Program note

This is the second program note in a series that features the UN process indicators 1,2. Issued by UNICEF, WHO and UNFPA, they are used to identify the availability, use, and, to some extent, quality of emergency obstetric care (EmOC). They are also useful at monitoring changes in these three important aspects of health care. The definitions and recommended levels of the indicators are summarized in Table 1. The UN indicators developed from an understanding that certain medical services or procedures are necessary to save the lives of women with obstetric complications. These procedures or ‘signal functions’ distinguish facilities that provide Basic or Comprehensive emergency obstetric care (EmOC) from those that do not. parenteral antibiotics; parenteral oxytocic drugs; parenteral anticonvulsants for pregnancy-induced-hypertension; manual removal of placenta; removal of retained products (e.g. vacuum aspiration); assisted vaginal delivery (e.g. vacuum extraction, forceps); surgery (e.g. cesarean delivery); and blood transfusion. The following brief reports present the data from the Needs Assessments in Bhutan, Cameroon and Rajasthan, India, undertaken in 2000 and 2001. In each case, they reflect 12 months of hospital data. A needs assessment was the first step in carrying out the Averting Maternal Death and Disability project in these three countries. The Needs Assessment of district hospitals in the country of Bhutan was conducted by the Department of Health Services within the Ministry of Health and Education in February and March of 2000. In 2000, the Bhutanese population estimate was approximately 658 000 inhabitants with a crude birth rate of approximately 36 per 1000 population. The Needs Assessment team visited all 31 health facilities in which a medical officer was posted. This included six grade 1 basic health units, 19 district and sub-district level hospitals, three regional referral hospitals and three army hospitals. Only 29 of 31 facilities admitted obstetric patients. For its population size, Bhutan should have at least five Basic and one Comprehensive EmOC facilities (Table 2). Four facilities provide Basic EmOC, or 80% of the recommended number, and four facilities provide the full range of Comprehensive signal functions, or 400% of the recommended number. The Comprehensive EmOC facilities are well distributed geographically, but the Basic facilities are concentrated in the western and south-western regions of the country. The UN indicator or ratio of Basic and Comprehensive EmOC facilities per population is a minimum standard. Since the country has nearly met or exceeded this minimum in the case of Comprehensive facilities, the health system is moving forward towards achieving a larger ratio of one Comprehensive facility for a population smaller than 200 000. The additional coverage in EmOC is important given the problems of access to facilities that women face in this mountainous country. The UN indicator specifies ‘births in EmOC’ facilities, those that can treat most obstetric emergencies. An estimated 15% of pregnant women develop obstetric complications that require medical care, therefore, the recommendation that at least 15% of births deliver in EmOC facilities (Table 3) 1. Almost 15% of births occurred in all of the facilities surveyed, but not all of these facilities provide all of the signal functions, therefore further improvement is needed. Met need is based on the major obstetric complications, those that are considered the direct causes of death 1. Using this definition, 19% of the women who experience severe complications in pregnancy, delivery or the postpartum period are being treated (Table 4). Slightly more than one percent of all births in the population are by cesarean (Table 5); many women who would benefit from surgical deliveries are not receiving this potentially life-saving intervention. The case fatality rate for the facilities studied is a little higher than the recommended maximum of 1% (Table 6). Furthermore, only six of the 29 hospitals with obstetric admissions reported a maternal death. If only those six hospitals are considered, the case fatality rate increases to 10% (10/100). The Needs Assessment for Cameroon covered five of the country's 10 provinces. The five provinces have a population of 7 481 920 or approximately half of the country's total population. The crude birth rate varied across regions but was approximately 42 births per 1000 population. The Needs Assessment was conducted by the Ministry of Health and UNFPA in March and April of 2001. Of a total of 783 facilities, 487 were surveyed. The ratio of Comprehensive EmOC facilities to a population of 500 000 equals or exceeds that which is recommended in every province, but Basic EmOC facilities are very few (Table 7). The ratio of