, 1995).
The use of this indicator in a wide variety of countries has revealed at least three difficulties in its application. First, where geographical terrain is particularly challenging and transportation is precarious, the ratio of facilities to population may require adjustment for local use. Second, the reference period for assessing whether a signal function or procedure has been performed is generally three months, but when patient volume is low, one or more of the signal functions may not be performed, because an occasion did not present itself, not for lack of infrastructure or provider skills. Finally, a third situation concerns normative medical practice that fails to include one of the procedures, for example, assisted vaginal delivery. In some countries, vacuum extraction or a forceps delivery is no longer taught to medical students or midwives and only a few older providers are experienced at performing these procedures.
To solve these problems, one may consider preparing the indicator in several ways. But, to compare facilities across space and time effectively, it is recommend to maintain the original operational definitions of these ratios. Evaluators should well document alternative calculations, and should report the adjusted ratio of population to facility; the length of the new reference period, (if it is extended); the way a category of “potential” basic EmOC was created (if a procedure is generally performed, but during the study period was not); or the way country-specific criteria were established (if the criteria omits a particular signal function).
Evaluators can also calculate the “number of EmOC facilities” for smaller geographical areas to show the distribution of EOC facilities at a sub-national level.
access, health system strengthening (HSS), obstetric fistula (OF), emergency, safe motherhood (SM)
Monitoring emergency obstetric care: a handbook. WHO, UNFPA, UNICEF, AMDD. 2009.
Much of the text for this indicator comes from Maine, McCarthy, and Ward, 1992 and UNICEF, WHO, and UNFPA, 1997.