Percent of pregnant women with obstetrical complications treated within two hours at a health facility
The percent of women with obstetric complications who are treated within two hours of admittance to a health facility measured during a given reference period.
Obstetric complications include:
- Hemorrhage: antepartum, intrapartum or postpartum;
- Prolonged/obstructed labor;
- Postpartum sepsis;
- Complications of abortion;
- Ectopic pregnancy; and
- Ruptured uterus.
Treatment for obstetric complications depends on the complication and local protocols for treatment.
This indicator is calculated as:
|# of women with obstetric complications treated within 2 hours of admittance to a health facility x 100
# of women admitted at a health facility with obstetric complications
Numerator: date and time of admission; date and time of treatment/delivery; total number of women admitted with complications and their diagnosis at the time of admission; and information on the time and nature of treatment given.
Denominator: number of women admitted to the health facility with obstetric complications.
All registers that record where women are admitted to a facility (e.g., labor ward register, antenatal, emergency room or postnatal ward register); registers that record where definitive treatment is administered (e.g., operating theatre register, specific complications registers); case records
The purpose of this indicator is to provide a measure of the quality of maternity care, because maternal mortality is directly related to the effectiveness and timelines of treatment for emergency complications (Koblinsky, et al., 1995).
This indicator is most appropriate at a facility level for those facilities interested in auditing their own care practice. It is less suitable for comparison purposes across facilities because of variation in the services provided and in case mix at different facilities as well as variations in the definitions of the indicator.
Information required to construct the indicator should be available directly from facility registers and case notes. The lack of certain information may signal suboptimal care/management. The feasibility of the indicator also critically depends on standard definitions of admission-to-treatment-time-interval (ATTI) for each obstetric complication. For example, does admission time mean time of first arrival at the hospital, time seen by the admissions clerk, or something else? What is the treatment time for an obstetric hemorrhage? Is it when an intravenous drip is inserted, when a blood transfusion starts, when an oxytoxic is given, or when the hemorrhage stops?
This indicator should respond rapidly to changes in staff or facility administration practice. Early rapid response may simply be due to a Hawthorne effect (i.e., apparent improvement simply because of an observation taking place), but this type of improvement will not be sustained. To maintain improvement, programs should regularly audit ATTI. Better still, ATTI could be incorporated into routine management practice (e.g., discussed routinely in all case reviews). (See indicator, Percent of Facilities that Conduct Case Reviews/ Audits into Maternal Death/Near Miss).
This type of indicator has several ambiguities and deficiencies, as follows:
- The recording of the actual admission time may be seriously delayed if the facility lacks a triage system, and women must wait a long time on first arriving at the facility;
- The ATTI should be reviewed for all women developing obstetric complications. If the admissions
register serves as the sampling frame to identify women with complications, then the register will exclude those women who had a complication but whose diagnosis was missed at the time of admission;
- The severity of the complication and hence the need for rapid treatment may be difficult to ascertain retrospectively for all cases (a further reason for facilities to set their own realistic standards);
- The indicator fails to capture the timeliness of treatment for those women who develop complications while in the hospital;
- Women who arrive at the hospital, but who are not admitted for a variety of reasons (e.g., they
cannot afford the treatment), will be omitted from both the numerator and denominator. This omission may be a potentially important source of bias if poorer patients have a disproportionately high complication rate; and
- The indicator does not measure the appropriateness of the type of treatment given.
Because of these limitations, evaluators can best measure ATTI in combination with other indicators or approaches that measure complementary aspects of the quality of care, for example in the context of care reviews or near-miss audits.
access, obstetric fistula (OF)