5 - 4 - Video 4.4 EmOC Monitoring and Assessment (5 22), Childbirth A Global Perspective
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In this section,we will talk about what monitoring andassessment of EMOC look like on the groundat the country and sub-national levels.Including specific examplesfrom Malawi and Zambia.A number of steps are involvedin monitoring the EmOC,which we will now review.Note the WHO's handbook for monitoringobstetric care provides forms andworksheets that summarize each of thesesteps and can assist in completing them.Which I encourage you to take a look atif you'd like more detailed information.So, the first step is to determinethe areas to be studied andto develop a list of all possibleEmOC facilities in these areas.If the aim of the study isto generalize findings,findings to the country as a whole,it is recommended that atleast 30% of the total number ofsub-national areas to be included.So provinces, states, districts, regions.Through a process of random selection.Given available resources,the idea is to include as many areas aspossible without compromising quality.The next step is to assessthe health facilities ora randomly selected subset of facilitieswithin a single 12 month period.And then categorize these facilities asbasic EmOC, comprehensive EmOC or neither.If you'll remember, when discussingthe signal functions earlier,I mentioned the need to use a three monthreference period when determining whethera health facility qualifiesas providing these services.This is the point at which the personconducting the assessment will record thisinformation, which is collected byreviewing health facility registers,making targeted observations andinterviewing staff.Specific considerations include theavailability of trained health workers,and the presence andfunctioning of necessary drugs andsupplies to perform the signal functions.If a signal function was not performed inthe past three months, the reasons forwhy this was the case are accessed.Including the issues relatedto training supplies andequipment, management,policy or other reasons.Besides the signal functions,facility statistics that informthe process indicator calculation are alsocollected, including numbers of births,direct obstetric complications,cesarean sections,maternal deaths, maternal deaths fromdirect and indirect obstetric causes, etc.Often collecting this informationin an accurate manner can bea difficult task depending on how wellrecords are kept in a particular facility.The third step then is to summarize thedata collected using the forms provided inthe monitoring handbook.After that, the process indicators can becalculated for all areas being studied.So country, region, province,state and district.Remember, then in order toperform these calculations,information on population andbirth rates are required.Which can be obtained from the mostrecent country census demographic andhealth survey or other relevant sources.In some countries, EmOC indicators havealready been incorporated into routinehealth information systems, both atthe national and sub-national levels.And finally,what you'd want to try to do isconduct whatever supplementarystudies would be needed.So sometimes more detail in healthfacility capabilities is desired from ourlocal assessments, such as information ongeographic accessibility, infrastructure,staffing and quality issues.Additional assessment modelscan be added as needed,some of which are availableamddprogram.org.So in putting this together,let's look at a few examples of somepublished studies that apply the UNprocess indicators for EmOC.First is an example of EmOC monitoringin three districts of central,of the central region of Malawi.This study assessed all 73 ofthe health facilities in this area andfound that although the total numberof comprehensive EmOC facilities wasadequate, the distributionbetween urban areas, so Lilongwe.And rural areas in Kasungu was uneven,leaving some rural areasvery poor access to care.In addition, the authors foundthat no functional basic EmOCfacilities existed in anyof the districts assessed.You can see some of the results forthe other process indicators in the table.Note that the study did notinclude indicators seven andeight, which were more recently added.Nor did it assess the signal functionof basic neonatal resuscitation.Here now, is an example ofEmOC monitoring in Zambia.In their, in the study of EmOCavailability at the country level,these authors used data collectedas part of a national healthfacility survey that includedthe EmOC signal functions.They specifically examined the extentto which the facilities were performingthe EmOC signal functions as indicatedby the minus signifier in the table.As you can see,few health facilities qualified ashaving all of the signal functions.As a result, only 12% met the criteria forhaving either basic or comprehensive EmOC.Again, availability in ruralareas was especially low.Before we move on to quality improvement,it is important to recognize that the ideahere is not to be critical of countriesand health systems for under-performing,but rather to obtain a baseline level sothat capabilities can be increased overtime and hopefully future improvementscan be made in maternal health.
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