5 - 3 - Video 4.3 United Nations Process Indicators for Monitoring EmOC (8 52), Childbirth A Global Perspective
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In this section, we will learnabout a series of indicators formonitoring the progress that countriesare making toward providing EmOC, andthus reducing maternal deaths.Much of the information presented here,as well as in the preceding section,can be found in the World HealthOrganization's handbook, formonitoring emergency obstetric care,which can be freely accessed at the linkincluded in the weekly reading list.In general terms, facilities providingEmOC, must be adequately, andequitably distributed interms of geographic location.They must be used by pregnantwomen particularly thoseexperiencing complications, if there notused they are not going to be helpful.They must function properly in providingcritical life saving services ofsufficient quality as well.To understand to whether andto what extent countries as well regions,provinces, and states within countries,are meeting these objectives.Scientists at UN agencies andvarious academic institutionshave developed a set of eightprocess indicators that can be reassessedon a regular basis, preferably annually.I will be using the most recentversion of these indicators from 2009.But be aware that an updated version,may be available in the next year or so.The first process indicatoris availability, soin a particular region or country,are there enough health facilitieswith the capacity to provide EmOC?This means a minimum of onecomprehensive EmOC facility, andfive basic EmOC facilitiesper 500,000 population.This indicator is calculated by dividingthe total population by 500,000 andthen multiplying by 5, to give the overallminimum number of EmOC facilities.The number is then compared to that ofthe actual health facilities found,in order to classify services as basicEmOC, comprehensive EmOC, or neither.The results are expressed as a percentageof the minimum acceptable number ofEmOC facilities.So, for example, in 2012,Amay and colleagues publisheda cross-sectional survey of healthfacilities in six developing countries.They found that in Kenya,50% of all provincial hospitals inthe country were meeting the minimumrequirement for comprehensive EmOC.In India, 43% of the selected facilitiesin four states met the standard forcomprehensive EmOC, butonly 15% qualified as having basic EmOC.And in eight districts of Nigeria,no facilities offering maternalhealth services met the standard forcomprehensive EmOC,while 2% qualified as having basic EmOC.The next process indicator isgeographical distribution,are the existing EmOC facilities bothadequately and equitably distributed?The minimal standard for this indicatoris that all sub-national areas meetthe same level as the indicator,that I just discussed, mm, in number one,.So one comprehensive EmOC facility and5 basic EmOC facilitiesper 500,000 population.This indicator is calculated in the sameway as the first indicator except,that it takes into considerationthe geographical distribution of EmOC byusing subnational areas of study,rather than region or country.The third U.N indicator, is the proportionof births in EmOC facilities.Are enough women using this care?Here the minimal acceptable standard islocally defined, based on the proportionof births that occur in health facilitiescurrently as well as the national orsubnational goals.So for example,countries estimating that 70% of,of their births are taking place in healthfacilities might want this number to beset at 100%,while countries with facility births atonly 30% might be currently strivingto achieve 50% for their goal.It's calculated by dividing the numberof women registered as giving birth inan EmOC facility, by an estimateof all live births in the area.To give a more complete picture of what'sgoing on in a country or an area, and tomake comparisons, this estimate, and allof the estimates that follow, should becalculated for all health facilities, aswell as for just the facilities with EmOC.The fourth UN progress indicatoris proportion of women with a ma,with major direct obstetric complicationswho are treated in EmOC facilities.Are the right women using this care?Is the question that thisindicator attempts to answer.So another term forthis indicator is met need for EmOC.Which might be familiar foranyone with experience working inpopulation studies or family planningprograms, where Met need forcontraception is a commonly used estimate.The goal here, is for 100% of women withmajor directives obstetric complications,to be treated in an EmOC facility.It's calculated by dividingthe number of women treated fora complication in an EmOC facilityover a specified period of time,by the expected number of women witha major, major complication, or15% of expected, expected birthsduring the same time period.The fifth progress indicator isthe proportion of all births bycesarean section.So are enough critical services,being provided but not overused.The estimated proportion of births bycesarean section is no less than 5%or more then 15%.The optimal rate of cesareandelivery is still unknown, butis typically consideredto be between 5 and 15%.This indicator is calculated by dividingthe number of cesarian sectionsperformed in EmOC facilitiesduring a specified period, forany reason, by the expected number oflive births during the same period.The sixth indicator, is proportion ofwomen with a major direct obstetriccomplication, who received care in an EmOCfacility, and who died prior to discharge.So this gets at the question,is the quality of maternalhealth services adequate?This indicator also known as the casefatality rate, the goal, forthe indicator is less than 1%, soless than 1% of women with a complicationin EmOC facility, died before discharge.This indicator is calculated by dividingthe number of women dying from a majordirect obstetric complication in an EmOCfacility during a specified period,by the number of womenwho were treated forall direct obstetric complicationsduring the same period.UN process indicator number seven is,proportion of births that result ina intrapartum fetal death, or an earlynewborn death in an EmOC facility.This indicator, is also trying toget at the question of quality,is the quality of care forfetuses and newborns sufficient?Also known as the intrapartum and veryearly neonatal death rate, the minimumstandard for this more recently addedindicator is yet to be determined.The indicator is calculated by dividingthe sum of intrapartum fetal deaths andnewborn deaths that occurwithin 24 hours of birth inan EmOC facility duringa specified period,by the number of women who gave birth inthat same facility during the same period.It is recommended that newbornsunder 2.5 kilograms beexcluded from both the numerator anddenominator when possible,because low birth weight babies tendto have a high fatality rate, andthe purpose of this indicatoris to measure quality of care.UN process indicator number eight,is proportion of maternal deathsfrom indirect obstetric causes inEmOC facilities, for this indicator,no standard can be set.It's a more recent indicator that isthought to highlight the broader socialand health system context of a region,or country.And it has implications forintervention outside, or beyond, EmOC.If it were to be calculated,it would be calculated by dividing allmaternal deaths due to indirect causes inEmOC facilities in a specified period,by all maternal deaths occurring in thesame facilities during the same period.So now we've finished discussingthe United Nations process indicators fromthe EmOC.Before moving on, I do want to note that,like many measures in global health andparticularly in maternal health.These estimates are not without flaws, andhave been critiqued by experts inthe field for a variety of reasons.Without going in toa great deal of detail,I want to refer you to another public,publication by Gabrish andcolleagues on your reading list andthis is from 2012,that describes measurement inconsistenciesbetween different UN documents.So, for example, use of differentdenominators for some of the indicators.This article also makes recommendationsfor which approach may be best to take.Next we will explore the practicalapplications of these process indicatorsin the monitoring andassessment of the MOC.
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