services to population is particularly favorable in the southern province. Many facilities that potentially could offer Basic services lack supplies, equipment or human resources. Overall, almost 6% of all births took place in the facilities visited, far fewer than the 15% estimate of pregnant women who may require medical attention during pregnancy, delivery or postpartum (Table 8). Met need in Cameroon is low; fewer than one in 10 women with severe obstetric complications receives care (Table 9). The cesarean rate is less than 1%, falling short of the 5–15% range recommended (Table 10). The aggregated case fatality rates in these Comprehensive facilities are high (Table 11). Among those that registered at least one death, the lowest rate is in the Southern province where coverage of EmOC facilities is highest. The Needs Assessment in Rajasthan, India, covered seven of the state's 31 districts. The seven districts have a population of approximately 13 million inhabitants or approximately one-quarter of the state's population (53.9 million in 2000). The crude birth rate used to calculate the expected number of births was 31 per 1000 population. The Needs Assessment was conducted by UNFPA and the Government of Rajasthan between June and September of 2000. A total of 82 facilities were surveyed. Given the size of the population, Rajasthan has only approximately one-third of the Comprehensive or Basic EmOC facilities that are recommended. The district of Sawai Madopur has better availability of EmOC services than other districts. While the district hospitals provide the complete range of Comprehensive EmOC services, some of the sub-district hospitals that were surveyed provide similar services except for blood transfusions (Table 12). Policy barriers deter the wider availability of blood. Overall, 10% of births occur in the facilities surveyed, falling short of the 15% minimum (Table 13). The highest proportion of institutional births took place in Sawai Madopur. Met need is less than 10% and ranges from 5 to 12% at the district level, suggesting that many women with obstetric emergencies are not receiving adequate care (Table 14). Some women with complications may attend private facilities and these private facilities were not surveyed. Thus, met need at the state or district level may be underestimated, but because the private health sector in Rajasthan is not well developed, the true situation may not be very different. Only approximately 1% of all deliveries are cesareans, falling short of the recommended lower level of 5% (Table 15). The overall case fatality rate exceeds the recommended maximum of 1% and ranges from a low of 0.2% in Karauli to 2.3% in Bhilwara (Table 16). High case fatality rates may be affected by a shortage of blood, anesthesia, or qualified staff contributing to inadequate treatment. In addition, some women must travel considerable distances to reach care. Like the previous Program Note 2, we have described the baseline indicators in three country projects. The UN indicators in each of the countries point to specific interventions that are needed. In the case of Bhutan and Cameroon, Comprehensive EmOC services are in place although access to them may be made difficult by geography or transportation. Because many obstetric complications can be resolved at the Basic EmOC level, project efforts should be directed at increasing access to Basic EmOC facilities, especially in Cameroon. The Indian state of Rajasthan has an even mix (proportionately) of Basic and Comprehensive facilities although the numbers fall short of the recommendations. In Cameroon only 6% of women delivered in hospital, almost 15% in Bhutan and 10% in Rajasthan. Met need ranged from 6% in Cameroon to 19% in Bhutan. Although met need was extremely low in Cameroon, one in five women who delivered in facilities had an obstetric complication. Delivering at home is clearly the common practice in these three countries, which is a problem when women cannot or do not seek EmOC services when the need arises. The small proportions of births delivered by cesarean in each country further indicate that many women are not receiving the emergency care they need. As facilities add services to those they already provide, drugs and equipment are increasingly in stock, staff are receiving specialized training in EmOC, and services are better organized, we hope to measure an increase in the number of pregnant women seeking maternity services, especially those who have complications. The process indicators will be calculated periodically to monitor the progress of program efforts towards improving access to, utilization of and quality of emergency obstetric services. The Working Group on Indicators thanks the teams from Bhutan, Cameroon and Rajasthan for sharing these early results with others.